ChanBeDu/relevant_section_length · Datasets at Hugging Face

32,525

135,066

34080

Discharge summary

report

Admission Date: [**2130-4-20**] Discharge Date: [**2130-5-8**] Date of Birth: [**2055-2-19**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: Low back pain Major Surgical or Invasive Procedure: Ex-laparoscopy, retroperitoneal mass biopsy History of Present Illness: The Pt is a 75y/o F who transferred from OSH with worsening renal failure, elevated uric acid and a newly diagnosed abdominal mass. The pt was in USOH until 1 month ago when she developed increasing low back pain. Three days prior to transfer the pt developed abd pain intially located in the RLQ and later radiating to LLQ as well as increased urinary frequency and dysuria. She was admitted to an OSH where she left prior to intervention. She then presented to her PCP and [**Name Initial (PRE) **] CT abdomen was obtained demonstrating a large retroperitoneal mass, multiple lymphadenopathies. She was also found to have a Cr of 1.9 and was directly admitted to [**Hospital3 417**] medial center. There she had a CXR which was WNL, renal ultrasound with no hydronephrosis and a percutaneous biopsy of the retroperitoneum was performed. Her labs were remarkable for uric acid 23, her creatinien went from 1.9 to 2.5 in 24 h. The pt was transferred to [**Hospital1 18**] for further management. . The pt was admitted to the BMT service. Given her elevated LDH, uric acid and worsening renal failure she was given IV hydration with bicarb, allopurinol and Rasburicase. Her retroperitoneal mass was felt concerning for lymphoma and she underwent a CT guided biopsy. Per report the CT guided biopsy yielded only necrotic tissue. Urology was consulted for question of bladder wall thickening. This pm pt underwent ex-lap and cystoscopy and is transferred to the [**Hospital Unit Name 153**] for HD monitoring. OR cystoscopy demonstrated that the left lateral wall has a smooth 1.5-2cm area of invagination into the lumen of the bladder. This may be a primary bladder mass or more likely, extrinsic compression of the bladder by an external mass. Multiple core biopsies were taken in OR. Estimated blood loss 600cc. Post-op the pt had low BP and neo was started. She remained vented [**12-24**] poor reflexes with sedation. . While in the [**Hospital Unit Name 153**], the patient was tx'd for TLS with bicarb containing IVF. xfused 2u PRBCs for ~600ccs blood loss. Extubated and started on clears. On cystoscopy was found to have: OR "left lateral wall has a smooth 1.5-2cm area of invagination into the lumen of the bladder. This may be a primary bladder mass or more likely, extrinsic compression of the bladder by an external mass." Transferred back to BMT service for initiation of chemotherapy. Past Medical History: Low back pain Osteopenia Dejenerative joint disease Social History: Born in NH. Lives with her husband. [**Name (NI) **] two children. Currently retired. Formerly worked for an insurance company. + smoking for about 40 years 1 pack a day, quit in [**2101**]. Alcohol - 2 drinks of vodka daily. Family History: denied any history of cancer or heart disease Physical Exam: PE: Vitals: T 97.0; HR 86; R 20; BP 122/71, 96-97% on 4L General: Awake, alert, NAD. HEENT: oropharinx clear. no JVD< no LAD Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. heart sounds a bit muffled. Abdomen: soft, normoactive bowel sounds, mild tenderness to palpation over hypogastrium. no rebound. tender to palpation along the incision. ecchymosis along the incision, no rebound. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: no rashes or lesions noted. Neurologic: alert, oriented x3. movilizing all extremities . Pertinent Results: Chem 7: 145 4.3 97 30 38 1.8* 181 Ca 9.4 Mg 1.8 P 6.5 LFTS: 23 41 66 0.5 A46 L32 LDH 695* CBC: 2 36 125 Coags 13 23 1.1 UA pH5 189RBC 2WBC few bacteria Uric acid 18.2 UCx pending Rads (OSH): ABDOMEN AND PELVIC CT [**2130-4-19**]: Spiral images of the abdomen and pelvis were obtained after the administration of oral contrast material. No intravenous contrast material was given due to renal insufficiency. ABDOMINAL CT: The liver and spleen are normal in size without focal defects. Gallbladder is partially contracted. Pancreas is normal in size but there is peripancreatic adenopathy and inflammation. There are multiple enlarged lymph nodes adjacent to the aorta in the upper retroperitoneum. More distally a dense conglomerate mass surrounds the aorta and IVC. Adenopathy extends into the pelvis along the iliac chains. There is infiltration of the mesenteric fat anteriorly adjacent to the stomach and transverse colon. Enlarged mesenteric nodes are present. The small and large bowel have a normal diameter. There is no free air in the peritoneal cavity. Renal contours are unremarkable. There is no hydronephrosis or perinephric collection. PELVIC CT: There is bilateral pelvic adenopathy. Inflammatory changes are present in the pelvic fat. There are a few enlarged inguinal nodes bilaterally. The bladder is contracted. Bladder is irregularly thickened possibly due to tumor infiltration. Review at bone window settings shows degenerative changes in the lumbar spine. There is disc space narrowing at L3-4 and L4-5. Destructive lesions are demonstrated. Lung bases are clear. IMPRESSION: Large retroperitoneal mass with mesenteric and pelvic adenopathy, accompanied by inflammatory changes. Wall of the urinary bladder is thickened possibly infiltrated by tumor. . [**4-21**] ECHO The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No 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. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal biventricular systolic function. Moderate estimated pulmonary artery systolic hypertension. . [**4-21**] Retroperitoneal biopsy SPECIMEN #1. RETROPERITONEAL BIOPSY 1 (A). DIAGNOSIS: FIBROADIPOSE TISSUE. SPECIMEN #2. LEFT RETROPERITONEAL BIOPSY 2 (B). DIAGNOSIS: INVOLVEMENT BY HIGH GRADE B CELL LYMPHOMA, SEE NOTE. SPECIMEN #3. LEFT RETROPERITONEAL TISSUE 3 (C-D). DIAGNOSIS: INVOLVEMENT BY HIGH GRADE B CELL LYMPHOMA, SEE NOTE. SPECIMEN #4. ADDITIONAL LEFT RETROPERITONEAL TISSUE (E) DIAGNOSIS: INVOLVEMENT BY HIGH GRADE B CELL LYMPHOMA, SEE NOTE. SPECIMEN #5. ADDITIONAL LEFT RETROPERITONEAL TISSUE "5" (F): DIAGNOSIS: INVOLVEMENT BY HIGH GRADE B CELL LYMPHOMA Brief Hospital Course: 75 y/o F with no significant past medical history who presented with new of abdominal/pelvic retroperitoneal mass and tumor lysis syndrome, s/p intraop biopsies, with results consistent with aggressive B cell lymphoma. . # B cell lymphoblastic follicular lymphoma: She initially presented from an OSH with a new abdominal and pelvic retroperitoneal mass and with tumor lysis syndrome, with a uric acid of 22 and in acute renal failure. She was started on rasburicase and allopurinol with improvement of her tumor lysis labs. On [**4-21**], she underwent CT guided biopsy which yielded necrotic samples. For definitive diagnosis, on that same date, [**4-21**], she underwent an exploratory laparotomy with biopsy. Due to the vascular nature of the mass, her operative course was prolonged and she was kept intubated and transferred to the ICU following this procedure. She also had a cystoscopy in the operating room by the urology service for further characterization of the bladder thickening seen on CT. Immediately following her post-operative course, she spiked a temperature in the ICU and was started on vancomycin, cefepime and flagyl for presumed ventilator associated pneumonia (see below for further details). She received the above antibiotics through her nadir and completed a 14 day course total of the above antibiotics. Pathology revealed an aggressive B cell lymphoma and on [**4-22**] she was started on [**Hospital1 **] at 80% dose given recent surgery. She tolerated this well and subsequently received rituxan. Of note, on her first day of rituxan, she developed acute abdominal pain. STAT CT of the abdomen revealed no acute pathology. Her abdominal pain soon resolved and she tolerated the remainder of rituxan without event. She will return in [**11-23**] weeks for her second cycle of R-[**Hospital1 **]. . # Tumor lysis syndrome: She was admitted with tumor lysis syndrome, with uric acid 22 and in ARF with SCr at 2.2. She received rasburicase x 1 on [**4-21**] and was started on allopurinol and IVF with bicarb. During the first 3 days of her hospital course, TLS labs were checked q8 hours. Her tumor lysis labs began to trend down and her acute renal failure resolved on hospital day 3. LDH 291 and SCr 0.8 at discharge. . # Pneumonia: Given prolonged anesthesia on [**4-21**] during open biopsy as noted above, she was remained intubated on POD 1. She was weaned from the ventilator without event in the ICU. Given her fever, she was started on vancomyin, cefepime and flagyl for presumed VAT. She remained off of supplemental oxygen on the BMT service and was kept on the above antibiotics for a 14 day course through her nadir. She remained afebrile throughout the remainder of her hospital course. . # Hypotension: She had a systolic pressures of 90 during her immediate post-op course, and required neosynephrine. Her EBL was 600cc. She was given IVF and blood transfusions to maintain her hematocrit. Throughout her course on the BMT service she remained normotensive. . # ARF: SCr 2.2 upon discharged from OSH. Renal ultrosund was performed and ruled out hydronephrosis. SCr was back to baseline at 0.8 on discharge with resolution of TLS. . Medications on Admission: Alleve PRN 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. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*30 Tablet Sustained Release(s)* Refills:*0* 3. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 4. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*180 Capsule(s)* Refills:*0* 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Brimonidine 0.2 % Drops Sig: One (1) Ophthalmic 1 drop to right eye (). 7. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO MWF. Disp:*15 Tablet(s)* Refills:*0* 8. Nystatin 100,000 unit/mL Suspension Sig: 5cc PO four times a day. Disp:*30 1* Refills:*0* 9. Colace 100 mg Capsule Sig: One (1) Capsule PO BID prn. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Retroperitoneal mass B cell lymphoma Pneumonia, ventilator associated Back pain Tumor lysis syndrome Acute renal failure Discharge Condition: stable, O2 sat 98% RA, tolerating PO Discharge Instructions: You were admitted with a mass in your abdomen and tumor lysis syndrome (electrolyte and metabolic disturbances secondary to malignancy). You had this mass biopsied by the surgical team. The biopsy revealed that you had B-cell lymphoma. You were treated with chemotherapy called R-[**Hospital1 **]. In addition, you were treated with broad spectrum antibiotics for a pneumonia. Please take all your medications as prescribed and attend your appointments as listed below. Please call your doctor or return to the emergency room if you have fever, chills, shortness of breath, nausea, vomitting, diarrhea, painful urination, or other symptom that concerns you. Followup Instructions: You have the following appointment with Dr. [**First Name (STitle) **]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2130-5-10**] 1:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18554**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2130-5-10**] 1:00 You should also call Dr.[**Name (NI) 6218**] office (general surgery) for a follow up appointment. Her number is as below: ([**Telephone/Fax (1) 15665**]. Completed by:[**2130-5-14**]

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icd9cm

[ [ [] ] ]

[ "54.11", "96.71", "99.28", "57.32", "99.25", "54.23", "38.93", "40.11" ]

icd9pcs

[ [ [] ] ]

11575, 11630

7258, 10464

336, 382

11795, 11834

3878, 7235

12546, 13107

3144, 3191

10525, 11552

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283, 298

410, 2809

2831, 2885

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20,865

172,392

25406

Discharge summary

report

Admission Date: [**2115-2-21**] Discharge Date: [**2115-3-13**] Date of Birth: [**2057-7-20**] Sex: M Service: [**Last Name (un) **] CHIEF COMPLAINT: Alcoholic cirrhosis. He presents for preoperative liver transplant. HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old male with a history of alcoholic cirrhosis, status post TIPS, sent home from the [**Hospital1 18**] 2 days prior for possible liver transplant. The donor liver was not viable at that time. Last admission on [**2115-1-25**], for lethargy and nausea and low grade encephalopathy, for which he was treated aggressively with lactulose and Rifaximin. He improved. Since discharge from the hospital 2 days ago he has noted an increase in ascites and a slight increase in shortness of breath, and increased leg edema. His ideal weight is approximately 160. No nausea, vomiting, constipation. Appetite is good. No abdominal pain. No dysuria. Denies fever, chills, headache, dizziness, chest pain, phlegm, or indigestion. PAST MEDICAL HISTORY: Alcoholic cirrhosis, encephalopathy [**2114-8-9**], varices with banding, anemia secondary to end stage liver disease, left hydrothorax status post thoracentesis, radiology evidence of hepatocellular carcinoma, CAD, status post MI in [**2099**], hypertension, had a catheter angioplasty in [**2099**]. PAST SURGICAL HISTORY: A TIPS, umbilical hernia repair, bilateral inguinal hernia repair. PHYSICAL EXAMINATION: Temperature 96.6. Heart rate 85. Respiratory rate 20. Blood pressure 115/57. One hundred percent on room air. Weight was 81.4 kilograms. The patient is 5 feet, 7 inches. The patient was alert and oriented in no acute distress. Mildly anxious with his wife present. [**Name2 (NI) 4459**]: PERLA, EOMs intact with positive scleral icterus. Neck was supple. No JVD, 2+ carotids, no bruits, no lymphadenopathy. Lungs: Decreased left lower lobe, clear otherwise, non labored. Cor: S1 and S2 normal. No murmur, regurgitation or gallop. Abdomen: Positive ascites. Positive hepatosplenomegaly. Nontender, well healed umbilical scar. Extremities: Trace edema and mild jaundice. Dry. Onychomycosis of fingernails and toenails. Abdomen with faint erythematous rash. Vascular: There was 2+ femoral pulses and 2+ dorsalis pedis pulses. No bruits. Neurological: Alert and oriented x3. Cranial nerves II through XII intact. No asterixis. Strength 5/5 bilateral. Reflexes symmetric. The patient was preopped. ALLERGIES: No known drug allergies. MEDICATIONS: Medications upon admission: Lactulose 30 cc q.i.d., Mag citrate 60 cc q.i.d., Rifaximin 200 mg p.o. b.i.d., multivitamin 1 daily, Spironolactone 100 mg daily, Lasix 40 mg p.o. q a.m., Tylenol p.r.n., Ambien 5 mg p.o. p.r.n., and Clotrimazole 1 troche 5 times a day. BRIEF HOSPITAL COURSE: The patient was preopped. Transplant preoperative work up was complete. The patient was taken to the OR on [**2115-2-21**], for a DCD liver transplant with piggyback technique, portal vein to portal vein anastomosis, common duct choledochocholedochostomy, and proper hepatic artery to donor to the common hepatic artery recipient. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The co-surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Intraoperatively the patient received 6 liters of crystalloid, 6 units of FFP packed cells, and 1 unit of platelets. Please see operative report for further details. Postoperatively the patient was taken to the surgical intensive care unit in critical, but stable condition, intubated. He was maintained in the ICU for a total of 5 days, during which time he was extubated from the vent, and seemed to tolerate this without difficulty. A duplex ultrasound of the liver on postoperative day 1 demonstrated multiple predominantly echogenic lesions in the liver, most likely hemangiomas, likely hematoma adjacent to the left lobe of the transplanted liver, patency of the portal vein, its major tributaries, the major hepatic veins, the major hepatic artery and its major branches. LFTs increased from pre-transplant within the first 2 to 3 days, and then trended down. Of note a chest x-ray was done while in the ICU that demonstrated left pleural effusion with associated compressive atelectasis and linear atelectasis with scarring in the left mid lung zone. The cardiac, mediastinal, and hilar contours were unchanged. Postoperative day 1 a repeat chest x-ray demonstrated increased size of bilateral pleural effusion. He demonstrated coarse breath sounds at the bases, right greater than the left. His white blood cell count was stable at 4.2. ABG was acceptable with an O2 saturation of 98%. On postoperative day 2 it was noted that the patient's creatinine had increased to 2.5 from his baseline of 0.8. He received increased IV fluids for that. There was concern for ATN. He exhibited mild acidosis and an elevated potassium of 5.6. These were treated. A renal consult was obtained. Renal ultrasound was recommended and done. This demonstrated no evidence of renal calculi or hydronephrosis, solid renal mass, or renal calculus within either kidneys. There was no perirenal fluid collections identified. Prograf, of noted, was started on postoperative day 1 at 2 mg twice a day. With an increase in the creatinine the Prograf was held for 5 doses and resumed at 2 mg b.i.d. Creatinine increased to a high of 3.2. Fluconazole was decreased, as well as Ganciclovir. Dr. [**Last Name (STitle) 63515**] saw the patient. Concern was for FK toxicity. After further review it was felt that the etiology of the acute renal failure was unknown, and it was less likely to be due to FK toxicity. IV bicarbonate was administered for hyponatremia and acidosis. CO2 was 15 and creatinine was 3.2 and he was oliguric. He received IV albumin and fluid bolus. The albumin was noted to be 2.3. Of note the patient's weight had increased from a preoperative weight of 81.4 kilograms up to a high of 90.6. Urine output gradually increased to 1-1/2 liters. His creatinine started to trend down to 1.5. His Prograf was adjusted to 4 mg and then 5 mg p.o. b.i.d. His Prograf level increased to 14.5 and the Prograf was decreased to 4 mg p.o. b.i.d. and his level still continued to rise to 17.4. The creatinine had been trending down to 1.5 and this increased to 1.8. Again the Prograf was held and dose adjusted to 2 mg b.i.d. Gradually the creatinine trended down to baseline of 1.4 to 1.5. Urine output increased to approximately 1-1/2 liters. He was initiated on IV Lasix and his weight decreased from a high of 90.6 to 78.1. On hospital day 5, a bedside speech and swallow evaluation was requested for patient complaints of difficulty swallowing with coughing after thin liquids after extubation the previous day. Findings demonstrated that after each bite or sip he produced a cough upon voicing. He denied that any food or liquid was getting stuck in his throat. However, he said that the nectar thick liquids were easier to swallow than water. A video swallow was done. This demonstrated a moderate amount of oropharyngeal dysphagia. Mild amounts of aspiration were noted without recognition by the patient. Chin tuck reduced the amount of silent aspiration. The patient was made n.p.o. and he had successful placement of a post pyloric feeding tube. A nutrition consult was obtained and he was started on continuous post pyloric tube feed. On [**2115-2-26**], he had a chest x-ray after repositioning of the central venous line. A left pleural effusion was identified. The left hemithorax was entirely opacified, obscuring the margins of the previously demonstrated left pleural effusion. There was no appreciable rightward shift of the mediastinum. A small right pleural effusion was identified. A left hydrothorax was noted. Interventional pulmonary was consulted. He underwent a thoracentesis for a total of 1700 cc of fluid. He tolerated this without incident. O2 saturations ranged 98% on 35% face mask. He did complain of a non productive cough, and he appeared tachypneic at times with a heart rate in the range of 60 to 80's, normal sinus rhythm. Blood pressure ranged 110 to 120/60. Pleural fluid demonstrated no malignant cells. Pleural culture was sent and this demonstrated no organisms and no growth. A sputum culture was contaminated. A repeat pleuro path was done on [**3-3**] for complaints of shortness of breath, a chest x-ray that demonstrated a large effusion, 1300 cc were removed. A culture was sent and this demonstrated no growth. Repeat sputum culture was also sent. This demonstrated greater than 25 PMNs and less than 10 epithelial cells, 3+ gram positive cocci, and 3+ gram positive rods. No fungus was isolated. He remained on humidified face tent for his hoarse voice. O2 saturations were in the 98% range, respiratory rate 20. A repeat chest x- ray demonstrated no pneumothorax, but there remained a moderate amount of pleural fluid on the left, which was partially loculated apically and laterally. There was some decrease in pleural effusion following the thoracentesis. A repeat chest x-ray on [**3-4**] again demonstrated increased pleural effusion with large left pleural effusion. Interventional pulmonary recommended a Pleurx catheter placement, although they recognized that the patient had had a Pleurx catheter in the past that resulted in protein wasting and decreased nutritional status. After review of recommendations from IT, the transplant team in conjunction with hepatology decided against placing a Pleurx catheter. Of note, on [**2-26**] the pleural fluid was exudative. On [**3-3**] it was transudate. The suspicion was that this was consistent with hepato hydrothorax and that it would hopefully improve with time after a liver transplant stabilization of function. In summary, his nutritional status improved. He remained on post pyloric feeding tubes for inability to take in sufficient calories to meet caloric goals. He did have 2 further video swallows, one on [**3-5**] that demonstrated improved oral and pharyngeal swallowing ability compared to [**2115-2-26**], but continued aspiration with thin liquids due to impaired vocal cord closure was noted. Of note, the patient had received an ENT evaluation with notation of the right vocal cord paresis felt to be likely secondary to extubation. A repeat video swallow on [**3-12**] demonstrated significantly improved oral and pharyngeal swallowing ability with no evidence of aspiration. His diet was advanced to ground solids and nectar thick liquids. No thin liquids were allowed. Pills were to be crushed in applesauce with the patient swallowing twice with a chin tuck, followed by a sip of nectar thick liquid via chin tuck to clear any residual. Recommendations also included small bites with swallowing twice with a chin tuck, alternating between 1 bite and 1 sip of nectar thick liquid, as well as the patient remaining seated upright for 30 minutes after meals. A nutrition consult was initiated and then the dietician followed the patient throughout this hospital course, making recommendations. He was eventually able to cycle his tube feeds at full strength Nepro with a goal of 80 cc for 12 hours. He was also followed closely by hepatology during this hospital course, who made recommendations and agreed with the overall management by the transplant team. Physical therapy followed the patient throughout this hospital course for chest PT and overall strength conditioning to improve overall endurance and maximize function. Given persistent lower extremity edema, pitting edema of 2+ up to the knees despite IV Lasix to 120 mg t.i.d., Diamox was initiated at 250 mg p.o. daily, as well as Zaroxolyn 5 mg p.o. daily. Of note, the creatinine did increase to 1.8 on the last 2 days of the [**Hospital 228**] hospital stay. BUN ranged between 64 to 63. Potassium ranged 4.6 to 4.8. Other lab data demonstrated a white count in the range of 3.4 to 3 with a hematocrit of 24.9. He did receive 1 unit of packed red blood cells on hospital day 19. Repeat hematocrit was 28.1. Liver function tests decreased with his AST being 14, ALT 12, alkaline phosphatase 144, and total bilirubin of 0.7 with an albumin of 2.7. On hospital day 20 he underwent another duplex of his liver to evaluate the inferior vena cava, as well as the hepatic veins for evaluation of edema. Conclusion demonstrate patent hepatic portal veins and inferior vena cava. There was patent hepatic artery with good systolic upstroke. No peri transplant fluid collections were noted. Of note, the platelet count had decreased around postoperative day 4 to 55. He did receive 1 bag of platelets and a HIT antibody was sent off. This was subsequently found to be negative. In summary, the patient was discharged home on hospital postoperative day 20 in stable condition. He was ambulatory independently. Vital signs were stable. His weight had decreased to 78.1 kilograms. He was tolerating his tube feed and voiding independently. DISCHARGE MEDICATIONS: 1. Bactrim single strength 1 p.o. daily in the form of 10 ml of liquid Bactrim. 2. Cellcept 1 gram p.o. b.i.d. 3. Lansoprazole 30 mg solution delayed release daily. 4. Fluconazole 400 mg p.o. daily. 5. Prednisone 20 mg p.o. daily. 6. Valcyte 400 mg p.o. daily. 7. Zaroxolyn 5 mg p.o. daily. 8. Colace 100 mg p.o. b.i.d. 9. Prograf 4 mg p.o. b.i.d. 10. Lasix 80 mg p.o. t.i.d. 11. Percocet 5/325 mg tabs 1 to 2 tabs p.o. p.r.n. q.4-6h. 12. Insulin regular sliding scale q.i.d. p.r.n. 13. Nepro full strength at 80 cc and hour cycled over 12 hours. He was instructed to followup in the outpatient transplant clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2115-3-18**], at 10:40. DISCHARGE DIAGNOSES: 1. End stage liver disease secondary to alcoholic cirrhosis. 2. Vocal cord paresis, aspiration risk. 3. Glucose intolerance. 4. Recurrent left pleural effusion hydrothorax. 5. Renal insufficiency related to Prograf. DISCHARGE CONDITION: Stable. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Name8 (MD) 4664**] MEDQUIST36 D: [**2115-3-14**] 11:59:09 T: [**2115-3-14**] 13:17:59 Job#: [**Job Number 63516**]

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icd9cm

[ [ [] ] ]

[ "96.6", "50.59", "96.72", "00.93", "34.91" ]

icd9pcs

[ [ [] ] ]

2792, 13046

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172, 241

270, 1013

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1036, 1339

19,620

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49802

Discharge summary

report

Admission Date: [**2164-3-28**] Discharge Date: [**2164-4-3**] Date of Birth: [**2120-9-25**] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old female with type 1 diabetes mellitus, end-stage renal disease status post failed living related donor kidney transplant, now on hemodialysis. On [**2164-3-28**] the patient was found to have a clotted right upper extremity graft at hemodialysis. This happened following surgery for removal of an infected AVG remnant on [**2164-3-27**]. She went to interventional radiology for fistulogram and on the evening of [**2164-3-28**] had a TPA infusion to declot the graft. From interventional radiology the patient went to the CSRU but had continued oozing from the procedure site. After the TPA transfusion was stopped, light pressure was held with a pressure dressing applied. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 1. 2. End-stage renal disease on hemodialysis status post living related donor kidney transplant rejection. 3. Hypertension. 4. Osteoporosis. 5. Gastroparesis. 6. Right eye blindness. 7. Hyperlipidemia. ALLERGIES: Sulfa. MEDICATIONS: 1. Percocet. 2. Gabapentin 300 t.i.d. 3. Levothyroxine 50 once a day. 4. Simvastatin 20 once a day. 5. Nephrocaps 1 once a day. 6. Midodrine 2.5 to 10 p.r.n. 7. Aspirin 81 q.o.d. 8. Calcium acetate 3 t.i.d. 9. Aluminum 30 t.i.d. 10. Insulin Lantus 12 units q.d. and Humalog sliding scale. PHYSICAL EXAMINATION: The patient was afebrile at 97.4, pulse 79, blood pressure 107/53, respiratory rate 12, 100% on three liters nasal cannula. She was sleepy, comfortable and arousable, regular rate and rhythm without murmurs. Clear to auscultation bilaterally. Her abdomen was soft, nontender, nondistended with positive bowel sounds. Right upper extremity had an erythematous and tender area. She had a positive bruit and no thrill. LABORATORY DATA: On admission to medicine her white count was 8.1, hematocrit 35.1, platelet count 368, 134/5.8, 91/21, 75/12.8 and 157. PT was 13.1, INR 1.1, PTT 27.2, calcium 7.9, magnesium 2.7, phosphorous 11.0, vancomycin level was greater than 15. HOSPITAL COURSE: This is a 43-year-old female who came in for right upper extremity arteriovenous graft thrombectomy. 1. Arteriovenous graft: The patient had a partial thrombectomy in interventional radiology after which time the patient was admitted to the surgical intensive care unit overnight for TPA infusion. This was unsucessful, and she went to the OR the next day for replacement of the clotted graft segment. The patient's dialysis was complicated the following day because it was very difficult to get access the graft. 2. Right upper extremity pain: The patient was given both Percocet and IV morphine but they were weaned off as the pain decreased status post surgery. 3. Renal: The patient had end-stage renal disease on dialysis. The patient missed Wednesday's dialysis and therefore needed extra dialysis on [**2164-4-3**]. The patient's electrolytes improved dramatically. The patient was continued on home medications. 4. Diabetes mellitus: The patient was given Lantus 12 units as per home schedule and Humalog sliding scale with q.i.d. fingersticks and a diabetic diet. 5. Hypothyroidism: The patient was continued on levothyroxine 15 mcg. 6. Disposition: The patient was discharged home with [**Hospital6 407**] for dressing changes and is to follow up with both her primary care physician and transplant surgery. 7. Infectious disease: The right antecubital graft that was infected with MRSA. The patient's vancomycin level was followed. The patient was given a dose of vancomycin on [**2164-4-3**] prior to discharge. DISCHARGE DIAGNOSIS: AVG graft thrombosis and surgical repair. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Insulin sliding scale. 2. Levothyroxine 15 mcg q.d. 3. Simvastatin 20 mg q.d. 4. Nephrocaps 1 q.d. 5. Midodrine 2.5 to 10 mg q.d. p.r.n. 6. Aspirin 81 mg q.d. 7. Lantus 12 units subcutaneous q.h.s. 8. Sevelamer 1,600 mg t.i.d. with meals. 9. Calcium acetate four tablets t.i.d. with meals. 10. Reglan 5 mg q.i.d. p.r.n. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Dictated By:[**Name8 (MD) 23023**] MEDQUIST36 D: [**2164-4-3**] 12:59 T: [**2164-4-3**] 14:09 JOB#: [**Job Number 104082**]

[ "250.01", "536.3", "996.81", "E879.1", "244.9", "E878.0", "403.91", "996.73", "733.00" ]

icd9cm

[ [ [] ] ]

[ "39.50", "99.10", "39.95", "39.42", "88.67" ]

icd9pcs

[ [ [] ] ]

3851, 4396

3751, 3794

2184, 3729

1488, 2166

169, 877

900, 1465

3819, 3828

28,072

146,844

7435

Discharge summary

report

Admission Date: [**2192-4-9**] Discharge Date: [**2192-4-15**] Date of Birth: [**2120-4-12**] Sex: F Service: MEDICINE Allergies: Meperidine / Codeine / Lasix / Hydrochlorothiazide Attending:[**First Name3 (LF) 330**] Chief Complaint: Hypotension, AMS, Inc WBC from NH Major Surgical or Invasive Procedure: Central venous line insertion Ventilation History of Present Illness: 71 yo F with obesity hypoventilation syndrome, OSA, restrictive lung disease s/p Trach, hypotensive 70s at rehab facility, AMS, hypoxic 87%, FS 157, received bolus 250cc, transferred to [**Hospital1 18**] for further evaluation. Of note, pt with long complicated hosp course at [**Hospital **] Hosp, discharged to rehab on [**2192-4-6**]. . ED COURSE: Initial VS T 103.0 HR 93 BP 90/40 RR 24 94%TC, received 1LNS, Vancomycin 1gm x1, Ceftriaxone 1gm x1, levofloxacin 750mg IV x1. Head CT negative, admit to MICU for hypotension, AMS. Past Medical History: - Stage IV sacrum ulcer 6x5x3cm w/wound vac - Restrictive lung disease, hypercarbic resp failure, O2 Dependent - s/p Trach [**6-/2191**] - Morbid obesity - CHF - Ischemic CM - CAD, angina-type chest pain - PAF anticoagulated, s/p PM - ESRD on HD, tunnelled HD R chest, HD T, TH, SAT - DM II, diabetic nephropathy/retinopathy/neuropathy - Hypercholesterolemia - Hypertension - Migraines - Osteoarthritis - Peripheral vascular disease, LE venous stasis ulcers - POCS - Anemia of CKD 12,000 per HD - Hypothyroidism - Status post total abdominal hysterectomy for endometriosis. - Status post multiple hernia surgeries - Recurrent Klebsiella UTI, E Coli UTIs - Strep B bacteremia [**6-/2185**] - pannus cellulitis Social History: -previous smoker, bed bound, used to live w/sister until [**6-/2191**], [**Name2 (NI) **]y living in different hospitals/rehab facilities. Family History: NC Physical Exam: VS: 98.2 BP 73/46 HR 94 RR 17 100% AC 500X16 FiO2 0.4 PEEP 5 GEN: opens eyes, follows commands HEENT: Trach in place, NGT in place RESP: diminished BS b/l CV: Irreg Nml S1, S2, no murmurs appreciated ABD: soft, morbidly obese, pannus, +BS EXT: UE edema/increased adipose tissue with emaciated LE/wasted/cachectic COCCYX: Large gaping wound, foul smelling deep penetrates to bone, ~6x6cm NEURO: intermittently follows commands Pertinent Results: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2192-4-14**] 12:30AM 18.4* 2.72* 7.9* 25.2* 93 29.2 31.4 20.0* 471* [**2192-4-13**] 05:55AM 20.2* 2.65* 7.8* 24.9* 94 29.4 31.3 19.0* 491* [**2192-4-12**] 05:45PM 20.2* 2.68* 7.8* 24.5* 92 29.0 31.7 19.3* 497* [**2192-4-12**] 11:15AM 19.5* 2.44* 7.2* 22.7* 93 29.4 31.6 19.1* 510* [**2192-4-12**] 02:37AM 21.5* 2.13* 6.2* 20.0* 94 29.3 31.2 19.5* 579* [**2192-4-11**] 03:13AM 26.0* 2.42* 7.1* 23.2* 96 29.1 30.5* 19.5* 625* [**2192-4-10**] 10:26AM 27.3* 2.50* 7.3* 23.8* 95 29.1 30.5* 19.9* 654* [**2192-4-10**] 04:11AM 25.0* 2.64* 7.6* 25.3* 96 28.6 30.0* 18.2* 605* [**2192-4-9**] 09:16PM 17.4* 2.42* 6.9* 23.5* 97 28.6 29.4* 18.2* 423 . Glucose UreaN Creat Na K Cl HCO3 AnGap [**2192-4-15**] 04:37AM 92 86* 2.0* 143 4.3 110* 21* 16 [**2192-4-12**] 11:39AM 157 67* 5.0* 130* 4.6 97 19* 19 . CRP [**2192-4-10**] 10:26AM 202.9 . ESR [**2192-4-10**] 04:11AM 146 . Lactate [**2192-4-9**] 10:01PM 3.6 . calTIBC Ferritn TRF [**2192-4-9**] 09:16PM 104* 1011* 80* . TSH [**2192-4-9**] 09:16PM 1.1 . COAGS: PT PTT INR(PT) [**2192-4-14**] 12:30AM 14.4* 26.4 1.2 [**2192-4-10**] 04:11AM 61.5* 63.2* 7.3 . Studies: Head CT [**4-9**]: 1. No acute intracranial hemorrhage or major vascular territorial infarction. Please note that if ischemia is of significant clinical concern evaluation with MR [**First Name (Titles) 151**] [**Last Name (Titles) 4639**]n-weighted imaging is suggested as this is a more sensitive means of evaluation. 2. Aerosolized secretions and mucosal thickening of the sphenoid sinus could indicate acute sinusitis in the appropriate context. Opacification of a few right-sided mastoid air cells. . CXR [**4-9**]: 1. Lines and tubes appear well positioned as described above. 2. Left lower lobe and mid lung opacities likely representing effusion and atelectasis; however, underlying infectious process cannot be entirely excluded. . CXR [**4-14**]: IMPRESSION: Persistent complete opacification of the left hemithorax consistent with a combination of left lung collapse and known left pleural effusion. . MICRO: [**2192-4-11**] 10:52 pm CATHETER TIP-IV Source: PICC line. **FINAL REPORT [**2192-4-15**]** WOUND CULTURE (Final [**2192-4-15**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ 1 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ 2 S . [**2192-4-9**] 11:07 pm BLOOD CULTURE #2. **FINAL REPORT [**2192-4-15**]** Blood Culture, Routine (Final [**2192-4-15**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CEFUROXIME------------ 32 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [**2192-4-10**]): GRAM NEGATIVE ROD(S). . [**2192-4-9**] 9:16 pm BLOOD CULTURE **FINAL REPORT [**2192-4-14**]** Blood Culture, Routine (Final [**2192-4-14**]): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 248-5859P [**2192-4-9**]. CLOSTRIDIUM SPECIES NOT C. PERFRINGENS OR C. SEPTICUM. Anaerobic Bottle Gram Stain (Final [**2192-4-10**]): GRAM NEGATIVE ROD(S). GRAM POSITIVE ROD(S). REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] CC7D 12:25PM [**2192-4-10**]. Aerobic Bottle Gram Stain (Final [**2192-4-10**]): GRAM NEGATIVE ROD(S). Brief Hospital Course: AP: 71 yo F with obesity hypoventilation syndrome, restrictive lung disease, s/p trach, vent dependent now with L sided opacity, AMS, hypotension. . #. Hypotension: Septic shock, increaseing WBC, fever, elevated lactate, AMS, source c/w PNA, large 9cmx6cmx5cm foul smelling sacral decub stage IV c/w osteo, in addition to GNR bacteremia. Pt's PICC line was also removed, micro data c/w coag neg staph, oxacillin resistant bacteremia in addition to GNR bacteremia. Pt was broadly covered with [**Last Name (un) 2830**]/vanc. Pt was initially placed on pressors-neo, which were never weaned, IVF hydration and broad spectrum Abx. Plastics was consulted to debride osteo given excessive smell, large necrotic decub ulcer. Given pt's persistent pressor requirement and poor prognosis, family mtg was held to address goals of care. Family requested to view large sacral decub ulcer. Family subsequently decided on no further aggressive measures, no further debridement. On [**4-14**] pt made [**Month/Day (1) 3225**], morphine gtt was started. Pt remained comfortable. SW involved to provide family support. Pressors and vent were withdrawn [**4-14**] at midnight. Pt expired [**4-15**] 10:18pm. . #. Respiratory Failure: Multifactorial in setting of PNA, effusion vs. underlying restrictive lung disease, OSA, obesity hypoventilation syndrome, sputum c/w PNA. Covered with broad spectrum abx-[**Last Name (un) 2830**], vanc. Pt's vent was withdrawn [**4-15**] am due to [**Month/Day (4) 3225**] status as noted above. . #. AMS: Most likely in setting of PNA, large sacral decub stage IV, c/w osteo, her sedating meds were held. Her sepsis was treated as above until family decided to make pt [**Name (NI) 3225**] and withdraw care. . #. Sacral decub stage IV: ESR, CRP elevated c/w osteo, foul smelling, wound care nurse came to evaluate-very concerned given necrosis, foul smell 9x6x5 in dimension, much enlarged compared to prior admit at [**Hospital1 2025**] last month. [**Hospital1 3225**] as above. . #. ESRD on HD: Renal involved was unable to undergo HD due to hypotension, septic shock. Started CVVH. stopped CVVH due to [**Hospital1 3225**]. . #. PAF: Anticoagulated, supratherapeutic upon presentation. held coumadin on presentation. Started hep gtt on [**4-13**], however stopped within a couple of hours due to clots coming out of Trach/ETT. Was unable to give BB due to hypotension/septic shock as above. . #. CODE: DNR/DNI-[**Month/Day (4) 3225**], supportive care, SW involved. Morphine gtt, titrated to comfort. Pt expired [**2192-4-15**] 10:18pm. . #. COMMUNICATION: Sister-[**Name (NI) 4489**] [**Name (NI) 26010**] [**Telephone/Fax (1) 27265**] W, [**Telephone/Fax (1) 27266**] H; Nephew [**Name (NI) 122**] [**Name (NI) 26010**] very involved in care. Medications on Admission: MEDS from Rehab [**4-6**]: -NPH 10U AM, 26U PM -Vitamin D 50,000U qweek -Epogen 12,000 T,TH,Sat at HD -FENTANYL PATCH 25MCG q 72hr -Zemplar 1mcg on HD days - Miralax 17gm daily - peridex rinse [**Hospital1 **] -zinc sulfate 220mg daily -zocor 40mg daily -celexa 30mg [**Hospital1 **] -Senakot -Norvasc 10mg daily -Nephrocaps 1 tablet daily -Aspirin 325mg daily -Isordil 40mg [**Hospital1 **] -Syntrhoid 75mcg daily - ritalin 10mg daily am, 5mg pm -Lopressor 25mg Q6HR -Coumadin 1.5mg HS -RENAGEL 1,600 Q6HR -Seroquel 25mg HS -ZENADERM TOP -Tyelenol 650mg Q6HR prn -seroquel 25mg Q12hr -nepro 45ml 6pm-7am Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: NA Followup Instructions: NA Completed by:[**2192-4-15**]

[ "585.6", "403.91", "428.0", "427.31", "357.2", "V45.01", "362.01", "995.92", "250.60", "707.03", "250.50", "486", "250.40", "244.9", "414.8", "038.42", "785.52", "518.84", "285.21", "730.28", "278.01", "327.23", "V44.0" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93", "96.72", "96.6" ]

icd9pcs

[ [ [] ] ]

11105, 11114

7651, 10422

343, 386

11166, 11176

2344, 7628

11227, 11260

1854, 1858

11078, 11082

11135, 11145

10448, 11055

11200, 11204

1873, 2301

270, 305

414, 949

971, 1682

1698, 1838

83,288

113,415

35401

Discharge summary

report

Admission Date: [**2116-4-17**] Discharge Date: [**2116-4-19**] Date of Birth: [**2062-10-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7333**] Chief Complaint: PVI Major Surgical or Invasive Procedure: Pulmonary Vein Isolation Pericardial drain placement History of Present Illness: Mr. [**Known lastname **] is a 53 yo otherwise healthy man with lone atrial fibrillation who presented for elective pulmonary vein isolation. Following isolation of the first pulmonary vein, the pt became hypotensive and tachycardic. Echocardiography demonstrated evidence of a moderate pericardial effusion and evidence of earely tamponade physiology (RV diastolic collapse), and the pt underwent urgent pericardiocentesis with drainage of approximately 400 cc of blood. As he was anticoagulated with warfarin and heparin, he received protamine, Vitamin K and FFP. He was transiently on neosynephrine. A pericardial drain remains and continues to drain about 10 cc/hr. He was also DC cardioverted into junctional rhythm. Repeat echocardiogram demonstrated no pericardial effusion. . In the CCU, pt is hemodynamically stable, awake, and comfortable. He denies dizziness, lightheadedness, chest pain, palpitations or shortness of breath. He also denies nausea, abdominal pain, extremity pain, numbness or weakness Past Medical History: Atrial fibrillation - Diagnosed [**2116-11-15**], after a road bike competition in which he had become uncharacteristically short of breath. Pt was placed on warfarin and elected to attempt this definitive procedure given his active lifestyle and the associated risk of bleeding on anticoagulation therapy. He has previously defered antiarrhythmic medications due to concerns over long term side effects. . CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, - Hypertension . Social History: Denies tobacco, EtOH or illicit drug use. Pt is an avid and competitive runner and biker (55 marathons, 3 triathalons) Family History: No family history of early MI, otherwise non-contributory Physical Exam: VS: HR 81 BP 99/62 RR 25 SpO2 100 GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were light pink, pallor of the oral mucosa is present. No xanthalesma. NECK: Supple with JVP of [**6-21**] cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Regular rate, S3 and S4 present. No m/r/g. No thrills, lifts. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Lab results: [**2116-4-17**] 06:45AM BLOOD WBC-3.4* RBC-4.63 Hgb-14.0 Hct-39.9* MCV-86 MCH-30.2 MCHC-35.0 RDW-13.6 Plt Ct-205 [**2116-4-18**] 06:33AM BLOOD WBC-5.9# RBC-3.54* Hgb-11.0* Hct-31.0* MCV-88 MCH-31.0 MCHC-35.5* RDW-13.9 Plt Ct-156 [**2116-4-19**] 02:53AM BLOOD WBC-5.5 RBC-3.51* Hgb-11.0* Hct-30.0* MCV-85 MCH-31.3 MCHC-36.7* RDW-13.8 Plt Ct-168 [**2116-4-17**] 06:45AM BLOOD Neuts-54.2 Lymphs-33.9 Monos-6.8 Eos-4.3* Baso-0.9 [**2116-4-17**] 06:45AM BLOOD PT-23.0* INR(PT)-2.2* [**2116-4-17**] 07:40PM BLOOD PT-19.9* PTT-28.3 INR(PT)-1.9* [**2116-4-18**] 06:33AM BLOOD PT-20.5* PTT-29.1 INR(PT)-1.9* [**2116-4-19**] 02:53AM BLOOD PT-16.9* PTT-26.9 INR(PT)-1.5* [**2116-4-17**] 06:45AM BLOOD Glucose-80 UreaN-16 Creat-1.0 Na-142 K-4.2 Cl-106 HCO3-28 AnGap-12 [**2116-4-18**] 06:33AM BLOOD Glucose-105 UreaN-13 Creat-0.9 Na-139 K-3.9 Cl-104 HCO3-29 AnGap-10 [**2116-4-19**] 02:53AM BLOOD Glucose-102 UreaN-13 Creat-0.9 Na-135 K-3.9 Cl-102 HCO3-27 AnGap-10 [**2116-4-18**] 06:33AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.0 [**2116-4-19**] 02:53AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.9 . TTE: [**2116-4-18**] The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2116-4-17**], no change. Brief Hospital Course: # Cardiac tamponade: [**2-17**] perforation of either pulmonary vein or right atrium. Patient remained stable in the ICU and pericardial drain output diminshed significantly. The tube was pulled the next day. Anticoagulation had been reversed during procedure but was restarted on discharge. Transient pressor requirement was weaned and patient remained hemodynamically stable on the floor. He was sent home with indomethacin for 5 days and coumadin and will follow up with his cardiologist regarding his atrial fibrillation. # Anemia: Baseline HCT of 39 now down to 29, likely secondary to acute blood loss. Hcts remained stable. He did not require a transfusion. # Atrial fibrillation: Not in sinus rhythm. Had only one PVI, and was in NSR s/p DC cardioversion upon arrival to the CCU. Initially all anticoagulants were held overnight given concern for bleeding and then restarted upon discharge. Pt continues to defer antiarrythmic medications, will readdress this issue if he reverts to atrial fibrillation while in the hospital. He will follow up with his outpatient cardiologist to address his options for treatment of AF. Medications on Admission: Warfarin (since [**2116-11-15**]) Magnesium MVI Discharge Medications: 1. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 5 days. Disp:*15 Capsule(s)* Refills:*0* 2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 3. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Atrial fibrillation Cardiac tamponade, secondary to pericardial bleed during pulmonary vein isolation Discharge Condition: The patient is hemodynamically stable, with no evidence of cardiac tamponade on exam. Discharge Instructions: You were admitted to [**Hospital1 18**] for an elective procedure of pulmonary vein isolation for attempted ablation of your atrial fibrillation. You had a complication during the procedure which caused a small bleed into the pericardial space, the space around your heart. You had a drain placed to remove the fluid around your heart. Your symptoms improved, and it appears that the bleed has stopped. You should follow up with your cardiologist regarding this procedure and your atrial fibrillation. . You should restart coumadin 5mg to be taken every day. Please follow up in the coumadin clinic in 5 days for an INR check. . You will be given a prescription for a medication, Indomethacin, to help the pain from the procedure, to be taken for 5 days. . If you experience worsening chest pain, shortness of breath, lightheadedness, loss of consciousness, dizziness, fever, chills or any other worrisome symptoms please seek medical attention. Followup Instructions: Please follow up with your primary cardiologist regarding further therapy and possible repeat procedure. . Please follow up with the coumadin clinic in 5 days for an INR check. . Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 35663**], in the next 2-3 weeks to discuss your recent hospitalization. The phone number to the office is [**Telephone/Fax (1) 80692**] Completed by:[**2116-4-19**]

[ "427.31", "998.11", "998.2", "V58.61", "285.1", "423.3", "E870.6" ]

icd9cm

[ [ [] ] ]

[ "99.62", "37.27", "37.34", "37.0" ]

icd9pcs

[ [ [] ] ]

6472, 6478

4928, 6064

320, 375

6643, 6731

2933, 4905

7730, 8227

2069, 2128

6163, 6449

6499, 6622

6090, 6140

6755, 7707

2143, 2914

277, 282

403, 1418

1440, 1917

1933, 2053

76,803

189,589

38101

Discharge summary

report

Admission Date: [**2163-8-5**] Discharge Date: [**2163-8-10**] Date of Birth: [**2093-7-14**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: [**2163-8-6**]: ORIF of the right interochanteric fracture. History of Present Illness: Pt is a 70 yo F, transferred from OSH- [**Hospital3 **] s/p ped struck by vehicle. Per EMS report, pt was struck by a car traveling at 10mph. Per report pt did not experience LOC, though +head strike occurred at scene. At OSH abrasions to R elbow were remarkable as well as scans showing fx to R hip and "fluid around the heart." Pt arrives to [**Hospital1 18**] ED, [**Apartment Address(1) **], fully alert and Ox3, cooperative with medical exam and staff. Pt states her name to be "[**Known firstname **] [**Known lastname 15568**]", lives alone in [**Location (un) 3307**], MA and has PMH of hypertension, high cholesterol and depression; currently on MH medications Zoloft, Wellbutrin and Elavil. During exam pt c/o pain to R sided hip and lower back pain. Past Medical History: hypertension, high cholesterol and depression Family History: Noncontributory Physical Exam: Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Normal Extr/Back: right hip pain with shortening present Skin: Normal Neuro: cn 2-12 intact, cerebellar function intact Pertinent Results: [**2163-8-5**] 03:50AM GLUCOSE-126* UREA N-10 CREAT-0.4 SODIUM-138 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-24 ANION GAP-13 [**2163-8-5**] 03:50AM CALCIUM-8.4 PHOSPHATE-3.9 MAGNESIUM-1.8 [**2163-8-5**] 03:50AM WBC-13.0* RBC-4.02* HGB-12.5 HCT-37.0 MCV-92 MCH-31.0 MCHC-33.7 RDW-13.3 [**2163-8-5**] 03:50AM PLT COUNT-269 [**2163-8-4**] 06:40PM PLT COUNT-334 [**2163-8-4**] 06:40PM PT-13.5* PTT-33.7 INR(PT)-1.2* [**2163-8-4**] CT torso Pericardial fluid [**2163-8-4**] Xray Hip Right intertronchanteric fracture of femur [**2163-8-4**] TTE mod to lg pericardial eff, no hemodynamic problems. EF 55% CT Chest/Abd/Pelvis IMPRESSION: 1. Large pericardial effusion, likely simple. 2. No acute vascular or pulmonary injury detected in the chest. No pneumothorax. 3. No acute traumatic injury detected in the abdomen and pelvis. 4. Comminuted intertrochanteric right femur fracture with mild overlap of the fracture fragments, without significant displacement. 5. Multiple compression fractures of the thoracolumbar spine without evidence of retropulsion into the spinal canal. These fractures suggest likely a chronic nature. 6. Diffuse atherosclerotic disease of the abdominal aorta with focal ectasia of the infrarenal aorta. Brief Hospital Course: She was admitted to the surgery service. Geriatric medicine was consulted for the pericardial effusion and for clearance for going to the OR. She underwent an ECHO to assess pericardial fluid noted upon initial trauma assessment; the report showed moderate to large (1.4-2cm) circumferential pericardial effusion without evidence of hemodynamic compromise. Her EF was normal. No further intervention warranted. Orthopedics was consulted and she was taken to the operating room for repair of her right intertrochanteric fracture. There were no intraoperative complications. Postoperatively she has made slow progress and has worked with Physical therapy who are recommending rehab after her acute hospital stay. She is on a regular diet and her pain is adequately controlled with oral narcotics prn. Medications on Admission: elavil, zoloft, wellbutrin, ?others Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 3. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. 11. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 13. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 14. Dulcolax 10 mg Suppository Sig: One (1) supp Rectal once a day as needed for constipation. 15. Heparin (Porcine) 5,000 unit/mL Cartridge Sig: One (1) ML Injection three times a day. Discharge Disposition: Extended Care Facility: Bear [**Doctor Last Name **] Nursing Center - [**Location (un) 2199**] Discharge Diagnosis: s/p Pedestrian struck by auto 1. Right interochanteric fracture. 2. Chronic pericardial effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Right lower extremity: Full weight bearing 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. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *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. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please call [**Telephone/Fax (1) 23012**] to arrange a follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] after discharge from rehab. Please call [**Telephone/Fax (1) 1228**] to arrage a follow up appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP orthopedic trauma to be seen in 2 weeks. Completed by:[**2163-8-17**]

[ "291.0", "272.0", "311", "820.21", "305.1", "E814.7", "599.0", "401.9", "423.8", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "79.35" ]

icd9pcs

[ [ [] ] ]

5080, 5177

2827, 3630

328, 390

5317, 5317

1562, 2804

6380, 6768

1270, 1287

3716, 5057

5198, 5296

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5536, 5853

5868, 6357

1302, 1543

274, 290

418, 1185

5332, 5512

1207, 1254

56,224

188,791

18173

Discharge summary

report

Admission Date: [**2165-1-3**] Discharge Date: [**2165-1-29**] Date of Birth: [**2134-2-10**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 759**] Chief Complaint: bilateral femur fractures Major [**First Name3 (LF) 2947**] or Invasive Procedure: [**2165-1-3**]: S/P ORIF Bilateral Proximal Femur Fractures [**2165-1-9**]: PICC placed, L arm, catheter switched to double lumen power PICC on [**1-25**] [**2165-1-15**]: EGD (upper endoscopy) [**2165-1-25**]: percutaneous cholecystostomy tube History of Present Illness: 30M with hx of [**Doctor Last Name **] muscular dystrophy who is wheelchair dependent at home fell after transfer and was down for several hours. EMS was activated and he was found to have bilateral femoral fractures, and initially admitted to the orthopaedics service at this hospital. Pt has significant LE contractures and weakness 2/2 muscular dystropy as well as diffuse osteopenia. He has a significant hospital course that can be found below in this document. Past Medical History: [**Doctor Last Name **] muscular dystrophy Bipolar disorder Chronic opioid use with chronic pain Seizure d/o (last seizure 5 years ago) Osteoporosis Social History: reports smoking 1ppd for the past 6 years. denies EtOH. Lives with a roommate in independent living. Family History: non-contributory Physical Exam: Gen: In pain. Oriented x3. SKIN: B lateral hip incisions w staples clean/dry/intact, back not assessed due to pt's lack of mobility HEENT: NC/AT. Sclera anicteric. EOMI. dry MM, OP clear, no exudates or ulceration. Neck: Supple, JVP not elevated. CV: regular rate & rhythm, no mrg Chest: CTA B Abd: Obese, Soft, NTND. No HSM or tenderness. Ext: Edematous and cool in all extremities, [**1-11**]+ strength throughout. No calf tenderness. On discharge: Afebrile, All vital signs stable General: Alert and oriented, No acute distress Resp: Reg even rate no audible wheeze Cardiac: rrr, no rubs, murmurs, gallops Extremities: right/left lower/upper Incision: intact, no swelling/erythema/drainage Dressing: clean/dry/intact Sensation intact to light touch, Neurovascular intact distally, Capillary refill brisk, 2+ pulses, Weight bearing: full/partial/non weight bearing Pertinent Results: IMAGING: [**2165-1-3**] CT lower extremity: IMPRESSION: Bilateral femur fractures. Diffuse pelvis and thigh muscle atrophy. [**2165-1-25**]: Gallbladder U/S: Acute cholecystitis with no definite vascularity identified within the material in the gallbladder lumen. [**2165-1-24**] MRCP 1. No evidence of enhancement in the large area of abnormal signal intensity within the lumen of the gallbladder. This therefore most likely represents an area of sludge or debris. Small gallstones within this cannot be excluded. However, given the suggestion of vascular flow on ultrasound within this tumefactive gallbladder mass, recommend targeted followup assessment by ultrasound prior to any potential intervention to help reconcile the discrepency between ultrasound and MRI findings. 2. Thickening of the gallbladder wall and heterogeneous enhancement are compatible with cholecystitis. 3. No biliary dilatation. 4. Bibasal pleural effusions and basal collapse/consolidation. 5. Diffuse muscle atrophy compatible with background history of muscular dystrophy. [**2165-1-21**] CT Folded gallbladder with marked edema on its wall, this is compatible with acute cholecystitis. Small free abdominal fluid. Bilateral lower lobe atelectasis and small bilateral effusions. [**2165-1-18**]: Duplex Ultrasound: No LE DVT [**2165-1-7**] ECHO The left atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is mild global left ventricular hypokinesis (LVEF = 45-50 %). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild global LV hypokinesis. No significant valvular abnormality seen. [**2165-1-3**] Head CT: No intracranial hemorrhage or skull fracture. [**2165-1-3**] LE CT: Bilateral femur fractures. Diffuse pelvis and thigh muscle atrophy. [**2165-1-2**] 10:49PM WBC-15.3*# RBC-4.47* Hgb-12.5* Hct-37.3* Plt Ct-281 [**2165-1-3**] 09:29PM WBC-25.1*# RBC-4.02* Hgb-11.8* Hct-34.8* Plt Ct-353 [**2165-1-24**] 06:08AM WBC-6.3 RBC-3.29* Hgb-10.3* Hct-29.7* Plt Ct-311 [**2165-1-25**] 06:11AM WBC-8.0 RBC-3.41* Hgb-10.6* Hct-30.6* Plt Ct-335 [**2165-1-25**] 12:28PM PT-16.5* PTT-35.2* INR(PT)-1.5* [**2165-1-23**] 05:47AM ESR-20* [**2165-1-21**] 09:48AM Ret Aut-1.6 [**2165-1-2**] 10:49PM Glucose-96 UreaN-7 Creat-0.1* Na-138 K-3.9 Cl-98 HCO3-31 [**2165-1-4**] 09:15AM Glucose-111* UreaN-5* Creat-0.1* Na-136 K-4.4 Cl-99 HCO3- [**2165-1-6**] 01:34PM Glucose-131* UreaN-5* Creat-0.1* Na-136 K-3.5 Cl-97 HCO3- [**2165-1-25**] 06:11AM Glucose-70 UreaN-6 Creat-0.3* Na-142 K-3.9 Cl-98 HCO3-34* [**2165-1-6**] 01:34PM ALT-18 AST-17 LD(LDH)-220 AlkPhos-72 TotBili-0.8 [**2165-1-18**] 06:42AM ALT-62* AST-58* LD(LDH)-344* AlkPhos-179* TotBili-0.6 [**2165-1-24**] 06:08AM ALT-16 AST-15 AlkPhos-167* TotBili-0.4 [**2165-1-12**] 08:54AM CK-MB-NotDone cTropnT-0.01 [**2165-1-12**] 06:31PM CK-MB-NotDone cTropnT-0.02* [**2165-1-13**] 10:54AM CK-MB-4 cTropnT-0.02* [**2165-1-4**] 09:15AM Calcium-8.3* Phos-2.3* Mg-1.6 [**2165-1-6**] 01:34PM Calcium-7.9* Phos-2.7 Mg-1.6 [**2165-1-25**] 06:11AM Calcium-8.6 Phos-3.2 Mg-1.9 [**2165-1-23**] 05:47AM CRP-69.7* [**2165-1-18**] 06:42AM Ferritn-507* DISCHARGE LABS; COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2165-1-29**] 06:44AM 8.8 3.71* 11.2* 33.3* 90 30.3 33.7 15.3 359 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2165-1-29**] 06:44AM 146* 24* 0.2* 140 4.5 104 29 12 Brief Hospital Course: In brief, Mr. [**Known lastname 50249**] is a 30 y/oM with [**Doctor Last Name **] Muscular Dystrophy who was admitted to the orthopaedics service with bilateral femoral fractures, whose course was complicated by aspiration pneumonia requiring intensive care unit but no intubation, course complicated by stress ulcers and significant upper GI tract bleed requiring intensive care, endoscopy-directed therapy, and significant blood transfusion, and also hospital course complicated by low grade fever and found to have acute cholecystitis requiring percutaneous cholecystostomy tube placement. He has had poor PO intake and was started on TPN. Over the hospitalization he has had progressive anasarca that is now significantly improving with IV furosemide. He has chronic pain issues, and is being managed with his home regimen of MS contin and PRN hydromorphone as well as adjuvant medications. At time of discharge, he is afebrile, but has not been getting out of bed. His PO intake remains marginal. His issues are discussed in more detail below: HIP FRACTURE: Mr. [**Known lastname 50249**] is a 30 y/oM with [**Doctor Last Name **] muscular dystrophy (BMD) who was initially admitted to [**Hospital1 18**] ortho with bilat subtrochanteric femur fractures after fall at home. On [**2165-1-3**], he had bilateral intramedullary rod fixation. He tolerated the surgery and was placed on Lovenox for post DVT prophylaxis. On POD#1, he received 2un pRBC on [**1-5**] for a HCT of 23.3 (prev 30); post transfuse HCT was 30.5. He will follow-up with ortho (scheduled). ASPIRATION PNEUMONITIS: On POD #2 ([**1-6**]) he developed a fever (104) and had an increase in his O2 requirement. He was subsequently transferred to the medical ICU for probable aspiration pneumonia. He did not require intubation. He completed a course of vanco/zosyn/azithro from [**Date range (1) 50250**]. CHRONIC PAIN: While in the MICU, he also had an acute exacerbation of his chronic pain and was seen by the acute pain service. His pain has been somewhat difficult to control throughout his admission. Of note, he had frequent issues with chronic pain and is a chronic opioid user who has required multiple medications on board, including ketamine and dilaudid PCA, during his stay. He was discharged on a regimen of MSContin 30mg TID w/ po dilaudid for breakthrough pain. There were multiple reports of him being too sedated for pain meds but him still asking. PEPTIC ULCER/STRESS ULCER BLEED While on the hospital floor, developed coffee ground emesis and although normotensive, he was tachycardic to the 110s. His HCT decreased from mid to upper 20s (25-28) to 21. He was started on IV PPI and he received 2 units of pRBCs overnight, as well as 4 units FFP for INR 1.6 (? nutritional deficit). On the morning of [**1-14**], he received 2 units of pRBCs, continued to tachycardic, and went down to endoscopy. He was transfused another 2un and was transferred to the MICU for monitoring and serial HCTs. In the MICU, the pt had some lightheadedness and weakness and developed maroon stools. On the morning of [**1-15**], his HCT was 23; he was transfused 2un pRBCs and 2un FFP, his PPI was converted to a drip, and had an EGD. The EGD showed 3 large ulcers measuring about 3cm in diameter and few small (less than 1 cm) ulcers in the pre-pyloric area, all suggestive of stress ulcers. The large ulcers were treated w/ epinephrine. He received an addition 1un after the EGD. On [**1-16**], the pt's HCT was stable and he returned to the floor. In total, pt rec'd 14un pRBCs and 7un FFP over course of admission. PSYCHIATRY Upon return to the floor, the pt seemed very depressed. He was seen by psychiatry who felt that his current medication regimen was appropriate and no changes were made. His mood steadily increased and then plateaued for the rest of his admission. . CHOLECYSTITIS/FEVER Following his return to the medical floor after GIB, the pt developed a fever. He was, and remains, high risk for [**Last Name (LF) 11011**], [**First Name3 (LF) **] he was worked up for DVT and PE. He had neg LE ultrasounds and CTA did not reveal PE or pneumonia. A wound consult was obtained to evaluate for sacral decubiti or other skin breakdown that could cause a fever. It was noted that his alk phosphatase was rising and it was decided to get a RUQ ultrasound and acute cholecystitis was diagnosed. He was started on ciprofloxacin and flaygl. Given his multiple comorbodities, it was decided that percutaneous intervention w/ a cholecystostomy tube was the best treatment. While ultrasounding for placement, a mass was discovered within his gallbladder lumen. This mass appeared to have pulsatile flow, and an MRI was obtained for further characterization. This revealed that the mass was likely sludge or debris, and a f/u ultrasound appeared more reassuring that this was not a true mass. On [**1-25**], IR placed a perc cholecystostomy tube. He would still need a cholecystectomy but in approximately 6 weeks. He was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Plan is for perc chole drain to remain in place until f/u with Dr. [**First Name (STitle) **]. HYPERNATREMIA/ANASARCA His hospital course was complicated by hypernatremia and severe anasarca. His hypernatremia improved slowly. He developed scrotal edema which also had decreased in size by the time of discharge. He was treated with alternating lasix and albumin. He was seen by nutrition but he had been NPO for 3-4 days prior to discharge while waiting for treatment of his inflammed gallbladder. . URINE GROWTH He did grow enterbacter cloacae in one urine sample but this resolved after his foley was changed. . NUTRITION He was started on TPN for poor PO intake, though will need fluid balance carefully monitored and may need more furosmide. He was started on a RISS while on TPN. Medications on Admission: Lyrica, risperidol, trazadone, baclofen, lexapro, ms contin, oxycodone, lamictal, klonopin Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 2. Risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Trazodone 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime) as needed. 4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). 7. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 12. Modafinil 100 mg Tablet Sig: One (1) Tablet PO qam (). 13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 16. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). 17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. 18. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 20. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting 21. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 22. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 23. Milk Of Magnesia Concentrated 2,400 mg/10 mL Suspension Sig: Thirty (30) mL PO every six (6) hours as needed for constipation. 24. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 25. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q6H (every 6 hours) as needed for constipation. 26. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection every six (6) hours: while on TPN. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: Bilateral Proximal Femur Fractures Aspiration Pneumonia Upper GI Bleed Acute cholecystitis Discharge Condition: Stable, tolerating clear liquids (can advance as tolerated), pain adequately controlled Discharge Instructions: You were admitted to the hospital after your broke your legs. You had surgery and had rods placed in your thigh bones. You also developed pneumonia and ulcers in your stomach. You were also treated for cholecystitis or infection of your gallbladder. You had a tube placed into your gallbladder in order to help drain your gallbladder. Your were started on a medicine called Pantoprazole. This is a medication for your stomach ulcers. Please do not stop taking it unless directed to do so by your doctor. Please see the list of medications for all of your other medications. 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: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SPECIALTIES CC-3 (NHB) Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2165-2-13**] 1:30 ORTHO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2165-2-22**] 9:00 [**First Name8 (NamePattern2) 3996**] [**Last Name (NamePattern1) **], PA (Orthopaedics) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2165-2-22**] 9:20

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icd9cm

[ [ [] ] ]

[ "79.35", "51.02", "44.43", "99.04", "99.15", "38.93", "99.07" ]

icd9pcs

[ [ [] ] ]

14744, 14827

6343, 12254

14962, 15052

2319, 4542

16024, 16475

1388, 1406

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251, 582

610, 1081

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32581

Discharge summary

report

Admission Date: [**2108-12-22**] Discharge Date: [**2108-12-31**] Date of Birth: [**2076-1-12**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Chief Complaint: Chest pain Major Surgical or Invasive Procedure: pericardectomy [**12-24**] History of Present Illness: 32 y.o. M with multiple episodes of pericarditis presenting with CP. . The patient states that he awoke from sleep several times the evening prior to admission with severe aching substernal chest pain. At 6AM he awoke for good with 8/10 pain. He describes associated shortness of breath and episodes of chills and sweats. The patient took 2 percocet with improvement in the pain to [**2111-5-18**] and then 2 more percocet with improvement in the pain to [**3-24**]. The patient's pain resolved in the ED 12 hours after it began. This is identical to the patient's prior episodes of chest pain associated with pericarditis except today's episode is not as severe. Of note, the patient was feeling well in the days prior to admission and interviewed for a job at a health club as a personal trainer 1 day prior to admission. The interview consisted of a strenuous workout. . The patient had multiple episodes of pericarditis, last 11.02.07-11.06.07 at [**Hospital1 18**]. During that admission, the patient presented with CP radiating to the back, diaphoresis, N/V and abdominal pain with some hypotension. The patient had no echo and cath signs suggestive of tamponade with small-moderate sized effusion. The patient underwent pericardiocentesis on [**2108-12-15**]. He transiently had a pericardial drain in place. Extensive work-up of for a source of pericarditis, including rheumatologic, infectious and malignant is ongoing and thus far negative (including pericardial fluid negative for AFB, viral cultures or malignant cells). 1 out of 2 bottles of pericardial fluid is growing presumptive peptostreptococcus from [**2108-12-15**]. The patient was scheduled for outpatient rheumatology follow-up though this has not yet occured. . In the ED 98.7 92-98 120-138/60-70 18 97% RA. Pulsus <4 by report. The patient received aspirin 325 mg and toradol 30mg IV. He underwent bedside echocardiogram with verbal report of small pericardial effusion, elevated RA pressure but no tamonade. The patient had a CXR with a question of left lower lobe pneumonia and he received levofloxacin 500mg IV. . Past Medical History: Pericarditis x 4 , last time complicated by tamponade Social History: Social history is significant for occasional tobacco and occasional marijuana use. He admits to cocaine use in the past, but not in the past 5 years. He denies IVDU. He occasionally drinks ETOH. Family History: There is no family history of pericarditis. He has a first cousin with a diagnosis of lupus, otherwise no other rheumatological diseases. Physical Exam: AdmissionPHYSICAL EXAMINATION: VS 99.1 102 140/78 18 99%RA Gen: Well-appearing. NAD. HEENT: PERRL. Pink, moist oral mucosa without lesions. CV: RRR. Normal S1 and S2. No M/R/G. Pulsus 5. Pulm: CTA bilaterally. Abd: Soft, nontender. Ext: No edema. Discaharge VS 99.3 82SR 118/76 18 100% RA Gen NAD Pulm CTA bilat CV RRR S1-S2. Sternum stable, incision CDI Abdm soft, NT/ND/+BS Ext warm, well perfused, no edema Pertinent Results: [**2108-12-22**] 07:40PM GLUCOSE-142* UREA N-14 CREAT-1.0 SODIUM-132* POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-25 ANION GAP-14 [**2108-12-22**] 07:40PM cTropnT-<0.01 [**2108-12-22**] 07:40PM WBC-20.0*# RBC-4.01* HGB-11.5* HCT-35.3* MCV-88 MCH-28.7 MCHC-32.6 RDW-13.3 [**2108-12-22**] 07:40PM PLT COUNT-783* [**2108-12-31**] 06:05AM BLOOD WBC-14.5* RBC-3.34* Hgb-9.3* Hct-28.8* MCV-86 MCH-27.8 MCHC-32.3 RDW-14.3 Plt Ct-1189* [**2108-12-31**] 06:05AM BLOOD Plt Ct-1189* [**2108-12-31**] 06:05AM BLOOD Glucose-93 UreaN-18 Creat-1.7* Na-132* K-4.8 Cl-91* HCO3-29 AnGap-17 RADIOLOGY Final Report CHEST (PA & LAT) [**2108-12-29**] 9:27 AM CHEST (PA & LAT) Reason: eval for effusions [**Hospital 93**] MEDICAL CONDITION: 32 year old man s/p pericardectomy REASON FOR THIS EXAMINATION: eval for effusions EXAMINATION: Chest x-ray. CLINICAL HISTORY: 32-year-old man status post pericardiectomy, evaluate for effusions. FINDINGS: Two views of the chest were obtained and compared to the prior examination dated [**2108-12-27**]. A tiny left apical pneumothorax persists that has slightly decreased in size since the prior examination. There is an interval decrease of the right pleural effusion associated with improved aeration of the right base. There is a minimal right basilar atelectasis present. No new focal opacities are seen. Sternotomy wires are intact and unchanged in position. The cardiac silhouette is mildly enlarged, grossly unchanged since the prior examination. RADIOLOGY Final Report RENAL U.S. [**2108-12-29**] 11:51 AM RENAL U.S. Reason: HYDO/STONES [**Hospital 93**] MEDICAL CONDITION: 32 year old man with increase creat x 4 days / no hiistory of CRI REASON FOR THIS EXAMINATION: hydro / stones INDICATION: 30-year-old man with increasing creatinine for four days. COMPARISON: CT of the torso, [**2108-12-13**]. RENAL ULTRASOUND: The right kidney measures 12.8 cm. The left kidney measures 13.2 cm. There is no evidence of hydronephrosis or stones. Relatively echogenic region within the interpolar left kidney appears to correspond to an area of normal cortex seen on CT in association with a duplicated collecting system on the left side. IMPRESSION: No evidence of hydronephrosis or stones. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 75957**] [**Hospital1 18**] [**Numeric Identifier 75958**]Portable TTE (Focused views) Done [**2108-12-22**] at 11:08:39 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] S. [**Hospital1 **] C [**Location (un) 830**], E/RW-453 [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2076-1-12**] Age (years): 32 M Hgt (in): 72 BP (mm Hg): 123/68 Wgt (lb): 180 HR (bpm): 92 BSA (m2): 2.04 m2 Indication: Pericarditis, r/o tamponade. ICD-9 Codes: 786.05, 423.9, 786.51 Test Information Date/Time: [**2108-12-22**] at 23:08 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) **], MD Test Type: Portable TTE (Focused views) Son[**Name (NI) 930**]: Doppler: Limited Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2007W000-0:00 Machine: Vivid [**8-18**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 2.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.4 cm <= 5.2 cm Right Atrium - Four Chamber Length: *6.4 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.0 cm Left Ventricle - Fractional Shortening: *0.25 >= 0.29 Left Ventricle - Ejection Fraction: 50% >= 55% TR Gradient (+ RA = PASP): 16 mm Hg <= 25 mm Hg Pericardium - Effusion Size: 1.0 cm Findings This study was compared to the prior study of [**2108-12-17**]. LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal IVC diameter (<2.5cm) with <50% decrease during respiration (estimated RAP 10-15mmHg). LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild global LV hypokinesis. Low normal LVEF. RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Normal descending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential. Effusion echo dense, c/w blood, inflammation or other cellular elements. Pericardium appears thickened. No echocardiographic signs of tamponade. No RA or RV diastolic collapse. Echo findings are suggestive but not diagnostic of constriction. GENERAL COMMENTS: Emergency study performed by the cardiology fellow on call. Echocardiographic results were reviewed with the houseofficer caring for the patient. Conclusions The left atrium is elongated. The right atrium is moderately dilated. The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis (LVEF = 50 %). Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size is normal. There is mild global right ventricular free wall hypokinesis. 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 a small to moderate sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. The pericardium appears thickened. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. The echo findings are suggestive but not diagnostic of pericardial constriction. Compared with the prior study (images reviewed) of [**2108-12-17**], the small echolucent pericardial effusion has become a small to moderate sized circumferential pericardial effusion that is echodense, largest posterior to the left ventricle. There is severe tethering of both the left and right ventricular epicardium resulting in mildly depressed function. There is no echocardiographic evidence of tamponade, but effusive/constrictive process is suggested. Electronically signed by [**Name6 (MD) **] [**Name8 (MD) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2108-12-23**] 00:32 DR. [**First Name (STitle) 2353**] [**Doctor Last Name **] Brief Hospital Course: Mr. [**Known lastname 63208**] is a 32 yo M with multiple episodes of pericarditis presenting with CP, leukocytosis, and cough due to recurrence of pericarditis versus PNA. Patient has a history of recurrent pericarditis and now presents with chest pain similar to previous episodes. Echo showed no signs of tamponade, but showed small to moderate effusion and constrictive process. Pt was seen by rheum on previous admission and extensive workup was positive only for mildly elevated RF and SSA anitbodies. Pericardial fluid was found to be positive for peptostreptoccocus and 1+WBCs. He was started on Penicillin G for peptostreptococcus in pericardial fluid. and Levo for PNA. Echo showed pericardial effusion and constriction. Cardiac surgery was consulted and he underwent subtotal pericardiectomy on [**12-24**]. He was extubated post op. He spiked a temp to 102 on POD #1 and was pancultured. Infectious diseases and rheumatology were consulted. He continued on PCN. His chest tube was dc'd on POD #2. His creatinine became elevated and his toradol was dc'd. THe renal ultrasound was negative. His urine lytes were normal. He spike a temp to 101.1. He was pancultured, UA was negative, blood cultures with no growth to date and a chest x-ray reveal atelectasis. He remained afebrile and was discharged to home on POD #7. Medications on Admission: CURRENT MEDICATIONS: Indomethacin 25 mg TID x 2 weeks Famotidine 20 mg [**Hospital1 **] Colchicine 0.6 mg [**Hospital1 **] Oxycodone-Acetaminophen 5-325 1-2 tablets po q4 hr Colace 100 mg [**Hospital1 **] x 2 weeks . 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Amoxicillin 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 weeks. Disp:*2 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Pericarditis x 4 now s/p subtotal pericardiectomy 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. No Motrin or Aleve Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2109-1-11**] 9:00 [**Name6 (MD) 39063**] [**Last Name (NamePattern4) 39064**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2109-2-13**] 1:30 Provider: [**First Name8 (NamePattern2) 4021**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2109-2-21**] 10:00 Dr [**Last Name (STitle) **] in 2-3weeks, pt to call [**Telephone/Fax (1) 1504**] to schedule appt Completed by:[**2108-12-31**]

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Discharge summary

report

Admission Date: [**2120-4-21**] Discharge Date: [**2120-4-30**] Date of Birth: [**2036-6-4**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 800**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 83 YO F w likely NASH cirrhosis c/b portal htn, grade 1 varices, prior SMV and PVT and multiple liver masses s/p RFA of 2 liver masses on [**4-17**]. Directly after the RFAs the patient developed nausea and chills. She went home where she noted abdominal pain and persistent nausea. These symptoms persisted and she also developed poor PO intake and vomiting. She had several dark BMs on [**4-20**] but denies frank melena or hematochezia. Given her symptoms, she decided to present to the ED. . Upon presentation to the ED, her VS were: 98.0 88 108/54 20 100%. Her exam was notable for R-sided and epigastric discomfort. Labs were notable for plts 89K, elevated LFTs (114, 127), alk phos 227, doubling of tbili from baseline (to 3.4), lactate 2.7, and INR 1.4. CT abd showed a new occlusion/thrombus in right portal vein and SMV with small bowel and cecal wall thickening and stranding concerning for ischemia/vasc congestion given occlusion of vessels. She was given morphine for pain control as well as IV protonix and zofran. She was additionally started on a heparin gtt. She was seen by transplant surgery who recommended serial abdominal exams and trending lactate. Hepatology was contact[**Name (NI) **] and recommended keeping the patient NPO, on heparin with [**Name (NI) **] PTT 60-70, with plans for EGD in the am. VS prior to transfer: 98.5 61 104/81 12 100% RA. . On arrival to the floor, the patient reports being tired; otherwise as above. Past Medical History: OSTEOARTHRITIS ELEVATED CHOLESTEROL S/P UTERAL STONE CALCIUM OXALATE [**5-/2099**] SEBORRHEIC KERATOSES HYPERTENSION APPENDECTOMY HERPES ZOSTER GASTROESOPHAGEAL REFLUX OSTEOPENIA [**2114-9-25**] DEPRESSION SCIATICA CIRRHOSIS C/B THROMBOCYTOPENIA AND HEPATIC VEIN THROMBOSIS TREATED WITH ANTI-COAGULATION [**7-/2117**] (0.8 cm Liver dome lesion noted [**8-26**]; RFA w/ bx done on [**2120-2-7**], no malignancy seen on path. CT on [**2120-3-6**] for 1 month f/u post RFA showed residual disease at tumor site and 2 new lesions, 9mm in seg 4a and another in seg 6. Post RFA scan showed 2 areas that looked like residual disease, one along superior aspect and the other along inferior aspect of tumor. Also possibility of post-RFA changes. Two other lesions, one present before initial RFA and stable the other was new, but both were too small to fully characterize so patient again underwent RFA on [**4-17**].) GRADE 1 VARICES AND PORTAL HYPERTENSIVE GASTROPATHY [**2117**] PELVIC FRACTURE [**8-/2118**] BASAL CELL CARCINOMA [**2111**] RIGHT HIP REPLACEMENT Social History: She is currently living in an apartment in her son's house. Denies ETOH and tobacco use. She is independent at baseline. Family History: aunt with ovarian ca daughter with breast ca in 50s no family history of liver disease Physical Exam: Vitals - T: 97.8 BP: 128/64 HR: 96 RR: 20 02 sat: 94% RA GENERAL: Sleepy although oriented times 3, well appearing female 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, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB anteriorly. Dullness to percussion in RLL. ABDOMEN: Decreased bowel sounds. Tender to moderate palpation in the RUQ. Her abdomen is soft and there is no guarding or rebound. EXTREMITIES: No edema or calf pain, venous dermatitis with 2 small areas of skin breakdown on her right calf. SKIN: as above as well as several scattered ecchymoses. NEURO: Appropriate. CN 2-12 grossly intact. No asterixis. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: ADMISSION LABS: [**2120-4-21**] 11:55AM WBC-7.8# RBC-4.30 HGB-13.3 HCT-41.1 MCV-96 MCH-31.0 MCHC-32.5 RDW-14.9 [**2120-4-21**] 11:55AM NEUTS-85.2* LYMPHS-9.2* MONOS-4.9 EOS-0.4 BASOS-0.3 [**2120-4-21**] 11:55AM PLT COUNT-89* [**2120-4-21**] 11:55AM PT-15.5* PTT-28.9 INR(PT)-1.4* [**2120-4-21**] 11:55AM HBsAg-NEGATIVE HBs Ab-NEGATIVE [**2120-4-21**] 11:55AM HCV Ab-NEGATIVE [**2120-4-21**] 11:55AM CEA-2.7 AFP-1.8 [**2120-4-21**] 11:55AM ALBUMIN-3.2* [**2120-4-21**] 11:55AM ALT(SGPT)-114* AST(SGOT)-127* ALK PHOS-227* TOT BILI-3.4* [**2120-4-21**] 11:55AM LIPASE-45 [**2120-4-21**] 11:55AM GLUCOSE-117* UREA N-22* CREAT-0.8 SODIUM-136 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-25 ANION GAP-15 [**2120-4-21**] 12:25PM LACTATE-2.7* K+-3.9 DISCHARGE LABS [**2120-4-30**] 06:50AM BLOOD WBC-4.0 RBC-3.56* Hgb-11.3* Hct-35.4* MCV-99* MCH-31.7 MCHC-32.0 RDW-16.1* Plt Ct-101* [**2120-4-30**] 06:50AM BLOOD Plt Ct-101* [**2120-4-30**] 06:50AM BLOOD Glucose-92 UreaN-16 Creat-0.8 Na-135 K-4.1 Cl-106 HCO3-22 AnGap-11 [**2120-4-27**] 09:35AM BLOOD ALT-30 AST-39 AlkPhos-175* TotBili-1.4 [**2120-4-30**] 06:50AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.7 CT A/P [**2120-4-21**]: FINDINGS: There is a large right pleural effusion. There is no pericardial effusion. The patient is status post RFA of right liver lobe lesion. Small amount of hyperdensity in the RFA site likely represents coagulation necrosis versus hemorrhage(2, 11). There is no evidence of active extravasation. Mild hyperemia surrounding the RFA site is also noted. There is tubular dilation adjacent to RFA site likely representing mild degree of focal biliary obstruction secondary to RFA. The liver appears nodular and shrunken consistent with cirrhosis. A persistent arterially enhancing lesion within the inferior aspect of the right lobe of the liver (3A, 40) is unchanged. Multiple subcentimeter hypodense lesions are identified (3B, 118) and (3B, 113). The two subcentimeter hypodensities adjacent to the RFA site (3B, 114) was not definitely seen on prior exam. There has been interval development of complete occlusion of the right portal vein (3B, 117) since [**2120-3-6**], and worse since [**2120-4-17**]. Small amount of non-occlusive thrombus is identified within the main portal vein. There is complete occlusion of the SMV which is also new since [**2120-3-6**] and slightly worse when compared to [**2120-4-17**] (3B, 147). The celiac artery, hepatic artery, SMA and renal arteries are patent. Within the left adrenal gland, there is a nodule, unchanged measuring 1.3 cm, previously characterized as adenoma. The right adrenal gland is unremarkable. The right kidney is stable. The left kidney contains a hypodense lesion which is consistent with a simple cyst measuring 1.7 x 2.5 cm. Extensive esophageal varices are unchanged. The gallbladder contains stones. There is mild bowel wall thickening involving the small bowel loops in the right lower quadrant as well as the cecum and ascending colon. Stranding within the mesentery of these small bowel loops as well as small amount of free fluid in the dependent portions of the pelvis are also identified. These findings are new when compared to prior exams. There is no evidence of pneumatosis or free air. There is no mesenteric or retroperitoneal lymphadenopathy. A fat-containing midline hernia is unchanged. CT OF THE PELVIS: There is extensive sigmoid diverticulosis. There is no evidence of acute diverticulitis. There is no pelvic or inguinal lymphadenopathy. The bladder is unremarkable. The uterus is stable. BONE WINDOWS: Patient is status post right hip replacement. Multilevel degenerative changes are unchanged. IMPRESSION: 1. Interval worsening of right portal vein occlusive thrombus and thrombus extending within the SMV when compared to prior exams. Small bowel loops in the right lower quadrant as well as cecum and ascending colon appear thickened with a small amount of fat stranding and fluid within the mesentery. These findings are highly concerning for ischemia due to venous congestion, given vascular findings. 2. Cirrhotic-appearing liver. Status post RFA ablation. No evidence of active extravasation. 3. Liver hypodense lesions and arterial enhancing lesion in the right lobe of the liver. Close interval follow up and definitive characterization is recommended. 4. Gallbladder stones. 5. Large right pleural effusion. 6. Left adrenal adenoma. 7. Diverticulosis. . CXR [**2120-4-21**]: New mild to moderate right-sided pleural effusion with bibasilar atelectasis. Cannot rule out small superimposed consolidation in the right base. . CT CHEST [**4-23**] - FINDINGS: A large right nonhemorrhagic pleural effusion is increased in size from [**2120-4-21**], and causes near complete collapse of the right lung, with only partial aeration of the right middle and upper lobes. The effusion also exhibits severe mass effect on the trachea with near apposition of the anterior and posterior walls of the trachea, as the AP diameter of the trachea measures only 2 mm maximally. Similarly, there is near complete collapse of the bronchus intermedius and right lower lobe bronchus. A small left pleural effusion is associated with minimal basal atelectasis. Septal thickening in the left lung suggests mild interstitial edema. The heart is mildly enlarged, without pericardial effusion. Minimal coronary artery and aortic arch atherosclerotic calcifications are noted. This examination is not tailored for subdiaphragmatic evaluation. A hypoattenuating lesion in the dome of the liver, with central areas of high attenuation, reflects the RF ablation site and is better characterized on the CT of the abdomen performed just 2 days ago. Additional smaller hypodensities in the right lobe are too small to characterize. The previously characterized thrombosis of the right portal vein is better also assessed on prior study. Small perihepatic free fluid is new. A left adrenal nodule and renal cyst are stable. No lytic or sclerotic osseous lesion is identified. IMPRESSION: 1. Large non-hemorrhagic right pleural effusion, causing critical mass effect on the trachea, which is nearly completely collapsed. 2. Near complete collapse of the right lung, with partial aeration of the right middle and upper lobes. 3. Mild interstitial edema in the left lung, with a small left pleural effusion. 4. Mild cardiomegaly . CXR [**2120-4-26**] - CHEST, PA AND LATERAL: Mild cardiomegaly with a tortuous aorta is stable. The lungs are clear without consolidation or edema. Small bilateral pleural effusions are stable. No pneumothorax is identified. IMPRESSION: Stable small bilateral pleural effusions. No pneumothorax. The study and the report were reviewed by the staff radiologist . TTE [**2120-4-30**] - LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: The rhythm appears to be atrial fibrillation. Ascites. Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 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 estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2101-9-28**], mild left ventricular hypertrophy is now detected. Brief Hospital Course: The patient is an 83 year old female with a past medical history of cryptogenic cirrhosis complicated by portal htn, grade 1 varices, and prior SMV and PV thrombosis ([**2117**]) s/p recent RFA admitted with abdominal pain found to have a new right portal vein and SMV thrombus with CT changes concerning for bowel ischemia. . #. SMV and Portal Vein thrombosis with associated bowel wall thickening/stranding concerning for mesenteric ischemia. The patient presented with abdominal pain and underwent a CT A&P on admission which demonstrated a new occlusive thrombus in right portal vein and SMV with small bowel and cecal wall thickening and stranding concerning for ischemia/vasc congestion given occlusion of vessels. Labs were notable for elevated LFTs (114, 127), alk phos 227, doubling of tbili from baseline (to 3.4), lactate 2.7, and INR 1.4. She was given morphine for pain control as well as IV protonix and zofran. She was additionally started on a heparin gtt. She was seen by transplant surgery who recommended serial abdominal exams and trending lactate. Hepatology was contact[**Name (NI) **] and recommended keeping the patient NPO, on heparin with [**Name (NI) **] PTT 60-70. Following the addition of the heparin gtt the patient was noted to have serial hematocrits downtrending, initially 41 with trend to 33.9. Due to GI bleed anticoagulation was stopped. Given the patient's ongoing risk of bleed, the decision was made to without further anticoagulation. Her abdominal exam remained stable throughout her hospitalization. She will follow up in [**Hospital 3585**] clinic for consideration of future anticoagulation and need for follow imaging of the thrombus. . # GI Bleed - The patient was initiated on a heparin gtt as above for portal vein thrombus. She was noted to have melena with HCT drop off 41 to 33. Heparin gtt was discontinued and the patient was transferred to the ICU for EGD. EGD on [**4-22**] demonstrated varices without stigma of bleeding. Otherwise normal EDG to 3rd portion of duodenum. The patient's HCT remained stable between 33-35 and she required no blood transfusions. She had no further evidence of bleeding during her hospitalization. She continues on a PPI [**Hospital1 **] for history of varices. . # Right pleural effusion - The patient underwent a thoracentesis with results consistent with hepatic hydrothorax. Micro cultures were negative. She continues on diuretics lasix and spironolactone without evidence of reaccumulation. . #. Cirrhosis, portal gastropathy - the patient's home diuretic regimen of spironolactone 100mg and lasix 10mg daily were held given GI bleed. Initially her lasix was restarted at 40mg and spironolactone at 100mg daily. The patient developed low blood pressure and urine output with this regimen requiring 1L NS and albumin. Her diuretics were held for one day, then restarted at lasix 10mg and spironolactone 50mg with good effect. Her weight should continue to be monitored daily and diuretics adjusted as needed to prevent weight gain for accumulation of ascites. Her chem 7 should be checked on [**5-2**] for further monitoring. . # Atrial Fibrillation with RVR - the patient developed AF with RVR on [**4-26**]. Her blood pressure remained stable with a rate in the 130s. The patient received IV diltiazem 7.5mg with good effect. She was started on diltiazem 15mg QID with holding parameters of BP<100 and HR<60 with subsequent good control of HR. She is being discharged on telemetry for continued monitoring and titration of meds for heart rate control. She underwent a TTE on [**4-30**] which demonstrated a normal EF and no evidence of valvular abnormalities. . # Mood d/o. - the patient continues on sertraline . The patient is being dishcarged to rehab for continued monitoring on telemetry with blood pressure monitoring and diuretic titration. Medications on Admission: asix 10mg daily ativan 0.5mg [**Hospital1 **] prn anxiety omeprazole 20mg daily oxycodone 5mg TID prn pain sertraline 25mg daily spironolactone 100mg daily sucralfate 1g TID before meals docusate 200mg daily prn MVI senna 1 tab daily prn Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary: 1. Cryptogenic Cirrhosis 2. GI Bleed 3. Splenic Vein and Portal Vein Thrombosis 4. Atrial Fibrillation Secondary: 1. Hypertension. 2. Osteoarthritis 3. Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital after presenting with abdominal pain and being found to have a blood clot in the portal vein of your liver and small bowel. You were unable to be anticoagulated for this clot because you developed a bleed in your bowel. You were followed closely by the Surgery and Hepatology service. You were treated with blood transfusions for your bleed. Your hematocrit stabilized and you required no further blood transfusions. You are completing a 14 day course of antibiotics to treat the inflammation in your GI tract caused by the blood clot. . You were found to have a pleural effusion caused by your liver disease. You underwent a thoracentesis to treat this fluid accumulation. You are continuing on diuretics, lasix and spironolactone to help prevent a reoccurrence of this effusion. . During your hospitalization you also developed an irregular and fast heart rate called atrial fibrillation. You were treated with a medication called diltiazem to slow your heart rate. You are being discharged on telemetry for further monitoring of your heart rate and adjustment of your medications. . Your diuretics spironolactone and lasix were briefly held. You have been restarted on lasix 10mg daily and spironolactone 50mg daily. Your urine output and weight will continued to be monitored and adjusted as needed. . You will need to follow up with Hepatology as scheduled below. You are being discharged to a acute rehabilitation facility for continued physical therapy and medication adjustment. Followup Instructions: Department: LIVER CENTER When: THURSDAY [**2120-5-23**] at 1:40 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: RADIOLOGY When: TUESDAY [**2120-5-14**] at 11:15 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital1 18**] [**Location (un) 2352**] When: TUESDAY [**2120-6-18**] at 11:10 AM With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1579**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

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icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

16537, 16608

12405, 16249

294, 300

16828, 16828

3989, 3989

18549, 19557

3019, 3107

16629, 16807

16275, 16514

17004, 18526

3122, 3970

240, 256

328, 1785

4005, 12382

16843, 16980

1807, 2865

2881, 3003

20,686

187,353

3340

Discharge summary

report

Admission Date: [**2131-6-5**] Discharge Date: [**2131-6-12**] Date of Birth: [**2092-1-17**] Sex: F Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 39-year old female with a history of chronic pain from pancreatitis (thought to be traumatic in nature) who underwent a cholecystectomy and sphincteroplasty times two in the [**2117**]. On [**2131-5-3**] the patient was taken to the operating room for a near total pancreatectomy and splenectomy. She was discharged home on postoperative day twelve and was well for two weeks when she saw Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] on [**2131-5-28**]. However, over the next few days the patient began having fevers and the same abdominal pain. She presented to [**Hospital3 15516**] Hospital where she had a computer tomography showing a phlegmon in the lesser sac and portal vein thrombosis. She was therefore transferred to the [**Hospital1 190**] with a diagnosis of an abdominal abscess with a portal vein thrombosis. The patient reported that she did have fevers up to 101, chills, night sweats, nausea, and vomiting. Her last bowel movement was two days prior to admission. She did report flatus. Her pain is constant with radiation to the back. PAST MEDICAL HISTORY: 1. Pancreatitis. 2. Depression. PAST SURGICAL HISTORY: 1. Pancreatectomy and splenectomy on [**2131-5-3**]. 2. Transduodenal sphincteroplasty times two. 3. Cholecystectomy. 4. Total abdominal hysterectomy. ALLERGIES: 1. EFFEXOR. 2. NEURONTIN. 3. VALIUM. MEDICATIONS ON ADMISSION: 1. Insulin sliding scale. 2. Atenolol 25 mg by mouth once per day. 3. Demerol. 4. Reglan. 5. Protonix 40 mg by mouth twice per day. 6. Compazine. SOCIAL HISTORY: PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed her temperature was 99.8 degrees Fahrenheit, her heart rate was 125, her blood pressure was 134/81, her respiratory rate was 18, and her oxygen saturation was 100 percent on room air. In general, the patient looked worried. Head, eyes, ears, nose, and throat examination revealed the pupils were equal, round, and reactive to light. The oropharynx was clear. Chest revealed decreased breath sounds at the bases. Heart was regular in rate and rhythm. The abdomen revealed some epigastric tenderness with some guarding. Extremities were warm. Rectal examination was guaiac negative with soft stool. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 40, her hematocrit was 34, and her platelets were 703. Differential with 78 polymorphonuclear neutrophils, 5 bands, and 9 lymphocytes. Sodium was 128, potassium was 4.2, chloride was 88, bicarbonate was 26, blood urea nitrogen was 6, creatinine was 0.5, and her blood glucose was 234. PERTINENT RADIOLOGY-IMAGING: A computed tomography of the abdomen showed portal vein thrombosis and a lesser sac phlegmon with gas. SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit. Her electrolytes were corrected, and she was started on Zosyn for her elevated white blood cell count, and history of fevers, and the abdominal abscess. She was also started on a heparin drip with a goal partial thromboplastin time of 60 to 80. Her INR on admission was 3.6; for which she received several units of fresh frozen plasma to bring her INR down to 1.2. Her prothrombin time after the initial bolus of heparin was also rather elevated but was later well regulated on heparin. Following hydration, the patient's hematocrit dropped to 23.9, and she subsequently received one unit of packed red blood cells; bringing her hematocrit up to 28.6. The patient also had a temperature to 101.1 degrees Fahrenheit on hospital day two. The patient was transferred to the floor on hospital day two and was continued on her heparin drip and Zosyn. The patient was also started on aspirin 325 mg by mouth once per day, and Coumadin was started. The patient's INR was down to 1.3. The patient remained nothing by mouth until hospital four when she was started on a clear diet, despite the fact that the patient had slight nausea. The patient was continued on her clear diet with mild nausea for several days until she was advanced to a regular diet on hospital day seven. The patient tolerated that diet well except for some mild nausea which was treated with Zofran and Compazine. The patient was taking Compazine at home for ongoing nausea and was ultimately discharged with Compazine. By hospital day four, the patient remained afebrile with temperatures staying below 100 degrees Fahrenheit, but she continued to have an elevated white blood cell count at 20.9. The patient had a line change done on hospital day six. The culture on the tip came back negative, and the patient continued to have an elevated white blood cell count which hovered in the 20 to 23 range, but dropped to 19 on the day of her discharge. The patient's INR on a dose of 5 mg of warfarin daily rose slowly, becoming therapeutic on hospital day seven, at which point her heparin drip was stopped. By hospital day seven, the patient's abdominal tenderness had resolved; however, she continued to report a right upper quadrant ache. The patient's Zosyn was actually stopped earlier in the [**Hospital 228**] hospital course while her white blood cell count continued to drop. The patient was ultimately discharged without abdominal pain and with a therapeutic INR (2). CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. MEDICATIONS ON DISCHARGE: 1. Insulin sliding scale. 2. Atenolol 25 mg by mouth once per day. 3. Phenergan. 4. Protonix 40 mg by mouth q.12h. 5. Aspirin 325 mg by mouth once per day. 6. Warfarin 5 mg by mouth once per day. 7. Ambien 10 mg by mouth at hour of sleep. 8. Dilaudid one to two tablets by mouth q.2h. as needed (for pain). DISCHARGE INSTRUCTIONS-FOLLOWUP: 1. Pancreatitis. 2. Depression. 3. Portal vein thrombosis. DISCHARGE DIAGNOSES: 1. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] on [**2131-7-9**] at 11:15 in the morning. 2. The patient was instructed to follow up with her primary care physician on [**Name9 (PRE) 2974**], three days after her discharge, after having blood drawn, so that your Coumadin dose may be adjusted (with a goal INR of 2 to 3). 3. The patient was also instructed to work with her primary care physician to wean from pain medications. [**Name6 (MD) **] [**Last Name (NamePattern4) 7542**], [**MD Number(1) 7543**] Dictated By:[**Last Name (NamePattern1) 15517**] MEDQUIST36 D: [**2131-6-16**] 13:50:37 T: [**2131-6-18**] 08:37:15 Job#: [**Job Number 15518**]

[ "452", "577.1", "998.59" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

5968, 6730

5541, 5947

1589, 1737

1360, 1563

2944, 5454

182, 1281

1303, 1337

1754, 2915

5479, 5515

23,380

189,336

9178+56006+56007

Discharge summary

report+addendum+addendum

Admission Date: [**2137-9-13**] Discharge Date: [**2137-9-23**] Date of Birth: [**2074-5-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: Pt. presents for laparoscopic esophagectomy Major Surgical or Invasive Procedure: [**9-13**] Laparoscopic esophagogastrectomy History of Present Illness: The patient is a 62-year-old gentleman who has been diagnosed with T3, N1 esophageal cancer. He has undergone induction chemoradiotherapy and has been restaged. He has no evidence of progression. He was deemed to be a good operable candidate, and therefore, he was taken forward for a combined thoracoscopic and laparoscopic approach with two attending surgeons. Past Medical History: 1. Esophageal CA - S/P Cisplatin/5FU and XRT 2. h/o bilateral PE 3. Diabetes mellitus 4. Herniated disk 5. Degenerated disk disease 6. Hyperlipidemia Past Surgical History 1. Operation for cholesteatoma at [**Hospital 31406**] 2. Multiple orthopaedics operations 3. Laparoscopy, laparoscopic jejunostomy and port placement under fluorscopic guidance Social History: Pt. lives in [**Location (un) **]. He is not married but lives with a female companion. He does not have any children. Has been smoking 2 ppd for 50 yearas. Social ETOH use. Family History: Father died of lung cancer Mother is [**Age over 90 **] [**Name2 (NI) **] and living in nursing home No other family history of malignancy Physical Exam: AVSS NAD RRR CTA B/L soft, NT, ND no C/C/E Pertinent Results: [**2137-9-13**] 04:34PM WBC-14.3*# RBC-2.93* HGB-9.0* HCT-26.2* MCV-89 MCH-30.6 MCHC-34.2 RDW-16.8* [**2137-9-13**] 04:34PM PLT COUNT-276 [**2137-9-13**] 04:34PM PT-12.7 PTT-20.7* INR(PT)-1.1 [**2137-9-13**] 04:34PM CALCIUM-8.9 PHOSPHATE-5.0* MAGNESIUM-1.6 [**2137-9-14**] 03:06AM BLOOD WBC-12.7* RBC-2.74* Hgb-8.5* Hct-24.5* MCV-89 MCH-31.0 MCHC-34.7 RDW-17.2* Plt Ct-246 [**2137-9-19**] 04:30AM BLOOD WBC-8.0 RBC-2.73* Hgb-8.4* Hct-24.2* MCV-89 MCH-30.7 MCHC-34.6 RDW-16.1* Plt Ct-264 [**2137-9-17**] 03:07AM BLOOD PT-13.0 PTT-26.3 INR(PT)-1.1 [**9-13**] CXR: Postoperative changes status post esophagogastrectomy with gastric pull through. No evidence of pneumothorax. [**9-17**] Barium Swallow: No evidence of anastomotic leak. Contrast is not seen passing past the tip of the nasogastric tube. [**9-19**]: CXR: Improving atelectasis. Status post drain and chest tube removal. Suspected small pneumothorax. [**9-20**]: CXR: R pneumothorax unchanged. Brief Hospital Course: The patient is a 62-year-old gentleman who has been diagnosed with T3, N1 esophageal cancer. He presents for a lap esophagectomy. For details of the procedure please see operative note. Post-operatively he was transfered to the CSRU and did well. He was extubated on POD1. However on POD1 he was noted to have gone into rapid A.fib. This converted to normal sinus rhythm after a bolus of amiodarone, IV lopressor, and magnesium. He was started on an amiodarone drip afterwards. He was started on lovenox for his history of a recent PE. On POD2 he continued to complain of significant pain and was started on his home dose of a fentanyl patch in addition to dilaudid IV. In addition, he had a second episode of rapid a.fib, again responding to an amiodarone bolus and magnesium. TF were started at 10cc/hr and were not advanced. On POD3 the amiodarone was converted to oral dosing down his j-tube and he was seen by physical therapy. On POD4 he was transfered out of the CSRU, was given one unit of packed red cells for a hematocrit that had drifted down to 20. In addition his L chest tube was removed. Post-transfusion hematocrit the next morning was 25, CXR after removal showed no pneumothorax on the L, and a stable pneumothorax on the R. TF were advanced to goal. A barium swallow study on POD4 demonstrated no leak of contrast into the mediastinum. On POD5 his NGT was removed, he was started on sips, and his foley catheter was removed. However, he failed to void after 7 hours and the catheter was replaced. He was started on flomax for this. On POD6 his diet was advanced to clears, his TF were decreased because the patient was taking food orally, he was changed to oral medications and he was started on 2.5mg of coumadin. his foley was removed after midnight. He was seen by [**Last Name (un) **] for elevated BS, they recommended increasing his Lantus dose and increased his sliding scale insulin. In addition they recommended diabetic TF. This was not changed because his TF were stopped the next day. His R chest tube was removed since the output did not increase after starting clears and his JP drain was removed as well. The post removal CXR showed a slightly larger pneumothorax on the R. On POD7 he voided spontaneously, tolerated a regular diet, and the TF were stopped. A repeat CXR showed that the R pneumothorax was stable. On POD8 he was discharged to the rehab facility he came to the hospital from on POD8 tolerating a regular diet, ambulating, on a lovenox bridge and coumadin. He will follow-up with the [**Hospital **] clinic, his PCP, [**Name10 (NameIs) **] Dr. [**Last Name (STitle) **]. Medications on Admission: lipitor 40', insulin lantus 45, RISS, coumadin 5, percocet,klonadin, prevacid 30' Discharge Medications: 1. other Sig: Zero (0) every six (6) hours: Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose Fingerstick QACHSInsulin SC Fixed Dose Orders Bedtime Glargine 55 Units Refular Insulin SC Sliding Scale Breakfast, Lunch, and Dinner; 0-70 mg/dL: Give 4 oz. juice 71-80 mg/dL: 0 units 81-120 mg/dL: 3 units 121-160 mg/dL: 5 units 161-200 mg/dL: 7 units 201-240 mg/dL: 9 units 241-280 mg/dL: 11 units 281-321 mg/dL: 13 units >321 mg/dL: Notify MD Bedtime 0-70 mg/dL: 4 oz. juice 71-80 mg/dL: 0 units 81-120: 0 units 121-160 mg/dL: 2 units 161-200 mg/dL: 4 units 201-240 mg/dL: 6 units 241-280 mg/dL: 8 units 281-321 mg/dL: 10 units >321 Notify MD . 2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-17**] Puffs Inhalation Q4H (every 4 hours). 6. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): Hold for HR < 60 Hold for SBP < 90. 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2 hours) as needed for pain: Hold for sedation. 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for loose stool. 13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-21**] hours as needed for pain. Discharge Disposition: Extended Care Facility: On [**Location (un) **] - [**Location (un) **] Discharge Diagnosis: Esophageal cancer Discharge Condition: Good Discharge Instructions: Notify MD/NP/PA/RN at rehabilitation facility if you experience: *Increased or persistent pain not relieved by pain medications *Fever > 101.5 or chills *Nausea or vomiting *Inability to pass gas, stool, or urine *If incision or jejunostomy exit site appears red, is warm to touch, or if there is drainage. *Shortness of breath or difficulty swallowing *Chest pain or palpitations *Any other symptoms concerning to you Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in [**12-17**] weeks, call [**Telephone/Fax (1) 2981**] for an appointment. Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**] for management of your Coumadin and Lovenox therapy in 1 week, call [**Telephone/Fax (1) 2936**] for an appointment. Follow-up with the [**Hospital **] Clinic for management of your diabetes in [**12-17**] weeks, call [**Telephone/Fax (1) 2384**] for an appointment. Name: [**Known lastname 5482**],[**Known firstname 422**] Unit No: [**Numeric Identifier 5483**] Admission Date: [**2137-9-13**] Discharge Date: [**2137-9-23**] Date of Birth: [**2074-5-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 203**] Addendum: Addendum to follow-up instructions. Discharge Disposition: Extended Care Facility: On [**Location (un) **] - [**Location (un) **] Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in [**12-17**] weeks, call [**Telephone/Fax (1) 5484**] for an appointment. Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for management of your Coumadin and Lovenox therapy as soon as possible next week, call [**Telephone/Fax (1) 5485**] for an appointment. Please stop lovenox once therapeutic on coumadin. Follow-up with the [**Hospital 616**] Clinic for management of your diabetes in [**12-17**] weeks, call [**Telephone/Fax (1) 614**] for an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**] Completed by:[**2137-9-21**] Name: [**Known lastname 5482**],[**Known firstname 422**] Unit No: [**Numeric Identifier 5483**] Admission Date: [**2137-9-13**] Discharge Date: [**2137-9-23**] Date of Birth: [**2074-5-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 203**] Addendum: Addendum to hospital course: Patient's insurance company initially refused payment for the nursing home and so the patient was kept over the weekend as it was felt he was not physically rehabilitated enough to be discharged to home. No events occurred over the weekend. He was therefore discharged to his nursing facility on POD10 tolerating a regular diet, without tube feeds. His INR at discharge was 1.7. He will be discharged on lovenox and coumadin and will follow-up with his PCP regarding his coumadin dosing, lovenox, and continuation of amiodarone. Discharge Disposition: Extended Care Facility: On [**Location (un) **] - [**Location (un) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**] Completed by:[**2137-9-23**]

[ "272.4", "150.5", "285.1", "997.1", "V12.51", "512.1", "V16.1", "196.1", "250.80", "V15.3", "722.10", "427.31" ]

icd9cm

[ [ [] ] ]

[ "96.6", "42.41", "34.04", "46.39", "43.5", "99.04", "54.21", "34.21" ]

icd9pcs

[ [ [] ] ]

10615, 10843

2585, 5234

358, 404

7441, 7448

1598, 2562

8939, 10041

1379, 1520

5366, 7283

7400, 7420

5260, 5343

10058, 10592

7472, 7893

1535, 1579

275, 320

432, 796

818, 1171

1187, 1363

3,744

104,891

9528

Discharge summary

report

Admission Date: [**2113-3-29**] Discharge Date: [**2113-4-4**] Service: MEDICINE Allergies: Iodine / Xylocaine / Nitroglycerin Attending:[**First Name3 (LF) 425**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterizations: [**2113-3-30**] & [**2113-3-31**] History of Present Illness: 85F with hypertrophic cardiomyopathy, paroxysmal atrial fibrillation on amiodarone, reported EF of 32% who reports with increasing substernal [**7-14**] chest pressure lasting 15 minutes to hours with radiation to her neck, associated with palpitations, exacerbated with movement, alleviated with rest. Patient reports that she's had increasing chest pain over the past few months who presents with increasing chest pain pver 5 days refusing to go to the ED but came to Dr. [**Last Name (STitle) 1911**]??????s office on [**2113-3-29**]. He did blood tests and told her to go to the ED. She did not and instead went home. The labs came back with a troponin of 2.28 so he called her and had her come to [**Location (un) **] ED for transport to our cath lab. Of note she had a nuclear stress test in [**12-10**] that was reported as completely normal. Her EF was 32%. . Labs at [**Location (un) **]: WBC 8.3 Hgb 14.9 Hct 42.5 Plt 180 INR 1.0 Calcium 8.9 Na 131 K 3.9 Cl 86 CO2 29 [**Name8 (MD) **] Crt CPK 173 MB 19.8 Index 11.2 Troponin 2.28 Past Medical History: CAD Hypertrophic cardiomyopathy Paroxysmal atrial fibrillation dermatomyositis Social History: Etoh neg Tob neg Illicits neg Family History: NC Physical Exam: VS: T:95.3 BP:68/41 HR:65 RR:18 O2:99% 2LNC Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 2 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. II/VI SEM along precordium. No rubs or gallops. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Bibasilar crackles. No 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: bilateral lower extremity ecchymosis. No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: Imaging: C.CATH Study Date of [**2113-3-29**] COMMENTS: 1. Coronary angiography of this left dominant system revealed severe single vessel coronary artery disease. The left main coronary artery had no angiographically apparent flow limiting stenoses. The LAD had a 90% stenosis in the mid segment involving the bifurcation of the first major diagonal branch. The LCX was a large caliber dominant artery and had no angiographically apparent flow limiting stenoses. The RCA was a small caliber nondominant vessel with no angiographically apparent flow limiting stenoses. 2. Resting hemodynamics revealed low right sided filling pressures (mean RA pressure was 3 mm Hg and RVEDP was 4 mm Hg). Pulmonary artery pressures were normal (PA pressure was 30/11 mm Hg). Left sided filling pressures were normal (mean PCW pressure was 13 mm Hg). Systemic arterial pressure ranged from low to normal (aortic pressure averaged 90/47 mm Hg). Cardiac output was low (CI was 2.1 L/min/m2). Post intervention and bolus administration normal saline, left sided filling pressures were slightly higher (mean PCW pressure was 14 mm Hg). 3. Successful PCI/stent to mid LAD/Diagonal bifurcation with a 3.0x23mm Cypher stent deployed at 14atms. Excellent result with normal flow and no residual stenosis in both vessels. Patient left cathlab painfree. FINAL DIAGNOSIS: 1. Severe single vessel coronary artery disease. 2. Low right sided filling pressures and relatively low left sided filling pressures. 3. Successful rotation atherectomy, angioplasty, and stenting with DES of the mid LAD with rescue of the first diagonal branch. . CT PELVIS W/O CONTRAST [**2113-3-30**] 9:32 AM IMPRESSION: 1. No evidence of retroperitoneal bleed but hematoma in right groin in soft tissues at site of recent cath. 2. Heavy coronary artery and aortic calcifications. 3. Low-attenuation lesion in segment 3 of the liver which is too small to characterize but may represent a cyst. 4. Minimal free fluid in the pelvis. 5. Catheter in situ in right common femoral artery and vein . CHEST (PORTABLE AP) [**2113-3-30**] 7:05 AM IMPRESSION: Interval resolution of pulmonary edema and effusions. . ECHO Study Date of [**2113-3-30**] Conclusions: The left atrium is mildly dilated. The estimated right atrial pressure is 11-15mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (ejection fraction 40-50 percent) secondary to hypokinesis of the interventricular septum and apex. There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis (preacceleration of flow in the left ventricular outflow tract may also be contributing to the elevated flow velocity across the aortic valve). No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is a minimally increased gradient consistent with trivial mitral stenosis. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a fat pad. Impression: 1. septal and apical hypokinesis 2. left ventricular hypertrophy 3. Mild-to-moderate left ventricular outflow tract obstruction 4. Minimal mitral stenosis (from severe annular calcification) 5. At least moderate-to-severe mitral regurgitation 6. Possible minimal aortic stenosis . C.CATH Study Date of [**2113-3-31**] COMMENTS: 1. Patent mid LAD stent. 2. Diagonal branch has no significant stenosis 3. Normal dominant LCX and RCA FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Patent mid LAD stent with no major stenosis in diagonal side branch. . ECHO Study Date of [**2113-3-31**] Conclusions: The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of basal and mid-anterior septum. Right ventricular chamber size and free wall motion are normal. Mild (1+) aortic regurgitation is seen. There is severe mitral annular calcification. Moderate to severe (3+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Focused study, showing mild regional left ventricular systolic dysfunction. Mild aortic regurgitation. Moderate-to-severe mitral regurgitation. . CHEST (PA & LAT) [**2113-4-1**] 6:13 PM IMPRESSION: New small bilateral pleural effusions with adjacent basilar atelectasis. . FEMORAL VASCULAR US RIGHT [**2113-4-1**] 2:01 PM IMPRESSION: No evidence of AV fistula, pseudoaneurysm, or large hematoma. . Micro: [**2113-4-1**] Sputum Cx: no growth [**4-3**] Urine Cx: pending . Admission Labs: [**2113-3-29**] 06:29PM O2 SAT-98 [**2113-3-29**] 06:29PM NA+-121* K+-2.8* [**2113-3-29**] 06:29PM TYPE-ART PO2-152* PCO2-39 PH-7.43 TOTAL CO2-27 BASE XS-2 INTUBATED-NOT INTUBA [**2113-3-29**] 07:25PM CALCIUM-7.0* PHOSPHATE-4.2 MAGNESIUM-1.7 [**2113-3-29**] 07:25PM estGFR-Using this [**2113-3-29**] 07:25PM GLUCOSE-154* UREA N-17 CREAT-0.9 SODIUM-123* POTASSIUM-3.9 CHLORIDE-90* TOTAL CO2-24 ANION GAP-13 [**2113-3-29**] 08:31PM PT-12.8 PTT-150* INR(PT)-1.1 [**2113-3-29**] 08:31PM PLT COUNT-159 [**2113-3-29**] 08:31PM WBC-6.6 RBC-3.83* HGB-13.1 HCT-38.1 MCV-99* MCH-34.3* MCHC-34.5 RDW-16.6* [**2113-3-29**] 08:31PM URINE OSMOLAL-233 [**2113-3-29**] 08:31PM URINE HOURS-RANDOM CREAT-6 SODIUM-47 [**2113-3-29**] 08:31PM FREE T4-1.5 [**2113-3-29**] 08:31PM TSH-0.34 [**2113-3-29**] 08:31PM OSMOLAL-281 [**2113-3-29**] 08:31PM ALBUMIN-2.9* CALCIUM-6.8* PHOSPHATE-4.1 MAGNESIUM-1.6 [**2113-3-29**] 08:31PM CK-MB-22* MB INDX-10.0* [**2113-3-29**] 08:31PM CK(CPK)-219* [**2113-3-29**] 08:31PM GLUCOSE-175* UREA N-15 CREAT-0.9 SODIUM-126* POTASSIUM-3.1* CHLORIDE-94* TOTAL CO2-19* ANION GAP-16 [**2113-3-29**] 10:07PM URINE RBC-[**2-6**]* WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2113-3-29**] 10:07PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2113-3-29**] 10:07PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.030 [**2113-3-29**] 11:30PM UREA N-15 CREAT-0.8 SODIUM-133 POTASSIUM-4.8 Brief Hospital Course: Pt is a 85F with NSTEMI s/p catheterization and DES to LAD, with subsequent hypotension, transiently on pressors, currently normotensive without support. . #) CAD: Patient with diagnosed CAD, s/p Cypher stent to mid-LAD. Pateint underwent repeat cardiac catheterization on [**3-31**] in the setting of chest pain,. Probability of instent thrombosis was low and cath revealed patent mid-LAD cypher stent. Patient never had EKG changes. Patient also had US or R groin given a new bruit, although, as reported above, there was no evidence of fistula or aneurysm. The patient was continued on ASA & Plavix, and had daily EKG without changes. She had episodic bouts of chest pain without EKG changes and it was thought that these this pain was no ischemic. She was not given nitrates in the setting of mild HCM, and this pain responded well to low dose opiates. . #). Chest Pain: Patient with transient chest pain, nonpositional, nonpleuritic, not associated with SOB, and temporally associated with food intake. Probability of ischemia is low, recent re-cath negative, EKGs without significant changes. Patient may have an esophageal component of chest pain. Ddx includes DES, Zenker's diverticulum, GERD. Other less likely etiologies include Boerhaave's/MWT, Schatzki's ring. Patient has been CP free for over 24 hours and may benefit from an outpatient workup for possible GI relates issues. . #) Pump: Given Right heart catheterization, patient presented hypovolemic and is also hypotensive. Patient with known HCM and the best BP support for her was fluids. She was also transiently on neosynephrine to which she responded well. She received aggressive volume support and had mild pulmonary edema, that of which she autodiuresed well. Her diuretics were held and these were not restarted upon discharge. She was hoever, started on Toprol XL. . .#) Rhythm: hx of pAF, although not on Coumadin given prior hx of bleeding risk. Patient has hx of cardioversion in 2/[**2111**]. Patient was continue on Amiodarone 200 qd and monitored on telemetry without event. . #)UTI- Patient with urinary symptoms, and was started empirically on Bactrim for a 3 day course. . #) Dermatomysositis: - Continue Prednisone 2.5 mg po qd Medications on Admission: Prednisone 2.5 mg daily LD this am Methotrexate weekly LD [**2113-3-21**] Amiodarone 200 mg daily LD this am Fosamax weekly LD was Sunday [**3-26**] Aldactazide 2.5/25 mg daily LD this am ASA 325 mg @ 12:40pm today Benadryl 50 mg po @ 12:40 pm today Zantac 150 mg po @ 12:40 pm today Solumedrol 60 mg IV @ 12:40 am today Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*3* 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day for 10 days. Disp:*10 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 13. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO once a day for 10 days. Disp:*5 Tablet Sustained Release 24 hr(s)* Refills:*0* 14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Primary Diagnosis: Myocardial Infarction . Secondary Diagnoses: Hypertrophic cardiomyopathy Paroxysmal atrial fibrillation S/P DCCV in [**1-/2112**] CHF Dermatomyosistis diagnosed [**2107**] - on MTX/Prednisone Osteoporosis Cataracts Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating without assistance. Discharge Instructions: You were admitted for treatment of a heart attack. You had a stent placed into one of the main arteries of your heart. You also had low blood pressure that was treated with fluid hydration. . 1. Please take all medication as prescribed. 2. Please attempt to make all medical appointments. 3. Please return to the Emergency Room if you have any concerning symptoms. Followup Instructions: Please call your PCP: [**Last Name (LF) 32375**],[**First Name3 (LF) 2801**] M. [**Telephone/Fax (1) 32376**] . Please call [**Doctor First Name **] [**Doctor Last Name 1911**] for a follow-up appointment . Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2113-5-19**] 3:40 Completed by:[**2113-4-4**]

[ "428.0", "425.4", "410.71", "366.9", "599.0", "733.00", "427.31", "414.01", "710.3", "276.50" ]

icd9cm

[ [ [] ] ]

[ "37.23", "00.44", "88.56", "00.66", "00.45", "00.40", "36.07", "37.22" ]

icd9pcs

[ [ [] ] ]

13684, 13752

9254, 11476

251, 313

14030, 14109

2519, 3857

14524, 14904

1551, 1555

11848, 13661

13773, 13773

11502, 11825

6618, 7713

14133, 14501

1570, 2500

13837, 14009

201, 213

341, 1384

7730, 9230

13792, 13816

1406, 1487

1503, 1535

25,225

109,122

4372

Discharge summary

report

Admission Date: [**2177-2-4**] Discharge Date: [**2177-3-5**] Date of Birth: [**2147-8-13**] Sex: F Service: UROLOGY Allergies: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril / Heparin Agents Attending:[**First Name3 (LF) 11304**] Chief Complaint: Bilateral renal masses Major Surgical or Invasive Procedure: Bilateral laparoscopic radical nephrectomies, ex-lap and evacuation of hematoma History of Present Illness: 29yF with ESRD secondary to SLE s/p failed renal transplant in [**2174**] now with bilateral renal masses noted on MRI. Consultations with radiology, transplant nephrology, and urology felt that the primary concern was need for tissue diagnosis and removal to facilitate relisting as transplant candidate. The least morbid and most efficient approach was considered laparoscopic bilateral nephrectomies. Past Medical History: 1. SLE diagnosed [**2166**] complicated by lupus/nephritis, anemia, serositis and ascites 2. End stage renal disease secondary to lupus, HD T/Th/Sat 3. History of VSD s/p corrective surgery, age 13 4. Hypertension 5. ITP 6. MSSA endocarditis 7. Sickle cell trait 8. s/p left oophorectomy related to IUD associated infection 9. Restrictve lung disease noted on PFTs [**2166**]. In [**2173**], chest CT with diffuse ground glass opacities. 10. GERD 11. s/p cadaveric renal transplant on [**8-/2175**] complicated by rejection and capsule rupture 11/[**2174**]. 12. Right pelvic abscess s/p TAH/RSO 13. B/L renal solid masses Social History: No smoking, occasional alcohol, no drug use. Lives at home with husband and son. Not currently employed. Family History: NC Physical Exam: 98.6 84 130/72 18 94%RA GEN: AAOx3, NAD CHEST: CTAB CARDIOVASCULAR: RRR, 2-3/6 systolic murmur. Abd: soft, ND, min TTP Incision: c/d/i with steri strips Ext: no c/c/e Pertinent Results: [**2177-2-4**] 03:36PM GLUCOSE-83 UREA N-46* CREAT-11.2*# SODIUM-137 POTASSIUM-5.2* CHLORIDE-97 TOTAL CO2-29 ANION GAP-16 [**2177-2-4**] 03:36PM CALCIUM-8.5 MAGNESIUM-2.6 [**2177-2-4**] 03:36PM WBC-10.6# RBC-2.99* HGB-9.0* HCT-28.3* MCV-95 MCH-30.0 MCHC-31.7 RDW-21.3* [**2177-2-4**] 03:36PM PLT COUNT-105* [**2177-2-4**] 01:59PM TYPE-[**Last Name (un) **] PO2-54* PCO2-45 PH-7.43 TOTAL CO2-31* BASE XS-4 INTUBATED-INTUBATED [**2177-2-4**] 01:59PM GLUCOSE-248* LACTATE-3.3* NA+-136 K+-5.3 CL--98* [**2177-2-4**] 01:59PM HGB-9.2* calcHCT-28 [**2177-2-4**] 01:59PM freeCa-1.19 [**2177-2-4**] 01:09PM TYPE-[**Last Name (un) **] PO2-48* PCO2-45 PH-7.44 TOTAL CO2-32* BASE XS-5 [**2177-2-4**] 01:09PM GLUCOSE-131* LACTATE-2.4* NA+-138 K+-5.4* CL--99* [**2177-2-4**] 01:09PM HGB-10.1* calcHCT-30 [**2177-2-4**] 01:09PM freeCa-1.04* [**2177-2-4**] 11:10AM TYPE-[**Last Name (un) **] PO2-57* PCO2-53* PH-7.38 TOTAL CO2-33* BASE XS-4 INTUBATED-INTUBATED [**2177-2-4**] 11:10AM TYPE-[**Last Name (un) **] PO2-57* PCO2-53* PH-7.38 TOTAL CO2-33* BASE XS-4 INTUBATED-INTUBATED [**2177-2-4**] 11:10AM GLUCOSE-147* LACTATE-1.9 NA+-139 K+-5.1 CL--98* [**2177-2-4**] 11:10AM HGB-10.3* calcHCT-31 [**2177-2-4**] 11:10AM freeCa-1.06* [**2177-2-4**] 09:16AM TYPE-[**Last Name (un) **] PO2-60* PCO2-45 PH-7.44 TOTAL CO2-32* BASE XS-5 [**2177-2-4**] 09:16AM GLUCOSE-100 LACTATE-2.0 NA+-140 K+-4.9 CL--97* [**2177-2-4**] 09:16AM HGB-10.9* calcHCT-33 [**2177-2-4**] 09:16AM freeCa-1.09* [**2177-2-20**] 04:33AM BLOOD WBC-13.2* RBC-3.60* Hgb-11.2* Hct-32.6* MCV-91 MCH-31.1 MCHC-34.3 RDW-18.7* Plt Ct-143* [**2177-2-19**] 09:57AM BLOOD WBC-12.9* RBC-3.99* Hgb-11.9* Hct-37.0 MCV-93 MCH-29.7 MCHC-32.1 RDW-18.2* Plt Ct-104* [**2177-2-18**] 07:28PM BLOOD WBC-13.0* RBC-3.82* Hgb-11.6* Hct-34.9* MCV-91 MCH-30.4 MCHC-33.2 RDW-17.8* Plt Ct-72* [**2177-2-18**] 11:28AM BLOOD WBC-12.0* RBC-3.60* Hgb-11.3* Hct-32.5* MCV-90 MCH-31.2 MCHC-34.6 RDW-17.7* Plt Ct-74* [**2177-2-18**] 05:15AM BLOOD WBC-11.1* RBC-3.32* Hgb-10.2* Hct-30.5* MCV-92 MCH-30.7 MCHC-33.4 RDW-17.7* Plt Ct-64* [**2177-2-17**] 03:15AM BLOOD WBC-8.6 RBC-2.83* Hgb-8.8* Hct-24.9* MCV-88 MCH-31.2 MCHC-35.5* RDW-17.5* Plt Ct-63* [**2177-2-16**] 04:13PM BLOOD Hct-24.7* [**2177-2-16**] 03:04AM BLOOD WBC-7.9 RBC-2.94* Hgb-9.2* Hct-25.5* MCV-87 MCH-31.2 MCHC-36.0* RDW-17.4* Plt Ct-50* [**2177-2-15**] 09:48PM BLOOD Hct-24.8* [**2177-2-15**] 10:30AM BLOOD Hct-24.5* [**2177-2-14**] 08:45PM BLOOD WBC-10.2 RBC-3.22*# Hgb-9.9*# Hct-27.2*# MCV-85 MCH-30.7 MCHC-36.3* RDW-16.9* Plt Ct-64* [**2177-2-14**] 05:29PM BLOOD WBC-9.9 RBC-2.34* Hgb-7.2* Hct-20.0* MCV-86 MCH-30.9 MCHC-36.0* RDW-18.3* Plt Ct-74* [**2177-2-14**] 02:35PM BLOOD WBC-10.8 RBC-2.23* Hgb-6.7* Hct-19.2* MCV-86 MCH-30.2 MCHC-35.1* RDW-19.3* Plt Ct-94* [**2177-2-14**] 08:53AM BLOOD Hct-18.0* [**2177-2-14**] 05:38AM BLOOD Hct-21.0* Plt Ct-113* [**2177-2-14**] 02:01AM BLOOD WBC-15.2*# RBC-2.55* Hgb-7.9* Hct-23.3* MCV-91 MCH-30.8 MCHC-33.8 RDW-20.9* Plt Ct-109* [**2177-2-13**] 05:44AM BLOOD WBC-7.6 RBC-3.32* Hgb-10.1* Hct-29.3* MCV-88 MCH-30.5 MCHC-34.5 RDW-19.6* Plt Ct-85* [**2177-2-12**] 09:05PM BLOOD Hct-33.0* Plt Ct-85* [**2177-2-12**] 04:38AM BLOOD WBC-6.4 RBC-3.63* Hgb-11.1* Hct-32.7* MCV-90 MCH-30.7 MCHC-34.0 RDW-19.2* Plt Ct-90* [**2177-2-12**] 01:27AM BLOOD WBC-6.6 RBC-3.64* Hgb-10.7* Hct-32.6* MCV-90 MCH-29.4 MCHC-32.8 RDW-19.2* Plt Ct-100* [**2177-2-11**] 08:42PM BLOOD WBC-6.7 RBC-3.91* Hgb-11.6* Hct-33.8* MCV-86 MCH-29.7 MCHC-34.4 RDW-19.2* Plt Ct-75* [**2177-2-11**] 03:46PM BLOOD WBC-6.9 RBC-3.55* Hgb-10.5* Hct-32.0* MCV-90 MCH-29.7 MCHC-32.9 RDW-19.3* Plt Ct-76* [**2177-2-11**] 11:45AM BLOOD WBC-6.0 RBC-3.63* Hgb-11.1* Hct-31.9* MCV-88 MCH-30.5 MCHC-34.7 RDW-19.3* Plt Ct-104* [**2177-2-11**] 08:49AM BLOOD Hct-34.1* [**2177-2-11**] 04:05AM BLOOD WBC-8.2 RBC-3.65* Hgb-10.9* Hct-33.7* MCV-92 MCH-30.0 MCHC-32.4 RDW-19.2* Plt Ct-86* [**2177-2-10**] 08:08PM BLOOD WBC-7.8 RBC-3.63* Hgb-11.1* Hct-32.3* MCV-89 MCH-30.7 MCHC-34.5 RDW-19.4* Plt Ct-68* [**2177-2-10**] 01:26PM BLOOD WBC-7.2 RBC-3.78* Hgb-11.3* Hct-34.0* MCV-90 MCH-29.8 MCHC-33.2 RDW-19.0* Plt Ct-75* [**2177-2-10**] 03:10AM BLOOD WBC-7.9 RBC-3.89* Hgb-11.5* Hct-34.9* MCV-90 MCH-29.6 MCHC-33.0 RDW-19.0* Plt Ct-68* [**2177-2-9**] 07:45PM BLOOD Hct-35.3* Plt Ct-73* [**2177-2-9**] 09:32AM BLOOD Hct-36.6 Plt Ct-73* [**2177-2-9**] 05:48AM BLOOD WBC-8.5 RBC-3.97* Hgb-11.8* Hct-35.2* MCV-89 MCH-29.9 MCHC-33.6 RDW-19.3* Plt Ct-82* [**2177-2-9**] 12:55AM BLOOD WBC-9.0 RBC-3.88* Hgb-11.7* Hct-34.2* MCV-88 MCH-30.1 MCHC-34.1 RDW-19.1* Plt Ct-78* [**2177-2-8**] 08:40PM BLOOD WBC-10.2 RBC-4.07* Hgb-12.3 Hct-35.5* MCV-87 MCH-30.2 MCHC-34.7 RDW-19.1* Plt Ct-76* [**2177-2-8**] 04:52PM BLOOD WBC-9.3 RBC-4.02* Hgb-12.1 Hct-34.9* MCV-87 MCH-30.0 MCHC-34.6 RDW-19.0* Plt Ct-85* [**2177-2-8**] 12:41PM BLOOD WBC-10.8 RBC-4.28 Hgb-12.8 Hct-37.0 MCV-87 MCH-29.8 MCHC-34.4 RDW-19.0* Plt Ct-80* [**2177-2-8**] 08:49AM BLOOD WBC-8.7 RBC-3.66* Hgb-10.8* Hct-32.0* MCV-87 MCH-29.5 MCHC-33.8 RDW-19.5* Plt Ct-95* [**2177-2-8**] 03:18AM BLOOD WBC-7.7 RBC-3.06* Hgb-9.0* Hct-26.1* MCV-85 MCH-29.3 MCHC-34.4 RDW-20.2* Plt Ct-84* [**2177-2-7**] 11:55PM BLOOD WBC-7.4 RBC-2.85* Hgb-8.3* Hct-24.5* MCV-86 MCH-29.0 MCHC-33.8 RDW-19.9* Plt Ct-75* [**2177-2-7**] 08:28PM BLOOD WBC-7.1 RBC-2.62* Hgb-8.0* Hct-22.5* MCV-86 MCH-30.3 MCHC-35.3* RDW-20.3* Plt Ct-76* [**2177-2-7**] 02:01PM BLOOD Hct-23.2* [**2177-2-7**] 10:25AM BLOOD Hct-25.5*# [**2177-2-6**] 09:50AM BLOOD WBC-7.3 RBC-2.38* Hgb-7.1* Hct-22.9* MCV-96 MCH-29.9 MCHC-31.1 RDW-21.7* Plt Ct-105* [**2177-2-5**] 10:03PM BLOOD WBC-7.9 RBC-2.61* Hgb-8.0* Hct-24.5* MCV-94 MCH-30.6 MCHC-32.7 RDW-21.6* Plt Ct-79* [**2177-2-5**] 01:54PM BLOOD Hct-27.4* [**2177-2-5**] 05:26AM BLOOD WBC-9.0 RBC-2.67* Hgb-8.2* Hct-24.8* MCV-93 MCH-30.5 MCHC-32.9 RDW-21.7* Plt Ct-85* [**2177-2-4**] 03:36PM BLOOD WBC-10.6# RBC-2.99* Hgb-9.0* Hct-28.3* MCV-95 MCH-30.0 MCHC-31.7 RDW-21.3* Plt Ct-105* [**2177-2-15**] 12:51AM BLOOD Neuts-81.1* Lymphs-17.4* Monos-1.4* Eos-0 Baso-0.1 [**2177-2-14**] 02:01AM BLOOD Neuts-81.7* Lymphs-15.2* Monos-2.8 Eos-0.1 Baso-0.2 [**2177-2-8**] 12:41PM BLOOD Neuts-70.2* Lymphs-24.3 Monos-3.9 Eos-1.2 Baso-0.3 [**2177-2-15**] 12:51AM BLOOD Anisocy-1+ Poiklo-1+ Microcy-1+ [**2177-2-14**] 05:29PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-OCCASIONAL Target-OCCASIONAL [**2177-2-14**] 02:01AM BLOOD Anisocy-2+ Macrocy-1+ Microcy-1+ [**2177-2-8**] 12:41PM BLOOD Anisocy-2+ Poiklo-1+ Macrocy-1+ Microcy-1+ [**2177-2-20**] 04:33AM BLOOD Plt Ct-143* [**2177-2-20**] 04:33AM BLOOD PT-12.3 PTT-27.0 INR(PT)-1.1 [**2177-2-19**] 09:57AM BLOOD Plt Ct-104* [**2177-2-18**] 07:28PM BLOOD Plt Ct-72* [**2177-2-18**] 11:28AM BLOOD Plt Ct-74* [**2177-2-18**] 05:15AM BLOOD Plt Ct-64* [**2177-2-18**] 05:15AM BLOOD PT-12.0 PTT-26.5 INR(PT)-1.0 [**2177-2-17**] 03:15AM BLOOD Plt Ct-63* [**2177-2-17**] 03:15AM BLOOD PT-12.5 PTT-25.2 INR(PT)-1.1 [**2177-2-16**] 11:42AM BLOOD PT-13.1 PTT-25.8 INR(PT)-1.1 [**2177-2-16**] 03:04AM BLOOD Plt Ct-50* [**2177-2-15**] 04:14AM BLOOD Plt Ct-60* [**2177-2-15**] 04:14AM BLOOD PT-11.5 PTT-24.9 INR(PT)-1.0 [**2177-2-14**] 08:45PM BLOOD Plt Ct-64* [**2177-2-14**] 08:45PM BLOOD PT-9.3* PTT-24.5 INR(PT)-0.8* [**2177-2-14**] 05:29PM BLOOD Plt Ct-74* [**2177-2-14**] 05:29PM BLOOD PT-15.1* PTT-26.6 INR(PT)-1.4* [**2177-2-14**] 02:35PM BLOOD Plt Ct-94* [**2177-2-14**] 02:35PM BLOOD PT-14.9* PTT-27.2 INR(PT)-1.3* [**2177-2-14**] 08:53AM BLOOD PT-15.0* PTT-26.8 INR(PT)-1.3* [**2177-2-14**] 05:38AM BLOOD Plt Ct-113* [**2177-2-14**] 05:38AM BLOOD PT-15.2* PTT-26.6 INR(PT)-1.4* [**2177-2-14**] 02:01AM BLOOD Plt Ct-109* [**2177-2-14**] 02:01AM BLOOD PT-15.7* PTT-26.3 INR(PT)-1.4* [**2177-2-13**] 05:27PM BLOOD Plt Ct-95* [**2177-2-13**] 03:25PM BLOOD PT-14.1* PTT-25.1 INR(PT)-1.2* [**2177-2-13**] 02:12PM BLOOD Plt Ct-84* [**2177-2-13**] 05:44AM BLOOD Plt Ct-85* [**2177-2-13**] 05:44AM BLOOD PT-14.2* PTT-27.0 INR(PT)-1.3* [**2177-2-12**] 05:08PM BLOOD Plt Ct-76* [**2177-2-12**] 04:38AM BLOOD Plt Smr-LOW Plt Ct-90* [**2177-2-12**] 04:38AM BLOOD PT-13.1 PTT-23.8 INR(PT)-1.1 [**2177-2-12**] 01:27AM BLOOD Plt Ct-100* [**2177-2-12**] 01:27AM BLOOD PT-13.8* PTT-25.3 INR(PT)-1.2* [**2177-2-11**] 08:42PM BLOOD Plt Ct-75* [**2177-2-11**] 03:46PM BLOOD Plt Smr-VERY LOW Plt Ct-76* [**2177-2-11**] 03:46PM BLOOD PT-13.0 PTT-24.2 INR(PT)-1.1 [**2177-2-11**] 04:05AM BLOOD PT-13.7* PTT-25.4 INR(PT)-1.2* [**2177-2-10**] 08:08PM BLOOD Plt Ct-68* [**2177-2-10**] 08:08PM BLOOD PT-13.4* PTT-25.6 INR(PT)-1.2* [**2177-2-10**] 01:26PM BLOOD Plt Ct-75* [**2177-2-10**] 01:26PM BLOOD PT-13.5* PTT-24.0 INR(PT)-1.2* [**2177-2-10**] 03:10AM BLOOD PT-14.4* PTT-25.4 INR(PT)-1.3* [**2177-2-9**] 07:45PM BLOOD Plt Ct-73* [**2177-2-9**] 07:45PM BLOOD PT-13.8* PTT-24.7 INR(PT)-1.2* [**2177-2-9**] 01:41PM BLOOD Plt Ct-71* [**2177-2-9**] 09:32AM BLOOD Plt Ct-73* [**2177-2-9**] 05:48AM BLOOD Plt Ct-82* [**2177-2-9**] 05:48AM BLOOD PT-13.3* PTT-24.3 INR(PT)-1.2* [**2177-2-9**] 05:48AM BLOOD PT-13.3* PTT-24.3 INR(PT)-1.2* [**2177-2-9**] 12:55AM BLOOD Plt Ct-78* [**2177-2-9**] 12:55AM BLOOD PT-13.1 PTT-24.1 INR(PT)-1.1 [**2177-2-8**] 08:40PM BLOOD Plt Ct-76* [**2177-2-8**] 08:40PM BLOOD Plt Ct-76* [**2177-2-8**] 04:52PM BLOOD PT-11.9 PTT-22.7 INR(PT)-1.0 [**2177-2-8**] 12:41PM BLOOD Plt Ct-80* [**2177-2-8**] 12:41PM BLOOD PT-12.3 PTT-25.5 INR(PT)-1.1 [**2177-2-8**] 08:49AM BLOOD Plt Ct-95* [**2177-2-8**] 08:49AM BLOOD PT-12.6 PTT-23.4 INR(PT)-1.1 [**2177-2-8**] 03:18AM BLOOD Plt Ct-84* [**2177-2-7**] 11:55PM BLOOD PT-12.9 PTT-25.0 INR(PT)-1.1 [**2177-2-7**] 08:28PM BLOOD Plt Ct-76* [**2177-2-20**] 04:33AM BLOOD Fibrino-376 [**2177-2-16**] 11:42AM BLOOD Fibrino-389 [**2177-2-15**] 12:51AM BLOOD Fibrino-385 [**2177-2-14**] 05:29PM BLOOD Fibrino-287 [**2177-2-13**] 03:25PM BLOOD Fibrino-436* [**2177-2-12**] 09:05PM BLOOD Fibrino-323 [**2177-2-12**] 04:38AM BLOOD Fibrino-335 [**2177-2-11**] 08:42PM BLOOD Fibrino-304 [**2177-2-11**] 04:05AM BLOOD Fibrino-289 [**2177-2-10**] 03:10AM BLOOD Fibrino-287 [**2177-2-9**] 12:55AM BLOOD Fibrino-404* [**2177-2-8**] 08:49AM BLOOD Fibrino-341 D-Dimer-7832* [**2177-2-8**] 03:18AM BLOOD Fibrino-276 D-Dimer-7656* [**2177-2-7**] 11:55PM BLOOD Fibrino-285 D-Dimer-8650* [**2177-2-20**] 04:33AM BLOOD Glucose-103 UreaN-63* Creat-8.8* Na-137 K-4.3 Cl-100 HCO3-24 AnGap-17 [**2177-2-18**] 05:15AM BLOOD Glucose-118* UreaN-89* Creat-8.9*# Na-138 K-4.7 Cl-99 HCO3-23 AnGap-21* [**2177-2-16**] 03:04AM BLOOD Glucose-131* UreaN-38* Creat-5.0*# Na-143 K-4.0 Cl-103 HCO3-27 AnGap-17 [**2177-2-14**] 05:29PM BLOOD Glucose-125* UreaN-51* Creat-6.7* Na-139 K-5.1 Cl-102 HCO3-25 AnGap-17 [**2177-2-14**] 02:01AM BLOOD Glucose-108* UreaN-44* Creat-6.2*# Na-141 K-4.7 Cl-98 HCO3-29 AnGap-19 [**2177-2-12**] 04:38AM BLOOD Glucose-79 UreaN-52* Creat-6.1*# Na-141 K-3.5 Cl-99 HCO3-31 AnGap-15 [**2177-2-9**] 05:48AM BLOOD Glucose-90 UreaN-31* Creat-5.3* Na-138 K-4.3 Cl-95* HCO3-30 AnGap-17 [**2177-2-8**] 03:18AM BLOOD Glucose-108* UreaN-33* Creat-6.8*# Na-141 K-4.4 Cl-97 HCO3-31 AnGap-17 [**2177-2-7**] 01:03AM BLOOD Glucose-101 UreaN-24* Creat-5.0*# Na-142 K-2.8* Cl-100 HCO3-33* AnGap-12 [**2177-2-5**] 10:03PM BLOOD Glucose-101 UreaN-25* Creat-6.6*# Na-146* K-3.6 Cl-102 HCO3-29 AnGap-19 [**2177-2-5**] 05:26AM BLOOD Glucose-100 UreaN-53* Creat-12.1* Na-135 K-6.9* Cl-97 HCO3-28 AnGap-17 [**2177-2-14**] 05:29PM BLOOD LD(LDH)-269* [**2177-2-14**] 02:01AM BLOOD ALT-38 AST-22 LD(LDH)-311* AlkPhos-149* Amylase-65 TotBili-0.9 DirBili-0.4* IndBili-0.5 [**2177-2-13**] 05:44AM BLOOD ALT-43* AST-30 LD(LDH)-282* AlkPhos-141* Amylase-67 TotBili-0.6 DirBili-0.4* IndBili-0.2 [**2177-2-7**] 10:25AM BLOOD LD(LDH)-70* [**2177-2-20**] 04:33AM BLOOD Calcium-8.8 Phos-5.1* Mg-2.3 [**2177-2-18**] 05:15AM BLOOD Albumin-2.9* Calcium-6.6* Phos-6.5* Mg-2.4 [**2177-2-16**] 03:04AM BLOOD Calcium-8.0* Phos-7.0* Mg-1.9 [**2177-2-14**] 05:29PM BLOOD Calcium-7.9* Phos-6.6* Mg-1.8 [**2177-2-14**] 02:01AM BLOOD Albumin-3.6 Calcium-9.7 Phos-6.0* Mg-1.9 [**2177-2-12**] 04:38AM BLOOD Calcium-8.9 Phos-3.9# Mg-2.0 [**2177-2-10**] 03:10AM BLOOD Calcium-8.2* Phos-7.6* Mg-2.2 [**2177-2-7**] 06:02AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.9 [**2177-2-6**] 09:50AM BLOOD Calcium-8.0* Phos-5.5* Mg-2.1 [**2177-2-5**] 05:26AM BLOOD Calcium-8.9 Phos-7.4*# Mg-2.8* [**2177-2-17**] 06:00AM BLOOD Vanco-25.7* [**2177-2-15**] 06:10PM BLOOD Vanco-21.9* [**2177-2-8**] 05:16AM BLOOD Vanco-81.8* [**2177-2-19**] 04:53PM BLOOD Type-MIX pH-7.35 [**2177-2-15**] 01:27AM BLOOD Type-ART pO2-153* pCO2-29* pH-7.55* calTCO2-26 Base XS-4 [**2177-2-14**] 05:45PM BLOOD Type-ART Temp-37.2 pO2-141* pCO2-43 pH-7.46* calTCO2-32* Base XS-6 [**2177-2-14**] 12:25PM BLOOD Type-ART pO2-174* pCO2-49* pH-7.41 calTCO2-32* Base XS-5 Intubat-INTUBATED Vent-CONTROLLED [**2177-2-7**] 10:53AM BLOOD Type-[**Last Name (un) **] pH-7.48* [**2177-2-4**] 01:09PM BLOOD Type-[**Last Name (un) **] pO2-48* pCO2-45 pH-7.44 calTCO2-32* Base XS-5 [**2177-2-15**] 04:42AM BLOOD Glucose-126* Lactate-0.8 K-5.2 [**2177-2-14**] 08:54PM BLOOD Glucose-114* Lactate-1.7 K-5.1 [**2177-2-14**] 03:00PM BLOOD Lactate-1.7 [**2177-2-13**] 03:43PM BLOOD Lactate-1.2 [**2177-2-4**] 01:09PM BLOOD Glucose-131* Lactate-2.4* Na-138 K-5.4* Cl-99* [**2177-2-4**] 09:16AM BLOOD Glucose-100 Lactate-2.0 Na-140 K-4.9 Cl-97* [**2177-2-15**] 04:42AM BLOOD O2 Sat-98 [**2177-2-14**] 12:25PM BLOOD Hgb-9.1* calcHCT-27 [**2177-2-4**] 11:10AM BLOOD Hgb-10.3* calcHCT-31 [**2177-2-19**] 04:53PM BLOOD freeCa-1.15 [**2177-2-15**] 01:27AM BLOOD freeCa-1.15 [**2177-2-14**] 05:45PM BLOOD freeCa-0.98* [**2177-2-14**] 12:25PM BLOOD freeCa-1.01* [**2177-2-7**] 10:53AM BLOOD freeCa-1.03* [**2177-2-4**] 01:09PM BLOOD freeCa-1.04* [**2177-2-4**] 09:16AM BLOOD freeCa-1.09* ***RECENT RESULTS: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2177-3-4**] 07:30AM 8.1 3.56* 10.6* 33.2* 93 29.9 32.0 18.2* 134* [**2177-3-1**] 12:20PM 9.8 3.48* 10.3* 32.1* 93 29.7 32.1 18.2* 146* [**2177-2-28**] 05:45AM 6.9 3.19* 9.7* 29.2* 92 30.3 33.0 18.3* 157 [**2177-2-27**] 07:40AM 8.2 3.16* 9.6* 28.3* 90 30.5 34.0 18.1* 180 BASIC COAGULATION PT PTT INR(PT) Plt [**2177-2-27**] 07:40AM 12.5 28.3 1.1 180 [**2177-2-25**] 06:50AM 11.6 27.4 1.0 210 [**2177-2-24**] 05:20PM 11.8 27.7 1.0 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2177-3-4**] 07:30AM 113* 32* 9.4* 139 4.9 99 25 20 [**2177-3-1**] 12:20PM 27* 8.7* 138 5.3* 97 [**2177-2-27**] 07:40AM 75 34* 8.9*# 136 5.0 99 25 17 PTH [**2177-3-5**] 05:40AM 361* HEPATITIS HBsAg HBsAb [**2177-3-5**] 05:40AM PND PND Brief Hospital Course: - The patient was admitted on [**2-4**] and underwent left laparoscopic radical nephrectomy and right laparoscopic radical nephrectomy the same day. EBL 100cc. There were no intraoperative complications. The patient was stable and was transferred to the floor. The patient's post-operative course was complicated by post-op bleeding noted as increased abdominal pain and falling hematocrit on POD 2. The patient was transferred to the intensive care unit and Hematology was consulted. She was started on vancomycin for elevated temps. The patient was found to have a coagulopathy and aggressive resuscitation was started. She was also found to have a decreasing Plt count, thought to be from her uremia. She was transfused with PRBC's, platelets, FFP and cryo PRN to maintain her levels. A HIT Ab panel was sent which came back negative on the final tests. See table below for details. -PreOp --- Hct 33.4 BP 90/57 [**2-5**] (POD#1) Stable on 12R, sips --- Hct 27.4 BP 90/52 [**2-6**] (#2) taking clears, [**Last Name (un) 103**] pain in pm --- Hct 25.9 BP 85/55 [**2-7**] (am) low bp ?????? transfer unit --- Hct 20.2 BP 85/50 Initial Hematology consult ?????? possible DIC. Given baseline uremia manage with DDAVP, FFP, Cryo for fibrinogen > 100 and platelets for > 100. Initial Coagulation and DIC screen PT 13.8, PTT 66, INR 1.2 Fibrinogen 405, FDP 10-40, D-dimer 8500, Thrombin 150 -On POD #3 a CT of abd/pelvis was obtained which revealed 1. Bilateral retroperitoneal hematomas with some active extravasation on the left and the patient is status post bilateral nephrectomy. 2. Free intraperitoneal air status postop. 3. Coronary artery calcifications. 4. Several cystic areas in the pancreas which measure 1-2 mm which may represent IPMT. She contineud to have a significant requirement for PRBC's (9 units total at this point), platelets, and cryo. She was continued on DDAVP and was continued on hemodialysis. Due to difficulties in peripheral access a right femoral line was placed. An ECHO was obtained on POD #5 which revelaed a Linear mitral annular echodensity and mitral regure, which was seen on a previos echo. Blood and sputum cultures were sent which were both negative. The renal team followed the patient regarding her dialysis and electrolyte control. On POD #[**5-15**] the patient's platelt counts and coags stabilized and the DDAVP was held. She was kept on Vitamin K and estrogens. -On POD #9 the patient had a large requirement in her pain medications and developed severe increasing abdominal pain. She also had increased bleeding around her incision. A CT scan was obtained which showed 1. Marked interval increase in size of right retroperitoneal hematoma in the nephrectomy bed. Given the relative high attenuation of this collection, the degree of short-term increase in size, and the presence of a small hyperenhancing focus, active extravasation cannot be excluded. 2. Relatively stable left retroperitoneal hematoma. 3. Stable bilateral lower lobe airspace disease. . Stable cardiomegaly. Due to this finding the transplant general surgery team was consulted and it was felt that would need to return to the OR for a washout and to stop the bleeding. Her HCT reached a nadir of 18.0 for which she was transfused 5 units. -The patient was transferred to the SICU on the [**Hospital Ward Name **] and taken to the OR on POD #10 with Dr. [**Last Name (STitle) 3748**] and Dr. [**Last Name (STitle) **]. In the OR The right colon was mobilized and the large clot evacuated from the right retroperitoneum. Hemostasis was secured with argonbeam coagulation, application of topical hemostatic sheets and fibrin glue. There was a small hematoma on the left retroperitoneum, which was also controlled in a similar fashion. There were several mesenteric hematomas both in the small and large bowel, but all of the colon and small bowel itself was viable. Please see Dr. [**Last Name (STitle) 18846**] operative note for further details. The patient tolerated the procedure well and was sent back to the SICU postoperatively. She was given activated factor VIIa in the post operative period, which greatly improved her coagulopathies. At this point in her stay she had required 17u PRBC, 11u platelets, and 4u of cryo. After being given the factor VII, the patient did not require any further transfusions of blood products for the remainder of her hospital stay. -She was found to be hemodynamically stable and remained so, therefore she was transferred to the floor. Post-operatively she did very well. Her HCT's remained stable and her adbominal exam was much improved. Her vanco was d/c'd and her JP drains were d/c'd on [**2-18**]. She was continued on dialysis and her pain was controlled with a PCA. A chronic pain service consult was requested who started her on a PO pain regimen on [**2177-2-19**]. Her pain was controlled with PO meds, she was tolerating a regular renal diet, and her CVL was d/c's on [**2177-2-20**]. The renal team continued to follow to assist with her electrolye imbalances and dialysis management. Over the weekend on [**4-23**] the patient did extremely well - she was able to ambulate, her pain was controlled on PO meds, and she was tolerating a regular diet. On [**2-24**] the patient developed increasing left abdominal pain and her HCT dropped 4 points. The next day her HCt was down another two points and a noncontrasted CT scan was obtained which revealed 1. Post-surgical changes in both nephrectomy beds with fibrin net placement. 2. Decreased size of right nephrectomy bed hematoma. 3. Slight increase in size of fluid collection in left nephrectomy site. High-density internal areas likely represent residual clot. The collection is lower in Hounsfield units than on the prior study and is likely due to combination of hematoma and fluid. The patient was felt to be stable and a post dialysis HCT on [**2-26**] was back up to 31 (stable from previous checks). Blood cultures were sent on [**2-27**] and her HCT was stable. The patient continued to do well, tolerating her renal diet, ambulating, and her pain controlled on PO medications. -Due to some increase in abdominal pain on [**3-1**], a CT repeat CT was obtained which revelaed postsurgical changes in both nephrectomy beds with bilateral hematomas in evolution, which have not significantly changed in size compared to 4 days prior but are smaller and liquifying compared to [**2-13**]. On [**3-2**] a CXR was taken to evaluate some consolidation seen on the upper cuts of her abd CT. The CXR showed: Slight improvement in fluid balance with persistent bilateral patchy opacities in lung bases, suspicious for pneumonia or aspiration. Underlying pulmonary arterial hypertension as previously noted. The pulmonoly team was asked for advice on treatment of the consolidation and PA HTN, and recommended no Abx at this time due to the fact the the patient has no clinical symptoms of a pneumonia, she has been afebrile, and has a normal WBC. She will followup in pulmonology clinic for further eval of her PA HTN. On [**2096-3-1**] she was much improved. Her labs were stable and she had no further complaints. All of her cultures were negative to date, she has been afebrile, and has a normal WBC count. She is being discharged in stable condition, tolerating a regular renal diet, pain control on PO meds, ambulating well, with stable HCT's, WBC's, and a benign abdominal exam. She will start back on her home dialysis schedule at [**Hospital 1263**] hospital and will f/u with her PCP, [**Name10 (NameIs) **], and Dr. [**Last Name (STitle) 3748**]. Medications on Admission: AMOXIL 500 mg--4 tablet(s) by mouth 4 tabs one hour prior to procedure then 1 tab every 8 hours 1 hour prior to procedure AZTREONAM 1 gram--1 gram iv q24 hours until [**11-26**] Amitriptyline 50 mg--1 tablet(s) by mouth at bedtime for neuropathy DILAUDID 4 mg--1 tablet(s) by mouth twice a day as needed for pain IBUPROFEN 600MG--One pill by mouth every 6-8 hours as needed for joint pain NEPHROCAPS 1MG--One by mouth every day PREDNISONE 5MG--Take as directed PROTONIX 20MG--One by mouth every day for gerd Sevelamer 800 mg--1 tablet(s) by mouth three times a day phosphate binder Amitriptyline 75 mg--1 tablet(s) by mouth at bedtime for neuropathy Discharge Medications: 1. Folic Acid 1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. B-Complex with Vitamin C Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Sevelamer 800 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 6. Prednisone 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 8. Amitriptyline 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 9. Fentanyl 100 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Transdermal Q72H (every 72 hours). Disp:*10 patches* Refills:*2* 10. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*180 Capsule(s)* Refills:*2* 11. Hydromorphone 2 mg Tablet [**Last Name (STitle) **]: 1-3 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: care group vna Discharge Diagnosis: Bilateral renal masses Discharge Condition: Stable Discharge Instructions: [**Name8 (MD) **] M.D. if fever > 101.5, nausea, vomiting, increasing abdominal pain, shortness of breath, chest pain, difficulty urinating, , noted bleeding, dizziness, or any other concerns. [**Month (only) 116**] resume a regular renal diet as directed. Activity as tolerated except no heavy lifting or strenuous activity. You may take a shower but no tub bathing or soaking until followup. A VNA will visit you for the first week to assess your wound and make sure you are not having any problems. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 3748**] in 2 weeks. Please call ([**Telephone/Fax (1) 18591**] to schedule your appointment. Please call for an appointment to followup with Pulmonology. Call ([**Telephone/Fax (1) 513**] to schedule an appointment in [**12-10**] weeks for followup of pulmonary hypertension. Please followup with you PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 1 week for reassesment of your home medications, followup. Call ([**Telephone/Fax (1) 18847**]. Please resume your normal dialysis schedule at [**Hospital 1263**] hospital. Please call [**Telephone/Fax (1) 18848**] to set up your next appointment Completed by:[**2177-3-5**]

[ "V42.0", "228.04", "282.5", "V58.65", "753.19", "403.91", "416.8", "286.9", "585.6", "285.1", "338.18", "710.0", "998.11" ]

icd9cm

[ [ [] ] ]

[ "54.19", "39.95", "99.77", "99.07", "99.06", "55.54", "99.00", "99.05", "99.04" ]

icd9pcs

[ [ [] ] ]

26366, 26411

16493, 24144

355, 437

26478, 26486

1874, 16470

27036, 27733

1657, 1661

24845, 26343

26432, 26457

24170, 24822

26510, 27013

1676, 1855

293, 317

465, 872

894, 1518

1534, 1641

21,752

198,878

24434

Discharge summary

report

Admission Date: [**2201-4-21**] Discharge Date: [**2201-4-25**] Date of Birth: [**2146-2-5**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2698**] Chief Complaint: s/p cath with hypotension Major Surgical or Invasive Procedure: Cardiac catheterization s/p stent to LCX History of Present Illness: 55 yo male inmate who fell out of bunk bed, found seizing, shocked twice, intubated. EKG showed inferior STE with lateral STD and anterior STD. He received lidocaine 2 mg, then lidocaine drip, lopressor, valium 10 mg IV x3, dilantin 1 gram IV, [**First Name3 (LF) **] 325 mg, heparin drip. He also got vecuronium, etomidate for intubation. CK 206, Trop I 0.6, WBC 12.7 EKG: Sinus, STE inferiorly, ST depression anterolaterally. EF 35% Cath showed total occlusion of LCX which was stented. IABP was placed for hypotension. He was started on neosynephrine and dopamine in the cath lab. He was also given antibiotics and steroids for question of dye allergy. CO 10.68, CI 5.32, RA 9, RV 37/6, PA 35/13, mean 21, PCW 11. Past Medical History: Hypertension Social History: In prison Physical Exam: Afebrile, BP: 80-100/50-60, HR 80's, RR 18 on vent, 100% on vent GENL: intubated, sedated HEENT: Intubated CV: RRR +systolic murmur LUNGS: CAT ABD: soft, nt, nd, +bs Ext: trace pedal edema Skin: erythmatous rash on buttocks Pertinent Results: Echo: Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with dyskinesis of the basal half of the inferior wall and akinesis of the basal half of the inferolateral wall. The remaining segments contract well (overall). Trace aortic regurgitation is seen. No mitral regurgitation is seen. Physiologic mitral regurgitation is seen (within normal limits). There is an anterior space which most likely represents a fat pad. - - [**2201-4-25**] 06:55AM BLOOD WBC-7.4 RBC-4.29* Hgb-12.3* Hct-36.7* MCV-86 MCH-28.7 MCHC-33.5 RDW-13.5 Plt Ct-181 [**2201-4-21**] 07:58PM BLOOD Neuts-80* Bands-12* Lymphs-6* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2201-4-23**] 04:12AM BLOOD Neuts-79.7* Lymphs-14.5* Monos-5.0 Eos-0.5 Baso-0.3 [**2201-4-21**] 07:58PM BLOOD WBC-14.4* RBC-4.96 Hgb-14.3 Hct-41.5 MCV-84 MCH-28.9 MCHC-34.5 RDW-12.9 Plt Ct-210 [**2201-4-25**] 06:55AM BLOOD Plt Ct-181 [**2201-4-24**] 02:08AM BLOOD PT-12.4 PTT-24.4 INR(PT)-1.0 [**2201-4-25**] 06:55AM BLOOD Glucose-88 UreaN-12 Creat-0.8 Na-142 K-4.1 Cl-104 HCO3-28 AnGap-14 [**2201-4-21**] 07:58PM BLOOD Glucose-185* UreaN-11 Creat-0.7 Na-143 K-4.2 Cl-110* HCO3-23 AnGap-14 [**2201-4-24**] 02:08AM BLOOD CK(CPK)-924* [**2201-4-23**] 04:12AM BLOOD ALT-43* AST-81* CK(CPK)-1025* AlkPhos-75 TotBili-0.2 [**2201-4-22**] 12:15PM BLOOD CK(CPK)-1777* [**2201-4-22**] 04:10AM BLOOD CK(CPK)-2085* [**2201-4-21**] 07:58PM BLOOD ALT-59* AST-95* LD(LDH)-403* CK(CPK)-1483* AlkPhos-91 TotBili-0.5 [**2201-4-24**] 02:08AM BLOOD CK-MB-9 [**2201-4-23**] 04:12AM BLOOD CK-MB-46* MB Indx-4.5 cTropnT-1.36* [**2201-4-22**] 12:15PM BLOOD CK-MB-151* MB Indx-8.5* [**2201-4-22**] 04:10AM BLOOD CK-MB-268* MB Indx-12.9* cTropnT-2.76* [**2201-4-21**] 07:58PM BLOOD CK-MB-178* MB Indx-12.0* cTropnT-0.98* [**2201-4-25**] 06:55AM BLOOD Mg-1.9 [**2201-4-21**] 07:58PM BLOOD Albumin-4.3 Calcium-8.8 Phos-1.6* Mg-1.6 [**2201-4-24**] 02:08AM BLOOD LDLmeas-72 [**2201-4-23**] 04:12AM BLOOD Triglyc-657* HDL-36 CHOL/HD-4.7 LDLmeas-52 [**2201-4-21**] 11:30PM BLOOD Cortsol-36.7* [**2201-4-24**] 02:08AM BLOOD Phenyto-21.1* Brief Hospital Course: 55 yo M s/p fall from bunk bed, seizure, STEMI, s/p cath with stent to LCX, post cath course complicated by hypotension requiring pressors, intra-aoritc ballon pump. 1. STEMI: His EKG showed SR, STE in inferior leads and SFD in lateral leads. He ruled in by enzymes. He is S/P cath with stent to LCX. He was started on [**Last Name (LF) 4532**], [**First Name3 (LF) **], metoprolol and lisinopril. He will need 6 months of [**First Name3 (LF) 4532**]. His repeat echo showed an improved EF of 55% from 35% peri-MI. He does not required ICD given that he had an MI and that explains his VT/VF arrest. 2. Hypotension: Initial differential included cardiogenic shock v. septic shock v. acute blood loss. Swan numbers more c/w sepsis (CO 10 and CI 5.5). Dopamine and neosyephrine were weaned shortly after arrival to CCU. IABP was discontinued. His BP was stable. Cultures drawn but no growth. He was started on vancomycin, levofloxacin and flagyl. Antibiotics were discontinued after 48 hours after no growth of cultures and no fever or elevated WBC. There was also concern for RP bleed post cath given his hypotnesion. CT was negative for RP bleed. 3. Respiratory: He was intubated in field during seizure. He was extubated on HD 2 without complication. 4. Fall: Neck CT with no fracture. No tenderness to suggest ligamentous injury. Neck cleared on HD 2 and collar removed. 5. Seizures: Neurology team consulted on the patient. He was reloaded with dilantin and placed on dilantin 100 mg TID. Neurology recommended weaning the dilantin over 2 weeks. His seizure was felt to be secondary to his STEMI. He would benefit from an outpatient MRI to [**Doctor First Name **];uate for potential predisposition to seizure. 6. Disposition: He was medically stable for discharge on [**2201-4-25**]. His ambulating oxygen sat was 92%. He was able to walk up 12 stairs. He was slightly unsteady and deconditioned on his feet and would benefit from physical therapy. Medications on Admission: ?antihypertensive medication Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO once a day. 7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 5 days: Take 100 mg [**Hospital1 **] for 5 days, then 100 mg QD for 5 days, then stop. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Extended Care Discharge Diagnosis: STEMI Seizures Discharge Condition: Good Discharge Instructions: Take all medications as prescribed. You now take medications for your heart attack. You need to take [**Hospital1 4532**] for at least 6 months because of your stent. You should not stop until told to do so by your cardiolgist. Follow up with a cardiologist within 1-2 months. You need an MRI of your brain to evaluate for any predisposition for seizures. Followup Instructions: Follow up with a cardiologist within 1-2 months. You need an MRI of your brain to evaluate for any predisposition for seizures.

[ "E884.4", "458.8", "276.5", "427.1", "427.5", "414.01", "410.41", "780.39" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.61", "37.23", "89.64", "96.71", "36.07", "36.01" ]

icd9pcs

[ [ [] ] ]

6307, 6322

3590, 5544

321, 364

6381, 6387

1434, 3567

6791, 6922

5623, 6284

6343, 6360

5570, 5600

6411, 6768

1189, 1414

256, 283

392, 1111

1133, 1147

1163, 1174

27,142

139,112

13575

Discharge summary

report

Admission Date: [**2151-2-8**] Discharge Date: [**2151-3-4**] Date of Birth: [**2088-2-4**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Type A dissection seen on CTA [**2-5**] Major Surgical or Invasive Procedure: None. History of Present Illness: 63 yo M with history of afib, CHF, Bentall with mechanical valve in [**2132**]. Presented with ascites, concern for SBP so underwent paracentesis. HCT dropped, CT scan showed large left sided abdominal hematoma as well as ascending and arch aortic aneurysm with chronic dissection. He was transfused 13 units [**Hospital 40999**] transferred to [**Hospital1 **] for further evaluation. Past Medical History: PMH: cirrhosis secondary to ETOH, ?hepatitis C(pt denies hep C), chronic afib, HTN, COPD PSH: AVR(mechnical) with Aortic reconstruction Social History: lives alone quit smoking 2 months ago, 1 ppd x 45 yrs 5 etoh/day until 2 months ago Family History: NC Physical Exam: T: 99.3 BP: 106/54 P: 86 RR: O2 sat: 97% RA Gen: speaking in full sent, NAD HEENT: PERRL, EOMI, MMM CV: irreg irreg, mechanical valve, 2/6 systolic murmur, best at apex Resp: CTA b/l Abd: distended, echymosis over left lower quadrant, ttp over left lower quadrant. No hepatomegaly. Examination of spleen limited by pain Ext: 1+ pedal edema, 2+ pedal pulses b/l. b/l venous stasis changes Neuro: AAO, no asterixis. CN II-XII intact. Brief Hospital Course: He was admitted to the CVICU. He was started on IV heparin for his mechanical AVR, with frequent hematacrit checks. His HCT was stable and he was transferred to the floor. He was started on coumadin. He developed an ileus likely secondary to narcotic use and and NGT was placed. Serial KUB showed improvement and the NGT was removed and his diet was advanced succesfully. Scan showed an abdominal intramuscular hematoma.Paracentesis done. His INR on coumadin became supertherapeutic during his period of not eating secondary to his ileus.Gentle diuresis continued. His INR was allowed to drift down and then his coumadin was restarted at a lower dose than he usually takes at home. IV heparin started when his INR became subtherapeutic.Rehab screening continued. His abdominal intramuscular hematoma was monitored while coumadin dosing was adjusted.Nutritional consult done to teach pt. about fluid restrictions.Bowel regimen started for constipation. Cleared for discharge to rehab on [**3-4**]. Target INR is 2.0-2.5 for mechanical valve and A fib. IV heparin is to continue until INR 2.0 or greater. Pt. is to follow up with Dr. [**Last Name (STitle) 17025**] in [**1-20**] weeks. Medications on Admission: lopressor 12.5", aldactone 50", doxazosin 1', lasix 80", kayciel replacement, percocet prn, digoxin 0.25', xanax prn, coumadin Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO once a day. 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Coumadin 5 mg Tablet Sig: Two (2) Tablet PO once for today only 2/14 days: then all further daily dosing per rehab provider-[**Name10 (NameIs) **] INR 2.0-2.5. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 15. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once a day: please check potassium levels daily and adjust repletion accordingly. 16. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 1300 (1300) units per hour Intravenous ASDIR (AS DIRECTED): goal PTT 60-80 until INR 2.0 or greater for mechanical valve. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] TCU - [**Location (un) 701**] Discharge Diagnosis: Chronic aortic arch dissection Ileus cirrhosis secondary to ETOH chronic afib HTN COPD s/p AVR(mechanical) with Aortic reconstruction Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Take coumadin as directed to reach an INR goal of [**2-20**].5 for a mechanical aortic valve. Make all follow appts. as scheduled. Monitor blood pressure for ANY elevations and contact Dr. [**Last Name (STitle) 17025**] Followup Instructions: Dr. [**Last Name (STitle) 17025**] 1-2 weeks Completed by:[**2151-3-4**]

[ "787.91", "790.92", "789.59", "428.0", "571.2", "V12.09", "553.1", "496", "427.31", "V43.3", "560.1", "441.01", "E935.8", "276.8", "998.12", "373.11", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4351, 4427

1534, 2720

358, 365

4605, 4613

4927, 5003

1058, 1062

2898, 4328

4448, 4584

2747, 2875

4637, 4904

1077, 1511

279, 320

393, 780

802, 940

956, 1042

81,407

167,539

14155

Discharge summary

report

Admission Date: [**2141-2-22**] Discharge Date: [**2141-3-10**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: ascending aortic aneurysm (8.9cm)-incidental finding Major Surgical or Invasive Procedure: repair of ascending aortic aneurysm, aortic valve replacement (21mm tissue [**Last Name (un) 3843**]/[**Doctor Last Name **]) under circulatory arrest [**2-22**], chest closure [**2141-2-23**], permanent pacemaker [**2141-3-1**], evacuation of tamponade [**2140-3-1**] History of Present Illness: The patient is an 85yo white male who was found to have an 8.9cm ascending aortic aneurysm during a recent workup for prostate cancer. He does admit to dyspnea on exertion as well as worsening fatigue. He is admitted for surgical management. Past Medical History: ascending aortic aneurysm prostate cancer, s/p external beam radiation [**2124**] gastroesophageal reflux diseaase (h/o esophageal stricture) atrial fibrillation/ atrial flutter- s/p cardioversion/ablations diverticular disease cholelithiasis s/p appendectomy, hernia repair, decortication for empyema (2yo), esophageal dilatation Social History: retired machinist, lives with wife, currently maintains two family homes, denies tobacco, 1 alcoholic beverage per day Family History: denies family history of premature coronary artery disease Physical Exam: Admission: VS: 124/92, 74, 20 General: elderly white male in NAD Skin: unremarkable HEENT: unremarkable Neck: supple, full ROM Chest: lungs CTAB Heart: irregular with murmur Abdomen: soft, non-tender, non-distended, +BS extremities: warm, well-perfused, gross edema bilaterally, no varicosities Neuro: grossly intact pulses: 1+ throughout bilaterally no carotid bruits Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-3-10**] 04:47AM 11.6* 2.87* 9.3* 27.6* 96 32.5* 33.9 18.5* 268 Source: Line-picc BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct [**2141-3-10**] 04:47AM 268 Source: Line-picc Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-3-10**] 04:47AM 95 38* 1.8* 142 3.9 108 28 10 Source: Line-picc ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2141-3-10**] 04:47AM 98* 140* 444* 216* 10.1* Source: Line-picc CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2141-3-10**] 04:47AM 2.4* Source: Line-picc Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 42131**],[**Known firstname **] J. [**2055-2-6**] 86 Male [**Numeric Identifier 42132**] [**Numeric Identifier 42133**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif SPECIMEN SUBMITTED: aortic valve leaflets, aortic tissue. Procedure date Tissue received Report Date Diagnosed by [**2141-2-22**] [**2141-2-23**] [**2141-2-27**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 1431**]/dsj?????? DIAGNOSIS: 1. Heart valve, aortic (A): With calcification and degenerative changes. 2. Aortic tissue (B): With atherosclerosis, medial degeneration and adventitial chronic inflammation. Clinical: Coronary artery disease, AVR; ascending aorta; ? coronary artery bypass. Gross: The specimen is received fresh labeled with the patient's name, "[**Known lastname 34366**], [**Known firstname **]" and the medical record number. Part 1 is additionally labeled "aortic valve leaflets." It consists of three aortic valve leaflets. They are arbitrarily designated 1, 2, and 3. Leaflet 1 measures 2.9 cm across the base, 1.6 cm from apex to base and 0.5 cm in thickness. Leaflet 2 measures 2.8 cm across the base, 1.7 cm from apex to base, and 0.3 cm in thickness. Leaflet 3 measures 1.8 cm across the base and 1.7 cm from apex to base and 0.4 cm in thickness. All three leaflets are mildly calcified. It is represented in A. Part 2 is additionally labeled "aortic tissue." It consists of a segment of aorta, measuring 10.1 cm in length and 7.5 cm in greatest diameter. The adventitial surface is pink, red and mottled. The intimal surface is irregular and heterogeneously yellow and tan. The aorta measures 0.4 cm in maximal thickness. Additionally received are smaller fragments of aorta measuring 11.5 x 6.0 x 0.4 cm in aggregate. These fragments are similar to the large section of aorta. It is represented in B. By his/her signature above, the senior physician certifies that he/she personally conducted a gross and/or microscopic examination of the described specimens(s) and rendered or confirmed the diagnosis(es) related thereto. Immunohistochemistry test(s), if applicable, were developed and their performance characteristics were determined by The Department of Pathology at [**Hospital1 69**], [**Location (un) 86**], MA. They have not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. These tests are used for clinical purposes. They should not be regarded as investigational or for research. This laboratory is certified under the Clinical Laboratory Improvement Amendments of [**2120**] (CLIA - 88) as qualified to perform high complexity clinical laboratory testing. [**Known lastname **],[**Known firstname **] J. [**Medical Record Number 42134**] M 86 [**2055-2-6**] Radiology Report ABDOMEN U.S. (PORTABLE) Study Date of [**2141-3-4**] 8:35 PM [**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2141-3-4**] 8:35 PM ABDOMEN U.S. (PORTABLE) Clip # [**Clip Number (Radiology) 42135**] Reason: RUQ US to r/o biliary obstruction [**Hospital 93**] MEDICAL CONDITION: 86 year old man with elevated bilirubin REASON FOR THIS EXAMINATION: RUQ US to r/o biliary obstruction Final Report INDICATION: 86-year-old male with elevated bilirubin. Evaluate for biliary obstruction. COMPARISON: None. FINDINGS: Ultrasound of the right upper quadrant performed. Exam is limited by poor acoustic windows secondary to overlying bandage. The liver shows normal echogenicity without focal lesion. The gallbladder is normal without evidence of stone. There is no intra- or extra-hepatic biliary dilatation. The common duct measures 3 mm. The portal vein is patent with hepatopetal flow. The right kidney shows no hydronephrosis. IMPRESSION: Limited exam secondary to poor acoustic windows from overlying bandage. The liver and gallbladder are normal. No intra- or extra-hepatic biliary dilatation. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] Approved: SUN [**2141-3-5**] 4:45 PM Imaging Lab [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 42136**] (Complete) Done [**2141-2-22**] at 4:44:21 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2055-2-6**] Age (years): 86 M Hgt (in): 63 BP (mm Hg): / Wgt (lb): 128 HR (bpm): BSA (m2): 1.60 m2 Indication: ascending aorta and hemiarch replacement with AVR ICD-9 Codes: 440.0, 424.1, 424.0 Test Information Date/Time: [**2141-2-22**] at 16:44 Interpret MD: [**Known firstname **] [**Last Name (NamePattern1) **], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW2-: Machine: 2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Annulus: 1.9 cm <= 3.0 cm Aorta - Ascending: *8.0 cm <= 3.4 cm Aorta - Arch: *8.3 cm <= 3.0 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Markedly dilated ascending aorta. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Moderate to severe (3+) AR. MITRAL VALVE: Mild mitral annular calcification. The MR vena contracta is <0.3cm. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Results were Conclusions PREBYPASS * patient has a histroy of esophageal strictures which have been dilated ~ 20 times over the past 25 years. He has had successful TEE (without transgastric view) without problems in the past. Only midesophageal views obtained. 1. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). 2. Right ventricular chamber size and free wall motion are normal. 3. The ascending aorta is markedly dilated The aortic valve leaflets are severely thickened/deformed. Moderate to severe (3+) aortic regurgitation is seen. 4. Mild (1+) mitral regurgitation is seen. 5. There is no pericardial effusion. 6. Dr. [**Last Name (STitle) 914**] was notified in person of the results during the surgery. POSTBYPASS 1. Patient on norepinephrine, epinephrine, phenylephrine, and vasopressin 2. Left ventricular function remains good with an EF 55% 3. A well seated, well functioning prostetic valve is seen in the aortic position. No transgastric views were obtained. 4. As volume transfusion progresses, the RV function began to decline. Epinephrine started with moderate return of function. 5. Dr [**Last Name (STitle) 914**] aware I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Known firstname **] [**Last Name (NamePattern1) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2141-2-24**] 09:26 ?????? [**2135**] CareGroup IS. All rights reserved. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier **]Portable TTE (Complete) Done [**2141-3-2**] at 11:24:30 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2055-2-6**] Age (years): 86 M Hgt (in): 63 BP (mm Hg): 105/67 Wgt (lb): 128 HR (bpm): 96 BSA (m2): 1.60 m2 Indication: Evaluate for Tamponade. ICD-9 Codes: 423.9 Test Information Date/Time: [**2141-3-2**] at 11:24 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **] Doppler: Limited Doppler and no color Doppler Test Location: West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2009W005-0:00 Machine: Vivid [**8-8**] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: >= 55% >= 55% Pericardium - Effusion Size: 2.7 cm Findings This study was compared to the prior study of [**2141-2-27**]. LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). PERICARDIUM: Large pericardial effusion. Effusion echo dense, c/w blood, inflammation or other cellular elements. RV diastolic collapse, c/w impaired fillling/tamponade physiology. GENERAL COMMENTS: Echocardiographic results were reviewed by Conclusions Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is a large pericardial effusion anterior to the right ventricle. The effusion is echo dense, most consistent with blood. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. IMPRESSION: Large anterior intrapericardial hematoma with right ventricular compression and tamponade physiology. Compared with the prior study (images reviewed) of [**2141-2-27**], anterior pericardial effusion has expanded, compressing the right ventricle. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2141-3-2**] 11:38 ?????? [**2135**] CareGroup IS. All rights reserved. Brief Hospital Course: The patient was brought to the operating room on [**2141-2-22**] where he underwent aortic valve replacement and replacement of the ascending aorta and hemi-arch with a 28mm gelweave graft. Please see full operative report for details. The patient had significant bleeding and multiple blood products were used. Satisfactory hemostasis could not be achieved, so the patient's chest was left open. He returned to the operating room the following day, [**2141-2-23**] for mediastinal exploration and chest closure. The patient tolerated this procedure well and left the operating room on levophed. On POD 2 the patient developed rapid atrial fibrillation, which he did not tolerate hemodynamically. He was started on amiodarone and cardioverted to an underlying rhythm of asystole. He was A-paced and remained pacer dependent. Electrophysiology was consulted and placed a temporary pacing wire at the bedside under fluoro. The patient received a St. [**Male First Name (un) 923**] permanent pacemaker on [**2141-3-1**]. The patient had a prolonged intubation, and tube feeds were started for nutrition. Chest tubes were discontinued on POD 3. The patient was extubated on [**2141-2-28**]. He became confused and agitated and attempted to remove his lines, therefore was placed in restraints. Coumadin was initiated for atrial fibrillation. On [**2141-3-2**], the patient was found to be slightly hypotensive with a rising PT/INR. Echo demonstrated tamponade physiology with RV collapse, and the patient returned to the operating room for evacuation of pericardial clot and left pleural effusion. Following this, the patient returned to [**Location 42137**] on epi and neo. The patient was found to have hematuria, and GU consult was obtained. Given his history of prostate cancer and radiation treatment, and anticoagulation- hematuria is not an unusual finding. The patient is instructed to follow up with GU [**7-10**] weeks post-op. He developed a leukocytosis and infectious disease was consulted. He was found to grow pseudomonas from sputum and urine, and zosyn therapy was initiated. The patient was again extubated on [**2141-3-4**]. He developed jaundice, and was found to have elevated LFTs, including a Tbili of 15. GI was consulted. Likely explanation is hemolysis from multiple blood products received. The patient made progress and was transferred to the telemetry floor on [**2141-3-7**]. he continue to do well w/ WBC, LFT's, BUN/CREAT trending downward. He is diuresisng slowly. Remains on zosyn until [**2141-3-13**]. He was screened by PT and rehab was recommended. 2/4/9 Medications on Admission: atenolol 25mg daily spectravite multivitamin daily advil pm prn Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 6. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks: until edema resloves. 8. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: 2.25 gms Intravenous Q6H (every 6 hours) for 3 days. 9. picc line care pic line care and flushes per protocol non-heparin dependent line. 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: 9cm ascending aortic aneurysm, prostate cancer (s/p external radiation [**2124**]), GERD (h/o esophageal stricture), h/o afib/flutter-s/p ablations, diverticular dz, cholelithiasis, s/p appy, herniorraphy, empyema s/p R decortication @2yo, esophageal dilatation hematuria- blood clots- keep foley until urology appointment. Discharge Condition: deconditioned. Discharge Instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks shower daily, no baths or swimming for 6 weeks no lotions, creams or powders to incisions report any redness of, or drainage from incisions report any weight gain greater than 2 pounds a day or 5 pounds a week report any fever greater than 100.5 take all medications as directed zosyn will be completed last dose [**2141-3-13**] Keep foley until urology follow up [**2141-3-23**]- irrigant as needed. Followup Instructions: Dr. [**Last Name (STitle) 770**] (urology) [**Telephone/Fax (1) 5727**], [**3-23**] 4pm, [**Hospital1 18**], [**Hospital Ward Name 23**] [**Location (un) **] Follow up with Dr. [**Last Name (STitle) 914**] in 4 weeks Follow up with PCP and cardiologist when d/c'd from rehab Completed by:[**2141-3-10**]

[ "997.1", "518.81", "293.0", "585.9", "999.89", "423.3", "286.6", "998.11", "427.5", "V10.46", "441.2", "599.71", "E878.2", "424.1", "511.9", "562.10", "530.81", "427.81", "285.1" ]

icd9cm

[ [ [] ] ]

[ "35.21", "86.59", "37.83", "96.71", "99.61", "39.61", "34.09", "38.45", "37.78", "37.72", "37.12", "96.72" ]

icd9pcs

[ [ [] ] ]

16971, 17050

13287, 15898

320, 590

17418, 17435

1833, 5914

17973, 18279

1369, 1429

16013, 16948

5954, 5994

17071, 17397

15924, 15990

17459, 17950

1444, 1814

228, 282

6026, 13264

618, 863

885, 1217

1233, 1353

57,642

131,270

39717

Discharge summary

report

Admission Date: [**2152-8-12**] Discharge Date: [**2152-8-17**] Date of Birth: [**2116-3-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2195**] Chief Complaint: Somnolence Major Surgical or Invasive Procedure: None. History of Present Illness: 36 yo male presenting from a prerelease center with somnolence. He had reportedly been not feeling well at home for the last 6 days with no oral intake. Then last night he was reportedly more somnolent and spent the night on the floor per roommates. He lives in a halfway house in [**Location (un) 86**] and has lived there for approximately 2 weeks. In the ED, initial vitals were T 92 BP 93/56 HR 88 RR 24 O2 Sat 100%. He was noted to be somnolent. FSBS was 600. Initial VBG showed 7.00/41/59/11/-21 and chem7 showed Na 122, K 6.4, lipase 285. He was given 10units IV insulin, started on an insulin gtt @ 7units/hr, 1g calcium gluconate, 3-4L NS and vancomycin/zosyn. A bair hugger was also placed. EKG showed peaked T waves with [**Doctor Last Name **] waves, with ? ST elevation in in V1, though these changes resolved after starting rewarming. Repeat ABG one hour later was 7.12/24/203/8/-20. Vitals on transfer T 35.3 HR 104 BP 116/63 O2 Sat 100%2L. Initial FS in the MICU was approximately 1500. Past Medical History: Last PPD [**1-5**] negative Last annual visit [**1-5**] (refused physical exam) Per incarceration records, has h/o substance abuse, alcohol use, and drug use. Denied h/o DM on past medical reports Social History: Lives in [**Location 87520**] center/halfway house in [**Hospital1 778**], [**Location (un) 86**]. Smokes. In [**1-5**], drank few beers daily. Also used marijuana, denied IVDU. Family History: No history of DM. Physical Exam: Upon admission: VS: 98.1 114 114/62 28 98%2L GEN: Somnolent, responsive only to pain [**Date Range 4459**]: Pupils equal and minimally reactive, anicteric, MM dry, no supraclavicular or cervical lymphadenopathy, no jvd, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: Tachycardic with regular rhythm, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: Downgoing toes, moving all 4 extremities. Patellar reflexes intact. At discharge: VS: AF, BP 113/69, HR 86, RR 15, O2 99% RA GEN: Seated, conversant, alert and friendly [**Name (NI) 4459**]: moist mucosa, anicteric RESP: CTA b/l with good air movement throughout CV: regular, no murmurs ABD: nontender, nondistended EXT: warm, no edema SKIN: no rashes or jaundice Pertinent Results: Admission Labs: [**2152-8-12**] 08:40AM WBC-10.8 RBC-5.59 HGB-13.3* HCT-52.0 MCV-105* MCH-24.3* MCHC-22.2* RDW-14.0 [**2152-8-12**] 08:40AM NEUTS-87* BANDS-2 LYMPHS-8* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2152-8-12**] 08:40AM PT-12.3 PTT-28.5 INR(PT)-1.0 [**2152-8-12**] 08:40AM FIBRINOGE-454* [**2152-8-12**] 08:40AM GLUCOSE-2340* UREA N-76* CREAT-5.7* SODIUM-122* POTASSIUM-6.9* CHLORIDE-75* TOTAL CO2-8* ANION GAP-46* [**2152-8-12**] 08:40AM ALT(SGPT)-19 AST(SGOT)-11 ALK PHOS-181* TOT BILI-0.2 [**2152-8-12**] 08:40AM LIPASE-285* [**2152-8-12**] 08:40AM cTropnT-0.02* [**2152-8-12**] 08:40AM ALBUMIN-4.6 CALCIUM-9.8 PHOSPHATE-12.2* MAGNESIUM-5.2* Studies: CXR [**2152-8-12**]: No acute intrathoracic process. At discharge: [**2152-8-17**] 06:35AM BLOOD WBC-5.6 RBC-3.95* Hgb-10.2* Hct-30.6* MCV-78* MCH-25.7* MCHC-33.1 RDW-15.0 Plt Ct-212 [**2152-8-16**] 04:27AM BLOOD PT-11.8 PTT-26.2 INR(PT)-1.0 [**2152-8-17**] 06:35AM BLOOD Glucose-225* UreaN-10 Creat-0.8 Na-139 K-3.9 Cl-106 HCO3-26 AnGap-11 [**2152-8-17**] 06:35AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.1 Iron-90 [**2152-8-17**] 06:35AM BLOOD calTIBC-215* Ferritn-286 TRF-165* Brief Hospital Course: 36 yo male presenting from a half-way house with somnolence, elevated blood sugar and AG metabolic acidosis. Hyperosmolar Hyperglycemic Non-Ketotic Syndrome: Had AG of 35 on admission with VBG pH 7.00. He was given IV insulin and started on an insulin drip. He was initially given normal saline aggressively for volume resuscitation. His blood sugar on admission was profoundly elevated to 2300 and with normal saline administration he became hypernatremic to 164. His acidosis normalized and he required K and Phos repletion. His fluids were switched to D5W. Nephrology and [**Last Name (un) **] followed closely. He began to eat a diabetic diet. He was subsequently weaned off insulin gtt and D5W and started on sub-q insulin. His sugars were well controlled. His A1c returned at 22%, with an estimated average glucose of 585. He was started on 30units of Lantus prior to bedtime with Humalog sliding scale coverage. He should be started on an ACEi and have his lipids checked as an outpatient. Appointments were made for him to follow up with [**Last Name (un) **] and establish care with Dr. [**First Name4 (NamePattern1) 9572**] [**Last Name (NamePattern1) **] as his PCP. [**Name10 (NameIs) **] were given to him so that he may renew his insurance coverage with Mass Health. AMS: He was somnolent on admission. TSH was normal and tox screen was negative. CK was normal. His mental status improved with improvement in his glycemic control. Acute renal failure: Creatinine elevated to 5.9 on admission which rapidly corrected with volume resuscitation. Hypothermia: He was hypothermic on admission that improved with volume resuscitation. Hyperkalemia: Had hyperkalemia on admission that changed to hypokalemia with correction of the acidosis. This normalized prior to discharge. Elevated lipase: Had elevated lipase on admission but no obvious physical exam evidence of pancreatitis. Elevated troponin: He had elevated troponins to 0.02 and 0.03 on admission that was felt to be likely demand ischemia in the setting of profound dehydration and illness. Prophylaxis: SC heparin. Medications on Admission: None Discharge Medications: 1. Insulin Glargine 100 unit/mL Solution Sig: Thirty Three (33) units Subcutaneous at bedtime for 30 days. Disp:*qs qs* Refills:*2* 2. Insulin Needles (Disposable) Needle Sig: One (1) needles Miscellaneous qid for 1 months. Disp:*qs qs* Refills:*2* 3. Insulin Syringe 1 mL 28 x [**11-27**] Syringe Sig: One (1) syringe Miscellaneous qid for 1 months. Disp:*qs qs* Refills:*2* 4. Diabetic Supplies, Miscellan. Misc Sig: One (1) glucometer Miscellaneous once. Disp:*1 glucometer* Refills:*0* 5. test strips Sig: One (1) strip qid for 30 days. Disp:*qs qs* Refills:*0* 6. Humalog 100 unit/mL Solution Sig: 4-14 units Subcutaneous qidachs for 1 months: per sliding scale. Please provide quantity sufficient to administer up to 14 units qid. Disp:*qs qs* Refills:*0* 7. Lancets,Thin Misc Sig: One (1) lancet Miscellaneous qidachs for 1 months. Disp:*qs qs* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Diabetes Secondary: Diabetic ketoacidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of your during your stay here at [**Hospital1 18**]. You came to the hospital because of feeling sick and confusion. You were found to have extremely high blood sugars, which means you have diabetes. You were in the intensive care unit and received IV insulin and fluids. Your blood sugar and your confusion improved. You will need to take insulin at home to make sure your blood sugar doesn't go up again. It is very important that you take your insulin every day. New Medications: -insulin lantus 33 units every evening -humalog sliding scale Followup Instructions: The following appointments have been made for you: Name: [**Last Name (LF) **], [**Name8 (MD) 32440**] MD Phone: [**Telephone/Fax (1) 2378**] Appointment: Wednesday [**2152-8-23**] 10:30am When you are able to obtain insurance through Mass Health: Department: [**Hospital3 249**] When: MONDAY [**2152-8-28**] at 10:10 AM With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. Department: [**Hospital3 249**] When: TUESDAY [**2152-10-3**] at 2:45 PM With: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 15413**] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Dr [**First Name4 (NamePattern1) 9572**] [**Last Name (NamePattern1) **] is your new physician in [**Name9 (PRE) 191**] and Dr [**Last Name (STitle) **] works closely with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] both will be involved in your care. For insurance purposes please indicate Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as your Primary Care Physician.

[ "584.9", "250.13", "276.7", "790.01", "780.65", "276.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6973, 7030

3901, 6013

325, 333

7125, 7125

2712, 2712

7880, 9506

1809, 1828

6068, 6950

7051, 7104

6039, 6045

7276, 7857

1843, 1845

3472, 3878

275, 287

361, 1376

2728, 3458

1859, 2396

7140, 7252

1398, 1596

1612, 1793

18,468

107,249

10397+10508

Discharge summary

report+report

Admission Date: [**2144-8-5**] Discharge Date: [**2144-8-23**] Date of Birth: [**2080-10-11**] Sex: M Service: Green Surgery ADDENDUM TO HOSPITAL COURSE: The patient was admitted to urology for further work-up. He received a morphine PCA and Toradol for pain control, but his pain was difficult to control throughout his stay. He underwent an MRI of the pelvis without contrast to rule out local recurrence of metastasis. This examination was notable for no evidence of definite tumor recurrence, no evidence of hydronephrosis, but was notable for a soft tissue signal at the anterior pelvic floor representing either radiation changes or inflammation. A bone scan showed no evidence of metastatic disease. CT scans of the chest, abdomen, and pelvis were performed with and without contrast. These studies were notable for a fluid collection with air measuring 4.4 x 1.8 cm anterior to the pubic symphysis with extension inferolaterally to the space between the left pectineus and adductor musculature. This finding was concerning for an abscess. A fistulous tract was extending from the abscess to the anterior abdominal wall. Multiple prominent mediastinal lymph nodes, borderline in size, were also noted. Cholelithiasis and a left adrenal prominence with focal enlargement within the body and right posterior limb of the left posterior gland were noted. A culture of the sinus drainage grew alpha Streptococcus, Carinii bacterium (diphtheroids), gram-negative rods (species not elucidated). Anaerobic culture was notable for a mixed bacterial flora. The patient was transferred to the general surgery service and underwent incision and drainage of suprapubic wound with debridement of the pubic bone. He was started on piperacillin/tazobactam as well as vancomycin IV. He received a morphine PCA for pain control. Of note, preoperatively, the patient had an echocardiogram that was notable for a normal ejection fraction and normal wall motion. He was cleared medically prior to his surgery. A wound culture of the abscess grew alpha Streptococcus and gram-positive rods (unable to further identify). Anaerobic culture was negative. Culture of the bone revealed gram-positive rods, alpha Streptococcus, Carinii bacterium, [**Female First Name (un) 564**] (presumptive identification), Prevotella, but no acid-fast bacilli. Bone pathology revealed extensively necrotic soft tissue and cartilage with acute inflammation, fibrinopurulent exudate, and granulation tissue, as well as acute osteomyelitis. There was no evidence of malignancy. The patient was seen by the infectious disease consultant, who felt that the patient would require at least six more weeks of IV Zosyn therapy. A PICC line was placed for long-term treatment. The patient did well postoperatively, and was afebrile with a normal white blood cell count. His pain was not well controlled on the morphine PCA, so he was changed to p.o. Dilaudid with subcutaneous Dilaudid for pre-dressing change. He received a V.A.C. drain, which resulted in a decrease in the purulence surrounding the patient's pubic bone. On the day of discharge, he was hemodynamically stable, afebrile, tolerating a regular diet, and ambulating. His pain was well controlled. He was deemed clinically stable for transfer to rehabilitation. The current plan was for him to go to the Lifecare Center in [**Location 15289**]. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is being discharged to an extended care facility. DISCHARGE DIAGNOSES: 1. Hypertension. 2. Diabetes. 3. Coronary artery disease/myocardial infarction. 4. Bladder cancer. 5. Pain in joint, pelvic region and thigh. 6. ? prostate cancer. FOLLOW-UP PLANS: The patient was instructed to take antibiotics for six weeks and Dilaudid for pain. He was also instructed to notify his doctor if he experiences fever, chills, or increasing pain. He was told that he may shower and walk around, but should avoid heavy lifting. He was told that Dr. [**Last Name (STitle) 519**] would call him with the date and time of his follow-up appointment with himself and with Dr. [**Last Name (STitle) **] (plastic surgery). DISCHARGE MEDICATIONS: 1. Tylenol 325 mg, 1-2 tablets p.o. q. 4-6 hours p.r.n. 2. Colace 100 mg p.o. b.i.d. 3. Atenolol 25 mg p.o. q.d. 4. Simvastatin 40 mg (2 tablets) p.o. q.d. 5. Losartan 50 mg p.o. q.d. 6. Heparin 5,000 units subcutaneously b.i.d. 7. Nicotine 21/24-hour patch, one patch q. 24 hours. 8. Hydromorphone HCl 2 mg (1-2 tablets) q. 4-6 hours p.r.n. 9. Hydromorphone HCl 2 mg per mL, 0.5 to 2 mg injection subcutaneously p.r.n. 10. Piperacillin/tazobactam 4.5 g IV q. 8 hours x 6 weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**] Dictated By:[**Last Name (NamePattern1) 2512**] MEDQUIST36 D: [**2144-8-23**] 00:58 T: [**2144-8-23**] 07:05 JOB#: [**Job Number 34436**] Admission Date: [**2144-8-5**] Discharge Date: [**2144-8-23**] Date of Birth: [**2080-10-11**] Sex: M Service: Surgery HISTORY OF PRESENT ILLNESS: The patient is a 63 year old man with a history of squamous cell carcinoma of the bladder who presented with chronic pain and fistula drainage status post cystectomy and prostatectomy in [**2142-11-15**]. The patient was in his usual state of health until [**2142**], when he was diagnosed with a T4N0MX squamous cell carcinoma of the bladder. He underwent cystectomy and prostatectomy and has suffered multiple wound dehiscences and a chronically draining fistula since that time. The patient reportedly was doing well until five to six weeks prior to admission, when his wound reopened and began to drain yellow fluid. He also began to experience progressively worsening pelvic pain radiating to his testicles, perineal area and inner thighs. This pain was relieved with Demerol. The patient also reports fevers, chills, loss of appetite and a three to five pound weight loss over the past six weeks. The patient was initially admitted to the urology service for further workup. PAST MEDICAL HISTORY: 1. Coronary artery disease, myocardial infarction, status post angioplasty. 2. Diabetes mellitus. 3. Hypertension. 4. Questionable prostate cancer. PAST SURGICAL HISTORY: 1. Exploratory laparotomy for perforated bowel. 2. Cystectomy. MEDICATIONS ON ADMISSION: Atenolol 25 mg p.o.q.d., Demerol dose unknown, ciprofloxacin dose unknown Zocor 80 mg p.o.q.d., Cozaar 50 mg p.o.q.d., insulin NPH 25 units b.i.d. ALLERGIES: Ativan (reaction unknown). FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: On physical examination, the patient had a temperature of 99.2, heart rate 67, respiratory rate 18, blood pressure 110/75 and oxygen saturation 99% in room air. General: Awake, alert and oriented times three, in no acute distress. Head, eyes, ears, nose and throat: Normocephalic, atraumatic, pupils equal, round, and reactive to light and accommodation, extraocular movements intact, moist mucous membranes. Neck: Supple, no jugular venous distention, no lymphadenopathy. Cardiovascular: Regular rate and rhythm, no murmur, rub or gallop. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, suprapubic tenderness, midline incision with draining sinus lower portion of incision, ostomy on right draining clear yellow urine. Genitourinary: Normal uncircumcised phallus, testes descended bilaterally, nontender, no masses. Extremities: Warm and well perfused, no cyanosis, clubbing or edema. Neurologic: Nonfocal. LABORATORY DATA: Sodium 126, potassium 6, chloride 98, bicarbonate 16, BUN 36, creatinine 1.3, hematocrit 37.4, prothrombin time 14.4, INR 1.4, alkaline phosphatase 150, amylase 30, testosterone 67, free testosterone pending. HOSPITAL COURSE: The [**Hospital 228**] hospital course and remainder of this discharge summary will be dictated as an addendum later this evening. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**] Dictated By:[**Last Name (NamePattern1) 2512**] MEDQUIST36 D: [**2144-8-23**] 12:04 T: [**2144-8-23**] 06:40 JOB#: [**Job Number 34644**]

[ "401.9", "412", "730.05", "V10.46", "414.01", "998.59", "276.7", "250.00", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "77.69", "38.93" ]

icd9pcs

[ [ [] ] ]

6623, 6641

3552, 3717

4211, 5110

6418, 6606

7843, 8251

6325, 6391

6664, 7825

3735, 4188

5139, 6127

6149, 6302

3440, 3531

24,289

145,534

15421+56645

Discharge summary

report+addendum

Admission Date: [**2136-5-21**] Discharge Date: [**2136-7-9**] Date of Birth: [**2071-5-8**] Sex: M Service: NMED Allergies: Phenytoin / Neosporin Attending:[**First Name3 (LF) 7575**] Chief Complaint: seizures Major Surgical or Invasive Procedure: PEG tube placement, intubation x two History of Present Illness: 65 yo LH man with h/o metastatic melanoma, initially dx'd [**2134-1-8**] s/p wide local excision, recurrence in the right parotid gland, s/p radical neck dissection [**9-8**], s/p adjuvant local field irradiation from [**10-9**] to [**11-8**] and finally adjuvant alpha-interferon, [**Date range (1) 44733**]. He experienced his first seizure in [**Month (only) 205**] and was admitted to the [**Hospital1 1170**] neurology service. He was initially put on dilantin but developed a rash and gradually was placed on keppra as well as decadron because MRI showed changes in the right temporal lobe consistent with radiation necrosis. His seizures are varied and are remarkable for aphasia as either the ictal or post-ictal phenomenon as well as generalized tonic-clonic seizures. He was admitted again [**10-10**] and MRI showed no change but he was increased on his decadron. He was readmitted [**3-11**] after having 3 generalized seizures and prolonged post-ictal aphasia. An EEG only showed PLEDS during this aphasia state. He was kept on keppra and lamictal was added to his regimen. He last saw Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] in neuro-oncology on [**2136-3-29**] and the plan was to remain on Keppra [**2131**] mg [**Hospital1 **] while the Lamictal was to be increased to 100 mg [**Hospital1 **] within one month or so. In mid-[**Month (only) 116**] he was hospitalized with chest pain, underwent stress testing and subsequent cardiac catheterization with placement of an LAD stent. He recently visited with his oncologist Dr. [**Last Name (STitle) 1729**] on [**2136-5-10**] who performed torso CT which showed no evidence of systemic disease. On the day of admission he was apparently visiting with his girlfriend at [**Name (NI) 44734**] and had at 4:30pm he said "make a right turn, make a right turn" as they were driving to dinner. He didn't answer her when she asked him how his heart was doing. He tried to indicate that he was all right but he was not able to talk at all. His left arm was "scooping" about 10 minutes after he stopped talking. He was just quiet but he was not staring off into space. The "scooping" lasted 10 minutes and by the time she was able to pull over and get attention, his whole body is "swaying" with his left arm and leg but she is not able to give me a great description. She states that this typically happens with his seizures. This may have lasted 5 minutes and then EMS came and were able to give him 5mg valium iv and 1mg ativan iv. He stopped just about right after he was given the iv meds. He was brought to [**Hospital 25143**] Hospital in Wolfeboro and then transferred to [**Hospital1 18**] for further management. His fiancee states that he has been extremely compliant with his meds. She denies him having recent fevers, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea. But he did state that he was more depressed and tired in the last couple days. Baseline his talking has been much improved but not 100% normal, almost talking normally according to his girlfriend. However, she denies him having headache, numbness, weakness, vision problems, lethargy etc. Past Medical History: 1. metastatic melanoma as above c/b radiation necrosis of the right temporal lobe and seizures 2. hypertension 3. CAD s/p LAD stent [**4-10**] Social History: Social history: lives with girlfriend, she gives him all his medicines Family History: family history of MI, no family history of melanoma Physical Exam: On admission: Examination: T 95.6 BP 150/100 HR 72 RR 16 98% 2l General: ill appearing in NAD, cushingoid face HEENT: MMM Lungs: CTA bilaterally CV: RRR Abd: soft, NT Ext: no pedal edema, no rashes, multiple ecchymoses. Mental Status: Patient is alert with his eyes open, does not follow simple one-step motor commands. drawing are normal. Cranial nerves: Active eye closing and I could not visualize discs. Eyes are at midline and conjugate. Pupils react normally to light, both directly and consensually. Face seems symmetric. Motor: He keeps both arms up against gravity when lifted. There is no obvious drift. He withdraws legs briskly to noxious stimulus. There is a left sided rest tremor. Coordination: not tested Reflexes: The deep tendon reflexes are all present, symmetric and normal. The plantar responses are mute on the left, question upgoing on the right. Sensory: Withdraws all 4 extremities to pain. Gait and stance: deferred Upon discharge: Exam: afebrile VSS Gen: sitting up in bed, NAD HEENT: moist mucous membranes Lungs: coarse anteriorly but no wheezing CV: regular rate and rhythm, no murmurs, rubs or gallops Abd: soft and nontender Ext: hand wound granulating well, multiple ecchymoses unchanged Neuro: alert, eyes open, follows some one-step midline and appendicular commands. He can stick out his tongue, close his eyes, lift his right hand. He does not completely accurately show two fingers or point to the window or ceiling. He has preserved automatic speech- says "fine" when we ask "How are you?" No utterances longer than 2 or 3 words. Repeat simple words. Motor exam: at least 4/5 strength but some limited cooperation due to decreased comprehension. Moves all extremities spontaneously. Pertinent Results: Phenobarbital level on [**2136-7-5**] = 35.1 Brief Hospital Course: He was admitted on [**2136-5-21**] after having seizures on keppra 2g po bid, lamictal 100mg po bid and decadron 2mg po bid. He was admitted to the neurology [**Hospital1 **] service initially but while waiting in the ED for a bed, he continued to have recurrent seizure activity (at least 3 additional ones) which were treated with ativan, and then depakote was loaded as a third anticonvulsant [**Doctor Last Name 360**]. Subsequently he was on the neurology icu service until [**2136-6-13**], when he was transferred to the MICU service for persistent fevers, chronic aspiration and nosocomial pneumonia. A brief outline of his hospital course on neurology is as follows (also taken from Dr.[**Initials (NamePattern4) 44735**] [**Last Name (NamePattern4) **] note of [**2136-6-8**]): [**5-21**]: dexamethasone increased for 2mg to 4mg [**Hospital1 **] for temporal lobe necrosis secondary to XRT therapy, lamictal dose increased, loaded with depakote [**5-23**]: experienced some shaking, given phenobarbital, periodic lateralized epileptiform discharges over right hemisphere (PLEDS) seen on EEG [**Date range (1) 44736**]: repeat head CT with no change from [**5-21**], no hemorrhage. He was unable to get MRI due to recent CAD stent. Continuous EEG showed spikes and slow waves thus patient was intubated on [**5-25**] for versed coma ([**Date range (1) **]) for burst suppression. Patient required BP support, thus versed d/c'd. Phenobarbital added, then d/c'd on [**5-29**]. Multiple discussions with pt's significant other took place during this time. (Formal epilepsy consult obtained at this time, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**].) [**5-25**]: anemic, requiring transfusions to keep hct>30 given CAD and recent stent placement in [**4-10**]. Also, spiked to 101.2 and started on ceftriax/vanco/flagyl for presumed aspiration pna [**5-28**]: Urine growing enterococcus and sputum showing signs of infection, all [**Last Name (un) 36**] to levaquin so antibiotics changed to levofloxacin/flagyl. Pt completed 10 day course of levofloxacin. [**5-31**]: vancomycin was added to levofloxacin as pt still spiking and WBC 20K. [**6-4**]: lines changed over a wire out of concern for infection. Catheter tip eventually showed no growth in cultures. [**6-6**]: extubated [**Date range (1) **]: Patient started waking up (prolonged depressed mental status thought to be secondary to phenobarbital effect and post-ictal lethargy), alert, frontal signs- grasp, perseveration. Able to state his name, but perseverates on it. Develops a hand hematoma on the left. 7/3-4: Still required frequent suctioning but able to follow commands, name some objects, somewhat perseverative. 7/5-6: Plastic surgery expressed a large hematoma by I/D [**2142-6-13**]: Transferred to MICU service for persistent fevers, chronic aspirations, frequent respiratory care due to inability to handle secretions. An infectious disease consult recommended two weeks of vancomycin and ceftazidime for MSSA nosocomial pneumonia, but this was only given for one week, starting [**6-14**] ending on [**6-21**]. Patient pulled out NGT on [**6-16**] at 11am. All other cultures remained negative. [**6-17**]: (unable to find [**Month (only) 16**] from [**2143-6-16**]) Per resident's note: missed doses of keppra (8pm [**6-16**], 8am [**6-17**]), lamictal (8pm [**6-16**], 8am [**6-17**]), depakote (10pm [**6-16**], 6am [**6-17**], 2pm [**6-17**]). Neurology was called to evaluate for unresponsiveness. His eyes were deviated to the left. He got a total of 6mg ativan (2pm, 3pm and 8pm) and a load of depakote 2g. EEG showed spike/slow wave which resolved after ativan. Thereafter it showed persistent periodic lateralized epileptiform discharges (PLEDS) over the right hemisphere predominantly, with some occasional generalization over the left hemisphere, not correlating with any clinical seizure activity. [**Date range (1) 44737**]: During this week, a bleeding time was obtained and was prolonged to greater than 20 minutes. The decision was made with the family's knowledge that since the depakote on top of the ASA and Plavix was prolonging bleeding time, he would be transitioned to phenobarbital, while keeping keppra and lamictal the same. His phenobarbital level was titrated to a level in the mid- to high-30s, and his EEG recordings did improve, with fewer PLEDS. On [**6-22**], he was transferred from the MICU service back to the neuroSICU service, with Dr. [**Last Name (STitle) 851**] as the attending of record. Depakote was tapered after phenobarbital reached the goal level, and while sleepy, he remained without clinical seizure activity. [**Date range (1) 44738**]: Unfortunately he was reintubated [**6-25**] for persistent secretions resistant to suctioning and tachypnea. He did remain febrile, and vancomycin and ceftazidime were restarted for another week's course given that the original recommendations were for two weeks total. Vancomycin was ultimately changed to oxacillin because of absence of MRSA organisms to finish off the week's course. Again, all cultures remained negative and the question of phenobarbital drug fever was raised. He defervesced on his own, and still remains afebrile. [**Date range (1) 44739**]: He was extubated [**7-3**] and remained stable, requiring only 2l nasal cannula and occasional suctioning and chest PT. Phenobarbital again is being titrated to goal level of mid- to high-30s, but he is waking up and following some commands. He remains aphasic both with decreased fluency, repetition and comprehension. MRI head done which shows no appreciable change from the last MRI obtained [**2136-3-8**], consistent with static radiation necrosis. On [**7-4**], he received a PEG tube for feeding. We verified with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] from neuro-oncology that he should stay on dexamethasone 3mg po bid indefinitely but that he will follow him in clinic along with Dr. [**Last Name (STitle) 851**] for seizures. Consults: infectious disease, plastic surgery Medications on Admission: 1. Toprol XL 50mg po qpm 2. Plavix 75mg po qam 3. Lipitor 10mg po qam 4. ECASA 81mg po qd 5. Keppra 2g po bid 6. Lamictal 100mg po bid 7. Decadron 2mg po bid 8. Protonix 40mg po qd 9. Hyzaar 100-25 mg po qd 10. Multivitamin 1 tab po qd 11. Oscal-D 500mg po tid 12. Fosamax 35mg po qweek Discharge Medications: 1. Phenobarbital 390 mg PO/NG QD 2. Lamotrigine 150 mg PO/NG [**Hospital1 **] 3. Albuterol-Ipratropium [**12-9**] PUFF IH Q6H and q4prn 4. Metoprolol 37.5 mg PO BID 5. Lansoprazole Oral Suspension 30 mg NG QD 6. Alendronate Sodium 5 mg PO qd 7. Dexamethasone 3 mg PO Q12H 8. Nystatin Oral Suspension 5 ml PO QID:PRN swish and swallow 9. Bisacodyl 10 mg PR HS:PRN 10. Docusate Sodium (Liquid) 100 mg PO BID 11. Aspirin 81 mg PO QD 12. Miconazole Powder 2% 1 Appl TP PRN prn 13. Lacri-Lube Oint 1 Appl OU PRN 14. Insulin SC (per Insulin Flowsheet) Sliding Scale 15. Folic Acid 1 mg PO QD 16. Vitamin D 400 UNIT PO QD 17. Calcium Carbonate 500 mg PO TID 18. Multivitamins 1 CAP PO QD 19. Levetiracetam [**2131**] mg PO BID 20. Atorvastatin 10 mg PO QD 21. Clopidogrel Bisulfate 75 mg PO QD 22. Acetaminophen 325-650 mg PO Q4-6H:PRN fever, pain Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: 1. seizures secondary to right temporal lobe radiation necrosis- first seizure [**2135-6-7**] 2. history of metatstatic melanoma status post neck dissection and XRT [**2134-11-7**] 3. coronary artery disease status post coronary stent to left anterior descending artery [**2136-4-7**] 4. nosocomial pneumonia with methicillin-sensitive staph aureus 5. left hand hematoma from IV, drained and debrided by plastic surgery Discharge Condition: good, sitting up in bed or cardiac chair, following some commands Discharge Instructions: none Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] in neuro-oncology in [**12-9**] weeks Please follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) 851**] in the epilepsy clinic. Please follow up with the [**Hospital3 **] clinic to establish primary care. Please follow up with cardiology to establish cardiology care. Name: [**Known lastname 8203**],[**Known firstname 4240**] Unit No: [**Numeric Identifier 8204**] Admission Date: [**2136-5-21**] Discharge Date: [**2136-7-9**] Date of Birth: [**2071-5-8**] Sex: M Service: NMED Allergies: Phenytoin / Neosporin Attending:[**First Name3 (LF) 8205**] Chief Complaint: as above Major Surgical or Invasive Procedure: as above History of Present Illness: as above Past Medical History: as above Social History: as above Family History: as above Physical Exam: as above Pertinent Results: as above Brief Hospital Course: as above Medications on Admission: as above Discharge Medications: as above Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 2314**] Discharge Diagnosis: as above Discharge Condition: as above Discharge Instructions: as above Followup Instructions: Patient will also need followup in the plastic surgery clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 4288**] in approximately two weeks time [**First Name11 (Name Pattern1) 422**] [**Last Name (NamePattern4) 8206**] MD [**MD Number(1) 7588**] Completed by:[**2136-7-5**]

[ "909.2", "599.0", "285.1", "437.8", "V45.82", "560.1", "996.74", "345.3", "482.41" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "43.11", "38.93", "96.04", "86.04", "38.91", "99.04", "86.22" ]

icd9pcs

[ [ [] ] ]

14774, 14854

14672, 14682

14463, 14473

14906, 14916

14639, 14649

14973, 15331

14585, 14595

14741, 14751

14875, 14885

14708, 14718

14940, 14950

14610, 14620

14415, 14425

4855, 5621

14501, 14511

4247, 4839

3903, 4110

4125, 4231

14533, 14543

14559, 14569

383

173,723

1289

Discharge summary

report

Admission Date: [**2143-8-20**] Discharge Date: [**2143-9-13**] Date of Birth: [**2063-4-7**] Sex: F Service: MEDICINE Allergies: Aspirin / Biaxin / Codeine / Bactrim Attending:[**First Name3 (LF) 2704**] Chief Complaint: initially admitted for 7 days shortness of breath, transferred to CCU for hypotension Major Surgical or Invasive Procedure: Bi Ventricular Pacemaker placement History of Present Illness: This is a 80 yo F CAD s/p CABG, known CHF with EF of 20% presenting with 7 days shortness of breath and weight gain. Patient has had gradual worsening of these symptoms over the week PTA. At baseline she is able to walk the 3 blocks to her church. On day of admission she was unable to walk 5 feet without being short of breath. She weighs herself daily. Her baseline weight is 133lbs and she was at 141 on the day of admission. She has noticed some symmetric mild swelling of her legs similar to other episodes of decompensated CHF. She reports orthopnea. She reports a non-productive cough and sore throat for the last 2 days. She also complained of a few episodes of her typical anginal pain (left back/shoulder pain) that resolved with sublingual nitro and tylenol. . Of note she had a somewhat recent medication ([**6-4**]) change from bumex (thought to have caused a rash which resolved with steroid treatment) and was changed onto her old regimen of lasix (160 QAM, 80QPM-although at her last cardiology appt here she was stable at 160QAM, 160QPM). . She went to see her PCP [**Last Name (NamePattern4) **] [**2143-8-20**], who found her to be hypoxic to 88% and then sent her to the ED. In the ED CXR showed CHF, BNP was elevated from 4000 to [**Numeric Identifier 7987**], PE/dissection were ruled out. In addition, she was given 80mg IV lasix, and only put out 350cc (UO) over 8 hours at the ED. She was admitted to the [**Hospital1 1516**] service overnight for further management. Past Medical History: Coronary Artery Disease: s/p anterioseptal MI in [**2125**] CABG [**2126**]/[**2127**]- LIMA - LAD and SVG - RCA -status post coronary artery bypass graft and aneurysmectomy s/p PCTA in [**2134**] with stent placed proximal circumflex artery Hypertension Hypothyroidism Diabetes type II x 40 years Chronic Sinusitis Cataract in L eye, scheduled for surgery . Social History: Tobacco: denies Alcohol: denies Living Situation: Primarily Italian-speaking woman who lives by herself on the [**Location (un) 1773**] of a building (no elevator). Her son and his family live below and one of her grandkids sleeps in her apt everynight. She also has a med alert call bracelet. Patient has 2 sons and one daughter; all who live in relatively close vicinity of her. Family History: Family History: Brother and dad with coronary artery disease. Father had diabetes and cancer (skin?). Physical Exam: Vitals: T: 97.1 P: 67 BP: 80/50 R: 24 SaO2: 99% on 2L General: Awake, alert, NAD. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, OP erythematous without exudate Neck: supple, no LAD, no carotid bruits appreciated, + JVD to earlobe sitting at 30 degree Pulmonary: left basilar crackles Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: minimal bilateral edema, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. Neurologic: Alert, oriented x 3. Speaks italian primarily. grossly non-focal. . Pertinent Results: Admission Labs: [**2143-8-20**] WBC-19.5 HGB-10.6 HCT-31.6 PLT 356 [**2143-8-20**] DIGOXIN-1.2 [**2143-8-20**] TSH-0.89 [**2143-8-20**] ALBUMIN-3.6 CALCIUM-7.8 PHOSPHATE-3.7 MAGNESIUM-2.1 [**2143-8-20**] cTropnT-0.05* [**2143-8-20**] AST-273 LD-414 CK-33 ALK PHOS-97 TOT BILI-0.3 [**2143-8-20**] GLUCOSE-96 UREA N-52 CREAT-1.0 SODIUM-135 POTASSIUM-3.5 CHLORIDE- 103 TOTAL CO2-18 ANION GAP-18 [**2143-8-20**] URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2143-8-20**] PT-19.4 PTT-28.9 INR(PT)-1.8 [**2143-8-21**] Cortsol-29.3 [**2143-8-21**] WBC-23.3 Hgb-11.8 Hct-35.2 Plt Ct-410 [**2143-8-22**] WBC-18.4 Hgb-10.5 Hct-30.8 Plt Ct-301 [**2143-8-22**] Glucose-45* UreaN-64* Creat-1.5* Na-135 K-4.2 Cl-101 HCO3-23 AnGap-15 [**2143-8-22**] ALT-353 AST-122 LD(LDH)-292 AlkPhos-93 TotBili-0.2 [**2143-8-20**] BNP-[**Numeric Identifier 7987**] [**2143-8-23**] Glucose-111 UreaN-49 Creat-1.1 Na-137 K-4.4 Cl-103 HCO3-23 [**2143-8-23**] WBC-16.3 Hgb-10.8 Hct-33.1 Plt Ct-307 [**2143-8-21**] HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE . Discharge Labs: [**2143-9-13**]: WBC 11.8, Hct 36.5, Na 138, K 4.1, Cl 93, HCO2 33, BUN 27, Cr 0.9, Mg 2.2 . Micro: URINE CULTURE (Final [**2143-8-21**]): NO GROWTH. URINE CULTURE (Final [**2143-8-22**]): NO GROWTH . CXR ([**2143-8-22**]) IMPRESSION: Mild pulmonary edema. CXR ([**2143-8-21**]) IMPRESSION: Interval resolution of the probable interstitial edema seen on prior exam. No pneumonia. . CTA ([**2143-8-20**]) IMPRESSION: 1. No pulmonary embolism or aortic dissection. 2. Moderate congestive heart failure. Redemonstration of marked cardiomegaly, mitral and coronary artery calcifications. . EKG ([**2143-8-20**]) Sinus rhythm. Intraventricular conduction disturbance. Multiform ventricular premature beats. Compared to the previous tracing of [**2143-8-19**] ST segments are currently elevated in leads VI and V3-V5. Possible nanterior injury. . TTE [**2143-8-22**]: 1. The left atrium is markedly dilated. The right atrium is markedly dilated. 2. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis with some preservation of basal lateral and basal inferior wall motion. Overall left ventricular systolic function is severely depressed. 3. The right ventricular cavity is moderately dilated. There is severe global right ventricular free wall hypokinesis. 4. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Moderate (2+) mitral regurgitation is seen. 6. There is severe pulmonary artery systolic hypertension. . EKG ([**2143-8-22**]) Sinus rhythm. Intraventricular conduction delay. Left axis deviation. Probable atypical left bundle-branch block. Possible anterior myocardial infarction, age indeterminate. Clinical correlation is suggested. Since the previous tracing of [**2143-8-21**] no significant change. . ECHO [**2143-9-3**]: Conclusions: The left atrium is moderately dilated. The right atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is severely depressed. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Tissue synchronization imaging demonstrates significant left ventricular dyssynchrony with the septal wall contracting 280 ms later than the lateral wall. These findings are c/w significant LV dysnchrony for which the patient may benefit from CRT therapy. The right ventricular cavity is dilated. There is severe global right ventricular free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [**2143-8-22**], the mitral regurgitation is increased, and the left ventricular ejection fraction is somewhat higher. . CXR [**2143-9-5**]: IMPRESSION: 1. Biventricular pacing leads in standard position on this portable projection, but dedicated PA and lateral view would be helpful to confirm appropriate location. No pneumothorax. 2. CHF with interstitial pulmonary edema. . Brief Hospital Course: 80F with h/o DM, CAD s/p cath, who presents with SOB and weight gain x7days. Admitted to CCU for hypotension not relieved with fluids. . 1) Hypotension: On second hospital day, she got all her daily BP medications in the am with additional lasix. She was found to be hypotensive with BP running 70-80/40-50s on [**2143-8-21**] and triggered on the [**Hospital1 1516**] service. She had normal mentation, denied feeling SOB or dizzy. She was given 250cc NS bolus x 3, and her SBP went up to 85 (baseline SBP 90-100). Decision was made to transfer her to CCU service for further management of her hypotension overnight. In the CCU, patient was given an additional 500cc bolus of NS with only minimal improvement in blood pressure. All blood pressure meds were held. Patient continued to be without sob, dizziness, and mentating well. Echo was ordered for [**2143-8-22**] that showed moderate dilation of the right ventricular cavity with severe global right ventricular free wall hypokinesis (a change from prior). TTE continued to show severely depressed systolic function with EF<20% but no other significant change. Given this new, biventricular failure, her [**Last Name (un) **] was restarted at a loser dose. BB and other heart failure medications were also restarted. She was re-admitted to the CCU for hypotension and decreased urine output. She was given a medication holiday and responded. Her BP increased and she began to diurese on her own, and become respnsive to lasix. Hypotension was likely a result of biventricular failure and anit-hypertensive medications, as well as intravascular volume depletion. . 2) SOB/CHF: Her shortness of breath likely due to CHF exacerbation. Pt was afebrile and no focal consolidation on imaging or exam to suggest pna. She had a non-productive cough. Pt had poor output to 80mg of IV lasix on [**2143-8-20**], but repeat dosing on [**2143-8-21**] had good effect of 350/3 hours. Echo was performed, and digoxin was held initially. After being transferred out of the CCU, she initially responded well to diuresis. However, her urine output progressively decreased despite being put on a lasix drip. She was again transferred to the CCU. While there, her lasix drip was stopped, as well as her CHF medications (metoprolol/valsartan). A repeat ECHO showed an EF of 20%. Her BP improved off of her medications, she was given compression stalkings and she proceeded to mobilize her own fluids. After that, she responded very well to lasix boluses (80mg IV) TID. Near the time of discharge, the patient was switched to Lasix 160mg PO BID, responding well. Her D/C wt was 59kg, with an estimated dry weight of 58kg. She was length of stay negative 19-20L. . Also, EP was consulted given her degree of CHF. She also experienced asymptomatic NSVT during her stay. EP thought she would benefit from PCM +\- ICD. A BiV pacemaker was placed by EP on [**2143-9-5**] successfully without complications. Her BP responded favorably and post placement check was normal. . 3)Leukocytosis: Upon admission, patient found to have elevated WBC count to 23. She was empirically started on antibiotics. Her cortisol found to be WNL. Patient continued to be afebrile with negative chest xrays. On [**2143-8-22**], antibiotics were discontinued, and she remained hemodynamically stable and afebrile. Her WBC remained elevated, but decreased from admission between 15-18 to normal. She remained afebrile. . 4) Elevated BUN/Cr: On the 3rd hospital day, patient was noted to have elevated BUN/Cr. It was noted that she had been on high doses of ibuprofen for an undisclosed reason. The ibuprofen was discontinued. Moreover, the patient was on lasix and failing to diurese. She was admitted to the CCU and her BUN/Cr improved by holding her anti-hypertensives. She was transferred to the floor, and once again experienced elevation in her BUN/Cr while on a lasix drip. She was admitted to the CCU a second time. While there, they stopped her BP meds. Her BP improved, as did her BUN/Cr. She then responded to lasix after fluid mobilization with stockings and ambulation. Her transient renal insufficiency was thought secondary to intravascular depletion/pre-renal, as it improved with increased BP and increased renal perfusion. . 5) CAD: Chest pain resolved with sl nitro and tylenol. MI was ruled out and patient to be under medical management. ***Importantly, her PCP may wish to consider re-starting her statin, which was discontinued with her elevated liver enzymes.*** . 6) Transaminitis: Her elevated LFTs were thought due to drug effect (statin), vs hypoperfusion secondary to hypotension. Her LFTs improved and she remained asymptomatic. . Anticoagulation: The patient was started on warfarin due to her ECHO findings of decreased EF and hypokinesis. Her INR was stable, but her warfarin was stopped upon her second admission to the CCU for BiV pacemaker. She was started instead on aspirin and plavix. She tolerated this well. She tolerated aspirin 81mg without incident, despite previous history of dyspepsia on higher aspirin doses. . Anemia: remained stable in mid 30s. Was consistent with anemia of chronic disease. . Diabetes: Her blood sugars were difficult to control. She was on [**Hospital1 **] dosing of Lantus (30units/60units), but had episodes of hypoglycemia. On her second admission to the CCU, her lantus was changed to 25units qAM plus a humalog sliding scale. this regimen was later changed to Lantus 35units qPM, 10 units qAM plus the sliding scale. Her sugars fluctuated in the 200s. Further titration of her insulin will be needed as an outpatient . Hypothyroidism: Stable during admission on home regimen. . Code: She was initially DNI, but later changed her status to FULL CODE once the procedures were explained to her. . Outstanding Issues: 1. She will need close follow up and monitoring of her CHF, particularly with regards to her blood pressure medications (? add spironolactone, statin, titrate beta blocker/acei), diet, and weights. . 2. Her BiV pacemaker will need to be followed by EP. . 3. Her blood sugars were running high throughout admission. She will need further adjustment of her diabetes regimen. . 4. VNA will be following her as an outpatient. . 5. PCP should address sleep habits. Medications on Admission: Levoxyl 125mcg QD DIGOXIN 125 MCG ENTERIC COATED ASA 81MG FUROSEMIDE 160mg QAM, 160QPM Imdur 30 MG QD METOPROLOL 50 MG Spironolactone 25mg QD atorvastatin 20 QHS Lantus 60U QAM 60UQPM Humalog Albuterol PRN Ativan 1mg QHS PRN Ultram 50mg PO BID PRN Tylenol occassionally lactulose 2 TBSP QHS Colace 100mg [**Hospital1 **] VitB-12 1000mcg QD Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 6. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Please take at 8AM and 4PM. Disp:*120 Tablet(s)* Refills:*2* 9. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 10. Lantus 100 unit/mL Solution Sig: Thirty Five (35) units Subcutaneous at dinner. Disp:*1 vial* Refills:*2* 11. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous in the morning. Disp:*1 vial* Refills:*2* 12. Humalog 100 unit/mL Solution Sig: Per scale units Subcutaneous qACHS. Disp:*1 vial* Refills:*2* 13. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation every six (6) hours as needed for cough: Take as needed. Disp:*1 1* Refills:*0* 14. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**1-1**] Tablet, Sublinguals Sublingual PRN (as needed) as needed for chest pain: take 1 sublingual nitro for chest pain, if persists can repeat every 5 minutes x2 additional tablets. Call 911 if no relief. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO QPM (once a day (in the evening)). Disp:*60 Capsule, Sustained Release(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: 1. Heart Failure Secondary: 1. Coronary Artery Disease 2. Diabetes Mellitus 3. Hypothyroidism Discharge Condition: Good condition, vital signs stable, discharged to home with services and follow-up arranged. Discharge Instructions: You have been evaluated and treated for shortness of breath. You were found to have an exacerbation of your congestive heart failure (CHF). Your medications were changed; see the list included in your discharge paperwork. Please take all medications as directed and keep all follow-up appointments. . Please weigh yourself every morning, and call your PCP if your weight increases more than 3 lbs. Please limit your sodium intake to 2 grams per day. Do not take in more than 2 liters of fluid per day. . If you develop further shortness of breath, chest pain, nausea/vomiting, lightheadedness/dizziness, or any other symptom that is concerning to you, please call your PCP or go to the nearest hospital emergency department. Followup Instructions: 1. An appointment has been made for you to follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7988**] ([**Telephone/Fax (1) 6951**]), on [**9-25**] at 8:40AM. . 2. An appointment has been made for you to follow up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] from cardiology on [**9-16**] at 1 PM ([**Telephone/Fax (1) 4451**]) . 3. An appointment has been made for you to follow up with the pacemaker device clinic on Thurs, [**11-28**] at 12:30PM ([**Telephone/Fax (1) 59**]) , and with Dr. [**Last Name (STitle) **] on Thurs, [**11-28**] at 1:00PM ([**Telephone/Fax (1) 2934**])

[ "584.9", "285.29", "427.1", "398.91", "244.9", "414.8", "V45.81", "276.50", "250.80", "276.7", "397.0", "401.9", "396.3" ]

icd9cm

[ [ [] ] ]

[ "00.50" ]

icd9pcs

[ [ [] ] ]

17222, 17279

8502, 14803

382, 418

17426, 17521

3505, 3505

18294, 18944

2758, 2845

15194, 17199

17300, 17405

14829, 15171

17545, 18271

4660, 8479

2860, 3486

257, 344

447, 1944

3521, 4644

1966, 2327

2343, 2726

11,871

118,167

26333

Discharge summary

report

Admission Date: [**2107-12-25**] Discharge Date: [**2108-1-11**] Date of Birth: [**2030-12-24**] Sex: M Service: CARDIOTHORACIC Allergies: Morphine Sulfate Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2107-12-30**] Aortic Valve Replacement utilizing 27 mm CE perimount pericardial bioprosthesis and Mitral Valve Repair with 28 mm Annuloplasty Band [**2107-12-30**] Cystoscopy, dilatation of bladder neck with cystoscopic guidance of foley catheter [**2107-12-27**] Aortic and Carotid Angiography History of Present Illness: Mr. [**Known lastname 65171**] is a 77 year old male with longstanding history of a heart murmur. Over the last several months, he has been experiencing increasing dyspnea on exertion. His most recent echocardiogram from [**2107-8-15**] which showed moderate to severe aortic stenosis with a mean gradient of 50 mmHg and [**Location (un) 109**] of 0.9 cm2. There was mild aortic insufficiency. There was mitral annular calcification with mitral valve thickening and mild to moderate mitral regurgitation. His left ventricle was dilated and hypertrophied with no regional WMA. The LVEF was estimated at 60-65%. Subsequent cardiac catheterization in [**2107-11-15**] revealed no severe coronary artery disease in a right dominant system. Based on the above results, he was referred for cardiac surgical intervention. He will be admitted for heparinization as his Coumadin was held in anticipation of surgery. Past Medical History: Aortic Stenosis and Mitral Regurgitation, Congestive Heart Failure, Symptomatic Bradycardia s/p Pacemaker, Paroxysmal Atrial Fibrillation, Hypertension, History of Bladder CA, History of Prostate CA s/p radiation and chemotherapy, s/p total knee replacements, s/p back surgery Social History: Retired autoworker. Quit tobacco over 40 years ago. Denies excessive ETOH. Currently lives with his wife. Family History: Significant for CAD, both brother and sister died of myocardial infarctions. Physical Exam: T 98.0, BP 110/64, P 60, SAT 96% on RA General: elderly male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, 4/6 systolic ejection murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 1+ distally Neuro: nonfocal Pertinent Results: [**2108-1-11**] 07:19AM BLOOD Hct-27.3* [**2108-1-8**] 04:45AM BLOOD WBC-7.3 RBC-2.64* Hgb-8.9* Hct-25.8* MCV-98 MCH-33.8* MCHC-34.7 RDW-15.1 Plt Ct-168 [**2108-1-11**] 07:19AM BLOOD PT-16.5* INR(PT)-1.9 [**2108-1-11**] 07:19AM BLOOD UreaN-28* Creat-1.5* K-4.2 [**2108-1-10**] 01:44AM BLOOD Glucose-102 UreaN-32* Creat-1.7* Na-140 K-4.4 Cl-103 HCO3-31 AnGap-10 [**2108-1-9**] 05:55AM BLOOD Mg-2.0 [**2108-1-6**] 05:56AM BLOOD ALT-89* AST-56* AlkPhos-185* TotBili-1.7* Brief Hospital Course: Mr. [**Known lastname 65171**] was admitted prior to his operation for further evaluation and heparinization. A carotid ultrasound was obtained which was remarkable for a 70-79% stenosis of the left internal carotid artery. An echocardiogram confirmed moderate to severe aortic stenosis. It was also notable for moderate to severe mitral regurgitation. His overall LVEF was estimated at 60%. It appeared his aortic root and ascending aorta were dilated, measuring 3.9 cm at the valve level and 4.3 cm in the ascending portion. The peak and mean aortic gradients were 68 and 45 mmHg respectively. Given his carotid disease and above aortic findings, interventional cardiology was consulted for aorta and carotid angiography with possible carotid stenting. The study revealed only moderate left internal carotid artery stenosis for which stenting was deferred. Angiography was also notable for mild left subclavian artery stenosis at the origin. His preoperative course was otherwise uneventful. He remained stable on intravenous Heparin. On [**2107-12-30**], Dr. [**Last Name (STitle) 1290**] performed an aortic valve replacment and mitral valve repair. It is important to note, he required foley placement by cystoscopy just prior to his operation. And given his prior history of prostate cancer, his foley remained in place throughout his hospital stay. His heart operation was otherwise uneventful and he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. Episodes of paroxsymal atrial fibrillation were noted. Beta blockade was resumed. He was intermittently transfused with PRBCs to maintain hematocrit near 30%. His platelet count dropped as low as 61K. HIT assays were checked, returning negative. Given his episodes of PAF, he was re-heparinized with slow transition back to Warfarin. He otherwise maintained stable hemodynamics and transferred to the telemetry floor on postoperative day three. Warfarin was dosed for a goal INR between 2.0 - 2.5. It took several days for his prothrombin time to become therapeutic. He had a transient rise in LFTs for which an RUQ ultrasound was obtained. The ultrasound was unremarkable and by discharge, his LFTs essentially normalized. By discharge, his platelet count also normalized. Beta blockade was slowly advanced over several days for continued episodes of PAF and better rate control. He was occasionally noted to be Apaced on telemetry. His PPM was interrogated and found to be functioning normally. His other preoperative medications were also resumed and he responded well to diuresis. By discharge, he was near his preoperative weight with room air saturations of 97-99%. His discharge chest x-ray showed only small bilateral pleural effusions. Over his hospital stay, he made steady progress with physical therapy and continued to make clinical improvments. Once medical therapy was optimized, he was cleared for discharge to home on postoperative day 12. He remained on antibiotics for foley coverage and will follow up with his local urologist for removal. Medications on Admission: Flecainide 100 qam, 50 qpm Warfarin Lupron q month Toprol XL 25 qd Ketoconazole 800 tid Hydrocortisone 20 qam, 10 qpm Vitamins Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 4. Flecainide 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*30 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*1* 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily): 5 mg [**1-11**], check INR [**1-12**] with results called to Dr. [**Last Name (STitle) 32679**]. Disp:*90 Tablet(s)* Refills:*0* 8. Ketoconazole 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): While with foley catheter. Disp:*60 Tablet(s)* Refills:*0* 10. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 11. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO Q AM (). 12. Codeine Sulfate 30 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Aortic Stenosis and Mitral Regurgitation, Congestive Heart Failure, Symptomatic Bradycardia s/p Pacemaker, Paroxysmal Atrial Fibrillation, Hypertension, History of Bladder CA, History of Prostate CA s/p radiation and chemotherapy Discharge Condition: Good. Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. [**Last Name (NamePattern4) 2138**]p Instructions: Cardiac surgeon, Dr. [**Last Name (Prefixes) **] in [**4-19**] weeks PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**2-17**] weeks Cardiologist, Dr. [**Last Name (STitle) 5051**] in [**2-17**] weeks Oncologist, Dr. [**Last Name (STitle) 32679**] for coumadin follow up Dr. [**First Name (STitle) **] (urologist) for foley f/u Completed by:[**2108-2-6**]

[ "596.0", "V10.51", "595.82", "433.10", "443.9", "447.1", "396.2", "V53.31", "585.9", "398.91", "427.31", "403.91", "909.2", "V10.46" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61", "57.92", "38.93", "99.04", "35.33", "57.94", "88.41", "88.72", "88.44", "89.45" ]

icd9pcs

[ [ [] ] ]

7700, 7759

2929, 6016

305, 605

8033, 8041

2437, 2906

1981, 2059

6193, 7677

7780, 8012

6042, 6170

8065, 8453

8504, 8882

2074, 2418

246, 267

633, 1541

1563, 1842

1858, 1965

55,821

198,372

53027

Discharge summary

report

Admission Date: [**2140-4-26**] Discharge Date: [**2140-5-29**] Date of Birth: [**2059-9-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: weight gain Major Surgical or Invasive Procedure: placement of tunneled dialysis line placement of temporary dialysis line CVVH History of Present Illness: Mr. [**Known lastname **] is an 80 year old gentleman with CLL, CKD, apical hypertrophic cardiomyopathy, Afib on coumadin, recent PPM placement one month ago, presenting with dyspnea, edema, and mild weight gain. He is followed by VNA at home, and was noted by wife to have decreasing urinary output, generalized edema, and dyspnea with minimal exertion. Weight slightly up from 157.5 at last clinic visit with Dr. [**Last Name (STitle) 171**] one week ago, now up to 158.5 lbs, though his wife notes that his baseline weight is actually 145 lbs. Patient notes that he has been feeling increasingly short of breath over the last week with minimal exertion. He feels bloated with swelling of his face, abdomen, back, scrotum. On review of systems, he does admit to some lightheadedness. He notes that he feels he has something in the back of his throat but cannot cough it up. Otherwise denies any chest pain, orthopnea, cough, hemoptysis, constipation, diarrhea, black stools or red stools. He denies recent fevers, chills or rigors. He does have frequent urination, unchanged from prior. He also notes dry mouth, which he "always" has. Does also complain of right shoulder pain, particularly with movement. Past Medical History: Cardiac Risk Factors: (-)Diabetes, (-)Dyslipidemia, (+)Hypertension . Cardiac History: CABG: none Percutaneous coronary intervention: none . Pacemaker/ICD, in [**2140-3-30**] for AV block and syncope - dual chamber in VVIR mode. . Other Past History: - Chronic atrial fibrillation - [**Last Name (un) 51827**] type apical hypertrophic cardiomyopathy - Tricuspid valve prolapse with severe regurgitation and RV volume overload - Hypertension - CLL - diagnosed [**2137**], CT C/A/P ([**2-/2138**]) was negative for enlarging lymphadenopathy. Skin bx reviewed by pathologist confims CLL and negative for 11;14 translocation. - BPH s/p TURP - shoulder surgery repair ligament - bilateral total hip replacements Social History: Married. Lives with his wife. Nonsmoker. Retired salesman and lives in [**Hospital3 **]. Patient notes that he used to be a gymnast and has been physically fit most of his life. Family History: Mother had stroke, father had heart disease Physical Exam: Admission Exam: VS - 109/71 73 24 99%RA Gen: WDWN elderly male in NAD, though heavy breathing, lying supine, speaks [**5-2**] words at a time prior to taking breath. Mood, affect appropriate. HEENT: Edematous face. Sclera anicteric. EOMI. Conjunctiva pink, oropharynx clear, mildly dry mucus membranes. CV: irregular rhythm, distant heart sounds. Lungs: Resp somewhat labored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: + Distended and firm but not tympanic. Normoactive bowel sounds. No HSM or tenderness. Ext: Bilateral weeping arm edema. Right shoulder pain with abduction or any movement; pain goes away when patient lifts arm above 45 degrees. No ankle edema, but significant pitting sacral edema, back edema, scrotal edema. 1+ DP pulses. Skin: stasis dermatitis changes on lower extremities, left lateral leg stitch in place from previous hospitalization. good sensation in feet. Pertinent Results: ADMISSION LABS: [**2140-4-26**] 12:50PM BLOOD WBC-9.4 RBC-3.03* Hgb-8.7* Hct-28.3* MCV-93 MCH-28.7 MCHC-30.7* RDW-17.9* Plt Ct-229 [**2140-4-26**] 12:50PM BLOOD PT-17.2* INR(PT)-1.5* [**2140-4-26**] 12:50PM BLOOD Glucose-111* UreaN-85* Creat-2.6* Na-131* K-4.0 Cl-94* HCO3-20* AnGap-21* [**2140-4-26**] 12:50PM BLOOD Calcium-8.8 Phos-5.9* Mg-2.6 CHEST (PA & LAT) Study Date of [**2140-4-26**] 6:25 PM IMPRESSION: PA and lateral chest compared to [**3-26**] through [**4-18**]: Since [**4-18**] minimal increase in severe chronic cardiomegaly and pulmonary vascular congestion could be due to different phases of cardiac and respiratory cycles, while small bilateral pleural effusions have decreased, and there is no pulmonary edema. Transvenous right atrial and right ventricular pacer leads are unchanged in their respective positions. [**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) Study Date of [**2140-5-2**] 2:49 PM FINDINGS: Duplex evaluation was performed of bilateral lower extremity veins. Visualization of the tibial veins was difficult due to leg swelling. There is normal compression, augmentation and phasicity of the common femoral, thigh femoral, and popliteal veins bilaterally. There is no deep venous reflux bilaterally. There is reflux in the right greater saphenous vein below the knee. There is no reflux in the left greater saphenous vein. There is no reflux. The lesser saphenous veins bilaterally. Tibial veins were visualized and noted to be patent by color flow evaluation. Cannot rule out nonocclusive thrombus. Incidental note is made of a right groin node measuring 2.4 cm. IMPRESSION: No evidence of proximal deep vein thrombosis in bilateral lower extremities. Cannot rule out nonocclusive tibial vein thrombosis. There is reflux only on the right greater saphenous below the knee. CAROTID ULTRASOUND ON [**2140-5-13**] [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 867**] was performed of the right and left ECA, ICA, CCA, and vertebral arteries. Grayscale imaging demonstrates mild plaque within the right and left ICAs. No left carotid artery dissection is seen. Antegrade flow is seen within the vertebral arteries. The following velocity measurements were obtained: RIGHT: Proximal ICA 88/16 cm/sec, mid ICA 82/26 cm/sec, distal ICA 52/18 cm/sec, CCA 104/22 cm/sec, ECA cm/sec, vertebral artery 50 cm/sec. The right ICA/CCA ratio is 0.84. LEFT: Proximal ICA 91/17 cm/sec, mid ICA 67/23 cm/sec, distal ICA 81/15 cm/sec, CCA 106/20 cm/sec, ECA 121 cm/sec, vertebral artery 43 cm/sec. Left ICA/CCA ratio 0.85. IMPRESSION: Findings are consistent with less than 40% stenosis bilaterally. RENAL ULTRASOUND ON [**2140-5-14**] CLINICAL INDICATION: Elevated creatinine. This study was done portably at the bedside demonstrating the right kidney to measure 10.4 cm in length and the left kidney 10.1 cm. These measurements are unchanged from a prior scan of [**4-5**]. Neither kidney shows evidence of hydronephrosis, stone disease or concerning masses. There is a small subcentimeter lower pole cyst in the right kidney and a 1.2 x 1.5 cm parapelvic cyst in the left kidney with a single thin septation. These are also unchanged in size. The bladder is not well evaluated due to limited amount of urine within, but there is evidence of ascites in the pelvis and right flank. CONCLUSION: Normal-sized kidneys without evidence of obstruction and without significant change since [**4-5**]. There is new ascites however. ECHOCARDIOGRAM ON [**2140-5-27**] The left and right atria are markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is diastolic septal flattening c/w right ventricular volume overload. Apical hypertrophy is not appreciated, but there is an apically displaced papillary muscle and the apex is now well delineated. The right ventricular cavity is markedly dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-28**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is borderline 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, primarily around the apical portion of the right atrium. Compared with the prior study (images reviewed) of [**2140-3-28**], the severity of tricuspid regurgitation is somewhat incresaed. The other findings are similar. Brief Hospital Course: Mr. [**Known lastname **] is an 80 year old gentleman with hypertrophic cardiomyopathy, atrial fibrillation on coumadin, recent PPM placement, now presenting with edema, weight gain, and shortness of breath consistent with CHF exacerbation. #. Acute on Chronic Diastolic Congestive Heart Failure - Patient has hypertrophic (apical predominent) cardiomyopathy with small LV cavity, diastolic LV failure, causing pulmonary hypertension; also with long standing severe TR and right sided overload and underfilling of left ventricle. Having presented to clinic with volume overload the week prior to admission, patient's torsemide was increased to 40mg daily, and his spironolactone was discontinued. He noted a one pound increase in weight since the week prior to admission, though nearly 14 lbs above his baseline. He presented with significant fluid overload and pitting edema in sacrum, back, dependent areas, and decreased breath sounds in lung bases. CXR from last week clinic visit showed small pulmonary effusions. Patient was started on furosemide drip on admission at 20mg/hr with metolazone 2.5mg [**Hospital1 **] to which he diuresed well. He was placed on 1L fluid restriction per day. Furosemide drip was gradually increased to 40mg/hr with metolazone 5mg [**Hospital1 **] with improvement in lower extremity and scrotal edema, though patient persisted with thigh and sacral edema. Because progress was limited with furosemide drip, patient was transferred to CCU to for ultrafiltration through temporary HD IJ line. Patient had successful CVVH and was near euvolemic upon discharge back to the floor where torsemide and metolazone was tried for diuresis. . Patient subsequently spiked a fever [**5-12**] to 102 (see below) and was transferred back to the CCU. . After transfer back to CCU, the pt was again diuresed, however in the setting of poor forward flow, the pt's kidney function began to deteriorate (see below). As the kidneys began to stop responding to IV diuretics, Renal was consulted again and the decision was made to put the patient back on CVVH. . Unfortunately, the patient was unable to sustain blood pressures high enough for CVVH, and so was maintained on a levophed drip much of the time to assist with CVVH. The patient's BPs often would fall to the 70s systolic, and the pt's mental status began to wane during this time. Throughout the last two weeks, the pt remained volume overloaded. A thorough workup of potential causes of hypotension was undertaken, but no obvious reversible cause could be determined. The pt's course continued to deteriorate over another 2 weeks on CVVH and levophed, and the pt was made CMO and taken off CVVH on [**2140-5-26**]. . #. Acute on Chronic Renal Failure - Patient with acutely elevated creatinine to 2.6 on presentation from ~1.9-2.1 the week prior, likely in setting of poor forward flow. He presented with a mild gap acidosis, likely in the setting of new renal failure. During diuresis, creatinine improved to 2.2, then peaked at 2.8 despite still being very fluid overloaded, likely still due to poor forward flow. Creatinine improved to around 1.5 with CVVH. Patient's creatine bumped on [**5-12**] to the 3s. He was given 4L ivfs, without any improvement in Cr. Urine sediment was notable for granular/hyaline casts and renal US w/o evidence of obstruction. Subsequent ARF likely secondary to hypotensive episodes and ATN secondary to sepsis (see below). Patient's urine output was reduced, and as above, CVVH was started after consulting with renal. The pt eventually became anuric. . #. Sepsis: Patient spiked a fever [**5-12**] to 102; [**2-28**] blood cultures demonstrated MSSA. Patient was hypotensive and tachycardic, requiring levophed pressor support. Patient was resucitated with ivfs and treated with nafcicillin. Pressors were weaned off [**5-14**]. The patient was maintained on nafcillin as per ID recommendations throughout his stay. . #. Hyponatremia - Hypervolemic hyponatremia fluctuated in the setting of diuresis with a nadir of 125. When possible, the patient was fluid restricted in the setting of hyponatremia. . #. Atrial Fibrillation - Patient was in atrial fibrillation on presentation and was intermittently paced throughout hospitalization. He had been subtherapeutic on warfarin because his warfarin dosing had been reduced previously. The primary team attempted to restart the patient's warfarin, however in the setting of uremia and anticoagulation, the pt began to bleed from puncture sites and instrumentation sites after a tunneled line was placed. For that reason, the coumadin was d/c'ed and was not restarted for the remainder of his hospitalization. . #. Leukocytosis - The pt developed a leukocytosis of uncertain etiology. The patient remained afebrile for his last two weeks, and a systematic approach was taken to identify the source, however this was unsuccessful. . #. Right Shoulder pain Patient has chronic shoulder pain; he had shoulder surgery about three years ago, notes that pain persists constantly. His symptoms were controlled with tylenol and oxycodone. #. Anemia - Hematocrit remained stable. Anemia likely secondary to CLL. In the setting of bleed after procedure, and in the setting of longstanding anemia, the patient was transfused with pRBCs to maintain a Hct of ~29%. #. BPH, s/p TURP - Patient has frequency of urination for at least a couple of years. Was started on tamsulosin the week prior to admission at cardiology clinic appointment but did not notice subjective improvement, likely in setting of acute renal failure and decreased urine output overall. Tamsulosin was discontinued per outpatient cardiologist. # Left leg Varicosity Patient had left leg varicosity with uncontrollable bleeding during last hospitalization with stitch placed in his wound by Vascular Surgery with successful hemostasis. Patient was scheduled for a followup appointment with Dr. [**Last Name (STitle) 21080**] which was missed because of this hospitalization. Vascular surgery removed stitch on admission. Venous duplex ultrasound was done to look for reflux, showing no evidence of proximal DVT in lower extremities, though nonocclusive tibial vein thrombosis could not be ruled out. Reflux was seen only in the right greater saphenous vein below the knee. . Of note, on the venous duplex ultrasound, there was an incidental finding of one enlarged groin lymph node. The patient does have a history of CLL. . #. Gout - Allopurinol was held on admission in setting of acute renal failure. Medications on Admission: Warfarin 1 mg p.o. daily torsemide 40 mg p.o. daily (dose had just been increased week prior to admission) metoprolol succinate 25 mg p.o. daily allopurinol 100 mg p.o. daily. tamsulosin 0.4 mg daily (STOPPED LAST WEEK, per Dr. [**Last Name (STitle) 171**]: spironolactone 12.5 mg p.o. daily) Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2140-5-30**]

[ "425.4", "454.9", "V66.7", "275.3", "428.0", "397.0", "427.31", "719.41", "584.5", "416.8", "293.0", "285.1", "204.10", "038.11", "995.91", "288.60", "600.01", "276.7", "276.1", "426.10", "E879.1", "996.62", "V45.01", "789.59", "274.9", "285.22", "788.41", "788.5", "V58.61", "428.33", "458.8", "403.90", "585.9", "608.86", "276.2" ]

icd9cm

[ [ [] ] ]

[ "88.72", "45.13", "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

15496, 15505

8597, 15153

327, 407

15557, 15567

3600, 3600

15619, 15782

2596, 2641

15526, 15536

15179, 15473

15591, 15596

2656, 3581

276, 289

435, 1651

3617, 8574

1673, 2383

2399, 2580

48,939

139,380

37947

Discharge summary

report

Admission Date: [**2187-8-12**] Discharge Date: [**2187-8-29**] Date of Birth: [**2125-12-19**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Right shoulder pain Major Surgical or Invasive Procedure: [**2187-8-12**] Repair of type A aortic dissection with a 28-mm Dacron interposition tube graft from the sinotubular junction to the proximal arch using deep hypothermic circulatory arrest. History of Present Illness: 61 year old white male was woken at 2AM last PM with R scapular pain. He presented to [**Hospital1 2436**] ED at 2PM today and was hypertensive, had a creat. of 4, troponin of 10 and a pericardial effusion on CT. He was transferred to [**Hospital1 18**] ED. Past Medical History: Hypertension Social History: Occupation: Musician; plays tenor sax Tobacco: smoked 4 ppdx 10 yrs, quit [**2160**] ETOH: none Family History: noncontributory Physical Exam: Pulse:65 Resp: 18 O2 sat: 96% on 2 liters NC B/P Right: 170/134 Left: Height: Weight: General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: tr Left: tr Radial Right: 2+ Left: 2+ Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 84809**] (Complete) Done [**2187-8-12**] at 10:37:38 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2125-12-19**] Age (years): 61 M Hgt (in): BP (mm Hg): 125/83 Wgt (lb): HR (bpm): 65 BSA (m2): Indication: intraop Aortic Dissection v intramural hematoma ICD-9 Codes: 440.0, 441.00 Test Information Date/Time: [**2187-8-12**] at 22:37 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW1-: Machine: aw1 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.2 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.4 cm <= 5.2 cm Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Annulus: *3.1 cm <= 3.0 cm Aorta - Sinus Level: 3.5 cm <= 3.6 cm Aorta - Sinotubular Ridge: *3.8 cm <= 3.0 cm Aorta - Ascending: *4.4 cm <= 3.4 cm Aorta - Arch: *3.4 cm <= 3.0 cm Findings LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Mildly dilated aortic sinus. Moderately dilated ascending aorta. Mildly dilated aortic arch. Complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. Thickened aortic wall c/w intramural hematoma. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. [**Name13 (STitle) **] MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PR. PERICARDIUM: Moderate 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. Conclusions Pre Bypass: No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size is normal. with borderline normal free wall function. Left ventricular function was initally boarderline/mildly depressed globally, but improved after drainage of pericardial effusion (LVEF 55%, no wall motion abnoralities). The ascending aorta is moderately dilated with some wall thickening consistent with intramural hematoma in the distal ascending aorta. The aortic arch is mildly dilated. There are complex (>4mm) atheroma in the aortic arch and some possible intramural hematoma. No obvious dissection is seen in the arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic wall is thickened consistent with an intramural hematoma. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is a moderate sized pericardial effusion with no obvious echocardiographic signs of tampanode. Post Bypass: Patient is a paced on phenylepherine infusion. Preserved biventricular function LVEF 55% . No AI or AS. A conduit is seen in the ascending aorta from the sinus of valsalva to the proximal aortic arch. Some thickening, plaque or intramural hematoma is still seen in the mid arch. MR is now trace. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2187-8-13**] 02:50 [**2187-8-29**] 03:40AM BLOOD WBC-6.2 RBC-3.20* Hgb-9.4* Hct-29.4* MCV-92 MCH-29.3 MCHC-31.9 RDW-15.9* Plt Ct-257 [**2187-8-27**] 06:15AM BLOOD PT-22.5* INR(PT)-2.1* [**2187-8-29**] 03:40AM BLOOD Glucose-88 UreaN-29* Creat-2.0* Na-141 K-4.4 Cl-110* HCO3-23 AnGap-12 Brief Hospital Course: Transferred from outside hospital with type a dissection and went to operating room emergently for aortic repair. See operative report for further details. He received cefazolin for perioperative antibiotics. He remained intubated due to hypoxia with increased PEEP requirement and on neosynphrine for blood pressure management. He was started on lasix drip for diuresis and remained intubated. He developed atrial fibrillation and was treated with amiodarone and betablockers converted back to normal sinus rhythm. On postoperative day three he was noted to have neurological deficits and remained intubated because he was unable to protect his airway. Ancef was started for some mild sternal drainage. A CT scan was performed to assess for neurologic injury given his confusion and left sided weakness which was negative. The nephrology service was consulted for assistance in his care for acute renal failure. On postoperative day seven, he was extubated without issue. His renal function continued to improve. He again had atrial fibrillation and underwent successful cardioversion. The psychiatry service was consulted for assistance with his postoperative delerium. On [**2187-8-25**], He was transferred to the step down unit for further recovery. Coumadin was started for atrial fibrillation with a heparin bridge. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He continued gentle diuresis towards his preoperative weight. He was given sarna lotion for a contact dermatitis which improved with this treatment. As his renal function improved his Quintin catheter was removed. This site was fibrinous was improved by being painted with betadine twice daily. By post-operative day 16 he was cleared for discharge to rehab by Dr. [**Last Name (STitle) 914**]. All follow-up appointments were advised. Medications on Admission: HCTZ unsure of dose 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. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take 2 pills (400mg daily) for one week and then decrease to 1 pill (200mg daily) ongoing. Disp:*60 Tablet(s)* Refills:*2* 3. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for to affected areas. Disp:*qs * Refills:*0* 7. Ipratropium Bromide 0.02 % Solution Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed for sob/WZ. Disp:*qs puffs* Refills:*0* 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed for sob/WZ. Disp:*qs puffs* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: type A dissection s/p aortic repair Renal Failure Cardiac Tamponade Post operative atrial fibrillation Hypertension Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming Monitor wounds for infection and report any redness, warmth, swelling, tenderness or drainage Please take temperature each evening and Report any fever 100.5 or greater Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Surgeon Dr [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care [**First Name8 (NamePattern2) 1037**] [**First Name8 (NamePattern2) 3239**] [**Last Name (NamePattern1) 30891**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2187-9-3**] 3:15 Cardiologust: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2187-10-3**] 1:00 Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2187-8-29**]

[ "785.51", "585.9", "997.1", "584.5", "348.30", "441.01", "570", "403.90", "427.31", "518.5", "423.3" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "35.11", "33.22", "38.45", "99.62", "38.95", "96.04", "38.93", "39.95", "39.61" ]

icd9pcs

[ [ [] ] ]

9556, 9628

6419, 8292

342, 534

9788, 9795

1616, 6396

10424, 11012

990, 1007

8362, 9533

9649, 9767

8318, 8339

9819, 10401

1022, 1597

282, 304

562, 824

846, 860

876, 974

19,408

106,880

13942

Discharge summary

report

Admission Date: [**2130-1-31**] Discharge Date: [**2130-2-7**] Date of Birth: [**2063-7-20**] Sex: M Service: CHIEF COMPLAINT: Gangrene and nonhealing ulceration of the left fourth toe times three weeks. HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 4281**] is a 66-year-old male with a past medical history significant for noninsulin dependent diabetes mellitus for the last twelve years along with coronary artery disease, who presented with a nonhealing ulceration and gangrene of his left fourth toe, which started three weeks ago as a small pressure ulceration. The patient deferred medical treatment until his wife took him to a doctor one week prior to admission and he was directly admitted for IV antibiotics. The patient also admitted to rest pain of the foot, which was relieved with narcotics and had been occurring in the same time frame. He denied any previous history of claudications, fevers, chills, labile blood sugars, nausea, vomiting, or shortness of breath. He was admitted for angiogram and pre-anginal hydration with renal protection as he had a mild chronic renal insufficiency with the serum creatinine of 1.5. MRA done at an outside hospital revealed a normal aortoiliac system, superficial femoral artery, and popliteal artery with runoff. The anterior tibial artery, which lead into a diseased dorsalis pedis. PAST MEDICAL HISTORY: 1. Positive for noninsulin dependent diabetes mellitus for the last twelve years. 2. Hypertension. 3. Coronary artery disease with a myocardial infarction in [**2126**] status post coronary artery bypass graft at that time. 4. Positive nicotine abuse of over 120 pack per year, but stopped ten years ago. 5. The patient has a history of anemia of unknown origin, most likely secondary to chronic renal insufficiency with serum creatinine noted to be 1.5. 6. Benign prostatic hypertrophy. 7. Chronic obstructive pulmonary disease. 8. Neuropathy and arthritis of his left hand. PAST SURGICAL HISTORY: 1. History is significant for Coronary artery bypass grafting with the use of right greater saphenous vein in [**2126**], as well as transurethral resection of the prostate. 2. Appendectomy. 3. Umbilical hernia repair. MEDICATIONS ON ADMISSION: 1. Levaquin 500 mg PO q.d. 2. Colace 100 mg PO b.i.d. 3. Aspirin 325 mg PO q.d. 4. Digoxin 0.25 mg PO q.d. 5. Diltiazem 240 mg PO q.d. 6. Glipizide 10 mg PO b.i.d. 7. Trental 400 mg PO t.i.d. 8. Lasix 20 mg PO q.d. 9. Protonix 40 mg PO q.d. 10. Glucophage 750 mg PO q.a.m. and 500 mg q.p.m. 11. Tylenol #3. 12. Regular insulin sliding scale. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**], where he was transferred from an outside institution. He was initially started on oral Levaquin and Flagyl for his toe ulceration. Angiogram was scheduled for the day after admission and he was subsequently hydrated gently overnight. He was given the Mucomyst protocol. The Glucophage and Lasix were held prior to angiogram. The creatinine was 1.6. The hematocrit at that time was noted to be 25. On hospital day #1, noninvasive studies were also obtained. These revealed a limited study due to the examination being technically difficult as the patient declined having the cups placed for the volume recordings at any location other than the ankles. EBIs were noted to be inaccurate due to extensive vessel compressibility. The angiogram revealed no significant proximal inflow disease from the level of the renal arteries to the knee. The anterior tibial artery was the only continuously patent leg vessel and it was severely stenosed in its first and few centimeters. A patent dorsalis pedis artery was noted. No plantar arteries were opacified. Based on this information the patient was taken to the operating room on [**2-2**], where a left superficial femoral to dorsalis pedis artery bypass was performed with the use of nonreverse saphenous vein graft. At that time a left fourth toe open amputation was also performed. Details of this procedure are dictated in a separate operative note. The patient did fairly well hemodynamically, postoperatively and was transferred up to the Vascular Intensive Care Unit. PA catheter was placed, which revealed significant pulmonary hypertension. This was noted on preoperative echocardiogram. These were obtained from the [**Hospital **] [**Hospital **] Medical records. A Cardiolite imaging study revealed a large fixed hypoperfusion defect involving the inferior apical and inferolateral regions. It was suggestive of an area of prior myocardial infarction with no significant residual ischemia. On gated images the left ventricle was moderately enlarged with moderately reduced systolic function due to wall-motion abnormalities. The right ventricle was also noted to be enlarged. The pulmonary was noted to be approximately 56 mmHg and a left ventricular ejection fraction was noted to be approximately 30%. On postoperative day #2, the patient's pulmonary artery catheter was pulled out to monitor CVP. He was able to get out of bed to a chair and he was started on a regular diet. He did have some nausea, which was relieved with Reglan and Compazine. Consultation was sought by his medical internist, Dr. [**Last Name (STitle) 3845**] at that time. On postoperative day #3, the CVP line was changed over to central-venous catheter. He was transferred to the floor and he started to ambulate with physical therapy. After that time, he did extremely well and progressed very rapidly. His wound was left open, however, it did continue to show evidence of healing with pink granulation tissue. He had a palpable dorsalis pedis graft pulse. He was seen by the Department of Physical Therapy routinely throughout the hospital stay and he was eventually cleared for discharge home. He was sent home with a walker and he was only going to need VNA care for his left fourth toe amputation site. On postoperative day #4, he did have some nausea, while on the floor. However, an EKG was obtained and revealed no significant changes from previous EKGs. On postoperative day #5, the patient was discharged to home on PO Keflex. It was to be continued for approximately ten days. The patient was instructed by Dr [**Last Name (STitle) 1391**] to followup in his office in ten days to two weeks. PHYSICAL EXAMINATION: Examination at the time of discharge revealed a well-developed, well-nourished male appearing slightly older than his stated age of 66. NECK: Neck was supple without evidence of JVD or carotid bruits. HEART: Regular rate and rhythm. LUNGS: Lungs were clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended without evidence of masses or bruits. EXTREMITIES: Revealed 1+ edema on the left lower extremity. He had a palpable dorsalis pedis graft pulse. The wound was clean, dry, and intact and granulating well at that time. Wet-to-dry dressings were initiated for the wound to be changed twice daily. An ACE wrap was to be applied from the toes to the knee while the patient was ambulatory. He was able to full weightbearing with a healing sandle. DISCHARGE MEDICATIONS: 1. Protonix 20 mg PO q.d. 2. Keflex 500 mg PO q.i.d. times ten days. 3. Albuterol metered dose inhaler two puffs q.i.d. 4. Reglan 10 mg PO q.i.d. 5. Lasix 20 mg PO q.d. 6. Trental 400 mg PO t.i.d. with food. 7. Lopressor 500 mg PO b.i.d. 8. Aspirin 325 mg PO q.d. 9. Digoxin 0.25 mg PO q.d. 10. Colace 100 mg PO b.i.d. 11. Diltiazem 240 mg PO q.d. 12. Glipizide 10 mg PO b.i.d. 13. Glucophage 750 mg PO q.a.m.; 500 mg PO q.p.m. 14. Tylenol 650 mg PO q.4h. and Percocet 1 to 2 mg q.4h. DISCHARGE DIAGNOSIS: 1. Gangrene and nonhealing ulceration of the left fourth toe secondary to tibial peroneal disease. 2. Noninsulin dependent diabetes mellitus. 3. Hypertension. 4. Coronary artery disease status post myocardial infarction. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Doctor First Name 22875**] MEDQUIST36 D: [**2130-2-7**] 13:49 T: [**2130-2-7**] 14:43 JOB#: [**Job Number **]

[ "V45.81", "414.01", "357.2", "416.8", "496", "285.9", "593.9", "250.60", "440.24" ]

icd9cm

[ [ [] ] ]

[ "38.93", "84.11", "88.48", "39.29", "89.64" ]

icd9pcs

[ [ [] ] ]

7169, 7664

7685, 8173

2256, 2608

2626, 6346

2007, 2230

6369, 7146

148, 1377

1399, 1984

26,012

199,816

9508

Discharge summary

report

Admission Date: [**2186-7-30**] Discharge Date: [**2186-8-1**] Date of Birth: [**2109-11-11**] Sex: M Service: MEDICINE Allergies: Ambien Attending:[**First Name3 (LF) 10682**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: 76M with history of metastatic small cell lung cancer, HTN, COPD, DM2 presented to the ED with AMS, determined to have hyperglycemia, stable brain mets and possible infection. On discussion with patient's wife, Mr. [**Known lastname 32340**] health had been stable until approximately 2 weeks prior to admission. On [**7-16**] weekend, patient had become confused, not remembering his wife or children on a care ride from [**Doctor First Name 5256**] to [**State 350**]. He had just been treated for cough with Levoquin by his PCP. [**Name10 (NameIs) **] was taken to [**Hospital1 18**] and was shown to have progressing brain mets. He was placed on Dexamethasone and started whole brain XRT during that admission. Additionally, due to concern of CAP, he was treated with 5-day course of Levaquin. He was then discharged and completed his 5 day course of Levaquin and subsequently his 5 dose whole brain XRT. He has had waxing and [**Doctor Last Name 688**] of his mental status over the past 4-5 days, with delay in his dexamethasone taper to continue at 5 mg TID instead of going to [**Hospital1 **] dosing. This morning, Mr. [**Known lastname 16745**] was noted to be walking around without his cane and turning on lights around his house. Throughout the morning, he became more confused and agitated, prompting his wife to bring him to the [**Name (NI) **]. On review of symptoms, patient's wife states that he has had some intermittant incontinence over the past week, subjective chills (no temperature taken) and a "rattly cough" noted today in the ED. In the ED, initial vs were: T 98.0 P 128 BP 168/107 R 16 O2 sat. 96% RA. He was initially given Tylenol and Dexamethasone due to thinking this was [**2-14**] his intracranial disease. He was then given Ceftriaxone for possible infection, source unknown. UA was negative for UTI. Blood glucose was elevated and he recieved insulin subcutaneously. CT head was negative. CT abdomen and pelvis was then done to evaluate for possible intra-abdominal source of infection - this was negative for acute process. He was extremely agitated in the ED, requiring haldol and zyprexa. He was also restrained. On the floor, initial vitals are 96.6 BP 144/91 HR 114 RR 34 O2sat 96% on 4L by NC. He is restrained, not agitated. Patient is non-verbal. Review of systems: unable to obtain as patient non-verbal Past Medical History: -Metastatic Small Cell Lung Cancer -CAD s/p CABG in [**2183**] with LIMA to LAD, saphenous vein grafts to a diagonal, circumflex marginal, and right PDA. EF 50-55%. -Hypertension -COPD -Diabetes type 2 -Hyperlipidemia -GERD -Dysphagia- S/P endoscopic balloon dilatation -Anxiety -Left diaphragmatic paralysis [**2-14**] phrenic nerve injury -S/P CVA in [**12/2184**] - R putaminal and periventricular stroke Past Oncologic History: The patient initially presented with dyspnea 0n [**2185-12-9**]. Chest imaging revealed primary lung malignancy. PET CT showed contralateral lymph node and bilateral SC node involvement as well as innumerable bony lesions. Tissue biopsy was attempted first by bronchoscopy but was aborted due to bleeding. FNA of supraclavicular lymph node on [**12-13**] confirmed the diagnosis of small cell carcinoma. He was transferred to the oncology service, where he completed his first round of cisplatin & etoposide chemotherapy. CSF cytology was negative for malignancy x3, ruling out leptomeningeal involvement. He is now Cycle 2, Day 20 of cisplatin/etoposide. He is due to begin his next cycle of chemo on [**1-31**] at which point cisplatin will be replaced with carboplatin [**2-14**] magnesium wasting. Social History: He lives with his wife. Previously worked in maintenance. He has a 100 pack year smoking history but quit about 10 years ago. No alcohol or illicits. Family History: There is no family history of premature coronary artery disease or sudden death. Father's side of family with CAD but all lived to 80-90's. Mother's side died from stomach ulcers that became cancerous (several members with same diagnosis). No other cancer in family. Physical Exam: Vitals: T: 96.6 BP: 144/91 P: 114 R: 16 O2: 96% on 4L O2NC General: Awake, agitated, lying in bed in restraints HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: minimal breath sounds throughout left hemithorax when auscultated anteriorly, right hemithorax CTA with no wheezes or rhonchi. CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: warm, well perfused, trace edema in bilateral feet, 2+ pulses, no clubbing, cyanosis Neuro: alert, oriented x 0, non-verbal. spontaneously moves all 4 extremities. Pertinent Results: Admission labs: [**2186-7-30**] 12:51PM WBC-15.1* RBC-4.02* HGB-12.5* HCT-36.4* MCV-91 MCH-31.0 MCHC-34.3 RDW-14.4 [**2186-7-30**] 12:51PM NEUTS-88* BANDS-5 LYMPHS-2* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-2* [**2186-7-30**] 12:51PM PLT SMR-LOW PLT COUNT-95* [**2186-7-30**] 12:51PM GLUCOSE-652* UREA N-47* CREAT-1.6* SODIUM-135 POTASSIUM-3.9 CHLORIDE-90* TOTAL CO2-29 ANION GAP-20 [**2186-7-30**] 12:51PM ALT(SGPT)-54* AST(SGOT)-104* ALK PHOS-159* TOT BILI-0.2 [**2186-7-30**] 12:51PM LIPASE-49 [**2186-7-30**] 12:51PM PT-11.9 PTT-19.9* INR(PT)-1.0 CT HEAD W/O CONTRAST Study Date of [**2186-7-30**] IMPRESSION: 1. No acute hemorrhage or midline shift. 2. Multiple hyperdense foci consistent with known metastatic disease and better evaluated on MRI of [**2186-6-29**]. 3. Prominence of the ventricles, similar in appearance to the recent examination of [**2186-7-18**], however, increased from CT of [**2184-12-17**]. A component of hydrocephalus cannot be excluded. ADDENDUM AT ATTENDING REVIEW: I believe there is a hetergenous density appearance of the basisphenoid, which correlates with extensive MR [**First Name (Titles) 16313**] [**Last Name (Titles) 32341**]s in that area, as seen on the [**2186-6-29**] study, and is consistent with metastatic tumor involvement. There is prominent atherosclerotic calcification of the cavernous internal carotid arteries. CHEST (PORTABLE AP) Study Date of [**2186-7-30**] IMPRESSION: 1.Left hilar opacity corresponds with patient's known mass. Markedly elevated left hemidiaphragm, left base opacity and mediastinal shift to the left are likely due to left lower lobe collapse. 2. Clear right lung. CT PELVIS W/O CONTRAST Study Date of [**2186-7-30**] IMPRESSION: 1. Evaluation limited by lack of IV contrast. 2. Trace bilateral pleural effusions at the left lung base. There is partial collapse of the left lower lobe, increased since the previous study and incompletely imaged on this study. Underlying infectious process is of concern. 3. Multiple hypodense lesions throughout the liver, consistent with hepatic metastases. These are overall stable in size and number since the previous study. 4. Diffuse osseous metastases as seen before and stable compression fracture of L3 with mild retropulsion. 5. Diverticulosis without diverticulitis. [**2186-7-30**] 1:35 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS. Aerobic Bottle Gram Stain (Final [**2186-8-1**]): REPORTED BY PHONE TO DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2186-8-1**] AT 0025. GRAM POSITIVE COCCI IN CLUSTERS. Brief Hospital Course: 76 year old male with history of metastatic small cell lung cancer, HTN, COPD presented with AMS, found to have bandemia, left lung collapse, stable brain mets, and positive blood cultures. # Toxic/metabolic encephalopathy: This was likely secondary to septicemia +/- hyperosmolar hyperglycemic state in the setting of known brain metastases s/p radiation therapy. # Septicemia with GPCs in blood culture # Hyperosmolar hyperglycemic state # Small cell lung cancer, metastatic Patient was initially admitted to the medical ICU. There, a goals of care discussion was held, and, given the progression of tumor burden, patient's clear wishes to be DNR/DNI, and his mental status, care was focused on comfort. Patient was started on a morphine gtt. He died on [**2186-8-1**] with family at his bedside. Medications on Admission: Amlodipine 10 mg qday Calcium Carbonate 500 mg qdaily Cholecalciferol (Vitamin D3) 800 unit qdaily Dexamethasone 4mg TID Fluticasone 50 mcg/Actuation Spray 2 Spray daily Fluticasone 110 mcg/Actuation Aerosol 2 Puff twice a day Glyburide 5 mg [**Hospital1 **] Lorazepam 0.5 mg every six (6) prn nausea. Paroxetine HCl 40 mg daily Prochlorperazine Maleate 10 mg every 6 hours prn nausea. Ranitidine HCl 150 mg daily Tamsulosin 0.4 mg qhs Tiotropium Bromide 18 mcg daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Primary: Toxic/Metabolic encephalopathy Secondary: Septicemia with bacteremia Hyperosmolar hyperglycemic state Small cell lung cancer, metastatic Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

[ "250.20", "272.4", "414.00", "349.82", "V66.7", "198.3", "530.81", "162.2", "519.4", "V15.82", "196.8", "V45.81", "V12.54", "401.9", "518.0", "496", "038.9", "198.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9125, 9134

7768, 8578

290, 296

9324, 9333

5084, 5084

9385, 9391

4122, 4391

9097, 9102

9155, 9303

8604, 9074

9357, 9362

4406, 5065

7489, 7745

2639, 2680

229, 252

324, 2620

5100, 7445

2702, 3938

3954, 4106

22,804

144,102

7898

Discharge summary

report

Admission Date: [**2176-3-7**] Discharge Date: [**2176-3-9**] Date of Birth: [**2118-9-18**] Sex: M Service: CCU CHIEF COMPLAINT: The patient is status post a syncopal episode. HISTORY OF PRESENT ILLNESS: This is a 57-year-old male with a past medical history of type 2 diabetes mellitus, sarcoidosis, and a left bundle-branch block who was brought to the [**Hospital1 69**] Emergency Department after being found down at the gymnasium where he had been exercising on a treadmill. The patient states that he had been feeling tired earlier in the day but went to the gymnasium to do his usual 15-minute walk on the treadmill. He usually does this three times per week. Following his exercise session, he passed out. Emergency Medical Service found him and documented a heart rate of 20 beats per minute with a blood pressure of 90/palpable. The patient was given 2 mg of atropine without a response. Transcutaneous pacing was attempted as well, unsuccessfully. The patient was started on a dopamine drip and was taken to the [**Hospital1 69**] Emergency Department. In the Emergency Department, the patient's vital signs revealed a heart rate of 36 with a blood pressure of 66/40. He was continued on the dopamine drip with an improvement in his heart rate to the 40s to 50s. STAT laboratories disclosed a potassium elevated at 6.6, and the patient was given calcium gluconate, bicarbonate, and insulin. Shortly thereafter, the patient's heart rate began to decrease to the 20s. Dopamine was administered "wide open," and the patient was given normal saline fluid boluses. The patient was intubated for airway protection. He was brought to the Coronary Care Unit for further management. REVIEW OF SYSTEMS: Before intubation, the patient denied chest pain, cough, fevers, chills, abdominal pain, nausea, and vomiting. He also denied orthopnea, paroxysmal nocturnal dyspnea, and palpitations. He did report occasional shortness of breath with exertion. He reported that he exercises approximately 15 minutes on a treadmill two to three times per week. PAST MEDICAL HISTORY: 1. Status post cervical spine surgery in [**2175-5-6**]; complicated by a lacerated esophagus. 2. Chronic stable angina. 3. A left bundle-branch block. 4. Onychodystrophy. 5. An echocardiogram in [**2175-5-6**] disclosed an ejection fraction of 40% with no wall motion abnormalities. 6. A stress test in [**2175-5-6**] disclosed regional left ventricular systolic dysfunction, but no reversible defects. 7. Paroxysmal atrial fibrillation. 8. Sarcoidosis diagnosed in [**2151**]; the patient took steroids for four years. 9. Hypothyroidism. 10. Type 2 diabetes mellitus times 10 years. 11. Hypercholesterolemia. 12. Cardiac catheterization revealed there was moderate left and mild right ventricular diastolic function, there was mild focal left ventricular systolic dysfunction, there was mild pulmonary arterial hypertension, there was a left-sided superior vena cava. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. once per day. 2. Glucophage 1 g p.o. twice per day. 3. Lipitor 20 mg p.o. once per day. 4. Atenolol 100 mg p.o. once per day. 5. Synthroid 75 mcg p.o. once per day. 6. Lasix 40 mg p.o. once per day. 7. Irbesartan 300 mg p.o. once per day. SOCIAL HISTORY: The patient is married. He works at home. He is employed as an investment advisor. He has two children; ages 22 and 16. He denies the use of tobacco, alcohol, and drugs. FAMILY HISTORY: Mother is status post a valve repair. Father with diabetes mellitus. PHYSICAL EXAMINATION ON PRESENTATION: General physical examination revealed an obese male lying in bed with face mask. The patient initially to be in no apparent distress. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. Pupils were equally round and reactive to light. Extraocular movements were intact. The mucous membranes were moist. The oropharynx was clear. The neck was supple. Difficult to assess jugular venous distention due to body habitus. Right internal jugular was in place. Heart examination revealed bradycardia in the 40s. Normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops. The lungs revealed bibasilar crackles. The abdomen was obese, nontender, and nondistended. Positive bowel sounds. Extremity examination revealed 1+ lower extremity edema. Right first toe with ulcer. Left first toe with hyperkeratosis on the plantar surface. Neurologic examination evaluated alert and oriented times three. Cranial nerves II through XII were grossly intact. Examination was otherwise nonfocal. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data revealed white blood cell count was 9.7, hematocrit was 33.7, and platelet count was 204. Chemistries were significant for a potassium of 6.6, blood urea nitrogen was 54, and creatinine was 1.9. Magnesium was 2.2. Creatine kinase was 341. The second creatine kinase was 348. The third creatine kinase was 240. A toxicology screen was negative. PERTINENT RADIOLOGY/IMAGING: A chest x-ray was consistent with pulmonary edema. Electrocardiogram revealed a heart rate in the 40s, a junctional rhythm versus atrial fibrillation, with low rate. A left bundle-branch block (old). Left axis deviation. IMPRESSION: This is a 57-year-old male with nonischemic cardiomyopathy, type 2 diabetes mellitus, hypertension, sarcoidosis, and hypercholesterolemia status post a syncopal episode with a heart rate initially in the 20s and an electrocardiogram consistent with probable junctional rhythm. The patient was admitted to the Coronary Care Unit for further management. HOSPITAL COURSE: The patient was maintained on a dopamine drip to maintain his heart rate and blood pressure. His cardiac enzymes were cycled to rule out an ischemic event, and they peaked with a creatine kinase of 348. Cardiac troponin was 0.9. The patient was administered aspirin. The patient underwent an electrophysiology study. Mapping disclosed dysfunction of the patient's sinus node. The patient underwent placement of a dual-mode, dual-pacing, dual-sensing pacemaker. His heart rate was atrioventricularly paced in the 80s, and his blood pressure was stable off of dopamine. The patient was extubated the following morning and remained stable. An echocardiogram with contrast was performed. The left atrium was normal in size. The left ventricular wall thickness was normal. The left ventricular cavity size was normal. Overall left ventricular systolic function was mildly depressed. Resting regional wall motion abnormalities included anteroseptal hypokinesis. The right ventricular chamber size and free wall motion were normal. The aortic valve leaflets appeared structurally normal with good leaflet excursion, and no aortic regurgitation. The mitral valve leaflets were mildly thickened, and trivial mitral regurgitation was seen. There was no pericardial effusion. The ejection fraction was estimated to be between 45% to 50%. DISCHARGE STATUS: Discharge status was to home. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with his primary care physician (Dr. [**Last Name (STitle) **] in two weeks. 2. The patient was to follow up in the Electrophysiology Clinic on [**3-14**]. MEDICATIONS ON DISCHARGE: 1. Metformin 1 g p.o. twice per day. 2. Levothyroxine 75 mcg p.o. once per day. 3. Atorvastatin 20 mg p.o. once per day. 4. Aspirin 325 mg p.o. once per day. 5. Atenolol 100 mg p.o. once per day. 6. Irbesartan 300 mg p.o. once per day. 7. Lasix 40 mg p.o. once per day. DISCHARGE DIAGNOSES: 1. Sinus node dysfunction with apparent junctional rhythm. 2. Old left bundle-branch block. 3. Status post dual-mode, dual-pacing, dual-sensing pacemaker placement. 4. Reduced ejection fraction of 45% to 50%. 5. Hypothyroidism. 6. Type 2 diabetes mellitus. 7. Hypercholesterolemia. 8. Sarcoidosis. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**] Dictated By:[**Last Name (NamePattern1) 5092**] MEDQUIST36 D: [**2176-3-13**] 22:32 T: [**2176-3-14**] 09:29 JOB#: [**Job Number 28415**]

[ "244.9", "584.5", "276.7", "135", "425.4", "780.2", "427.81", "250.00", "458.9" ]

icd9cm

[ [ [] ] ]

[ "37.26", "96.04", "96.71", "37.72", "88.51", "38.93", "37.83" ]

icd9pcs

[ [ [] ] ]

3545, 5737

7699, 8249

7400, 7678

3066, 3336

5755, 7150

7183, 7374

1740, 2088

148, 196

225, 1720

2111, 3040

3353, 3527

7,275

134,152

43683

Discharge summary

report

Admission Date: [**2140-4-12**] Discharge Date: [**2140-4-16**] Date of Birth: [**2078-11-11**] Sex: M Service: SURGERY Allergies: Penicillins / Iodine; Iodine Containing / Carbamazepine Attending:[**First Name3 (LF) 668**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 61M formerly listed on liver-kidney [**First Name3 (LF) **] list and recently (yesterday) discharged from [**Hospital1 18**] after being treated for suspected Norovirus that triggered seizure and required assisted ventilation. Notes continued abdominal pain x 6d, presents to the ED, and a CT non-contrast of the abdomen demonstrates splenic hematoma subcapsular and intraparenchymal. Unable to obtain contrast CT due to adverse affect noted (pruritus). Hemodynamically stable, LUQ fullness appreciated, sequelae of liver disease and kidney disease noted. [**Hospital1 **] catheter in place. No fevers, chills, nausea, no more diarrhea noted. Past Medical History: - Multiple pulm infiltrates on CT scan [**12/2139**] concerning for malignancy. - ESRD on HD [**3-15**] idiopathic glomerulonephritis - Liver failure secondary to Hepatitis C - Epilepsy - This began in childhood with generalized tonic-clonic seizures. His usual seizure is nonconvulsive and characterized by confusion, disorientation. He was admitted in [**Month (only) 116**] and [**2139-9-12**] for a seizure that presented with confusion. He is followed closely by neurologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**], for seizure prevention takes Lamictal 250 mg [**Hospital1 **], Keppra 375 mg [**Hospital1 **] plus an additional 250 mg [**Hospital1 **] after each hemodialysis session, Dilantin 200 mg [**Hospital1 **]. - coagulase negative staph bacteremia secondary to HD line sepsis - History of CHF now with transesophogeal [**Hospital1 461**] in [**2139-9-12**] showing normal left ventricular function. - Hypertension - VRE - Septic arthritis of left shoulder - AVNRT s/p ablation [**2133**] PSH: - s/p two failed renal transplants - s/p arthroscopic debridement of L shoulder - synovectomy and tenotomy L shoulder, Social History: Lives at [**Hospital3 **] facility on Mission [**Doctor Last Name **] called [**Hospital1 **] at [**Hospital1 1426**]; the facility, per his son does not help him take medications or provide any other care besides ensuring that the patient has 3 meals per day and that he is accounted for on a daily basis. He is on disability, has two sons. Smokes 1ppd x 40 yrs, no Etoh, no drugs. Family History: Mother died of breast cancer. Father has coronary artery disease and congestive heart failure, alive at [**Age over 90 **] yo. Two sons are healthy. Physical Exam: Tm 99.7 108 104/66 18 98RA NAD Lungs: CTAB CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, distended, mild fluid shift, bowel sounds present , LUQ fullness and tenderness elicited, superficial venous distention Ext: Warm, well perfused, 2+ pulses, No edema, L subclavian tunnelled line C/D/I , scars and evidence of prior surgery Pertinent Results: [**2140-4-11**] 06:40AM BLOOD WBC-5.2 RBC-3.83* Hgb-10.1* Hct-30.9* MCV-81* MCH-26.3* MCHC-32.7 RDW-21.3* Plt Ct-149* [**2140-4-12**] 11:50AM BLOOD WBC-8.8# RBC-3.02* Hgb-8.3* Hct-24.5* MCV-81* MCH-27.5 MCHC-33.9 RDW-22.1* Plt Ct-246# [**2140-4-12**] 08:15PM BLOOD Hct-19.1* [**2140-4-12**] 11:50AM BLOOD Plt Ct-246# [**2140-4-12**] 04:56PM BLOOD PT-12.7 PTT-26.0 INR(PT)-1.1 [**2140-4-11**] 06:40AM BLOOD Glucose-96 UreaN-26* Creat-5.2*# Na-139 K-3.9 Cl-96 HCO3-30 AnGap-17 [**2140-4-12**] 11:50AM BLOOD ALT-16 AST-51* AlkPhos-157* TotBili-0.7 [**2140-4-13**] 01:45AM BLOOD Albumin-3.1* Calcium-7.7* Phos-6.5* Mg-1.8 [**2140-4-12**] 11:59AM BLOOD Glucose-94 Lactate-2.2* Na-140 K-4.3 Cl-92* calHCO3-32* Imaging: RUQ U/S [**4-12**]: 1. Cirrhosis with diffuse ascites. Marker placed over largest fluid pocket in the right lower quadrant. 2. New splenic lesion has a wide differential diagnosis, including infection, hemangioma, abscess, hematoma, and neoplasm. Correlate clinically. CT A/P -C [**4-12**]: 1. Large perisplenic, subcaspular and intraparenchymal hematoma within the spleen. Evaluation for active extravasation is limited due to lack of IV contrast. Repeat imaging to confirm resolution of hematoma and exclude underlying splenic lesion is recommended. This could be done with ultrasound given the patient's renal failure and allergy to iodinated contrast. 2. Cirrhosis with splenomegaly and moderate amount of ascites. 3. Extensive [**Month/Day (2) 1106**] calcifications. 4. Atrophic, cystic native kidneys. Calcified atrophic right lower quadrant renal [**Month/Day (2) **]. 5. Diverticulosis without evidence of acute diverticulitis. 6. Cholelithiasis. CT abd w/contrast [**4-12**] (premedicated): Unchanged intraparenchymal, subcapsular and perisplenic hematomas of the spleen without evidence of active extravasation. Brief Hospital Course: Patient was admitted with a large perisplenic, subcapsular and intraparenchymal hematoma within the spleen. On admission he was hemodynamically stable, but his hematocrit was clearly dropping from 30.9 the day before admission to 24.5 in the [**Last Name (LF) **], [**First Name3 (LF) **] a decision was made to admit the patient to the ICU and premedicate him for a CT with contrast to rule out active extravasation. The CT with contrast did not see any active extravasation, but the Hct kept dropping to 19.1 that night and multiple transfusions of pRBC were necessary. Serial Hct were performed and were fairly stable after the initial transfusions on HD1. On HD2 the Hct was maintained in the 29s without any further need for transfusions. He was advanced to a clear liquid diet and was transferred to the floor on HD3. He tolerated a regular diet, and hi abdominal pain was well controlled with po pain medications. His Hct stayed in the 30s. On HD5 the Hct was 35.4, had minimal abdominal pain and was feeling well. He was discharged to home with physical therapy at home to help him return to his baseline activity. He will continue his HD as usual Monday, Wednesday, [**First Name3 (LF) 2974**] and will follow-up as an outpatient with Dr. [**First Name (STitle) **] in the [**First Name (STitle) **] clinic. Medications on Admission: clonidine patch 0.2', lamictal 250'', lansoprazole 30', lisinopril 40', nifedipine 60''', phenytoin xr 200'', rifaximin 200''', asa 81' Discharge Medications: 1. Lisinopril 20 mg Tablet [**First Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**First Name (STitle) **]: One (1) Cap PO DAILY (Daily). 3. Lamotrigine 100 mg Tablet [**First Name (STitle) **]: 2.5 Tablets PO BID (2 times a day). 4. Levetiracetam 250 mg Tablet [**First Name (STitle) **]: 1.5 Tablets PO BID (2 times a day). 5. Phenytoin Sodium Extended 100 mg Capsule [**First Name (STitle) **]: Two (2) Capsule PO BID (2 times a day). 6. Rifaximin 200 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 7. Hydromorphone 2 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO QID (4 times a day). 10. Clonidine 0.2 mg/24 hr Patch Weekly [**Last Name (STitle) **]: One (1) Patch Weekly Transdermal QWED (every Wednesday). 11. Levetiracetam 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO PRN (as needed) as needed for after [**Last Name (STitle) 2286**]. 12. Nifedipine 30 mg Tablet Sustained Release [**Last Name (STitle) **]: Two (2) Tablet Sustained Release PO Q 8H (Every 8 Hours). Discharge Disposition: Home With Service Facility: caregroup Discharge Diagnosis: Splenic hematoma Hepatitis C cirrhosis ESRD on hemodialysis Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance Discharge Instructions: Please call your primary care physician or return to the emergency room if you develop chest pain, shortness of breath, increased abdominal pain, dizziness, weakness, nausea, vomniting, diarrhea, inability to take or keep down food, fluids or medications. Continue your outpatient [**Last Name (STitle) 2286**] schedule Continue all food, fluid restrictions and medications as recommended by your kidney doctor. Call the access clinic at [**Telephone/Fax (1) 673**] for problems with the [**Telephone/Fax (1) 2286**] catheter You should not shower with the [**Telephone/Fax (1) 2286**] catheter in place. Followup Instructions: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2140-4-20**] 9:30 [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD Phone:[**Telephone/Fax (1) 2928**] Date/Time:[**2140-5-13**] 9:00 Please follow-up with Dr. [**First Name (STitle) **] in the [**First Name (STitle) **] clinic. Please call the office to schedule an appointment in 1 week. (As hemodialysis MWF, thursday is an appropiate day) Completed by:[**2140-4-18**]

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

7969, 8009

5035, 6353

330, 337

8113, 8113

3170, 5012

8898, 9412

2614, 2765

6539, 7946

8030, 8092

6379, 6516

8269, 8875

2780, 3151

276, 292

365, 1014

8128, 8245

1036, 2197

2213, 2598

54,861

152,989

49670

Discharge summary

report

Admission Date: [**2127-4-3**] Discharge Date: [**2127-4-8**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1943**] Chief Complaint: Bloody bowel movements Major Surgical or Invasive Procedure: Flexible sigmoidoscopy on [**2127-4-7**] History of Present Illness: Mrs. [**Known firstname 4890**] [**Known lastname **] is a very nice 88 year-old woman with a severe dementia, diverticolosis, PUD, chronic anemia who comes with after having multiple bowel movements with clots. She was in her prior state of health until ~1 week ago when at the facility that she lives (Newbridge on [**Doctor Last Name **] at Deedham). She was seen by her VNA who performed a rectal exam 4 days ago and found her to have guaiac positive stools which may have been a false positive due to iron supplementation. On the morning of admission, she started passing blood clots with her bowel movments so she was sent to the ER. She denies any palpitations, chest pain, diziness, lightheadedness, epigastric pain, abdominal pain, orthopnea, shortness of breath. There has not been any bright red blood per rectum. Ambulance was called and when EMS arrived her VS were T97.4 HR:60 BP:146/67 Resp:18 O2Sat:100 normal. In the ER her initial VS were T 97.4 F, BP 146/67 mmHg, HR 60 BPM, RR 18 X', SpO2 100% on RA with pain 0/10. Her BP was table thoughout the ED stay with SBP ranging from 120-150 with HR in 60s (on metoprolol). Pt had no abdominal pain and was guaiac positive. She had multiple bowel movements with dark maroon-colored stools. Her CXR showed opacity in the LLL that could be compatible with atelectases or PNA, so patient received Ceftriaxone/Azithromycin. She was T&S and received 2 RBC units. She had an 18-G placed in the antecubital fosa, but Dr. [**First Name (STitle) **] expressed patient had "2 large IVs". ECG showed sinus bradycardia without signs of ishcemia. Past Medical History: Diverticulosis - Patient was scoped 3-4 years ago for anemia. Peptic Ulcer Disease - Patient with EGD showing PUD 3-4 years ago. Alzheimer's Dementia - A&O x1. Breast cancer s/p right mastectomy & radiation Anemia - chronic on iron replacement therapy HTN Hypercholesterolemia Urinary incontinence Depression - after the death of her husband in [**11-18**] Chronic diarrhea Social History: She lives in [**Location 19168**] on the [**Doctor Last Name **] in Deedham by herself. Denies any current or past history of smoking, alcohol or illegal substance use. She is not currently sexually active. Has 1 son and 1 daughter. Family History: Denies family history of stroke, CAD, sudden cardiac death. Her daughter had breast cancer. Physical Exam: VS - T 98.6, BP 176/68, HR 59, RR 20, O2 98% RA GENERAL - well-appearing woman in NAD, comfortable, appropriate, not jaundiced (skin, mouth, conjuntiva) HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding, + guaiac, maroon stools in vault. EXTREMITIES - WWP, no c/c/e SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox1 (person), CNs II-XII grossly intact, muscle strength 5/5 throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2127-4-3**] 08:00AM BLOOD WBC-8.8 RBC-2.70* Hgb-7.9* Hct-24.1* MCV-89 MCH-29.2 MCHC-32.8 RDW-14.6 Plt Ct-362 Neuts-78.4* Lymphs-14.6* Monos-3.9 Eos-3.0 Baso-0.2 PT-12.9 PTT-23.9 INR(PT)-1.1 Glucose-101* UreaN-36* Creat-1.9* Na-139 K-4.8 Cl-105 HCO3-25 ALT-11 AST-24 LD(LDH)-319* AlkPhos-80 TotBili-0.9 Albumin-3.4* Calcium-8.2* Phos-4.3 Mg-1.9 Iron-249* calTIBC-291 VitB12-286 Folate-GREATER TH Ferritn-21 TRF-224 [**2127-4-3**] 04:56PM Hct-30.6 [**2127-4-3**] 04:56PM Hct-26.0* [**2127-4-4**] 04:27AM Hct-28.5* [**2127-4-4**] 12:07PM Hct-27.0* [**2127-4-4**] 04:15PM Hct-29.4* [**2127-4-4**] 11:15PM Hct-30.1* [**2127-4-5**] 06:15AM Hct-26.0* [**2127-4-8**] 06:00AM Hct-28.8* CXR [**2127-4-3**]: PA AND LATERAL VIEWS OF THE CHEST: The heart size is mildly enlarged. The aorta is tortuous. The pulmonary vascular markings are slightly prominent, overt pulmonary edema is seen. There is ill-defined patchy opacity within the retrocardiac region, likely atelectasis, but an area of developing infection cannot be excluded. No large pleural effusion or pneumothorax is seen. Mild degenerative changes are noted in the thoracic spine. Minimal fluid is seen within the right minor fissure. IMPRESSION: Probable retrocardiac atelectasis. Developing infection in this region cannot be fully excluded. GI BLEEDING STUDY (TAGGED RBC SCAN) [**2127-4-5**]: IMPRESSION: Evidence of very slow but steady GI bleed likely at the sigmoid colon. Recommend angiography for further evaluation. ANGIOGRAPHY [**2127-4-5**]: FINDINGS: 1. Angiography of the SMA and [**Female First Name (un) 899**] demonstrated no evidence of active contrast extravasation to localize the source of gastrointestinal bleeding. 2. The patient has extensive atherosclerotic disease. 3. Note is made of replaced right/common hepatic artery arising from the SMA. IMPRESSION: No source of gastrointestinal bleeding was identified on angiography. FLEXIBLE SIGMOIDOSCOPY [**2127-4-7**]: Impression: - Grade 1 internal hemorrhoids - Diverticulosis of the sigmoid colon and descending colon - Polyp at 70cm in the splenic flexure (polypectomy) - Otherwise normal sigmoidoscopy to proximal transverse colon Brief Hospital Course: 88 year-old woman presents with maroon-colored stool with blood clots. Tagged RBC scan showed that the bleed was from a sigmoid vessel. The patient was transfused 6 units of PRBC (last unit on [**2127-4-5**]). She was initially observed to have maroon colored stool. HCT remained stable after last transfusion on [**2127-4-5**]. Angiography was performed to try to intervene on the bleeding vessel after it was identified on the Tagged RBC Scan, but no further bleeding was found. Flexible sigmoidoscopy on [**2127-4-7**] found no active bleed, but did find Grade 1 internal hemorrhoids and diverticular disease. The patient was continued with iron supplementation throughout the hospital admission and was witnessed to have black (non-foul-smelling) stool on the day of discharge (but no blood clots and no further maroon-colored stool). With the known GI bleed being in the sigmoid colon and the hematocrit being stable, the black stool is attributed to iron supplementation rather than upper GI bleed. PROBLEM LIST: # Anemia: Patient with normocytic, normochromic anemia with normal RDW, who has history of PUD and diverticulosis and prior diagnosis of iron deficiency anemia on iron replacement therapy. Iron deficiency was likely [**2-11**] prior bleeding. Iron studies this admission were normal. Iron was discontinued at discharge given normal iron levels. # Alzheimer Dementia: Baseline is A&O x name only. Continue Donepezil. # Hypertension: Beta blocker intially held. Metoprolol restarted as metoprolol 25mg PO bid in place of the long acting form. Transitioned to long-acting Toprol XL at discharge. # Hypercholesterolemia: Statin continued. # H/o Breast cancer: In remision. No BP or blood draws in R arm. # Code Status - DNR/DNI confirmed with daughter who is HCP. Medications on Admission: Aricept 10 mg Daily Citalopram 20 mg one a day Iron 325 mg a day Lovastatin 40 mg a day Omeprazole 20 mg delayed release Toprol XL 50 mg once a day Lomotil 2.5 QID PRN Discharge Medications: 1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Fever / pain. 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: PRIMARY DIAGNOSES: - Lower gastrointestinal bleeding from hemorrhoids or diverticulosis - Hemorrhoids, Grade 1 - Diverticulosis - Anemia from blood loss SECONDARY DIAGNOSES: - Alzheimer's disease - Hypertension - Hypercholesterolemia - History of breast cancer Discharge Condition: Mental Status: Always Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted for evaluation and management of rectal bleeding. Studies showed that your bleeding was in the sigmoid colon. You required blood transfusion with 6 units of red blood. Your hematocrit remained stable for the last 3 days of hospital admission. A flexible sigmoidoscopy was performed on [**2127-4-7**] that revealed hemorrhoids, diverticulosis, and a small polyp which was removed. No active bleeding was seen during the procedure. You were previously iron deficient, but our tests show that your iron is now normal. You were on iron supplements during your hospitalization that made your stools black. You are in stable condition with stable hematocrit. You will be discharged to a skilled nursing facility at [**Hospital3 4103**]. MEDICATION CHANGES: 1. Discontinue ferrous sulfate (iron) Followup Instructions: Appointment #1: Name: GLASSMAN,YOSEF PESACH Phone: [**Telephone/Fax (1) 81140**] Appointment: [**2127-4-22**] 11;30am

[ "455.2", "311", "285.1", "401.1", "787.91", "294.10", "V12.71", "211.3", "V10.3", "280.9", "331.0", "562.12", "V45.71", "272.0", "V15.3", "788.39" ]

icd9cm

[ [ [] ] ]

[ "88.47", "45.42", "88.42" ]

icd9pcs

[ [ [] ] ]

8505, 8599

5863, 6876

283, 325

8904, 8904

3665, 5840

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7688, 7857

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9818, 9857

221, 245

353, 1952

6890, 7662

8919, 9015

1974, 2349

2365, 2599

21,320

108,696

4318

Discharge summary

report

Admission Date: [**2149-5-30**] Discharge Date: [**2149-6-8**] Date of Birth: [**2081-8-7**] Sex: M Service: Urology CONDITION UPON DISCHARGE: Stable. The patient is discharged to home. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 18685**] is a 67-year-old male noted to have a right kidney mass consistent with a renal cell carcinoma after presenting with microscopic hematuria. By imaging, he was noted to have bilateral renal cysts as well as a 2nd lesion in the right kidney that was consistent with a Bosniak III cyst. The patient was subsequently prepared for a right partial nephrectomy with the knowledge of a possible right total nephrectomy. Of note, the patient's more recent past medical history included a recent gastrointestinal bleed from a hiatal hernia ulcer for which he was found to be H. pylori positive and a pulmonary embolus in the setting of the gastrointestinal bleed where he had an IVC filter placed. His past medical history otherwise includes: 1. Coronary artery disease, status post left anterior descending artery stent in [**2144**], cardiac catheterization in [**2149-3-21**], status post stent and PTCA again of the left anterior descending artery as well as PTCA of the obtuse marginal. Ejection fraction was 58% with anterolateral and apical hypokinesis. 2. Congestive obstructive pulmonary disease with a FEV1 of 54% of predicted, FVC of 80% of predicted, and FEV1/FVC ratio of 67% of predicted. 3. Gastrointestinal bleed as noted above. 4. Pulmonary embolus as noted above. 5. Hernia repair in [**2138**]. His medications at home include Nifedipine XL 30 mg po q day, metoprolol 25 mg [**Hospital1 **], tamsulosin 0.4 mg po q day, aspirin which was stopped [**2149-5-21**], sublingual nitroglycerin for which he rarely uses, and an incomplete treatment for his H. pylori. His allergies include a question of an allergy to one of the medications in his Prevpak. His examination on admission shows an elderly Russian speaking male in no acute distress. His blood pressure is 145/94. His heart rate is 78. His head and neck examination are benign. His lungs show some diffuse scattered mild expiratory wheezes. His heart is regular, rate, and rhythm. His abdomen is soft and nontender with a well-healed vertical incisional scar consistent with is previously known hiatal hernia repair. He has no costovertebral angle tenderness. He has slight bilateral lower extremity edema with easily palpable pulses. HOSPITAL COURSE: The patient was admitted status post a right partial nephrectomy performed on [**2149-5-30**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**]. His postoperative pain management included an epidural which appeared to be working. At the initial night in the Intensive Care Unit, due to a postoperative temperature of 102 and a decreased respiratory rate felt consistent with his residual anesthesia and epidural. Overnight he did well with good pain control. He completed his perioperative course of antibiotics. His temperature curve returned to [**Location 213**]. He was slowly started on sips on postoperative day two. He was transferred out of the Intensive Care Unit. On postoperative day three, the patient was originally doing well. However, in the afternoon, he developed acute respiratory distress. He was transferred back down to the Intensive Care Unit, where he was intubated with a question of an aspiration pneumonia versus lobar collapse versus pulmonary embolus. That night he subsequently underwent a chest, abdomen, and pelvic CT scan which showed no evidence of pulmonary embolus and no evidence of postoperative bleed. He was status post bronchoscopy which was unrevealing showing no inflammation of the bronchial mucosa. He also underwent a thoracentesis under ultrasound guidance for which 500 cc of a bloody effusion on the right was obtained. The effusion, bronchoalveolar lavage, and sputum cultures were all negative. The cytologies were all negative. Patient subsequently underwent recruitment maneuvers on the ventilator and was subsequently extubated on postoperative day six. He did well status post extubation, and was transferred to the surgical floor on postoperative day seven. He continued on a presumptive course for aspiration pneumonia including levofloxacin and Flagyl. With the passage of flatus, his diet was advanced as tolerated. He continued to do well, weaning off the oxygen. On discharge, by postoperative day nine, he was continuing on his levofloxacin and Flagyl on day [**7-30**]. He was ambulating without difficulty. He was on room air without any recurrence of respiratory distress or wheeze on auscultation. He is tolerating a regular diet. He was moving his bowels. He is voiding without difficulty. His incision was clean, dry, and intact. His [**Location (un) 1661**]-[**Location (un) 1662**] drain had been removed postoperatively previously on postoperative day three. He was subsequently discharged to home after verifying that there is no evidence of any deep venous thrombosis for his lower extremity edema with a lower extremity noninvasive test on the date of discharge. His medications on discharge include his preoperative medications of Nifedipine XL 30 mg po q day, Lopressor 25 mg po bid, levofloxacin 500 mg po q day, Flagyl 500 mg po tid, Percocet 1-2 tablets po q 4 hours prn pain, Colace 100 mg po bid, and albuterol inhaler two puffs qid prn wheeze. He will follow up with his primary care physician to further workup his preoperative and postoperative pulmonary issues. Prior to discharge, his staples were removed. His pathology results were given to him and his family. He will follow up with Dr. [**Last Name (STitle) 9125**] in approximately two weeks as well to reassess his wound healing and to finalize his postoperative oncologic plan. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13269**] Dictated By:[**Last Name (NamePattern1) 18686**] MEDQUIST36 D: [**2149-6-8**] 18:35 T: [**2149-6-9**] 10:15 JOB#: [**Job Number 18687**]

[ "401.9", "492.8", "507.0", "189.0", "V45.82", "511.9", "285.9", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.04", "34.91", "96.71", "33.24", "55.4" ]

icd9pcs

[ [ [] ] ]

2499, 6180

161, 206

235, 2481

11,693

125,988

14939

Discharge summary

report

Admission Date: [**2145-6-21**] Discharge Date: [**2145-7-1**] Date of Birth: [**2094-5-5**] Sex: M Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: This was a 50-year-old man with a history of metastatic melanoma who entered with a small bowel obstruction. The patient initially was diagnosed in [**2143-8-8**] with a left cheek melanoma measuring 1.25 mm deep. He underwent wide excision with a negative sentinel node biopsy at that time. However, in [**2144-4-7**] he recurred with a left submandibular mass requiring a modified radical neck dissection. He underwent local radiotherapy. He had a short course of Interferon which was not well tolerated. In [**2144-9-7**] I met the patient for the first time because he had developed a left chest wall metastasis. I resected this and he then underwent additional rounds of experimental systemic therapy. Most recently, he had been receiving biochemotherapy. On the day of admission, the patient had reported nausea and progressive abdominal distention. He was initially admitted to the Medical Service but ultimately was transferred to the surgical service after undergoing a laparotomy with resection of his small bowel metastasis. PAST MEDICAL HISTORY: Depression and gastroesophageal reflux. MEDICATIONS: Celexa and Protonix. HOSPITAL COURSE: The patient was taken to the Operating Room on [**6-24**] where he was found to have an area of intussusception in the mid small bowel due to an implant of metastatic melanoma. He was also noted at that time to have multiple subcentimeter serosal implants along the bowel and throughout his mesentery diffusely. He underwent resection with a stapled anastomosis. Postoperatively, he did extremely well. He regained bowel function by the fifth day and was discharged to home on the seventh postoperative day eating a normal diet with a well-appearing wound. DISCHARGE DIAGNOSIS: Metastatic melanoma with small bowel obstruction. OPERATIONS AND PROCEDURES: [**2145-6-24**]: Exploratory laparotomy with small intestine resection and anastomosis. DISPOSITION: To home. CONDITION ON DISCHARGE: Improved. [**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**] Dictated By:[**Last Name (NamePattern4) 17555**] MEDQUIST36 D: [**2145-8-10**] 13:30:41 T: [**2145-8-10**] 13:49:37 Job#: [**Job Number 43764**]

[ "560.0", "197.4", "197.0", "198.89", "276.5", "V10.82" ]

icd9cm

[ [ [] ] ]

[ "96.07", "45.61" ]

icd9pcs

[ [ [] ] ]

1930, 2123

1346, 1908

181, 1228

1251, 1328

2148, 2431

21,590

170,076

22199

Discharge summary

report

Admission Date: [**2198-8-27**] Discharge Date: [**2198-9-4**] Date of Birth: [**2136-3-27**] Sex: M Service: CTS HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This patient was originally seen on [**2198-6-20**], in Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office for initial history and physical examination. This 60 year old male was referred by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. He had a known history of mitral regurgitation. Echocardiogram [**2198-4-30**], showed severe mitral regurgitation with a myomatous degeneration and bileaflet prolapse, ejection fraction 55 percent, mild tricuspid regurgitation and mild to moderate pulmonary hypertension. He had a cardiac catheterization on [**2198-6-20**], the day that he was seen with no coronary artery disease, and he is now referred for mitral valve repair to Dr. [**Last Name (Prefixes) **], who reported his only symptom as bilateral lower extremity edema. No chest pain, palpitations or shortness of breath. His catheterization showed mildly elevated filling pressures, normal wall motion with four plus mitral regurgitation and ejection fraction of 55 percent. He had a right dominant system with a 20 percent right coronary artery lesion. PAST MEDICAL HISTORY: Mitral regurgitation. Deep venous thrombosis. Cerebrovascular accident in [**2197-3-7**], with no residual. Arthritis. Hypercholesterolemia. Mitral valve degeneration. PAST SURGICAL HISTORY: Transurethral resection of the prostate approximately eight years ago. Left ankle surgery in [**2197-5-7**]. ALLERGIES: He had no known drug allergies. MEDICATIONS ON ADMISSION: 1. Crestor 10 mg p.o. daily. 2. Ecotrin 325 mg p.o. daily. 3. Lorazepam 0.5 mg p.o. p.r.n. which he says he takes approximately three times a week. 4. Hydrocodone for his arthritis which he took p.r.n. on rare occasions. 5. Multivitamin. 6. Vitamin E. SOCIAL HISTORY: He is retired and lived alone, but is engaged. He lives in [**Location **]. He uses a cane occasionally for ambulation. He was a past pipe smoker on rare occasions but no tobacco otherwise. He takes one beer every night. PHYSICAL EXAMINATION: Repeat examination was done on preadmission testing on [**2198-8-14**], which showed no change since his initial visit when he was seen in [**Month (only) 205**]. His carotid ultrasound on [**2198-7-6**], showed no significant disease bilaterally. He had dental clearance which was faxed to the office. Hi[**Last Name (STitle) 57929**] was six feet, his weight 240. He was sitting up in bed in no apparent distress. He was alert and oriented times three and neurologically grossly intact. He had a grade III to IV/VI systolic ejection murmur with excellent S2 heart sound. His lungs are clear bilaterally. His abdomen was soft, obese, nontender, nondistended with positive bowel sounds. His extremities were warm and well perfused with two plus edema. He is wearing [**Male First Name (un) **] stockings in place. He had no varicosities. He had two plus bilateral radial, dorsalis pedis and posterior tibial pulses. The plan was for him to have a minimally invasive mitral valve repair or replacement with Dr. [**Last Name (Prefixes) **] scheduled originally for [**2198-8-22**]. LABORATORY DATA: Preoperative laboratory studies are as follows: White blood cell count 7.2, hematocrit 43.7, platelet count 178,000. Prothrombin time 12.5, partial thromboplastin time 31.1, INR 1.0. Urinalysis was negative. Glucose 81, blood urea nitrogen 16, creatinine 0.7, sodium 140, potassium 4.1, chloride 104, bicarbonate 28, anion gap 12, ALT 23, AST 16, alkaline phosphatase 73, total bilirubin 0.7, total protein 6.5, albumin 4.2, globulin 2.3. Hemoglobin A1C 5.0 percent. Preoperative chest x-ray showed no evidence of acute cardiopulmonary disease. Preoperative electrocardiogram showed sinus bradycardia at 56 beats per minute with atrial and ventricular premature beats and left axis deviation with left anterior fascicular block and left ventricular hypertrophy. Please refer to the official report dated [**2198-8-14**]. HOSPITAL COURSE: The patient did have his surgery on [**2198-8-27**], the date of admission. He had a mitral valve repair with a 31 millimeter mosaic porcine tissue valve. He was transferred to the Cardiothoracic Intensive Care Unit in stable condition on a titrated Propofol drip. On postoperative day number one, he had been extubated overnight. He had no other events. His temperature maximum was 99.2, was in sinus rhythm at 62, blood pressure 109/49, saturating 95 percent on 4.5 liters nasal cannula. His heart was regular rate and rhythm. His lungs were clear bilaterally. His abdomen was soft, nontender, nondistended. He was on an insulin drip at four units per hour and Neo- Synephrine drip at 0.1 mcg/kg/minute. Postoperatively, his white blood cell count was 15.4, hematocrit 32.8, platelet count 155,000. Sodium 144, potassium 4.4, chloride 111, bicarbonate 25, blood urea nitrogen 12, creatinine 0.6 with a blood sugar of 114. INR was 1.3. He was transferred to the floor on postoperative day number one late in the day. Later that day, he was anxious and was flailing about a little bit stating that he could not breathe. He was very anxious and had some rapid breathing. He was saturating 90 percent on three liters. Nursing staff worked to calm him down, gave him a little bit of Morphine and Percocet to help eliminate his pain. He had minimal drainage from his mediastinal pleural tubes. His Foley catheter was discontinued early that morning. He needed a significant amount of encouragement to cough and deep breathe. Nursing staff worked with him on this. On postoperative day number two, he complained of being pretty uncomfortable, unable to take deep breaths, was very anxious. He was in sinus rhythm in the 60s with a blood pressure of 104/60. White blood cell count rose slightly to 17.4, hematocrit 32.4. Creatinine stable at 0.9. His heart was regular rate and rhythm, and he had positive rub and no murmur. He had decreased breath sounds on the right with rhonchi on the left. He had positive bowel sounds. The abdomen was soft, nontender, nondistended. He had one to two plus peripheral edema. His incisions were clean, dry and intact, sternal and right groin incisions. Ativan p.r.n. was restarted as were his home medications. His mediastinal chest tube was pulled. His chest x-ray the day prior showed a 10 percent right pneumothorax. Right chest tube was left in place on water seal. Motrin was also started. The patient was seen and worked with by physical therapy. On postoperative day number three, chest x-ray showed some right lower lobe atelectasis. The patient had episode of bronchospasm with splinting after chest physical therapy. He coughed up several large mucous plugs, was feeling much better in the morning. He developed atrial fibrillation after his nebulizer treatment this morning. He went from 69 to 100, in atrial fibrillation with a blood pressure of 106/62, respiratory rate 18, saturating 95 percent on three liters nasal cannula. His weight was down one kilogram from his preoperative weight. He was alert and oriented and much less anxious. His heart rate was irregular and decreased breath sounds but he had better aeration of his right base but scattered rhonchi throughout, a small amount of subcutaneous air over his right chest. He had hypoactive bowel sounds, but his abdomen was softly distended. He had two plus peripheral bilateral edema. His extremities were warm and well perfused. Sternal incision was clean, dry and intact and sternum was stable. His creatinine remained stable at 0.7. Amiodarone was started for his atrial fibrillation. Pacing wires were discontinued. The patient was given intravenous Lasix for more aggressive diuresis. On postoperative day number four, the patient was doing much better. He converted from atrial fibrillation to normal sinus rhythm at midnight without any change in hemodynamics. He was hemodynamically stable. His lungs were a little rhonchorous bilaterally with some wheezes. He had some ecchymosis on his right flank near his right thoracotomy incision. His sternal incision was clean, dry and intact. His sternum was stable. His extremities had significant two to three plus bilateral lower extremity edema but was perfusing well. His chest tubes and pacing wires were discontinued. The patient was encouraged strongly to cough and deep breathe and to continue to ambulate. Intravenous Lasix was switched back to p.o. Beta blockade continued with Lopressor. On postoperative day number five, his final chest tube was removed. His blood pressure was 126/61 with a heart rate of 62, saturating 95 percent in room air. His examination was unremarkable. He got some clearance on physical therapy. He continues to be out of bed and ambulating. Repeat chest x-ray was obtained to evaluate his pneumothorax. He had [**Male First Name (un) **] stockings replaced with a plan that if the patient went out of sinus rhythm back into atrial fibrillation then Heparin would be started as well as Coumadin, but this was not the case that morning. On the evening of [**2198-9-1**], the patient complained of coughing and having some trouble raising phlegm and general discomfort trying to breathe. About one hour after that, the patient went into atrial fibrillation. He was completely asymptomatic with a blood pressure of 106/70. He went back into sinus rhythm approximately twenty minutes after that. On postoperative day number six, he started Heparin drip for atrial fibrillation. He was given 5 mg of Coumadin a night earlier for atrial fibrillation. He was hemodynamically stable, saturating 98 percent in room air. His incisions were clean, dry and intact. His lungs were clear bilaterally. He was only doing level II to III for his physical therapy. His coagulations were rechecked with an INR of 1.1. His partial thromboplastin time was 31.6 and his Heparin was increased to 1200 units per hour and he received 3 mg of Coumadin that evening. The next day the patient had some complaints of pain. He felt that his sternum was feeling a little click. He was examined. He had scattered rhonchi but no rales. He was following commands. His heart was regular rate and rhythm, in sinus rhythm at 67 beats per minute. His abdomen was soft, nontender, nondistended, and his sternum was stable. The incision was clean, dry and intact. His extremities were warm with one to two plus edema. He was only doing currently level III. His Heparin was increased to 1500 units per hour. He received an order for 5 mg of Coumadin that evening. Amiodarone had been started and was continued at 400 mg p.o. twice a day. The patient continued Lasix and potassium. The patient was informed as well as nursing staff to help him reinforce sternal precautions with the plan to discharge him home in the next few days. On postoperative day number eight, the patient remained in sinus rhythm on Amiodarone and Coumadin, hemodynamically stable following all commands. His examination was unchanged. His sternum was stable. The patient did a level V activity in the morning and is now ready for discharge home. Amiodarone and Coumadin are continued for atrial fibrillation with a goal INR of 2.0 to 2.5. Th[**Last Name (STitle) 1050**] was instructed to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) 57930**] in three to four weeks and to see Dr. [**Last Name (Prefixes) 411**] in the office for his postoperative surgical visit at four weeks. The patient was also instructed to take 4 mg of Coumadin this evening. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o. twice a day. 2. Potassium Chloride 20 mEq p.o. twice a day for two weeks. 3. Rosuvastatin Calcium 10 mg p.o. daily. 4. Ibuprofen 600 mg p.o. q4-6hours p.r.n. for pain. 5. Dilaudid 2 to 4 mg q4-6hours p.r.n. for pain. 6. Metoprolol Tartrate 25 mg p.o. twice a day. 7. Amiodarone 400 mg p.o. twice a day times one week and then Amiodarone 400 mg p.o. daily times one week and then Amiodarone 200 mg p.o. daily. 8. Lasix 20 mg p.o. twice a day times two weeks. 9. Enteric Coated Aspirin 81 mg p.o. daily. 10. Coumadin dosing for this evening only 4 mg with instructions to check INR on [**2198-9-6**], two days after discharge, goal INR 2.0 to 2.5. The patient was instructed to monitor his INR and have his first INR check on [**2198-9-6**], and to contact Dr. [**Last Name (STitle) 57930**], telephone number [**Telephone/Fax (1) 57931**], for Coumadin and INR level management. DISCHARGE DIAGNOSES: Status post mitral valve replacement. Deep venous thrombosis. Cerebrovascular accident. Arthritis. Hypercholesterolemia. Mitral valve degeneration. Status post transurethral resection of the prostate. Status post left ankle surgery. DISCHARGE STATUS: The patient was discharged home in stable condition on [**2198-9-4**]. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2198-11-2**] 14:08:55 T: [**2198-11-2**] 15:42:42 Job#: [**Job Number 57932**]

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Discharge summary

report+addendum

Admission Date: [**2167-5-27**] Discharge Date: [**2167-7-20**] Date of Birth: [**2099-6-25**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: acute myocardial infarction Major Surgical or Invasive Procedure: [**2167-5-28**] left heart catheterization, coronary angiogram,attempted angioplasty of right coronary artery, placement of intraaortic balloon [**2167-5-28**] emergency right ventricular assist device [**2167-5-28**] exploration for mediastinal bleeding [**2167-6-2**] exploration of mediastinum, attempted wean of assist device [**2167-6-3**] mediastinal exploration,washout [**2167-6-8**] removal ventricular assist device/mediastinal washout/closure of chest [**2167-6-22**] Exploratory laparotomy, small bowel resection. [**2167-6-23**] Exploratory laparotomy,enteroenterostomy, cholecystectomy and gastrostomy tube placement. [**2167-6-30**] Exploratory laparotomy with lysis of adhesions. History of Present Illness: As per the patient,the night prior to admisssion she felt acutely diaphoretic, cold, with left leg weakness and had an episode of diarrhea. She denies any pain with this episode, however, it was associated with nausea. She tried to get out of bed but could not support herself on the left leg. Today she awoke with 6/10 anginal chest pain and tried to get out of bed, but felt lightheaded and fell down. She felt weaker in the left leg and is not sure whether she was weaker on the arm. She fell down on the left side. Her husband called 911 and she went to an outside hospital where she was found to have an evolving infarction and was transferred here. Past Medical History: Dyslipidemia hypertension migraines s/p hysterectomy h/o amaurosis fugax s/p cervical disc surgery [**76**] yrs ago osteoarthritis Social History: -Tobacco history: 45 pack year history (current) -ETOH: occ -Illicit drugs: denies Family History: Sister died of pancreatic cancer a few months ago. No stroke , CAD Physical Exam: Admission PE: VS: 98.1, 70-90, 100-119/60-77, 14-23, 97-100 RA GENERAL: NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva pink, No xanthalesma. NECK: Supple with no JVD noted. CARDIAC: RR, normal S1, S2. No m/r/g. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. slightly inattentive Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. No right-left confusion. No evidence of apraxia or neglect. memory [**1-21**] immediate and 0/3 at 5 mins, calculations slightly impaired. [**Location (un) 1131**] writing intact. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Extraocular movements intact bilaterally. BL end gaze nystagmus 6-7 beats. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Sternocleidomastoid and trapezius full strength bilaterally. Tongue midline, movements intact. Motor: Normal bulk and tone bilaterally. No pronator drift. [**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE R 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 4- 4- 5 4- 5 4- Sensation: Intact to light touch, pinprick. No extinction to DSS., impared vibration in toes, left greater than right. Position normal. Reflexes: 1 + except 2 plus on left kness. Toes downgoing bilaterally. Coordination: FNF and [**Doctor First Name **] normal. Gait/ Rhomberg - defd Pertinent Results: [**2167-7-7**] 03:25AM BLOOD WBC-7.2 RBC-3.28* Hgb-9.3* Hct-29.1* MCV-89 MCH-28.3 MCHC-31.8 RDW-16.4* Plt Ct-578* [**2167-5-27**] 02:30PM BLOOD WBC-6.5 RBC-4.24 Hgb-12.1 Hct-36.3 MCV-86 MCH-28.5 MCHC-33.2 RDW-14.2 Plt Ct-341 [**2167-7-1**] 04:20AM BLOOD PT-16.0* PTT-32.8 INR(PT)-1.4* [**2167-5-27**] 02:30PM BLOOD PT-12.3 PTT-117.7* INR(PT)-1.0 [**2167-7-7**] 03:25AM BLOOD Glucose-114* UreaN-20 Creat-0.5 Na-138 K-3.9 Cl-104 HCO3-29 AnGap-9 [**2167-5-27**] 02:30PM BLOOD Glucose-116* UreaN-18 Creat-0.9 Na-144 K-4.2 Cl-111* HCO3-21* AnGap-16 [**2167-7-2**] 03:57AM BLOOD ALT-36 AST-23 LD(LDH)-220 AlkPhos-96 Amylase-101* TotBili-1.2 [**2167-5-28**] 12:35PM BLOOD ALT-25 AST-84* LD(LDH)-369* AlkPhos-24* Amylase-41 TotBili-0.6 [**2167-7-1**] 04:20AM BLOOD Lipase-36 [**2167-5-28**] 12:35PM BLOOD Lipase-85* [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 2801**] [**Hospital1 18**] [**Numeric Identifier 39152**]Portable TTE (Complete) Done [**2167-6-30**] at 1:45:56 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2099-6-25**] Age (years): 68 F Hgt (in): 61 BP (mm Hg): 108/60 Wgt (lb): 140 HR (bpm): 107 BSA (m2): 1.62 m2 Indication: Left ventricular function. Right ventricular function. Shortness of breath. ICD-9 Codes: 785.0, 786.05, 416.9 Test Information Date/Time: [**2167-6-30**] at 13:45 Interpret MD: [**First Name8 (NamePattern2) 35980**] [**Name8 (MD) 35981**], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West SICU/CTIC/VICU Contrast: None Tech Quality: Adequate Tape #: 2010AW000-0:00 Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.6 cm <= 4.0 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Left Ventricle - Stroke Volume: 50 ml/beat Left Ventricle - Cardiac Output: 5.38 L/min Left Ventricle - Cardiac Index: 3.32 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.17 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 5 < 15 Aorta - Sinus Level: 2.0 cm <= 3.6 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm Aortic Valve - LVOT VTI: 16 Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A ratio: 1.00 Mitral Valve - E Wave deceleration time: 148 ms 140-250 ms Findings Patient on phenylephrine 1 mcg/kg/min LEFT ATRIUM: Normal LA size. LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). RIGHT VENTRICLE: Markedly dilated RV cavity. Moderate global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Severe [4+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: The patient appears to be in sinus rhythm. Resting tachycardia (HR>100bpm). Left pleural effusion. Conclusions The left atrium is normal in size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is markedly dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Severe [4+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Preserved left ventricular systolic function. Markedly dilated right ventriular size. Moderate right ventricular systolic dysfunction. Severe (4+) tricuspid regurgitation. Electronically signed by [**First Name8 (NamePattern2) 35980**] [**Name8 (MD) 35981**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2167-6-30**] 14:13 Brief Hospital Course: After arrival Mrs. [**Known lastname **] was taken to the cath lab, where catheterization showed an occluded RCA. Attempts to open the RCA were unsuccessful and she was returned to the CCU for monitoring and became hemodynamically unstable with hypotension. She returned to the cath lab in cardiogenic shock and an IABP was placed. Cardiac Surgery was consulted and she was taken emergently to the Operating Room for ventricular assist device placement. Please refer to Dr[**Doctor First Name **] operative report for further details. The right heart was essentially akinetic and the Abiomed assist device was implanted, the IABP left in place and multiple pressors infusing. She transferred to the CVICU in critical condition on phenylephrine, Milrinone and insulin drips. Later that day she returned to the Operating Room for mediastinal washout for bleeding. Clot evacuation was performed and the chest was left open. Over the next several days the patient required increasing pressor support. Bedside washout was done again on [**5-29**] and she went back to Operating Room for washout and possible device weaning on [**6-2**]. On [**6-3**] another mediastinal washout was done and the patient did not tolerate device weaning. She was kept sedated and paralyzed during this time and total parenteral nutrition was begun. On [**6-6**] and 18 Dopamine was weaned off, Levophed and Neo Synephrine were weaned significantly, the balloon pump was weaned to 1:2, and the device to 3 liters a minute. She was aggressively diuresed during this time and maintained on Vancomycin/Zosyn and Diflucan (for yeast in sputum) perioperatively. She was appropriately Heparinized during this time as well. On [**6-8**] she returned to the Operating Room and the device was explanted and the chest closed. Milrinone was increased empirically and Levophed added. The right ventricular function appeared significantly improved. On [**6-9**], IABP was removed. All pressor support was weaned off. She continued to have fevers to 102, without a source, despite multiple cultures being obtained. She was extubated on [**6-15**] and continued to have an ileus. She was very confused, with auditory hallucinations, although there was a non focal exam and she recognized family. This persisted and gradually improved. A CT of the torso was repeated for continued fevers and a small bowel obstruction was noted. An exploratory laparotomy found necrotic small bowel which was resected. The abdomen was left open and a reexploration the following day resulted in a cholecystectomy and the abdomen was closed. [**6-30**] she was taken back to the operating room for significant adhesions of the omentum to the small and large bowel, as well as interloop adhesions of the small bowel that were lysed. Antibiotic regimen followed according to Infectious Diseases recommendations. She was ultimately weaned from the ventilator and extubated. TPN was continued for nutritional support. Trophic tube feeding was begun when approved by the surgical team. She continued to slowly clear her mental status and improve her strength. The Physical Therapy service worked with her during the ICU stay. She continued to progress and was transferred to the step down unit for further monitoring on POD# 40 from her original procedure. She continued on triple abx therapy. Mrs. [**Known lastname **] had intermittant recurrent abdominal pain on [**7-12**]. Tube feeds were held and the exam improved. Tube feeds were resumed at 3/4 strength through her jejunal feeding tube with no abd pain. The G-j tube was noted to be leaking from a crack. It was replaced on [**2167-7-15**] with a simple G-tube for continued feeding. TPN was stopped on [**2167-7-19**] when her full strength elemental tube feeds were at goal. She suffered from copious amount of loose stool which was c-diff negative. A flexiseal device was used to protect her skin and collect stool. Her tube feeds were changed to full strength vivonex and banana flakes were added. Her diarrhea improved and stool cultures from [**2167-7-16**] were negative for c-diff. the flexiseal was removed. She passed her swallowing study and began to take po's slowly but in sufficicent quantity to stop tube feeds at the time of discharge. Prior to discharge Nutrition and speech and swallow final recommendations were made. She continues to have persistant sinus tacycardia on diltiazem and carvedilol. She requires tacycardia due to her poor RV function. We have attempted to keep her systolic blood pressure greater than 110 for gastric perfusion. Her mental status has cleared considerably but remains intermittantly confused and she suffers from overwhelming anxiety at times. Her anxiety responds well to low dose ativan and reassurance. On POD# 53 from her original surgery, she was cleared by Dr.[**First Name (STitle) **] for discharge to [**Hospital3 105**] [**Hospital 39153**] in [**Location (un) 701**]. All follow up appointments were advised. Medications on Admission: MEDICATIONS: (OPT) Amitriptyline 25 mg POQHS Simvastatin 40 mg POQHS Topiramate 200 mg PO daily Verapamil 40 mg POQD Buspirone 5 mg POBID prn depression/anxiety ( prior to OR): Acetaminophen Amitriptyline Aspirin EC Atropine Sulfate BusPIRone Clopidogrel DOPamine Eptifibatide Heparin Metoprolol Tartrate Ondansetron Ranitidine Topiramate Warfarin Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for HA. 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for to groin. 7. Ibuprofen 100 mg/5 mL Suspension Sig: Two (2) PO Q8H (every 8 hours) as needed for pain. 8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for loose stool. 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID PRN () as needed for anxiety. 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 11. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 12. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO HS (at bedtime) as needed for insomnia. 13. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: coronary artery disease s/p attempted angioplasty cardiogenic shock with right heart failure s/p right ventricular assist (Abiomed) placement s/p explant of Abiomed device s/p mediastinal exploration,chest washout x 3 acute inferior myocardial infarction hypertension dyslipidemia migraines degenerative joint disease postoperative small bowel obstruction s/p exploratory laparotomy,small bowel resection,lysis of adhesions s/p re-eploration of abdomen,cholecystectomy and abdominal closure s/p hysterectomy s/p lumpectomy Discharge Condition: Alert and oriented x 2, nonfocal Ambulating with assistance Incisional pain managed with oral analgesics Incisions: Sternal - healed no erythema or drainage abdomen: healing, no erythema or drainage, steristrips intact Edema [**12-24**]+ LE edema to the hips Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**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. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) Monday [**8-17**] @ 1:00 pm [**Hospital Ward Name **] 2A Cardiologist Dr. [**Last Name (STitle) **] Tuesday [**8-25**] @ 9:00 AM Please call to schedule appointments with: General Surgery: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] #[**Telephone/Fax (1) 673**] please call for appoinment follow up in 2 weeks Primary Care: Dr.[**First Name (STitle) **] L.[**Doctor Last Name **] in [**11-22**] weeks after discharge from rehab ([**Telephone/Fax (1) 8129**]) **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2167-7-20**] Name: [**Known lastname 7087**],[**Known firstname 4193**] Unit No: [**Numeric Identifier 7088**] Admission Date: [**2167-5-27**] Discharge Date: [**2167-7-20**] Date of Birth: [**2099-6-25**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 265**] Addendum: Follow up Appointment with Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] has been arranged for Thursday [**7-30**] at 2:20 pm. Discharge Disposition: Extended Care Facility: [**Hospital3 2215**] Northeast - [**Location (un) 50**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2167-7-20**]

[ "410.41", "414.01", "707.25", "401.9", "997.4", "785.51", "557.1", "575.11", "560.81", "998.11", "707.07", "707.09" ]

icd9cm

[ [ [] ] ]

[ "43.19", "96.6", "99.15", "45.62", "88.56", "37.22", "00.40", "37.62", "37.61", "54.59", "37.64", "51.22", "38.93", "00.66", "45.93", "34.1" ]

icd9pcs

[ [ [] ] ]

18219, 18421

8336, 13327

348, 1046

15740, 16002

3800, 8313

16757, 18196

2004, 2073

13742, 15068

15194, 15719

13353, 13719

16026, 16734

2088, 2478

281, 310

1074, 1733

2892, 3781

2493, 2876

1755, 1887

1903, 1988

1,705

181,345

49769

Discharge summary

report

Admission Date: [**2110-1-24**] Discharge Date: [**2110-1-28**] Date of Birth: [**2046-4-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2159**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: Rigid bronchoscopy with biopsy History of Present Illness: 63Yo with HIV, no hx OI, recent CD4# 780, VL not detectable with dx of small cell lung cancer this year s/p chemo with disease in remission presented to OSH yesterday his gross hemoptysis X 7. Pt reports coughing large quantity of blood on to hands and soaked one towl at 3pm yesterday. He was unable to quantify volume. He denies CP, SOB, hx fevers, nose bleed. He did have hemoptysis with his malignancy presentation early this year but not this degree. ROS: + hunger, - abd pain, -n/v/d, - le edema, -ST. Pt notes ongoing mild cough mainly at night in the past week. Pt had nl CXR reportedly at OSH. He was transferred to [**Hospital1 18**] the next day for further intervention by IP. As he had poor access, a right SC line was placed at OSH. HIs HCt was 41 on presentation and he remained hemodynamically stable without reported Hct drop. He was put on cough suppressants and was started on cefuroxime for ? bronchitis Past Medical History: HIV [**2098**], CD4 #780, VL not detectable (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13275**] at BU) PPD negative [**6-23**] -Small cell lung cancer dx [**4-23**], s/p chemo [**2109-4-27**], currently in remission , followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 104037**] at [**Hospital 8**] Hospital -depression, MDD with recent psych admit at [**Hospital1 8**] [**1-7**] to [**1-17**] - HTN anemia - hx osteomyelitis L3/L4 -hepatitis B/C -hx MRSA PSH: L3/L4 laminectomy for epidural abscess/ osteomyelitis Social History: + hx IVDA, been sober for >1.5 years -ETOH quit smoking 2 months ago, 40 pack year hx lives in [**Hospital1 3494**] alone contact: [**Name (NI) **] [**Name (NI) 104038**] [**Telephone/Fax (1) 104039**] Family History: mother died of lymphoma at 52 father died of unknown malignancy Physical Exam: PE: chronically ill appearing, cachectic male, no distress VS: 97.6 100 119/79 21 98% RA NC WT 145lbs, 5"10, HEENT: anicteric, EOMI, dry MM with crusted blood on lips Neck: supple, JVP not elevated lungs: CTA Bilat right SC line c/d/i heart: RRR -murmurs abd: soft NT ND -organomeglay appreciated ext: no edema, neuro: CN grossly intact, A&OX3 Pertinent Results: Admission Labs: [**2110-1-24**] 05:55PM PT-12.4 PTT-26.1 INR(PT)-1.0 [**2110-1-24**] 05:55PM PLT COUNT-157 [**2110-1-24**] 05:55PM WBC-6.4 RBC-4.02* HGB-13.3*# HCT-38.4* MCV-96# MCH-33.1*# MCHC-34.7# RDW-14.0 [**2110-1-24**] 05:55PM CALCIUM-9.9 PHOSPHATE-4.3 MAGNESIUM-1.8 [**2110-1-24**] 05:55PM GLUCOSE-129* UREA N-32* CREAT-1.0 SODIUM-138 POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-23 ANION GAP-15 [**2110-1-24**] 09:22PM PT-12.6 PTT-26.3 INR(PT)-1.1 [**2110-1-24**] 09:22PM PLT COUNT-150 [**2110-1-24**] 09:22PM WBC-4.8 RBC-4.02* HGB-13.3* HCT-38.2* MCV-95 MCH-33.1* MCHC-34.9 RDW-14.0 [**2110-1-24**] 09:22PM CALCIUM-9.9 PHOSPHATE-5.2* MAGNESIUM-1.8 [**2110-1-24**] 09:22PM GLUCOSE-120* UREA N-30* CREAT-0.9 SODIUM-137 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15 . CXR [**2110-1-24**]: Chest, a single AP upright view at 11:30 p.m. is interpreted without prior films available for comparison. There is a right subclavian central venous catheter with the tip in proximal SVC. There is no evidence of pneumothorax. The lungs are clear with linear atelectasis in left lung base. No pleural effusion is seen, however the right costophrenic sulcus is not entirely included on the film. The cardiomediastinal silhouette appears normal. . CT Chest [**2110-1-25**], post-bronch: FINDINGS: There is extensive central adenopathy, most pronounced at the left hilus and widespread in the mediastinum. The left lower lobe bronchus is occluded by the hilar mass at the level of the superior segment producing severe volume loss in the lower lobe and heterogeneous consolidation distally, either atelectasis or postobstruction pneumonia. Adenopathy extends centrally posterior to the left main bronchus to a 31x16 mm subcarinal mass. Enlarged lymph nodes are present throughout the right and left upper and lower paratracheal stations including a 15-mm wide node posterior to and inseparable from the right subclavian artery, image 2:9. . Severe narrowing of the left brachiocephalic vein and milder generalized narrowing of the superior vena cava are not due to mass and probably represent strictures from long-term catheterization. Small pericardial effusion is present with no indication of tamponade. Study is not designed for subdiaphragmatic evaluation except to note the absence of adrenal mass or obvious hepatic metastasis. There are no lung nodules, consolidation or interstitial abnormality except for subpleural findings in the right lung base probably due to dependent atelectasis. . There is heavy calcification in the aortic valve which could be hemodynamically significant. . IMPRESSION: 1. Obstructing left hilar mass producing severe left lower lobe atelectasis and/or obstructive pneumonia. Extensive bilateral mediastinal adenopathy and small pericardial effusion suggest widely metastatic carcinoma. 2. Possible calcific aortic stenosis. 3. No evidence of opportunistic infection. 4. Strictures, left brachiocephalic vein and superior vena cava. . Brief Hospital Course: Pt. was admitted to the MICU and taken by interventional pulmonology to Bronch overnight. There there found an extensive submucosal irregularity in LLL bronchus c/w SCLC recurrence. They took a sample for biopsy (pathology pending at tiem of transfer) and used Argon Laser tx to cauterize the lesion. Pt. was monitored in the MICU overnight with no further episodoes of hemoptysis. A CT of the Chest was obtained to eval for SCLC recurrence, and prelim radiology read showed LLL consolidation and that LLL bronchus was not patent, along with L paratracheal and hilar [**Doctor First Name **] (final Radiology read pending at time of transfer). His hct was stable over admission (38 -> 40 -> 39), and he was transferred to the floor after a night of ICU monitoring for further management. . On the floor Radiation Oncology was contact[**Name (NI) **]. They recommended urgent radiation of LLL lesion to prevent further hemoptysis. As pt's Oncologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], is at [**Hospital 8**] Hospital and he has received his Chemo and Radiation there in the past, a decision was made to transfer him back there for evaluation for Radiation Tx. Arrangements were made for the pathology from the biopsy and for a copy of the CT scans to be sent to [**Hospital 8**] hospital. . Psychiatry saw the pt. on the floor and felt that he was stable from a Psychiatry standpoint for discharge, as he had no further SI and was less Depressed than he had been on admission to [**Hospital 8**] Hospital. Medications on Admission: cefuroxime 500mg [**Hospital1 **] viracept 1250mg [**Hospital1 **] epivir 150mg PO BID zerit 30mg PO BID abilify 15mg HS Megace 1200mg PO QD heparin SC BID cymbalta 60mg PO HS nictotine patch robitussin with codeine 15 CC PO Q4hr atarax PRN benadryl HS PRN percocet 2 tabs Q$ prn pain protonix 40mg QD Discharge Medications: 1. Nelfinavir 625 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO HS (at bedtime). 5. Stavudine 15 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 6. Megestrol 40 mg/mL Suspension Sig: Thirty (30) mL PO DAILY (Daily). 7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 8. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 9. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Transdermal once a day as needed. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Home Discharge Diagnosis: Primary: Small cell lung cancer Secondary: HIV Discharge Condition: [**Name (NI) 97288**] pt. had not further episodes of hemoptysis Discharge Instructions: Please call your doctor or go to the ER if you have any further episodes of coughing up blood, dizziness or lightheadedness, shortness of breath or fatigue, chest pain, or any other symptoms that concern you. Followup Instructions: Oncology: Please call Dr.[**Name (NI) 104040**] office tomorrow at [**Telephone/Fax (1) 92277**] to set up a follow up appointment for early next week. Primary Care: Please call Dr.[**Name (NI) 104041**] office at [**Telephone/Fax (1) 104042**] to set up a follow up appointment for next week. Completed by:[**2110-6-10**]

[ "V08", "162.5", "786.3", "070.70", "311", "305.60" ]

icd9cm

[ [ [] ] ]

[ "32.01", "33.24" ]

icd9pcs

[ [ [] ] ]

8388, 8394

5602, 7151

326, 358

8485, 8552

2584, 2584

8809, 9135

2138, 2204

7504, 8365

8415, 8464

7177, 7481

8576, 8786

2219, 2565

276, 288

386, 1312

2601, 5579

1334, 1902

1918, 2122

12,581

129,004

52535

Discharge summary

report

Admission Date: [**2105-12-30**] Discharge Date: [**2106-1-5**] Service: [**Hospital Unit Name 196**] HISTORY OF THE PRESENT ILLNESS: This is a 81-year-old male with a history of hypertension and diabetes mellitus, who presents for elective catheterization in the setting of worsening shortness of breath. The patient had an exercise tolerance test in [**2105-9-17**], which was positive for inferior and inferolateral reversible defects. He was recently admitted from [**11-25**] to [**11-29**] with congestive heart failure. Echocardiogram at that time showed an ejection fraction of 30% with focal left ventricular hypokinesis and posterolateral akinesis and 1+ MR. Over the past several weeks, the patient has had increasing dyspnea on exertion. He is unable to walk more than 25 yards without dyspnea. He also notes increasing lower extremity edema bilaterally. He does not note any chest pain, diaphoresis, nausea, vomiting, palpitations, lightheadedness. He was seen by his primary cardiologist, Dr. [**Last Name (STitle) **]. He now comes in for elective cardiac catheterization. History is also notable for chronic renal insufficiency and, thus, he will require close observation and optimization prior to catheterization. PAST MEDICAL HISTORY: 1. Coronary artery disease, as outlined above. 2. Congestive heart failure, as outlined above. 3. Atrial fibrillation, status post pacer placement in [**2103**]. 4. Prostate cancer. 5. Embolic CVA, no residual deficits. 6. Chronic lymphedema. 7. Diabetes mellitus type 2. 8. Hypertension. 9. Skin cancer. 10. Degenerative joint disease. 11. Chronic renal insufficiency. ALLERGIES: The patient is allergic to PENICILLIN, SULFA, DYE, AND SHELLFISH. MEDICATIONS ON ADMISSION: 1. Coumadin 5 mg p.o.q.d.(held). 2. Lasix 80 mg p.o.b.i.d. 3. NPH 50 units p.o.q.a.m. 4. Regular insulin 14 units subcutaneously q.a.m. 5. Amiodarone 200 mg p.o.q.d. 6. Accupril 10 mg p.o.q.d. 7. Toprol XL 25 mg p.o.q.d. 8. Stopped Aldactone two weeks ago. PHYSICAL EXAMINATION: Examination revealed the following: Temperature 97.9, blood pressure 114/58, pulse 70, respirations 18, oxygen saturation 95% on room air. HEENT: Unremarkable. Neck was supple with jugulovenous pulsation at 10-cm. There is no thyromegaly. There are 2+ carotids with no bruits. LUNGS: Crackles at the bases bilaterally. HEART: Heart is regular in rate and rhythm, with no rubs, murmurs, or gallops. ABDOMEN: Obese, normal bowel sounds, soft, nontender, and nondistended. EXTREMITIES: Extremities have 3+ edema to the thighs bilaterally and stasis changes and skin breakdown in the leg bilaterally. NEUROLOGICAL: The patient is alert and oriented times three. The strength is [**3-21**] bilaterally. Sensation and reflexes are normal. LABORATORY DATA: Laboratory data revealed the following: Significant for hematocrit of 31.0, platelet count 148,000, potassium 4.4, BUN 52, creatinine 2.5. (baseline creatinine 1.8 to 1.9). The INR is 3.1. Chest x-ray: ([**2104-12-10**]): Increased pleural effusions bilaterally. EKG: HA and V paced. No acute ST or T changes. HOSPITAL COURSE: This is a 81-year-old man with diabetes, hypertension, congestive heart failure, chronic renal insufficiency, who presents with progressive dyspnea on exertion. He was admitted for elective catheterization. He does not have any additional signs or symptoms of coronary artery disease. Hospital course by systems is as follows: #1. CORONARY ARTERY DISEASE: The patient was ruled out for myocardial infarction. He was continued on aspirin and beta blocker. He underwent coronary artery catheterization on [**1-4**], which showed no significant coronary disease. #2. CONGESTIVE HEART FAILURE: The patient was initially diuresed as it was felt that he was in significant congestive heart failure. He was briefly transferred to the Coronary Care Unit, where a Swan-Ganz catheter was placed which showed normal pulmonary capillary wedge pressure, but elevated right sided pressures. He was, therefore, transferred back to the floor to await coronary catheterization. Diuresis was held at that point. The patient was taken off an Ace inhibitor and placed on Hydralazine for afterload reduction secondary to his chronic renal insufficiency. At cardiac catheterization on [**1-4**], the patient was found to have elevated left and right side filling pressures, as well as pulmonary artery hypertension (pulmonary artery pressure 59/21; pulmonary capillary wedge pressure 21). These elevated filling pressures explained the patient's left heart and right heart failure symptoms. However, the etiology of his failure is unclear. The patient will need further evaluation, especially of pulmonary disease to explain his right heart failure. The patient would benefit from a chest CT as an outpatient and perhaps a VQ scan to evaluate for pulmonary embolism. In the meantime, the patient is continued on Hydralazine and nitrates for afterload reduction, as well as Lasix 80 mg p.o.b.i.d. for gentle diuresis. #3. PAROXYSMAL ATRIAL FIBRILLATION: The patient's Coumadin was held while he was hospitalized. The rhythm was consistently A-V paced. He should be started back on his Coumadin at his usual dose of 5 mg p.o.q.h.s. on discharge. He also gets 7 mg p.o.q.h.s. on Sunday and Monday. The INR should be followed closely until it is therapeutic at 2 to 3. #4. INFECTIOUS DISEASE: The patient had a Foley catheter placed for fluid monitoring. He was found to have a urinary tract infection and Levofloxacin renally dosed was begun for a five-day course. The last dose will be on [**1-6**]. #5. CHRONIC RENAL INSUFFICIENCY: The patient has a baseline creatinine of 1.7, creatinine is now stable at 2.2 to 2.5. He was given Mucomyst and hydration before his catheterization. Following the catheterization, the patient was placed on Hydralazine and nitrates for afterload reduction. His creatinine should be followed closely for several days to assure that it is stable and at a new baseline. #6. ENDOCRINE: The patient has a history of insulin dependent diabetes mellitus type 2. He was continued on NPH and a regular insulin sliding scale. His blood sugars were in good control. #7. HEMATOLOGY: The patient had a hematocrit drop following the catheterization and he was transfused three units of packed red blood cells. There was no evidence of bleeding. There was no evidence of hemolysis. The hematocrit remained stable following the transfusions. The patient also had a drop in his platelet count to a level of 90 while on heparin in the Intensive Care Unit. The heparin was discontinued and the platelets rose back to his baseline of 150,000. However, HIT antibodies were negative. CODE STATUS: Full. CONDITION ON DISCHARGE: The patient is discharged in good condition to a rehabilitation hospital. He will require [**Hospital 3058**] rehabilitation as he was seen by the Department of Physical Therapy and felt not to be ambulating his baseline and safe to return home. He will need close followup with Dr. [**Last Name (STitle) **] of the Department of Cardiology, as well as Dr. [**Last Name (STitle) **], who is his primary care physician. The patient's INR, potassium, BUN and creatinine should be followed closely until stable. DISCHARGE DIAGNOSIS: 1. Congestive heart failure. 2. Pulmonary artery hypertension. 3. Paroxysmal atrial fibrillation. 4. Diabetes mellitus type 2. 5. Status post coronary catheterization. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o.q.d. 2. Protonix 40 mg p.o.q.d. 3. Colace 100 mg p.o.b.i.d. 4. Aspirin 325 mg p.o.q.d. 5. Lopressor 12.5 mg p.o.b.i.d. 6. Regular insulin scale q.i.d. 7. NPH insulin 25 units subcutaneously q.a.m. 8. Levofloxacin 250 mg p.o.q.d. (last dose [**2106-1-6**]). 9. Hydralazine 10 mg p.o.q.i.d. 10. Imdur 30 mg p.o.b.i.d. 11. Lasix 80 mg p.o.b.i.d. 12. Coumadin 5 mg p.o.q.h.s. (7 mg p.o.q.h.s. on Sunday and Monday). [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Last Name (NamePattern1) 11548**] MEDQUIST36 D: [**2106-1-5**] 11:01 T: [**2106-1-5**] 11:17 JOB#: [**Job Number 31865**]

[ "599.0", "427.31", "584.9", "250.00", "593.9", "416.8", "285.9", "428.0", "287.4" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.23" ]

icd9pcs

[ [ [] ] ]

7553, 8278

7356, 7530

1763, 2029

3155, 6796

2052, 3137

1278, 1737

6821, 7335

76,151

130,183

30450

Discharge summary

report

Admission Date: [**2158-10-13**] Discharge Date: [**2158-10-18**] Service: [**Month/Day/Year 662**] Allergies: digoxin / Sulfa(Sulfonamide Antibiotics) / parabin / diuretics Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: left hip fracture repair History of Present Illness: Ms. [**Known lastname **] is a 88 year old female with a history of HTN, questionable prior TIA, recently admitted for recurrent C. diff who is now presenting for her 3rd admission since mid-[**Month (only) 216**] s/p a mechanical fall resulting in a left femoral neck fracture. She had been discharged on [**2158-10-12**] on a long PO vancomycin taper after a re-admission for recurrent C. diff. She had been feeling better following discharge, but she continued to have [**3-26**] loose BM's a day with persistent fatigue. There was some disagreement between the family and the hospital about a safe discharge to home and on the day of this admission, she slipped on a wet towel in the bathroom and landed on her left hip with resulting severe pain. She was taken to [**Hospital1 **]-[**Location (un) 620**] and transferred to [**Hospital1 18**] for surgical repair. She was admitted to the [**Hospital1 **] team for a planned hemiarthroplasty on [**10-14**]. Her clopidogrel was held in anticipation of surgery and she was started on Lovenox for prophylaxis. She required an assortment of medications to help with her pain, which may have resulted in nausea that also required medications for relief. She went for ORIF with Orthopedics on [**10-14**] and it was uncomplicated, without mention of any significant blood loss, though she was given 1 unit pRBCs in the PACU. She returned to the medical floor and her bowel movement continued without any increase in volume or frequency. She was hypotensive to 80s/40-50s most of the day without tachycardia (received atenolol the night prior), but has been oliguric. In total, she has received 4.5L IVF and an additional unit of pRBCs over last 24 hours without improvement in urine output or blood pressure. She continued to mentate well throughout. She has been afebrile (and has spiked fevers in the past for her C. diff). The Orthopedics team recommended continued transfusion but no urgent imaging. Of note, she was on plavix for ?TIA and does have a left facial droop that is stable. On arrival to the MICU, she had good peripheral access with 18 and 20g IVs. She continues to mentate well and her blood pressures remain in the 80s/50s. Past Medical History: - Hypertension - ? TIA - Skin cancer of RUE s/p excision - Glaucoma - Cataracts - Osteoarthritis s/p ankle surgery Social History: Retired nurse. Lives in [**Hospital3 **] and is independent. ETOH- 3 glasses of wine or port per week. Denies smoking or illicit drug use. Family History: Breast cancer in daughter and sister. Mother had high blood pressure and TIA. Denies FH of heart disease. Physical Exam: Vitals: T: 97.6 BP: 100/58 P:69 R: 18 O2: 94% RA General: Alert and oriented x3, no acute distress, resting comfortably in bed HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP almost to earlobe at 30 degrees, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: bibasilar crackles with mildly decreased BSs to bases, no wheezes or rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or edema; left hip mildly tender to palpation without signs of bleeding Neuro: CNII-XII intact, 4/5 strength upper/lower extremities, grossly normal sensation, gait deferred Discharge exam: 98.1 69 125/55 24 97 2L General: Alert and oriented x3, no acute distress, resting comfortably in bed HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP almost to earlobe at 30 degrees, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: CTAB , no wheezes or rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ DP pulses, no clubbing or cyanosis. Trace edema; left hip mildly tender to palpation without signs of bleeding. Right upper extremity with mild swelling. Neuro: CNII-XII intact, 4/5 strength upper/lower extremities, grossly normal sensation, gait deferred Pertinent Results: [**2158-10-12**] 05:45AM PLT COUNT-224 [**2158-10-12**] 05:45AM WBC-6.4 RBC-3.42* HGB-9.8* HCT-30.6* MCV-89 MCH-28.5 MCHC-31.9 RDW-15.2 [**2158-10-12**] 05:45AM CALCIUM-8.0* PHOSPHATE-2.3* MAGNESIUM-1.9 [**2158-10-12**] 05:45AM GLUCOSE-135* UREA N-7 CREAT-0.5 SODIUM-133 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-28 ANION GAP-8 [**2158-10-13**] 07:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2158-10-13**] 07:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007 [**2158-10-13**] 07:40PM PT-13.4* PTT-35.4 INR(PT)-1.2* [**2158-10-13**] 07:40PM PLT COUNT-289 [**2158-10-13**] 07:40PM NEUTS-85.2* LYMPHS-6.6* MONOS-7.7 EOS-0.2 BASOS-0.3 [**2158-10-13**] 07:40PM WBC-8.8 RBC-4.01* HGB-11.6* HCT-35.1* MCV-88 MCH-28.9 MCHC-33.0 RDW-14.8 [**2158-10-13**] 07:40PM CALCIUM-8.6 PHOSPHATE-1.7* MAGNESIUM-1.8 [**2158-10-13**] 07:40PM GLUCOSE-118* UREA N-4* CREAT-0.4 SODIUM-128* POTASSIUM-3.8 CHLORIDE-92* TOTAL CO2-24 ANION GAP-16 FEMUR (AP & LAT) LEFT Study Date of [**2158-10-13**] 8:07 PM FINDINGS: Again demonstrated is a left mid cervical femoral neck fracture with superior and lateral displacement of the dominant distal fracture fragment. No other fracture is identified. There is no dislocation. A linear 12 mm sclerotic intramedullary lesion within the distal femoral diaphysis may reflect a small enchondroma. No suspicious lytic or sclerotic osseous abnormalities are detected. IMPRESSION: Unchanged appearance of a displaced left femoral neck fracture. CHEST (PORTABLE AP) Study Date of [**2158-10-15**] 10:27 PM IMPRESSION: AP chest compared to [**10-13**]: Mediastinal veins are not appreciably dilated. Heart size is top normal. There might be a small residual of edema in the right mid and lower lung zones, particularly since there is a new small right pleural effusion. Left lung is clear aside from basal atelectasis which is also probably present on the right. Heart size top normal, unchanged. No pneumothorax. Portable TTE (Complete) Done [**2158-10-16**] at 11:47:56 AM FINAL The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis (most prominent in the mid RV free wall with relative apical sparing). There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. Moderate [[**2-24**]+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: RV hypokinesis/dilation - consider pulmonary embolism. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2158-10-16**] 12:38 PM FINDINGS: There is no evidence of pulmonary embolism to the subsegmental level. There are however bilateral moderate-sized pleural effusions, right greater than left with associated compressive atelectasis. The lung parenchyma is clear of any focal opacities concerning for an infectious process or worrisome nodules or masses. Aorta and the great vessels appear grossly unremarkable. No mediastinal, hilar or axillary lymphadenopathy by CT criteria is identified. Subdiaphragmatically no gross abnormalities are noted. BONES: No suspicious lytic or sclerotic lesions are seen. Ossification of anterior longitudinal ligament is noted in the mid vertebral bodies. IMPRESSION: 1) No evidence of pulmonary embolism to the subsegmental level. 2) Bilateral pleural effusions, moderate in size, right greater than left with associated compressive atelectasis. UNILAT UP EXT VEINS US RIGHT Study Date of [**2158-10-17**] 4:04 PM INDICATION: Right arm swelling. Evaluate for DVT. COMPARISON: None. FINDINGS: Grayscale, color, and spectral Doppler son[**Name (NI) 1417**] were acquired of the right internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins. There is occlusive thrombus throughout one of the two paired brachial veins. No additional thrombus is seen within the imaged veins of the right upper extremity. Subcutaneous edema along the right upper extremity is noted. IMPRESSION: Occlusive thrombus within one of the two paired brachial veins, age indeterminate. No additional thrombus identified in the right upper extremity. Pertinent findings were discussed with Dr. [**Last Name (STitle) 14740**] by Dr. [**Last Name (STitle) 4033**] at 6:54 p.m. via telephone on the day of the study. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**2158-10-18**] 04:17AM BLOOD WBC-11.7* RBC-3.46* Hgb-9.9* Hct-30.6* MCV-89 MCH-28.6 MCHC-32.3 RDW-15.2 Plt Ct-351 [**2158-10-13**] 07:40PM BLOOD Neuts-85.2* Lymphs-6.6* Monos-7.7 Eos-0.2 Baso-0.3 [**2158-10-18**] 04:17AM BLOOD PT-14.8* PTT-123.4* INR(PT)-1.4* [**2158-10-18**] 12:19PM BLOOD PTT-80.2* [**2158-10-18**] 04:17AM BLOOD Glucose-101* UreaN-8 Creat-0.4 Na-125* K-3.8 Cl-95* HCO3-25 AnGap-9 [**2158-10-18**] 04:17AM BLOOD Calcium-7.7* Phos-2.1* Mg-1.7 [**2158-10-15**] 09:42PM BLOOD Osmolal-266* [**2158-10-15**] 05:17AM BLOOD TSH-2.1 [**2158-10-15**] 9:42 pm URINE Source: Catheter. **FINAL REPORT [**2158-10-18**]** URINE CULTURE (Final [**2158-10-18**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 88 year old female with history of HTN, ?TIA, and recurrent C. diff on PO vancomycin taper, transferred to the ICU for hypotension s/p left hip hemiarthroplasty. # Left hip fracutre: s/p hemiarthroplasty uncomplicated. Patient to continue physical therapy as outpatient. Was treated with DVT prophylaxis. # Urosepsis/hypotension: in setting of hypotension with absence of other etiology, patient found to have UTI w/ KLEBSIELLA PNEUMONIAE which was pansensitive and was treated with ciprofloxacin for 10 days. Blood cultures were still pending but negative on discharge. She was also resusciated with IVFs. # Unprovoked Right arm DVT: noticed new onset of swelling [**2158-10-17**], unknown precipitant (no PICC line), started on heparin and switched to therapeutic lovenox. # Right heart failure: with pulmonary hypertension. Unlikely to be related to pulmonary embolus given no finding on CTA. More likely etiology is left heart failure/diastolic dysfunction. Other primary causes of pHTN can be considered such as autoimmune processes. Consider right heart cath but want to hold off on further dye load for now, consider as an outpatient. # C. difficile colitis: She can now be classified as recurrent C. difficile colitis given her re-presentation, for which she has been on a long PO vancomycin taper which was continued in MICU. # Hyponatremia: Chronically borderline low serum sodium without any known etiology. She was at 133 mEq/L prior to discharge and returned at 128 on this admission. This acute drop is likely secondary to hypovolemia with low Na on urine lytes, but her chronically low level is probably of a different etiology. TSH normal, AM cortisol pending to rule out adrenal insufficiency. Treated with IVF and sodium remained stable at 125. Possible component of SIADH. Trend sodium at Skilled nursing facility. Transitions of care: - possible right heart catheterization with cardiologist as outpatient - continue CDiff antibiotics - trend Sodium at [**Hospital1 1501**] - f/u w/ orthopedics appointment - finish Abx for UTI at [**Hospital1 1501**] - determine course for Lovenox with PCP given unprovoked DVT. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Acetaminophen 650 mg PO Q6H:PRN pain or fever 2. Atenolol 25 mg PO DAILY 3. Calcium Carbonate 500 mg PO BID 4. Clopidogrel 75 mg PO DAILY 5. Systane Ultra *NF* (peg 400-propylene glycol) 0.4-0.3 % OU TID:PRN 6. Valsartan 80 mg PO DAILY 7. Ondansetron 4 mg PO Q8H:PRN nausea 8. Vancomycin Oral Liquid 125 mg PO Q6H 9. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250 mg-mcg-mcg Oral Daily 10. Istalol *NF* (timolol maleate) 0.5 % OU Daily 11. Cyanocobalamin 100 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain or fever 2. Calcium Carbonate 500 mg PO BID 3. Clopidogrel 75 mg PO DAILY 4. Cyanocobalamin 100 mcg PO DAILY 5. Vancomycin Oral Liquid 125 mg PO Q6H - 125 mg by mouth 4 times daily for 14 days (through [**2158-10-24**]) - 125 mg by mouth 2 times daily for 7 days (through [**2158-10-31**]) - 125 mg by mouth once daily for 7 days (through [**2158-11-7**]) - 125 mg by mouth once every other day for 8 days (4 doses) (through [**2158-11-15**]) - 125 mg by mouth once every third day for 15 days (5 doses) (through [**2158-11-30**]) 6. Bisacodyl 10 mg PR DAILY:PRN constipation 7. Cepacol (Menthol) 1 LOZ PO PRN sore throat 8. Ciprofloxacin HCl 250 mg PO Q12H D1 = [**2158-10-17**] To complete on [**2158-10-26**] 9. Docusate Sodium 100 mg PO BID 10. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain Hold for RR < 12 or sedation. 11. Prochlorperazine 25 mg PR Q12H:PRN nausea 12. Senna 1 TAB PO BID:PRN constipation 13. Polyethylene Glycol 17 g PO DAILY 14. Atenolol 25 mg PO DAILY 15. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250 mg-mcg-mcg Oral Daily 16. Istalol *NF* (timolol maleate) 0.5 % OU Daily 17. Systane Ultra *NF* (peg 400-propylene glycol) 0.4-0.3 % OU TID:PRN 18. Enoxaparin Sodium 40 mg SC Q12H Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: Primary: s/p hip fracture repair urinary tract infection right upper extremity deep vein thrombosis clostridium difficile right heart dilation Seconary: hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Weight bearing as tolerated of left lower extremity with anterior precautions Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted to the hospital and treated for a hip fracture and the surgery team repaired this. You continued your therapy for CDiff diarrhea and also were started in treatment for a urinary tract infection. A right upper arm blood was found when swelling was noticed in your arm and blood thinning [**Hospital1 **] was started. We wish you all the best for a continued recovery. Followup Instructions: ****Dr [**First Name (STitle) **] [**Name (STitle) 72381**] office in Orthopedics is working on an appt for you and will call you at the Facility with the appt. If you dont hear from the office by Friday, please call them directly at [**Telephone/Fax (1) 1228**] to book. Please followup with your primary care physician regarding the course of this hospitalization once you leave the skilled nursing facility. Your primary care doctor will help decide how long to continue treatment for the blod clot in the right arm. Please discuss with Primary care doctor whether or not you should see a heart specialist regarding the ultrasound findings of the heart. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2158-10-18**]

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Discharge summary

report

Admission Date: [**2162-6-5**] Discharge Date: [**2162-6-25**] Date of Birth: [**2123-3-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: fever Major Surgical or Invasive Procedure: PICC line placed: [**2162-6-18**] History of Present Illness: Mr. [**Known lastname 38598**] is a 39 year old patient with NHL s/p alloSCT [**2155**] and DLI [**2156**], in remission but with GVHD-associated bronchiolitis obliterans and severe restrictive lung disease who was recently admitted with fever, hypoxia and respiratory distress and discharged to [**Hospital1 **] on [**2162-6-3**]. He is readmitted today in the setting of fever and increased cough. . Please see discharge summary from [**2162-6-3**] and [**2162-5-19**] for details of his previous hospitalizations. In brief, the patient has pseudomonal infection of his lungs, he has been treated with 21 day course of Colistin and Meropenem to treat this, and was on Colistin IH for suppression. Additionally, he has an upper extremity DVT that, since that admission, is being treated with Fondaparinux 2.5 mg SubQ, lower dose secondary to history of serious GI bleeding. . Per rehabilitation notes, the patient spiked temperature to 101.6, and wbc count increased to 25.5. He resports increased coughing. He had some low bloood pressures, 90/53 and 107/73. Additionally, given the worsening symptoms, on [**2162-6-4**], he recieved 1 dose of 125mg IV colistin (rehab discussed with outpatient ID attg, Dr. [**Last Name (STitle) 724**]. . On admission to the ICU the patient is comfortable. He denies, abdominal pain, dysurea. reports increased cough and fevers while at rehab. . In the ER, initial vitals T101.1, BP 122/79, HR 122, RR 18, vented. He recieved Vancomycin 1gm IV, Zosyn 4.5mg IV, tylenol 1gm PO, morphine 2mg IVx1. Past Medical History: Past Oncologic History: - [**4-/2154**] p/w fevers, night sweats, and weight loss in the setting of a left inguinal lymph node. - CT scan: 15x14x10cm mass in the LUQ. - Bx grade II/III follicular lymphoma. - Treated with six cycles of CHOP/Rituxan with good response, but showed evidence for relapse in [**12/2154**] and was treated with MINE chemotherapy for two cycles. - [**3-/2155**]: Underwent stem cell mobilization with Cytoxan followed by autologous stem cell transplant in - [**7-/2155**]: Noted for disease recurrence. He was initially treated with a course of Rituxan without response followed by Zevalin with - [**3-/2156**]: Noted progression of his disease. He was treated with one cycle of [**Hospital1 **] followed by one cycle of ESHAP. - [**2156-7-29**]: Nonmyeloablative allogeneic stem cell transplant with a [**5-30**] HLA-matched unrelated donor with Campath conditioning - Six-month follow-up CT noted for disease progression. - [**1-/2157**]: Received donor lymphocyte infusion in , complicated by acute liver/GI GVHD grade IV, for which [**Known firstname **] required a prolonged hospitalization in the summer of [**2156**]. - Multiple GI bleeds requiring ICU admissions and multiple transfusions and embolization of his bleeding. - Noted to have CNS lesions felt consistent with PTLD and this was treated with a course of Rituxan. No evidence for recurrence of the PTLD. - Acute liver GVHD, on CellCept, prednisone, and photophoresis. - [**2157-12-28**] Photophoresis was d/c'd due to episodes of bacteremia and eventual removal of his apheresis catheter. - [**2158-6-13**] restarted photopheresis on a weekly basis on , but then discontinued this again on [**2158-9-7**] as this was felt not to be making any impact on his liver function tests. - undergone phlebotomy due to iron overload with corresponding drop in his ferritin. He has continued with transient rises in his transaminases and bilirubin and has remained on varying doses of CellCept and prednisone which has been slowly tapered over the time. - [**2160-1-10**] CellCept discontinued. - [**2159-1-19**] admission due to increasing right hip pain. MRI revealed edema and infiltrating process in the psoas muscle bilaterally. After extensive workup, this was felt related to an infection and required several admissions with completion of antibiotics in 03/[**2158**]. - [**7-/2160**]: Last scans showed no evidence for lymphom and he has remained in remission. - [**2160-10-20**]: URI and treatment with course of Levaquin. - [**2160-11-13**] completed a 4 week course of Rituxan to treat his GVHD. -In [**5-/2161**], noted to have tiny echogenic nodule on abdominal [**Year (4 digits) 950**]. MRI of the liver also showed this nodule but was not as concerning on review and he is due to have a repeat MRI imaging in early [**Month (only) **]. -- GI varices and attempts at banding have been unsuccessful due to difficulty with passing the necessary instruments. He has been on a low dose beta blocker as well as simvastatin, which was started on [**2161-7-7**] to help with medical management of his varices. -On [**2161-8-3**], worsening cough and was noted to have a small new pneumothorax in the left apical area. This has essentially resolved over time - Issues with weight loss (followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]); multiple tests done with no etiology found; question malabsorption related to GVHD - Has on and off respiratory infections and has been treated with antibiotics (now colistin inhaled and IV) for resistant pseudomonas. Question underlying exacerbations of pulmonary GVHD in setting of his URIs. - Currently receives IVIG every month. . Other Past Medical History: 1. Non-Hodgkin's lymphoma s/p allo SCT 2. Grade 4 Acute GVHD of GI/liver following DLI with GI bleed, chronic transaminitis, portal HTN with esophageal varices (not able to band) 3. History of intracranial lesions felt consistent with PTLD. 4. Extensinve chronic GVHD of lung, liver, skin, mucous membranes. 5. Grade II esophageal varices, intollerant to beta blockade. 6. HSV in nasal washing [**11/2159**](completed course of Valtrex) 7. Hypothyroidism 8. hx of Psoas muscle infection Social History: Smoke: never EtOH: none currently; occassional use prior to NHL dx Drugs: never Born in [**Country **] and moved to the U.S. for college ([**Hospital1 **]). Married in [**2160-8-25**] and lives in [**Location **]. No children. Stays at home and writes (currently writing a book on being diagnosed with cancer at young age). Family History: No lymphoma or other cancers in the family. Father had CAD s/p PCI. Physical Exam: On Admission: Vitals: T 99, HR 93, BP 91/61, sat 100% on AC 500/18/8/50% Gen: Cachectic male HEENT: sclera anicteric NEC: trach in place CV: Tachycardic, no m/r/g Pulm: coarse breath sounds bilaterally, no wheezes, crackles Abd: soft, NT, ND, bowel sounds present Ext: no peripheral edema Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2162-6-20**] 06:25 11.1* 2.54* 7.4* 23.6* 93 29.0 31.2 16.3* 344 [**2162-6-15**] 05:29 58* 70* 640* 0.7 Source: Line-picc OTHER ENZYMES & BILIRUBINS Lipase [**2162-6-5**] 05:30 80* IMAGING: [**6-5**] CT chest FINDINGS: The endotracheal tube terminates 1.9 cm above the carina. A right-sided PICC line terminates at the cavoatrial junction. An NG tube is identified inferiorly to level of the stomach. There has been interval worsening of multifocal bilateral nodular airspace opacities which are most prominent in the right upper lobe, some of which have air bronchograms. Also noted are numerous tiny centrilobular nodules at the lung bases, right greater than left. Moderate bilateral pleural effusions and adjacent compressive atelectasis is again identified. Secretions are noted within the superior aspect of the trachea. he heart is normal in size. There is no pericardial effusion. No pathologically enlarged mediastinal lymph nodes are identified. The visualized upper abdominal organs are unchanged in appearance with no gross abnormalities identified. No suspicious lytic or sclerotic lesions are identified within the osseous structures. IMPRESSION: 1. Interval worsening of multifocal nodular opacities, most prominent in the right upper lobe compared to prior CT of [**2162-4-27**], which may represent recurrent or residual worsening infection. However, given the possible chronicity of these findings, organizing pneumonia cannot entirely be excluded. 2. Stable moderate bilateral pleural effusions and adjacent airspace disease, which is at least in part secondary to atelectasis. 3. Redemonstration of secretions within the superior trachea, slightly increased when compared to the prior study. [**6-15**] Chest X ray: FINDINGS: The tracheostomy tube is in place, with its tip 3 to 3.5 cm above the carina. An endogastric tube projects over the antrum of the stomach. Additionally, coils projecting over the epigastrium are consistent with embolization coil. The heart and mediastinal contours appear unremarkable. The previously described right upper lobe and retrocardiac opacities persist with increase of the retrocardiac opacity. This likely represents components of atelectasis and consolidation. Additionally, in the right lower lobe, at the right cardiophrenic angle, there is developing opacity concerning for additional foci of pneumonia. Bilateral effusions persist. There is no pneumothorax. The osseous structures appear intact. IMPRESSION: Multifocal opacities, worse in the retrocardiac and right cardiophrenic regions; unchanged small bilateral pleural effusions. [**2162-6-6**] 10:07 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2162-6-18**]** GRAM STAIN (Final [**2162-6-6**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2162-6-17**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. HEAVY GROWTH. COLISTIN SUSCEPTIBILITY REQUESTED BY DR. [**Last Name (STitle) **] (#[**Numeric Identifier 38652**]) [**2162-6-8**]. COLISTIN SENSITIVE AT <=2 MCG/ML. PSEUDOMONAS AERUGINOSA. HEAVY GROWTH. COLISTIN SUSCEPTIBILITY REQUESTED BY DR. [**Last Name (STitle) **] (#9/0841) [**2162-6-9**]. COLISTIN SENSITIVE AT <=2 MCG/ML, Sensitivities performed by [**Hospital1 **] laboratories. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | PSEUDOMONAS AERUGINOSA | | AMIKACIN-------------- 8 S 16 S CEFEPIME-------------- 8 S 16 I CEFTAZIDIME----------- 4 S 8 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R =>16 R MEROPENEM------------- 4 S 8 I PIPERACILLIN/TAZO----- =>128 R =>128 R TOBRAMYCIN------------ =>16 R =>16 R Brief Hospital Course: Fevers: The patient was admitted from rehab after less than 48 hrs since his discharge for multidrug resistant pseudomonas. He presented with fevers and hypotension. He complained of increased yellow/white sputum, so it was thought that the source of his fevers was recurrent lung infection. A CT chest revealed multifocal nodular opacities, most prominent in the right upper lobe consistent with recurrent pneumonia. He was started on meropenem in addition to IV and inhaled Colistin. C diff was initially in the differential and he was started on PO vancomycin. However he had two stools that were negative for C diff so this antibiotic was stopped. Urine and blood cultures were obtained and were negative. Sputum showed two strains of psuedomonas that were sensitive to Amikacin and intermediately sensitive to meropenem. ID was closely involved and felt that slow infusion meropenem was appropriate treatment in addition to IV Colistin. He did well with only occasional low grade fevers and decreased sputum. He completed 17/28 days of meropenem and colistin by day of discharge. Last day of antibiotics will be on [**7-1**]. He was discharged on a regimen of meropenem and colistin for 6 more days (to be completed [**7-1**]) and daily [**Month (only) 3242**] prophylaxis of bactrim, acyclovir, voriconazole. He will follow up with ID outpatient. Leukocytosis: Mr. [**Known lastname 38598**] presented with an elevated white count of 28 with left shift. WBC trended down with initiation of meropenem and colistin and was 11 on day of discharge. Pt was briefly given flagyl for empiric treatment of presumptive C. Diff but stopped treatment when toxins repeatedly returned negative. Ventilator dependence: Pt has history of Bronchiolitis Obliterans from allo-SCT with tracheostomy. He has history of pseudonomas infections and hospitizations for pneumonias. The patient initially presented on a ventilator with the following settings: Assist Control 400/18/8/50%. He had been unable to wean off the vent at rehab and during his previous hospitalization due to increased secretions. While in ICU, was put on pressure support trials and some days was able to undergo trach collar for a few hours at a time. At night he would request to be put back on assist control and tolerated PS during the day. He was given chest PT. It will be important to continue to encourage trach collar trials and aggressive chest PT for the goal of becoming ventilator independent. There was some discussion of lung transplant and coordinating outpatient meeting with the Pulm transplant team at [**Hospital1 112**]. Before meeting with physicians there, he must meet criteria of walking 500 ft in 6 minutes which he has not yet achieved. Upper extremity DVT: The patient was found at his previous hospitalizations to have a LUE DVT. Given his history of massive GI bleed (secondary to GVH of GI)it was decided not to anticoagulate him with theraputiuc doses of heparin. He was eventually switched to fundaparinoux. During the present hospitalization he was continued on low dose fundaparinox, 2.5mg. On [**6-6**] there was questionable right upper extremity swelling in the arm with his PICC. LENI negative. Day before discharge he had repeat U/S of Left Upper Extremity and showed no progression of clot in brachial v. Decision was made to stop fundaparinox. Graft versus Host Disease: The patient was continued on his regimen of prednisone 15mg, mycophenolate 250mg dialy, and prophylactic Bactrim, acyclovir, and voriconazole. Nutrition/Electrolytes: He lost about 4kg since admission despite appropriate tube feeds and TPN. Nutrition was closely involved. Pt likely has malabsorption in setting of GVHD of GI. By day of admission, he was getting TPN 42 mL/hr, Tube feeds 60mL/hr in addition to 200cc free water boluses every 4 hours through NGT. NHL: Mr. [**Known lastname 38598**] is status post allo [**Known lastname 3242**] complicated with GVHD of GI and Bronchiolitis obliterans. [**Known lastname 3242**] was closely involved in patient's care. He was given prednisone, mycophenolate, acyclovir, bactrim, and voriconazole. Pt also received IVIG [**2162-6-23**] for low levels of IgG. Pt has been recieving infusions of IVIG every 2-3 weeks. Psych: Seen by psych who felt that he had adjustment disorder related to medical illness but he declined treatment with SSRI at this moment. Medications on Admission: Acyclovir 400mg every 12 hours Ascorbic Acid 500mg daily Colistin 75mg INH [**Hospital1 **] qMWF Ergocalciferol 50,000 units every saturday Ferrous sulfate 300mg liquid daily Fluticasone intranasally 1 spray daily Fondiparinux 2.5mg SC dailt Lansoprazole 20mg daily Levothyroxine 125mcg daily Mycophenolate Mofetil 250mg daily Prednisone 15mg daily BActrim DS qMWF Voriconazole 200mg every 12 hours Zinc sulfate 22mg daily PRNS: Tylenol 650mg ever 4 hours as needed Acetylcysteine 10% neb every 4 hours as needed Albuterol 6 puffs every 2 hours as needed Guaifenesin 200mg every 6 hours as needed Lorazepam 1mg every 4 hours as needed Morphine 2mg every 2 hours as needed Zogran 8mg as needed Senna 10mg as needed Simethicone 80mg as needed Trazdone 25mg as needed nightly insomnia . Discharge Medications: 1. Colistimethate Sodium 150 mg Recon Soln [**Hospital1 **]: 75mg Recon Solns Injection DAYS (MO,WE,FR) as needed for [**Hospital1 **]: Continue indefinitely . 2. Meropenem 1 gram Recon Soln [**Hospital1 **]: 1000 mg Recon Solns Intravenous Q8H (every 8 hours): 6 more days through [**7-1**]. 3. Colistimethate Sodium 150 mg Recon Soln [**Month (only) **]: 125 mg Recon Solns Injection Q12H (every 12 hours): Take 6 more days through [**7-1**]. 4. Acetaminophen 325 mg Tablet [**Month (only) **]: 650 mg Tablets PO Q6H (every 6 hours) as needed for pain/fever: indefinitely . 5. Acyclovir 400 mg Tablet [**Month (only) **]: 400 mg Tablets PO Q12H (every 12 hours): Take indefinitely. 6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month (only) **]: Six (6) Puff Inhalation Q2H (every 2 hours) as needed for SOB: take as needed. 7. Ascorbic Acid 500 mg/5 mL Syrup [**Month (only) **]: 500 mg PO DAILY (Daily): take indefinitely. 8. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Month (only) **]: 5mL MLs PO Q6H (every 6 hours) as needed for cough: Take as needed. 9. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [**Month (only) **]: 50,000 U Capsules PO 1X/WEEK (SA): take once a week. 10. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Month (only) **]: 300 mg PO DAILY (Daily). 11. Fluticasone 50 mcg/Actuation Spray, Suspension [**Month (only) **]: One (1) Spray Nasal DAILY (Daily). 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: 30 mg Tablet,Rapid Dissolve, DRs [**Last Name (STitle) **] [**Name5 (PTitle) **] (Daily). 13. Levothyroxine 125 mcg Tablet [**Name5 (PTitle) **]: 125 mcg Tablets PO DAYS (MO,TU,WE,TH,FR,SA). 14. Ondansetron 8 mg Tablet, Rapid Dissolve [**Name5 (PTitle) **]: 8mg Tablet, Rapid Dissolves PO Q8H (every 8 hours) as needed for nausea. 15. Prednisone 5 mg Tablet [**Name5 (PTitle) **]: 15 mg Tablets PO DAILY (Daily): take indefinitely. 16. Senna 8.6 mg Tablet [**Name5 (PTitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 17. Simethicone 80 mg Tablet, Chewable [**Name5 (PTitle) **]: 40-80mg Tablet, Chewables PO QID (4 times a day) as needed for indigestion. 18. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet [**Name5 (PTitle) **]: 1 tab Tablet PO DAYS (MO,WE,FR): take indefinitely. 19. Trazodone 50 mg Tablet [**Name5 (PTitle) **]: 25 mg Tablets PO HS (at bedtime) as needed for insomnia. 20. Voriconazole 200 mg Tablet [**Name5 (PTitle) **]: 200 mg Tablets PO Q12H (every 12 hours): Take indefinitely. 21. Zinc Sulfate 220 mg Capsule [**Name5 (PTitle) **]: 220 mg Capsules PO DAILY (Daily). 22. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Name5 (PTitle) **]: One (1) Inhalation Q2H (every 2 hours) as needed for SOB/wheezing. 23. Acetylcysteine 20 % (200 mg/mL) Solution [**Name5 (PTitle) **]: 20% 6-10 mL neb MLs Miscellaneous Q2H (every 2 hours) as needed for secretion. 24. Cyanocobalamin 250 mcg Tablet [**Name5 (PTitle) **]: 250mcg Tablets PO DAILY (Daily). 25. Insulin Regular Human 100 unit/mL Solution [**Name5 (PTitle) **]: One (1) Injection ASDIR (AS DIRECTED): Please follow attached sliding scale. 26. Heparin, Porcine (PF) 10 unit/mL Syringe [**Name5 (PTitle) **]: 10 U MLs Intravenous PRN (as needed) as needed for line flush: prn to flush PICC line. Flush 10 mL NS followed by heparin (10U/ml) 2 mL IV daily and prn per lumen. 27. Lorazepam 2 mg/mL Syringe [**Name5 (PTitle) **]: 0.5-2.0mg Injection Q4H (every 4 hours) as needed for anxiety. 28. Morphine 2 mg/mL Syringe [**Name5 (PTitle) **]: 2mg Injection Q2H (every 2 hours) as needed for pain. 29. Mycophenolate Mofetil HCl 500 mg Recon Soln [**Name5 (PTitle) **]: 250 mg Recon Solns Intravenous [**Hospital1 **] (2 times a day): take indefinitely. 30. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Hospital1 **]: 4mg Injection Q8H (every 8 hours) as needed for nausea. 31. Diphenhydramine HCl 50 mg/mL Solution [**Hospital1 **]: 25 mg Injection Q6H (every 6 hours) as needed for pre-medication for IVIG: take before IVIG. 32. Heparin, Porcine (PF) 10 unit/mL Syringe [**Hospital1 **]: 2mL (10U/mL) MLs Intravenous PRN (as needed) as needed for line flush: Flush PICC with NS followed by heparin. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Ventilator associated pneumonia Deep vein thrombosis Acute on chronic hypoxemic respiratory failure malnutrition Non hodgkins lymphoma status post bone marrow transplant Acute renal failure Graft versus host disease Bronchiolitis obliterans hypothyroidism Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with fever and high white blood cells possibly indicating infection. Your infection was partially treated with antibiotics. Please continue taking Meropenem and Colistin antibiotics for total course of 28 days through [**7-1**]. You have 6 more days left at the day of discharge. Please continue your TPN (42mL/hr) and Tube feeds (60ml>hr) to ensure appropriate nutritional status. Continue to take your prophylactic bone marrow transplant medications each day: Bactrim, Acyclovir, Voriconazole to prevent infections in an immunocompromised state. You made great progress with walking toward the end of your hospitization. Please continue to walk each day with a goal of 500 ft in 6 minutes. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2162-6-29**] 2:00 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**2162-7-22**] at 11:30 am. [**Hospital Ward Name 23**] [**Location (un) 436**] on [**Hospital Ward Name **]. phone: [**Telephone/Fax (1) 3237**] Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2162-9-23**] 2:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD and pulmonary transplant group at [**Hospital6 1708**]. Clinic number [**Telephone/Fax (1) 23428**]. Pt's family to call to set up appt. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2162-7-22**] 11:30 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

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25537

Discharge summary

report

Admission Date: [**2134-11-15**] Discharge Date: [**2134-11-24**] Date of Birth: [**2075-8-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2736**] Chief Complaint: Transferred from OSH for cardiac catheterization and ICD placement s/p VF arrest Major Surgical or Invasive Procedure: pRBC blood transfusion Cardiac catheterization ICD placement History of Present Illness: Patient is a 59 yr old male with PMHx of CAD s/p prior MI and stents placed 5 years ago transferred from LGH s/p VF arrest. Patient arrested on [**2134-11-9**] while at work driving a fork lift. Fork lift crashed into wall, although pt did not have any traumatic injury from that. Shocked in the field x 3 by an AED at his workplace. He was down for almost 8 minutes. He was sent to LGH and found to have decorticate posturing by ER MD. EKG on arrival was reviewed by Dr. [**Last Name (STitle) **] at LGH and it was not felt that pt had an STEMI. (0.5mm STE in (1 and AVF). He was intubated and underwent Artic Sun cooling protocol. He was extubated x 3 days. Since rewarming, he was found to be neurologically intact. ECHO showed EF 30% with RV hypokinesis. He was also hypoxic with concern for COPD flare vs CHF exacerbation. He was treated with nebs, PO steroids as well as lasix. Patient was transferred to [**Hospital1 18**] for cath to r/o CAD and subsequent ICD placement. . On arrival to [**Hospital1 18**], patient was hemodynamically stable. He was admitted to [**Hospital Ward Name 121**] 3 but was found to be hypotensive to 60s. This initially responded well to fluids but he then experienced another hypotensive episode to the 70s. The patient denied chest pain, shortness of breath, dizziness, or lightheadedness. No syncopal events occurred. He also has occasional episodes of hypoxia down the the 80s but denies shortness of breath. He is currently on IV heparin and IV amiodarone. He is being transferred to the CCU for closer monitoring. . He is currently endorsing left hip pain, LLQ pain. This started last night. He is lightheaded when sitting up. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: s/p inferior STEMI [**7-17**] with 2 [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] placed to RCA and LCx PERCUTANEOUS CORONARY INTERVENTIONS: -[**2129-7-31**]- The mid LCX had an 80% stenosis. The RCA was occluded in the proximal/mid segment without receiving significant collaterals. Successful PCI of the proximal/mid RCA with a 3.0 x 23 mm Cypher DES, post-dilated with a 3.5 mm balloon. -[**2129-8-3**]- The LMCA and LAD were non-obstructed, and the LCX had an 80% lesion after a large OM bifurcation. The RCA stent was widely patent. Successful PCI of the LCX with a 3.0 x 23 mm Cypher DES. 3. OTHER PAST MEDICAL HISTORY: HTN Asthma Hypercholesterolemia h/o spinal surgery [**2128**] Social History: -Tobacco history: Quit tobacco in [**2123**] -ETOH: denies -Illicit drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On transfer to CCU: GENERAL: Cachetic male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD. 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, ND. tender in LLQ, firm, no rebound, guarding. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs: [**2134-11-15**] 05:02PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2134-11-15**] 05:02PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2134-11-15**] 05:02PM URINE RBC-0-2 WBC-[**4-16**] BACTERIA-RARE YEAST-NONE EPI-0-2 [**2134-11-15**] 05:02PM URINE HYALINE-0-2 [**2134-11-15**] 05:02PM URINE MUCOUS-MOD [**2134-11-15**] 04:18PM GLUCOSE-144* UREA N-22* CREAT-0.6 SODIUM-140 POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-37* ANION GAP-10 [**2134-11-15**] 04:18PM estGFR-Using this [**2134-11-15**] 04:18PM CK(CPK)-397* [**2134-11-15**] 04:18PM CK-MB-3 cTropnT-<0.01 [**2134-11-15**] 04:18PM CALCIUM-9.3 PHOSPHATE-2.6* MAGNESIUM-2.0 [**2134-11-15**] 04:18PM WBC-16.9*# RBC-3.81* HGB-11.8* HCT-33.5* MCV-88 MCH-30.9 MCHC-35.1* RDW-14.1 [**2134-11-15**] 04:18PM PLT COUNT-235 [**2134-11-15**] 04:18PM PT-12.0 PTT-50.5* INR(PT)-1.0 [**2134-11-15**] 03:35PM TYPE-ART PO2-57* PCO2-47* PH-7.52* TOTAL CO2-40* BASE XS-13 [**2134-11-15**] 03:35PM LACTATE-1.9 CTA-Torso [**11-16**]: 1. Massive left-sided retroperitoneal hematoma involving the left pararenal spaces, with intramuscular component in left psoas, iliopsoas, iliacus and proximal anterior thigh compartment. There is suggestion of active bleeding within the left psoas muscle. Small right psoas hematoma also present. 2. Multifocal pulmonary opacity with severe emphysema. In conjunction with the regions of bronchial wall thickening and impaction, the lower lobe opacities are likely infectious (possibly aspiration related) while the additional opacities may relate to superimposed alveolar/interstitial edema, hemorrhage, or additional sites of infection. Small left simple pleural effusion. 3. Atherosclerotic disease involving the coronary circulation, aorta and suggestion of high-grade focal stenosis involving the proximal right renal artery. 4. Abnormal thick-walled appearing sigmoid colon in conjunction with moderate-to-severe diverticulosis. While this may relate to underlying sequelae of acute or chronic diverticulitis, the lumen appears irregular and a colonoscopy or follow up CT is recommended when feasible to exclude underlying neoplasm. 5. No findings of aortic dissection or pulmonary embolism. Mild-to-moderate amount of ascites noted within the abdomen and pelvis. TTE [**2134-11-17**]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Diastolic function could not be assessed. 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. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. Cardiac Cath [**2134-11-18**]: COMMENTS: 1. Selective coronary angiography in this right dominant system demonstrated insignificant coronary artery disease. The LMCA was free of angiographically apparent disease. The LAD had a 20-30% stenosis in the mid vessel. The LCx had a 40-50% stenosis in the first OM branch. The RCA had some ectatic dilation in the mid vessel at the stent. There were minor 30% luminal irregularities. 2. Resting hemodynamics revealed low [**Hospital1 **]-ventricular pressures with RVEDP 7mmHg and LVEDP 10mmHg. The cardiac index was perserved at 3.42 l/min/m2. There was no step-up consistent with a shunt. There was no evidence of constriction or restrictive physiology. 3. There was no evidence of a gradient across the aortic valve on careful pullback of the angled pigtail from the left ventricle to the ascending aorta. 4. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Coronary arteries have insignificant disease. 2. Normal right and left heart filling pressures. Cardiac MR [**2134-11-19**]: Prelim read - Basal/Inferior transmural enhancement c/w old scar/prior MI; EF 49%. LE LENIs [**2134-11-21**]: No evidence for DVT in the bilateral lower extremities. CXR PA-L [**2134-11-24**]: IMPRESSION: PA and lateral chest compared to [**11-15**] through [**11-23**] at 6:07 p.m. A left trans-subclavian pacer defibrillator lead is unchanged in position,with the proximal part of the distal electrode probably in the tricuspid valve, and the tip short of the likely location of the right ventricular apex. There is no pneumothorax or mediastinal widening. Small bilateral pleural effusion has increased, while moderate-to-severe peribronchial opacification in the upper lungs has improved slightly on the left, worsened on the right. If this patient is not experiencing hemoptysis or recurrent aspiration, asymmetric pulmonary edema would be the most likely explanation, given the rapidity of changes. Emphysema is severe. Dr. [**First Name (STitle) 63778**] and I discussed the findings and their clinical significance over the telephone at the time of dictation. Brief Hospital Course: CCU Course: 59 yoM with h/o IMI (s/p LCx & RCA [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] [**2129**]) transferred to [**Hospital1 18**] for Cath & ICD s/p VF arrest, initially in CCU for symptomatic hypotension due to a venous RP bleed. . # Hypotension due to RP hemorrhage: Presented to CCU with symptomatic hypotension and palor. CTA torso showed large L > R RP hemorrhage with question of sigmoid thickening, unable to rule out sigmoid luminal irregularity. IR and vascular surgery were consulted and deferred percutaneous or operative intervention. Anticoagulation was held and the patient received 4U PRBCs on night of transfer to the CCU with appropriate HCT response. When DVT prophylaxis with sub-cutanous Lovenox was subsequently restarted, Hct transiently dropped and the patient was transfused another unit of PRBCs with an appropriate response; thereafter his Hct remained stable and pressures were normotensive. He will require outpatient work-up of the underlying cause of his RP bleed; in the absence of any known instrumentation to the left groin and given the luminal irregularities noted on CT, the leading diagnosis is GI neoplasm - colonoscopy is indicated after discharge. # VF Arrest, CAD: After resuscitation and cooling protocol at an OSH, was transferred to [**Hospital1 18**] for catheterization and ICD placement. EKG on admission was consistent with inferior ischemia superimposed on old inferior infarct. Catheterization showed no significant coronary vessel disease. Preliminary cardiac MRI was suggestive of the VF arrest being due to old scar. Echo results are detailed above. The patient underwent successful ICD placement. The patient was discharged on ASA, Simvastatin, Lisinopril, and Metoprolol for secondary prevention. # Hypoxia: Given the findings on CT in the setting of fever, was transferred to the CCU on empiric antibiotics for presumed hospital-acquired pneumonia; however, in the absence of any clinical evidence supporting this diagnosis, antibiotics were stopped. His presentation seemed more consistent with a COPD flare given his history; he was treated accordingly with albuterol and ipratropium nebs, prednisone pulse, and doxycycline. His hypoxia subsequently resolved. He was discharged on Combivent and Fluticasone-Salmeterol. He will require outpatient follow-up for full assessment of PFTs. Medications on Admission: Home: 1. Aspirin 81 mg daily 2. Combivent, unknown dose . Transfer: 1. Gabapentin 300 mg PO/NG [**Hospital1 **] 2. Acetaminophen 325-650 mg PO/NG Q6H:PRN Pain 3. Heparin IV Sliding Scale 4. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB 5. Ipratropium Bromide Neb 1 NEB IH Q6H 6. Amiodarone 400 mg PO/NG TID 7. Aspirin EC 325 mg PO DAILY 8. Simvastatin 20 mg PO/NG DAILY 9. CeftriaXONE 2 gm IV Q24H 10. Doxycycline Hyclate 100 mg PO Q12H 11. Vancomycin 1000 mg IV Q 12H Discharge Medications: 1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain. 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*1 Disk with Device(s)* Refills:*2* 5. metoprolol succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO at bedtime. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for post-ICD for 2 days. Disp:*8 Capsule(s)* Refills:*0* 7. Outpatient Lab Work Please check Chem-7 on Friday [**11-26**] and call results to Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 63309**] Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Retroperitoneal Bleed Acute Blood Loss Anemia Ventricular fibrillation Cardiac arrest Chronic Obstructive Pulmonary Disease Exacerbation Hyperlipidemia Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. Discharge Instructions: It has been a privilege to take care of you in the hospital. You were hospitalized for cardiac catheterization to determine why your heart stopped and for placement of an implantable cardiac defibrillator (ICD) to prevent your heart from stopping again in the future. The cardiac catheterization and a cardiac MR showed that your cardiac arrest may have been due to an old scar in your heart from a previous heart attack, not from a new heart attack. The ICD was placed prior to your discharge. You were also treated for an exacerbation of your chronic obstructive pulmonary disease with antibiotics and prednisone, those medicines are now finished. Your hospitalization was complicated by a drop in blood pressure due to internal bleeding of unclear cause. The bleeding stopped on its own without need for surgery and you received blood transfusions to restore your blood levels. Your blood levels and blood pressures remained stable after you were transfused, but it is still unclear what caused your bleeding and you will need to follow-up with your primary care physician for referral to other specialists, including a gastrointestinal doctor, for further testing. . The following changes were made to your medications: # Started: Simvastatin 20 mg daily # Started: Metoprolol Succinate 25 mg daily, please take at night # Continued: Aspirin 81 mg daily # Started: Fluticasone-Salmeterol Diskus inhaled twice daily # Continued: Combivent twice daily # Started Cephalexin four times a day for 2 days to prevent an infection at the ICD site # Your Lisinopril was held at time of discharge for low blood pressure and dehydration. You will need to talk to Dr. [**Last Name (STitle) **] about starting this medicine at a low dose. . You will come back in 1 week to have the ICD checked. Please leave the dressing on for 3 days, you can then remove, keeping the strips in place and shower. No baths or pools until after you are seen in the device clinic. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] Address: [**Street Address(2) 63779**], [**Location **],[**Numeric Identifier 21771**] Phone: [**Telephone/Fax (1) 63309**] When: Thursday, [**12-2**], 2:05PM Department: CARDIAC SERVICES When: TUESDAY [**2134-11-30**] at 11:00 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 Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Address: [**Street Address(2) **]. [**Apartment Address(1) **], [**Location **],[**Numeric Identifier 21918**] Phone: [**Telephone/Fax (1) 63780**] When: Tuesday, [**2134-12-7**]:15AM Department: CARDIAC SERVICES When: MONDAY [**2135-1-3**] 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 Department: CARDIAC SERVICES When: MONDAY [**2135-1-3**] at 11:40 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "493.22", "412", "458.9", "V45.82", "568.81", "427.5", "414.01", "285.1", "427.41", "401.9", "272.4" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.23", "88.53", "37.94" ]

icd9pcs

[ [ [] ] ]

13973, 14022

10044, 12417

398, 460

14218, 14308

4686, 4686

16349, 17773

3665, 3780

12940, 13950

14043, 14197

12443, 12917

8819, 10021

14369, 16326

3795, 4667

2844, 3457

278, 360

488, 2712

4703, 8802

14323, 14345

3488, 3552

2756, 2824

3568, 3649

47,739

178,987

46275

Discharge summary

report

Admission Date: [**2121-7-14**] Discharge Date: [**2121-7-17**] Date of Birth: [**2045-7-24**] Sex: F Service: MEDICINE Allergies: Fluconazole / Penicillins / Shellfish Derived Attending:[**First Name3 (LF) 1973**] Chief Complaint: Diarhea, Pulmonary Embolism, DVT Major Surgical or Invasive Procedure: None History of Present Illness: 75 year-old female with a history of metastatic adenocarcinoma of the small bowel (last dose of chemo FOLFOX [**2121-6-17**]) who presents with abdominal pain/nausea/vomiting/diarrhea incidentally found to have saddle PE and DVT. The patient was seen by her oncologist on [**7-11**] for c/o diarrhea in clinic and was given 1L IVF, given immodium and imaging was deferred given improvement in symptoms. Over the weekend she states that her diarrhea improved and did not have any further episodes. She reports that today she had 2 more episodes of loose stools, yellowish in color. She also reports SOB and labored breathing. She called her oncologist's office and they advised her to go to the ED. In the ED, VS 97.2, 99/61, HR: 90 RR:16 100% RA. Patient underwent CT torso that showed saddle PE. The patient underwent CT-head that did not show brain mets or hemmorhage and was started on heparin gtt. ED spoke with IR and not candidate for clot removal at this time. The CT torso also showed abnormal bowel wall thickening with bowel wall edema involving a long segment of jejunum. The DDx being likely angioedema in the setting of chemo, but also possible infectious vs ischemic (although SMA/[**Female First Name (un) 899**] and SMV are patent). She was given 750mg levofloxacin and 500mg flagyl. The patient also had an episode of hypotension thought to be a syncopal episode with SBP dropping to 50's, but improved to baseline without intervention. Currently, the patient states that her abdominal pain has resolved and no further episodes of diarrhea. She denied and SOB and states that her breathing was comfortable. No history of travel or recent surgery. Of note, pt was on levoflox on [**2121-6-30**] by her oncologist for neutropenia and dysphagia/hoarse voice and also given neulasta. Her WBC count increased to 54.6, but now trending down. ROS: + 10lbs weight loss since starting chemo in [**Month (only) 547**]. The patient denies any fevers, chills, constipation, melena, hematochezia, chest pain, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: 1. Metastatic small bowel adenocarcinoma 2. Osteoporosis 3. Right breast abscess 4. Hysterectomy for fibroids 5. HTN 6. s/p bunion surgery 7. s/p left rotator cuff surgery Social History: SOCIAL HISTORY: She used to work as a systems analyst. She is a never smoker, does not drink alcohol or do any other drugs. Family History: FAMILY HISTORY (per initial onc note): Her mother died during childbirth when she was two years old. Her father had diabetes and died of an MI at age 70. She has two brothers with no medical problems. She has five half siblings with diabetes, one who died from complications of diabetes. She had a paternal grandmother with throat cancer. She has three children who are healthy. There are no other cancers in the family. Physical Exam: Physical Exam: Vitals: T:97.8 BP:135/73 HR:86 RR:13 O2Sat:100% GEN: elderly female in no acute distress, no labored breathing HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: 5cm JVD, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2 PULM: bibasilar crackles otherwise CTAB ABD: Soft, NT, ND, +BS EXT: No C/C/ trace edema 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. Chemo Port in left side of chest Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2121-7-17**] 06:00AM 8.3 2.87* 8.2* 24.9* 87 28.7 33.1 20.3* 282 [**2121-7-16**] 06:00AM 9.5 2.95* 8.3* 25.6* 87 28.1 32.4 20.0* 278 [**2121-7-15**] 01:34PM 25.5* [**2121-7-15**] 04:15AM 13.9* 3.02* 8.6* 26.8* 89 28.4 32.0 19.9* 265 [**2121-7-14**] 09:45AM 22.0* 3.70* 10.4* 32.2* 87 28.1 32.2 18.8* 290# [**2121-7-11**] 12:40PM 35.0* 3.17* 9.2* 27.0* 85 29.0 34.1 18.5* 135* [**2121-7-10**] 12:00AM 54.6*#1 3.93* 11.1* 34.1* 87 28.4 32.7 17.7* 170 [**2121-7-3**] 09:15AM 31.6*# 3.27* 9.6* 28.1* 86 29.4 34.3 17.5* 268 [**2121-7-1**] 03:50AM 3.0*#2 3.19* 9.2* 27.4* 86 28.9 33.7 17.7* 201 [**2121-6-30**] 09:20AM 1.6*#3 3.29* 9.4* 28.6* 87 28.5 32.7 17.1* 175 [**2121-7-15**] 04:15AM BLOOD Neuts-76.7* Lymphs-15.3* Monos-7.6 Eos-0.2 Baso-0.2 [**2121-7-17**] 06:00AM BLOOD PT-13.3 PTT-36.0* INR(PT)-1.1 [**2121-7-15**] 04:15AM BLOOD PT-13.7* PTT-57.5* INR(PT)-1.2* [**2121-7-14**] 09:45AM BLOOD PT-12.0 PTT-21.3* INR(PT)-1.0 [**2121-7-17**] 06:00AM BLOOD Glucose-87 UreaN-6 Creat-0.7 Na-143 K-4.0 Cl-106 HCO3-28 AnGap-13 [**2121-7-14**] 09:45AM BLOOD Glucose-105 UreaN-8 Creat-0.9 Na-140 K-4.1 Cl-103 HCO3-26 AnGap-15 [**2121-7-14**] 09:45AM BLOOD ALT-16 AST-28 CK(CPK)-106 AlkPhos-127* TotBili-0.3 [**2121-7-14**] 09:45AM BLOOD Lipase-34 [**2121-7-15**] 04:15AM BLOOD proBNP-134 [**2121-7-14**] 09:45AM BLOOD cTropnT-<0.01 [**2121-7-14**] 09:45AM BLOOD CK-MB-2 [**2121-7-17**] 06:00AM BLOOD Calcium-9.0 Phos-4.8* Mg-1.8 [**2121-7-14**] 09:45AM BLOOD Albumin-3.3* Calcium-9.0 Phos-4.2 Mg-2.2 [**2121-7-14**] 09:46AM BLOOD Glucose-103 Lactate-1.8 K-4.3 [**2121-7-14**] 01:50PM BLOOD Lactate-0.9 [**2121-7-14**] 11:45AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004 [**2121-7-14**] 11:45AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2121-7-14**] 11:45AM URINE RBC-0-2 WBC-0-2 Bacteri-MANY Yeast-NONE Epi-[**2-27**] [**2121-7-14**] 9:30 am STOOL CONSISTENCY: FORMED **FINAL REPORT [**2121-7-15**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2121-7-14**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). OVA + PARASITES (Final [**2121-7-15**]): NO OVA AND PARASITES SEEN. ECG Study Date of [**2121-7-14**] 9:36:12 AM Sinus rhythm. Non-specific T wave changes. Compared to the previous tracing of [**2121-6-18**] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 75 164 76 400/426 63 -26 41 CT PELVIS W/CONTRAST Study Date of [**2121-7-14**] 11:31 AM CT CHEST W/CONTRAST Study Date of [**2121-7-14**] 11:31 AM IMPRESSION: 1. Newly developed saddle pulmonary embolism since examination from [**2121-5-14**]. 2. Extensive metastatic disease with multiple subcentimeter cavitating pulmonary nodules and hypodense liver lesions. 3. Abnormal bowel wall thickening with bowel wall edema involving a long segment of jejunum. There is associated focused mesenteric fluid adjacent to abnormal loop of small bowel. CT HEAD W/O CONTRAST Study Date of [**2121-7-14**] 12:42 PM IMPRESSION: 1. No evidence of obvious masses or hemorrhage. Note that only post-contrast images are provided and this limits the detection of subtle areas of hemorrhage or enhancement due to lack of precontrast images. MRI has a much greater sensitivity for the detection of intracranial metastasis and can be obtained as clinically indicated. 2. Stable appearance of sclerotic focus in the right frontal bone with nonaggressive features, again differential most likely includes fibrous dysplasia; however, in the context of known primary malignancy, osteosclerotic metastasis is a consideration and can be correlated with bone scan as indicated. Comparison with any remote priors may be helpful. Portable TTE (Complete) Done [**2121-7-15**] at 2:58:07 PM Conclusions The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60-70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion CHEST (PORTABLE AP) Study Date of [**2121-7-15**] 4:46 AM IMPRESSION: Satisfactory position of the left-sided Port-A-Cath. No consolidation, pneumothorax or pleural effusion. BILAT LOWER EXT VEINS PORT Study Date of [**2121-7-15**] 9:09 AM IMPRESSION: Acute DVT involving the mid and distal right superficial femoral vein, popliteal vein and peroneal veins. Brief Hospital Course: 1. Massive Central Pulmonary Embolism, Deep Venous Thrombosis: - Pt had CT-chest that showed saddle PE, and a LENI was performed which showed an extensive DVT in her leg. However she was hemodynamically stable and 100% on room air. Ambulatory saturation monitoring, showed a SAO2 of 97% on ambulation. She was started on heparin after neg head CT, this was transitioned to lovenox given underlying malignacny and move to coumadin. Although lovenox may be superior long term, the patient cannot afford the $900/month copay for the lovenox. An echocardiogram was performed and also did not demonstrate cardiac compromise so no need for IVC filter at this time. She will be followed in [**Hospital 191**] [**Hospital3 271**]. 2. Diarrhea/Abdominal Pain: Patient with intermittent episodes of diarrhea/ abdominal pain. CT-abd showed likely angioedema from chemotherapy, but also infectious or ischemic. C. Diff was negative and it self resolved. The feeling is this is most likely due to the small bowel neoplasm. 3. Leukocytosis: Patient was given neulasta on [**6-30**] and white blood counts increased to 54. After stopping her WBC trended down to normal. 4. Malignant Neoplasm Small Bowel, Metasteses to Lung, Liver: Pt last treated with FOLFOX on [**6-17**]. Lesions slightly smaller on repeat CT. See above for GI complaints possibly related to chemo. hematology/Oncology consultation was obtained and outpatient follow up will be given. The patient had a family meeting with her primary oncologist on the [**Hospital1 **]. 5. Benign Hypertension: stable, will cont home regimen 6. Osteoporosis: stable, cont home regimen # Access: PIV, left sided Power port-a-cath (can do CTA through this) # Code: FULL (confirmed with pt) # Comm: [**Name (NI) 4049**] (son) [**Telephone/Fax (1) 98378**] [**Name (NI) **] (sister) [**Telephone/Fax (1) 98379**] Medications on Admission: Alendronate 70mg QWeek Levofloxacin 500mg daily Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] Lisinopril-Hydrochlorothiazide 20/12.5 Daily Prochlorperazine 10mg PO Q6Hprn Calcium Carbonate OTC Ergocalciferol 800units Daily Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours) for 6 days. Disp:*12 syringe* Refills:*6* 6. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO once a day: To Be adjusted by coumadin clinic. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Physician [**Name9 (PRE) **] [**Name9 (PRE) **] Discharge Diagnosis: Saddle Pulmonary Embolism Deep Venous Thrombosis Diarhea NOS Leukocytosis Malignant Neoplasm Small Intestine Metastesis to Lung Metastesis to Liver Discharge Condition: Good Discharge Instructions: Return to the hospital with chest pain, shortness of breath, fever/chills, inability to eat. You are being discharged on Lovenox (Enoxaparin) and have been given teaching on its use. It is very important to continue this medication until told to stop by the [**Hospital3 **]. You are being discharged on Coumadin (Warfarin) which is designed to prevent clots. This medication is highly diet senitive, particularly around food which contain vitamin-K such as green vegetables. It is important to eat only a moderate amount of these, and even more important to eat a CONSTANT amount of these each day. You will be on this medication for life. You will have your coumadin level, called the INR, followed at the [**Hospital 191**] [**Hospital3 271**] Followup Instructions: Follow up with the [**Hospital 191**] [**Hospital3 271**]. They should contact you with appointments this week. In case they do not contact you, the information for the [**Name (NI) 191**] Anticoagulation Management Service phone: [**Telephone/Fax (1) 2173**] / fax: [**Telephone/Fax (1) 3534**] Dr. [**Last Name (STitle) **] will also contact you for an appointment

[ "415.19", "197.0", "152.8", "197.7", "401.1", "787.91", "453.41", "288.60", "458.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11912, 11990

9141, 10998

339, 346

12181, 12187

4118, 9118

12984, 13354

2929, 3351

11297, 11889

12011, 12160

11024, 11274

12211, 12961

3381, 4099

267, 301

374, 2576

2598, 2771

2803, 2913

736

164,142

21111

Discharge summary

report

Admission Date: [**2118-9-19**] Discharge Date: [**2118-9-26**] Date of Birth: [**2083-9-14**] Sex: F Service: MED Allergies: Latex / Morphine / Codeine Attending:[**First Name3 (LF) 3266**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: 1. intubation [**9-19**] 2. central line placement [**9-19**] 3. lumbar puncture [**9-19**] 4. Paracentesis [**9-19**] History of Present Illness: 35 yo woman transferred from OSH with sepsis. Per report, pt presented to the OSH with altered mental status, headache (possibly her typical migraine), myalgias, n/v, and slurred speech; these symptoms had reportedly been present for 2 days. At the OSH she was initially afebrile (100.7 orally) but soon spiked a temperature to 102; she was initially tachycardic but was otherwise hemodynamically stable throughout her time there. Her physical examination was reportedly noteworthy for mild lethargy, slightly dry mucous membranes, and no meningeal signs; her exam was reportedly otherwise unremarkable. Her labs were noteworthy for a WBC of 16.6 (75 PMN, 20 bands, 3 monos, 2 eos), Hct 36.1 (baseline high 20's), plt 31 (baseline low 40's); Na 130, no anion gap, albumin 2.7, INR 1.9, AST 80, ALT 81, alk phos 146, bili 2.6 (direct 0.85). U/A hazy, 3+ blood, 15-25 RBC, no WBC/bacteria. LP not done due to thrombocytopenia and coagulopathy. Two units FFP were given prior to a diagnostic paracentesis that reportedly demonstrated ~2300 WBC with 87% PMN. A head CT was reportedly normal. She received vancomycin 1 gram iv, ampicillin 1 gram iv, Zosyn, ceftriaxone 2 grams iv, and hydrocortisone 100 mg iv at the OSH. A RIJ central line was placed there. OSH blood cxs were already growing gram negative rods by time of arrival here. She is transferred here for further management since her hepatologist, Dr. [**Last Name (STitle) 497**], is based here. Past Medical History: 1. primary sclerosing cholangitis vs. stricture in the CBD 2. Crohn's disease s/p ex-lap with cecectomy and ileectomy [**2108**] 3. autoimmune hepatitis c/b cirrhosis with portal HTN, splenomegaly, and varices, listed for liver [**Year (4 digits) **] 4. diffusely thickened gallbladder wall with increased enhancement on MRCP [**9-10**] (suggesting chronic cholecystitis vs. inflammation due to PSC vs. diffuse neoplastic process) 5. possible early proliferative phase of myelofibrosis vs. hypercellularity of autoimmune disease 6. R adrenal adenoma 7. moderate L pleural effusion 8. R nephrolithiasis 9. depression 10. anxiety 11. raynaud's phenomenon 13. fibromyalgia 14. dermatitis herpetaformis 15. appendectomy Social History: The patient is unemployed and currently living with her mother and step-father. She has never been married and has no children; she had a long-term partner with whom she lived until [**Month (only) 956**] [**2117**]. She denies any history of heavy alcohol abuse and no longer drinks any alcohol at all. She does not smoke cigarettes and has never used illicit drugs. Family History: Father has ankylosing spondylitis. One half-sister has hypothyroidism and rheumatoid arthritis. Mother is alive and well. Physical Exam: Temp 98.9 orally, BP 139/49, HR 145, RR 36, SpO2 96% on 35% humidified face mask Gen: Confused, not answering questions appropriately, tachypneic but not using accessory muscles of respiration, thin, mild distress due to tachypnea HEENT: NCAT, no sinus tenderness, PERRL, conjunctivae edematous, dry oral mucosae with dried blood on the lips and teeth, OP otherwise clear Neck: Soft, supple, no cervical adenopathy, R IJ triple lumen catheter in place CV: Tachycardic, regular, normal S1 and S2, S3 present, no murmurs or rubs appreciated Pulm: R > L basilar crackles, otherwise CTA bilaterally Abd: Soft, diffusely tender, non-distended, active bowel sounds, no rebound or guarding, [**Doctor Last Name 515**] sign present (exam limited by pt's confusion and inability to cooperate), liver span 5-6 cm on scratch testing, no splenomegaly noted Back: No CVA or paraspinal tenderness Ext: 2+ DP and PT pulses, no edema Skin: Scattered ecchymoses at sites of attempted IV placement, no rashes or lesions otherwise, no petechiae Neuro: Unable to name place or date, confused and answering questions inappropriately ("My Darvon" was her response when asked whether or not she were having any pain), mild neck pain on passive rotation of her head to the left but no pain on flexion or passive rotation to the right, complaint of back pain on extension of the L knee, no eye closing on assessment of pupil reactivity to light but complaint of photophobia Pertinent Results: OSH Labs: WBC 16.6 (75 PMN, 20 bands, 3 monos, 2 eos), Hct 36.1, plt 31 PT 21.0, PTT 35.7, INR 1.9 Na 130, K 4.3, Cl 96, bicarb 22, BUN 28, Cr 1.1, gluc 58, calcium 10.2 ALT 81, AST 80, alk phos 146, bili 2.6 (direct 0.85), albumin 2.7 U/A hazy, 3+ blood, 15-25 RBC, no WBC/bacteria Urine tox with benzos, otherwise negative Ascites: ~2300 WBC (87% PMN), gluc 63, alb 0.4, TP <1, bili 0.43, [**Doctor First Name **] 25, LDH 39 ABG: 7.47/28/91 CXR: Mild bibasilar patchy opacities (L > R) consistent with mild pulmonary edema, R IJ catheter in good position, no frank infiltrates Head CT: "negative" per report Labs Here: WBC-19.6 HCT-28.3 MCV-89 PLT COUNT-19 NEUTS-88 BANDS-6 LYMPHS-1 MONOS-4 EOS-0 BASOS-0 ATYPS-1 METAS-0 MYELOS-0 PT-19.3 PTT-40.1 INR(PT)-2.3 FIBRINOGEN-325 D-DIMER-5973 FDP-10-40 SODIUM-138 POTASSIUM-3.3 CHLORIDE-106 TOTAL CO2-18 BUN-26 CR-0.9 GLUC-141 CALCIUM-8.7 MAGNESIUM-1.3 PHOSPHATE-2.4 URIC ACID-3.1 ALT-63 AST-112 LDH-215 ALK PHOS-92 TOT BILI-1.9 AMYLASE-47 LIPASE-24 ALBUMIN-2.5 ABG 7.47/27/66 on 35% face mask, lactate 5.0, ionized calcium 1.19 CXR: Progressive, bibasilar patchy opacities (L > R) consistent with worsening pulmonary edema, no clear infiltrate, R IJ catheter in good position Brief Hospital Course: 35 yo woman with autoimmune hepatitis leading to cirrhosis currently undergoing evaluation for liver transplantation, Crohn's disease, primary sclerosing cholangitis, pancytopenia, who was transferred from OSH with sepsis most likely due to spontaneous bacterial peritonitis complicated by bacteremia. She was in the MICU from [**9-19**] - [**9-22**]. Then she was transferred to the floor. 1. Sepsis: The pt was initially empirically treated with Ceftriaxone for a presumed SBP, along with Vancomycin and Flagyl to cover possible secondary SBP and/or cholangitis. An LP was preformed revealing no WBC's. Blood and urine cx's did not grow out anything. Blood cultures from the OSH however, grew out Klebsiella x2, sensitive to Levofloxacin, but only intermediately sensitive to Cefoxitin, so her Ceftriaxone was switched to Levofloxacin. A repeat paracentesis was preformed on HD2 which revealed ~1100 WBCs, down from 2300 at prior to admission. Because the WBC decline was not as substantial as anticipated on Levofloxcin, Flagyl and Vancomycin were continued. She was given a course of sepsis dose hydrocortisone and fludrocortisone for 7 days. She did not require pressors. She becamse hemodynamically stable and was transferred to the floor. The patient did not have a repeat paracentesis because her white count continued to decline. Flagyl was stopped on [**9-26**]. Levofloxacin will be continued for a total of 14 days from the start and she will be placed on Cipro 500 qd for SBP ppx. 2. Altered Mental Status: Altered MS [**First Name (Titles) **] [**Last Name (Titles) 2771**] to toxic-metabolic encephalopathy secondary to overwhelming sepsis. Other etiololgies for altered mental status were investigated: An LP was preformed to rule out meningitis. Head CT was preformed and was negative. Ammonia levels were checked given her history of cirrhosis, and returned only mildly elevated at 49. Serum and urine tox screens were negative. Once extubated, pt was alert and oriented with baseline MS. 3. Respiratory Distress: On admission patient had a primary respiratory alkalosis secondary to persistent tachypnea, likely induced by her septic state. In addition she had a lactic acidosis. Her RR had been greater than 30 for nearly 12hours on admission, hence she was intubated to ensure an adequate airway. On HD1, after aggressive fluid ressucitation and receiving blood products, she became increasingly hypoxic secondary to pulmonary edema, and required increased PEEP's to 10 for adequate oxygenation. She was gently diuresed, and her respiratory status improved. On HD3 she was requiring minimal pressure support and PEEP, and was successfully extubated. She had no ongoing respirtoy issues. 4. ARF: Developed a Cr increase from 1.0 to 1.5 post-diuresis. ARF thought to be secondary to intravascular depletion secondary to over-diuresis. Lasix was held pts ARF resolved, with Cr returning to 1.0 and brisk UOP daily. 5. Cirrhosis: The patient has decompensated liver failure with decreased synthetic function and portal hypertension. The GI service followed the patient throughout her ICU and floor stay. Her admission INR of 2.3 improved daily back to her baseline of 1.5 with hydration. Her DIC labs were followed daily and were within normal range. She received an albumin infusion on HD 1 and 3 per SBP protocol to prevent hepatorenal syndrome sequelae. As she was a candidate for liver [**Last Name (Titles) **], she was followed by the [**Last Name (Titles) **] service as well. On her last day of ICU stay, her INR rose to 2.0. Given that she was NPO for several days, this was thought to be secondary to malnutrition, and she was given Vit K. However, the patient had repeated doses of vitamin K over a few days and her INR failed to respond. This will need to be followed as an outpatient. For her extravascular volume overload, her aldactone was restarted and she was discharged on her home dose of Lasix - 40 po qd. 5. Anemia: Pt's admission Hct was roughly at baseline of 28. HCT decreased progressively to 19 on HD2 with guaiac + stools and NG lavage with blood clots. Pt was transfused with PRBC's and HCT stabilized at ~30, with NG lavage back to bilious aspirates. GI considered an EGD, however once HCT stabilized this was held off. No evidence of hemolysis on lab data. Protonix continuous infusion was started for GI protection. This was switched to PO when she was sent to the floor. The patient will continue her lansoprazole as an outpatient. 6. Thrombocytopenia: Pt has known baseline thrombocytopenia due to myelofibrosis and/or end stage liver disease of ~40. Plt levels continued to drop during hospital course, with no evidence of obvious bleed or hemolysis. The likely cause is splenic sequestration. Pt was transfused to keep Plts >50 prior to invasive procedure, otherwise >10K unless suspicion for active bleed. Her platlets were 24 on day of discharge and this will need to be followed closely as an outpatient. 7. Transaminitis: Most likely due to mild tissue hypoperfusion in the setting of sepsis, although liver enzymes may be elevated due to cholangitis as noted above. Liver enzymes gradually declined throughout stay with adequate hydration. 8. Crohn's Disease: Pts Sulfasalizine was continued. Stress dose steroids were started in setting of sepsis in place of budesonide for total of 7 days. The patient was tapered to 10mg of prednisone and will continue on this. Budesemide was no restarted and Dr. [**Last Name (STitle) 497**] will follow this up as an outpatient with the patient's gastroenterogist. 10. Allergies/Pruritis: Cetirizine, hydroxyzine as needed 11. Subconjunctival hemorrhage: pt developed a subconj hemorrhage post-extubation. Her vision was unaffected, and her platelets were kept > 50 to prevent further bleeding. This was stable for several days on day of discharge. 13. HTN: post-extubation pts BP rose gradually from SBP 130's to 170's. She was started on Lopressor 25 PO TID with good response. This was stopped on discharge because the patient's blood pressure was slightly low and she has no documented history of varices. 14. Abd Pain: Post extubation, pt experienced mild diffuse abd discomfort. This was accompanied by an amylase of 133 and lipase of 228. Given that she had no other sx's of pancreatitis, and no obvious cause, she was continued on clear sips and monitored closely for resolution. In the subsequent days of admission, she had no abdominal pain. 15. F/E/N: Initial exam and labs were consistent with intravascular volume depletion. After receiving aggressive fluids, albumin, blood and platelets, she became volume overloaded with pulmonary congestion and subsequent hypoxemia. She was gently diuresed until her lungs and respiratory status stabilized, and kept even from then on. She was advanced to a full diet and tolerated this for many days withougt nausea or vomiting. 16. Access: R IJ triple lumen catheter (with ability to measure SvO2) placed [**9-19**] and removed with out incident on [**9-25**]. 17. Communication: Mother and step-father 18. Code: Full (confirmed with mother and step-father) Medications on Admission: 1. spironolactone 200 mg once daily 2. furosemide 40 mg once daily 3. prednisone 20 mg once daily 4. budesonide 9 mg once daily 5. sulfasalazine 1500 mg twice daily 6. lansoprazole 30 mg once daily 7. propoxyphene 65 mg twice daily 8. sertraline 100 mg once daily 9. hydroxyzine 25-50 mg as needed for pruritis 10. cetirizine 10 mg once or twice daily 11. alprazolam 1 mg at bedtime Discharge Medications: 1. Sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*10 Tablet(s)* Refills:*0* 3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 4. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:*2700 ML(s)* Refills:*2* 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO at bedtime: Begin this after you finish the Levofloxacin ([**10-3**]). Disp:*30 Tablet(s)* Refills:*2* 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 8. Walker 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Darvon 65 mg Capsule Sig: One (1) Capsule PO twice a day as needed for pain. 12. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. Hydroxyzine HCl 25 mg Tablet Sig: 1-2 Tablets PO once a day as needed for itching. 14. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms. Discharge Disposition: Home With Service Facility: [**Hospital6 486**] Discharge Diagnosis: Spontaneous Bacterial Peritonititis complicated by sepsis Respiratory Failure requiring intubation acute renal failure Delirium Cirrhosis Crohn's Disease Primary Sclerosing Cholangitis Depression Discharge Condition: stable, afebrile, no abdominal pain, ascites Discharge Instructions: Take all medications as prescribed. Do not take more than 2grams /day of tylenol. Call your hepatologist or go to the ED if you have fevers, chills, abdominal pain, or blood in your stool or vomit. Followup Instructions: Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) 819**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB) Where: LM [**Hospital Unit Name **] [**Hospital **] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2118-10-4**] 2:50 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2118-10-5**] 9:10 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 1046**] Where: [**Name12 (NameIs) **] SOCIAL WORK Date/Time:[**2118-10-5**] 10:30

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icd9cm

[ [ [] ] ]

[ "96.71", "03.31", "54.91", "99.07", "99.09", "99.05", "38.93", "96.34", "96.04", "99.04" ]

icd9pcs

[ [ [] ] ]

14816, 14866

5893, 7404

289, 409

15106, 15152

4638, 5220

15399, 16009

3031, 3154

13490, 14793

14887, 15085

13083, 13467

15176, 15376

3169, 4619

243, 251

437, 1891

5229, 5870

7419, 13057

1913, 2630

2646, 3015

65,878

150,533

43966

Discharge summary

report

Admission Date: [**2175-11-2**] Discharge Date: [**2175-12-4**] Date of Birth: [**2113-10-5**] Sex: F Service: MEDICINE Allergies: Darvon Attending:[**First Name3 (LF) 898**] Chief Complaint: Back pain and hip pain Major Surgical or Invasive Procedure: Left knee washout Laminectomy History of Present Illness: This is a 62 year old female with a history of multiple psychiatric disorders, alcohol abuse, multiple falls, s/p VP shunt placement in [**2169**] for subdural hematoma and left hip replacement in [**4-20**] who presents from [**Doctor Last Name **] House s/p fall on [**2175-10-29**] with worsening left hip pain. She was taken to NEBH for evaluation after her fall on [**2175-10-29**]. At that time she was complaining of left hip pain and was noted to have bruising over her surgical incision site. Per notes she had a CT scan of her left hip which was negative and was diagnosed with trochenteric bursitis and was sent home with vicodin and physical therapy. Per notes when she returned from this hospital stay she was confronted about her alcohol use and instructed to throw away any alcohol in her room. Since that time she has been complaining of worsening left hip pain despite treatment with vicodin. She has also been noted to be more lethargic by staff. She was sent here out of concern that she could be withdrawing from alcohol. On my interview she reports that since her fall she has been having worsening left hip pain as well as back pain. This has been preventing her from walking. The back pain is diffuse and not well localized. She does endorse mild pain with movement of her neck but no photophobia or headaches. She also endorses pain with deep inspiration. She denies fevers but endorses chills. She denies cough or congestion. She has chest pain only with deep inspiration and no frank shortness of breath. No nausea, vomiting, diarrhea. She does have chronic constipation. She has mild diffuse abdominal pain. She denies dysuria or hematuria. She endorses mild decreased urine output. No bowel or bladder incontinence. She has chronic left leg weakness which she does not think is worse than her baseline. She has mild numbness in her left foot which is also unchanged. . In the ED, initial vs were: T: 96.8 P: 77 BP: 82/45 R 18 O2 sat 95% on RA. She received two liters of normal saline with improvement in her blood pressure as well as morphine for pain. EKG showed normal sinys rhythm, normal axis, normal intervals, diffuse TW flattening, no priors for comparison. She had a CXR which showed no focal infiltrates. CT head showed stable hydrocephalus. Her labs were notable for a leukocytosis with left shift and bandemia, acute renal failure, hyponatremia, hypokalemia, thrombocytopenia and anemia. Toxicology screen was positive only for opiates. She was admitted to the floor for further management. . On the floor she continues to complain of left hip pain and diffuse back pain and pleuritic chest pain. She is very difficult to engage and cries throughout the interview and asks for pain medications. Past Medical History: Past Medical History: Depression Anxiety Obsessive compusive disorder with hoarding tendencies Anxiety Alcohol Abuse History of bulemia Hepatitis C contracted from a blood transfusion Hypertension Hip fracture [**12-19**] s/p ORIF at [**Hospital6 **] Left Knee meniscus repair in [**9-18**] at [**Hospital1 2025**] VP shunt placed for hydrocephalus that developed after a fall in [**2169**] with subdural hematoma h/o hemolytic uremic syndrome [**2152**] h/o seizure [**2152**] (at time of HUS), none since chronic numbness L leg and mild weakness L leg and L arm since her fall in [**2169**] Chronic constipation Left hip replacement at [**Hospital3 **] [**4-20**] Social History: Social History: Patient currently lives at [**Doctor Last Name **] house. She has two sons but she has no contact with them. She has a limited relationship with her husband who sends alimony support. She denies ever using illicit drug use. She previously worked as a bank teller. She denies a history of smoking. She has a history of heavy alcohol use per notes although she denies this on my interview. Drink of choice is wine. Family History: Father has hypertension and stroke. Mother has rheumatoid arthritis. Sibling is healthy. Physical Exam: Physical Exam: (at 7:30 AM on [**2175-11-3**]) Vitals: 97.0 BP 106/67 P 98 RR 18 O2 sat 95% RA General: AOX3, tearful throughout exam but easily calmable and redirectable. Somewhat lethargic but appropriate, interactive HEENT: Sclera anicteric, MMM, dentures removed with no remaining teeth, no clear mouth lesions Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, III/VI SEM at LUSB, no rubs or gallops Abdomen: soft, mildly tender in RUQ, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. L trochanteric bursa notable for TTP, light pink area of blanching erythema and edema extending from trochanteric bursa extending towards L glutteal muscle. R hip w/ no erythema or fullness. Nails are dirty. She has no [**Last Name (un) 1003**] lesions or Osler nodes. Back: Tenderness to palptation over entire spine and paraspinal muscles. Most prominent along spinous processes, but very tender throughout. Does have mild tenderness when moving neck but is able to move in all directions with full range of motion Neurologic: CN II-XII tested and intact, strength 5/5 in upper extremities, [**5-16**] in right lower extremity, [**4-16**] in left lower extremity but limited due to pain. L upper extremity with limited range of motion due to pain, unable to lift shoulder above 90 degrees on active motion, and passive motion limited due to pain. Sensation intact to light touch throughout. Reflexes 2+ and symmetric.Gait not tested. No saddle anesthesia. Pertinent Results: On admission: [**2175-11-2**] 04:18PM BLOOD WBC-13.1*# RBC-2.90* Hgb-9.2* Hct-27.2* MCV-94 MCH-31.6 MCHC-33.6 RDW-14.9 Plt Ct-124* [**2175-11-2**] 04:18PM BLOOD Neuts-82* Bands-8* Lymphs-2* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2175-11-2**] 04:18PM BLOOD Plt Smr-LOW Plt Ct-124* [**2175-11-2**] 06:33PM BLOOD PT-13.9* PTT-26.5 INR(PT)-1.2* [**2175-11-2**] 06:33PM BLOOD Fibrino-665* [**2175-11-3**] 05:45AM BLOOD ESR-60* [**2175-11-2**] 04:18PM BLOOD Glucose-133* UreaN-40* Creat-1.5* Na-121* K-3.0* Cl-88* HCO3-22 AnGap-14 [**2175-11-2**] 04:18PM BLOOD ALT-26 AST-36 LD(LDH)-189 CK(CPK)-14* AlkPhos-64 TotBili-0.9 [**2175-11-2**] 04:18PM BLOOD Albumin-2.9* Calcium-8.7 Phos-1.7* Mg-1.9 Iron-8* [**2175-11-3**] 05:45AM BLOOD CRP-218.7* Brief Hospital Course: 1. MSSA bacteremia: was complicated by abscesses at T1-T2, L3-L4, septic left hip and septic left knee. Underwent the following procedures given multiple abscesses on the following dates: a. Washout, left knee, with anterior synovectomy. [**2175-11-5**] b. Revision, left knee, one component. [**2175-11-5**] c. Bilateral laminectomies, C7, T1, and upper T2. [**2175-11-6**] d. Bilateral laminectomies, L3, L4, L5, and S1. [**2175-11-6**] e. Washout, left hip, with revision of acetabular component. [**2175-11-14**]. She was also started on IV nafcillin, however she developed persistent fevers, rash across her sternum and renal failure which raised concern for AIN. She had received about 3 weeks of nafcillin before it was changed to IV vancomycin given the above concerns. She should continue IV vancomycin until [**2175-12-20**] to complete the six week course of antibiotics. Surveillance cultures were drawn following initiation of antibiotics and these were negative; she was also afebrile after the above procedures were complete. She will need weekly safety labs (CBC, Chem 7) faxed to the infectious disease department (see discharge instructions). She has follow up appointments set up with ID, orthopedics, and neurosurgery given the above procedures. . 2. Acute renal failure: Likely secondary to AIN following initation of nafcillin. Creatinine rose from baseline near 1 to 1.9 with development of fever and rash across sternum 10 days after initiation of nafcillin. Differential includes ATN secondary to hypotension perioperatively. [**Month (only) 116**] have attained new baseline of 1.7 or could be slowly resolving. Received fluids perioperatively and has led to volume overload grossly (especially noted in upper extremities, lower extremities, abdomen). Diuresis has been cautious given renal function, although in general she auto-diureses. Despite these attempts, she continues to be overloaded and attempts at further diuresis with monitoring of renal function are encouraged when she is at rehab. She did not have any difficulty with pulmonary edema during the hospitalization and saturated well on room air. Chest x-ray did not show any evidence of volume overload. Continued monitoring of renal function is encouraged. . 3. Anemia: HCT has been relatively stable but occasionally dropped and was thought to be secondary to hematoma along left hip s/p left hip washout. She remained guiaic negative. Other contributing factors included blood loss perioperatively, bome marrow suppression in setting of sepsis, and anemia of chronic disease. Around time of discharge, her hematoma appeared to be stable and she was hemodynamically stable. HCT at time of discharge was stable at 24. Orthopedics were called to evaluate and they did not feel it was expanding. Orthopedics will follow up this area after 1 month. We set a transfusion goal at 21. Rapid HCT drops should be evaluated and would require repeat imaging. . 4. Alcohol Abuse: She had no s/sxs of alcohol withdrawal. She was continued on her home thiamine, folate, multivitamins. SW was consulted. They felt that she occasionally felt depressed secondary to her prolonged hospitalization and that her drinking was likely related to masking underlying symptoms of depression. Following their assessment, they found that Ms [**Known lastname 94424**] found talking to a chaplain regularly quite useful and they recommended regular chaplain visits following discharge to rehab facility. . 5. Depression/Anxiety/OCD: She was continued on her fluoxetine and mirtazapine. Megace was initiated for poor PO intake; following initiation of megace, her appetite improved. Psychiatry was consulted just prior to discharge for OBRA form and during assessment they felt that she was not depressed and had likely underlying alcohol abuse as well as an element of cognitive impairment secondary to frontal disinhibition leading to her tearfulness and emotional lability. They encouraged further continuation of fluoxetine, mirtazapine, and megace. We also discontinued her trazadone and would encourage eventual discontinuation of her benzodiazepines as this can worsen her cognitive impairment. . 6. Chronic Constipation: Frequently constipated; she was given an aggressive bowel regimen including psyllium, senna, colace, and enemas PRN. . 7. Hypertension: Her antihypertensives were intially held while she was septic and she remained normotensive during her hospitalization. For these reasons her home antihypertensives were not restarted. . 8. Hyponatremia: Chronic going back to at least 2 years. Likely secondary to underlying liver disease from history of hepatitis C and alcohol abuse. She will be following up with liver in [**Month (only) 1096**]; this appointment has been scheduled. Medications on Admission: Alendronate 70 mg qweek on saturday Colace Thiamine 100 mg daily Multivitamin Amlodipine 5 mg daily Folic Acid 1 mg daily Fluoxetine 30 mg daily Calcium + D Aspirin 325 mg daily Labetalol 200 mg [**Hospital1 **] Ibuprofen 600 mg PO BID Lorazpam 1 mg PO TID Metamucil 15 mL TID Senna 2 tablets QHS Mirtazapine 30 mg QHS Lorazepam 1 mg Q6H:PRN anxiety Tums 2 tabs PO TID Tylenol PRN Vicodin 1 tab PO QHS and [**Hospital1 **] Discharge Medications: 1. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 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 Capsule Sig: One (1) Tablet PO HS (at bedtime). 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas pain. 12. Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: One (1) PO DAILY (Daily) as needed for appetite. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours). 16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 17. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 18. Metamucil Powder Oral Discharge Disposition: Extended Care Facility: Twins Oaks Care and Rehabilitation CTR Discharge Diagnosis: 1. MSSA bacteremia 2. Thoracic and lumbar osteomyelitis 3. Septic left knee and septic left hip 4. Acute renal failure secondary to ATN vs AIN from nafcillin 5. Left flank hematoma s/p left hip washout, stable 6. Anasarca 7. Depression 8. Chronic constipation 9. Hyponatremia Discharge Condition: Stable for rehab, saturating well at room air. Discharge Instructions: You presented to the [**Hospital1 69**] on [**2175-11-2**] with a complaint of lethargy, hip pain, and back pain. While you were here, we found that you had a serious infection caused by a bacteria called Staph aureus. This bacteria infected several places in your body including parts of your spine (your thoracic/lumbar spine), your left hip, and your left knee. For these reasons, we started you on antibiotics and surgically cleaned out your spine, hip and knee. Following these measures, your kidneys were slightly injured which we thought could be because of your antibiotics. As a result, we changed your antibiotics from nafcillin to vancomycin. You will need to be on these antiobitics for a long duration (6 weeks). You started your antibiotics on [**11-6**], so you should continue to take them until [**2175-12-20**]. You have a special line placed (A Picc line) for the antibiotic to be given. . While you were here, you also developed a lot of swelling because you had a lot of fluid given to you around the time of your surgeries. While in rehab, they will continue to give you water pills to help this swelling come down. . As a result of one of your left hip surgery, you developed a large area of bleeding around your left hip that we call a hematoma. Initially, this area continued to bleed but over time the bleeding stopped. You did initially require blood transfusions for this, however over the past week you have not required any. . The medication changes that we made during this hospitalization are summarized below: We started the following meds that you should continue: (1) Zofran - You can take this as necessary for nausea. (2) Vancomycin - You should continue to take 1 gm IV once a day until [**2175-12-20**]. (3) Calcium carbonate - increased the dose to 1250 mg three times a day (4) Megace - You can take this to help your poor appetite at 400 mg daily. (5) Simethicone - You can take this as needed for the pain that you have from gas. (6) Ranitidine - Take this daily to help protect your stomach from acid. (7) You can take bisacodyl as necessary for constipation, as this was a frequent problem during your hospitalization. (8) Vitamin D - you should take this daily. (9) Aspirin - You should take 81 mg instead of 325 mg because of your history of bleeding - high dose aspirin can make it worse. . We stopped the following medications and they should be held until your outpatient doctors feel that they can safely restart them: (1) We stopped your amlodipine and labetalol since they were dropping your blood pressures too low. If your blood pressures continue to be high, these can be restarted by your rehab doctors. (2) Aspirin 325 mg: we changed this to 81 mg daily because we wanted to lower your bleeding risk since you had a hematoma. (3) We stopped your ibuprofen because your kidneys have been slightly injured during your hospital stay: you should not continue this medicine while your kidneys recover. . You will need to follow up with both orthopedics and infectious disease. The appointment dates are listed below. . If you experience worsening fevers, chills, bleeding, dizziness, ligtheadedness, joint pains, or any other concerning symptoms, please let your primary care doctor know or return to the emergency department. Followup Instructions: 1. Please follow up with Dr [**Last Name (STitle) 2688**], [**First Name3 (LF) **] infectious disease doctor on [**2175-12-25**] at 2:10 PM. If you want to reschedule, please call [**Telephone/Fax (1) 457**]. . 2. Please follow up with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**12-25**] at 11 AM at the [**Hospital6 **]. . 3. You have been scheduled for re-imaging of your back on [**2175-12-21**]. This has been set up for 1 PM. If you want to reschedule, please call [**Telephone/Fax (1) 22726**] and press option 1, then option 1 again to reschedule. . 4. You also have a follow up appointment with neurosurgery to follow up your back surgeries on [**1-2**] at 10:00 AM. To reschedule, you can call [**Telephone/Fax (1) 79896**] at 10 AM at [**Hospital Unit Name 94425**]. . 5. Please follow up with Dr [**Last Name (STitle) **] on [**2175-12-28**] at 1120 AM, who is an orthopedic doctor, regarding your left hip.

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icd9cm

[ [ [] ] ]

[ "00.71", "00.81", "03.09", "38.91", "88.72", "96.6", "80.76", "96.71" ]

icd9pcs

[ [ [] ] ]

13673, 13738

6839, 11636

289, 320

14058, 14107

6067, 6067

17448, 18410

4239, 4330

12110, 13650

13759, 14037

11662, 12087

14131, 17425

4360, 6048

227, 251

348, 3086

6081, 6816

3130, 3776

3808, 4223

31,226

136,242

31100

Discharge summary

report

Admission Date: [**2113-8-21**] Discharge Date: [**2113-8-29**] Date of Birth: [**2035-6-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Transfered from an outside hospital with chest pain and anterior ST elevation MI. Major Surgical or Invasive Procedure: 1) Cardiac catheterization with left anterior descending coronary artery thrombectomy and drug eluting stent placement. 2) Left Internal Carotid Artery Stenting 3) Colonoscopy 4) Upper endoscopy History of Present Illness: 78 year-old female with significant smoking history, no other past medical history, who presents from an outside hospital with acute onset sub-sternal chest pain at rest with radiation to the left shoulder and diaphoresis. The paitent was in her usual state of health when the event occurred. Prior to this she reported 1 episode of chest pain a month prior which resolved on its own. Her current pain was graded as [**11-15**], sharp, midline with slight radiation. She denied any shortness of breath or dyspnea with the pain. The pain did not resolve on its own and she called EMS. At the outside hospital ED, the patient was given nitro, morphine with improvement of her pain. EKG demonstrated ST elevations in V1-V6. Her Trop I was 0.97. She received ASA 325, Plavix 600mg, heparin bolus, integrillin bolus x2 plus gtt at 2mcg/kg/min and lopressor 5mg IV x1. She was taken urgently to the cath lab. . In the cath lab, she was found to have 80% prox LAD stenosis, 80-90% LCx stenosis, 80% RCA and 60-70% ramus stenosis. Given her significant 3 vessel disease, she was transferred to [**Hospital1 18**] for possible CABG. . On arrival to [**Hospital1 18**], the patient felt well and denied chest pain. She was lying flat comfortably. The cath sheath was in place and intact. . On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Of note, the patient reports chronic LE edema for which she is taking a "water pill." Past Medical History: 1)Degenerative Joint Disease 2) Left Eye Blindness 3) Varicose veins-s/p bilateral lower extermity vein stripping Social History: Social history is significant for the current tobacco use of 4 cigs/day. She has a 50 pack year history. There is no history of alcohol abuse. She is a retired office worker who lives with her husband. She has 2 children. She is functional and independent with her activities of daily life. Family History: Her Father had a heart attack at age 64. There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 97.7, BP 108/55, HR 78, RR 24, O2 96% on RA Gen: Alert, talkative elderly female in no distress HEENT: Normal cephalic and atraumatic. Sclera anicteric, extra-occular movements intact, asymmetric pupils L>R. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of ~ 10cm. No bruits CV: PMI located in 5th intercostal space, midclavicular line. regular rate, normal S1, S2, no murmurs, rubs, or gallops Chest: Clear anteriorly with decreased BS and scattered rales postero-laterally Abd: Obese, soft, non-tender and non-distended, No hepato-splenomegally or tenderness Ext: Bilat. 2+ edema with diffuse varicosities. Dopplerable pulses Skin: No stasis dermatitis, venous insufficiency changes Pulses: Right: Carotid 2+ without bruit; Femoral with sheath in place; Left: Carotid 2+ without bruit; Femoral 2+ without bruit; Dopplerable pulses bilat Pertinent Results: FROM OSH: EKG FROM OSH: Sinus at 85bpm, nl axis with occ PVC, ST elevations V1-V5 . CARDIAC CATH at OSH ([**2113-8-21**]): 80% prox LAD stenosis, 80-90% LCx stenosis, 80% RCA and 60-70% ramus stenosis . . EKG on arrival: NSR at 70bpm, nl axis, near resolution of ST elevations in the precordium with biphasic T waves in V2-V5 . CXR ([**2113-8-22**]): Low lung volumes. Normal sized heart. No evidence of pulmonary edema or CHF. . CAROTID US ([**2113-8-22**].) 80% proximal stenosis of the right proximal internal carotid artery. ICA/CCA ratio of 2.64. 80-99% left internal carotid artery stenosis. ICA/CCA ratio of 4.72. There is decreased flow in the right vertebral artery, suggesting inflow stenosis. . 2D ECHO ([**2113-8-22**]): Ejection fraction of 60-70%. LVH. Normal left ventricular size. LV inflow patter consisten with impaired relaxation. Focal wall motion abnormality not able to be fully excluded. Dialted left atrium. Normal right ventricle size and function. Normal right atrial size. Mildly dilated arotic sinus. No AS or MS. Borderline pulmonary artery systolic hypertension. . CARDIAC CATH at [**Hospital1 18**] ([**2113-8-23**]): Right dominant circulation. 80% stenosis of the proximal LAD. Mid-LAD diffuse disease. 90% stenosis of the mid-LCX. 60% stenosis of the prox-ramus. LAD thrombectomy was performed and A Cyhper drug eluting stent (2.5 x 18mm) was placed in the LAD. TIMI 3 flow was obtained. Subclavian angiogram was normal. Carotid angiogram showed bilateral high grade focal disease. . PERIPHERAL (CAROTID)CATH at [**Hospital1 18**] ([**2113-8-24**]): Right subclavian artery with 80% stenosis. Left subclavian artery with minimal disease. Right Common Carotid Artery was patent. Right Internal Carotid Artery with 60% stenosis. Left Common Carotid Artery was patent. Left Internal Carotid Artery with 99% stenosis. Left Internal Carotid was stented with a [**7-14**] x 30 Acculink stent. This resulted in normal flow with filling of the ipsilateral Middle Carotid Artery. . ABDOMINAO/PELVIC CT: NO retroperitoneal bleed. Bilateral pleural effusions, sigmoid diverticula, degenerative changes in the right ischial bone. Mult. other degenerative changes. Exophytic lesion of the lower pole of right kidney measuring 42mm. Comparison to old studies is recommended to ensure stablity. COLONOSCOPY ([**2113-8-28**]): The patient was found to have Diverticulosis of the whole colon, external hemorrhoids, Polyps in the rectum (these were not removed as the patient was on Plavix.) There was no active bleeding during the colonoscopy. Recommendations: Repeat colonoscopy in 6 months to examine the colon and remove rectal polyps. Patient will have to stop Plavix 5 days before and after the procedure. This is to be scheduled by the patient's primary care physician. . UPPER ENDOSCOPY ([**2113-8-28**]): Normal EGD to second part of the duodenum Recommendations. No obvious upper GI source of bleeding. . Labs from OSH: [**2113-8-21**] 20:28 - Trop I 0.97 CK 66 BUN/Cr ?????? 22/0.96 Na 141 K 4.2 Cl 105 Co2 26 Glu 106 H/H 15.1/45.9 INR 0.92 PTT 23.5 . Labs at [**Hospital1 18**]: . Cardiac enzymes ([**8-22**]): CK 173-->84 --->124--->151-->191 CK-MB-20 --> 20-->4-->4--->4 MB Indx-11.6 cTropnT-0.67 --> 0.82 . [**2113-8-22**] WBC-8.6 RBC-4.29 Hgb-12.9 Hct-36.9 MCV-86 MCH-30.0 MCHC-34.9 RDW-14.5 Plt Ct-183 . [**2113-8-22**] PT-11.7 PTT-26.8 INR(PT)-1.0 . [**2113-8-22**] Glucose-113* UreaN-20 Creat-0.7 Na-139 K-3.8 Cl-109* HCO3-23 AnGap-11 [**2113-8-22**] Albumin-3.2* Calcium-9.3 Phos-3.7 Mg-2.3 . [**2113-8-22**] ALT-11 AST-17 LD(LDH)-173 AlkPhos-67 TotBili-0.3 . [**2113-8-22**] Triglyc-131 HDL-42 CHOL/HD-4.3 LDLcalc-111 Cholest-179 . [**2113-8-22**] %HbA1c-5.6% . [**2113-8-23**] TSH-0.49 . UA ([**8-22**]): > 50 RBCs, 0-2 WBCs, [**7-16**] epis Brief Hospital Course: Ms. [**Known lastname 15499**] is a 78 year-old female with a 50 pack year smoking history admitted to OSH for antero-septal ST elevation myocardial infarction with three vessel disease and was transferred to the [**Hospital1 18**]. She was treated with cardiac catheterization with LAD thrombectomy and placement of drug eluting stent in the LAD. . Anterior ST elevation MI. Patient with severe 3 vessel disease with smoking as an only known risk factor for coronary artery disease. Percutaneous cardiac intervention at the outside hospital revealed: 80% prox LAD, 80-90% LCx, 80% RCA, 60-70% ramus stenosis. On admission to the [**Hospital1 18**], the patient was chest pain free with improvement in ST elevations on EKG. Peak CPK was 191 and peak CK-MG was 20. The patient was started on aspirin, Statin, heparin drip, Integrilin, and metoprolol 12.5mg TID. Plavix was held because of the possibility of CABG. The patient was initially evaluated for a CABG by CT surgery. Pre-op carotid US showed a 80-90% bilateral carotid stenosis, making her a poor surgical candidate for CABG. Therefore, in the setting of the patient's recent anterior myocardial infarction and proximal LAD lesion, the patient was taken for a cardiac catheterization ([**2113-8-23**]) with LAD thrombectomy and drug eluting stent placement in the LAD. Plavix was started before cardiac catheterization. A lipid profile was found to be within normal limits. A HbAlc was found to be 5.6%. The patient will follow up with a cardiologist, Dr. [**Last Name (STitle) 1295**], at the [**Hospital1 **] cardiology group on [**2113-9-7**] for the possibility of stenting of the LCx and RCA. Her blood pressure was too low on discharge to add an ACEI, but she may benefit from Lisinopril in the future. . Carotid Stenosis: Carotid US showed bilateral 80-90% carotid stenosis. Peripheral catheterization on [**2113-8-24**] showed a 60% Right Internal Carotid Artery stenosis and a 99% Left Internal Carotid Artery stenosis. An Acculink stent was placed in the Left Internal Carotid Artery with subsequent robust flow through this artery into the Middle Cerebral Artery. After the procedure, the patient's blood pressure was monitored so that the systolic blood pressure ranged from 100's-140's. Additionally, the patient's neurologic exam was unchanged after the catheterization. The patient will continue on Plavix for at least one year and may need Plavix as a life-long medication. The patient will follow up with Dr. [**First Name (STitle) **] in on [**2113-9-26**]. . PUMP: Echocardiogram on [**2113-8-22**] showed an left ventricular ejection fraction of 60-70% with mild LVH and impaired ventricular relaxation. She has no know history of heart dysfunction or congestive heart failure. The patient was treated with metoprolol 12.5mg TID to maintain a low heart rate and allow left ventricular filling. Due to her low-normal blood pressure, an ACEI could not be started in the hospital, but she may benefit from one in the future. . Hypotension: On [**8-23**], the patient presented with MAPs in 50s overnight. She was completely asymptomatic at that time, without tachycardia, chest pain or shortness of breath. Etiology of hypotension unclear, but on questioning pt reports "always having very low blood pressure." There was no evidence of bleeding post cath, and HCT was stable. She was given 2 fluid boluses with slight elevation of blood pressure and good urine output, but continued to have MAPs lower than 60. At his point, she was initiated on neo-synephrine with good response. When the patient went to cardiac catheterization on [**2113-8-23**], an arterial line did show normal blood pressures (117-159/49-113) that were 30 points higher than cuff measurements. Additionally, peripheral catheterization showed an 80% Right Subclavian Artery Stenosis, causing even lower pressure readings by cuff measurements taken in her right arm. When the patient's blood pressure was taken from the left arm, it normalized. . Rhythm: The patient was placed on telemetry and remained in normal sinus rhythm with occasional PVC's. . GI Bleed. On [**2113-8-25**], the patient's Hct dropped from 28.8 to 25.2 to 23.5. The patient was stable with good urine output and no change in mental status. A abdomino-pelvic CT was performed to rule out an retroperitoneal bleed. Although her HCT rose to 27.0 on [**2113-8-26**], she reported that she had multiple loose, bloody stools. On [**2113-8-27**], a NG lavage showed no blood and the bleed was assumed be from a lower GI source. The patient was seen by GI. The patient's SQ heparin was discontinued, she was placed on a proton pump inhibitor [**Hospital1 **], two large bore IV's were placed, she was typed an crossed, and then given two unit of packed red blood cells with a Hct bump from 24.6 to 29.1. The patient tolerated the blood transfusion well. On [**2113-8-28**], the patient was taken to colonoscopy and upper endoscopy. The upper endoscopy was normal. The colonoscopy showed external hemorrhoids, diverticulosis of the entire colon, and rectal polyps (not removed because the patient was on Plavix.) There was no active bleeding during these studies. The patient was kept in the hospital overnight with HCT checks. The patient will follow up with a colonoscopy in 6 months. She will not be able to stop Plavix under any cirmcumstances for at least a year, so if plans are made for polyp removal, these must be done while the patient is on Plavix. . Arthritis: The patient reports a history of degenerative joint disease. When the patient describes the pain, she states that it does not stay confined to the joints and that the pain shoots down her arms and legs. The patient was treated with Tylenol, tramadol, and oxycodone PRN. . Smoking: Significant smoking history. Question underlying lung disease. The patient was maintained on Ipratropium and Albuterol. Social work spoke with the patient about smoking cessation. . FEN: The patient was started on a cardiac diet. Electrolytes were repleated as needed. . Prophy: Bowel regimen, Heparin/Integrilin/Sub-Q heparin, [**Male First Name (un) **] Stockings . Access: PIV x 1 . Code: FULL code on this admission. Patient would like to resume DNR after this hospitalization. . Dispo: The patient was seen by physical therapy and discharged to home with services. Follow up appointments scheduled with Dr. [**First Name (STitle) **], Dr. [**Last Name (STitle) 1295**], and DR. [**Last Name (STitle) **]. The patient will also need a follow up colonoscopy at 6 months. Medications on Admission: Tylenol prn Triamterene (unsure of dose) Tramadol (unsure of dose) Ibuprofen prn Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 7. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1) Anterior ST elevation myocardial infarction 2) Bilateral carotid stenosis 3) Right Subclavian Artery Stenosis 4) GI Bleed 5) Rectal polyps Discharge Condition: Stable, ambulating Discharge Instructions: During this hospitalization, you were diagnosed a myocardial infarction or a heart attack. The type of heart attack that you had is called an anterior ST elevation myocardial infarction. We treated this with a cardiac catheterization and a stent in one of the coronary arteries. Additionally, during this hospitalization, you were found to have narrowing of the arteries in your neck. This is called carotid artery stenosis. This was treated with left carotid artery stent placement. Finally, you had a GI bleed during this hospitalization. This was evaluated with a colonoscopy and an upper endoscopy. Even though you had a GI bleed, you need to stay on your aspirin and plavix. . During this hospitalization, you were started on several new medications to treat your heart and the arteries in your neck. It is very important that you take all of your medications. It is especially important that you take your aspirin and plavix everyday. Under no circumstance should you stop taking your aspirin or plavix- unless you have spoken to your cardiologist. If you become sick and are vomiting and cannot take your aspirin or plavix you should contact your cardiologist. . If you have any chest pain, shortness of breath, dizziness, feel hot and/or sweaty, feel confused, are not able to speak, have a change in your vision,or are suddenly are not able to move or feel a part of your body-please contact your doctor or go to the nearest emergency room. Please feel free to contact your doctor with any other concerns. Followup Instructions: 1) Please follow up with Dr. [**First Name (STitle) **] to evaluate your left carotid stent on [**2113-9-26**] at 3:20pm. The office is located on the [**Location (un) 436**] in the [**Hospital Ward Name 23**] Building of the [**Hospital1 771**]. Please call the office coordinator, Dauwn, at [**Telephone/Fax (1) 73427**] if you have any questions. . 2)Because you have had a heart attack, it is important for you to follow up with a cardiologist. You have an appointment with Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 1295**] on [**2113-9-7**] at 10:30am. Dr.[**Name (NI) 39613**] office is at the [**Hospital3 1280**] Heart Center on [**Last Name (NamePattern1) 26916**]. It is next to the [**Hospital 47**] [**Hospital 1281**] Hospital. Please call [**Telephone/Fax (1) 6256**] with any questions. Please discuss with Dr. [**Last Name (STitle) 1295**] if you need to start Lisinopril as an outpatient. . 3) Due to your hospitalization, you should follow up with your primary care doctor. You are scheduled for an appointment with Dr. [**Last Name (STitle) **] on [**2113-9-6**] at 11:00am. Please call [**Telephone/Fax (1) 7401**] if you have any questions. . 4) You should have a follow up colonoscopy in 6 months. Please speak to your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 51794**] this study.

[ "433.30", "362.50", "562.12", "211.4", "716.99", "447.1", "410.11", "414.01", "455.5", "285.1", "458.8", "305.1" ]

icd9cm

[ [ [] ] ]

[ "00.61", "00.40", "00.45", "00.66", "88.41", "36.07", "00.63", "37.22", "99.04", "45.13", "88.56", "45.23" ]

icd9pcs

[ [ [] ] ]

15157, 15215

7805, 14395

396, 593

15401, 15421

3956, 7782

16994, 18365

2910, 3033

14527, 15134

15236, 15380

14421, 14504

15447, 16971

3048, 3937

275, 358

621, 2448

2470, 2585

2601, 2894

58,054

188,294

36910

Discharge summary

report

Admission Date: [**2129-5-14**] Discharge Date: [**2129-5-18**] Date of Birth: [**2063-2-5**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: CC:[**CC Contact Info 83322**] Major Surgical or Invasive Procedure: none History of Present Illness: HPI:66yo male with witnessed syncopal episode. Fell,hit head brought to OSH.Transferred to [**Hospital1 18**] via [**Location (un) **] after obatining noncontrast head CT which revealed Brainstem, bifrontal and right sided hemorrhages. Pt also reported to have sustained a fall 3 weeks prior where he hit his face. No reported orbital fractures. Past Medical History: PMHx: Atrial fibrillation, HTN, Hypercholesterolemia,Perferated Diverticulum, One functioning kidney,s/p scrotal resection,?TIA Social History: Social Hx:Single, retired buisiness owner. Non smoker, No ETOH Family History: Family Hx: father deceased +aneurysm, mother deceased. Brother is alive and well. Physical Exam: PHYSICAL EXAM: Prior to Endotracheal intubation 3:50pm O: T:97 BP: 219/107 HR:91 R 18 O2Sats 100% Gen: Lethargic to obtundation, Ill appearing. HEENT: Pupils: 1.5mm to 1.0Bil EOMs full on right. Cannot separate edematous/eccymotic right eye due to swelling. Neck: Stabilized in cervical collar. No JVD or upstrokes noted. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, Flat, NT, BS+ Extrem: Warm and well-perfused. Neuro: Lethargic Mental status: Awake and alert, cooperative with exam, speech is garbled. Able to state his name Orientation: Oriented to person. Language: Speech slurred. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,1.5mm to 1.0 mm bilaterally. Visual fields are full to confrontation on the left. III, IV, VI: Extraocular movements intact on right without nystagmus. V, VII: Face symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Not tested XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power 4+/5 throughout. Unable to assess pronator drift due to pt not fully cooperating. Sensation: Intact to light touch Toes downgoing bilaterally Pertinent Results: CT/MRI: From OSH [**5-14**]: Severe [**Doctor First Name **], Brainstem low density and poor grey/white matter differentiation. Repeat NCHCT reviewed by Dr. [**First Name (STitle) **]. Labs: INR at OSH 2.3 [**2129-5-14**] 04:00PM WBC-21.0* RBC-4.65 HGB-14.1 HCT-39.1* MCV-84 MCH-30.3 MCHC-36.0* RDW-14.4 [**2129-5-14**] 04:00PM NEUTS-91.2* LYMPHS-4.7* MONOS-3.4 EOS-0.4 BASOS-0.3 [**2129-5-14**] 04:00PM PLT COUNT-257 [**2129-5-14**] 04:00PM PT-27.2* PTT-28.5 INR(PT)-2.7* [**2129-5-14**] 04:00PM DIGOXIN-1.5 Brief Hospital Course: Pt was admitted to the ICU for close neurologic monitoring. he continued to have poor neurologic exam. He was also seen in consultation by stroke neurology who also felt pt had unrecoverable injury with very poor longterm prognosis. Ongoing discussion was had with pt's brother and pt was made [**Name (NI) 3225**] [**5-17**], extubated. He expired morning [**2129-5-18**]. Medications on Admission: Coumadin 2.5mg, ASA 325mg,Digoxin,Lovastatin,Potassium,Propafenone 300mg, Atenolol 50mgDaily, HCTZ 25mg daily,Avapro 150mg Discharge Medications: none Discharge Disposition: Extended Care Discharge Diagnosis: Intraparenchymal/intraventricular hemorrhage Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2129-5-18**]

[ "752.89", "427.89", "593.9", "286.9", "331.4", "800.25", "348.4", "V58.61", "780.60", "801.25", "272.0", "458.9", "V66.7", "401.9", "E888.1", "285.9", "427.31" ]

icd9cm

[ [ [] ] ]

[ "99.07", "96.72", "96.04", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

3467, 3482

2888, 3265

346, 353

3571, 3580

2343, 2865

3633, 3668

976, 1060

3438, 3444

3503, 3550

3291, 3415

3604, 3610

1090, 1524

277, 308

381, 729

1697, 2324

1539, 1681

751, 880

896, 960

42,982

142,935

40299

Discharge summary

report

Admission Date: [**2118-12-23**] Discharge Date: [**2118-12-25**] Date of Birth: [**2072-9-13**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Upper endoscopy EGD with clipping x3 History of Present Illness: 46 y/o with obesity s/p [**2118-12-22**] EGD with doudenal adenoma removal presents wtih BRBPR. The adeonma was discovred on EGD during gastric bypass pre-screening. The 3 cm semi-pedunculated adenoma was succuslly removed yesterday via Endoscopy mucosal resection. He reports that after the procedure he had a normal bowel movement at approximately 530pm. Around that time was was also lightheaded and diaphoretic but did not loss consciousness. He spiked a fever with rigors to 101.3 at 6pm. At 10 pm he felt the need to deficatae and developed lightheadness and dizziness with walking. He became incoherent per the wife but did not lose consciousness. The symptoms were followed by an episode of incontinence of BRBPR described as a large amount (well over 1 cup) of marroon with clots. . He presented to [**Hospital3 **] where his HCT was 38. He was transfered to [**Hospital1 18**] before any transfusions. On arrival to [**Hospital1 18**] the HCT was 31. Initial VS were 98.3, 83, 20, 99%2L. No pre-op HCT inthe system. Abd exam significant for LUQ tenderness without rebound. Complained of nausea without vomitting. CT abd without obstruction or re-air. Rectal exam with mahogony colored stool. PIV 18G x 2 placed. Received 3L IVF. No medications received. VS prior to transfer 81, 104/86, 99% RA. No blood received prior to transfer. Pt reports passing additional blood stool in ED prior to arrival. . On arrival the patient is without pain. VS stable, no dizziness. Past Medical History: Obesity HTN (NL BP with meds 120s to 130s) Duodenol adenoma s/p removal via EGD [**2118-12-22**] GERD / hiatal hernia Social History: Lifetime non smoker, rare Etoh, no illicits Family History: Mother with DM, Colon CA, HTN, heart murmer Physical Exam: VS: Temp: 96.7 BP:133 /68 HR:89 RR:17 O2sat 99%RA GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no , no jvd, RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. Pertinent Results: EGD: Impression: -Normal mucosa was noted in esophagus and stomach. -Visible vessels noted in the base of ulceration from previous EMR. -No fresh or altered blood noted in upper GI tract examined. -Three endoclips were successfully applied for the purpose of hemostasis. [**2118-12-23**] 03:15AM BLOOD WBC-8.4 RBC-3.82* Hgb-11.1* Hct-31.2* MCV-82 MCH-28.9 MCHC-35.4* RDW-13.6 Plt Ct-258 [**2118-12-23**] 04:08PM BLOOD Hct-29.0* [**2118-12-23**] 08:40PM BLOOD Hct-33.4* [**2118-12-25**] 06:33AM BLOOD WBC-8.3 RBC-3.68* Hgb-10.8* Hct-30.7* MCV-83 MCH-29.4 MCHC-35.3* RDW-13.7 Plt Ct-237 [**2118-12-23**] 03:15AM BLOOD PT-15.0* PTT-24.8 INR(PT)-1.3* [**2118-12-23**] 10:45AM BLOOD Glucose-91 UreaN-20 Creat-1.0 Na-139 K-4.0 Cl-106 HCO3-26 AnGap-11 Brief Hospital Course: 46 y/o with hematochezia after endoscopic mucosal resection performed 1 day prior to admission for duodenal adenoma. . # GI Bleed/Acute blood loss anemia: Given the recent manipulation, the duodenal adenoma site was felt to be the most likely site of bleeding. His hematocrit stabilized upon admission, confirming that the active bleeding had subsided. He was given 1 unit of pRBCs with appropriate response. His ASA was held and the ERCP team performed an EGD. The findings were as follows: normal mucosa in esophagus and stomach, visible vessels noted in the base of ulceration from previous resection --> three endoclips were successfully applied for the purpose of hemostasis, and no fresh or altered blood in upper GI tract. Serial Hct's were done s/p EGD and continued to remain stable, not requiring further transfusion. He passed a melenotic stool while in the ICU and was monitored for transition back to brown stools. On the floor he passed brown stool - Follow up with PCP for repeat CBC - GI follow up as needed - Aspirin held at discharge pending PCP follow up and stability of Hct - Protonix increased to [**Hospital1 **] . 2. Presyncope: His symptoms were likely positional, in the setting of bloody BMs. Likely orthostatic vs vasovagal etiology. EKG showed S1Q3T3, but no tachycardia or O2 requirement, leaving low suspicion for PE. He was volume repleted with 3L IVF prior to arrival to [**Hospital1 18**] and received 1 more liter bolus in the ICU. His orthostatics were negative upon transfer from the ICU. . 3. Fever: Likely from translocation of bacteria at site of GI bleed. He was empirically treated with ceftriaxone, but did not spike any further fevers. Blood and urine cultures were negative and his chest x-ray was unremarkable. The antibiotics were discontinued prior to transfer from the ICU. . 4. Hypertension, benign: Instructed to resume Lisinopril the day after discharge . 5. OSA: Continued CPAP . FULL CODE Medications on Admission: - cephalexin 500mg PO daily x 1 week given for acne - lisinopril 10mg PO daily - Protonix 40mg PO daily - aspirin 81mg PO daily - B-Complex PO daily - vitamin B12 1000mcg SL daily - vitamin D - multivitamin PO daily - Fish Oil 1200mg-144mg PO daily Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever. 3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Vitamins Please resume your home vitamins as before Discharge Disposition: Home Discharge Diagnosis: GI bleeding Acute blood loss anemia Hypertension, benign Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with a GI bleed, caused by your recent endoscopic procedure and biopsy. You received a blood transfusion. Your bleed was successfully stopped with clips. Please follow up closely with your PCP for repeat blood work. Your discharge hematocrit is 30.7 Please do NOT take your aspirin until you follow up with your PCP. [**Name10 (NameIs) **] your Protonix twice daily Followup Instructions: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 54195**] - 1 week after discharge, blood work

[ "553.3", "998.11", "E878.8", "278.00", "401.1", "285.1", "530.81" ]

icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

6064, 6070

3387, 5343

314, 353

6171, 6171

2617, 3364

6733, 6884

2079, 2125

5643, 6041

6091, 6150

5369, 5620

6322, 6710

2140, 2598

268, 276

381, 1859

6186, 6298

1881, 2001

2017, 2063

28,859

154,332

28020

Discharge summary

report

Admission Date: [**2150-9-16**] Discharge Date: [**2150-9-27**] Date of Birth: [**2077-8-30**] Sex: M Service: NEUROSURGERY Allergies: Aminophylline Hydrate Attending:[**First Name3 (LF) 1835**] Chief Complaint: consulted for brain mass found on outside CT Major Surgical or Invasive Procedure: left brain biopsy History of Present Illness: 73yo M transferred from OSH after CT showed 4.2x4.7x6cm ring enhancing lesion L parietal lobe with 2mm midline shift. Pt presented to [**Hospital3 10310**] today at 5pm after new sx's not recognizing family, repeating "no no no". Pt has been followed for a lesion in the same area seen on MRI 1 year ago. At OSH, pt had tonic-clonic seizure, stopped after 4mg Ativan. He was intubated and sedated with propofol and vecuronium. Propofol weaned [**1-30**] hypotension. Past Medical History: TIA's since [**2143**] (on Plavix), ?prostate CA (per report, high grade biopsies without definite CA, elevated PSA) Social History: Pt lives with wife. [**Name (NI) **] health care proxy. Family History: non-contributory Physical Exam: PHYSICAL EXAM upon admission: T: 100.3 BP: 116/69 HR: 73 R: 14 100% on CMV: FiO2 0.5, PEEP 5, TV 550x14 Gen: Intubated, small movement hands with deep sternal rub Lungs: CTA bilaterally. Cardiac: RRR Abd: Soft, NT, BS+ Neuro: Pupils 1mm bilat, fixed. sedated. Unable to test other cranial nerves. Small hand movements to noxious stimuli. Babinski toes upgoing bilaterally. Pertinent Results: [**2150-9-16**] 05:10AM PHENYTOIN-21.8* [**2150-9-16**] 05:10AM WBC-6.1 RBC-4.04* HGB-14.0 HCT-38.3* MCV-95 MCH-34.6* MCHC-36.5* RDW-12.9 [**2150-9-15**] 11:45PM GLUCOSE-139* UREA N-11 CREAT-1.2 SODIUM-138 POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13 [**2150-9-15**] 11:45PM CK(CPK)-447* Brief Hospital Course: Mr. [**Known lastname 68211**] was admitted to the ICU with a new brain mass and was intubated upon arrival to the unit. He had a steriotactic brain biopsy on [**9-18**]. The pathology showed the tumor was Glioblastoma (WHO grade IV). The patient recovered well from the procedure. While in the ICU he self-extubated himself and his respiratory status remained good. He did not require reintubation. The patient was transferred to the floor on [**2150-9-21**]. His mental status improved daily. He was neurologically stable upon discharge and has been scheduled for outpatient radiation close to his home. PT and OT evaluated the patient and felt that he was safe to be discharged home. Medications on Admission: Plavix 75, ASA 81, Atenolol 25, Lasix 40, Combivent, Asmanexex inhalent, Aricept 5 Discharge Medications: 1. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO once a day for 1 weeks: Take 1 hour before chemotherapy. Disp:*7 Tablet, Rapid Dissolve(s)* Refills:*0* 2. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO once a day for 5 weeks: Take 1 hour before chemotherapy. Disp:*35 Tablet, Rapid Dissolve(s)* Refills:*1* 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 1 weeks. Disp:*28 Tablet(s)* Refills:*0* 5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO twice a day for 5 weeks. Disp:*140 Tablet(s)* Refills:*1* 6. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 1 weeks. Disp:*21 Tablet(s)* Refills:*0* 7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 5 weeks. Disp:*105 Tablet(s)* Refills:*1* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. 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* 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 14. Ambien 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia for 5 weeks. Disp:*70 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Brain tumor / GBM Discharge Condition: neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR BRAIN BIOPSY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Patient will follow up with WBRT at [**Hospital 1121**] Cancer Center in [**Location (un) 1456**]. You have an appointment on Wed [**9-30**] at 8am. They are at [**Street Address(2) 68212**], phone number is [**Telephone/Fax (1) 45791**]. Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2150-10-26**] 3:00 Completed by:[**2150-9-27**]

[ "298.9", "191.3", "V12.59", "780.39", "401.9", "493.90" ]

icd9cm

[ [ [] ] ]

[ "96.71", "01.13", "96.6" ]

icd9pcs

[ [ [] ] ]

4507, 4578

1847, 2538

331, 351

4640, 4664

1519, 1824

6039, 6452

1085, 1103

2672, 4484

4599, 4619

2564, 2649

4688, 6016

1118, 1134

247, 293

379, 853

1148, 1500

875, 994

1010, 1069

46,109

133,235

52330

Discharge summary

report

Admission Date: [**2119-4-6**] Discharge Date: [**2119-4-8**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2297**] Chief Complaint: Unresponsive Major Surgical or Invasive Procedure: Pleurex catheter History of Present Illness: Pt is a [**Age over 90 **] year old woman with PMH of stage IV NSCLC, CVA, and a recurrent malignant right sided pleural effusion who presented after attempted IP procedure on day of admission with altered mental status and an unresponsive episode. Pt was scheduled for outpatient pleuroscopy, pleurodesis, and PleurX Catheter placement today. She was prepped and received 75Mcg of Fentanyl and 1.5 mg total of Midazolam. An incision was made, but at that time the patient became unresponsive with bradycardia into the 30s and hypotension with SBPs in the 60s. She required ventilatory support with a BVM briefly, got Atropine 0.5mg x 2 and the procedure was aborted (and small incision sutured closed). She was given flumazenil 0.5mg as well as narcan 0.4mg with minimal response. She was not responding verbally/appropriately. She was withdrawing to painful stimuli and moving all extremities. At the time of this incident, an EKG was performed that showed atrial fibrillation and ST depressions (reportedly in V2-V3). Repeat EKG 30 minutes later showed normalization of these abnormalities. Prior to the procedure she reported cough, dyspnea, and weight loss. She specifically denied orthopnea, PND or leg edema. Of note, she has had thoracentesis x 2 on [**1-26**] and [**2-27**] draining 850ml and 1300ml respectively. Post procedure her dyspnea improved and there was complete lung expansion. On the floor, the patient is responsive to painful stimuli only. Review of systems: Unable to obtain due to patient's mental status. Past Medical History: 1. CVA 2. Right-sided breast cancer: This was about 30 years ago and treated with mastectomy and radiation therapy. 3. Type 2 diabetes: Diet controlled. 4. Hypertension. 5. Atrial fibrillation. 6. Gout. 7. Hypothyroidism. 8. Osteopenia/osteoporosis. 9. Glaucoma. 10. NSCLC as below: -[**10-7**] CXR for cough showed R-sided opacity, chest CT which showed a nodular lesions in superior RLL and mod/large R pleural effusion - [**2118-11-2**] pleural effusion tapped and negative for malignancy Pt then developed hoarseness and was seen by ENT [**1-8**] and determined to have recurrent nerve paralysis, highly concerning for malignancy. - [**2119-1-13**] repeat imaging disclosed a smaller LUL nodule and paratracheal mass, likely a lymph node conglomerage - [**2119-1-26**] EBUS with FNA sampled paratracheal mass and lymph node, both positive for poorly differentiated adenocarcinoma. Brochial brushings of the right lobar bronchi were atypical - [**2119-2-9**]: C1D1 09-018: irreversible EGFR/ErbB2 TKI PF-[**Numeric Identifier 108198**] Social History: The patient currently lives with her family in [**Location (un) 2312**], she has VNA 2X/week. She is originally from the [**Country 31115**] but moved here in [**2081**] and has not been back there recently. She previously lived in [**Location 86**] and then moved to [**State 108**] and has now been back up in [**Location (un) 86**] for the last 2 years. She denies any other areas of residence. She denies any alcohol use and she denies any past or present cigarette smoking. However, her husband was a significant smoker. The patient previously worked for the Red Cross and had no occupational exposures. Family very involved in her care. Family History: No family history of lung disease. However, note that her husband who is a long time smoker died of lung cancer. Physical Exam: Vitals: T: 95.6 (axillary) BP:97/62 P: 62 R: 20 O2: 99% 2 L General: Withdraws to painful stimuli only, no posturing. HEENT: No evidence of trauma. Sclera anicteric, MMM, oropharynx clear, PERRL Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, limited air movement at apices only (decreased breath sounds bilateral bases) CV: irregularly irregular normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: withdraws all extremities to painful stimuli only, 1+ LE reflexes, toes downgoing bilaterally. Pertinent Results: [**2119-4-6**] 09:08PM TYPE-ART TEMP-35.0 PO2-127* PCO2-65* PH-7.40 TOTAL CO2-42* BASE XS-12 INTUBATED-NOT INTUBA [**2119-4-6**] 09:08PM GLUCOSE-157* LACTATE-0.7 K+-3.8 [**2119-4-6**] 09:08PM freeCa-1.13 [**2119-4-6**] 05:06PM GLUCOSE-219* UREA N-50* CREAT-1.1 SODIUM-139 CHLORIDE-92* TOTAL CO2-41* [**2119-4-6**] 05:06PM CK(CPK)-79 [**2119-4-6**] 05:06PM CK-MB-NotDone cTropnT-<0.01 [**2119-4-6**] 05:06PM CALCIUM-8.9 PHOSPHATE-5.2* MAGNESIUM-2.4 [**2119-4-6**] 05:06PM TSH-7.8* [**2119-4-6**] 05:06PM FREE T4-1.6 [**2119-4-6**] 05:06PM WBC-8.2 RBC-3.71* HGB-11.7* HCT-37.8 MCV-102* MCH-31.5 MCHC-30.9* RDW-16.4* [**2119-4-6**] 05:06PM PLT COUNT-249 [**2119-4-6**] 05:04PM TYPE-ART RATES-/18 PO2-413* PCO2-78* PH-7.34* TOTAL CO2-44* BASE XS-12 INTUBATED-NOT INTUBA VENT-SPONTANEOU [**2119-4-6**] 05:04PM GLUCOSE-266* LACTATE-2.3* NA+-137 K+-3.6 CL--85* [**2119-4-6**] 05:04PM HGB-12.4 calcHCT-37 O2 SAT-98 [**2119-4-6**] 05:04PM freeCa-1.11* [**2119-4-6**] 11:20AM GLUCOSE-151* [**2119-4-6**] 11:20AM UREA N-52* CREAT-1.1 SODIUM-138 POTASSIUM-3.2* CHLORIDE-90* [**2119-4-6**] 11:20AM estGFR-Using this [**2119-4-6**] 11:20AM ALT(SGPT)-27 AST(SGOT)-32 LD(LDH)-201 ALK PHOS-86 TOT BILI-0.7 [**2119-4-6**] 11:20AM TOT PROT-6.7 ALBUMIN-3.7 GLOBULIN-3.0 CALCIUM-9.4 PHOSPHATE-3.7 MAGNESIUM-2.3 [**2119-4-6**] 11:20AM WBC-8.1 RBC-3.61* HGB-11.8* HCT-36.9 MCV-102* MCH-32.8* MCHC-32.1 RDW-15.9* [**2119-4-6**] 11:20AM NEUTS-71.9* LYMPHS-18.3 MONOS-6.2 EOS-3.3 BASOS-0.4 [**2119-4-6**] 11:20AM PLT COUNT-217 [**2119-4-6**] 11:20AM PT-13.9* PTT-24.6 INR(PT)-1.2* [**2119-4-8**] 06:50AM BLOOD WBC-8.7 RBC-3.54* Hgb-11.0* Hct-35.1* MCV-99* MCH-31.1 MCHC-31.3 RDW-17.3* Plt Ct-183 [**2119-4-8**] 06:50AM BLOOD Glucose-139* UreaN-60* Creat-1.3* Na-144 K-4.4 Cl-100 HCO3-39* AnGap-9 . CXR (portable): [**2119-4-6**] CHEST, AP: Lung volumes are low, with increased left lower lobe atelectasis and a tiny left apical pneumothorax. Right lower lobe atelectasis and subpulmonic effusion persist. Hazy opacity in the right upper lobe corresponds to known primary tumor. Left upper lobe nodule is vaguely seen overlying the second anterior and fourth posterior ribs. Mild-to-moderate cardiomegaly and aortic tortuosity persist. The stomach is markedly distended, with PEG tube in place. IMPRESSION: 1. Bibasilar atelectasis, tiny left pneumothorax. 2. Distended stomach, please decompress through PEG tube. CT Head w/o Contrast [**2119-4-6**]: IMPRESSION: 1. No acute intracranial process. 2. 1.4 cm calcified left paraclinoid lesion most consistent with meningioma without associated edema. 3. Areas of hypodensity within the right parietal and right frontal regions corresponding to FLAIR abnormalities on prior MRI and consistent with remote infarcts. . MRI Head [**2119-4-7**]: No acute pathology (prelim) . CXR [**2119-4-7**] (post Pleurex): No evidence of residual pneumothorax. Brief Hospital Course: # Altered Mental Status: The patient's unresponsiveness/altered mental status was possibly due to versed/fentanyl with slow metabolism, but also possibly due to hypoxia and resultant CNS insult that occurred as a result of her hypoperfusion with low HR and blood pressure. Alternative explanations include CVA and other toxic/metabolic abnormalities. Glucose level was normal. As this change in level of consciousness was so acute, less likely due to infection/sepsis. Patient also with long history of atrial fibrillation, not currently on anticoagulation with an INR of 1.2. The patient was admitted to the SICU under the care of the MICU team. Her airway was monitored closely and she had a repeat ABG that showed 7.4/65/127. She did not receive any further opiates/benzodiazepines. Her mental status was waxing and [**Doctor Last Name 688**], and she would have periods throughout the night where she would open her eyes and follow simple commands (squeeze hands). Otherwise, she was responsive only to painful stimuli. An MRI of her brain was performed due to concern for embolic CVA which showed no acute pathology. She did receive flumazenil 0.5mg again along with narcan 0.4mg. Approximately one hour after the administration of these medicines, the patient was fully awake, alert and oriented. On the day following admission, she was able to converse with her family (present at bedside) although she frequently reported feeling "tired." She later tolerated her IP procedure well and was alert on discharge. # Hypotension: When the patient first arrived to the ICU, her blood pressures were in the high 90s and low 100s systolic. Over the subsequent several hours, her blood pressures drifted down to a nadir of 70s systolic. She received 2 IV fluid boluses of 500ml. She showed improvement in her blood pressure to 90s-100s. A central line set up was at bed side in case pressors were needed, but her blood pressure remained stable and then increased to 120s systolic when she became fully awake. During this time her UOP remained satisfactory, averaging 30ml/hour. # EKG changes: The patient had EKG changes during her initial bradycardic/hypotensive episode with new RBBB and minimal ST depressions in V2-V3. A repeat EKG 30 minutes later showed resolution of these findings and only showed atrial fibrillation with no ST/T wave abnormalities. The patient does not carry the diagnosis of CAD, but is a diabetic and is predisposed to vascular abnormalities. As a result cardiac enzymes were cycled. A second set did show a small increase in troponin T to 0.02, but no MB component. Third set of enzymes was negative. # NSCLC with pleural effusion: Patient is now status post 2 cycles with investigatory drug, now with reaccumulation of pleural effusion. The reaccumulation likely represents progression of tumor. On the day following admission, she was seen by IP and a PleurX catheter was placed at bedside with drainage of 1100 cc of fluid. After the procedure, the patient reported feelling "much better." F/U chest x-ray showed no PTX. She was called out to the general medical wards after this procedure. She was discharged the following day with no acute issues. # DM 2: The patient's diabetes was generally diet controlled, here with glucose range 150-250. She was maintained on a RISS. # Afib: Atenolol was discontinued given her hypotension. Pt's heart rate was stable prior to discharge. # Hypothyroidism: A TSH was sent and was elevated at 7.8, however, a free T4 was normal at 1.6. Te patient was maintained on her home dose levothyroxine via PEG daily. # Code status: The patient expressed wishes to be DNR/DNI during this admission. This decision was discussed with her daughter at bedside. The patient was provided with a DNR/DNI form to complete should she require future documentation of this decision. Patient was discharged home with VNA. The family did not want hospice but VNA will be there to assist them and help make the patient comfortable. Palliative care was also consulted this admission to help with planning. Medications on Admission: ALLKARE PROTECTIVE BARRIER WIPES - - use to cleanse area around your feeding tube twice a day or as needed Convatec ALLOPURINOL - 100 mg Tablet - 2 Tablet(s) by mouth once a day ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth once a day COLCHICINE - 0.6 mg Tablet - 1 Tablet(s) by mouth as directed take only with gout flare. do not take on regular basis FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for volume overload as directed HYDROCHLOROTHIAZIDE - 12.5 mg Capsule - 1 Capsule(s) by mouth qam for blood pressure IPRATROPIUM-ALBUTEROL - 0.5 mg-2.5 mg/3 mL Solution for Nebulization - 1 neb(s) inh every four (4) hours as needed for wheeze ICD9: 496 LEVOTHYROXINE - 75 mcg Tablet - 1 Tablet(s) by mouth once a day SALINE BULLETS - - 1 neb inh every four (4) hours as needed for wheeze Use with nebulizer machine TIMOLOL MALEATE - 0.5 % Drops - 1 drop(s) both eyes twice a day TRAZODONE - 50 mg Tablet - 1.5 Tablet(s) by mouth at bedtime Dose= 75 mg nightly Medications - OTC LACTOSE-FREE FOOD WITH FIBER [ISOSOURCE 1.5 CAL] - Liquid - 4 can via feeding tube daily Bolus feedings , 4 cans daily, URGENT delivery please LOPERAMIDE - 2 mg Tablet - 1 Tablet(s) by mouth q3h as needed for diarrhea Take after each episode of diarrhea, maximum 8 pills per day. NUTRITIONAL SUPPLEMENT - FIBER [FIBERSOURCE HN] - Liquid - 50 mL PEG 50 mL/hour continuous over 24 hours modify as directed by Nutritionist Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Doctor Last Name **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Senna 8.6 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*60 Tablet(s)* Refills:*0* 3. Levothyroxine 75 mcg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY (Daily). 4. Ipratropium-Albuterol 0.5-2.5 mg/3 mL Solution for Nebulization [**Doctor Last Name **]: One (1) Inhalation four times a day as needed for shortness of breath or wheezing. 5. Trazodone 50 mg Tablet [**Doctor Last Name **]: 1.5 Tablets PO at bedtime as needed for insomnia. 6. Loperamide 2 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO once a day as needed for constipation. 7. Nutritional Supplement - Fiber Liquid [**Doctor Last Name **]: Fifty (50) ml/hr PO once a day: ASDIR BY NUTRITIONIST. 8. Morphine Concentrate 20 mg/mL Solution [**Doctor Last Name **]: 5-10 mg PO q 15 min as needed for shortness of breath or wheezing. Disp:*20 ml* Refills:*0* 9. Allopurinol 100 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO once a day. 10. Docusate Sodium 50 mg/5 mL Liquid [**Doctor Last Name **]: Five (5) ml PO once a day as needed for constipation. Disp:*150 ml* Refills:*0* Discharge Disposition: Home With Service Facility: Caregroup VNA Discharge Diagnosis: Primary: (1) Unresponsiveness (2) Hypotension Secondary: (1) Non-Small cell lung cancer (2) Diabetes Mellitus (3) CVA (4) Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [**Known lastname 108197**], You were seen and evaluated for low blood pressure and a period of unresponsiveness in the hospital after a planned pulmonary procedure. Your unresponsiveness was likely due to the medications you received for sedation in the procedure, and you are probably an individual who breaks down these medicines very slowly. You were monitored closely in the intensive care unit and received fluid resuscitation for your low blood pressure. You also underwent the planned procedure, which involved placing a tube in your chest to drain the fluid. You tolerated the procedure well. As you may be aware, you had a discussion with our palliative care team, and decided that you did not want to be recussitated. You also indicated that your goals of care were geared towards comfort, but did not want to be set up with home hospice care. We made the following changes to your medication regimen: We stopped you blood pressure medications, including atenolol and hydrochlorothiazide, since you had low blood pressure. Should your blood pressure at home be elevated, and should you choose to treat this condition, you may contact your regular doctor to restart these medications. We also are giving you medication in case you develop constipation, i.e. loperamide, or diarrhea, i.e. colace, senna, bisacodyl; all of which may be taken on an as needed basis. Finally we are giving you morphine, to take sublingually, in case you have shortness of breath or pain. It was a pleasure taking care of you. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2119-4-13**] 11:20 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2119-5-31**] 10:00 Completed by:[**2119-4-8**]

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icd9cm

[ [ [] ] ]

[ "34.04" ]

icd9pcs

[ [ [] ] ]

14282, 14326

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230, 249

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178, 192

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2907, 3552

41,653

185,531

42436

Discharge summary

report

Admission Date: [**2117-2-17**] Discharge Date: [**2117-2-26**] Date of Birth: [**2048-1-3**] Sex: F Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 602**] Chief Complaint: hypoxia, hypotension Major Surgical or Invasive Procedure: You were transferred to [**Hospital1 18**] intubated and mechanically ventialted. [**2117-2-19**] - Extubation and discontinuation of mechanical ventilation [**2117-2-18**] - Bedside bronchoscopy with bronchoalveolar lavage History of Present Illness: This is a 69 year-old Female with oxygen-dependent COPD, CAD, diastolic CHF, mitral stenosis, IDDM, HTN, HLD who presented to an [**Hospital6 7472**] ED on [**2117-2-10**] with acute hypoxic respiratory failure with oxygen saturations in the 81-85% on 2L NC and hypotension. . Her partner states that she had been feeling unwell for several days prior to this with fatigue, chills, one an episode of non-bloody emesis, "indigestion," decreased urine output, and back pain. She had completed a course of antibiotics and Prednisone as an outpatient earlier this month for presumed pneumonia. . In the OSH ED, she was found to have acute renal failure with a creatinine of 1.9 (baseline 0.6). A CXR showed a right lower lobe infiltrate. Given her recent hospitalization 1-month prior, she was started on atypical coverage with Azithromycin as well as HCAP PNA coverage with Vancomycin and Zosyn. Her previous hospital course was complicated by an episode of hypercarbic respiratory failure requiring intubation, and she was intubated on [**2-13**] prior to bronchoscopy. She underwent a fiber-optic bronchscopy on [**2-13**] which showed clear tenacious secretions in the left mainstem, persistent bronchomalacia of the left mainsten, a stenosis of right middle lobe oriface. Biopsies showed acute inflammation and revealed no malignancy. . The patient was extubated to BiPAP following her bronchoscopy. She had an asystolic event with CPR and ROSC on [**2-14**] thought to be due to mucous plugging, resulting in re-intubation ([**2117-2-14**]). Of note, the patient has had a similar event on a prior hospitalization. The etiology of this event was thought to be pulmonary in origin. . She also underwent CT abdominal imaging on [**2117-2-10**] given her back pain complaints on admission and known cardiovascular disease, which showed bilateral lower lobe infiltrates and a left adrenal adenoma without AAA. CT chest imaging showed no pulmonary embolism, no aortic dissection, but was notable for bilateral pleural effusions. There was high grade stenosis at the level of the SMA. . She was transferred to [**Hospital1 18**] on [**2117-2-17**] for involvement of interventional pulmonology given her bronchiomalacia and cardiology consult for her worsening mitral stenosis, and further work-up of of her renal failure. . On arrival to the MICU, the patient was intubated and sedated with Fentanyl and Versed. Patient has received intermittent IV Lasix dosing with adequate diuresis. A 2D-Echo demonstrated severe mitral annular calcification with mild stenosis and regurgitation, moderate to severe pulmonary HTN (PASP 58 mmHg) with a preserved LVEF of 55%. A bronchoscopy was performed on [**2117-2-18**] showing COPD, accessory cardiac bronchus, no focal stenosis. BAL showed 3+ PMNs, 1+ GPCs in pairs and clusters with commensal respiratory flora speciated. Her antibiotic coverage was focused to IV Vanc and she was maintained on Prednisone 40 mg PO daily. She was successfully extubated on [**2117-2-19**]. Cardiac biomakers revealed a mild Troponin leak with flat CK-MBs. She received Lasix 40 mg IV x 1 prior to transfer and has been -5.7L for length-of-stay fluid balance. Of note, has intermittent episodes of discomfort, anxiety and bronchospasm with a history of mucus plugging. Prior to transfer, she was weaned from high flow oxygen fask mask to 3-4L NC. . On transfer to the floor, the patient appears fatigued but comfortable and is speaking in short sentences. Past Medical History: PAST MEDICAL & SURGICAL HISTORY: 1. Chronic obstructive pulmonary disease (baseline on [**2-18**].5L NC with baseline saturations in the 90-93% range; has had episodes of hypercarbic and hypoxic respiratory failure requiring intubation in the past) - question of bronchomalacia 2. Moderate mitral stenosis (severe annular mitral valve calcification with LAE; last 2D-Echo [**2117-2-19**], MV gradient 8 mmHg, 1+ MR, functional MS) 3. Congestive heart failure with preserved EF (attributed to mitral stenosis, diastolic dysfunction) 4. Coronary artery disease (question of prior anterior and inferior MI) 5. Insulin-dependent diabetes mellitus (on Levemir and Novolog) 6. Irritable bowel syndrome 7. Hypertension 8. Hypercholesterolemia 9. Peripheral vascular disease (s/p aortofemoral bypass, [**2108**]) 10. s/p cholecystectomy [**16**]. s/p hysterectomy Social History: Patient lives at home with partner, independent in ADLs. Smoked 1-PPD for 30-years (30 pack-year) - quit in [**2114**]. Denies current tobacco or alcohol use; no recreational substance use. Family History: non-contributory Physical Exam: ADMISSION EXAMINATION: . Vitals: T:98.0F BP:121/54 P:77 R:13 O2: 93% on vent General: intubated, sedated, responsive to voice HEENT: Sclera anicteric, OG tube in place, Neck: supple, JVP not elevated, right subclavian CVL in place CV: Regular rate and rhythm, normal S1 + S2, [**2-22**] diastolic murmur, no rubs, gallops Lungs: Faint bibasilar crackles, no wheezes, rales, ronchi Abdomen: soft, obese, slightly distended, non-tender, bowel sounds present, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, slight nonpitting edema edema Neuro: sedated, reponsive to voice . DISCHARGE EXAMINATION: . VITALS: 97.5 97.5 118/60 63 20 94% 3L NC BG: 154-212 mg/dL I/Os: 1080 | 4375 (-3.2L/day, [**Location 10226**]12L) weight: 74.3 kg GENERAL: Appears in no acute distress. Alert and interactive. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. NECK: supple without lymphadenopathy. JVD just above clavicle at 90-degrees. CVS: Regular rate and rhythm, without murmurs, rubs or gallops. S1 and S2 normal. RESP: Decreased breath sounds bilaterally throughout with faint inspiratory crackles at bases. No wheezing, no rhonchi. Stable inspiratory effort. ABD: soft, non-tender, mildly distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. No CVA tenderness. EXTR: no cyanosis, clubbing; 1+ pitting edema to dorsal ankles, 2+ peripheral pulses NEURO: CN II-XII intact throughout. Alert and oriented x 3. Strength 4/5 bilaterally (limited by effort), sensation grossly intact. Gait deferred. Pertinent Results: ADMISSION LABS: . [**2117-2-17**] 10:25PM BLOOD WBC-6.1 RBC-3.73* Hgb-11.3* Hct-33.8* MCV-91 MCH-30.3 MCHC-33.5 RDW-14.6 Plt Ct-156 [**2117-2-17**] 10:25PM BLOOD PT-11.2 PTT-31.1 INR(PT)-1.0 [**2117-2-17**] 10:25PM BLOOD Glucose-260* UreaN-41* Creat-0.8 Na-143 K-4.7 Cl-108 HCO3-30 AnGap-10 [**2117-2-18**] 04:27AM BLOOD CK(CPK)-17* [**2117-2-17**] 10:25PM BLOOD CK-MB-1 cTropnT-0.04* proBNP-3293* [**2117-2-18**] 04:27AM BLOOD CK-MB-1 cTropnT-0.06* [**2117-2-18**] 08:02PM BLOOD cTropnT-0.04* [**2117-2-17**] 10:25PM BLOOD Calcium-8.6 Phos-4.0 Mg-2.3 [**2117-2-17**] 10:29PM BLOOD Type-ART pO2-74* pCO2-55* pH-7.39 calTCO2-35* Base XS-6 . DISCHARGE LABS: [**2117-2-22**] 05:40AM BLOOD WBC-9.0 RBC-3.95* Hgb-11.6* Hct-34.8* MCV-88 MCH-29.5 MCHC-33.4 RDW-14.8 Plt Ct-184 [**2117-2-18**] 04:27AM BLOOD PT-11.5 PTT-28.8 INR(PT)-1.1 [**2117-2-26**] 05:45AM BLOOD Glucose-92 UreaN-36* Creat-1.1 Na-143 K-3.8 Cl-96 HCO3-41* AnGap-10 [**2117-2-26**] 05:45AM BLOOD Calcium-10.0 Phos-5.0* Mg-2.0 . URINALYSIS: None . MICROBIOLOGY DATA: [**2117-2-17**] Blood culture - negative [**2117-2-17**] MRSA screen - negative [**2117-2-18**] Bronchoalveolar lavage - 3+ PMNs, 1+ GPC pairs, cluster, > 100K commensal respiratory flora [**2117-2-18**] Bronchial washings - negative for malignant cells . IMAGING: [**2117-2-19**] 2D-ECHO - The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF > 55%). The right ventricular cavity is moderately dilated with normal free wall contractility. Trace aortic regurgitation is seen. There is severe mitral annular calcification. There is mild functional mitral stenosis (mean gradient 7 mmHg) due to mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly underestimated.] There is moderate to severe pulmonary artery systolic hypertension. There is no pericardial effusion. Calcific mitral valve disease with mild stenosis and at least mild regurgitation. Mild symmetric LVH with normal global and regional systolic function. Dilated right ventricle with preserved systolic function. Moderate to severe pulmonary hypertension. . [**2117-2-19**] CHEST (PORTABLE AP) - In comparison with the study of [**2-18**], the monitoring and support devices are essentially unchanged. There is continued substantial enlargement of the cardiac silhouette with pulmonary edema and bilateral effusions with compressive atelectasis at the bases. An area of increased opacification that is more confluent in the mid-lung on the right could reflect atelectasis or pneumonia. Brief Hospital Course: 69F with a PMH significant for oxygen-dependent chronic obstructive pulmonary disease (2L NC at home), coronary artery disease, diastolic congestive heart failure, type 2 diabetes mellitus on insulin, and hypertension admitted to OSH with hypoxemic respiratory failure requiring intubation. She was transferred to [**Hospital1 18**] for concern for bronchomalacia requiring stenting. However, she improved with treatment for health care associated pneumonia, acute on chronic diastolic heart failure, and COPD, and did not require bronchial stenting. . #ACUTE HYPOXEMIC RESPIRATORY FAILURE/CHRONIC OBSTRUCTIVE PULMONARY DISEASE EXACERBATION/ACUTE-on-CHRONIC DIASTOLIC HEART FAILURE/PNEUMONIA: Patient was transferred from [**Last Name (un) 91880**] Hospital following intubation for respiratory failure and concern for bronchomalacia as significant contributor (bronch there showed clear tenacious secretions in the left mainstem, persistent bronchomalacia of the left mainsten, and stenosis of right middle lobe oriface - biopsies revealed no malignancy). At [**Hospital1 18**] she was continued on treatment for HCAP with Vancomycin and Zosyn was aggressively diuresed with improvement. She underwent bronchoscopy just prior to extubation which did not show stenosis and BAL fluid grew only commensal flora after abx. She was extubated and completed treatement with a course of Vancomycin for 14 days as well as started on a prednisone taper given likely exacerbation of COPD as a contributor to respiratory failure. She was discharged to continue a prolonged taper as recommended by her outpatient pulmonologist. She also endorsed increased lower extremity swelling and increased abdominal girth in the month leading up to hospitalization along with weight gain and it was felt that worsening diastolic heart failure was a significant contributor to her respiratory symptoms. A repeat 2D-Echo showed preserved EF with mild symmetric LVH and severe mitral annulus calcification but only mild mitral stenosis and 1+ MR and pulmonary HTN. She was diuresed aggressively to a weight of 74kg on discharge with improvement in her respiratory symptoms (although not completely back to her baseline respiratory function-on 3L O2 by NC instead of usual 2L). She was continued on her home BB/ACEI as well as COPD bronchodilators and inhaled steroid. She was discharged to follow up with her Cardiologist, PCP, [**Name10 (NameIs) **] Pulmonologist for f/u of her COPD, heart failure, and renal function and to assess the need for any changes to her diuretic and COPD regimen. . # CORONARY ARTERY DISEASE, HYPERLIPIDEMIA, Hypertension: Patient was continued on home aspirin, statin, Carvedilol, ACEI, long acting nitrate. . #Type 2 DIABETES MELLITUS ON INSULIN - The patient has known IDDM and her home glucose range is noted to be 60-180s mg/dL, per the patient. She is controlled with Levemir 72 units SC QHS and Novolog sliding scale prior to meals. She was treated with Lantus +SSI during admission and transitioned back to her home Levemir on discharge. . TRANSITION OF CARE ISSUES: 1. Consider outpatient evaluation of MR, MS, diastolic heart failure and CAD with Cardiology - no acute indications for balloon valvuloplasty at this time (prefers to see [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 91881**], MD) 2. Monitoring oxygen saturations. Patient will continue on home oxygen therapy with goal oxygen saturation of 88-93% on 2.5-3L of oxygen via nasal cannula 3. Pulmonary rehabilitation is recommeneded and a prescription was provided 4. Patient will continue on steroid taper, as follows: Take 30 mg by mouth for 3-days ([**2117-2-26**] to [**2117-2-28**]). Take 20 mg by mouth for 3-days ([**2117-3-1**] to [**2117-3-3**]). Take 10 mg thereafter until follow-up. 5. Patient will be discharged on low dose narcotic for pain control and Flexeril for muscle spasm given her lower back complaints. AVOID taking this medication if you anticipate driving, or while consuming alcohol. 6. Patient should have her electrolytes checked (sodium, potassium, chloride, bicarbonate, BUN, creatinine and magnesium) on Tuesday, [**3-2**] - to help in determining appropriate home diuretic regimen. These results should be faxed to her primary care physician's office. She was discharged on Lasix 80mg po BID to maintain goal weight of 74kg. 7. Please check daily weights. Her DRY WEIGHT is estimated at 74-kg. Please check daily weight and HOLD Lasix dose in the evening if her weight is dropping. 8. Please provide teaching regarding low sodium and cardiac healthy diet strategies. Medications on Admission: 1. Albuterol/ipratropium (Combivent) nebulizers Q4-6H PRN wheezing 2. Fluticasone-salmeterol 500-50 1 puff INH [**Hospital1 **] 3. Tiotropium 18 mcg INH daily 4. Ambien 10 mg PO QHS 5. Lisinopril 10 mg PO daily 6. Isosorbide 30 mg PO daily 7. Rosuvastatin 20 mg PO QHS 8. Carvedilol 6.25 mg PO BID 9. Lasix 60 mg PO daily 10. Aspirin 81 mg PO daily 11. Levemir 72 units SC QHS 12. Novolog 10-20 units pre-prandial with meals 13. Vitamin Co-Q10 1 tablet PO daily 14. Iron 198 mg PO daily 15. Magnesium 250 mg PO QHS 16. Vitamin C 17. Vitamin D-calcium supplement Discharge Medications: 1. Combivent 18-103 mcg/actuation Aerosol Sig: One (1) nebulizer Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation twice a day. 3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 4. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 7. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Levemir 100 unit/mL Solution Sig: Seventy Two (72) units Subcutaneous at bedtime. 11. Novolog 100 unit/mL Solution Sig: 10-20 units Subcutaneous TID with meals. 12. Co Q-10 Oral 13. iron Oral 14. magnesium 250 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. Vitamin C Oral 16. Calcium-Vitamin D Oral 17. prednisone 20 mg Tablet Sig: see taper Tablet PO once a day: Take 30 mg by mouth for 3-days ([**2117-2-26**] to [**2117-2-28**]). Take 20 mg by mouth for 3-days ([**2117-3-1**] to [**2117-3-3**]). Take 10 mg thereafter until follow-up. Disp:*6 Tablet(s)* Refills:*0* 18. prednisone 10 mg Tablet Sig: see taper Tablet PO once a day: Take 30 mg by mouth for 3-days ([**2117-2-26**] to [**2117-2-28**]). Take 20 mg by mouth for 3-days ([**2117-3-1**] to [**2117-3-3**]). Take 10 mg thereafter until follow-up. Disp:*30 Tablet(s)* Refills:*0* 19. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 20. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain: AVOID taking this medication if you anticipate driving, or while consuming alcohol. Disp:*25 Tablet(s)* Refills:*0* 21. Outpatient Physical Therapy Patient needs pulmonary rehabilitation given her chronic obstructive pulmonary disease. 22. Outpatient Lab Work Patient should have her electrolytes checked (sodium, potassium, chloride, bicarbonate, BUN, creatinine and magnesium) on Tuesday, [**3-2**] - while on aggressive diuretic therapy. These results should be faxed to her primary care physician's office. FAX NUMBER: [**Telephone/Fax (1) 91882**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3100**]) 23. Lasix 40 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Doctor Last Name **]-[**Last Name (un) 45902**] VNA Discharge Diagnosis: Primary Diagnoses: 1. Acute on chronic obstructive pulmonary disease exacerbation 2. Acute diastolic heart dysfunction . Secondary Diagnoses: 1. Moderate mitral stenosis 2. Mild mitral regurgitation 3. Coronary artery disease 4. Insulin-dependent diabetes mellitus (on Levemir and Novolog) 5. Hypertension 6. Hypercholesterolemia 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: Patient Discharge Instructions: . You were admitted to the Internal Medicine service at [**Hospital1 1535**] on CC7 regarding management of your acute respiratory issues. You were initially treated at [**Hospital6 7472**] and transferred to [**Hospital1 18**] with a breathing tube and requiring mechanical ventilation. The breathing tube was removed after aggressive diuresis and you were treated with steroids as well as antibiotics for pneumonia. You will be discharged with a steroid taper in discussion with Dr. [**Last Name (STitle) 91883**] [**Name (STitle) **], your outpatient pulmonologist. You improved and were able to wean back to your home oxygen requirement. Overall, your worsening clinical picture was likely related to an exacerbation in both respiratory and cardiac function. You will be discharged to a rehabilitation facility where you will improve your strength. . Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include: dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit, or have a bowel movement. * You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. * Your pain is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any other concerning symptoms. . CHANGES IN YOUR MEDICATION RECONCILIATION: . * Upon admission, we ADDED: START: Prednisone taper, as directed (Take 30 mg by mouth for 3-days ([**2117-2-26**] to [**2117-2-28**]). Take 20 mg by mouth for 3-days ([**2117-3-1**] to [**2117-3-3**]). Take 10 mg thereafter until follow-up) START: Cyclobenzaprine 10 mg by mouth at nighttime as needed for back spasm START: Oxycodone 5 mg by mouth every 4-6 hours as needed for severe pain . * Upon admission, we CHANGED: We CHANGED: Lasix from 60 mg by mouth daily to 80 mg by mouth twice daily (with dose adjustment based on any evidence of leg swelling, shortness of breath) . * The following medications were DISCONTINUED on admission and you should NOT resume: NONE . * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: Name: [**Last Name (LF) 91884**], [**Name8 (MD) **] NP Location: [**Hospital **] MEDICAL GROUP Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 91885**] Phone: [**Telephone/Fax (1) 91882**] Appointment: THURSDAY [**3-4**] AT 11:35AM ** Please call your insurance to update your PCP with them. Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3100**] should now be listed as your PCP. ** . With: [**Last Name (un) **], [**Name6 (MD) **] S MD Location: PIONEER VALLEY RESPIRATORY ASSOCIATES Address: [**Street Address(2) 91886**] [**Location (un) **], [**Numeric Identifier 91887**] Phone: [**Telephone/Fax (1) 91888**] Appointment: MONDAY [**3-8**] AT 11:30AM . Name: [**Last Name (LF) **], [**Name8 (MD) **] MD Location: [**Hospital1 **] CARDIOLOGY Address: [**Location (un) 91889**], 2ND FL STE A, [**Location (un) **],[**Numeric Identifier 91890**] Phone: [**Telephone/Fax (1) 91891**] Appointment: TUESDAY [**3-9**] AT 9AM

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Discharge summary

report+report

Admission Date: [**2128-7-13**] Discharge Date: [**2128-7-17**] Date of Birth: [**2103-8-15**] Sex: M Service: Medicine, [**Location (un) **] Firm HISTORY OF PRESENT ILLNESS: The patient is a 24-year-old gentleman with a history of migraine headaches who was found unresponsive on [**7-13**]. Four days prior to admission the patient developed cool and numb hands. He then developed fatigue and upper extremity weakness two days prior to admission. Also, roughly two days prior to admission, the patient had symptoms of photophobia, lightheadedness, and a headache at that time. On the day of admission, the patient went to bed at 5 a.m. and awoke at 1:30 p.m., e-mailed a friend, and went back to bed at 3:30 p.m. Shortly thereafter, his friend found him unresponsive to voice and called Emergency Medical Service. Other history revealed the patient is originally from [**State 622**]. He had travelled to [**Hospital3 **] three days prior to admission and had been staying with friends. The patient was admitted to the Medical Intensive Care Unit here and intubated for airway protection. He was also given some sedation, ceftriaxone, and acyclovir. Neurology Service and Infectious Disease Service were consulted. The patient was extubated roughly 18 hours later on [**7-14**]. PAST MEDICAL HISTORY: Other past medical history revealed the patient has a history of depression, migraine headaches, and a question history of obsessive-compulsive disorder. MEDICATIONS ON ADMISSION: His medications included Lexapro and Inderal. ALLERGIES: NKDA SOCIAL HISTORY: The patient is a college student at the [**State 51538**]. He gives no history of tobacco or alcohol. No recent sexual contacts. [**Name (NI) **] was born in [**Country 2559**] and moved to the United States at the age of eight. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination on admission the patient's temperature was 99.4 degrees Fahrenheit, heart rate was 81, and his blood pressure was 144/90. His pupils were equal, round, and reactive to light and accommodation. He had no lymphadenopathy. He had coarse breath sounds bilaterally. He was somewhat tachycardic. No murmurs were appreciated. His abdomen was soft and nontender. Bowel sounds were present. His extremities were warm and well perfused. There was no cyanosis, clubbing, or edema. His skin examination revealed he had no petechiae or rashes. PERTINENT LABORATORY VALUES ON PRESENTATION: His laboratory values were essentially unremarkable. His white blood cell count was 7.2, his hematocrit 47, and his platelets were 278. His creatinine was slightly elevated at 1.1. His liver function tests were normal. His fibrinogen was 250. His serum toxicology was negative. His urine toxicology was negative. A lumbar puncture was performed and showed 0 white blood cells, 3 red blood cells, a protein of 32, a glucose of 67. On Gram stain, there were no microorganisms or polymorphonuclear leukocytes. PERTINENT RADIOLOGY/IMAGING: His chest x-ray was unremarkable. His head computed tomography showed no lesions or bleeding. CONCISE SUMMARY OF HOSPITAL COURSE: The impression was for a possible meningeal encephalitis, possibly herpes encephalitis. A host of Infectious Disease studies were sent; including Lyme titers, West [**Doctor First Name **] antibodies, and Eastern equine studies. The patient was continued on acyclovir and ceftriaxone. The patient's mental status improved over the course of the next three days; going from [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale of 7 to being just slightly lethargic. He was responsive to individual voices and commands. He was fully interactive with Physical Therapy. The patient also had a magnetic resonance imaging early in the course of his admission which was also read as negative. Ultimately, all the patient's Infectious Disease workups came back negative; including herpes simplex virus PCR. Acyclovir was subsequently stopped. During the course of his admission, the patient had an electroencephalogram performed that was read as low voltage, suggestive of wide-spread encephalopathy. There were no areas of focal swelling, and no epileptiform activity was appreciated. Moreover, on hospital day three, more history was obtained from the patient suggestive of a bipolar disorder; including a history of racing of ideas and periods of writing stories in the middle of the night (writing up to 30 pages in one sitting). Psychiatry was consulted and felt that he did not have any acute psychiatric conditions. CONDITION AT DISCHARGE: The patient was discharged in stable condition with an alert mental status. CODE STATUS: Full code. DISCHARGE DIAGNOSIS: 1. Delirium, not otherwise specified. 2. history of depression 3. migraine headaches MEDICATIONS ON DISCHARGE: None. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up with a Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Friday, [**7-23**], at 10:15 a.m. DR [**First Name8 (NamePattern2) **] [**Doctor First Name **] 12.AHZ Dictated By:[**Name8 (MD) 51539**] MEDQUIST36 D: [**2128-8-12**] 12:17 T: [**2128-8-14**] 15:08 JOB#: [**Job Number 51540**] Admission Date: [**2128-7-13**] Discharge Date: [**2128-7-17**] Date of Birth: [**2103-8-15**] Sex: M Service: Medicine, [**Location (un) **] Firm HISTORY OF PRESENT ILLNESS: The patient is a 24-year-old gentleman with a history of migraine headaches who was found unresponsive on [**7-13**]. Four days prior to admission the patient developed cool and numb hands. He then developed fatigue and upper extremity weakness two days prior to admission. Also, roughly two days prior to admission, the patient had symptoms of photophobia, lightheadedness, and a headache at that time. On the day of admission, the patient went to bed at 5 a.m. and awoke at 1:30 p.m., e-mailed a friend, and went back to bed at 3:30 p.m. Shortly thereafter, his friend found him unresponsive to voice and called Emergency Medical Service. Other history revealed the patient is originally from [**State 622**]. He had travelled to [**Hospital3 **] three days prior to admission and had been staying with friends. The patient was admitted to the Medical Intensive Care Unit here and intubated for airway protection. He was also given some sedation, ceftriaxone, and acyclovir. Neurology Service and Infectious Disease Service were consulted. The patient was extubated roughly 18 hours later on [**7-14**]. PAST MEDICAL HISTORY: Other past medical history revealed the patient has a history of depression, migraine headaches, and a question history of obsessive-compulsive disorder. MEDICATIONS ON ADMISSION: His medications included Lexapro and Inderal. ALLERGIES: NKDA SOCIAL HISTORY: The patient is a college student at the [**State 51538**]. He gives no history of tobacco or alcohol. No recent sexual contacts. [**Name (NI) **] was born in [**Country 2559**] and moved to the United States at the age of eight. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination on admission the patient's temperature was 99.4 degrees Fahrenheit, heart rate was 81, and his blood pressure was 144/90. His pupils were equal, round, and reactive to light and accommodation. He had no lymphadenopathy. He had coarse breath sounds bilaterally. He was somewhat tachycardic. No murmurs were appreciated. His abdomen was soft and nontender. Bowel sounds were present. His extremities were warm and well perfused. There was no cyanosis, clubbing, or edema. His skin examination revealed he had no petechiae or rashes. PERTINENT LABORATORY VALUES ON PRESENTATION: His laboratory values were essentially unremarkable. His white blood cell count was 7.2, his hematocrit 47, and his platelets were 278. His creatinine was slightly elevated at 1.1. His liver function tests were normal. His fibrinogen was 250. His serum toxicology was negative. His urine toxicology was negative. A lumbar puncture was performed and showed 0 white blood cells, 3 red blood cells, a protein of 32, a glucose of 67. On Gram stain, there were no microorganisms or polymorphonuclear leukocytes. PERTINENT RADIOLOGY/IMAGING: His chest x-ray was unremarkable. His head computed tomography showed no lesions or bleeding. CONCISE SUMMARY OF HOSPITAL COURSE: The impression was for a possible meningeal encephalitis, possibly herpes encephalitis. A host of Infectious Disease studies were sent; including Lyme titers, West [**Doctor First Name **] antibodies, and Eastern equine studies. The patient was continued on acyclovir and ceftriaxone. The patient's mental status improved over the course of the next three days; going from [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale of 7 to being just slightly lethargic. He was responsive to individual voices and commands. He was fully interactive with Physical Therapy. The patient also had a magnetic resonance imaging early in the course of his admission which was also read as negative. Ultimately, all the patient's Infectious Disease workups came back negative; including herpes simplex virus PCR. Acyclovir was subsequently stopped. During the course of his admission, the patient had an electroencephalogram performed that was read as low voltage, suggestive of wide-spread encephalopathy. There were no areas of focal swelling, and no epileptiform activity was appreciated. Moreover, on hospital day three, more history was obtained from the patient suggestive of a bipolar disorder; including a history of racing of ideas and periods of writing stories in the middle of the night (writing up to 30 pages in one sitting). Psychiatry was consulted and felt that he did not have any acute psychiatric conditions. CONDITION AT DISCHARGE: The patient was discharged in stable condition with an alert mental status. CODE STATUS: Full code. DISCHARGE DIAGNOSIS: 1. Delirium, not otherwise specified. 2. history of depression 3. migraine headaches MEDICATIONS ON DISCHARGE: None. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up with a Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Friday, [**7-23**], at 10:15 a.m. DR [**First Name8 (NamePattern2) **] [**Doctor First Name **] 12.AHZ Dictated By:[**Name8 (MD) 51539**] MEDQUIST36 D: [**2128-8-12**] 12:17 T: [**2128-8-14**] 15:08 JOB#: [**Job Number 51541**]

[ "276.5", "346.90", "293.0", "276.3", "311" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10050, 10139

10166, 10173

6802, 6866

10207, 10569

8448, 9911

9926, 10029

5478, 6597

6620, 6775

6883, 8419

5,119

125,095

12119

Discharge summary

report

Admission Date: [**2188-3-25**] Discharge Date: [**2188-4-1**] Date of Birth: [**2111-4-14**] Sex: F Attending:[**Last Name (NamePattern4) 37996**] DIAGNOSIS: 1. Status post pyloric sparing Whipple procedure. HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 37997**] is a 76 year old woman who noted the onset of painless jaundice approximately at the beginning of [**2188-2-22**]. She underwent an endoscopic retrograde cholangiopancreatography which demonstrated 1 centimeter distal common bile duct stricture and a mass that was protruding into the lumen. At that time, she underwent a sphincterotomy and stent placement. She by Dr. [**Last Name (STitle) **] and presents to [**Hospital1 188**] for definitive treatment. PAST MEDICAL HISTORY: 1. Hypertension. 2. Osteoporosis status post compression fracture in 01/[**2188**]. PAST SURGICAL HISTORY: 1. Status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. 2. Status post appendectomy. MEDICATIONS ON ADMISSION: 1. Hydrochlorothiazide 25 mg p.o. q. day. 2. Diovan 80 mg p.o. q. day. ALLERGIES: Aspirin, shellfish which causes urticaria. SOCIAL HISTORY: One pack a year for 60 years. Husband died of pancreatic cancer nine years ago. Five children; lives alone. PHYSICAL EXAMINATION: The patient, on physical examination, had no neck lymphadenopathy, no carotid bruits. Lungs are clear to auscultation bilaterally. Heart was regular rate and rhythm with no murmurs, rubs or gallops. Abdomen showed normal bowel sounds, soft, nontender, no organomegaly. No peripheral edema, clubbing or cyanosis in extremities. Neurologic was intact. LABORATORY: On admission included a hematocrit of 37.4, white count of 9.9, platelets of 446, INR of 1.2, BUN of 17, creatinine of 0.8. ALT 693, AST 348, alkaline phosphatase 656, total bilirubin 12.8, amylase 235, lipase 1655, CEA 1869. CT scan showed dilatation of intrahepatic biliary tree and pancreatic duct. No lytic lesion. No evidence of metastatic disease. Pulmonary function tests showed an FVC of 2.26, which is 79% predicted, FEV1 of 1.45, which is 73% predicted. Echocardiography showed an ejection fraction of 55% with a mild tricuspid regurgitation and mitral regurgitation. EKG is normal sinus rhythm, no ischemia. HOSPITAL COURSE: On the day of admission, the patient went to the Operating Room where she underwent a pyloric sparing Whipple procedure and cholecystectomy. She tolerated the procedure well and received 10.5 liters of Crystalloid. She had 100 cc. of estimated blood loss. She was transferred to the Surgical Intensive Care Unit for postoperative recovery which occurred by the following systems: 1. Neurological: The patient had intraoperative epidural placed and on postoperative day number two, it was capped and removed. The patient was placed on a morphine PCA which treated her pain well. As she was advanced to a p.o. diet, she tolerated Oxycodone. The patient remained alert and oriented times three during her recovery. 2. Respiratory: The patient's saturations remained in the high-90s and the patient was weaned from O2. She has been using incentive spirometry and ambulates several times a day. She is stable. 3. Cardiovascular: The patient has remained hemodynamically with no tachycardia; blood pressures remained under good control. Her cardiovascular medications were held due to adequate cardiac status during her recovery. 4. Gastrointestinal: She remained n.p.o. with nasogastric tube for several days postoperatively. She started on total parenteral nutrition via central line on postoperative day number two. On postoperative day number four, she underwent an upper gastrointestinal study showing no leak and prompt stomach emptying through the anastomosis. Her diet was slowly advanced starting postoperative day number five and now tolerating a soft diet. Total parenteral nutrition was stopped. She has had flatus and bowel movement. 5. Genitourinary: Foley was discontinued on postoperative day number five. She voids without issue. 6. Infectious Disease: The patient received perioperative Unasyn times 24 hours. She has remained afebrile during her recovery. 7. Hematologic: The patient's hematocrit remained stable at 32. She has been on heparin and Venodyne for deep vein thrombosis prophylaxis. 8. Oncology: The patient received Oncology consultation. She decline chemotherapy at this time. 9. Tubes: The patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] draining serosanguinous fluid. [**Location (un) 1661**]-[**Location (un) 1662**] amylase was 17 and 19 on two separate occasions. [**Location (un) 1661**]-[**Location (un) 28048**] were discontinued on the day of discharge. 10. Pathology: Adenocarcinoma of the pancreas, well differentiated, one lymph node positive, no vascular invasion, positive perineural invasion; margin free of tumor. DISCHARGE DIAGNOSES: 1. Status post pyloric sparing Whipple with cholecystectomy. 2. Adenocarcinoma of the head of the pancreas. 3. Hypertension. 4. Osteoporosis. MEDICATIONS: 1. Hydrochlorothiazide 25 mg p.o. q. day. 2. Diovan 80 mg p.o. q. day. 3. Oxycodone 5 to 10 mg p.o. q. four hours p.r.n. 4. Protonix 40 mg p.o. q. day. 5. Zofran 4 mg intravenous q. six hours p.r.n. CONDITION ON DISCHARGE: Stable. DISPOSITION: The patient is discharged to rehabilitation and with follow-up by Dr. [**Last Name (STitle) 37998**]. She will see Dr. [**Last Name (STitle) **] in the office in one week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2188-5-16**] 10:09 T: [**2188-5-16**] 21:57 JOB#: [**Job Number 37999**]

[ "575.11", "157.0", "496", "577.1", "401.9", "263.9", "518.5", "305.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "51.22", "52.6" ]

icd9pcs

[ [ [] ] ]

5000, 5365

1020, 1151

2318, 4979

881, 994

1304, 2299

256, 749

771, 858

1169, 1280

5390, 5852

47,660

168,334

42866

Discharge summary

report

Admission Date: [**2144-2-7**] Discharge Date: [**2144-2-11**] Date of Birth: [**2065-2-17**] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5018**] Chief Complaint: Intracranial hemorrhage. Major Surgical or Invasive Procedure: None. History of Present Illness: [**Known firstname 4333**] [**Last Name (NamePattern1) 92570**] is a 79y/o woman with extensive medical history (includes DM2, HTN, HL, BrCa s/p bilateral masectomy, MVR-porcine and ?afib on warfarin and BB, ?anxiety, ?stroke on ASA; details unclear at this time). She is at this time intubated and unresponsive on a propofol drip. The available history is from the OSH notes at bedside. She was last known well to family or friends yesterday (Thursday). She was found down by a her son this morning when he visited her home after she did not answer the repeated phone calls. She was lying next to her bed, slumped against her nightstand, with an abrasion on her back and no obvious signs of head trauma. Based on her routine, he thinks that she had been awake already and that she probably fell around 9:30am because she already had her newspaper inside. He thinks it was a sudden problem because not only did she fail to answer the phone, but she did not even press the help button on her LifeResponse wristband. She was BIBA to the OSH around noon, where she was noted to be "alert but confused" with no spontaneous movements of the right side of her body. Her mental status declined and she was intubated (induced with ketamine and paralyzed with vecuronium). Her VS were remarkable for SBP ranging from 140s up to 178 (@12:30pm) with HR 110-143. RR 22 SaO2 96% on 4L. A NCHCT was performed and revealed a large (~4cm/irregular) hemorrhage originating in the Left basal ganglia with intraventricular extension. INR 1.5. She was transferred here on a propofol gtt. On arrival, her SBPs were in the 160s, but with increased propofol by nursing @NCHCT she has trended down to the 100s over 70s currently. She was noted to open eyes briefly and move all extremities spontaneously except for the Right leg. A NCHCT was obtained here, and showed enlarging temporal horns (L>r). INR 1.5 again. Neurosurgery was consulted and advised but did not pursue a goals-of-care discussion with the family (with anticipation of EVD placement for ICP management). and advised that Neurology be consulted as well. Her son on the phone mentioned that she had been falling and fainting or seizing often recently. The son thinks the falls were due to [**Name (NI) **] and had lessened after her Pulmonologist changed or stopped that medication. She bumped her head 2wks ago and had an MRI a few weeks ago; he thinks the MRI was "clean" w.r.t. stroke. He thinks she may have been having "mini-seizures," by which he means brief episodes of feeling "faint" in her chair during which she would say "OK, its doing it again," then appear shaky with eyes rolled back "like she is passing out" followed by full return to normal versus sometimes a confused state in which she thinks her husband is still alive or the room has changed colors. She is following with a Neurologist named Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1774**], who has not as far as the son knows started any AEDs. Review of Systems: unable (pt non-responsive). Past Medical History: 1. HTN (only on BB) 2. MVR (porcine, [**2128**]) on warfarin A/C 3. ?afib (in afib on arrival and on warfarin) 4. ?HL (on statin) 5. ?COPD (on Spireva recently) 6. DM2 (on metformin) 7. ?recent stroke (OSH) versus "mini-seizures" (son) with recent MRI, results unknown 8. ?CHF (pt on Lasix/KCl at home) 9. ?pain syndrome or neuropathy (pt on high-dose Lyrica at home) Social History: Lives alone. Contact is son: [**Name (NI) **] [**Name (NI) 92570**] -> (home) [**Telephone/Fax (1) 92571**] (cell) [**Telephone/Fax (1) 92572**] Has another son. Unknown [**Name2 (NI) **]/EtOH/illicits. Family History: Unknown. Physical Exam: ON ADMISSION: Vital signs: T: afeb per nsg P/HR: 100-130, irregular on monitor (presumed afib) BP: 108/7x - 117/75 (on my exam), up to 160s SBP on arrival RR: 20s-30s SaO2: 98% on vent General: Intubated, sedated with propofol gtt, which I stopped for exam. NAD. HEENT: ETT, OGT. Normocephalic and atraumatic. No scleral icterus. Mucous are moist. Hazy corneal spot at 7-o'clock overlying the [**Doctor First Name 2281**]. Neck: Supple, with full passive range of motion. No bruits. No lymphadenopathy. Pulmonary: Good air movement bilaterally with transmitted upper-airway sounds related to ETT/vent. No crackles or wheezes. Overbreathing into the 20s, non-labored, no retractions. Cardiac: Rapid, irregular, loud/sharp S2 loudest over apex. No loud murmur or rub. No S3. Abdomen: Soft, non-tender, and non-distended. Extremities: Cool, but well-perfused. No significant edema. Intact distal pulses bilaterally. ***************** Neurologic examination: off propofol for 10-15min. Mental Status: Does not open eyes to voice or sternal rub. Right eye hangs slightly open. Later opened eyes for just a few seconds. Reliably followed command to squeeze Left hand (not right hand). Intermittently followed command to open fingers of left hand (but not thumbs-up or anything else semi-complex). No blink to threat. Slight Leftward gaze deviation. Briely looked to the left on command, but not repeatable. but no tracking (including $20). -Cranial Nerves: II: PERRL, 3 to 2mm, brisk. No blink to threat in any direction. Cannot see fundi through her dense cataracts. III, IV, VI: Pt overrides dolls-eyes/OCR and does not move eyes or track, so unable to assess EOM beyond conjugate at slight left mid-position with no nystagmus. V: Corneals and nasopharyngeal brow-wrikle reflexes intact bilaterally, but much more pronounced on the Left than right. VII: Right eye hangs open a few mm and does not stay closed when I close it. Right face seems slack -- not evident in upper face (brow-furrow in response to noxious stimulation) except for slack eyelid closure on that side. Minimal resistence to eyelid opening. VIII: Hearing grossly intact (at one point follows command to squeeze and release fingers repeatedly). No Doll's eyes (?actively suppressed due to level of consciousness). IX, X: Strong gag to ETT tug. Strong cough to tracheal suction. Overbreathing vent (set 16, breathing 20-30). [**Doctor First Name 81**], XII: cannot assess. -Motor: Purposeful/spontaneous movements: Tone: RLE is flaccid and externally-rotated. Normal to slightly decreased tone in the UEs and LLE. No spasticity. Adventitious movements: none Withdrawal: triple-flexion type response, brisk #RLE; +/- @LLE. -Sensory: No withdrawal (except LE triple-flex) to noxious stimulation of extremities. -Reflexes (left; right): Biceps (++;++) Triceps (+;+) Brachioradialis (++;++) Quadriceps / patellar (+;++) Gastroc-soleus / achilles (0;0) Plantar response was briskly EXtensor bilaterally (Rt > lt). -Coordination/Gait: cannot assess . ON DISCHARGE: Vitals: on the patient's respiratory rate was being monitored @ 18-24. Patient was awake, makes eye contact, but is non-verbal. She squeezes hand on left, unclear to command or reflex. No movement on right side. Pertinent Results: ON ADMISSION LABS: [**2144-2-7**] 05:05PM BLOOD WBC-9.9 RBC-4.46 Hgb-10.4* Hct-31.4* MCV-70* MCH-23.2* MCHC-33.0 RDW-17.5* Plt Ct-161 [**2144-2-7**] 05:05PM BLOOD Neuts-89* Bands-0 Lymphs-6* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-2* [**2144-2-7**] 05:05PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-3+ Polychr-NORMAL Ovalocy-OCCASIONAL Target-OCCASIONAL Burr-OCCASIONAL [**2144-2-7**] 05:05PM BLOOD PT-15.5* PTT-35.7 INR(PT)-1.5* [**2144-2-7**] 05:05PM BLOOD UreaN-39* Creat-1.3* [**2144-2-7**] 05:05PM BLOOD ALT-18 AST-37 AlkPhos-74 TotBili-0.9 [**2144-2-7**] 05:05PM BLOOD cTropnT-<0.01 [**2144-2-7**] 05:05PM BLOOD Albumin-3.9 Calcium-8.8 Mg-2.4 [**2144-2-7**] 05:05PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2144-2-7**] 06:13PM BLOOD Type-ART Rates-/24 Tidal V-400 PEEP-5 FiO2-50 pO2-97 pCO2-38 pH-7.38 calTCO2-23 Base XS--1 -ASSIST/CON Intubat-INTUBATED [**2144-2-7**] 05:19PM BLOOD Glucose-323* Na-147* K-4.0 Cl-111* calHCO3-24 . PERTINENT IMAGING STUDIES: [**2144-2-7**] CXR FINDINGS: Single AP semi-erect portable view of the chest was obtained. Endotracheal tube is seen, terminating approximately 2.6 cm above level of the carina. Nasogastric tube is seen, coursing below the level of the diaphragm, to the expected location of the stomach, although the inferior aspect is not fully included on the image. Three rounded radiopaque structures are again seen projecting over the left cardiac silhouette. There is minimal left base streaky retrocardiac opacity, most likely relates to atelectasis, although underlying aspiration would not be excluded. No large focal consolidation is seen. There is no pleural effusion or pneumothorax. The cardiac silhouette remains mildly enlarged. The aorta is calcified. . [**2144-2-7**] CT HEAD W/O CONTRAST IMPRESSION: Large left basal ganglia intraparenchymal hemorrhage with extension into the lateral ventricles, third ventricle and fourth ventricle with mild hydrocephalus. . [**2144-2-8**] CT HEAD W/O CONTRAST IMPRESSION: 1. Left basal ganglia hemorrhage measuring approximately 3.5 x 3.4 cm, with intraventricular extension, stable since the prior study. 2. Stable mass effect on the left lateral ventricle and third ventricle, with 3-mm rightward shift of midline structures. The basal cisterns are patent. . ON DISCHARGE LABS: No labs were drawn after patient made DNR/DNI, CMO. Brief Hospital Course: On arrival the patient was found to have a large left basal ganglia bleed with extension into the lateral 3rd and 4th ventricles. She was seen by neurology and neurosurgery in the emergency department and extensive family discussions were held about prognosis. She underwent a repeat CT HEAD which was unchanged. Due to the minimal chance of resuming independent living in the future, the family opted to change the patient's code status to DNR/DNI with comfort measures only. She was successfully extubated on [**2144-2-8**], and has remained comfortable on minimal medication. She will be transferred to an extended care facility for hospice care. Medications on Admission: 1. warfarin 5mg 2. simvastatin 25mg 3. aspirin 81mg 4. Lasix 40mg PO daily 5. KCl 10mEq PO daily 6. metformin 500mg [**Hospital1 **] 7. metoprolol succinate 50mg daily 8. pregabalin (Lyrica) [**Hospital1 **] 225mg / 250mg 9. multivitamin 10. [**Hospital1 **] 25mcg inh cap daily (son says this was stopped due to falls) Discharge Medications: 1. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: One (1) dose PO Q2H (every 2 hours) as needed for pain, discomfort, breathlessness: Titrate to effect. Dosing may be 2.5-10mg. Disp:*qs * Refills:*0* 2. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1) tablet Sublingual QID (4 times a day) as needed for secretions. 3. acetaminophen 650 mg Suppository Sig: One (1) suppository Rectal Q4H (every 4 hours) as needed for fever or restlessness. 4. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q6H (every 6 hours) as needed for agitation: [**Month (only) 116**] give 2.5mg if 5mg is too large a dose. Discharge Disposition: Extended Care Facility: [**Location (un) 6598**] Manor Extended Care Facility - [**Location (un) 6598**] Discharge Diagnosis: Intracranial hemorrhage. Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You presented to our hospital with a large bleed in the left side of your brain. The bleed was caused by high blood pressure. It is likely that no matter what intervention is taken your bleed will cause obstructive hydrocephalus or fluid on the brain due to this large burden of blood. In order to respect your wishes, your family has changed your code status to do not resuscitate/do not intubate as well as asking for medical orders that will maintain your comfort and peace at an extended care facility. Followup Instructions: None. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2144-2-10**]

[ "401.9", "V45.71", "V49.86", "331.4", "356.9", "496", "427.31", "250.00", "431", "V10.3", "V42.2", "272.4", "300.00", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

11429, 11536

9729, 10380

329, 337

11605, 11605

7323, 7326

12272, 12424

4033, 4044

10750, 11406

11557, 11584

10406, 10727

11741, 12249

9653, 9706

5514, 7077

4059, 4059

7091, 7304

3374, 3403

265, 291

365, 3355

7342, 8317

4073, 4992

11620, 11717

5016, 5044

3425, 3795

3811, 4017

8334, 9637

28,264

193,004

34364

Discharge summary

report

Admission Date: [**2122-9-6**] Discharge Date: [**2122-9-9**] Date of Birth: [**2063-11-5**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 492**] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: 1. Tracheal Y-stent revision History of Present Illness: 58 year old female with multiple pulmonary morbidities, s/p tracheostome and Y stent now presents with inability to wean from the ventilator here for repositioning of stent and debridement of granuloma. Past Medical History: Tracheobronchomalacia COPD OSA Pulmonary HTN systemic HTN Chronic renal insufficiency ischemic bowel s/p colectomy Depression Social History: 30 pack year former smoker married, lives with family Family History: non contributory Physical Exam: GENERAL NAD AAO HEENT [x] tracheostomy c/d/i RESPIRATORY Rhonchi b/l increased peripherally compared to centrally. CARDIOVASCULAR RRR, No M/R/G GI Moderatlye distended, NT/ ND. Urostomy tube in LLQ. Bandage over oven wound site lateral to the umbilicus on the Left side wound without erythema or induration but with brown feculent material expressed cetrally from what seems to be mucosa. G tube in place, no leakage around tube. SKIN Grade III coxccygeal ulcer between gluteal folds 2 cm diater 2-3 cm deep to place of the skin. GU: presumed LLQ urostomy tube. MSK: No cyanosis, No edema, RLE calf 1 cm greater in diameter than LLE calf. PSYCHIATRIC Limited exam given trach, intubation. Normal eye contact, responsive to questions. Apporpropriate demeanor. Brief Hospital Course: 58F c respiratory failure, severe tracheobronchomalacia who underwent tracheal Y-stent revision, multiple bronchoscopy, granulation tissue debridement. On continued ventilator support. Deemed fit to return to vented rehab for now. Medications on Admission: Fentanyl 25 mcg/hr Patch Q72H, Docusate Sodium 50 mg/5 mL PO BID, Insulin Regular Human 100 unit/mL, Metoprolol 25 mg PO BID, Miconazole 2 % Powder DAILY, Venlafaxine 37.5mg PGT DAILY, Albuterol 2.5 mg /3 mL Neb Q6H prn wheeze, Acetaminophen 160 mg/5 mL Solution PO Q6H prn, Ipratropium-Albuterol 18-103 mcg 2puff Q6H, Trazodone 50 mg PO HS prn, Heparin 5,000U TID, Chlorhexidine Gluconate 0.12% Mouthwash 15mL [**Hospital1 **], Ranitidine HCl 15 mg/mL 150mg PO HS, Furosemide 20 mg PO BID, Metoclopramide 10 mg IV Q6H, Pantoprazole 40 mg SR PO BID Discharge Medications: 1. Morphine Sulfate 2-4 mg IV Q4H:PRN pain hold for rr<10 2. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Mid-line, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 3. Metoclopramide 10 mg IV Q6H 4. Ondansetron 4 mg IV Q8H:PRN nausea 5. Lorazepam 1 mg IV Q4H:PRN anxiety 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation QID (4 times a day). Disp:*qs * Refills:*2* 7. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). Disp:*qs * Refills:*2* 8. Insulin Lispro 100 unit/mL Solution Sig: As directed [**1-4**] Subcutaneous ASDIR (AS DIRECTED). Disp:*qs [**1-4**]* Refills:*2* 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for groin creases. Disp:*qs * Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:*qs Tablet(s)* Refills:*0* 12. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*qs Tablet(s)* Refills:*2* 13. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). Disp:*qs Capsule, Sust. Release 24 hr(s)* Refills:*2* 14. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 15. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*qs Tablet(s)* Refills:*2* 16. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*2* 17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). Disp:*90 ml* Refills:*2* 19. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:*qs * Refills:*2* 20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*qs Tablet(s)* Refills:*0* 21. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). Disp:*60 ML(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: 1. Respiratory failure 2. Tracheobronchomalacia Discharge Condition: Stable Discharge Instructions: 1. Call office or go to ER if fever/chills, chest pain, increasing shortness of breath, abdominal pain or distention. 2. Resume medications and treatments as directed. 3. Follow up with Interventional Pulmonology as needed. Followup Instructions: Follow up with Interventional Pulmonology as needed. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]

[ "707.03", "V55.0", "416.8", "518.83", "327.23", "585.9", "E879.8", "519.19", "401.9", "V44.2", "996.79", "428.0" ]

icd9cm

[ [ [] ] ]

[ "97.23", "33.78", "96.6", "32.01", "33.24", "96.71", "96.05" ]

icd9pcs

[ [ [] ] ]

4754, 4829

1674, 1908

338, 369

4921, 4930

5202, 5370

840, 858

2507, 4731

4850, 4900

1934, 2484

4954, 5179

873, 1651

279, 300

397, 602

624, 752

768, 824

80,927

196,675

36742

Discharge summary

report

Admission Date: [**2155-6-17**] Discharge Date: [**2155-6-23**] Date of Birth: [**2098-11-22**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 5893**] Chief Complaint: mental status changes/hypotension Major Surgical or Invasive Procedure: continuous renal replacement therapy History of Present Illness: 56-year-old male who was diagnosed with follicular lymphoma transitioning to a marginal zone lymphoma in [**1-/2154**] who is admitted from the ED with mental status changes. . The patient was admitted from [**2155-3-26**] to [**2155-6-10**] initially for autologous BMT. Post-transplant course was complicated by mucositis, diarrhea, febrile neutropenia, and transient hyperuricemia that responded to 1 dose of allopurinol. On [**2155-4-11**], the patient was transferred to the ICU for respiratory distress, altered mental status, renal failure, and transaminitis secondary to [**Last Name (un) **]-occlusive disease. He was subsequently intubated and remained so for 3 weeks secondary to restrictive physiology and impaired mental status. He subsequently had a tracheostomy and was weaned to a trach mask which coincided with improvement in his mental status. He was additionally significantly hypotensive throughout his ICU stay with BPs in the 70 systolic. This was intially thought to be sepsis related versus splanchnic vasodilation versus hypovolemia. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test was normal. He was initiated on levophed and had a prolonged course due to persistent hypotension. He was also on vasopressin for a period of time. His pressors were weaned down and his pressor requirement and perfusion was determined based on mental status. He was placed on midodrine and florinef for orthostasis and autonomic dysfunction which was thought to be a result of deconditioning. He also had a persistent leukocytosis with intermittent fevers. Paracentesis all negative for sbp. He did later have one positive pseudomonas sputum culture. He was subsequently started on broad spectrum antibiotics including Ceftaz, vanc, flagyl and levaquin. His CVVH catheter tip did grow pseudomonas as well; however, he did not have any positive blood cultures. His improved but persistent leukocytosis was thought to be in part a result of autosplenectomy that occurred during the previous admission. In terms of his VOD, this was diagnosed by liver biopsy. He did have worsening MS, INR elevation suggestive of liver failure. He was started on defibrotide protocol for his VOD; however, this was discontinued after an MRI demonstrated an unexpected subarachnoid hemorrhage. Renal failure also occured during this admission thought to be consistent with ischemic ATN. He required CVVH throughout admission and was able to tolerate HD without UF prior to discharge. . He was discharged to [**Hospital1 **] on [**2155-6-10**] and per report, was tolerating HD and doing well until the day prior to admission. Per his wife, he in fact was able to tolerate 0.5L of fluid removal on this past Saturday. Last pm, he was found to have altered MS [**First Name (Titles) **] [**Last Name (Titles) **]. Though the timing is unclear, it appears his HD catheter was dislodged at the nursing home some time during the day and he had planned to come in to [**Hospital 1281**] Hospital for manipulation the next day. Per his wife who spoke with him on the phone, he was not aware of where he was or what was going on. He was taken to [**Hospital 1281**] Hospital where a 2.5 L paracentesis was performed with a SAAG <1.1. He apparently had his HD catheter dislodged and required replacement tunneled line placement as well. His wife noted that he was not responsive to her or commands while at [**Hospital1 1281**]. He received stress dose steroids there as well and had a low grade temperature of 99. His blood pressures were 91-108 systolic. He was subsequently transferred to the [**Hospital1 18**] ED for further management. . In the ED, initial vs were: T P BP R O2 sat. Patient was given...He was apparently minimally responsive, with eyes open, but not aware of his surroundings and not talking. Per report, the patient's wife clearly stated he was DNR/I and did not want any further lines placed, nor did she want him to be restarted on the ventilator. . On the floor, the patient is awake and alert. He is able to mouth [**Hospital1 **] when asked where he is, though I am unable to interpret other attempts at speaking. He is able to follow commands and moves all extremities. He appears to deny pain. His wife is clear that she does not want aggressive resuscitation, and after discussion with the patient, he is adamant that he would not want to be put back on the ventilator. Past Medical History: -Follicular lymphoma transitioning to a marginal zone lymphoma in [**1-/2154**] (These cells were CD19 and CD20 positive and also co-expressed CD5 and CD10. They were also kappa light chain restricted. There was no expression of CD-23 or cyclin D1. Ki67 was 20-30%.). He received R-CVP x 3 cycles (vincristine discontinued 2.2 neuropathy), then continued on 2 additional cycles of RCVP; neupogen after each cycle of chemotherapy; then 4 cycles of R-Bendamustine; susbequently had mobilization HiDAC [**1-8**] followed by stem cell harvesting and transplant -Right thigh lymphedema (significantly improved, per patient) -RLE DVT from compression (was on coumadin until [**2154-11-25**]) -Mild diverticulitis -s/p vasectomy, tonsillectomy Social History: Currently living at LTAC. Worked in a management position at a metal fabrication plant overseeing production and quality control. He is married and has four children. He and his family live in Hooksett, [**Location (un) 3844**]. No current tobacco use. He previously smoked but quit 15 years ago after a 20-pack-year history. He drank several martinis a day but has decreased his drinking while on treatment. Family History: Father - died at 80, lung cancer, Charcot-[**Doctor Last Name **]-Tooth disease, pulmonary embolism Mother - alive at 80, diabetes and asthma Three brothers - all in good health No family history of leukemia or lymphoma; has 2 children from previous marriage and 2 children from his current marriage Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: [**2155-6-17**] 01:50PM BLOOD WBC-18.6* RBC-2.68* Hgb-9.3* Hct-30.6* MCV-114* MCH-34.8* MCHC-30.5* RDW-20.9* Plt Ct-70*# [**2155-6-17**] 01:50PM BLOOD Neuts-91* Bands-0 Lymphs-3* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-1* [**2155-6-17**] 01:50PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+ Macrocy-3+ Microcy-OCCASIONAL Polychr-OCCASIONAL Spheroc-OCCASIONAL Target-OCCASIONAL [**2155-6-17**] 01:50PM BLOOD PT-12.2 PTT-27.5 INR(PT)-1.0 [**2155-6-17**] 01:50PM BLOOD Glucose-106* UreaN-77* Creat-5.3* Na-135 K-4.8 Cl-93* HCO3-26 AnGap-21* [**2155-6-17**] 01:50PM BLOOD ALT-28 AST-34 LD(LDH)-209 AlkPhos-260* TotBili-2.9* [**2155-6-17**] 01:50PM BLOOD Lipase-46 [**2155-6-17**] 01:50PM BLOOD TotProt-4.3* Albumin-2.6* Globuln-1.7* Calcium-8.9 Phos-6.5*# Mg-2.2 [**2155-6-17**] 08:32PM BLOOD Type-ART Temp-37.3 pH-7.41 Comment-GREEN-TOP [**2155-6-17**] 11:02PM BLOOD Type-ART Temp-37.3 Rates-/30 FiO2-50 pO2-64* pCO2-36 pH-7.46* calTCO2-26 Base XS-1 Intubat-NOT INTUBA [**2155-6-17**] 01:55PM BLOOD Lactate-1.8 [**2155-6-17**] 08:32PM BLOOD freeCa-1.02* MICRO: [**Date range (1) 83069**] BCx: negative [**6-19**] BCx: pending [**6-18**] Sputum Cx: negative STUDIES: [**6-17**] ECG: Sinus tachycardia. Diffuse ST-T wave abnormalities are non-specific. Since the previous tracing of [**2155-6-1**] sinus tachycardic rate is slower and further ST-T wave changes are present. [**6-17**] CXR: Worsening large bilateral pleural effusions with layering on the right. [**6-18**] TTE: The left ventricle is not well seen. Right ventricular chamber size and free wall motion are normal. Compared with the prior study (images reviewed) of [**2155-5-23**], image quality is extremely poor on the current study. Only the sub-costal window was available. Comparison cannot be made [**6-18**] CXR: Very large bilateral pleural effusions obscure the lungs, unchanged since [**6-17**]. Cardiac silhouette also obscured. ET tube and a nasogastric feeding tube are in standard placements and a right PIC line ends in the SVC. Dr. [**Last Name (STitle) 34732**] and I discussed these findings by telephone. [**6-19**] ECG: Sinus tachycardia at a rate of 117. There is slight ST segment depression in leads I, II, aVL and V2-V6. Compared to the previous tracing of [**2155-6-17**] the changes are similar but somewhat more prominent to those seen at that time. No other diagnostic interval change. Brief Hospital Course: 56 year old man with past medical history of follicular lymphoma status post-BMT complicated by VOD, respiratory failure, renal failure on HD, and hypotension as well as pseudomonas pneumonia with positive culture tip last admission who is admitted with altered mental status and dyspnea. His mental status changes were thought to possibly be secondary to being underdialyzed while at his facility. He was placed on continuous renal replacement therapy, although it was difficult to remove fluid given his tenuous hemodynamics, and he required vasopressors to maintain an adequate blood pressure. He had bursts of tachycardia to ~200 bpm, and he was given PRN doses of lopressor. His pressors were also changed to reduce beta-adrenergic stimulation. The patient clearly stated that he did not want to remain on hemodialysis, and that he did not want to be placed on the mechanical ventilator again. The patient's family was called and his wife and children came to visit him and say good-bye. His pressors were turned off on [**6-22**], and the patient's care was transitioned towards comfort. He was given lorazepam, morphine, and scopolamine patch. He passed away in the evening of [**6-23**]. Medications on Admission: Medications at NH: Acyclovir 400 mg daily Atovaquone 1500 mg daily Fludrocortisone 0.1 mg daily Insulin SS, Regular Combivent neb prn Ativan 0.5 mg Q4H prn Riatlin 5 mg daily Midodrine 15 mg Q8H Nepro 50 ml/HR Ursodiol 600 mg nightly, 300 mg QAM 100 mL water flushes Q8H Artifical tears Ambien 5 mg nightly prn Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: -End stage renal disease -Hypotension -Follicular lymphoma transitioning to a marginal zone lymphoma s/p stem cell transplant -[**Last Name (un) **]-occlusive disease -Right thigh lymphedema -Right lower extremity DVT from compression -Diverticulitis -s/p vasectomy, tonsillectomy Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "458.9", "584.9", "403.91", "V42.81", "518.83", "585.6", "789.59", "V12.51", "202.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10838, 10847

9248, 10445

307, 345

11171, 11180

6823, 6823

11236, 11246

6020, 6321

10806, 10815

10868, 11150

10471, 10783

11204, 11213

6336, 6804

234, 269

373, 4816

6839, 9225

4838, 5577

5593, 6004

40,191

194,674

50005

Discharge summary

report

Admission Date: [**2118-5-23**] Discharge Date: [**2118-5-27**] Date of Birth: [**2045-4-12**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2186**] Chief Complaint: Suicidal Ideation Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy Colonoscopy History of Present Illness: Ms. [**Known lastname 104405**] is a 73F with bipolar, afib on warfarin, DVT, CRI who presents with worsening depression. She was just recently admitted to [**Hospital1 2025**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Point for a total of 2 months. She can't say exactly why she was admitted, other than she "just wasn't right" and was "yelling." Since coming home, she has felt overwhelmed by a large stack of mail and bills. She tried to reach her psychiatrist and felt disappointed that she was unable to do so. She just "wanted to die" and planned to do this by refusing her medical treatments. She also tried to find out if a "medically assisted death" was possible for her. She says that she did not overdose on any medications. She denies any racing thoughts. Over the last few days she has noticed loose, dark stools at home without any frank BRBPR. She apparently had a similar episode 1.5 weeks prior to presentation. She has not had bleeding anywhere else. She had a colonoscopy last in [**2115**] at [**Hospital3 **] and has history of colonic adenomas. She denies any prior EGD. No NSAID use, EtOH, liver disease. She hasn't felt dizzy at home, no abdominal pains, n/v, no CP or SOB. No new medications. In the ED, initial vs were 97.2 70 193/118 20 100. EKG showed V paced rhythm. Patient c/o of loose stools and found heme+ dark stool on rectal. NG lavage with coffee grounds per the ER. Admit labs with Hct 33 (at baseline), INR 7, Cr 4.1 at her baseline, negative tox screens. Patient was given 10mg of vitamin K, 1L of saline. Protonix ordered. Seen by psychiatry. Access PIV 18g x2. Vitals 97.8 70 114/77 20 98% on RA On evaluation in the MICU, she denies any SI. She wants to get some sleep and more help at home. Past Medical History: * Bipolar - psych is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 98837**] @[**Hospital1 2025**] * Hypothyroid * Hyperparathyroid s/p parathyroidectomy * CRI -- baseline 4.2, [**2117-7-9**] at [**Hospital3 **] * Atrial fibrillation s/p ablation, on warfarin * Sick sinus syndrome s/p pacer * Hyperlipidemia * Tremor * Diverticulosis * Colon polyps, h/o tubular adenomas [**2115**] * DVT? * Glaucoma Social History: The patient is a retired secretary. She lives alone at home. She has a remote history of smoking and denies any Etoh use. She has one brother who lives in southern MA who she does not see often. She also has an adopted daughter that she speaks of. She enjoys painting watercolors. She has a home health aid once a week and elder services. She says that her nurse prepares her pillbox and admits that she may confuse her pills. Home services through Nizhoni. Family History: No history of bleeding or GI disorders that patient can remember. Physical Exam: (Per Admitting Resident) Vitals 98 70 140/78 20 98% on RA General Pale elderly woman appears comfortable in bed HEENT Anicteric, pale conjunctiva, edentulous, MMM Neck no JVD Pulm lungs clear bilaterally, no rales CV regular S1 S2 no m/r/g Abd soft obese +bowel sounds nontender Guiac heme+ in the ER Extrem warm palpable pulses no edema Neuro alert, at times tangential. roving motions of tongue. CN [**3-18**] otherwise intact, strength and sensation to light touch are preserved in bilateral upper and lower extremities. Pertinent Results: Admission Labs [**2118-5-23**] 06:10PM BLOOD WBC-6.0 RBC-3.61* Hgb-11.1* Hct-33.3* MCV-92 MCH-30.8 MCHC-33.4 RDW-15.4 Plt Ct-178 [**2118-5-23**] 06:10PM BLOOD Neuts-71.3* Lymphs-19.2 Monos-7.1 Eos-2.3 Baso-0.2 [**2118-5-23**] 06:43PM BLOOD PT-61.5* PTT-37.0* INR(PT)-7.0* [**2118-5-23**] 06:10PM BLOOD Glucose-110* UreaN-72* Creat-4.1* Na-137 K-4.1 Cl-100 HCO3-23 AnGap-18 [**2118-5-23**] 06:10PM BLOOD ALT-14 AST-17 LD(LDH)-286* AlkPhos-50 TotBili-0.1 [**2118-5-23**] 06:10PM BLOOD Lipase-119* GGT-18 [**2118-5-23**] 06:10PM BLOOD Calcium-9.9 Phos-5.2* Mg-2.3 Iron-71 [**2118-5-23**] 06:10PM BLOOD calTIBC-342 VitB12-675 Ferritn-95 TRF-263 [**2118-5-24**] 06:59AM BLOOD Ammonia-27 [**2118-5-23**] 06:10PM BLOOD TSH-1.9 [**2118-5-23**] 08:27PM BLOOD Lithium-LESS THAN [**2118-5-23**] 06:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2118-5-23**] 08:29PM BLOOD Lactate-1.6 Discharge Labs [**2118-5-27**] 06:33AM BLOOD WBC-5.6 RBC-2.82* Hgb-8.7* Hct-25.8* MCV-91 MCH-30.7 MCHC-33.5 RDW-15.3 Plt Ct-121* [**2118-5-27**] 11:30AM BLOOD Hct-28.5* [**2118-5-27**] 06:33AM BLOOD PT-14.6* PTT-27.7 INR(PT)-1.3* [**2118-5-27**] 06:33AM BLOOD Glucose-76 UreaN-47* Creat-3.9* Na-141 K-3.8 Cl-106 HCO3-25 AnGap-14 [**2118-5-27**] 06:33AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1 CDiff - Negative. ECG - Atrial flutter with ventricular paced rhythm. Since the previous tracing of [**2099-5-24**] findings as outlined are now present. Gastrointestinal Biopsies - Pathology pending and needs to be followed up. Renal Ultrasound - PRELIM READ: no hyrdonephrosis, simple cysts in the kidneys, large amount of fluid in bladder (~1L) ***Final read needs to be followed up. Brief Hospital Course: Ms. [**Known lastname 104405**] is a 73 year old woman with bipolar disorder, CRI, atrial fibrillation on warfarin who presents with worsening depression and is incidentally found to have heme positive stools with a stable hematocrit on ER evaluation. * Heme positive stools: In the ED patient was found to be guiac positive and was also found to have coffee grounds on NG lavage. No evidence of active bleeding was seen on lavage. Patient's Hct dropped somewhat after receiving fluids, but remained stable and near her baseline throughout the duration of her hospitalization. Hct was checked [**Hospital1 **] prior to EGD. Patient was also monitored initially on telemetry due to risk of possible GI bleed. EGD showed mild gastritis and duodenal polyp. Colonoscopy positive for mild diverticulosis and sigmoid polyp. Final pathology results were still pending and will need to be followed up after discharge. At time of discharge guiac was negative. Patient had an EGD and colonoscopy performed on [**5-25**] which showed no signs of active bleeding. Patient was given GI follow-up at the time of discharge. #Urinary retention: During her hospitalization patient had episodes of urinary incontinence as well as urinary retention. She was straight cath'ed multiple times. Per patient, she has problems with overflow incontinence at baseline and uses diapers and pads. During her stay, we discontinued amitryptyline due to risk of contributing to her retention. While in the hospital the patient also had a renal ultrasound performed which showed no hydronephrosis but did show a large amount of urine (~1L) in the bladder. Of note, after returning from this ultrasound, pt was able to void approx 900 cc of urine on her own. * Bipolar/depression: On presentation patient reported suicidal ideation. Patient was seen by psychiatry in the ED and recommended a 1:1 sitter due to SI. In the ED, all tox screens were found to be negative. After transfer from MICU to medicine floor, psych felt that patient was no longer suicidal so sitter was DCed. Pt was continued on home sertraline and amytriptyline as well as home qutiapine, both standing and PRN for anxiety and sleep. Patient initially received ativan for anxiety, but this was DCed due to increased confusion and lethargy s/p medication. Per psych recs haldol and trazodone were stopped. Patient continued to to deny suicidal ideation and stated that her mood was improved throughout the duration of her hospitalization. Social work, PT and occupational therapy evaluated patient during her stay. Per psych recommendations patient will be dishcarged to a geriatric psych facility in order to better dose her medications to prevent lethargy and confusion. Prior to discharge, amitryptiline was d/c'ed out of concern that it was contributing to her urinary retention. At discharge, pt was given a follow-up appointment for outpatient neuropsychiatric testing, given her cognitive dysfunction. * Coagulopathy: When patient was admitted to the hospital her INR was 7.1. Patient denied having purposefully taken extra warfarin at home, but states that she does sometimes get confused with her medication doses. Pt. was given vitamin K in the ED, and FFP in MICU and warfarin was held. Overnight her INR fell from 7.1 to 1.4. At time of discharge INR is 1.3. Warfarin was initially held and was not restarted due to low CHADS score ([**2-8**]). Discussed this change in medication with patient's PCP who agreed that pt did not need to continue on warfarin as an outpatient. * Anemia: During her stay Hct remained stable and close to patient's baseline. Iron panel and b12 were performed looking for other cause of anemia, but all labs were normal. Patient's anemia is most likely [**3-8**] chronic renal injury. * Atrial fibrillation s/p ablation and pacer: At home patient is maintained on warfarin. However, due to elevated INR on admission (7.1), and risk of GI bleed, warfarin was held. Patient's CHADS score is [**2-8**]. Discussed with PCP that patient does not need to continue warfarin as an outpatient due to low CHADS score. Patient should not continue taking warfarin as an outpatient. * CRI. On admission to the hospital pt. Creatinine was 4.1. This was similar to recent value at [**Hospital3 **] which was 4.2. Baseline appears to be in the high 3s. Creatinine decreased somewhat over the course of her stay to 3.9. During her stay we renally dosed all medications. We also continued her on her home dose of calcitriol. * Hypothyroid: Patient has a history of hypothyroidism and is on levothyroxine. TSH was found to be normal during hospitalization. Pt. was maintained on her home dose of levothyroxine. She should continue on this medication as an outpatient. * Hyperlipidemia: Patient was continued on her home dose of simvastatin. She should continue on this dose as an outpatient. Medications on Admission: Warfarin Lorazepam 0.5mg prn Sertraline 200 mg daily Amitriptyline 100 mg daily Propranolol 60 mg daily Quetiapine 25 mg q.h.s. Simvastatin 20 mg q.h.s. levothyroxine 125 mcg daily calcitriol 0.25 mcg daily tramadol 50 mg every 6 hours p.r.n. tylenol #3 one tab every 4 hours as needed Timolol eye drops b.i.d. Xalatan eye drops q.h.s. calcium carbonate 1250 mg t.i.d. Colace 100 mg b.i.d. Discharge Medications: 1. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO once a day. 2. Propranolol 60 mg Capsule,Sustained Action 24 hr Sig: One (1) Capsule,Sustained Action 24 hr PO DAILY (Daily). 3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety / sleep. 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Timolol Maleate 0.25 % Drops Sig: One (1) Drop(s) to each eye Ophthalmic [**Hospital1 **] (2 times a day). 9. Latanoprost 0.005 % Drops Sig: One (1) Drop(s) to each eye Ophthalmic HS (at bedtime). 10. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO three times a day. 11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 2561**] - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis Depression with Suicidal Ideation Gastritis Secondary Diagnosis Bipolar Disorder Atrial Fibrillation Chronic Renal Insufficiency Hyperlipidemia Hypothyroidism 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 to the hospital for depression, anxiety, and suicidal thoughts. During your admission to the hospital you were found to have blood in your stool. Due to concern that you were bleeding somewhere in your belly you had several tests done. A test was done to look at your stomach and colon. Neither test showed any signs of bleeding. Your blood levels also remained stable during your stay. Your depression improved during your stay and you no longer felt suicidal when you were discharged. You were seen several times by the psychiatry team who felt that the best step for your after discharge from the hospital was to go to a geriatric psychiatric facility so that your medications can be properly dosed before you are ready to return home. Also, while you were in the hospitalized, you were having problems with urinary retention. Your medications were adjusted in case they were contributing to this, and your urinary retention was improving at the time of discharge. The following changes were made to your medications: - STOP Warfarin (Coumadin) - STOP Amitriptyline - STOP Ativan - STOP Tramadol - STOP Tylenol #3 - START Seroquel twice a day as needed for anxiety or insomnia (in addition to your normal nighttime seroquel dose) - START Protonix 40 mg twice a day - Your medications will be further adjusted at your geriatric psychiatric facility. It was a pleasure taking part in your medical care. Followup Instructions: You will be given psychiatry follow-up when you are discharged from your inpatient psychiatric facility. You also have the following follow-up appointments arranged: Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Address: [**Hospital3 **]., [**Apartment Address(1) **], [**Hospital1 **],[**Numeric Identifier 53049**] Phone: [**Telephone/Fax (1) 104406**] Appointment: [**2118-5-30**] 11:30am Department: GASTROENTEROLOGY When: FRIDAY [**2118-6-3**] at 8:30 AM With: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern4) 21383**], MD [**Telephone/Fax (1) 1983**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: COGNITIVE NEUROLOGY UNIT When: TUESDAY [**2118-7-26**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PHD [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage

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icd9cm

[ [ [] ] ]

[ "45.16", "45.42", "96.33" ]

icd9pcs

[ [ [] ] ]

11834, 11901

5444, 10331

333, 374

12123, 12123

3732, 5421

13763, 14954

3106, 3173

10771, 11811

11922, 12102

10357, 10748

12308, 13740

3188, 3713

276, 295

402, 2170

12138, 12284

2192, 2613

2629, 3090

32,495

120,257

22167

Discharge summary

report

Admission Date: [**2186-8-13**] Discharge Date: [**2186-8-17**] Date of Birth: [**2120-1-31**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: Diarrhea, increasing abdominal pain and distention, Fever Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: 66 yo F h/o AF, rheumatic heart disease s/p MVR and recent TVR 1month ago course complicated by persistent hypoxia, notable for severe tracheomalacia and partial R lung collapse s/p trach, PEG, vent dependent. Pt also with h/o Celiac disease with periods of diarrhea, however current episodes of diarrhea more significant than usual Celiac disease. Transferred from rehab for eval of worsening diarrhea and 1 day h/o abdominal pain >LLQ, distention. Fever to 101.7 at OSH. Cultures drawn, PICC line d/c'd [**8-10**], blood culture from PICC growing Staph Epidermidus-oxacillin resistant. Tolerating tube feeds. No emesis. KUB at rehab reportedly w/o dilated loops. CBC with WBC 21. Anticoagulated [**1-20**] mitral/tricuspid valve replacement. INR increasing from 6.4 to 8.4 to 9.1 here. At OSH she received 1 dose of Vanco IV, Flagyl PO for presumed C-Diff, had been getting Immodium for diarrhea and vitamin K given for last 3 days. Pt transferred to [**Hospital1 18**] for further evaluation and management. . [**Hospital1 18**] ED COURSE: Initial VS 100.0 HR 120AF BP 116/54 RR 24 100% AC. Pt received 2L NS, Levofloxacin 750mg IV x1, vitamin K 5mg SC x1, Dilaudid 0.5mg IV x1 and 40MEQ KCL. ABD CT notable for ascites, no significant wall stranding or thickened colon. Blood and Urine cultures sent. Pt admitted to MICU as vent dependent. . ROS: Pt denies any difficulty breathing on the vent, no CP/palpitations. She has significant abdominal pain, no nausea and diarrhea per HPI. No dysuria. No HA/Confusion. She has noted increasing swelling despite lasix. Past Medical History: -s/p cardiac cath [**2186-6-26**] for TVR procedure -TVR/RA reduction surgery via right thoracotomy [**2186-6-28**] ( 33 mm CE pericardial valve) c/b partial right lung collapse and persistent hypoxia -s/p bronch on [**2186-7-26**] showing moderate to severe tracheomalacia and left mild bronchomalacia. -s/p trach/PEG on [**2186-7-27**] -Mitral valve replacement, [**2165**] on coumadin. Treatment for rheumatic MS. h/o MV commissurotomy in [**2152**]. -Celiac sprue -does not have collagenous colitis with negative biopsies done at the last colonoscopy Per Dr. [**Last Name (STitle) **] [**Name (STitle) 57868**] Intolerance -Elevated LFTs -h/o AF prior to mechanical valve placement -Cirrhosis with cardiogenic ascites and ansarca Social History: -Married 4 kids -No current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 99.0 HR 122 AF BP 118/56 RR 15 AC 450X15 PEEP 5 FiO2 0.5 GEN: Trach, comfortable lying in bed, mouthing responses HEENT: Dry MM, EOMI RESP: CTABL Ant'ly, no wheezing CV: Irreg Nml S1, S2, no apical murmur appreciated, mid systolic click at LLSB, prominent PMI ABD: Soft, distended, dimnished BS, LLQ tenderness, no rebound/guarding, abdomen pitting edema EXT: diffuse dependent anasarca NEURO:A&O x3, weak throughout with UE strength 3-4/5; LE strength 2/5, no focal deficits, normal sensation throughout Pertinent Results: OSH LABS: -WBC 12.5-->22.1, HCT 30, PLT 255, ALB 1.5, K 2.6, BUN/CR 35/0.9 -MICRO Data: *Blood Culture from PICC line [**8-10**] +GPC, Staph epi, oxacillin resistant *C-diff negative [**8-5**] . [**Hospital1 18**] LABS: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2186-8-17**] 04:44AM 19.0* 2.64* 8.5* 26.0* 98 32.2* 32.7 18.2* 269 [**2186-8-16**] 04:15AM 18.8* 2.80* 9.0* 26.9* 96 32.2* 33.6 18.1* 262 [**2186-8-15**] 02:01AM 20.5* 2.96* 9.4* 28.6* 97 31.7 32.8 18.1* 255 [**2186-8-14**] 04:30AM 21.0* 3.07* 10.1* 29.8* 97 32.8* 33.9 18.5* 310 [**2186-8-13**] 07:34AM 18.7* 2.91* 9.4* 28.8* 99* 32.5* 32.8 17.7* 282 [**2186-8-12**] 08:30PM 15.3*# 3.00*# 9.7*# 29.1* 97#1 32.2* 33.3 17.6* 272 . Glucose UreaN Creat Na K Cl HCO3 AnGap [**2186-8-17**] 04:44AM 144* 46* 0.9 140 3.7 106 27 11 [**2186-8-16**] 04:15AM 114* 49* 1.0 136 5.4*1 102 22 17 [**2186-8-15**] 02:01AM 102 50* 1.1 138 3.5 103 24 15 [**2186-8-14**] 04:30AM 100 47* 1.0 138 4.7 104 25 14 [**2186-8-13**] 07:34AM 80 37* 0.7 140 4.5 105 25 15 [**2186-8-13**] 03:00AM 3.8 [**2186-8-12**] 08:30PM 112* 35* 0.7 143 3.0* 104 25 17 . LFTs: ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2186-8-17**] 04:44AM 322* [**2186-8-12**] 08:30PM 19 25 13* 100 20 1.1 . Albumin [**2186-8-17**] 04:44AM 1.8* . COAGS: PT PTT Plt Ct INR(PT) [**2186-8-17**] 04:44AM 16.6* 86.9* 1.5 [**2186-8-12**] 08:30PM 71.0* 65.9* 9.1 . calTIBC Ferritn TRF [**2186-8-16**] 04:15AM 124* 677* 95 . IgG IgA IgM [**2186-8-16**] 04:15AM 1244 531* 56 . HEPATITIS SEROLOGIES--Pending at time of d/c. HCV Ab [**2186-8-16**] 04:15AM PND HBsAg HBsAb HBcAb [**2186-8-16**] 04:15AM PND PND PND . Lactate [**2186-8-13**] 08:20AM 2.5* [**2186-8-13**] 04:39AM 3.0 . PERITONEAL FLUID FROM PARACENTESIS [**8-16**]: WBC RBC Polys Lymphs Monos Macroph [**2186-8-16**] 02:10PM 500* 2950* 57* 27* 8* 8* ASCITES CHEMISTRY Glucose LD(LDH) Albumin [**2186-8-16**] 02:10PM 94 294 <1.0 PERITONEAL FLUID . IMAGING: -ABD CT [**8-12**]: IMPRESSION: 1. Multiple foci of intraperitoneal gas could be related to recent gastrostomy placement (when was this installed?) but intraperitoneal infection cannot be excluded. No evidence of extravasation of oral contrast. 2. Wall thickening of the ascending colon and hepatic flexure. This is a common finding in cirrhosis complicated by ascites. However, it is pronounced enough to suggest possible underlying colitis. 3. Cirrhosis. Significant increase in volume of ascites, which is now large. 4. Extensive body wall edema. 5. Marked cardiomegaly and biatrial enlargement. 6. Moderate right pleural effusion and atelectasis of the base of the right lower lobe. Small left pleural effusion. . CXR [**8-12**]: -A tracheostomy tube is appropriately positioned. Moderate cardiomegaly persists. A moderate-sized right-sided pleural effusion has largely resolved. There is a stable right retrocardiac opacity representing atelectasis or underlying consolidation. . [**2186-8-14**] ECHO Conclusions: The left atrium is markedly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is markedly dilated. Mild spontaneous echo contrast is seen in the body of the right atrium. Left ventricular wall thicknesses and cavity size are normal. There is moderate global left ventricular hypokinesis (LVEF = 35-40 %). Right ventricular cavity size is increased with free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. A bileaflet mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal disc motion and transvalvular gradients. Trivial mitral regurgitation is seen. The degree of mitral regurgitation seen is normal for this prosthesis. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] A bioprosthetic tricuspid valve is present. The tricuspid prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2186-7-14**], global left ventricualr systolic function is now depressed. Right ventricular cavity size is slightly smaller with improved free wall motion. The pulmonary artery systolic pressure is lower as are the transmitral and transtricuspid mean gradients. . [**8-16**] ABDOMINAL U/S: IMPRESSION: 1. Cirrhosis and moderate ascites about the liver. 2. The visualized portal veins, hepatic arteries, and hepatic veins are patent as described. Not all vessels were identified. . . MICRO: Time Taken Not Noted Log-In Date/Time: [**2186-8-16**] 2:10 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [**2186-8-16**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Pending): ANAEROBIC CULTURE (Pending): . [**2186-8-13**] 12:38 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. **FINAL REPORT [**2186-8-15**]** GRAM STAIN (Final [**2186-8-13**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2186-8-15**]): OROPHARYNGEAL FLORA ABSENT. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA | TRIMETHOPRIM/SULFA---- <=1 S . [**2186-8-12**] 8:30 pm BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): . [**2186-8-12**] 9:45 pm BLOOD CULTURE AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): . Brief Hospital Course: AP: 66 yo F with h/o rheumatic heart disease s/p MVR, TVR 1month ago, AF, severe tracheomalacia and mild bronchomalacia s/p trach and peg, celiac disease p/w fever, diarrhea and increasing abdominal distension. . #. GI: Pt w/h/o Celiac Sprue recently hospitalized in [**Month (only) 205**] for cardiac surgery-TVR course complicated by respiratory failure requiring trach and PEG. Pt at rehab with diarrhea, abd distention and fever concerning for C-diff vs. celiac dz vs. viral gastroenteritis. Abd CT with some colitis, notable for significant ascites. Guaiac +. Colon also notable for wall edema which according to liver team was consistent with C-diff colitis. Her Tube feeds were [**Last Name (un) **] for 2 days. An abdominal U/S showed significant ascites with patent portal veins and flow. Hepatology service followed the pt but could not distinguish between cardiac cirrhosis vs. liver disease cirrhosis without a liver biopsy which was deferred due to other comorbidities and current illness. Her stool output was minimal since admission. She was treated for C-diff with flagyl, needs to complete a [**10-1**] day course, 7 days left of flagyl at time of discharge. A 1.5L paracentesis was done on [**8-16**] which was consistent with SBP, she was started on Ceftriaxone for SBP treatment, needs to complete a 10 day course. She was given 2 doses of albumin 25g on admission and the following day. She needs to start Bactrim DS 1 tab daily when her SBP treatment completes on [**8-25**], for continued prophylaxis of SBP. Her abdominal pain slowly improved, tube feeds were resumed. A PICC line was placed on [**8-17**] for Abx use. Per the liver team, she should continue on aldactone and lasix daily for her cirrhosis. The recommend to titrate aldactone to 50mg twice daily if blood pressure allows. She was on aldactone 25mg daily at time of discharge and 20mg lasix daily, her BP remained 90s to low 108/50s. She had persistent anasarca. . #. Fever: recent cardiac surgery course complicated by respiratory failure, CXR with stable retrocardiac opacity. OSH Culture with coag neg staph bacteremia-oxacillin resistant Staph Epi, PICC line d/c'd prior to transfer to [**Hospital1 18**]. Lactate 3.0 possibly from infection vs. poor forward flow due to CHF. Her sputume grew STENOTROPHOMONAS sensitive to bactrim. She had no thick secretions and she was treated emperically for this sputum for 3 days. Bactrim was d/c'd on [**8-17**] as no clinical signs of pneumonia. She was treated for C-diff and found to have SBP as noted above on [**8-16**]. A PICC was placed for Abx. She was afebrile with a stable WBC at time of discharge. ECHO showed no signs of vegetations given recent surgery. She had no positive blood cultures here. . . #. Cardiac: concerning for decompensated CHF given significant ascites, total body anasarca and recent surgery. A repeat ECHO showed well seated valves, no vegetations. She did have depressed EF 35-40% with LV global HK, her PASP were improved compared to prior ECHO. Her diuretics were resumed lasix 20mg daily and aldactone as noted above. Her CE did not show ischemia, neither did her EKG. Her CT surgeon was contact[**Name (NI) **] and saw pt in-house who recommended a Liver consult to help distinguish CHF, anasarca from liver vs. cardiac etiology. As noted above difficult to distinguish without a liver bx. Her BB was continued in addition to aspirin and statin. . . #. Resp: Severe tracheomalacia, mild bronchomalacia, significant R sided pleural effusion, and retrocardiac opacity s/p trach, vent dependent. Resp alkalosis, overbreathing on the vent. She was initially treated with bactrim as above for presumed PNA X3 DAYS but no increased secretions, retrocardiac opacity was old. She was not continued on bactrim for PNA. She was tolerating PS for several hours at time of discharge and ventilatory support as she tired and overnight. . #. Supratherapeutic INR: s/p MVR, TVR on hep and coumadin, malnourished. She received vit K x3 doses and coumadin held x2 days. She was started on a hep gtt when INR drifted down to <2.5. Her coumadin was resumed 5mg daily. INR needs to be closely watched while on Abx. . #. Cirrhosis: Significant Ascites most likely from congestive hepatopathy in setting of severe TR s/p TVR, diffuse anasarca, low albumin from malnutrition. SBP noted as above. Liver attending, Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 7033**] would like to continue to follow her in [**Month (only) **]/[**Month (only) **]. He recommended daily aldactone 50mg [**Hospital1 **] as BP tolerates and lasix 20mg daily. Her liver did show normal flow on doppler but significant ascites. Paracentesis -1.5L done on [**8-16**] without complications. She recieved 2 doses of albumin 25gm at time of admission x2 days. Given SPB and ascited albumin <1.0 she needs daily SBP prophylaxis after completion of treatment as noted above. Hepatitis serologies were sent but were pending at time of discharge. . #. CODE: FULL . Medications on Admission: Discharge Medications on [**7-31**]: 1. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **] 2. Atorvastatin 10 mg daily 3. Famotidine 20 mg [**Hospital1 **] 4. Ferrous Gluconate 300 mg Daily 5. Hexavitamin 1 tab Daily 6. Sertraline 50 mg daily 7. Ascorbic Acid 500 mg [**Hospital1 **] 8. Aspirin 81 mg Daily 9. White Petrolatum-Mineral Oil Cream TID prn 10. Miconazole Nitrate 2 % Powder TID prn 11. Metoprolol Tartrate 50 mg [**Hospital1 **] 12. Calcium Carbonate 500 mg QID prn 13. Loperamide 2 mg Capsule TID prn 14. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H 15. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Hospital1 **] 16. Furosemide 80 mg IV BID 17. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: Eight Hundred (800) units/hour Intravenous ASDIR (AS DIRECTED). 18. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ascorbic Acid 90 mg/mL Drops Sig: One (1) PO DAILY (Daily). 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for FEVER, PAIN. 14. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One (1) Inhalation [**Hospital1 **] (2 times a day). 15. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 16. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 17. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for Constipation. 18. Heparin, Porcine (PF) 10 unit/mL Solution Sig: One (1) Intravenous once a day: Weight based protocol PT, PTT Goal 60-80 until INR 2.5-3.5. 19. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. 20. Ceftriaxone 2 g Recon Soln Sig: One (1) Intravenous once a day for 8 days: needs to complete 10 day course on [**8-25**]. 21. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 22. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO once a day: START [**8-26**]. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] TCU - [**Location (un) 701**] Discharge Diagnosis: Primary: -SBP -Diarrhea, presumed C-diff -STENOTROPHOMONAS in sputum -Abdominal pain . Secondary -Anasarca -Cirrhosis -CHF EF 35-45% -MVR/TVR -Rheumatic heart disease -Respiratory Failure, Vent dependent s/p Trach Discharge Condition: The patient was discharged hemodynamically stable, afebrile with trials of PS on the vent. Discharge Instructions: -Please take all medications as directed. . -Return to the emergency room if you have fevers, increasing abdominal pain, fevers T>101.4, persistent diarrhea. . -Need to watch PEG closely, as contraindicated in Cirrhotics. Watch for any signs of bleeding around PEG, abdominal pain near PEG or leaking around PEG, if any above signs must stop TF through PEG. . -If Blood pressure allows titrate Spironolactone to 50mg [**Hospital1 **], twice per day. Systolic blood pressure baseline 90s, if above 100 may increase spironolactone to 50 mg twice daily. [**Month (only) 116**] use albumin 25gm daily x3 if available for low BP and low UOP. . -You must complete a 10 day course of Ceftriaxone 2gm daily for a total of 10 days for SBP. -You must complete a [**10-1**] day course of Flagyl 500mg TID for presumed C-Diff infection. -You must start Bactrim DS 1 tab daily for SBP prophylaxis once your 10 day course of Ceftriaxone has completed on [**8-25**], start taking bactrim on [**8-26**]. Followup Instructions: Follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 24522**] in [**1-22**] weeks, call for an appointment at [**Telephone/Fax (1) 3183**]. . Follow up with Hepatology DR. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 7033**] in [**Month (only) 359**]/[**Month (only) **], please call liver clinic at [**Telephone/Fax (1) 2422**] for an appointment. Completed by:[**2186-8-17**]

[ "789.5", "428.0", "790.92", "V58.61", "571.5", "008.45", "519.19", "263.9", "V44.0", "V43.3", "V44.1", "567.23", "579.0", "427.31", "E934.2", "996.62", "518.83" ]

icd9cm

[ [ [] ] ]

[ "54.91", "38.93", "96.72", "96.6", "99.04" ]

icd9pcs

[ [ [] ] ]

17748, 17824

9745, 14752

371, 386

18082, 18175

3479, 9557

19211, 19677

2851, 2933

15711, 17725

17845, 18061

14778, 15688

18199, 19188

2948, 3460

274, 333

9689, 9689

9718, 9722

414, 1980

2002, 2739

2755, 2835

52,978

129,936

53241

Discharge summary

report

Admission Date: [**2196-9-20**] Discharge Date: [**2196-9-28**] Date of Birth: [**2133-5-26**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (un) 2888**] Chief Complaint: fatigue, lethargy Major Surgical or Invasive Procedure: Right Internal Jugular Central line placement with Swan catheter Right heart cardiac catheterization History of Present Illness: 63M with systlic and diastolic CHF with dilated CMP (EF <20%) s/p BiV-ICD, Afib on warfarin s/p AVJ ablation, OSA and NAFLD who presents to the CCU from home with fatigue and lethargy. Patient reports worsening fatigue, dyspnea on exertion and abdominal distention over the past few weeks. His weight has increased slowly but steadily from 172lbs to 179-181 lbs over a period of months. His level of activity has decreased to the point where all he does is eat and sleep over the past week, although he is still able to climb 1 flight of stairs without needing to stop. He reports anorexia and early satiety, as well as nausea following meals over the past 2 weeks. He denies any recent fevers, chills or night sweats. He had an outpatient TEE on [**9-16**] which showed EF<20% with severely depressed global biventricular function, as well as moderate to severe tricuspid regurgitation with echodensity associated with the tricuspid annulus suggestive of torn leaflet. RHC the same day significant for CO 2.7, CI 1.36, PCW 25, PA 47-49/32. On arrival to the floor, patient complaining of fatigue and malaise, denies dyspnea, chest pain, fevers. Past Medical History: 1. Dilated cardiomyopathy (EF 35%, last echo in our system [**11-18**]) 2. AICD placed [**2183**] for non-sustained VT (recent interrogation) 3. Hyperferritin and polycythemia (ferritin up to 600s, Hct in 40s, possibly reactive to hepatic inflammation); therapeutic phlebotomy Q 3 months, last [**2195-4-12**]. No hemachromatosis, but no liver biopsy. 4. A fib on coumadin (previously on pradaxa) 5. Irritable bowel syndrome (diarrhea predominant) 6. Barrett's esophagus (last EGD [**2195-7-2**]) 7. Colon polyps (last colonoscopy [**2195-7-2**]) 8. GERD 9. Hiatal hernia 10. Hemorrhoids 11. h/o pancreatitis (date unknown) 12. Hypertriglyceridemia (832 [**10-22**]) 13. Fatty liver disease 14. Emphysema [**1-14**] tobacco abuse 15. Obstructive sleep apnea 16. Urinary frequency 17. Erectile dysfunction 18. Restless leg syndrome 19. Osteopenia 20. Vit D deficiency 21. Inguinal hernia 22. Hydradenitis supurativa 23. Rosacea 24. Depression 25. Anxiety 26. Night sweats 27. Insomnia 28. s/p drainage of perirectal abscess ([**2180**]) Social History: Retired Spanish teacher, lives with his spouse [**Name (NI) **] [**Name (NI) **] at home. -Tobacco history: smoke 3 cigarettes per day (previously 1ppd) -ETOH: 2 drinks per day -Illicit drugs: Denies Family History: His mother died at 81 of heart disease and she had some form of dementia possibly Alzheimer's disease. His father died at 55 of vascular complications. He has two brothers, one older and one younger. The older brother has sleep apnea and heart trouble. Physical Exam: Admission: VS: T 98.1 HR 85 (V-paced) BP 107/75 RR 10 SpO2 93%/2L GENERAL: NAD. Oriented x3. HEENT: NCAT. Sclera anicteric Moist MM. NECK: Supple with JVP to the earlobe. CARDIAC: PMI displaced laterally and inferiorly. RR, normal S1, S2. S3 present. [**1-18**] systlic murmur at the LLSB. LUNGS: Decreased breath sounds at the bases with crackles [**12-15**] way up the lungs. ABDOMEN: Soft, NT. Abdomen is distended with positive fluid wave and shifting dullness. EXTREMITIES: Minimal lower extremity edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Discharge: GENERAL: NAD. Oriented x3. HEENT: NCAT. Sclera anicteric Moist MM. NECK: Supple with JVP ~9-10 cm. CARDIAC: PMI displaced laterally and inferiorly. RR, distant heart sounds. normal S1, S2. 2/6 systolic murmur at the LLSB. LUNGS: Decreased breath sounds at the bases, no crackles/rhales/wheezes. ABDOMEN: Soft, NT. Abdominal distension has decreased, but still mild distension. EXTREMITIES: No lower extremity edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: On admission: [**2196-9-20**] 08:27PM BLOOD WBC-8.0 RBC-4.85 Hgb-14.3 Hct-45.3 MCV-94 MCH-29.6 MCHC-31.7 RDW-15.6* Plt Ct-186 [**2196-9-20**] 08:27PM BLOOD PT-39.4* PTT-42.9* INR(PT)-3.6* [**2196-9-20**] 08:27PM BLOOD Glucose-122* UreaN-38* Creat-2.0* Na-138 K-3.7 Cl-97 HCO3-30 AnGap-15 [**2196-9-20**] 08:27PM BLOOD ALT-26 AST-50* LD(LDH)-228 AlkPhos-43 TotBili-1.1 [**2196-9-20**] 08:27PM BLOOD Albumin-3.8 Calcium-8.9 Phos-4.1# Mg-1.9 [**2196-9-20**] 09:36PM BLOOD Lactate-2.1* Imaging/Studies: [**9-20**] CXR Cardiomegaly is severe, unchanged. There is unchanged appearance of the pacemaker leads. There is interval development of interstitial pulmonary edema. More pronounced bibasal opacities might be concerning for interval development of infectious process. [**9-21**] EKG: Sinus rhythm with biventricular pacing. Compared to the previous tracing of [**2196-9-16**] pseudofusion beats are not seen on the current tracing. Atrial tachycardia is not clearly seen on the current tracing, although there is some baseline artifact which makes interpretation difficult. [**2196-9-22**] Cardiac Cath: [**Known lastname **],[**Known firstname 5445**] [**Age over 90 109599**] M 63 [**5-26**],[**2132**] Cardiovascular Report Cardiac Cath Study Date of [**2196-9-22**] BRIEF HISTORY: 63-year-old man with non-ischemic dilated cardiomyopathy and biventricular failure with an EF less than 20% and worsening symptoms over the past several months. He under went a right heart catheterization on [**2196-9-16**] with a cardiac index of 1.36. He is now admitted to the CCU on milrinone and a furosemide drip. He is referred to the cath lab for placement of a pulmonary artery catheter to tailor inotrope therapy. INDICATIONS FOR CATHETERIZATION: Congestive heart failure, dilated cardiomyopathy. PROCEDURE: Right heart catheterization via the right internal jugular vein with a 8F sheath. Pulmonary artery catheter left in place after procedure for transfer back to the CCU. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.96 m2 HEMOGLOBIN: 13.4 gms % MILRINONE **PRESSURES RIGHT ATRIUM {a/v/m} 14/16/13 RIGHT VENTRICLE {s/ed} 41/14 PULMONARY ARTERY {s/d/m} 43/22/29 PULMONARY WEDGE {a/v/m} 23/29/22 **CARDIAC OUTPUT HEART RATE {beats/min} 69 CARD. OP/IND FICK {l/mn/m2} 2.92 MILRINONE **% SATURATION DATA (FL) SVC LOW 61 PA MAIN 68 OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 0 hour27 minutes. Arterial time = 0 hour0 minutes. Fluoro time = 1.7 minutes. Effective Equivalent Dose Index (mGy) = 36 mGy. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 0 ml Anesthesia: 1% Lidocaine subq. Anticoagulation: Other medication: Milrinone 0.375 mcg/kg/min Furosemide 15 mg/hr Cardiac Cath Supplies Used: - MERIT, RIGHT HEART KIT - ALLEGIANCE, CUSTOM STERILE PACK 5FR COOK, MICROPUNCTURE INTRODUCER SET 7.5MM [**Doctor Last Name **], SWAN-GANZ VIP COMMENTS: 1. Resting hemodynamics while on a milrinone drip showed elevated right-sided pressures. The RA pressure was elevated at 13 mmHg and the RV pressure was eleated at 41/14. The PA pressure was elevated at 43/22 with a mean PA pressure of 29. The wedge pressure was elevated at 22 mmHg. 2. Measurements of oxygen saturations revealed a low SVC and PA oxygen saturation of 61 and 68% respectively. FINAL DIAGNOSIS: 1. Hemodynamics improved on milrinone with a better cardiac index. 2. Adjust CHF medications in CCU with pulmonary artery catheter in place. HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.96 m2 HEMOGLOBIN: 13.4 gms % MILRINONE **PRESSURES RIGHT ATRIUM {a/v/m} 14/16/13 RIGHT VENTRICLE {s/ed} 41/14 PULMONARY ARTERY {s/d/m} 43/22/29 PULMONARY WEDGE {a/v/m} 23/29/22 **CARDIAC OUTPUT HEART RATE {beats/min} 69 CARD. OP/IND FICK {l/mn/m2} 2.92 MILRINONE **% SATURATION DATA (FL) SVC LOW 61 PA MAIN 68 [**2196-9-23**] CXR: FINDINGS: As compared to the previous radiograph, the patient has received a new Swan-Ganz catheter via a right internal jugular vein approach. There is improved ventilation of the lung parenchyma in both the retrocardiac lung areas and the right lung bases. Unchanged size of the cardiac silhouette. Unchanged evidence of mild pulmonary edema. Left pectoral pacemaker, no pleural effusions. No pneumothorax. [**2196-9-25**] EKG: Atrial tachycardia and biventricular pacing, similar to that recorded on [**2196-9-24**], without diagnostic interim change. Microbiology: [**2196-9-23**] 10:29 pm BLOOD CULTURE Source: Line-swan #1. Blood Culture, Routine (Preliminary): GRAM POSITIVE RODS. RESEMBLING CORYNEFORM BACILLI, UNABLE TO IDENTIFY FURTHER. Isolated from only one set in the previous five days. Anaerobic Bottle Gram Stain (Final [**2196-9-25**]): Reported to and read back by DR. [**First Name (STitle) **], CONSTOCK @ 950PM [**2196-9-25**]. GRAM POSITIVE ROD(S). Blood Culture [**2196-9-23**]: No growth x 6 days Urine culture [**2196-9-23**]: No growth Catheter Tip culture [**2196-9-23**]: No growth Labs on Discharge: [**2196-9-28**] 07:30AM BLOOD WBC-8.2 RBC-5.80 Hgb-16.6 Hct-53.6* MCV-92 MCH-28.7 MCHC-31.1 RDW-15.4 Plt Ct-256 [**2196-9-28**] 07:30AM BLOOD Glucose-75 UreaN-52* Creat-1.6* Na-141 K-4.1 Cl-96 HCO3-35* AnGap-14 [**2196-9-28**] 07:30AM BLOOD Mg-2.3 Brief Hospital Course: 63M with systolic and diastolic CHF with dilated CMP and recent RHC consistent with cardiogenic shock who presents from home for inotrope initiation and diuresis. # Acute on chronic systolic and diastolic CHF with dilated CMP (EF <20%)/PUMP: No clear precipitant for his worsening heart failure, he did not report symptoms of ischemia, infection and denies dietary indiscretion or medication non-compliance. Appeared volume overloaded on exam with crackles and ascites. CI was 1.3 on recent RHC with mean PCWP of 25. The patient was started on a lasix drip and milrinone infusion for inotropic support. Pt's BP tolerated milrinone well with SBPs in 90s-100s. On [**9-22**], pt underwent right heart catheterization with PA cath placement which showed initial numbers: CI 2.92, demonstarting improved hemodynamics on milrinone. The patient spiked a temp to 101 on [**9-23**] and therefore the PA catheter was pulled and cultures sent (see below). On [**9-23**] lasix gtt was stopped and patient transitioned to PO torsemide. Initially given 60mg [**Hospital1 **] torsemide. Patient weaned from milrinone on [**9-24**] and isordil and hydralazine were started for afterload reduction. Torsemide increased to 80 mg [**Hospital1 **] on [**9-24**]. Once patient appeared euvolemic torsemide was decreased to daily and dose titrated to maintain euvolemia. On [**9-26**] metoprolol was restarted. Physical therapy evaluated patient and determined ok to return home with walker. He was discharged with a dry weight of 161.5 lbs and on the following diuretic regimen: torsemide 60 mg daily. # RHYTHM: Patient with AF and is s/p AVJ ablation with biventricular pacing at rate of 85. INR supratherapeutic to 3.6 at admission and warfarin initially held. The patient recieved 4 mg Vitamin K on day of admission to reverse INR for procedure. Patient was placed on heparin gtt for anticoagulation during peri-procedural time. His warfarrin was restarted after procedure. The patient's metoprolol was initially held secondary to acute decompensated HF and was restarted when patient compensated. # Fever: The patient spiked a fever to 101 on [**9-23**]. The PA catheter was pulled at that time and cultures were sent. The patient was started on empiric antibiotics of vanc and cefepime. Catheter tip was with no growh. Urine culture was with no growth. One bottle of blood culture revealed gram positive rods, later determined to resemble CORYNEFORM BACILLI. Antibiotics were stopped at 48 hours when only culture data of gram positive rods (most likely contaminent). The patient remained afebrile and without signs/symptoms of infection after d/c antibiotics. # CKD: Cr at admission of 2.0 and appears to be close to recent baseline of 1.6-2.0. The patient's Cr was trended and initially improved with diuresis. Nephrotoxins were avoided when possible and medications were renally dosed. The patient had a Cr of 1.6 on discharge. #COPD: on home O2 at night- uses 2L NC overnight. Stable on admission with no signs/symptoms of exacerbation. Home tiotropium and overnight supplemental oxygen was continued. # Hypercholesterolemia: Continue atorvastatin # Hypothyroidism: contnue levothyroxine 125mcg daily # GERD: Continue omeprazole and ranitidine PRN # IBS: Still reporting intermittent diarrhea. Electrolytes were monitored. Diarrhea minimal during admission. Transitional issues: -admission weight: 83.1kg (183lbs) -discharge weight: 161.5 lbs -Patient instructed to call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. And also to call [**Doctor First Name **] if he notices bloating, nausea, a dry cough or trouble breathing. -Follow up with device clinic, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Dr. [**Last Name (STitle) **], and Dr. [**Last Name (STitle) **] [**Name (STitle) **] to have Chem-7 and INR on Monday [**2196-10-3**] with results sent to [**Doctor First Name **] and [**Doctor First Name **] [**Doctor Last Name 1395**], prescription provided. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 10 mg PO DAILY 2. Citalopram 40 mg PO DAILY 3. Clonazepam 2 mg PO QHS 4. Fish Oil (Omega 3) 1000 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Gabapentin 600 mg PO HS 7. Levothyroxine Sodium 125 mcg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. OxycoDONE (Immediate Release) 10 mg PO QHS:PRN pain 10. Tamsulosin 0.4 mg PO HS 11. Thiamine 100 mg PO DAILY 12. Vitamin E 400 UNIT PO BID 13. Warfarin 2 mg PO DAILY16 14. Ranitidine 75 mg PO QHS:PRN reflux 15. fenofibrate micronized *NF* 200 mg Oral daily 16. Torsemide 60 mg PO DAILY 17. Metoprolol Succinate XL 100 mg PO DAILY 18. Tiotropium Bromide 1 CAP IH DAILY Discharge Medications: 1. Atorvastatin 10 mg PO DAILY 2. Citalopram 40 mg PO DAILY 3. Clonazepam 2 mg PO QHS 4. Fish Oil (Omega 3) 1000 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Gabapentin 1200 mg PO HS 7. Levothyroxine Sodium 137 mcg PO DAILY 8. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 9. Omeprazole 40 mg PO DAILY 10. OxycoDONE (Immediate Release) 10 mg PO QHS:PRN pain 11. Ranitidine 75 mg PO QHS:PRN reflux 12. Tamsulosin 0.4 mg PO HS 13. Thiamine 100 mg PO DAILY 14. Tiotropium Bromide 1 CAP IH DAILY 15. Torsemide 60 mg PO DAILY 16. Vitamin E 400 UNIT PO BID 17. Warfarin 2 mg PO DAILY16 18. Losartan Potassium 25 mg PO DAILY RX *losartan 25 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 19. Nicotine Patch 7 mg TD DAILY RX *nicotine 7 mg/24 hour one daily Disp #*30 Transdermal Patch Refills:*0 20. fenofibrate micronized *NF* 200 mg ORAL DAILY 21. Multivitamins 1 TAB PO DAILY 22. Oxygen Oxygen 2L NP continuous for O2 sat 82% on RA with ambulation. 23. Outpatient Lab Work Please check Chem-7 and INR on Monday [**2196-10-3**] with results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 109600**] phone and [**Name6 (MD) **] [**Name8 (MD) 1395**], MD Phone: [**Telephone/Fax (1) 2205**] Fax: [**Telephone/Fax (1) 7922**] Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Acute on Chronic systolic congestive heart failure Acute on Chronic kidney injury Tobacco abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had an acute exacerbation of your congestive heart failure and required intravenous furosemide and milrinone to remove the extra fluid. Your weight today is 161.5 and this should be considered your dry weight. Weigh yourself every morning, call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Please also call [**Doctor First Name **] if you notice bloating, nausea, a dry cough or trouble breathing. It is extremely important that you stop smoking. Your oxygen level is low and you will need oxygen when you are walking. You cannot smoke around the oxygen or you risk starting a fire. Stopping smoking is the most important thing you can for for your health. Followup Instructions: . Department: CARDIAC SERVICES When: FRIDAY [**2196-10-14**] at 10:30 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: FRIDAY [**2196-10-14**] at 11:40 AM With: [**Name6 (MD) **] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: TUESDAY [**2196-10-18**] at 1 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 Department: CARDIAC SERVICES When: WEDNESDAY [**2196-10-5**] at 11:30 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: [**State **]When: MONDAY [**2196-10-10**] at 12:45 PM With: [**Name6 (MD) **] [**Name8 (MD) 9862**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Completed by:[**2196-9-29**]

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28926

Discharge summary

report

Admission Date: [**2115-8-26**] Discharge Date: [**2115-9-3**] Date of Birth: [**2058-6-2**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: s/p Assault; found down Major Surgical or Invasive Procedure: None History of Present Illness: 57 yo male who was found down by car with +LOC; ? assault. He was taken to an area hospital initial GCS 15; mental status began to decline and was intubated; head CT scan revealed bilateral frontal hemorrhages; he was then transferred to [**Hospital1 18**] for ongoing trauma care. Past Medical History: None Social History: Lives with wife Family History: Noncontributory Physical Exam: Upon admission to trauma bay: BP 130/palp HR 105 RR 20 O2 Sat 100% Gen: Intubated HEENT: Pupils 1 mm; TM's clear Neck: c-collar Chest: CTA bilat Cor: RRR Abd: soft, NT Extr: cool LE's, 2+ DP pulses bilat, no edema Pertinent Results: [**2115-8-26**] 11:03PM GLUCOSE-128* LACTATE-3.8* NA+-145 K+-3.7 CL--106 TCO2-22 [**2115-8-26**] 11:03PM HGB-12.8* calcHCT-38 O2 SAT-89 CARBOXYHB-2.0 MET HGB-0.7 [**2115-8-26**] 10:50PM AMYLASE-59 [**2115-8-26**] 10:50PM ASA-NEG ETHANOL-10 ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2115-8-26**] 10:50PM WBC-19.4* RBC-4.37* HGB-12.3* HCT-37.0* MCV-85 MCH-28.2 MCHC-33.4 RDW-14.4 [**2115-8-26**] 10:50PM PLT COUNT-340 CT HEAD W/O CONTRAST [**2115-8-26**] 10:58 PM CT HEAD W/O CONTRAST Reason: s/p fall [**Hospital 93**] MEDICAL CONDITION: 57 year old man s/p fall REASON FOR THIS EXAMINATION: s/p fall CONTRAINDICATIONS for IV CONTRAST: None. There is mild left parietal scalp subgaleal soft tissue swelling, presuambly post-traumatic in origin. INDICATION: 57-year-old man, status post fall. COMPARISON: None. TECHNIQUE: Non-contrast head CT. CT HEAD WITHOUT IV CONTRAST: There is intraparenchymal hemorrhage and surrounding edema within the anterior left frontal lobe, consistent with a hemorrhagic contusion, averaging 3cm in diamter. There is a small mixed density subdrual hematoma anterior to the right frontal pole. There is a question of a tiny amount of subarachnoid hemorrhage in a few left parietal vertex convexity sulci. The remainder of the brain parenchyma is within normal limits. The ventricles are symmetric, and there is no shift of normally midline structures. The fourth ventricle and foramen magnum are of normal configuration. No definite fracture is seen. The ethmoid air cells and sphenoid sinus are well aerated. There is minimal mucosal thickening within the maxillary sinuses. There are probable moderate amounts of secretions in the nasoharynx, with the patient being intubated. The remaining osseous structures are normal. No definite fracture is seen. IMPRESSION: Hemorrhagic contusion within the anterior left frontal lobe, and a small right subdural hematoma anterior to the right frontal lobe. MR CERVICAL SPINE Reason: r/o cord compression, please image to T2 level [**Hospital 93**] MEDICAL CONDITION: 57 year old man with left sided weakness REASON FOR THIS EXAMINATION: r/o cord compression, please image to T2 level INDICATION: 57-year-old with left-sided weakness. TECHNIQUE: Multiplanar T1- and T2-weighted sequences were obtained through the cervical spine. FINDINGS: Cervical spine is normal in alignment and marrow signal. The cord has normal intrinsic signal. At C3-4, there is a posterior osteophyte. This is slightly eccentric to the left causing mild left neural foraminal narrowing. At C4-5, there is a small posterior osteophyte with no evidence of significant neural impingement. At C5-6, there is a small posterior osteophyte. There is moderate-to-severe left neural foraminal narrowing due to uncovertebral degenerative changes. There is moderate right neural foraminal narrowing due to the osteophyte. At C6-7, there is a posterior osteophyte with bilateral uncovertebral degenerative changes. There is mild bilateral neural foraminal narrowing. The remainder of the levels is normal. The spine is visualized in both sagittal and axial planes through the T2-3 disc space. IMPRESSION: Minimal degenerative changes as above. CHEST (PORTABLE AP) Reason: ?acute change [**Hospital 93**] MEDICAL CONDITION: 57 year old man again with fever REASON FOR THIS EXAMINATION: ?acute change CHEST, SINGLE VIEW, ON [**8-31**] HISTORY: Fever. REFERENCE EXAM: [**8-28**]. There has been interval progression of bilateral mid lung infiltrates with patchy alveolar infiltrate seen in the right mid lung, left mid lung, and left lower lobe. The heart size is slightly increased compared to the prior study. There is no effusion. IMPRESSION: Increased bilateral infiltrates. Brief Hospital Course: Patient admitted to the trauma service. Neurosurgery was initially consulted because of his head injuries. Once stabilized in the emergency department he was taken to the Trauma ICU. He did receive Dilantin and Mannitol at the hospital where he was transferred from; the Dilantin was continued throughout his hospital stay. Serial head CT scans were followed closely. Neurology was later consulted because of left upper extremity weakness. He will follow up with Neurology after discharge for an outpatient EMG. It is also being recommended that he continue with his Dilantin for at least 4 weeks at which time he will have follow up with both Neurosurgery and Neurology. He is being treated for a pneumonia with 10 day course of Levofloxacin and Dicloxacillin. Social work was consulted early during his hospital stay for emotional support; the Center for Violence prevention and Recovery were also consulted for ongoing care that will be available to patient post discharge. Physical and Occupational therapy were consulted. He is being recommended for discharge to home with services. Discharge Medications: 1. Dicloxacillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 10 days. Disp:*80 Capsule(s)* Refills:*0* 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. Disp:*40 Tablet(s)* Refills:*0* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation: Please take as necessary while you are taking Percocet to avoid constipation. 5. Milk of Magnesia 800 mg/5 mL Suspension Sig: [**2-4**] PO twice a day as needed for constipation. 6. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*90 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: s/p Assault Left frontal intraparenchymal hemorrhage Right frontal subdural hematoma Enterobacter and s aureus pneumonia Discharge Condition: Stable Discharge Instructions: headache, vision changes, fever/chills, persistent left arm weakness or pain, shortness of breath, significant productive cough, nausea, vomiting and/or any other symptoms that are concerning to you. You should take all of the medications that are prescribed to you as directed. Continue with the Dilantin (anti-seizure medication) until follow up with Neurosurgery in 4 weeks. Complete your antibiotic course until the medication is all done. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 548**], Neurosurgery in 4 weeks; call [**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will need a repeat head CT scan for this appointment. Follow-up at [**Hospital 878**] clinic in 4 weeks with Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 29128**]). Call for an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2115-9-3**]

[ "E968.9", "851.86", "482.41" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

6642, 6697

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336, 343

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1001, 1533

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34107

Discharge summary

report

Admission Date: [**2131-6-21**] Discharge Date: [**2131-6-22**] Date of Birth: [**2066-10-2**] Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins Attending:[**First Name3 (LF) 398**] Chief Complaint: Unresponsiveness, hypoglycemia Major Surgical or Invasive Procedure: Patient was intubated. History of Present Illness: 54 yo F with ho DM2, HTN, PVD, OSA, aortic stenosis (1.2 cm), RBBB/LAFB on EKG, PAF, h/o PE s/p IVC filter, adrenal mass, gastric & colonic polyps, s/p CCY, admitted on [**6-12**] to [**Hospital3 **] with anorexia and weakness x 2days. In the 10 days prior to admission her FS had been in the 500s. Also, about 2-3 weeks prior to admission was started on bactrim for possible LE cellulitis. Per her family she had anorexia and elevated blood sugars and presented to OSH, where she was admitted. She was found to have elvated LFTs which were thought to be secondary to bactrim. She had an abdominal US with min ascites but no ductal dilation or stones, but was started on cipro for possible cholecystitis then referred for ERCP for unclear reasons, but procedure aborted due to afib with RVR to 140??????s. She was started on heparin and continued her on amiodarone and diltiazem and digoxin was added. She became increasingly confused per her family and was started on lactulose. In terms of her labs, WBC 14 AST 135, ALT 239, alkphos 154, bili 10.7 (trending up from 4.4 on admission), alb 1.7. Creatinine range 1.1 to low 2.0s and was trending up prior to transfer. AST and ALT remained stable but t bili increased to 10 and lipase 172. She became thrombocytopenic the day prior to transfer and heparin was d/c'd give concern for HIT. Her HRs 110s-120s. ABG 7.33/22/74 on RA. Was switched from cipro to aztreonam and vanco. Originally was transferred here for work-up of her hepatitis, then became unresponsive in the ambulance and FS found to be 25. On arrival to the ED she was agonally breathing with a thready pulse. She was given 1 amp of D50 and 1 amp HCO3 and was intubated. She was hypotensive was briefly on peripheral dopamine and an emergent femoral line was placed and she was started on levophed. An attempt at an a-line was made in both radial arteries as well as femoral, but was unsuccessful. Her VBG was 7.11/46/107 on AC with unclear settings and lactate 6.9. Her ECG showed a RBBB ? afib versus flutter with variable block. She was given 5 L NS, 1 liter LR, 2 amps D50, 2 amps HCO3, insulin, kayexalate, vancomycin, levofloxacin and flagyl. CXR revealed no PNA or CHF, CT abdomen with hepatomegaly, ascites, bilateral pleural effusions, pericardial effusion, anasarca and no biliary dilitation. CT head was negative. She was transferred to the ICU for further management. Past Medical History: DM2 OSA on CPAP aortic stenosis (1.2 cm) RBBB/LAFB on EKG PAF h/o PE s/p IVC filter adrenal mass gastric & colonic polyps s/p CCY LE cellulitis developed hepatitis while on Bactrim PVD Echo in [**9-2**] with EF 75% Social History: Lives with daughter. Quit smoking 10 years ago, no ETOH, no drugs. Family History: father with gastric cancer Physical Exam: General: Obese, intubated and sedates HEENT: sceral icterus, PERRL Abd: obese Ext: chronic venous stasis changes, 3x4 cm ulcertion on the medial aspect of right leg Pertinent Results: Patient expired, Brief Hospital Course: Patient entered [**Hospital Unit Name 153**] with hypoglycemia and agonal breathing s/p intubation with shock, liver failure and renal failure. She became markedly hypotensive despite being on 2 pressors and being intubated. At this juncture, the family decided on providing comfort measures only at which point a decision was made to extubate the patient. She expired shortly thereafter. Medications on Admission: NPH 18 [**Hospital1 **] Digoxin 125 mcg po qday Lacthytrim oscal 500 mg Po BID lactulose 30 ml Po QID vanco 1.5 g IV daily aztreonam 1 gram Q12H tylenol 650 q4h PRn (received 2 doses) Diltiazem ER 180 mg po qday Duoneb Discharge Disposition: Expired Discharge Diagnosis: Fulminant Hepatic Failure with associated cardiac arrest Discharge Condition: Patient Expired. Completed by:[**2131-6-22**]

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icd9cm

[ [ [] ] ]

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30794

Discharge summary

report

Admission Date: [**2160-8-8**] Discharge Date: [**2160-8-14**] Date of Birth: [**2079-10-11**] Sex: M Service: MEDICINE Allergies: Pyridium / Quinine Sulfate / Levaquin / Macrobid / Vytorin [**11-1**] / Quinolones Attending:[**Last Name (un) 2888**] Chief Complaint: fatigue, Shortness of breath Major Surgical or Invasive Procedure: [**8-8**] Right Heart Cath; swan placement [**8-10**] Right Subclavian PICC line placement History of Present Illness: HISTORY OF PRESENTING ILLNESS: 80 year old male with a history of coronary artery disease status post 2 prior CABG operations (in [**2128**] and [**2138**]) and multiple prior myocardial infarctions resulting in infarct related cardiomyopathy with a LVEF of 15%, Biventricular ICD, mitral regurgitation status post bioprosthetic mitral valve replacement in [**2155**], atrial fibrillation, chronic kidney disease, hypertension and hyperlipidemia, who has had a steady decline in his functional status over the last few months. He was last seen by Dr. [**Last Name (STitle) **] in [**2160-4-13**]. At that visit he was noted to be grossly volume overloaded in the setting of omitting lasix doses while caring for his sick wife. His dose of lasix was increased with significant improvement in his symptoms. He notes that over the last 3-4 weeks, however, he has been in a slow functional decline. Overall his symptoms are now closer to NYHA class III than NYHA class II than they were in [**Month (only) 1096**] [**2159**]. - No longer has any appetite, lost ~ 6 lbs since the end of [**Month (only) **]/begining of [**Month (only) 205**] (weight this morning was 139.5 lbs). - He feels tired and fatigued (often has to take naps throughout the day); he is having difficulty sleeping due to "racing thoughts" and difficulty finding a comfortable position, but states that he is not having orthopnea or PND. His breathing has been feeling "wheezy" at times. - He has been feeling "shaky" and "unsteady", and notes that although this has been chronic, it may now be slightly worse. He feels very weak and notes that although he does not have any shortness of breath at rest, when he walks across the street to get the mail he feels profound fatigue and does get dyspnic. He is also feeling more unsteady on his feet, and has had about 3 minor mechanical falls in the last month. but has not had any other neurologic symptoms. He saw Dr. [**Last Name (STitle) 3321**] on [**7-9**] who thought the patient's symptoms might improve with a higher heart rate. His Toprol XL 50 mg twice daily was discontinued, and his pacemaker lower rate was increased from 60 to 75 bpm. He was also started on sertraline on the chance that his symptoms of fatigue and insomnia were realted to depression. Despite this change, the patient's symptoms did not significantly improve. He was seen in the heart failure clinic on [**8-8**] where he appeared significantly volume overloaded on exam today, with prominent elevation in his JVP. Addtionally his severe fatigue, loss of appetite and a resultant loss of body mass, difficultly sleeping, and severe dyspnea on exertion were felt to be from low cardiac output. Therefore he was admitted to CCU for diureisis, placement of swan and possible initiation of milrinone if he has low CI. Review of systems is otherwise negative in detail: he has no chest pain, palpitations, lightheadedness, presyncope, syncope, focal neurologic symptoms, bleeding on coumadin, fevers, chills, abdominal pain, nausea or vomiting. Review of systems is otherwise unremarkable. Past Medical History: Past Medical History: 1. Infarct related cardiomyopathy with a LVEF of 15-20% 2. Coronary artery disease status post multiple prior MIs, CABG x2 ([**2128**] and [**2138**])most recently with LIMA-LAD, SVG-PDA, SVG-OM1 at [**Hospital1 2025**] and multiple prior PCIs. 3. Status post biventricular ICD placed initially in [**2154**] and revised most recently in [**2159-3-13**], complicated by a Fidelis lead 4. Atrial fibrillation, status post multiple cardioversions, failed Tikosyn therapy, and currently on amiodarone. 5. Hypertension 6. Hyperlipidemia 7. Chronic Renal insufficiency (baseline Cr ~2) 8. Mitral regurgitation status post bioprosthetic mitral valve replacement [**2155**]. 9. Benign thyroid nodule 10. BPH status post TURP Social History: Social History: He lives with his wife who recently was hospitalized and who now is back at home. He is her primary caretaker. She is scheduled for surgery to reverse a colostomy in 2 weeks. He is a retired contractor. He quit smoking over 40 years ago but has a 30-pack-year smoking history. He currently drinks [**1-14**] alcoholic drinks a day. Family History: Family History: He had a father with diabetes, a mother with [**Name (NI) 2481**] and three sisters with diabetes, stroke, and [**Name (NI) 2481**]. He has a brother with bladder cancer, and another brother with heart issues, but is not sure of what type of heart problems he has. Physical Exam: PHYSICAL EXAMINATION: Admission Exam: VS: 75 114/78 22 97% RA GENERAL: NT, ND, NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: JVD is significantly elevated at about 16 cmH2O with prominent V-waves. He has no carotid bruits and carotid pulses are equal in volume and upstroke CARDIAC: laterally displaced PMI. He has a [**3-18**] holosystolic murmur at the right lower sternal border and a [**2-18**] holosystolic murmur at the apex. Question S3. No S4. LUNGS: mostly ctab with very faint crackles at the bases that clear with coughing. No wheezing. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. WWP. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: Admission/Relevant Labs: [**2160-8-8**] 02:20PM BLOOD WBC-7.6 RBC-4.66 Hgb-14.8 Hct-44.9 MCV-96 MCH-31.7 MCHC-33.0 RDW-15.2 Plt Ct-182 [**2160-8-8**] 02:20PM BLOOD Neuts-78.7* Lymphs-12.4* Monos-6.4 Eos-1.3 Baso-1.2 [**2160-8-8**] 02:20PM BLOOD PT-35.8* PTT-44.2* INR(PT)-3.5* [**2160-8-8**] 02:20PM BLOOD Glucose-87 UreaN-34* Creat-1.6* Na-143 K-4.2 Cl-103 HCO3-30 AnGap-14 [**2160-8-8**] 02:20PM BLOOD ALT-33 AST-45* LD(LDH)-290* AlkPhos-145* TotBili-2.8* [**2160-8-8**] 02:20PM BLOOD Albumin-4.6 Calcium-9.5 Phos-3.9 Mg-2.4 . Discharge labs: [**2160-8-14**] 05:10AM BLOOD WBC-6.6 RBC-4.34* Hgb-14.0 Hct-41.0 MCV-95 MCH-32.2* MCHC-34.1 RDW-15.1 Plt Ct-183 [**2160-8-14**] 05:10AM BLOOD PT-26.7* INR(PT)-2.6* [**2160-8-14**] 05:10AM BLOOD Glucose-89 UreaN-39* Creat-1.5* Na-140 K-3.8 Cl-96 HCO3-38* AnGap-10 [**2160-8-14**] 05:10AM BLOOD Glucose-89 UreaN-39* Creat-1.5* Na-140 K-3.8 Cl-96 HCO3-38* AnGap-10 . Office EKG ([**8-8**]) reveals A-V sequential biventricular pacing at 75 bpm with a markedly prolonged QRS of ~200 milliseconds. This is unchanged from prior. . Right Heart Cath: [**2160-8-8**] COMMENTS: 1. Limited resting hemodynamics showed elevated right sided filling pressures with an LVEDP of 17 mmHg and severely elevated left sided filling pressures with a mean pulmonary capillary wedge pressure of 44 mmHg. FINAL DIAGNOSIS: 1. Markedly elevated left and right sided filling pressures. 2. Recommend diuresis and inotropes. . CXR Port Line Placement: [**2160-8-8**] IMPRESSION: 1. Right internal jugular vascular sheath in standard position with no visible pneumothorax. 2. Congestive heart failure with interstitial edema and small effusions. . CXR [**2160-8-10**] IMPRESSION: 1. Right internal jugular sheath unchanged in position. A left-sided pacemaker also unchanged. Status post median sternotomy for CABG. The heart continues to be enlarged and has a globular configuration which could reflect cardiomegaly, although a pericardial effusion should also be considered. There is a persistent but improved vascular congestion. There is persistent retrocardiac opacity which may reflect patchy atelectasis, although pneumonia cannot be entirely excluded. There are likely small effusions. In addition, there is an apparent right upper lobe asymmetry which may represent residual pulmonary edema, although an evolving infectious process in this area cannot be excluded. Clinical correlation is advised and followup imaging should be performed as clinically indicated. No pneumothorax. . CXR [**2160-8-10**]: IMPRESSION: 1. Interval placement of a right subclavian PICC line which has its tip in the distal SVC at the cavoatrial junction. A right internal jugular introducer catheter remains in place and a left-sided pacemaker is unchanged in position. Patient is status post median sternotomy for CABG with stable cardiac enlargement with a somewhat globular configuration, most likely representing cardiomegaly, although pericardial effusion should also be considered. There is increasing perihilar and vascular fullness suggestive of mild pulmonary edema. Small layering effusions are again seen. No pneumothorax. Previously described right upper lobe asymmetry has fluctuated and therefore likely represented edematous changes rather than an infectious process. . TTE [**2160-8-13**] The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20 %). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is dilated with severe global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is moderate-to-severe pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Suboptimal image quality. Markedly dilated left ventricular cavity with severe global hypokinesis (septum contracts best). Moderate right ventricular dilation and severe systolic dysfunction. At least moderate pulmonary artery systolic hypertension. Well-seated mitral bioprosthesis with at least mild regurgitation. Moderate tricuspid regurgitation. . Compared with the prior study (images reviewed) of [**2155-6-4**], a mitral valve prosthesis is present. Left ventricle is more dilated and systolic function is more impaired. Brief Hospital Course: 80 year old man with h/o severe infarct related cardiomyopathy(EF 10-15%) with worsening class III-IV symptoms over the last 1-2 months presented with acute on chronic systolic CHF exacerbation. Patient was admitted to CCU after being seen in the heart failure clinic for diuresis and initiation of milrinone infusion. . # Acute on Chronic Systolic CHF: Patient has chronic systolic CHF [**2-14**] ischemic CMP with EF 15-20%. On presentation he appeared significantly volume overloaded with significant elevation of his JVP and crackles on lung exam. Swan was placed and showed elevated right and left sided pressures with estimated CI of 1.2. He was started on aggressive diuresis with Lasix and torsemide. He was made -6L during his 3 days of CCU stay without any significant change in his Cr. He was also started on milrinone drip. After aggressive diuresis and initiation of milrinone drip, his CI improved in the range of [**2-14**].5 and CO of 3.8 along with SVR of 1253. The swan was then discontinued. His symptoms also improved as he did not complain of any SOB at rest, his lower extremity edema improved and his lungs became more clear. He had repeat TTE which showed further dilation of left ventricle along with worsening systolic function compared to TTE in [**2155**]. It was felt that patient would benefit from milrinone infusion in the outpatient setting for which a PICC line was placed. He was sent on the floor where he continued to do well on milrinone infusion. On discharge patient's weight was 128lbs compared to his admission weight of 153lbs. Patient was discharged on 80mg of torsemide daily. He was also continued on eplerenone, lisinopril and digoxin. He will follow up in the heart failure clinic for further management of his worsening chronic CHF. Patient was also seen by physical therapy who recommended LTAC because of patient's unsteady gait. Palliative care consult was also obtained and family meeting held where Dr. [**Last Name (STitle) **] spoke to patient and his family about patient's poor prognosis. . # Hypotension: While on the floor after CCU transfer, patient was triggered for episode of hypotension however he was asymptomatic and his blood pressures have ranged in the systolic 90s throughout this admission. . # Rhythm: Patient has history of known atrial fibrillation s/p multiple cardioversion on Coumadin. He continued to be in biventricular paced rhythm. His metoprolol had been recently dced by PCP because it was felt that higher heart rate may improve his symptoms. INR slightly supratherapeutic (INR 3.5) when first admitted so warfarin was held at first then restarted. We continued amiodarone, digoxin. INR on discharged was 2.6. Patient will have next INR drawn on [**2160-8-17**] . #3v CAD s/p MI at age 47, s/p cabg and revision ([**2128**], [**2138**] resp).LIMA-LAD, SVG-OM1, SVG-RCA-PDA S/P successful BMS placement. Patient did not report any chest pain during this admission. He was continued on asprin and pravastatin. #CKD: Patient's cr remained at baseline of 1.5-1.7 even with aggressive diuresis. . # Depression: continued sertraline . TRANSITIONAL ISSUES -Decompensating CHF: patient will follow up with his cardiologist for further management of CHF and for evaluation of further milrinone infusions. Contact person is Dr. [**Last Name (STitle) **] [**Name (STitle) **] who is patient outpatient cardiologist and inpatient attending on record. - Patient weight on admission was 153 lbs; Patient's discharge weight was 128lbs. Medications on Admission: 1. Amiodarone 100 mg daily 2. Diazepam 2.5 mg daily PRN 3. Digoxin 125 mcg daily 4. Eplerenone 25 mg daily 5. Lasix 40 mg daily (had been taking twice a day until recently) 6. Potassium chloride 10 mEq daily 7. Sertraline 50 mg daily 8. Pravastatin 40 mg daily 9. Warfarin 2 mg daily 10. Aspirin 81 mg daily 11. Multivitamin daily Discharge Medications: 1. Amiodarone 100 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Diazepam 2.5 mg PO Q12H:PRN anxiety 4. Digoxin 0.125 mg PO DAILY 5. Eplerenone 50 mg PO DAILY hold for SBP < 100 6. Multivitamins 1 TAB PO DAILY 7. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours Hold for K > 4.5 8. Pravastatin 40 mg PO DAILY 9. Sertraline 50 mg PO DAILY 10. Warfarin 2 mg PO DAILY16 11. Acetaminophen 650 mg PO Q6H:PRN pain do not exceed 4 grams per day 12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 13. Lisinopril 2.5 mg PO DAILY please hold for SBP<100 14. Milrinone 0.38 mcg/kg/min IV INFUSION 15. Senna 1 TAB PO BID:PRN Constipation 16. Torsemide 80 mg PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Acute on chronic systolic congestive heart failure Coronary artery disease Atrial fibrillation 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 worsening of your heart failure and was admitted to [**Hospital1 18**]. You were given medicines intravenously to remove extra fluid and your weight is now 128 pounds. You should consider this your dry or ideal weight. You will need to take your medicines as directed every day and watch for signs of fluid overload such as decreased appetite, trouble breathing or any swelling. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] 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. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2160-8-19**] at 3:30 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 6738**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Hospital Ward Name **] [**Initials (NamePattern4) **] [**Doctor Last Name 72900**], MD Specialty: Primary Care Address: [**Street Address(2) 72901**], [**Location (un) **],[**Numeric Identifier 72902**] Phone: [**Telephone/Fax (1) 63184**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge.

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icd9cm

[ [ [] ] ]

[ "37.21", "38.93" ]

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54146

Discharge summary

report

Admission Date: [**2123-12-22**] Discharge Date: [**2124-1-1**] Date of Birth: [**2065-9-20**] Sex: F Service: MEDICINE Allergies: Morphine Sulfate / Metformin Attending:[**First Name3 (LF) 2181**] Chief Complaint: Found down/multiple metabolic abnormalities Major Surgical or Invasive Procedure: Endotracheal intubation Central line placement History of Present Illness: Patient is a 58 yo f with pmh of htn, dm2, osa, was brought to the [**Hospital1 18**] ED after she was found down at her [**Hospital3 **] facility. Patient said she fell out in the kitchen on a banana on the "5th" and couldn't get up due to pain in her back and sob. She was found by EMS covered in stool, urine, and banana peels. Patient was alert on arrival to ED but unable to describe episode. Of note, has 3L of O2 at home. . In ED, temp was 91 tympanic. Sodium was found to be 164, given 4L of IVF (last 2 were 1/2 NS with K). Her glucose was found to be critically high so she was started on an insulin drip. Also, in ed, she was found to have lateral st depressions and hypokalemia. Cardiology was called and recommended asa, bb and cycle enzymes. . Recent hospitalizations include [**3-17**] for GI bleed, fall, hypercarbic resp. failure. [**9-14**] with med overdose, hypotension. [**3-/2117**] fall, ?rhabdo. [**1-/2116**] r knee replacement. [**1-/2115**] left knee replacement. Past Medical History: DM II HTN Anxiety Depression Narcotic dependence Hypercholesterolemia OSA Social History: Lives alone in housing for disabled ([**Hospital3 **]. She attends day program. no smoking, no EtOH, no drugs. Family History: Non-contributory Physical Exam: T 96.7 BP 145/56 P 79 RR 16 O2 95% 2L NC Alert, awake, no respiratory distress PERRLA, EOMI Erythematous rash on right breast No LAD CTA anteriorly RRR, s1 s2 no m/r/g Abd: soft nt/nd +bs, no palpable hepatomegaly Ext: 2+ dp pulses, no edema, right shoulder bruise Neuro: AOx3, 4/5 strength in upper and lower extremities Pertinent Results: LABS: [**2123-12-22**] 12:35PM BLOOD WBC-12.0*# RBC-4.01* Hgb-11.4* Hct-36.5 MCV-91 MCH-28.4 MCHC-31.2 RDW-16.5* Plt Ct-307 [**2123-12-31**] 07:00AM BLOOD WBC-4.6 RBC-3.49* Hgb-9.9* Hct-31.5* MCV-90 MCH-28.4 MCHC-31.5 RDW-17.0* Plt Ct-268 [**2123-12-22**] 12:35PM BLOOD Neuts-90.3* Bands-0 Lymphs-6.2* Monos-3.0 Eos-0.1 Baso-0.3 [**2123-12-22**] 12:35PM BLOOD PT-15.5* PTT-21.7* INR(PT)-1.4* [**2123-12-31**] 07:00AM BLOOD PT-11.4 PTT-27.2 INR(PT)-1.0 [**2123-12-22**] 11:32AM BLOOD Glucose-640* UreaN-76* Creat-2.0* Na-164* K-2.9* Cl-113* HCO3-25 AnGap-29* [**2123-12-25**] 03:13AM BLOOD Glucose-239* UreaN-42* Creat-1.5* Na-148* K-3.4 Cl-110* HCO3-30 AnGap-11 [**2123-12-29**] 06:55AM BLOOD Glucose-195* UreaN-16 Creat-1.1 Na-146* K-4.4 Cl-108 HCO3-29 AnGap-13 [**2123-12-30**] 07:15AM BLOOD Glucose-122* UreaN-14 Creat-1.2* Na-138 K-3.6 Cl-101 HCO3-29 AnGap-12 [**2123-12-31**] 07:00AM BLOOD Glucose-115* UreaN-14 Creat-1.2* Na-148* K-4.5 Cl-109* HCO3-30 AnGap-14 [**2123-12-22**] 11:32AM BLOOD ALT-2047* AST-302* CK(CPK)-520* AlkPhos-240* Amylase-115* TotBili-0.8 [**2123-12-23**] 03:20AM BLOOD ALT-1188* AST-157* LD(LDH)-495* CK(CPK)-386* AlkPhos-164* Amylase-82 TotBili-0.6 [**2123-12-29**] 06:55AM BLOOD ALT-210* AST-42* LD(LDH)-393* AlkPhos-146* Amylase-64 TotBili-0.4 [**2123-12-22**] 09:43PM BLOOD Lipase-95* [**2123-12-29**] 06:55AM BLOOD Lipase-53 [**2123-12-22**] 05:45PM BLOOD CK-MB-13* MB Indx-2.7 cTropnT-0.15* [**2123-12-22**] 09:43PM BLOOD CK-MB-12* MB Indx-2.4 cTropnT-0.18* [**2123-12-23**] 03:20AM BLOOD cTropnT-0.23* [**2123-12-24**] 06:00AM BLOOD CK-MB-5 cTropnT-0.20* [**2123-12-22**] 11:32AM BLOOD Albumin-3.8 Calcium-9.6 Phos-4.1 Mg-2.6 [**2123-12-23**] 03:20AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.9 [**2123-12-30**] 07:15AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.6 [**2123-12-23**] 03:20AM BLOOD VitB12-1736* Folate-18.2 [**2123-12-23**] 03:20AM BLOOD TSH-1.3 [**2123-12-23**] 03:20AM BLOOD Free T4-1.1 [**2123-12-22**] 09:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2123-12-22**] 11:29AM BLOOD Lactate-2.3* . CT HEAD W/O CONTRAST [**2123-12-22**] 3:36 PM No evidence of acute intracranial pathology including no sign of intracranial hemorrhage. No evidence of subdural hematoma. Probable mild brain atrophy. . CHEST (PORTABLE AP) [**2123-12-22**] 1:43 PM No evidence of pneumonia. . ECG Study Date of [**2123-12-22**] 11:34:12 AM Baseline artifact. Sinus rhythm with ventricular premature beat. Consider left ventricular hypertrophy. Diffuse ST-T wave abnormalities, cannot exclude in part, ischemia but clinical correlation is suggested. Since the previous tracing of [**2123-11-15**] ventricular ectopy and ST-T wave abnormalities are now present. . ANKLE (AP, MORTISE & LAT) RIGHT [**2123-12-23**] 3:37 PM No fracture or dislocation detected about the right ankle. . ECHO Study Date of [**2123-12-23**] The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF 70%). There is no ventricular septal defect. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [**2123-3-23**], the right heart [**Doctor Last Name 1754**] are dilated, and the right ventricle is hypokinetic. . PERSANTINE MIBI [**2123-12-28**] Mild reversible perfusion defect involving the distal anterior wall and septum (LAD territory). Normal left ventricular cavity size and systolic function. Calculated LVEF of 53%. . STRESS Study Date of [**2123-12-28**] No angina or ischemic EKG changes. Nuclear report sent separately. Brief Hospital Course: 58yo female with who was found down with hyperglycemia, ARF, EKG changes and metabolic abnormalities, altered mental status. . # Mental status changes: Originally attributed to acute metabolic issues, and appears to have improved as they resolved. However, per report, patient is still not at baseline. Given significant atrophy on head CT in a 58 year old, acute delerium overlying early onset dementia is likely possibility. Also carries diagnosis of bipolar disorder, which may be playing a role. Also she is found to have UTI (see below) and this too may contribute. However, patient scored 26/28 on the Folstein MMSE and now with new finding of R-sided deafness, question of whether some of patient's confusion is not being able to hear what is being asked of her. Consider getting in touch with pt's psychiatrist or have inpatient psychiatry see patient for further evaluation. - paxil and seroquel qhs - zyprexa TID prn . # Hypernatremia: Original anion gap of 26, hypokalemia 2.9, and hypernatremic at 164. Hypernatremia may be from no access to free water and glycosuria (although hyperglycemia often causes hyponatremia). Hypokalemia also likely from hyperglycemia. Anion gap likely from starvation ketosis, less likely DKA, or toxic ingestion. After 4L IVF (mostly 1/2NS) patient's sodium decreased to 157. Due to the rapid decrease of 6 in 6 hours, stopped fluids for 2 hours took po's. Then started D5W at 100 ml/hr for a free water defecit of 6 L. Corrected too quickly to 149, drip shut off [**12-23**], but Na back to 155 morning of [**12-24**], and D5W restarted while encouraging pt to take free water. Na now 148 with PO and IV free water. Urine Na and urine osmolality not concerning for diabetes insipidus. Patient had persistent free water depletion due to poor PO fluid intake. Na repeatedly corrected with IV free water administration and PO fluids. - poor IV access, cont to encourage PO intake - monitor daily lytes . # UTI: Proteus mirabilis in urine on culture. -10 day course of bactrim DS started [**12-24**], has 3 more days left. . # OSA: Significant restrictive disease and severe OSA on sleep study with hypoxemia. TTE demonstrating RA and RV dilatation, but suggesting relatively normal right sided filling pressures. Tolerating BiPap at recommended settings. Sleep service consulted with recommendation on BiPAP listed below. [**Hospital 110971**] Medical to came into the hospital and set her up with her home equipment (BIPAP 18/11, flexi-fit mask) and she will need 4L supplemental oxygen. Anything other than those settings is not adequate and she will need to remain non-supine during sleep. -BiPAP 18/11 O2 bled in at 4L No backup rate Needs to sleep on her side at all times -albuterol nebs prn -low dose klonipin for comfort while using BiPAP -followup at [**Hospital1 18**] Sleep Center in 1 month . # NSTEMI: In ICU, patient noted to have ST depressions laterally, with elevated troponin and CK CK 520, MB 13, Trop 0.16, has trended down. Almost certainly due to metabolic derangements described above. Cardiology consult service followed from admission. TTE showed new RV dysfunction and dilated right atrium and ventricle. TTE abnormalities concerning for PE (but no hypoxia, tachycardia etc to suggest dx), also could be from her pulmonary hypertension. Restart stain on discharge. MIBI stress negative for ST changes or anginal symptoms. Nuclear portion with mild reversible perfusion defect involving the distal anterior wall and septum (LAD territory), more apparent compared to previous study in [**2117**]. Cardiology deferred catherization given patient's comorbidities, stability of perfusion defect, lack of symptoms. Study was reviewed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Cardiology. He thought it was a difficult study to interpret because of the large amount of attenuation that is present in this large woman, but he could not identify any ischemia. The fixed defect of the anterior wall is relatively characteristic of breast attenuation, which is confirmed by the normal wall motion. . Pulmonary specialist who has followed her outpatient, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], was concerned that if she has any underlying heart disease her severe sleep apnea could cause a fatal arrythmia or a recurrent infarction from recurrent desaturations and persistant pulmonary hypertension. This was discussed with Cardiology who reiterated that the MIBI results likely did not represent a new perfusion defect and it was due to attenuation of signal from body habitus. Also, catherization would necessitate anticoagulation with plavix which would be risky given patient's non-compliance with medications in the past. -continue ASA, BB, ACEi -held statin due to transaminitis, restarted on discharge -will followup with [**Hospital1 18**] Cardiology outpatient . # Elevated LFT's: ALT>AST, not likely shock liver as no evidence of hypotension and based on enzyme distribution pattern. Trending down at discharge. -continue to monitor -held statin due to transaminitis, restarted on discharge . # Hypothermia: No EKG abnormalities to suggest hypothermia, warmed nicely with bear hugger in ICU, likely related to being found down for prolonged period of time. . # ARF: Admitted with acute on chronic renal failure with Cr 2.0, while baseline .9- 1.1. Cr 1.2 at discharge. Initial urine lytes suggested prerenal etiology and renal function improved with IVF. - restarted ACEi given improvement in renal function - renally dosed meds - trend renal function outpatient - monitor urine output . # DM Now titrated back to home dose of NPH (34U/29U) with sliding scale. Pt had elevated FS in setting of receiving D5W for hypernatremia. Insulin regimen titrated accordingly. - NPH and humalog sliding scale - encourage concommittant free water PO intake - on ACEi . # HTN: Stable - on ACEi, BB . # Back pain: Extensive evaluation by ortho, neuro, L4/L5 djd - cont lidoderm patch . # Hypercholesterolemia: - held atorvastatin pending improvement of LFTs, restarted at discharge . # FEN: - diabetic, heart healthy diet . # PPX: sc heparin, ppi . # CODE: Full Code . # Contact: [**Name (NI) **] [**Name (NI) 1968**] [**Telephone/Fax (1) 110972**] . # DISPO: PT/OT cleared patient, recommended 3-4x treatments per week. She will need BiPAP machine at home prior to discharge from [**Hospital1 1501**], they should contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Pulmonary Division at [**Hospital1 18**] for notification of dispo status and information regarding the BiPAP machine. - DC to [**Hospital 8218**] Rehab - f/u with [**Hospital1 18**] Cardiology - f/u with [**Hospital1 18**] Sleep Clinic in 1 month with [**First Name9 (NamePattern2) 110973**] [**Location (un) **] ([**Telephone/Fax (1) 612**]) - f/u with [**Hospital1 18**] Pulmonary Medications on Admission: albuterol inhaler atorvastatin 40' clonazepam .5''' ditropan 5''' ferrous sulfate 325' flovent 220 mcg ibuprofen 400''''prm\n lidoderm patch lisinopril 20'' loraz prn (not to be used with clonaz) mvi nph 34/29 paxil 40' protonix 40'' seroquel 100' toprol xl 50'' Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) 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. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed. 11. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 12. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. 14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD () as needed for back pain. 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO TID (3 times a day) as needed. 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 19. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for use with BiPAP. 20. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 34 units in AM and 26 units in PM Subcutaneous once a day. 22. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: SLIDING SCALE Subcutaneous with meals and bedtime. Discharge Disposition: Extended Care Facility: [**Hospital1 10283**] Center - [**Location (un) **] Discharge Diagnosis: PRIMARY DIAGNOSES: Altered mental status Hypernatremia UTI OSA NSTEMI Transaminitis HTN Acute renal failure, now resolved DMII Back pain . SECONDARY DIAGNOSES: Hypercholesterolemia Psych/Depression GI bleed Discharge Condition: Stable. Discharge Instructions: You were admitted to the hospital after being found down and unresponsive at home. You were treated in the intensive care unit. You were stabilized and transferred to the medicine floor. Your sodium level remains high and you are to drink water (at least 8 glasses per day) to keep yourself well hydrated. You have severe sleep apnea with decrease in oxygenation levels in your blood at night. You were seen by Sleep specialist and were instructed to remain on your side while sleeping. . Please take all your medications as prescribed. Please return to the ED if you experience chest pain, shortness of breath, nausea/vomiting, confusion. . Please go to all your followup appointments for further medical management. . DC to [**Hospital 8218**] Rehab. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. Date/Time:[**2124-1-10**] 3:50 Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2124-2-8**] 4:00 Provider: [**Name10 (NameIs) **] FERN, RNC Date/Time:[**2124-1-18**] 11:00 [**Hospital1 18**] Sleep Clinic in 1 month with [**First Name9 (NamePattern2) 110973**] [**Location (un) **] ([**Telephone/Fax (1) 612**]) Completed by:[**2124-1-1**]

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Discharge summary

report

Admission Date: [**2142-6-17**] Discharge Date: [**2142-6-19**] Date of Birth: [**2111-3-2**] Sex: F Service: CHIEF COMPLAINT: Unresponsiveness. HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old female with no past medical history who presented after being found unresponsive at work. The patient is a native of El [**Country 19118**] and does not speak any English. The patient was interviewed in [**Country 8003**] after arriving to the Intensive Care Unit. Before the Intensive Care Unit, details were retrieved from her family members and Emergency Room records. The patient had reported going to work early in the morning on [**Last Name (LF) 1017**], [**2142-6-17**]. While at work she experienced some chest discomfort which she described as in the middle of her chest radiating to her shoulders and present with activity as well as at rest. She had experienced this discomfort in the past, and in the past it had been responsive to consuming water. She also notes that this discomfort is worse in the supine position. Exertion did not seem to change the discomfort significantly, and it was present also while she was inactive. A male co-worker provided her with a mix of two different fruit juices. The patient took this mixture and noted initially the discomfort improved and then worsened. As it worsened, she noticed shortness of breath and palpitations. She described feeling like she was going to die. This is the last thing she remembers before awakening in the Emergency Department intubated. She was found in the laundry department at the Holiday Inn in one of the bathrooms unable to be aroused. There was some vomitus in the oropharynx. Emergency Medical Service was called, and the patient was found to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] Coma Scale of 3. Her fingerstick was 119. She was given Narcan 0.4 mg times two without a response. She was sent to the [**Hospital1 69**] Emergency Department where she was breathing shallowly with a temperature of 95.6. She was intubated for clinical concern of airway obstruction. During the process, she was given another two doses of Narcan without improvement. She was given succinylcholine and etomidate and intubated. Upon intubation, the patient became more aroused and was bucking the ventilator and was given Ativan, Versed, succinylcholine, and propofol titrated to the maximum dose. Initially screening laboratories revealed an alcohol level of 200, and osmolar gap of 43, and an anion gap of 17. The urine toxicology and serum toxicology screens were otherwise negative. An electrocardiogram was done without significant abnormalities noted. On discussion with the brother, this incident came as a surprise to the family. The patient had been healthy and in her usual state of self before going to work in the morning. There was no history of substance abuse, or psychiatric illness, or past suicide attempts. The brother did note that the patient has been quiet and has been somewhat withdrawn since childhood. PAST MEDICAL HISTORY: No known past medical history. No hospitalizations, and no surgeries. MEDICATIONS ON ADMISSION: None known. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives with her brother and sister. She moved from El [**Country 19118**] three years ago to [**Location (un) 86**]. She has worked in laundry at the Holiday Inn for the past two years. She denied any intravenous drug use, tobacco, or alcohol. She initially denied any alcohol consumption but upon further prodding, she admitted to occasional hard alcohol consumption but denies any excessive quantities and has never had any withdrawal or backout symptoms. FAMILY HISTORY: Father died at the age of 41 of an unclear intracranial event; although, the history sounded most consistent with an intracranial bleed. Her mother is alive and well at the age of 61 in El [**Country 19118**]. The patient's brother has skin problems; not otherwise specified. PHYSICAL EXAMINATION ON PRESENTATION: Initially, the patient had a temperature of 93 which improved to 97.8 in the Intensive Care Unit. The patient's heart rate was in the 90s to 100s. The patient's blood pressure was 95 to 100/50s. Fingerstick was 111. The patient arrived on intermittent mandatory ventilation 600 X 10, 40% FIO2, breathing 13 to 14, with an arterial blood gas of 7.44/35/556. Skin examination revealed warm and dry extremities and anicteric skin. Head, eyes, ears, nose, and throat examination revealed pupils that were 2 mm bilaterally symmetric and reactive. The eyes were closed. An endotracheal tube was in place. Neck examination was supple with no lymphadenopathy, and the trachea was midline. The lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops. Abdominal examination revealed the abdomen was soft, nontender, and nondistended with normal bowel sounds. Extremity examination revealed no edema. On neurologic examination, the patient responded to touch. PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent laboratory data revealed the patient had a white blood cell count of 16.5, hematocrit was 43.2, and platelets were 324. INR was 1.1. Fibrinogen was 309. Sodium was 144, potassium was 3.8, chloride was 105, bicarbonate was 22, blood urea nitrogen was 11, creatinine was 0.6, and blood glucose was 122. Amylase was 58. Calcium was 9.5, phosphate was 5.5, and magnesium was 2.2. Serum osmolarity was 342 with an osmolar gap of 43; and when this was corrected for alcohol the osmolar gap was completely attributable to alcohol consumption. Serum toxicology screen showed an alcohol of 200, and other toxins were negative. Urine toxicology screen was negative. Urinalysis was negative. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed sinus with a question of left atrial abnormality, normal intervals, QTc of 400, early repolarization V2 through V3, and P-R depression of 1 mm inferiorly. A computed tomography of the head was negative. A chest x-ray revealed endotracheal tube was in the correct position. A nasogastric tube was in the stomach, and there were no acute cardiopulmonary processes noted. IMPRESSION: The patient was a 31-year-old female with no significant past medical history who presented with alcohol intoxication, status post intubate for airway protection. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. ALCOHOL ISSUES: The patient presented with acute intoxication which initially was unclear as to whether this was intentional by the patient or intentional by a co-worker. The patient initially presented with an anion gap and an osmolar gap. These resolved with hydration. The patient was extubated upon arrival to the Fennard Intensive Care Unit without difficulty. On interviewing the patient in her native tongue of [**Country 8003**], she did not note drinking any alcohol herself while at work initially and denied that her co-worker gave her any alcohol; although she did note that the two juices were very sweet. She did not feel like her co-worker would have tried to intoxicate her to take advantage of her in any way. She said she had known this co-worker for two years and that he was a good person and would not have tried anything. She denied any chest pain, shortness of breath, abdominal pain, vaginal pain, or discomfort, or any other symptoms attributable to sexual assault. She was asymptomatic upon arrival to the Emergency Department. A depression screen revealed that she had occasionally felt sad with regard to losing her father several years prior and has had difficulty sleeping, feelings of guilt at work, and irritability, trouble concentration, and some psychomotor slowing. She denied any fatigue, decreased energy, decreased appetite, suicidal ideation, or hallucinations. Because of concern of possible substance abuse in the setting of a primary mood disorder, Social Work was consulted and evaluated the patient. They did not find any evidence of substance abuse in the patient. On further probing, the social worker for the Intensive Care Unit as well as the Safe Transition social worker were able to develop a confidence with the patient in which she admitted that she actually was given fruit juice mixed with Bicardi rum and that both she and her co-worker were consuming this while at work. She denied any possible malintention by her co-worker, and Social Work provided her with options for counseling regarding her safety at work and deemed that the patient was safe to return back to work from a Social Work standpoint. She was arranged to have counseling through the Social Work office to discuss any anxiety or sadness that she may have as a residual from this event as well as from her transition from El [**Country 19118**] to the United States. The Legal Department was consulted, and it was felt that there was no indication for reporting this event to either the authorities or the patient's place of work. She is currently not a legal citizen of the United States and had preferred that her work not know the circumstances of her hospitalization. The patient was cautioned about accepting drinks from strangers. While in the hospital she was watched for alcohol withdrawal, given thiamine and folate, and her chemistries were followed to insure that her osmolar and anion gaps had closed. These closed within 24 hours of her admission. She was counseled against the use of alcohol, and all of the instructions regarding her safe transition back to work and home, as well as her alcohol use, were provided to her in [**Country 8003**]. She will maintain contact with the Safe Transition social worker as well as the hospital social worker. Free care was being arranged through Case Management. She was arranged to have a primary care physician to insure that her substance use is followed. 2. PSYCHIATRIC ISSUES: There was concern on the patient's presentation of substance abuse given her alcohol use in the past and the secretive nature when around her family. A positive depression screen raised concern, and Psychiatry was consulted. They did not feel that there was any need for a further psychiatric evaluation, and she was felt to be safe and did not require a one-to-one sitter. She had previously had a one-to-one sitter upon initial presentation. They did not find evidence for a primary psychiatric disorder and felt that the patient may have an underlying anxiety disorder, but they did not feel that medication at this point was prudent and that she would need followup with her primary care physician on discharge. As above, Social Work saw the patient for evaluation of safety of her work environment and whether any further reporting steps were required. The patient remained without suicidal ideation throughout her hospitalization and did not show any signs of alcohol withdrawal or other substance withdrawal. It was thought that the patient's presentation was likely wholly attributable to her alcohol intoxication. A neurological examination was performed which, in conjunction with the psychiatric examination, did not show any focal abnormalities. The patient had extraocular movements were intact. Pupils were equal, round, and reactive to light. Tongue was midline. Palate was symmetric. Cranial nerve V, root 1 to 3, were intact to light touch; and the motor division was intact to resistance. Cranial nerve [**Doctor First Name 81**] was intact to resistance. Strength was intact in the upper extremity to [**6-4**] to abduction, adduction, flexion, extension, and grip bilaterally. Strength in the lower extremity [**6-4**] to hip flexion, leg extension, leg flexion, dorsiflexion, and plantar flexion bilaterally. Deep tendon reflexes were 2+ in the patellar and Achilles and downgoing at the plantar reflexes. Light touch was intact in all four extremities and trunk. Cerebellar function was intact to rapid alternating movements bilaterally. The patient was appropriate with Psychiatry. 3. CARDIOVASCULAR SYSTEM: The patient had experienced a short-lived episode of chest discomfort that seemed to be exacerbated by food, drink, and alcohol which improved with water; unrelated really to exertion. A cholesterol panel was checked and was within normal limits. The patient was a young woman with no clear cardiac risk factors and a normal cholesterol panel. She ruled out for a myocardial infarction, and serial electrocardiogram showed no evolution of electrocardiogram changes. It was felt that her chest discomfort may have been related to gastrointestinal related chest pain from reflux disease, possible primary arrhythmia causing palpitations, or less likely ischemia given the paucity of risk factors. The patient had 48 hours of negative cardiac telemetry; making a cardiac arrhythmia less likely. The patient was arranged to have an outpatient Holter monitor. She was maintained on a proton pump inhibitor and had no symptoms while in the hospital. This supported the diagnosis of gastroesophageal reflux disease. Given the atypical nature of her symptoms and circumstances of her presentation, it would be reasonable for the patient to have an outpatient stress test with imaging to remove ischemic heart disease as a potential etiology for her discomfort. 4. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was continued on thiamine and folate, and when she was extubated introduced to regular diet. 5. PROPHYLAXIS ISSUES: The patient was out of bed and ambulatory after extubation and received a proton pump inhibitor. 6. CODE STATUS: The patient was full code. DISCHARGE DISPOSITION: The patient was discharged to home after she was cleared by both Social Work and Psychiatry. A representative from Safe Transitions evaluated the patient and will establish good followup as an outpatient. The patient was felt to be stable and safe for return to home. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was discharged with instructions to her physician or to return to the Emergency Department if she experienced any chest discomfort, shortness of breath, loss of consciousness, abdominal pain, nausea, vomiting, palpitations, or if she felt unsafe at work or at home. 2. The patient was arranged to have to followup with a new primary care physician who is [**Name9 (PRE) 45534**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) at the [**Hospital6 733**] Clinic at the [**Hospital1 1444**], [**Last Name (un) 469**] Center, sixth floor, on [**2142-7-12**] at 2 p.m. The patient was given the telephone number ([**Telephone/Fax (1) 250**]) for directions and questions. 3. The patient was arranged to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor and underwent instructions from the [**Doctor Last Name **] of Hearts monitor Laboratory with a [**Doctor Last Name 8003**] interpreter to insure that she has outpatient monitoring for arrhythmia. 4. The patient was to follow up with Safe Transitions as she had been directed by Social Work. They will aid in arranging outpatient counseling for a possible anxiety disturbance as well as to insure her safety and avoid any episodes of substance abuse. 5. The patient was to follow up with Case Management regarding establishing free care at [**Hospital1 190**]. 6. The patient's new primary care physician (Dr. [**Last Name (STitle) **] was e-mailed regarding the [**Hospital 228**] hospital course and follow-up issues required including the [**Doctor Last Name **] of Hearts monitor reports. All of the above discharge instructions were reviewed with the patient, her brother, and her sister in [**Name (NI) 8003**] by both the nurse and the physician in the Intensive Care Unit. MEDICATIONS ON DISCHARGE: The patient was discharged on Protonix 40 mg p.o. once per day. DISCHARGE DIAGNOSES: 1. Acute alcohol intoxication requiring intubation. 2. Probable gastroesophageal reflux disease. 3. Probable anxiety disorder. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. 12.AAD Dictated By:[**Last Name (NamePattern1) 5246**] MEDQUIST36 D: [**2142-6-19**] 15:49 T: [**2142-6-19**] 18:22 JOB#: [**Job Number 46230**] cc:[**Initial (NamePattern1) 46231**]

[ "305.00", "300.00", "530.81" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

13812, 14093

3761, 6528

16103, 16560

16017, 16082

3202, 3253

14175, 15990

6562, 13788

14108, 14142

148, 167

196, 3080

3103, 3175

3270, 3744

54,487

150,789

42228

Discharge summary

report

Admission Date: [**2139-9-23**] Discharge Date: [**2139-10-2**] Date of Birth: [**2060-12-12**] Sex: F Service: CARDIOTHORACIC Allergies: sulfa Attending:[**First Name3 (LF) 165**] Chief Complaint: ventricular septal defect Major Surgical or Invasive Procedure: repair of ventricular septal defect [**2139-9-23**] exploratory laparotomy [**2139-9-25**] pacement of intra aortic balloon [**2047-9-24**] History of Present Illness: This 78 year old white female presented in late [**Month (only) **] with an acute infarction and undewrwent catheterization, angioplasty and drug eluting stent to the right coronary artery. She was found to have a ventricular septal defect with left to right shunting on echocardiogram. She was assymptomatic and was sent to rehab after discharge, having been consulted by the cardiac surgical service. She continued to fail, with significant lower extremity edema and weakness. She was admitted now for repair of the defect. Past Medical History: ventricular septal defect s/p multiple back surgeries hypertension gastroesophageal reflux coronary artery disease s/p coronary angioplasty/stent s/p hysterectomy Social History: Lives alone in [**Location (un) 26671**], retired office worker. - Tobacco history: 45 years of second hand smoke exposure, never smoked herself - ETOH: Denies - Illicit drugs: Denies Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. - Mother: Died at age 87, unclear history of CAD - Father: Stroke at age 65 Physical Exam: Pulse: 81 Resp:18 O2 sat: 92% BP Right: 78/46 Left: Height: 63" Weight:132# General: Frail elderly female in no acute distress, in wheelchair Skin: Dry [x] intact [x] HEENT: PERRL [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Mostly clear bilaterally, soft bibasilar rales noted Heart: RRR [] Irregular [] Murmur [x] grade HSM [**4-12**] LSB/apex Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Cool, no cyanosis with 1+ edema Varicosities: None [x] - did not stand 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: none Left: none Pertinent Results: [**2139-9-23**] 03:20PM BLOOD WBC-23.3* RBC-3.80*# Hgb-11.2*# Hct-32.0*# MCV-84 MCH-29.5 MCHC-34.9 RDW-16.0* Plt Ct-212 [**2139-9-23**] 03:20PM BLOOD UreaN-46* Creat-1.2* Na-138 K-3.5 Cl-106 HCO3-22 AnGap-14 INTRAOPERATIVE TEE: [**2139-9-23**] PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is a post-infarction ventricular septal defect (VSD) at the basal infero-septal wall measuring 1.3 cm. Color flow doppler demonstrates a significant left to right shunt. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. The tricuspid annulus is 3.8 cm. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at time of surgery. POST-BYPASS: The patient is status post VSD repair. The patient is on an epinephrine infusion and is AV paced. This is a technically suboptimal study. There is an echogenic density at the site of the previous VSD likely representing a patch repair. There is no blood flow across the patch. There does appear to be a small jet by color flow Doppler from the LV outflow tract into the RV. The left ventricular function is preserved. Right ventricular function appears moderately depressed. Mitral regurgitation is unchanged. Tricuspid regurgitation is moderate (2+). No aortic regurgitation is seen. No aortic stenosis is seen. The ascending aorta, aortic arch, and descending aorta are intact. Brief Hospital Course: Following same day admission she was taken to the Operating Room where the defect was repaired using a Dacron patch on the muscular septum. She was weaned from bypass on Epinephrine and TEE revealed no residual defect as well as minimal tricuspid and mitral regurgitation and the valves were left untouched. After transfer to the CVICU she required a moderate amount of volume resuscitation and awoke intact. She was subsequently extubated. She became hemodynamically unstable and progressively acidotic. Cardiac catheterization was performed on [**9-25**] demonstrating patent grafts and an intra aortic balloon was placed. Exploratory laparotomy was performed which reveaed low flow ischemic small bowel. She was resuscitated and prerssors resumed. Her renal function deteriorated and CVVH was instituted on [**9-26**]. She developed ischemic feet and hands with sloughing of skin and coldness. The balloon pump was removed. She remained in multisystem organ fsailure on multiple pressors. Family meetings were held and on [**10-1**] a DNR staus was begun. In keeping with family wishes she was made CMO on the 26th. She was extubated and all pressors discontionued. With the family at bedside, she expired at 15:08 on [**2139-10-2**]. Medications on Admission: Aspirin 81mg daily,Plavix 75 mg daily, Amiodarone 200mg daily, Lipitor 40mg daily,Citalopram 10mg daily, Clonazepam 0.5mg,Furosemide 40mg daily, Lidocaine Patch, Lisinopril 5mg daily, Metoprolol 25mg [**Hospital1 **], Actos 30mg daily, Pregabalin 50mg daily, Ranitidine, Ultram, Vit D,Calcium, Senna and Colace Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: ventricular septal defect coronary artery disease chronic back pain s/p coronary stent noninsulin dependent diabetes mellitus s/p multiple back surgeries s/p cholecystectomy s/p hysterectomy Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2139-10-2**]

[ "038.9", "401.9", "287.49", "427.31", "428.43", "785.4", "518.5", "286.9", "410.42", "995.92", "276.1", "285.1", "276.2", "789.59", "250.00", "785.51", "428.0", "444.21", "998.59", "584.5", "570", "429.71", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "37.23", "88.56", "88.72", "88.53", "39.95", "54.11", "35.72", "39.61", "99.62", "37.61", "96.72" ]

icd9pcs

[ [ [] ] ]

6080, 6089

4436, 5689

298, 440

6324, 6333

2337, 4413

6386, 6512

1404, 1569

6051, 6057

6110, 6303

5715, 6028

6357, 6363

1584, 2318

233, 260

468, 999

1021, 1186

1202, 1388

67,421

134,286

45474

Discharge summary

report

Admission Date: [**2156-1-27**] Discharge Date: [**2156-2-4**] Date of Birth: [**2082-2-9**] Sex: F Service: MEDICINE Allergies: Latex Attending:[**First Name3 (LF) 2763**] Chief Complaint: ILI, hypotension Major Surgical or Invasive Procedure: L percutaneous nephrostomy History of Present Illness: 73yo woman hx rectovaginal fistula, DM, kidney stones p/w ILI x2d, mild abd pain, decreased PO intake. Pt was found to have BP 74/44, HR 96, WBC 5-->21 with 16% bandemia, cr 3.6, lactate 6.7, INR 1.6. She was started on IVF, received 5L NS total. U/a showed small leuks, small blood, occasional bacteria. Pt had poor access so central line was placed and levophed was started. She was also given Vanc 1g IV and zosyn 4.5g IV (@0045). CVP 15. CT showed 6 mm stone in proximal left ureter with proximal dilation and left perinephric inflammation. Pt became increasingly acidotic and was tired by the work of breathing so she was intubated 100%/500/16/5. 7.22/41/294/18, so respiratory rate was increased to 22. Pt was also enrolled in the thiamine during sepsis study. . On arrival to the floor the pt was intubated and sedated. T 102 HR 96 BP 113/53 Sat 100%. CVP 9. She was anuric. Urology and IR were consulted for placement of percutaneous nephrostomy tube. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1) DM 2) HTN 3) nephrolithiasis 4) rectovaginal fistula 5) Diverticulitis, s/p temp colostomy tube in [**2150**] and abscess removal 6) UTI in [**2154**] Social History: Lives at home with granddaughter who is her primary caretaker. - Tobacco: None - Alcohol: None - Illicits: None Family History: NA Physical Exam: Admission PE: General: Intubated and sedated obese woman HEENT: MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diffuse rhonchi, no wheezes or rhales CV: Tachycardic regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place, little urine Ext: very warm, well perfused, 2+ pulses, no clubbing, cyanosis 1+ bl edema Pertinent Results: ADMISSION LABS: . [**2156-1-26**] 10:00PM WBC-5.6# RBC-3.95* HGB-10.6* HCT-30.0* MCV-76* MCH-26.8* MCHC-35.3* RDW-14.9 [**2156-1-26**] 10:00PM NEUTS-85* BANDS-9* LYMPHS-5* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2156-1-26**] 10:00PM ALBUMIN-3.3* [**2156-1-26**] 10:00PM LIPASE-14 [**2156-1-26**] 10:00PM ALT(SGPT)-25 AST(SGOT)-26 ALK PHOS-129* TOT BILI-1.1 [**2156-1-26**] 10:00PM GLUCOSE-191* UREA N-56* CREAT-3.9*# SODIUM-136 POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-18* ANION GAP-24* [**2156-1-26**] 09:47AM URINE HOURS-RANDOM UREA N-215 CREAT-244 SODIUM-25 POTASSIUM-62 CHLORIDE-10 [**2156-1-26**] 10:03PM LACTATE-6.7* . [**2156-1-27**] 01:50AM WBC-21.0*# RBC-3.65* HGB-9.8* HCT-27.4* MCV-75* MCH-26.9* MCHC-35.8* RDW-15.0 [**2156-1-27**] 01:50AM NEUTS-82* BANDS-16* LYMPHS-1* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2156-1-27**] 01:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-3+ POLYCHROM-NORMAL [**2156-1-27**] 01:50AM GLUCOSE-212* UREA N-54* CREAT-3.6* SODIUM-138 POTASSIUM-3.0* CHLORIDE-105 TOTAL CO2-19* ANION GAP-17 [**2156-1-27**] 01:52AM LACTATE-2.4* [**2156-1-27**] 04:52AM LACTATE-2.9* [**2156-1-27**] 06:19AM FIBRINOGE-600* [**2156-1-27**] 06:19AM PT-17.7* PTT-29.3 INR(PT)-1.6* [**2156-1-27**] 06:19AM PLT COUNT-104* [**2156-1-27**] 06:19AM HAPTOGLOB-218* [**2156-1-27**] 06:19AM ALT(SGPT)-27 AST(SGOT)-31 LD(LDH)-187 CK(CPK)-298* ALK PHOS-103 TOT BILI-0.8 [**2156-1-27**] 06:19AM CK-MB-6 cTropnT-0.02* [**2156-1-27**] 12:49PM FIBRINOGE-607* [**2156-1-27**] 12:49PM PT-17.3* PTT-31.4 INR(PT)-1.5* [**2156-1-27**] 12:49PM FDP-40-80* [**2156-1-27**] 08:00PM CORTISOL-43.2* . STUDIES: CT ABD/PELVIS [**2156-1-27**]: multiple left renal stones. 6 mm stone in proximal left ureter with proximal dilation and left perinephric inflammation. presence of infection /pyelo not well assessed on non-IV contrast exam. . EKG: Sinus tachycardia diffuse t-wave flattening, no STE or STD. . CXR [**2-2**]: HISTORY: Gram-negative sepsis. Intubated. IMPRESSION: AP chest compared to [**1-30**] through 30: Previous mild pulmonary edema has cleared. Moderate cardiomegaly is chronic. Thoracic aorta is generally large, probably dilated anteriorly, but not changed acutely. No evident pleural effusion or consolidation. Nasogastric tube ends in the upper stomach. Right jugular line in the low SVC. No pneumothorax. . DISCHARGE LABS: [**2156-2-4**] 05:52AM BLOOD WBC-26.2* RBC-3.35* Hgb-8.8* Hct-25.0* MCV-75* MCH-26.3* MCHC-35.3* RDW-17.0* Plt Ct-217 [**2156-2-4**] 05:52AM BLOOD Plt Ct-217 [**2156-2-1**] 05:40AM BLOOD FDP-10-40* [**2156-2-4**] 05:52AM BLOOD Glucose-86 UreaN-42* Creat-1.3* Na-148* K-3.9 Cl-110* HCO3-33* AnGap-9 [**2156-1-30**] 03:59AM BLOOD ALT-51* AST-31 LD(LDH)-158 AlkPhos-130* TotBili-0.3 [**2156-2-4**] 05:52AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.9 [**2156-2-3**] 04:42AM BLOOD Type-ART Temp-37.2 Rates-/20 pO2-71* pCO2-36 pH-7.54* calTCO2-32* Base XS-7 Intubat-NOT INTUBA Vent-SPONTANEOU Brief Hospital Course: 73 year-old female with diabetes mellitus, hx rectovaginal fistula and nephrolithiasis admitted to medical ICU with septic shock from gram negative bacteremia from left ureteral stone obstruction complicated by acute kidney failure and hypoxemic respiratory failure. # Septic shock with multiple end organ system dysfunction: Pt presented with complaints of ILI, was found to be hypotensive, febrile with a leukocytosis and bandemia, in [**Last Name (un) **], with an elevated INR and thrombocytopenia. She was found to have e.coli sepsis 2/2 L ureteral stone obstruction with resultant hydronephrosis and perinephric stranding. Pt was initially fluid resuscitated and then required pressure support with Levophed. She was started on Vanc/Zosyn, narrowed to ceftriaxone and subsequently broadened to vanc/[**Last Name (un) 2830**] out of concern for additional VAP. She underwent left percutenous nephrostomy by inteventional radiology. Xigris was initiated x96h. The pt was also treated with hydrocortisone 50mg q6h x5days. . # Hypoxemic respiratory failure: Patient intubated and sedated after tiring from increased work of breathing. Increased work of breathing likely [**2-4**] acidemia from sepsis and hyperchloremic acidosis [**2-4**] fluid resuscitation. CXR subsequent to large volume fluid resuscitation showed increased bilateral infiltrates. Pt was started on a lasix gtt with significant diuresis. She was also treated for presumed VAP with vanc/[**Last Name (un) 2830**]. On [**2-1**] the pt was able to be successfully extubated. . # Ventilator Associated Pneumonia: The patient developed increasing secretions, elevated WBC and low-grade fever while intubated, concerning for ventilator associated pneumonia. She was started on Vancomycin/meropenem/ciprofloxacin on [**2156-2-1**] and her O2 status continued to improve. This was narrowed to Meropenem/Vanc, which she should continue until [**2156-2-10**]. . #. Oliguric Acute on Chronic Kidney Injury: Pt with chronic kidney disease likely [**2-4**] DM and HTN. Admitted with creatinine of 3.9 which is increased from baseline of 1.5. Likely due to hydronephrosis from L ureteral obstruction as well as ATN from sepsis. Improved with percutaneous nephrostomy and volume resuscitation. Avoided nephrotoxins and renally dose all medications. Nehrology followed. No indications for CVVH. Creatinine on DC [**2156-2-4**] was 1.3 and her urine output was back to baseline. . #. Hypernatremia: The patient developed persistent hypernatremia with a peak of 152 on [**2156-2-3**]. She was treated with 250 cc free water boluses every four hours, and her Na was 148 at the time of discharge. Her tube feeds were subsequently discontinued, at which time she was encouraged to take in approximately 1-1.5L of free water by mouth. She should continue to have her Na checked daily upon discharge to the LTAC, and she should be encouraged to drink approximately 1 L in free water until this value normalizes. . #. Atrial fibrillation with RVR: The patient went into AFib with RVR on [**2-27**] in the setting of sepsis. She was started on Amiodarone and converted into sinus rhythm o [**3-1**]. The amiodarone was discontinued on [**2-3**], and she has remained in NSR since this time. . #. Elevated blood glucose: The patient has a history of type 2 diabetes, and her blood sugars have been labile on this admission in the setting of sepsis and tube feeds. She was placed on a insulin drip during this admission, and this was eventually transitioned to standing Lantus 30 U daily and a humalog insulin sliding scale. Her tube feeds were discontinued on [**2156-2-4**], and it is possible that her insulin requirement will decrease. Her blood sugars should be checked qid, and her lantus dose should be adjusted as needed. . # Communication: - HCP: [**Name (NI) 14387**] [**Name (NI) **] (granddaughter): [**Telephone/Fax (1) 97030**] - son: [**Name (NI) **] [**Name (NI) 6930**]: [**Telephone/Fax (1) 97031**] - daughter: [**Name (NI) **] [**Name (NI) **]: [**Telephone/Fax (1) 97032**] . # Code: Full (discussed with HCP and pt per [**Name (NI) **]) Addendum: PICC placement was attempted prior to discharge without success. Medications on Admission: Medications: (verified with home list) 1) Amlodipine 10mg daily 2) HCTZ 25mg daily 3) Repaglinide 2mg [**Hospital1 **] 4) Tramadol 50mg 1 tab q6h prn 5) Valsartan 320mg daily 6) Aloe [**Doctor First Name **] 800mg daily 7) D-[**2145**] 1 capsule daily 8) MVI 1 tab daily Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Septic Shock with E.Coli bacteremia Anuric Acute on Chronic Kidney Injury Ventilator Associated Pnemonia Diabetes Atrial Fibrillation . Secondary: Diabetes Mellitus Type 2 Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital due to an infected kidney stone in your ureter that caused you to go into septic shock. You were provided with IV antibiotics to treat your infection. Due to your systemic infection, you also went into respiratory failure and were intubated for several days. You also developed a pneumonia while intubated that was treated with antibitics. You were extubated when you were able to breathe on your own. You were discharged with a PICC line in place. Please make sure to take your IV antibiotics as prescribed through [**2156-2-8**]. . While you were here, we made the following changes to your medications: 1. We STARTED you on Vancomycin and Meropenem for your infections. You should continue both of these medications until [**2156-2-8**]. 2. We STARTED you on Lantus and a humalog insulin sliding scale for your diabetes 3. We STARTED you on ipratropium and albuterol nebulizations, as needed, for shortness of breath 4. We STARTED you on senna and colace for constipation 5. We STOPPED your Valsartan, given your acute renal injury. 6. We STOPPED your Repaglinide Followup Instructions: Department: SURGICAL SPECIALTIES When: MONDAY [**2156-2-16**] at 10:00 AM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please make a follow-up appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], upon discharge from [**Hospital 100**] Rehab. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2156-2-4**]

[ "250.40", "427.31", "585.9", "995.92", "785.52", "276.2", "518.81", "584.5", "038.42", "403.90", "583.81", "592.1", "591", "278.00", "590.10", "287.5", "997.31", "276.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "00.11", "38.97", "96.04", "55.03" ]

icd9pcs

[ [ [] ] ]

10157, 10223

5642, 9835

281, 309

10448, 10448

2606, 2606

11757, 12344

2090, 2094

10244, 10427

9861, 10134

10628, 11734

5040, 5619

2109, 2587

1318, 1766

225, 243

337, 1299

2622, 5024

10463, 10604

1788, 1944

1960, 2074

40,120

146,466

49925

Discharge summary

report

Admission Date: [**2120-1-27**] Discharge Date: [**2120-2-12**] Date of Birth: [**2045-4-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Cardiac Catheterization Abdominal fat pad biopsy History of Present Illness: The patient is a 74 y/o M with PMHx significant for HTN, COPD, dCHF (last EF 55% with LVH), who was initially admitted to the [**Hospital1 1516**] service earlier this evening for shortness of breath and leg swelling. On presentation, he complained of worsening DOE over the past few weeks, with associated PND and orthopnea. He also was experiencing bilateral leg and scrotal swelling. He triggered for hypotension in the ED and was given 1 L NS, with improvement of his BP. ECG in the ED was noted to [**Location (un) 381**] voltage, poor R wave progression, TWI in V5-V6; CXR showed BL pleural effusions. Labs in the ED showed an elevated creatinine to 2.2 from a baseline of 1.9, an elevated BNP, and a troponin of 0.24 with negative CK. In the ED, he was given aspirin and treated with azithromycin and nebs for CPOD exacerbation. On admission, it was thought that the patient's symptoms represented an exacerbation of his underlying heart failure. He was given lasix (20 mg IV x 1) and carvedilol (3.215 mg x 1). Within 1 hour of receiving these medications, his SBP dropped to 70/50 (from the 110's systolic). He was noted to have a pulsus of 5 and low voltage on ECG. The cardiology fellow was called out of concern for potential tamponade. The patient was tranferred to the CCU for further management at that time. On arrival to the CCU, the patient's VS were T 97.3; BP 66/32; HR 55; RR 14; SaO2 98% on 2L NC. He complained of nausea and had some episodes of dry heaves. He did complain of chest discomfort during these episodes. He denied any shortness of breath. He placed on peripheral dopamine and levophed while central access was established. Emergent bedside echo revealed moderate LVH, normal LV function, mild RVH and mild depressed/borderline RV function. Attempts to float a Swan-Ganz catheter were unsuccessful. However, the patient was quickly able to maintain a stable blood pressure on a small dose of levophed. On further questioning, the patient denied any recent fevers, chills, night sweats, or recent illnesses. He admitted to a chronic cough productive of clear sputum but denied any recent changes in this. He denied any headaches, visual changes, chest pain, nausea, vomiting, bowel changes, urinary symptoms, focal numbness/weakness, or skin rashes. He did complain of a "tiredness" in his neck today. Past Medical History: HTN COPD Angina systolic CHF with EF 48% per MIBI in [**3-29**] PUD/gastric outlet obstruction s/p partial gastrectomy OA s/p R knee replacement hemorrhoidectomy h/o alcoholism gout vit B12 deficiency iron deficiency anemia enlarged prostate Social History: The patient recently moved into senior housing. Reports histoy of drinking [**11-25**] pint of vodka per night, quit three months ago. Smokes two cigarettes per day, long history of heavy smoking. Denies other drug use. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T= 97.3; BP= 130/96; HR= 93; RR= 17; O2 sat= 98% on 2L NC GENERAL: 74 y/o M in NAD. Oriented. Mood, affect appropriate. HEENT: NC/AT. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma noted. NECK: Supple with JVP of [**8-2**] cm. CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Rhonchi/coarse breath sounds throughout. No significant crackles or wheezes noted. Decreased breath sounds at the bases. ABDOMEN: Soft. Non-tender. Somewhat distended. Bowel sounds present. No masses appreciated. EXTREMITIES: Pitting edema in the bilateral LE's to the thighs. ?slightly greater on the R. TTP of the distal RLE. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas noted. PULSES: Right: DP 1+ / PT by doppler / Radial 2+ Left: DP 1+ / PT by doppler / Radial 2+ Pertinent Results: Admission Labs [**2120-1-27**] 05:15PM BLOOD WBC-6.5 RBC-3.27* Hgb-8.1* Hct-25.8* MCV-79* MCH-24.8* MCHC-31.4 RDW-18.5* Plt Ct-210 [**2120-1-27**] 05:15PM BLOOD Neuts-59.1 Lymphs-31.3 Monos-7.0 Eos-1.9 Baso-0.6 [**2120-1-27**] 05:15PM BLOOD PT-12.8 PTT-30.9 INR(PT)-1.1 [**2120-1-27**] 05:15PM BLOOD Glucose-88 UreaN-44* Creat-2.2* Na-142 K-4.3 Cl-111* HCO3-22 AnGap-13 [**2120-1-27**] 05:15PM BLOOD ALT-21 AST-20 CK(CPK)-87 AlkPhos-137* TotBili-0.4 [**2120-1-27**] 05:15PM BLOOD Calcium-8.7 Phos-5.0* Mg-1.6 Discharge Labs [**2120-2-12**] 05:15AM BLOOD WBC-8.5 RBC-3.43* Hgb-8.4* Hct-26.8* MCV-78* MCH-24.6* MCHC-31.5 RDW-20.0* Plt Ct-282 [**2120-2-12**] 05:15AM BLOOD PT-14.1* PTT-44.6* INR(PT)-1.2* [**2120-2-12**] 05:15AM BLOOD Glucose-91 UreaN-49* Creat-2.6* Na-138 K-4.5 Cl-109* HCO3-20* AnGap-14 [**2120-2-12**] 05:15AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.2 Cardiac Biomarkers [**2120-1-27**] 05:15PM CK(CPK)-87 cTropnT-0.24* [**2120-1-28**] 02:38AM CK(CPK)-81 CK-MB-NotDone cTropnT-0.21* [**2120-1-28**] 04:30PM CK(CPK)-81 CK-MB-4 cTropnT-0.21* proBNP-[**Numeric Identifier 104275**]* Other Labs [**2120-1-31**] 05:09AM BLOOD calTIBC-261 Ferritn-282 TRF-201 [**2120-1-28**] 02:38AM BLOOD Triglyc-207* HDL-21 CHOL/HD-5.0 LDLcalc-44 [**2120-1-28**] 02:38AM BLOOD TSH-3.6 [**2120-1-28**] 02:38AM BLOOD Cortsol-14.1 [**2120-1-28**] 02:38AM BLOOD PEP-ABNORMAL T IgG-354* IgA-1000* IgM-9* IFE-MONOCLONAL Urine Studies [**2120-1-29**] 09:55AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009 [**2120-1-29**] 09:55AM URINE Blood-SM Nitrite-NEG Protein-150 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2120-1-29**] 09:55AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [**2120-1-29**] 09:55AM URINE Eos-POSITIVE MICROBIOLOGY Blood Cx Negative x 5 Urine Cx Negative x 1 C.Diff Positive x 1 ([**2-3**]) IMAGING CXR ([**2120-1-27**]) - IMPRESSION: Marked enlargement of the previously noted left pleural effusion with and emergence of a moderate-to-large size right pleural effusion well. Atelectasis in the lung bases is stable, although pneumonia or aspiration cannot be excluded. ECHO ([**2120-1-28**]) - The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with normal free wall contractility. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. Mild (1+) mitral regurgitation is seen. There is a very small pericardial effusion. IMPRESSION: Biventricular hypertrophy with preserved global and regional systolic function. Mild mitral and tricuspid regurgitation. RENAL U/S ([**2120-1-28**]) - IMPRESSION: 1. No hydronephrosis. Bilateral renal cysts. 2. Incomplete evaluation of renal vasculature. A repeat examination can be obtained when the patient is clinically more stable. ECHO ([**2120-1-29**]) - The left atrium is mildly dilated. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). 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 but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. There is a large left pleural effusion. Compared with the prior study (images reviewed) of [**2120-1-28**], moderate pulmonary artery systolic hypertension and increased PCWP are now identified. A large left pleural effusion is also now seen. CARDIAC CATH ([**2120-1-29**]) - FINAL DIAGNOSIS: 1. Mild biventricular diastolic dysfunction. 2. Vasodilatory hypotension. 3. Moderate pulmonary hypertension. 4. Elevated cardiac output/index on and off of levophed. KUB - IMPRESSION: 1. Circular area of air overlying the mid-abdomen of uncertain etiology. This may represent a dilated loop of small or large bowel, or even be related to the cecum. A cecal volvus is not entirely excluded. Please clinically correlate with patient's symptoms and a CT can be obtained. 2. Bilateral pleural effusions. Consolidation at the left lung base is not fully evaluated on this abdominal radiograph. Diagnostic considerations include atelectasis versus airspace disease. Dedicated chest radiograph may be warranted. Soft tissue (abdominal wall fat), biopsy: Adipose tissue with features consistent with amyloid deposition. Skeletal Survey - FINDINGS: Marked generalized inhomogeneity of the spongiosa, notably in the area of the right more than the left humerus. However, no safe detection of osteolytic lesion that would affect the cortex. No evidence of vertebral compression. Brief Hospital Course: 74 y/o M with history of HTN, COPD, dCHF (last EF 55% with LVH), admitted with suspected CHF exacerbation, found to be hypotensive shortly after admission and transferred to the CCU. # Hypotension / Heart Failure: Pt presented with symptoms concerning for heart failure exacerbation. Was also noted to be significantly hypotensive on arrival to the floor, requiring transfer to the CCU. Echo on presentation showed biventricular hypertrophy with preserved global and regional systolic function. However, ECG showed low voltage. This was concerning for an infiltrative process in the myocardium, in particular amyloidosis. Patient's hypotension persisted, and he continued to required pressors. Extensive work-up, including [**Last Name (un) 104**]. stim, was unrevealing. Ultimately, it was felt that the patient's hypotension was due to autonomic dysfunction in the setting of amyloidosis. He was started on midodrine. SPEP was performed and revealed monoclonal IgA kappa. Eventually, the patient underwent a fat pad biopsy, which was positive for amyloidosis. He was seen by the heme/onc consult service, who recommended follow-up with Dr. [**Last Name (STitle) **] as an outpatient. He will possibly need a bone marrow biopsy as an outpatient. He was also recommended to f/u with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as an outpatient for managment of his presumed cardiac amyloidosis. # Acute on Chronic Renal Failure: Creatinine on admission was 2.2 with a recent baseline of 1.9. [**Hospital 8351**] medical record review reveals worsening of the patient's renal fxn over the past few months. It was felt that the patient's renal failure was likely related to amyloidosis. The patient was initially diuresed; however, he eventually had decreasing urine output. He was followed by renal, who ultimately felt that he was developing an ATN-type picture. This was likely related to his hypotension and poor blood flow to his kidneys. Diuresis was held and, by the time of discharge, the patient's renal function was improving. He was discharged with renal follow-up. # LE Edema: Was felt to be related to hypoabuminemia as well as right-sided heart failure. The patient was seen by nutrition while in house. # Microcytic Anemia: Recent iron studies in [**2119-12-25**], show evidence of iron deficiency anemia. Colonoscopy in [**2114**] was normal. The patient's hematocrit remained relatively stable throughout his admission. He was continued on iron supplementation. # Hypertension: Antihypertensives held [**12-26**] hypotension as above. # Elevated LFT's: Pt noted to have an elevated alkaline phosphatase. This should be followed as an outpatient. Medications on Admission: Aspirin 81mg daily Thiamine 100mg daily Folic acid 1mg daily MVI maalox PRN IPRATROPIUM-ALBUTEROL 18 mcg-103 mcg 2 puffs inhaled twice a day LISINOPRIL-HYDROCHLOROTHIAZIDE 10 mg-12.5 mg once a day NITROGLYCERIN 0.4 mg PRN OMEPRAZOLE 40 mg DAILY CYANOCOBALAMIN 500 mcg 4 Tablet(s) by mouth 4 x a day Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**11-25**] nebs Inhalation Q6H (every 6 hours) as needed for sob, wheezing. 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 9. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. Discharge Disposition: Extended Care Facility: Radius Discharge Diagnosis: Primary Amyloidosis with autonomic dysfunction. Secondary Congestive Heart Failure Clostridium Difficile Infection Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted to the hospital because you had difficulty breathing and shortness of breath. Your blood pressures stayed low despite our interventions and this made us consider that you might have an infiltration of the heart muscle called amyloidosis. A biopsy of the fat pad from your belly showed that you did indeed have amyloidosis. There is a possibility that you have amyloidosis because you have an underlying malignancy. An oncologist saw you in the hospital and will see you as an outpatient as well for a full work up. The following changes have been made to your medications: -added metronidazole 750mg every 8 hours until [**2120-2-20**] for a total 14-day course. -added atorvastatin 80mg daily -added ranitidine 150mg daily (in place of omeprazole) -added midodrine 10mg TID -added multivitamin/thiamine/folate daily -added tylenol 650mg q6 H: PRN fever -added ipratropium bromide and albuterol nebs every 6 hours as needed PRN sob. -added aspirin 81mg once daily -added subcutaneous heparin for DVT prophylaxis -stopped lisinopril-hydrochlorothiazide Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: - You should follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **] in hematology-oncology. His office number is [**Telephone/Fax (1) 3237**]. - You should also follow-up with Dr. [**Last Name (STitle) **] within 1-2 weeks of your discharge. You can call his office at [**Telephone/Fax (1) 250**] to arrange an appointment. - You also have a follow-up with the kidney doctors: Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2120-3-27**] 9:00 - You should also follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who specializes in your condition. His office number is ([**Telephone/Fax (1) 22912**]. Please call his office to set-up an appointment in 2 weeks.

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icd9cm

[ [ [] ] ]

[ "37.23", "88.56", "38.93", "88.53", "83.21" ]

icd9pcs

[ [ [] ] ]

13509, 13542

9356, 12050

326, 377

13702, 13702

4245, 8243

15067, 15871

3262, 3344

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3025, 3246

55,477

184,325

44242

Discharge summary

report

Admission Date: [**2157-11-15**] Discharge Date: [**2157-11-17**] Date of Birth: [**2074-7-9**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1115**] Chief Complaint: fatigue/dizziness Major Surgical or Invasive Procedure: EGD History of Present Illness: Mr [**Known lastname 94895**] is a pleasant 83-year-old male with hx of afib who presents today with fatigue, dizziness and shortness of breath without chest pain for the past several days as well as 3d of black stools, also abd pain. He is unable to stand up at this time without significant dizziness. He also states that he went into afib 2 days ago and had some SOB with this, which is was found to have a SBP in 60s with standing, therefore was sent to the ED. Of note, he has been taking diclofenac with misoprostol TID x30-40 yrs. In the ED, initial vs were: 97.7 84 92/64 16 100%. Labs were notable for a crit of 26.1 (baseline normal), creatinine of 1.3, INR of 3.3. He was found to have heme + black stool, NG lavage showed coffee grounds not completely cleared with 200 ccs, NG removed by GI and pt now refusing. Patient was given pantoprazole and GI was consulted and recommended admission to the unit for urgent scope. Received 2 U PRBCs. Pressures 100 systolic. Access: 20, 16. On the floor, pt is asymptomatic, stating that his abd pain has been resolved for 15 hrs. He complains of intermittent, crampy urinary pain which has been occurring ever since foley placement. Past Medical History: -Atrial fibrillation -glaucoma -osteoarthritis -spinal stenosis -status post bilateral cataract surgery -total R hip replacement Social History: retired, lives alone Smoking: no tobacco Alcohol: Occasional Marijuana + Family History: mother with afib, dad with stroke, arthritis, brother with cardiac disease Physical Exam: ADMISSION EXAM: Vitals: T:96.9 BP:121/61 P:75 R:75 O2: 99% 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, rhonchi CV: irregular 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 in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly intact in all extremities Discharge PEx: VS: 96.2 119/64 59 (afib) 18 98%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2157-11-15**] 04:55PM BLOOD WBC-11.0 RBC-2.72*# Hgb-9.2*# Hct-26.1*# MCV-96 MCH-33.6* MCHC-35.1* RDW-14.0 Plt Ct-267 [**2157-11-15**] 04:55PM BLOOD Neuts-77.2* Lymphs-18.3 Monos-3.6 Eos-0.5 Baso-0.3 [**2157-11-15**] 04:55PM BLOOD PT-33.0* PTT-29.2 INR(PT)-3.3* [**2157-11-15**] 04:55PM BLOOD Glucose-125* UreaN-62* Creat-1.3* Na-142 K-4.4 Cl-108 HCO3-27 AnGap-11 [**2157-11-16**] 01:46AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.9 URINE: [**2157-11-16**] 01:44AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.018 [**2157-11-16**] 01:44AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD [**2157-11-16**] 01:44AM URINE RBC-54* WBC-5 Bacteri-NONE Yeast-NONE Epi-<1 TransE-<1 [**2157-11-16**] 01:44AM URINE CastHy-1* [**2157-11-16**] 01:44AM URINE Mucous-RARE MICRO: [**2157-11-15**] MRSA screen: pending [**2157-11-16**] UCx: no growth [**2157-11-16**] Hpylori: pending STUDIES: [**2157-11-16**] EGD: Abnormal mucosa in the esophagus Abnormal fold noted in cardia, possible diverticula Abnormal mucosa in the stomach Ulcer in the antrum Friability and erythema in the duodenal bulb compatible with duodenitis Otherwise normal EGD to third part of the duodenum Recs: Prilosec 40mg [**Hospital1 **] Please send H. pylori serology The gastric ulcer was the likely source of his bleeding. Given the appearance of the ulcer he is at a low risk to re-bleed. Avoid all NSAIDs He will need a repeat EGD in [**6-8**] weeks. . EKG ([**2157-11-16**]): Atrial fibrillation with a controlled ventricular response. Non-specific ST-T wave changes. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 83 0 90 392/432 0 30 -85 Brief Hospital Course: Mr. [**Known lastname 94895**] is a pleasant 83 yo gentleman with afib, on coumadin, presenting with dizziness, fatigue, coffee grounds by NG concerning for UGIB. #. UGIB: Patient admitted with upper GIB - EGD showed non-bleeding gastric ulcer. Patient was transfused a total of 5units pRBCs and 2units FFP. Patient should discontinue all NSAIDs. Holding anticoagulation with Coumadin for now - can re-assess risks/benefits as an outpatient with PCP. [**Name10 (NameIs) 94896**] from PPI gtt to omeprazole 40mg [**Hospital1 **]. Hpylori serology pending. . # [**Last Name (un) **]: Likely due to volume depletion, prerenal state. Improved to 1.0 with pRBCs. #. dysuria: intermittent, started with foley placement, most likley foley trauma vs bladder spasm, Urine culture negative. # afib: rate controlled with atenolol. Warfarin held, PCP [**Name Initial (PRE) 13109**]. Continued Dronedarone and Digoxin. # Glaucoma: continued home eye drops. . . Code status: Full . . Transitional Issues: --Patient to follow up with PCP [**Last Name (NamePattern4) **]: recent hospitalization, discontinuation of NSAIDS and coumadin. --Patient has an H pylori serology pending, we will contact the patient once results return. --Per patient, he follows with cardiology as outpatient regarding coumadin for afib, he wanted to make outpatient appointment himself and will call his cardiologist to discuss when to restart coumadin. --Patient to have GI follow up as outpatient and repeat EGD in [**6-8**] weeks; appointments are listed below. Medications on Admission: ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth daily DICLOFENAC-MISOPROSTOL [ARTHROTEC 50] - 50 mg-200 mcg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth TID DIGOXIN - (Prescribed by Other Provider) - 250 mcg Tablet - 0.5 (One half) Tablet(s) by mouth daily DRONEDARONE [MULTAQ] - (Prescribed by Other Provider) - 400 mg Tablet - 1 Tablet(s) by mouth twice a day LATANOPROST [XALATAN] - (Prescribed by Other Provider) - 0.005 % Drops - 1 drop OS daily SILDENAFIL [VIAGRA] - 100 mg Tablet - 1 Tablet(s) by mouth 20 minutes prior to intercourse Metamol [**Hospital1 **] both eyes WARFARIN - (Prescribed by Other Provider) - 5 Mg M W F, 2.5 other days Protoptic 3x/week to eyes Discharge Medications: 1. dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): left eye . 3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 6. Protopic 0.03 % Ointment Topical 7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: upper GI bleed, likely [**2-2**] gastric ulcer . afib osteoarthritis glaucoma, s/p cataract surgery total R hip replacement Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 94895**], It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted for a major decrease in your blood count, for which you were transfused and worked up. You were found to have a gastric ulcer which may have caused your episode. Based on the appearance of the ulcer, it will need close follow up as an outpatient. - In the mean time, we will be holding your DICLOFENAC as well as WARFARIN in the setting of an acute bleed. - You may discuss with your PCP as well as cardiologist regarding when to restart Warfarin. - Please start omeprazole 40mg by mouth twice daily. . You have several follow up appointments listed below. You have requested to make your follow up with your cardiologist yourself. Followup Instructions: You have the following appointments: Department: [**Hospital **] MEDICAL GROUP When: WEDNESDAY [**2157-11-23**] at 10:30 AM With: DR. [**First Name (STitle) 569**] PASTOR [**Telephone/Fax (1) 133**] Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**] Campus: OFF CAMPUS Best Parking: On Street Parking Department: [**Hospital **] MEDICAL GROUP When: WEDNESDAY [**2157-11-23**] at 11:30 AM With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3879**] [**Telephone/Fax (1) 133**] Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**] Campus: OFF CAMPUS Best Parking: On Street Parking Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2157-12-14**] at 2:00 PM With: [**First Name8 (NamePattern2) 4503**] [**Last Name (NamePattern1) 4504**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage

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icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

7680, 7686

4772, 5747

323, 328

7854, 7854

3037, 3037

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1810, 1886

7074, 7657

7707, 7833

6330, 7051

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5768, 6304

266, 285

356, 1552

3053, 4749

7869, 7981

1574, 1704

1720, 1794

21,105

184,450

48816

Discharge summary

report

Admission Date: [**2127-6-11**] Discharge Date: [**2127-6-17**] Date of Birth: [**2068-6-15**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing / Sulfa (Sulfonamides) / Hydroxychloroquine / Shellfish Attending:[**First Name3 (LF) 3705**] Chief Complaint: Bright red blood per rectum. Major Surgical or Invasive Procedure: None. History of Present Illness: 58 year-old female with history of coronary artery disease status post multiple stents, hypertension, diabetes mellitus type II, deep venous thrombosis (no longer on coumadin), chronic obstructive pulmonary disease, hyperlididemia who presents from [**Hospital1 **] with three episodes of bright red blood per rectum on [**6-9**]. The patient's hemtocrit was 23 and she was transfused two units packed red blood cells with repeat hematocrit only 25. She noted associated lower abdominal discomfort. She was then transferred to [**Hospital1 18**], where she was noted to have melena in the ED. Of note, the patient was recently discharged from [**Hospital1 2025**] for a prolonged course for respiratory failure from parainfluenza virus triggering a COPD exacerbation complicated by NSTEMI, atrial fibrillation, and oliguric renal failure. . The patient was admitted to the MICU. Her baseline hematocrit is 21 per her [**Hospital1 2025**] admission note. In the MICU, the patient was transfused three units packed red blood cells. She remained hemodynamically stable and hematocrit remained stable. She continued to have melanotic stools. She was seen by Gastroenterology, who decline [**Hospital1 2792**] at this time as she was stable and is less than three months from NSTEMI. . The patient states that she has occasional BRBPR every six months. Her most recent [**Hospital1 2792**] was two years prior and showed evidence of diverticula and hemorrhoids per the patient. She is chronically on aspirin and Plavix as an outpatient. She has had multiple episodes of diverticulitis before, but otherwise denies melena, reflux, vomiting, epigastric pain. She denies current chest pain, shortness of breath, dizziness. She does note fatigue. Past Medical History: 1. Coronary artery disease status post multiple PCI (RCA stent x 4 after it was dissected during catheterization [**2115**], stent to D1 [**2119**], stent to pRCA [**2121**], non drug-eluting stent to D1 [**2126**]) 2. Status post recent admission to [**Hospital1 2025**] with respiratory failure felt to be due to parainfluenza requiring intubation. Admission complicated by renal failure requiring CVVH, creatinine now normal and not on dialysis. Admission also complicated by NSTEMI and atrial fibrillation broken by diltiazem; patient not on coumadin. 3. Hypertension 4. Hyperlipidemia 5. Deep venous thrombosis in past 6. COPD 7. Diabetes mellitus type II 8. Diverticulitis 9. [**Hospital1 **] in [**2125**] significant for only diverticulosis and hemorroids per patient; has never had EGD Social History: Married, lives at home with husband, although was at [**Name (NI) **] prior to current admission after recent hospitalization at [**Hospital1 2025**]. 30 pack-year smoking history. Denies alcohol, other drug use. Family History: Father had CAD, died of gastric cancer. Mother died from COPD. Physical Exam: VS: 98.4 BP 140/70 HR 92 RR 18 O2sat 95% RA Gen: well appearing obese female in NAD HEENT: MMM. No oral ulcers Neck: Supple Hrt: [**3-11**] holosystolic murmur at LLSB. No rubs or gallops Lungs: CTAB no RRW Abd: Obese, nontender, nondistended, normoactive bowel sounds Ext: Warm, well perfused. No CCE Pertinent Results: Labwork on admission: [**2127-6-10**] 11:15PM WBC-6.8 RBC-2.50* HGB-7.7* HCT-21.8* MCV-87 MCH-30.8 MCHC-35.3* RDW-16.8* [**2127-6-10**] 11:15PM PLT COUNT-217 [**2127-6-10**] 11:15PM NEUTS-69.7 LYMPHS-20.0 MONOS-7.4 EOS-2.8 BASOS-0.1 [**2127-6-10**] 11:15PM GLUCOSE-58* UREA N-29* CREAT-0.9 SODIUM-144 POTASSIUM-4.8 CHLORIDE-112* TOTAL CO2-25 ANION GAP-12 [**2127-6-10**] 11:15PM CALCIUM-9.4 PHOSPHATE-3.5 MAGNESIUM-1.5* . ECG Study Date of [**2127-6-11**] Sinus rhythm, without diagnostic abnormality. No previous tracing available for comparison. . CHEST (SINGLE VIEW) PORT [**2127-6-14**] Lordotic positioning. A left-sided PICC line is present. The tip is poorly delineated as it overlies the vertebral bodies of the spine. I suspect that it terminates in the position corresponding to the distal SVC, but if clinically indicated, a repeat view may help to better demonstrate this. The lungs are grossly clear. . Labwork on discharge: [**2127-6-17**] 01:35PM BLOOD Hct-27.8* [**2127-6-17**] 04:50AM BLOOD Glucose-94 UreaN-14 Creat-0.8 Na-143 K-3.9 Cl-111* HCO3-25 AnGap-11 Brief Hospital Course: 58 year-old female with history of coronary artery disease status post multiple stents, hypertension, diabetes mellitus type II, deep venous thrombosis (no longer on coumadin), chronic obstructive pulmonary disease, hyperlipidemia who presents with bright red blood per rectum and anemia. . 1. Gastrointestinal bleed/anemia: The patient was transfused three units packed red blood cells in the intensive care unit. The patient's hematocrit then slowly trended down and she was transfused four additional units of packed red cells in the days prior to discharge. The patient did not have any further episodes of bright red blood per rectum but had some episodes of melanotic stool. The patient has a history of diverticulitis and hemorrhoids, and most likely has a slow diverticular or hemorrhoidal bleed in the setting of anticoagulation with aspirin/plavix and subcutaneous heparin and in the setting of recent prednisone use and recent hospitalization and intubation. The patient had been recently constipated and was maintained on a bowel regimen to prevent straining during bowel movements. There was no nasogastric lavage performed in the Emergency Department. The patient remained hemodynamically stable throughout admission. The patient was followed by Gastroenterology who felt that the patient did not need emergent [**Month/Day/Year 2792**] as she was stable but would benefit from outpatient [**Month/Day/Year 2792**] as they were reluctant to perform a [**Month/Day/Year 2792**] less than three months from NSTEMI. The patient may also need an upper endoscopy at that time for her history of anemia. The patient's protonix was increased to twice daily dosing. The patient's aspirin and anti-hypertensives were initially held but restarted three days prior to discharge when after the patient's hematocrit remained stable. The patient's aspirin was decreased from 325 mg to 81 mg. The patient's plavix was not restarted as it was greater than one year since the patient's last percutaneous intervention. The patient should have her hematocrit rechecked two to three times weekly and as clinically indicated with transfusions for goal hematocrit 28-30 given her recent cardiac event. The patient should follow-up with her primary care doctor [**First Name (Titles) 4120**] [**Last Name (Titles) 2792**] and potential upper endoscopy in [**Month (only) 216**], three months from her cardiac event. . 2. Anemia: The patient's acute anemia is from chronic gastrointestinal losses as above. The patient appears to have a history of chronic anemia. The patient's reticulocyte index was low this admission. Iron studies were not obtained given the patient's recent blood transfusions. The patient should have further work-up as an outpatient, including iron studies, [**Month (only) 2792**] as above, and likely upper endoscopy. . 3. Coronary artery disease: There were no active issues during admission. The patient's statin was continued. The patient's aspirin and anti-hypertensives were initially held but restarted three days prior to discharge when after the patient's hematocrit remained stable. The patient's aspirin was decreased from 325 mg to 81 mg. The patient's plavix was not restarted as it was greater than one year since the patient's last percutaneous intervention. The patient should have her hematocrit rechecked two to three times weekly and as clinically indicated with transfusions for goal hematocrit 28-30 given her recent cardiac event. . 4. Hypertension: The patient's anti-hypertensives were initially held but restarted three days prior to discharge when after the patient's hematocrit remained stable. The patient was hypertensive off her regimen but blood pressure improved on her outpatient regimen. The patient was initially allowed to be hypertensive to systolic 140-150 but lisinopril was increased to 10 mg for improved blood pressure control in this patient with recent NSTEMI once she remained hemodynamically stable. . 5. Diabetes mellitus type II with complications: The patient's blood sugars were stable during admission. The patient was maintained initially on half of her dose of NPH while NPO, but increased to full dose when taking a regular diet. The patient was maintained on humalog sliding scale. . 6. Chronic obstructive pulmonary disease: No active issues. The patient was maintained on advair, spiriva, and nebulizers as needed. . 7. History of atrial fibrillation: The patient remained in sinus rhythm throughout admission. . FEN: Regular/cardiac diet Prophylaxis: Pneumoboots (no heparin SC given bleed), PPI Access: PICC Code: Full Disposition: [**Hospital1 **] for rehabilitation Medications on Admission: Albuterol nebs QID Amlodipine 10 mg QD Aspirin 325 mg QD Atorvastatin 40 mg QD Baclofen 5 mg TID Plavix 75 mg QD Diltiazem 90 mg QID Colace 100 mg [**Hospital1 **] Ezetimibe 10 mg QD Advair 500/50 [**Hospital1 **] Lasix 60 mg QD Heparin SC NPH 55 QAM, 20 QPM Atrovent nebulizers QID Isordil 80 mg [**Hospital1 **] Lidocaine patch to low back Lisinopril 5 mg QD Miconazole powder Nystatin swish and swallow [**Hospital1 **] Prilosec 20 mg QD Oxycodone PRN Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 6. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifty Five (55) units Subcutaneous QAM. 11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous QPM. 12. Humalog 100 unit/mL Solution Sig: Sliding scale Subcutaneous four times a day. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 16. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 17. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 18. Isosorbide Dinitrate 40 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO Q12H (every 12 hours). 19. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual As directed as needed for chest pain. 20. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 21. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: 1. Gastrointestinal bleed 2. Anemia . Secondary: 1. Coronary artery disease status post multiple PCI (RCA stent x 4 after it was dissected during catheterization [**2115**], stent to D1 [**2119**], stent to pRCA [**2121**], non drug-eluting stent to D1 [**2126**]) 2. Status post recent admission to [**Hospital1 2025**] with respiratory failure felt to be due to parainfluenza requiring intubation. Admission complicated by renal failure requiring CVVH, creatinine now normal and not on dialysis. Admission also complicated by NSTEMI and atrial fibrillation broken by diltiazem; patient not on coumadin. 3. Hypertension 4. Hyperlipidemia 5. Deep venous thrombosis in past 6. COPD 7. Diabetes mellitus type II 8. Diverticulitis 9. [**Hospital1 **] in [**2125**] significant for only diverticulosis and hemorroids per patient; has never had upper endoscopy Discharge Condition: Afebrile, vital signs stable. Hematocrit 28. Discharge Instructions: You were admitted with bright red blood per rectum. This was likely due to your known diverticulosis and hemorrhoids. You were transfused six units of blood. Gastroenterology did not perform a [**Year (4 digits) 2792**] or upper endoscopy as you were stable and you are less than three months from a heart attack. You will have frequent blood draws at the rehabilitation facility and transfusions as necessary. You should follow-up with Gastroenterology in [**Month (only) 216**] regarding these procedures. . Please contact a physician if you experience fevers, chills, dizziness, chest pain, shortness of breath, abdominal pain, nausea, vomiting, black stools or blood in your stools, or any other concerning symptoms. . Please take your medications as prescribed. - Your aspirin was decreased from 325 mg to 81 mg. - Your plavix was discontinued as it is greater than one year since your last stent. - Your lisinopril was increased to 10 mg daily. - Your subcutaneous heparin was discontinued. . Please schedule a follow-up appointment with your primary care doctor within two weeks of discharge from the rehabilitation facility. Followup Instructions: Please schedule a follow-up appointment with your primary care doctor within two weeks of discharge from the rehabilitation facility. You should discuss follow-up with gastroenterology regarding future [**Month (only) 2792**] and upper endoscopy in [**Month (only) 216**].

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Discharge summary

report

Admission Date: [**2121-9-1**] Discharge Date: [**2121-9-15**] Date of Birth: [**2064-12-26**] Sex: M Service: SURGERY Allergies: Motrin / Glyburide / Glucophage Attending:[**Last Name (NamePattern1) 4659**] Chief Complaint: 4cm sessile mass in colon, not biopsied seconday to anticoagulation Major Surgical or Invasive Procedure: Right colectomy, laparoscopy assisted ([**2121-9-4**]) History of Present Illness: 56 yo male with multiple medical problems with 4cm sessile polyp in mid R ascending colon. Past Medical History: IDDM anemia Mechanical valve, AVR for MRSA endocarditis BKA Toe amp appy Social History: Cig 1ppd -> quit Pipe 3-4 qd Currently on disability. Lives at home with his partner, Ms. [**Name13 (STitle) **]. Denies alcohol, drugs, or tobacco. No pets. Family History: Family ALW. No hx of MI, CAD, or DM. Physical Exam: Afebrile, HR92 BP162/82 RR16 General: Large black male walking with cane accompanied by fiance, comfortable Neck: Normal thyroid, no masses, no LA, nl airway, 4+ carotid, radiating murmur and mechanical click Chest: Clear, well healed sternotomy COR: RRR with 2/6 creshendo/decreshendo SEM and soft mechanical click Back: No CVAT, or spine pain Abd: Indented RLQ appi scar in pannus, floppy pannus (overall has lost about 100lbs from his max wt, stable over last few months), ND, soft, no mass palpable, NT, no r/g, no hepatosplenomegaly Ext: 4+ femoral pulse b/l, no right popleteal pulse, R foot brace, no edema, L BKA with prosthesis. Pertinent Results: CHEST (PRE-OP PA & LAT) [**2121-9-1**] 4:54 PM IMPRESSION: Left-sided chest opacity could represent loculated fluid collection. CT is suggested for further characterization. CT PELVIS ABD W&W/O CONTRAST [**2121-9-2**] 11:49 AM IMPRESSION: 1. Large loculated left pleural effusion with a thick rim. The differential diagnosis includes an empyema or prior hemothorax. The finding is new since the postoperative studies from aortic valve replacement as of [**2120-8-20**]. Neoplastic involvement of the pleura cannot be excluded. 2. Large multilobulated low-density splenic lesion, which extends up to the posterior wall of the gastric fundus, and may extend into the gastric wall. The findings would be highly atypical for metastatic colon cancer given the lack of liver metastases, although this cannot be excluded. possible etiologies include prior trauma and embolic disease (including septic emboli given prosthetic aortic valve/endocarditis). Pancreas is unremarkable without evidence for pseudocyst extension into spleen/stomach. Correlate with history of trauma to this area. MRI may provide additional diagnostic information. Endoscopy could also be considered for assessment of the gastric fundal abnormality. Results and potential recommendations were called to Dr. [**First Name8 (NamePattern2) 96487**] [**Last Name (NamePattern1) 61028**] at 5:00 p.m. on [**2121-9-2**]. Cardiology Report ECG Study Date of [**2121-9-4**] 9:06:06 PM Sinus rhythm with 1st degree A-V block Since previous tracing, no significant change CHEST PORT. LINE PLACEMENT [**2121-9-5**] 6:25 PM IMPRESSION: Satisfactorily positioned right internal jugular central venous catheter, without a pneumothorax seen. Pathology Examination DIAGNOSIS: Terminal ileum and right colon, ileocolectomy: Adenoma of the right colon (3.8 x 2.5 cm) with foci of high-grade dysplasia, see note. Separate adenoma of the right colon (0.8 cm). Ileal mucosa with no diagnostic abnormalities recognized. Regional lymph nodes with no diagnostic abnormalities recognized. Note: No invasive carcinoma is identified. The adenoma is entirely submitted and an additional level of each block examined. The findings were discussed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] on [**2121-9-12**]. [**2121-9-1**] 03:00PM BLOOD WBC-13.1* RBC-3.81* Hgb-7.9* Hct-25.1* MCV-66*# MCH-20.6*# MCHC-31.3 RDW-16.1* Plt Ct-564* [**2121-9-2**] 09:45AM BLOOD WBC-11.9* RBC-3.86* Hgb-8.0* Hct-25.4* MCV-66* MCH-20.6* MCHC-31.4 RDW-16.2* Plt Ct-493* [**2121-9-3**] 10:10AM BLOOD WBC-15.6* RBC-4.83# Hgb-11.1*# Hct-33.0*# MCV-68* MCH-22.9*# MCHC-33.5 RDW-17.5* Plt Ct-535* [**2121-9-5**] 06:12PM BLOOD WBC-27.7*# RBC-5.20 Hgb-11.8* Hct-37.2* MCV-72* MCH-22.6* MCHC-31.6 RDW-19.3* Plt Ct-520* [**2121-9-6**] 02:10AM BLOOD WBC-28.6* RBC-4.57* Hgb-10.4* Hct-32.6* MCV-71* MCH-22.8* MCHC-32.0 RDW-19.1* Plt Ct-496* [**2121-9-7**] 02:20AM BLOOD WBC-20.7* RBC-3.71* Hgb-8.5* Hct-26.6* MCV-72* MCH-22.8* MCHC-31.8 RDW-19.7* Plt Ct-357 [**2121-9-8**] 01:58AM BLOOD WBC-16.9* RBC-3.65* Hgb-8.3* Hct-26.3* MCV-72* MCH-22.7* MCHC-31.5 RDW-19.8* Plt Ct-361 [**2121-9-9**] 04:42AM BLOOD WBC-11.8* RBC-3.51* Hgb-8.2* Hct-25.2* MCV-72* MCH-23.4* MCHC-32.5 RDW-19.8* Plt Ct-379 [**2121-9-12**] 01:30AM BLOOD Hct-25.4* [**2121-9-1**] 03:00PM BLOOD PT-20.4* PTT-31.0 INR(PT)-2.0* [**2121-9-1**] 03:00PM BLOOD Plt Ct-564* [**2121-9-2**] 01:00AM BLOOD PTT-39.7* [**2121-9-2**] 09:40AM BLOOD PT-19.5* PTT-49.0* INR(PT)-1.9* [**2121-9-2**] 09:45AM BLOOD Plt Ct-493* [**2121-9-2**] 03:00PM BLOOD PT-18.9* PTT-41.6* INR(PT)-1.8* [**2121-9-2**] 09:21PM BLOOD PT-18.2* PTT-53.6* INR(PT)-1.7* [**2121-9-3**] 10:10AM BLOOD PT-17.2* PTT-39.9* INR(PT)-1.6* [**2121-9-3**] 10:10AM BLOOD Plt Ct-535* [**2121-9-3**] 07:19PM BLOOD PTT-45.0* [**2121-9-4**] 12:55PM BLOOD PTT-41.1* [**2121-9-5**] 06:12PM BLOOD Plt Ct-520* [**2121-9-6**] 02:10AM BLOOD Plt Ct-496* [**2121-9-6**] 05:49PM BLOOD PTT-92.6* [**2121-9-7**] 02:20AM BLOOD PT-16.4* PTT-81.4* INR(PT)-1.5* [**2121-9-7**] 02:20AM BLOOD Plt Ct-357 [**2121-9-7**] 11:39AM BLOOD PT-16.5* PTT-57.4* INR(PT)-1.5* [**2121-9-7**] 10:26PM BLOOD PT-15.7* PTT-74.7* INR(PT)-1.4* [**2121-9-8**] 01:58AM BLOOD Plt Ct-361 [**2121-9-8**] 06:29AM BLOOD PT-15.3* PTT-56.2* INR(PT)-1.4* [**2121-9-8**] 08:55PM BLOOD PT-13.9* PTT-52.0* INR(PT)-1.2* [**2121-9-9**] 04:42AM BLOOD PT-15.2* PTT-50.7* INR(PT)-1.4* [**2121-9-9**] 04:42AM BLOOD Plt Ct-379 [**2121-9-9**] 03:38PM BLOOD PTT-58.5* [**2121-9-10**] 12:08AM BLOOD PTT-82.2* [**2121-9-10**] 06:02AM BLOOD PT-17.7* PTT-93.4* INR(PT)-1.6* [**2121-9-10**] 01:35PM BLOOD PTT-71.9* [**2121-9-10**] 09:00PM BLOOD PTT-68.5* [**2121-9-11**] 03:39AM BLOOD PT-21.1* PTT-84.4* INR(PT)-2.0* [**2121-9-11**] 03:38PM BLOOD PT-22.1* PTT-70.9* INR(PT)-2.2* [**2121-9-12**] 01:30AM BLOOD PT-22.3* PTT-77.0* INR(PT)-2.2* [**2121-9-12**] 09:09AM BLOOD PT-21.9* PTT-65.2* INR(PT)-2.1* [**2121-9-12**] 05:09PM BLOOD PT-22.3* PTT-56.2* INR(PT)-2.2* [**2121-9-13**] 01:29AM BLOOD PT-23.4* PTT-75.4* INR(PT)-2.3* [**2121-9-14**] 04:30AM BLOOD PT-23.7* PTT-57.3* INR(PT)-2.4* [**2121-9-15**] 05:55AM BLOOD PT-26.2* PTT-65.1* INR(PT)-2.7* [**2121-9-1**] 03:00PM BLOOD Glucose-258* UreaN-28* Creat-1.5* Na-133 K-4.0 Cl-100 HCO3-24 AnGap-13 [**2121-9-2**] 09:45AM BLOOD Glucose-207* UreaN-26* Creat-1.1 Na-134 K-4.1 Cl-100 HCO3-25 AnGap-13 [**2121-9-3**] 10:10AM BLOOD Glucose-206* UreaN-20 Creat-1.3* Na-132* K-4.3 Cl-98 HCO3-23 AnGap-15 [**2121-9-5**] 06:12PM BLOOD Glucose-160* UreaN-15 Creat-1.1 Na-134 K-4.5 Cl-104 HCO3-20* AnGap-15 [**2121-9-6**] 02:10AM BLOOD Glucose-218* UreaN-20 Creat-1.6* Na-132* K-5.8* Cl-104 HCO3-21* AnGap-13 [**2121-9-6**] 06:20AM BLOOD Glucose-151* UreaN-19 Creat-1.5* Na-135 K-5.3* Cl-106 HCO3-22 AnGap-12 [**2121-9-6**] 05:49PM BLOOD Glucose-127* UreaN-20 Creat-1.3* Na-138 K-5.1 Cl-107 HCO3-21* AnGap-15 [**2121-9-7**] 02:20AM BLOOD Glucose-117* UreaN-18 Creat-1.3* Na-136 K-4.6 Cl-104 HCO3-25 AnGap-12 [**2121-9-8**] 01:58AM BLOOD Glucose-80 UreaN-14 Creat-1.2 Na-136 K-4.2 Cl-101 HCO3-28 AnGap-11 [**2121-9-9**] 04:42AM BLOOD Glucose-106* UreaN-11 Creat-1.1 Na-136 K-3.9 Cl-102 HCO3-30 AnGap-8 [**2121-9-1**] 03:00PM BLOOD Lipase-31 [**2121-9-1**] 03:00PM BLOOD Albumin-3.4 Calcium-8.7 Phos-2.6*# Mg-2.2 [**2121-9-2**] 09:45AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.0 [**2121-9-3**] 10:10AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0 [**2121-9-5**] 06:12PM BLOOD Calcium-9.0 Phos-3.7 Mg-1.7 [**2121-9-6**] 02:10AM BLOOD Calcium-8.7 Phos-4.9* Mg-2.5 [**2121-9-6**] 06:20AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.5 [**2121-9-6**] 05:49PM BLOOD Calcium-8.5 Phos-3.4 Mg-2.4 [**2121-9-7**] 02:20AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.2 [**2121-9-8**] 01:58AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.2 [**2121-9-9**] 04:42AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.1 [**2121-9-2**] 09:45AM BLOOD CEA-1.8 [**2121-9-5**] 02:30PM BLOOD Type-ART pO2-160* pCO2-32* pH-7.46* calTCO2-23 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [**2121-9-5**] 03:45PM BLOOD Type-ART pO2-172* pCO2-31* pH-7.44 calTCO2-22 Base XS--1 Intubat-INTUBATED [**2121-9-6**] 02:38AM BLOOD Type-ART pO2-163* pCO2-39 pH-7.32* calTCO2-21 Base XS--5 [**2121-9-6**] 06:38AM BLOOD Type-ART pO2-136* pCO2-43 pH-7.34* calTCO2-24 Base XS--2 [**2121-9-7**] 02:32AM BLOOD Type-ART pO2-108* pCO2-44 pH-7.39 calTCO2-28 Base XS-0 [**2121-9-5**] 02:30PM BLOOD Glucose-102 Lactate-0.9 Na-131* K-4.2 Cl-106 [**2121-9-5**] 03:45PM BLOOD Glucose-115* Lactate-1.3 Na-136 K-4.3 Cl-110 [**2121-9-6**] 06:38AM BLOOD Lactate-2.5* [**2121-9-5**] 02:30PM BLOOD Hgb-9.4* calcHCT-28 [**2121-9-5**] 03:45PM BLOOD Hgb-10.1* calcHCT-30 [**2121-9-5**] 02:30PM BLOOD freeCa-1.11* [**2121-9-5**] 03:45PM BLOOD freeCa-1.05* Brief Hospital Course: 56 yo male admitted preop for anticoagulation adjustment secondary to mechanical valve for a R colectomy scheduled for HD5. Heparin gtt was started on HD1, and titrated accordingly for a goal PTT of 60-70 until 4am day prior to surgery. A CXR was done also for preop work up on HD1, which showed L-sided chest opacity that could represent loculated fluid collection, and a follow up CT was performed for further characterization on HD2. CT revealed new loculated left pleural effusion with a thick rim; multilobulated low-density splenic lesion, which extends up to the posterior wall of the gastric fundus, and may extend into the gastric wall. Cardiothoracic surgery team was consulted, and a decision not to work up the L lung or splenic fluid collection further was made as they are highly unlikely to represent metastatic colon CA, given nl liver and low CEA. Details of both the CXR and CT are available in the respective radiology reports elsewhere. Pt was also transfused with 1u PRBC on HD2, given a Hct of 25.1, which responded to the treatment, and the hct went up to 33.1. Cardiology team was consulted, and recommended prophylactic antibiotics prior to surgery. On day of surgery, PTT was appropriate at goal, and antibiotics were given as recommended. Pt [**Month/Day/Year 1834**] R hemicolectomy, the details of the procedure are available in the operative report elsewhere. Pt had uncomplicated intraoperative course; was transferred to the SICU POD0 overnight for monitoring. Pt was restarted on heparin for mechanical valve; not coumadin. Insulin gtt was started for better blood glucose control. Pt was transferred back to the floor on POD3. Pt's diet was started on sips and advance as tolerated and with respect to return of bowel function on POD3. Pt had no problems with n/v throughout his hospital stay. Coumadin was restarted on POD3, and heparin gtt continued to be titrated appropriately. INR was followed throughout the rest of the [**Hospital **] hospital course for a goal INR of 2.5-3.5. By POD10, pt was tolerating regular diabetic po, had return of bowel function, ambulant, pain controlled, and was found to have an INR of 2.7. Pt was d/c home in good condition on POD10, with PT to do home visits, to have INR checked at the [**Hospital 882**] Hospital on [**2121-9-17**], and to follow up with Dr. [**Last Name (STitle) **] on [**2121-9-22**]. Medications on Admission: coumadin 10mg' (tues-[**Last Name (un) **], sat, sun) coumadin 7.5mg' (m+f) protonix FeSO4 ASA 81' folate 1mg' colace 100mg" senna prn insulin NPH 16u qam, 10u qpm, sliding scale if BS>200 Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen (16) units Subcutaneous qAM (). Disp:*QSx 1 month QS* Refills:*2* 7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous qPM (). Disp:*QS x 1month QS* Refills:*2* 8. Lancets & Strips Lancets and glucose monitoring strips sufficient for 4 times daily fingersticks please. 2 refills. 9. Outpatient Lab Work Please have your PT, PTT, INR checked at the [**Hospital 882**] Hospital on [**2121-9-17**]. Please have the result reported to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 8792**]. 10. Coumadin 10 mg Tablet Sig: One (1) Tablet PO once a day: On Tues, Wed, Thurs, Sat, Sunday. Disp:*30 Tablet(s)* Refills:*2* 11. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO once a day: On Monday and Friday. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Colon mass Discharge Condition: Vital signs stable, afebrile, tolerating po, ambulant, pain controlled, INR at therapeutic range between 2.5-3.5. Discharge Instructions: You may resume your pre-hospital medications and activity - just take it easy in the beginning! No heavy lifting (greater that 10 pounds!) for 4 weeks after surgery. This could give you a hernia. You may shower, but no soaking in a tub for 4 weeks after surgery. Please call doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101, nausea/vomiting, inability to eat, wound redness, swelling, foul smelling drainage, or anything else that concerns you. Followup Instructions: Please call Dr.[**Name (NI) 6218**] office at ([**Telephone/Fax (1) 96488**] to schedule a follow up appointment for Monday, [**2121-9-22**]. Please follow up at the [**Hospital 882**] Hospital for your INR check on Wednesday, [**2121-9-17**]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**] Completed by:[**2121-9-15**]

[ "362.01", "V49.75", "285.9", "250.50", "511.9", "V43.3", "211.3" ]

icd9cm

[ [ [] ] ]

[ "45.73", "38.93", "45.93" ]

icd9pcs

[ [ [] ] ]

13413, 13471

9285, 11684

367, 424

13526, 13642

1546, 9262

14164, 14581

833, 871

11923, 13390

13492, 13505

11710, 11900

13666, 14141

886, 1527

260, 329

452, 544

566, 641

657, 817

54,182

141,628

25380

Discharge summary

report

Admission Date: [**2147-5-12**] Discharge Date: [**2147-5-16**] Date of Birth: [**2071-1-18**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1943**] Chief Complaint: hemetemesis Major Surgical or Invasive Procedure: EGD [**2147-5-13**] History of Present Illness: 76yoM with CAD s/p CABG, s/p nephrectomy [**2145**] for cancer, h/o AAA s/p endovascular repair in [**2144**], but otherwise with no h/o chronic liver or GI issues presents with acute onset hematemesis several hours prior to arrival. He laid down to take a nap at 2pm and woke up at 3pm sweaty. When he tried to stand up, he got dizzy, felt sick to his stomach, felt like he needed to have a BM, and sat right back down. His wife saw him and called 911. When they arrived he reportedly vomited about a liter of dark blood, "coffee grounds" per his wife who was a nurse. He was given 2L of NS in the field. There was some question of non-palpable pulses in the field, but noted to have palpable pulses by arrival to the ED. On arrival his bp was 106/50 p60 22 100% on 15L NRB. His Hct was 30.4, down from 41.1 at BIDN 2 days ago, where he was seen for Bell's Palsy and discharged with Doxycycline for ? Lyme exposure and Prednisone 60 mg PO daily, of which he's taken 2 doses. Labs o/w significant for normal plts and coags, BUN/Cr 42/1.2 which is within baseline (0.8-1.4 in [**Location (un) 620**] records), normal LFT's, and a blood gas with pH 7.29. He had NG lavage with 1L which showed some slightly pink tinged fluid, and guiac was negative, only with brown stool. CTA torso was done out of concern for aorto-enteric fistula given h/o AAA s/p endovascular repair [**2144**], but was negative. GI saw the pt and recommended start PPI bolus/gtt, follow Hcts with goal >30, keep NPO for possible EGD in the am. He has 3 PIV's -- and 18, a 20, and another unclear [**Name2 (NI) **] (placed by EMS). Did not get any blood products, but T&C for 4 units. He was given 3 more L of NS (for total of 5 -- 2 by EMS). Vitals before transfer: p75 14 98%RA 114/63. On arrival to the MICU his wife and daughter are present and he appears very well and has no complaint. He denies EtOH (a couple drinks per year), NSAID use other than his daily ASA 325, and is not taking Plavix. He denies any recent GI illness or recent retching. No abdominal pain. ROS as above and also positive for noctiuria in the setting of BPH, o/w negative for f/c/ns, wt loss, loss of energy, HEENT problems, SOB, CP, palpitations, d/c/abd pain, dysuria, skin/muscle/joint issues. Past Medical History: - CAD s/p DES to LAD and RCA [**2140**], s/p 5vCABG [**3-/2145**], post-op EF 40-45% - AAA s/p endovascular repair [**10/2140**] - h/o renal tumor s/p nephrectomy [**2145**] - hypertension - type 2 diabetes mellitus - hyperlipidemia - h/o cholelithiasis c/b chronic cholecystitis, s/p CCY with intra-op cholangiogram and ERCP for choledocholithiasis - s/p tonsillectomy Social History: Civil engineer but retired at 75yo Married, lives in [**Location 13588**] with his wife. [**Name (NI) **] a son and daughter. Former [**Name2 (NI) 1818**], 4PPD x30 years, quit [**2118**]. Drinks only a couple EtOH drinks per year. No drugs. Family History: Mother deceased [**Age over 90 **] [**Name2 (NI) **] of "old age" Father deceased MI age 74. Son with tonsillar ca at 45 yo No known GI or liver disease. Physical Exam: (admission physical exam) Very well appearing, pleasant M in no distress, conversant, alert. Has gross R facial droop EOMI, PERRLA, no scleral icterus. Mouth moist, normal appearing. No JVD or HJR. CTAB no w/c/r/r RRR but with faint S1/S2, best heard at LLSB without gross murmurs Abd obese, but NT ND, benign. No palpable hepatomegaly. No BLE edema. BLE's are much paler in comparison to face/arms but are warm and DP's are easily palpable. Radials palpable. CN 7 palsy noted on the R, speech is fluent and clear, no slurring. Spontaneously moving all 4 extremities, no focal deficit noted Pertinent Results: Initial Labs: [**2147-5-12**] 04:15PM WBC-10.8 RBC-3.24* HGB-10.7* HCT-30.4* MCV-94 MCH-33.0*# MCHC-35.1* RDW-13.2 [**2147-5-12**] 04:15PM NEUTS-88.7* LYMPHS-9.3* MONOS-1.5* EOS-0.2 BASOS-0.3 [**2147-5-12**] 04:15PM PLT COUNT-203 [**2147-5-12**] 04:15PM PT-12.8 PTT-18.9* INR(PT)-1.1 [**2147-5-12**] 04:15PM ALT(SGPT)-15 AST(SGOT)-20 CK(CPK)-46* ALK PHOS-52 TOT BILI-0.8 [**2147-5-12**] 04:15PM GLUCOSE-260* UREA N-42* CREAT-1.2 SODIUM-138 POTASSIUM-5.7* CHLORIDE-107 TOTAL CO2-24 ANION GAP-13 [**2147-5-12**] 04:22PM GLUCOSE-253* LACTATE-1.9 NA+-137 K+-5.3 CL--106 TCO2-24 [**2147-5-12**] 07:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2147-5-12**] 07:55PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.017 Hct trend: [**2147-5-12**] 04:15PM HCT-30.4* [**2147-5-12**] 09:20PM HCT-29.7* [**2147-5-13**] 03:01AM Hct-27.5* [**2147-5-13**] 08:51AM Hct-27.6* [**2147-5-12**] 09:20PM HCT-29.7* [**2147-5-15**] 06:50PM Hct-26.2* [**2147-5-16**] 07:00AM Hct-26.9* UA GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **] [**2147-5-12**] 19:55 Straw Clear 1.017 DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks [**2147-5-12**] 19:55 NEG NEG NEG 300 NEG NEG NEG 6.0 NEG [**2147-5-12**] 19:55 Microbiology: [**2147-5-12**] 7:55 pm URINE Site: CLEAN CATCH **FINAL REPORT [**2147-5-15**]** URINE CULTURE (Final [**2147-5-15**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 1 S Imaging: CTA abdoman: [**2147-5-13**] 1. No evidence of an aortoenteric fistula. 2. Scattered liver hypodensities and a larger right hepatic lobe cyst are not significantly changed compared to the prior exam. 3. Tiny left renal hypodensities are too small to characterize but statistically are simple cysts. EGD: [**2147-5-13**] Erosive esophagitis at GE junction and lower esophagus. Ulcer at the GE junction with stigmata of recent bleeding. Medium-sized hiatal hernia Otherwise normal EGD to third part of the duodenum Recommendations: The findings account for the symptoms. Continue PPI gtt x72 hours. Hold aspirin. Serial Hcts, transfuse PRN. Repeat endoscopy in 6 weeks to assess ulcer healing. Antireflux regimen: Avoid chocolate, peppermint, alcohol, caffeine, onions, aspirin. Elevate the head of the bed 3 inches. Go to bed with an empty stomach. Brief Hospital Course: 76yoM with CAD s/p DES x2 then 5vCABG, s/p nephrectomy [**2145**] for renal ca, h/o AAA s/p endovascular repair in [**2144**] who presents with hematemesis x1 and 10 pt Hct drop underwent EGD with finding of clean based ulcer in GE junction w/o active bleeding, treated conservatively with IV PPI [**Last Name (un) **] with subsequent stabilizaton of Hct count. # Hematemesis: Present with 1 episode of hematemesis with significant hematocrit drop from baseline of 41.1 to 30.4 two days after starting empirical treatment with doxycilline and prednisone for bell's palsey. Upon admission, prednisone, doxycycline, aspirin were held given potential contribution to esophagitis/gastric ulcerations. Atenolol was also held in setting of GI bleed. Following 5L NS volume resuscitation, hematocrit downtreanded to 26.5 and remained stable throughout his course. Patient was started on a protonix gtt and endoscopy on hospital day # 2 showed ulceration at the gastroesophageal junction with stigmata of recent bleeding and some evidence of esophagitis. Protonix gtt was continued for a total of 72 hrs. Hct remained remained stable. Discharged on Omeprazole 40mg [**Hospital1 **]. Aspirin was restarted on 81mg daily. Follow up endoscopy planned in 6 weeks to assess for resolution. # Bell's palsy: 1 month ago had tick for 24h and was treated with single dose of doxy. 2 days prior to current presentation developed right bell's palsey, his OSH lyme titers at this point were negative. he was started on PO prednisone + doxycilline and got two doses of each before presenting with UGIB. Most cases of lyme CN 7 palsey present with positive IgM, but patients may nevertheless be seronegative on presentation, especially with early infection, as patient is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] he had continous exposure and may have had another tick more recently which was not noticed. Serology for lyme was resent and was pending at discharge. Patient was discharged on Oral amoxicilline with plans for follow up at the ID lyme clinic. Steroids were not restarted as unlikely to be beneficial more then 72h after presentation. Facial nerve paralysis was slightly improved at discharge. # Hyperglycemia: Patient was on oral DM meds in the past but was weaned off these. Was hyperglycemic on admission, perhaps [**1-4**] to recent steroid therapy. HbA1c is 6.1. Patient was treated with ISS. He is discharged on diabetic diet for PCP [**Name Initial (PRE) **]- # CAD s/p CABG and multiple PCI: Throughout hospital course, patient remained chest pain free with no evidence of ischemia. EKG unchanged and cardiac enzymes on admission within normal limits. As above, given GI bleed, aspirin and atenolol were initially held. These were restarted at discharge, with aspirin decreased to 81mg daily after consulting with outpatient cardiologist. continued on statin. # Hyperlipidemia: simvastatin was continued # glaucoma: xalatan drops were continued. DVT PPx: pneumoboots. no anticoagulation was administered during this admission. Code Status: Full code Medications on Admission: - aspirin 325mg daily - atenolol 50mg daily - simvastatin 10mg QHS - Xalatan eye drops - fish oil - prednisone - doxycycline Discharge Medications: 1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. omega-3 fatty acids 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. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-4**] Drops Ophthalmic PRN (as needed) as needed for dry eye. Disp:*3 bottles* Refills:*0* 5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day for 6 weeks. Disp:*80 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 7. aspirin 81 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:*0* 8. amoxicillin 500 mg Capsule Sig: One (1) Capsule PO three times a day for 28 days. Disp:*84 Capsule(s)* Refills:*0* 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Upper GI bleeding Ulcer in Gastroesophageal Junction Bell's Palsy, possibly due to Lyme disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because of bleeding from your intestine. An endoscopy was performed which showed an ulcer between your esophagus and stomach which may have been the source of bleeding. You were treated with anti-acid medication and your bleeding resolved by itself. You will need to recheck your blood count and renal functions by the end of this week to make sure they are stable - see PCP appointment below. You will be followed up by our gastroenterology service as an out-patient (see appointments below). We made you an appointment with our Lyme specialist to follow-up on your facial nerve paralysis (Bell's palsy), in the meantime you have been restarted on treatment for possible Lyme's disease with amoxicillin. We noticed you had some abnormally high blood sugar measurements, this may have been due to a mild underlying diabetes worsened by steroid (prednisone treatment). Please observe a low-sugar diet and follow-up on this issue with your PCP. The following changes were made to your medications: - STOP prednisone - START omeprazole 40 mg Capsule, Delayed Release(E.C.). Please take One (1) Capsule, Delayed Release(E.C.) by mouth twice a day for 6 weeks for treatemt of your ulcer. - START amoxicillin 500 mg Capsule, please take One (1) Capsule PO three times a day for 28 days to treat possible Lyme disease. - Your aspirin dose was reduced from 325mg daily to 81mg daily: please take aspirin 81 mg Tablet, Delayed Release (E.C.) One (1) Tablet, Delayed Release (E.C.) by mouth once a day. - START polyvinyl alcohol-povidone 1.4-0.6 % Dropperette, please use 1-2 Drops Ophthalmic PRN (as needed) for dry eye. You may also tape your right eyelid shut with simple tape every night to prevent dryness and foreign body lodgement during sleep. Followup Instructions: PCP: [**Name10 (NameIs) **] Family Medicine [**Location (un) 1411**] When: Thursday [**2147-5-18**] at 11:00 AM With: [**Last Name (LF) **], [**Name8 (MD) **], MD [**Telephone/Fax (1) 17753**] Building: [**Street Address(2) **] Suit 220 2nf floor Your PCP will refer you to get blood tests to follow your blood count and renal functions Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2147-5-24**] at 2:30 PM With: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2147-5-31**] at 3:30 PM With: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2147-6-6**] at 9:00 AM [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2147-5-22**]

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icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

11255, 11261

6898, 9983

316, 337

11400, 11400

4071, 6875

13344, 14645

3290, 3445

10158, 11232

11282, 11379

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11550, 13321

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6,005

161,936

23316

Discharge summary

report

Admission Date: [**2138-12-15**] Discharge Date: [**2139-1-16**] Service: SURGERY Allergies: Penicillins / Heparin Agents Attending:[**First Name3 (LF) 5880**] Chief Complaint: 83F fall down stairs w/loss of consciousness, transferred to [**Hospital1 18**] with likely facial fractures, left distal radius fracture, , laceration on lip sewed at an outside hospital. GCS 15 throughout. Major Surgical or Invasive Procedure: open reduction, internal fixation of right distal radius fracture, emergent tracheostomy, formal tracheostomy and gastrojejunostomy feeding tube placement in operating room History of Present Illness: 83F fall down stairs w/loss of consciousness, transferred to [**Hospital1 18**] with likely facial fractures, left distal radius fracture, , laceration on lip sewed at an outside hospital. GCS 15 throughout. Past Medical History: PMH: DM, CAD (old MI on EKG), CRI, hyperchol, GERD Physical Exam: AVSS, afebrile A+Ox3 uncomfortable bilateral periorbital ecchymosis, lip lac sutured neck in hard collar CTAB RRR obese, ND, NABS, soft, nontender left wrist with some swelling, deformity, n/v intact BLE n/v intact, no obvious deformity Spine w/o tenderness or stepoff Pertinent Results: [**2139-1-2**] 10:40 am VIRAL CULTURE:R/O HERPES SIMPLEX VIRUS Site: NOT SPECIFIED **FINAL REPORT [**2139-1-12**]** VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2139-1-12**]): NO VIRUS ISOLATED. [**2138-12-26**] 10:23 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2139-1-12**]** GRAM STAIN (Final [**2138-12-27**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2138-12-29**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 I OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S FUNGAL CULTURE (Final [**2139-1-12**]): YEAST. Brief Hospital Course: The [**Hospital 228**] hospital course will be categorized by the different issues that arose during her stay at [**Hospital1 771**]. Patient was followed throughout her stay by the [**Last Name (un) **] diabetes service. On decadron 4 q6 for ?spinal cord synd. Now on insulin gtt. [**2138-12-19**] Pt seen in SICU, not responsive, not on insulin drip as nurse said she was just transferred there last night. Sugars in 200 range. Nurse gave her 12 units regular insulin and will be starting patient on insulin drip now. Artee [**2138-12-26**] Pt now in VICU, trach plugged yesterday so is followed by respiratory service. Eating breakfast but then appetite poor during day. Having low sugars at bed and in middle of night. Have cut back on NPH and sliding scale regular. Artee [**2139-1-2**] Pt has developed pneumonia so is on antibiotics and being followed by ID and respiratory service. Not eating well so started on TF last evening. Sugars have crept up since TF started yesterday. I increased her morning NPH from 4 to 6 and increased supper scale of regular insulin as well. Sugars 151-207. Artee [**1-3**]: Remains on TFs. BGs in low 200's Friday afternoon. [**Month (only) 116**] need further increase in AM NPH insulin. [**Doctor First Name 892**] [**1-4**] back to NPO after developin GIT bleeding. Did not take her NPH this morning. On SS Humalog tid. Switched to lantus 10 units HS and Humalog SS q6hr until she starts eating back. [**Doctor First Name 4375**] [**1-8**] - Was on drip for 24 hours at 10 units per hour as she transitioned to increased TF (70cc per hour continuosly). BG had gone up to 450s. Stopped drip last night at 1 am. Got 15 units of Lantus last night. On [**Hospital1 34**] q 6 hours. I increaseed Lantus to 18 units tonight. Will go to [**Hospital Ward Name 121**] 9 today. [**1-10**] On [**Hospital Ward Name 121**] 9. Sugars OK, and I left doses unchanged today, but may need some increases if they do not settle down a bit more in the next 24 hours [**1-11**]-i raised lantus dose 83 yo F s/p fall down 4stairs w/+LOC. Transferred to [**Hospital1 18**] multiple facial/nasal fractures, Left wrist/distal radius fracture. GCS 15 in route. Hemodynamically stable in ED. Lac on lip sutured at outside hospital. L PCA stroke- enlarged on/heparin gtt (w/epistaxis) Found unresponsive [**12-18**], emergent Trach. s/p formal trach and peg [**12-19**]. Difficult L SC access, has picc in place. Hep gtt bleed; MRSA + on nasal swab ; Several episodes of mucus plugging w/sob over [**Date range (1) 59877**] resulting in transfer to stepdown bed. GI called due to bright red blood in PEG and rectal tube, Hct drop. PEG didnt clear with lavage.. We did EGD in unit, showed clot behind internal bumper of pEG(Put in by either [**Doctor First Name **] or pulm but not us),likely secondary to bumper being too tight causing necrosis. We loosened it by 0.5 cms. Good pictures on gmed. Hematocrit values were followed throughout her stay. Patient also followed by pulmonary service during her stay: 83F [**Hospital 23789**] transferred from [**Hospital **] Hospital with face/neck/wrist fractures on [**12-15**], found to have L PCA stroke which progressed, c/b unresponsiveness on [**12-19**] requiring urgent tracheostomy with revision and PEG the following day. Has had L retrocardiac opacity since then with persistently elevated wbc. Sputum cx grew MRSA and she has been on vanco/levo x 9d, still with thick yellow secretions + high wbc although afebrile. On trachmask 40% but sats 99% last few days with on episodes of desats. Also has LUE clot for which she cannot go on heparin now b/c of CVA worsening. Consult requested for possible bronch given ? of yeast on sputum cultures. On exam seems extremely volume overloaded with bronchial breath sounds on L base. Diuresed appropriately with lasix. Daily weights followed, respiratory status improved though still requiring suctioning every 4-6 hours. Patient also followed by orthoapedics for left radius fracture that was repaired in the operating room by Dr. [**Last Name (STitle) **]. Patient to follow up with Dr. [**Last Name (STitle) **] within one to two weeks after discharge and to continue wearing cast. Patient also followed by cardiology during her stay and the following recommendations were followed. Patient placed on telemetry, ECG, ACE inhibitor started, atorvastatin started. Patient followed also by nephrology service for rising creatinine. Cr 1.2-->2.4 and facing a cranial angio to r/o vertebral dissection 1. ARF 2.4-->1.7 ---> 1.6 and good UOP 2. hemorrhage into L occipital infarct--off heparin now, awaiting cerebral angio for possible vertebral dissection Also followed by neurology stroke service for likely occipital infarct. [**12-18**]: MRI/MRA performed, MRI shows occipital infarct with small amount of hemorrhage into the infarct. MRA with fat sats poor quality, still cannot determine if there is dissection [**12-18**] pm: pt acutely developed resp distress, unable to be intubated given fx's, emergent trach placed, transferred to ICU. Since then has been in ICU, stabilzed, on ASA not heparin. Responsive on exam but relatively unchanged. [**12-21**] pt transferred to the floor in stable condition Medications on Admission: Insulin, Paxil, Aricept, NTG, Nifedipine, Lipitor, Glucotrol, protonix,Catapress, ASA, lasix 80, Xalatan eye drop, procardia Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical TID (3 times a day) as needed for Itch. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 7. Insulin Regular Human Subcutaneous 8. Dolasetron Mesylate 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed. 9. Hydralazine HCl 20 mg/mL Solution Sig: One (1) Injection Q6PRN (). 10. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1) Intravenous PRN (as needed) as needed for K<4.0. 11. Magnesium Sulfate 50 % Solution Sig: One (1) Injection PRN (as needed) as needed for Mg<2.0. 12. Calcium Chloride 10 % (100 mg/mL) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for iCa<1.15. 13. Calcium Gluconate 100 mg/mL (10%) Solution Sig: One (1) Intravenous PRN (as needed) as needed for Ca<8.4. 14. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln Intravenous Q48H (every 48 hours). 15. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical TID (3 times a day) as needed for Itch. 16. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscell. Q4-6H (every 4 to 6 hours) as needed for thick secretions. 17. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Dorzolamide HCl Ophthalmic 19. Acyclovir 200 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 20. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 21. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 22. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 23. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 25. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 26. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 27. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 28. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 29. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). 30. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 31. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: multiple nasal, facial fractures, left distal radius fracture, left posterior communicating artery stroke, diabetes mellitus, coronary artery disease, chronic renal disease, hyperlipidemia, gastroesophageal reflux disease, remote acute appendicitis Discharge Condition: stable Discharge Instructions: if having worsening shortness of breath, chest pain, fevers, chills, nausea, vomiting, or if there are any questions or concerns. Followup Instructions: Patient to follow up with trauma surgery in two weeks, call to schedule an appointment at [**Telephone/Fax (1) 2359**]. Patient to follow up with orthopaedics in two weeks, call to schedule an appointment at [**Telephone/Fax (1) 5499**]. Patient to follow up with plastic surgery in two weeks, call to schedule an appointment [**Telephone/Fax (1) 274**]. Patient to follow up with neurosurgery in two weeks, call to schedule an appointment [**Telephone/Fax (1) 274**]. They will address the duration of your neck collar.

[ "250.80", "851.02", "519.1", "263.9", "428.0", "434.91", "054.2", "482.41", "431", "584.9", "813.42", "536.49", "285.1", "V09.0", "287.4", "802.0", "363.62", "518.81", "E880.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "31.74", "96.6", "21.71", "96.72", "38.93", "45.13", "34.91", "99.04", "43.11", "31.1", "88.41" ]

icd9pcs

[ [ [] ] ]

10797, 10877

2775, 8005

445, 620

11170, 11178

1236, 2752

11356, 11881

8181, 10774

10898, 11149

8032, 8158

11202, 11333

947, 1217

197, 407

648, 858

880, 932

23,249

194,415

49576

Discharge summary

report

Admission Date: [**2131-9-29**] Discharge Date: [**2131-10-3**] Date of Birth: [**2052-1-28**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 2297**] Chief Complaint: elevated INR Major Surgical or Invasive Procedure: none History of Present Illness: 79 yo white male with end-stage renal disease on HD with recent STEMI on plavix and aspirin with EF 25%, atrial fibrillation on coumadin admitted with HCT 18.8 and INR 9.9. He had blood drawn at HD today that showed an INR of 16.2 and PTT 56.8. EMS picked patient up to bring to the ED. Vitals at that time were p110, bp 110/64, r20, 90%ra. He has been at [**Doctor First Name 391**] [**Hospital **] Rehab since his discharge from [**Hospital1 18**] following his STEMI on [**9-19**]. He denies headache, dizziness, nausea, abdominal pain, hematesis, melana, chest pain, shortness of breath. He had mild burning abdominal pain yesterday as per wife. As per daughter-in-law he had some blood on his stool yesterday. Additionally, he has been sundowning for the past few weeks. He had a colonoscopy last month that showed hemorrhoids and 4 colonic polyps. He was discharged from [**Hospital1 18**] on levofloxacin, presumably for a UTI. Also, he finished a 3day course of ciprofloxacin on [**9-22**], presumably for a UTI. He makes very little urine at baseline. His INR at dischare was 3.2, but had been as high as 7.5 while in the hospital. His HCT was 28.5-32.5 during his last admission. . ROS: occassional diarrhea, occasional orthopnea, dysuria for one month, poor appetite at baseline, . In the ED, he was given 5mg SC vitamin K, DDAVP, 2 bags of FFP, and one unit of pRBCs. He did not tolerate an attempt for central access by internal jugular due to agitation and a right femoral line was placed. Past Medical History: End stage renal disease on HD. He started dialysis in [**4-5**]. Renal failure [**1-3**] HTN nephropathy. Hypertension CAD- STEMI- [**9-5**] H/O HIT antibody COPD BPH Post-MI atrial fibrillation Recent b/l pleural effusions Aneurysms in right iliac artery seen by cath [**9-5**] Colonic polyps Hemorrhoids Social History: +tobacco- not since admission, married. Was living with wife before recent admission. No etoh. His wife requires a wheelchair. Family History: brother died of CAD in his 80's Physical Exam: PE: t100.6 max in ed, p102, bp 132/60, r20, 95%ra wt-137kg Thin elderly male in NAD. Pleasant. Poor attention span. Appears sleepy. Oriented to name, year, president, and birthdate. HEENT: perrl, nonicteric, supple, clear op, jvp approx 8cm CV: 1/6 sem right upper sternal border PULM: cta ABD: soft, NT, +bs EXT: no edema, some bruising, +symmetric DP pulses Neuro: follows commands, CN intact Pertinent Results: [**2131-9-29**] CXR: Left lower lobe collapse and/or consolidation with equivocal very small left effusion. No CHF or right effusion. No supine film evidence of pneumothorax is identified. . [**2131-9-29**] CT HEAD: No intracranial hemorrhage or mass effect. . [**2131-9-29**] ECG: Sinus tachycardia. Marked left axis deviation. Right bundle-branch block with left anterior fascicular block. Anteroseptal myocardial infarction of indeterminate age. Rate 105, PR 174, QRS 150, QT/QTc 384/445, P 62, T47. . [**2131-9-30**] CXR: new extensive bilateral alveolar opacities throughout both lungs, probably with bilateral pleural effusions. There is left lower lobe collapse and/or consolidation. Findings are compatible with severe pulmonary edema. . [**2131-10-1**] CXR: The diffuse alveolar edema present on the prior chest x-ray has improved. Interstitial [**Doctor Last Name 5926**] remains in the right upper lung and the left lower lung, and an associated left pleural effusion is present . [**2131-9-29**] PT-35.9* PTT-53.9* INR(PT)-9.9 [**2131-9-29**] PLT COUNT-283 [**2131-9-29**] NEUTS-61.8 LYMPHS-30.3 MONOS-4.2 EOS-3.0 BASOS-0.8 [**2131-9-29**] WBC-4.1 RBC-2.09*# HGB-5.9*# HCT-18.8*# MCV-90 MCH-28.4 RDW-18.7* [**2131-9-29**] GLUCOSE-85 UREA N-27* CREAT-3.1*# SODIUM-148* POTASSIUM-5.6* CHLORIDE-100 TOTAL CO2-38* ANION GAP-16 [**2131-9-30**] HCT-35 [**2131-10-1**] HCT-33 [**2131-10-2**] HCT-35 [**2131-10-3**] HCT-35.5 [**2131-9-30**] INR-2.7 [**2131-10-2**] INR-1.8 [**2131-10-3**] INR-2.2 Brief Hospital Course: A/P: 79 yo male with ESRD [**1-3**] hypertensive nephrosclerosis on HD, pAfib on coumadin, low EF, and recent STEMI with stent placement on plavix and aspirin who is admitted with elevated INR in the setting of recnt antibiotics and poor nutrition, low HCT, and altered mental status. . GI BLEED: Recent colonscopy showed hemmorhoids and 4 polyps as per daughter. A small amount of blood was visualized on NG lavage consistent with an upper GI bleed in setting of supratherapeutic INR, aspirin, plavix and uremic platelets. Initially treated with Protonix IV bid, DDAVP and FFP in ED. Hct remained stable at 33-35 for the rest of his hospitalization after 6 units of PRBCs. INR dropped to roughly 2 after FFP treatment. A slight bump in INR from 1.8 to 2.2 was seen on the day of discharge likely secondary to reinstitution of a normal diet including vitamin K. More FFP was not administered given recent coronary stent placement. An EGD was deferred, and will be performed as an outpatient. . DELIRIUM: Pt was agitated and confused since the last admission. New meds that were started on the last admission: lipitor, albuterol, atrovent, ASA, plavix, calcium acetate, seroquel, zydis, metoprolol, lisinopril, amiodarone. Meds stopped: trazadone, norvasc, clonidine, hydrazalne, and nicotine patch. Pts delirium cleared with discontinuation of standing seroquel/zydis and reinstitution of trazadone and nicotine. He had very occasional sundowning with his discharge medication regimen. . HYPERNATREMIA: Likely from hypovolemic hypernatremia. Normalized with fluid resuscitation. . CAD: ASA and Plavix were continued given recent placement of coronary stent. BB and ACEi were also reinstituted after being held for one day. . PULMONARY EDEMA: Pt manifested flash pulmonary edema on the second day of hospitalization secondary to EF=20% and fluid resuscitation. Pt received immediate HD and then daily HD for fluid overload with marked improvement in O2 requirement, CXR and clinical exam. . ESRD: Pt received HD every day while hospitalized or fluid overload. . HTN: antihypertensives were reinstituted with the stabilization of Hct . COPD: atrovent and albuterol were continued. . AFIB: Pt exhibited atrial fibrillation after [**Last Name (un) **] pulmonary edema requiring increased doses of metoprolol and amiodarone. He was continued on amiodarone at 200 mg QD and his home dose of metoprolol. He converted back to sinus ryhthm with his discharge dosing of amiodarone and metoprolol. . PPX: No heparin was given due to h/o HIT ab. Pneumoboots. PPI. ISS. Bowel regimen prn. Acetaminophen prn. . FEN: NPO . Line: right femoral line was placed for access and removed one day prior to discharge, peripheral access was obtained. . Code: Full code. Clarified with wife who is health care proxy. . Communication: Wife, son, and daughter in law. Medications on Admission: ASA 81mg po daily Lopressor 100mg po daily Atorvastatin 80 mg po daily Plavix 75mg po daily Coumadin 2mg po daily Lisinopril 10 mg po daily (Amiodarone 200mg po daily- stopped [**9-26**]) Albuterol prn Atrovent qid Nephrocaps Colace Vitamin B, Folate, B complex Pantoprazole 40mg daily Calcium acetate 1334 po tid with meals Quetiapine 25 mg oral pqhs Latanoprost 0.005% each eye qhs Olanzapine sublingual 5mg [**Hospital1 **] Flomax 0.4mg PO daily Avodart 0.5mg po daily Renal diet, fluid restriction to 960cc daily Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Ipratropium Bromide 0.02 % Solution Sig: Two (2) puffs Inhalation Q6H (every 6 hours). 4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitaion. 5. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 8. Albuterol Sulfate 0.083 % Solution Sig: Two (2) puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed): may take up to three tablets separated by 3 minutes. 12. Nitroglycerin 2 % Ointment Sig: One (1) Transdermal Q8H (every 8 hours) as needed. 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for SBP < 100 HR < 60. 14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 15. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily) for 14 days. 16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-3**] Sprays Nasal DAILY (Daily) as needed. 17. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 20. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 21. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay - [**Hospital1 392**] Discharge Diagnosis: PRIMARY: --gastrointestinal bleeding --delirium SECONDARY: --AFIB --CAD/STEMI s/p stent placement --ESDR on HD --COPD Discharge Condition: Hct >30 x 2days, O2sat 90s on room air Discharge Instructions: --seek immediate medical attention if experiencing worse than usual chest pain, marked shortness of breath, blood loss. --take all medications as prescribed --follow-up on all appointments Followup Instructions: EGD to be performed in [**2-2**] wks.

[ "285.1", "403.91", "790.92", "276.52", "414.01", "276.0", "428.0", "496", "V45.82", "427.31", "600.00", "578.9", "585.6", "V58.61", "410.72" ]

icd9cm

[ [ [] ] ]

[ "99.07", "39.95", "99.04" ]

icd9pcs

[ [ [] ] ]

9664, 9744

4312, 7165

288, 295

9906, 9947

2781, 2990

10184, 10225

2317, 2351

7733, 9641

9765, 9885

7191, 7710

9971, 10161

2366, 2762

236, 250

323, 1828

3000, 4289

1850, 2157

2173, 2301

42,652

146,704

53755

Discharge summary

report

Admission Date: [**2155-12-23**] Discharge Date: [**2156-1-1**] Date of Birth: [**2081-1-27**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 1505**] Chief Complaint: Throat burning and discomfort with exertion Major Surgical or Invasive Procedure: [**2155-12-23**] Cardiac cath [**2155-12-26**] Coronary artery bypass graft x 4 (Left internal mammary artrey to left anterior descending, saphenous vein graft to obtuse marginal, saphenous vein graft to diagonal, saphenous vein graft to posterior descending artery) History of Present Illness: 74 year old male with a fairly recent diagnosis of atrial fibrillation, recently evaluated for six weeks of new throat tightening with exertion and very mild dyspnea with exertion. At times he also will note chest discomfort that is not always exertional. Stress test revealed a new anterolateral and inferolateral reversible defect with a decline in LVEF. He was referred for cardiac catheterization to further evaluate. He was found to have coronary artery disease and is now being referred to cardiac surgery for revascularization. Past Medical History: Hypertension Hyperlipidemia Multiple sclerosis Borderline diabetes Cervical spondylosis s/p laminectomy Severe back pain d/t osteoarthritis Atrial fibrillation on Coumadin GERD Prostate cancer s/p resection s/p skin cancer resection from left leg and nose Remote GIB requiring transfusion (None recent) Iron deficiency anemia Past Surgical History: s/p laminectomy s/p Left shin and nose s/p melanoma excision Social History: Race:Caucasian Last Dental Exam:edentulous Lives with:wife Contact: [**Name (NI) **] (wife): [**Telephone/Fax (1) 110329**] cell Occupation:retired Cigarettes: Smoked no [] yes [x] Hx:quit in [**2131**], smoked 2ppd x45 years Other Tobacco use:denies ETOH: quit drinking in [**2136**], history of 6 beers/day Illicit drug use:denies Family History: Premature coronary artery disease - non contributory Physical Exam: Admission PE: Pulse:81 Resp:16 O2 sat:100/RA B/P Right:128/87 Left:138/79 Height:5' 8.5" Weight:227 lbs General: Skin: Dry [x] intact [] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [], bilateral lower extremity varicosities Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: dop Left: dop Radial Right: 2+ Left: 2+ Carotid Bruit Right: none Left: none Pertinent Results: [**2155-12-23**] Cath: 1. Selective coronary angiography in this right dominant system demonstrates three vessel coronary disease. There is an 80% lesion in the distal left main coronary artery. The circumflex artery is proxmally occluded and the obtuse marginals are filled by collaterals from the right. The left anterior descending is involved, with ostial diagonal and ramus lesions of 70% and proximal LAD lesion of 40%. The right coronary arteyr contains an 80% lesion in the proximal posterior descending. There is a 50% lesion in the distal right coronary artery. 2. Limited resting hemodynamics demonstrate normal blood pressure. [**2155-12-24**] Carotid U/S: Right ICA <40% stenosis. Left ICA <40% stenosis [**2155-12-26**] Echo: 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. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). The right ventricular cavity is dilated and displays mild to moderate global free wall hypokinesis. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is a suggestion of a possible fibroelastoma on the left or non-coronary cusp but it can not be definitively determined. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-22**]+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is atrially paced. There is now normal biventricular systolic function. Valvular function is essentially unchanged. A left pleural effusion is noted. The thoracic aorta is intact after decannulation. [**2155-12-29**] 02:32AM BLOOD WBC-15.4* RBC-4.15* Hgb-11.9* Hct-34.4* MCV-83 MCH-28.6 MCHC-34.5 RDW-15.9* Plt Ct-149* [**2155-12-23**] 09:30AM BLOOD WBC-7.8 RBC-3.95* Hgb-10.6* Hct-32.1* MCV-81* MCH-26.7*# MCHC-33.0# RDW-15.4 Plt Ct-280 [**2155-12-29**] 02:32AM BLOOD PT-14.9* PTT-30.8 INR(PT)-1.4* [**2155-12-23**] 07:20AM BLOOD PT-14.7* PTT-25.0 INR(PT)-1.4* [**2155-12-29**] 02:32AM BLOOD Glucose-114* UreaN-22* Creat-1.2 Na-133 K-4.3 Cl-98 HCO3-24 AnGap-15 [**2155-12-23**] 09:30AM BLOOD Glucose-118* Na-135 K-5.4* Cl-106 HCO3-18* AnGap-16 Brief Hospital Course: Mr. [**Known lastname 20622**] was admitted following his cardiac cath which revealed severe three vessel coronary artery disease. He was worked up for bypass surgery. While awaiting Plavix wash-out he was medically managed. On [**12-26**] he was brought to the operating room where he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery he was transferred to the CVICU intubated and sedated in critical but stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. He weaned off pressor support and Beta-blocker/aspirin/statin and diuresis were initiated. He was transfused with blood products postoperatively for coagulopathy and anemia likely due to blood loss and volume resucitation. POD#1 A right pneumothorax was evident on CXR. A thoracosotomy tube was inserted and remained in until pneumothorax resolved. All tubes and drains were discontinued per protocol. Anticoagulation was resumed for his chronic atrial fibrillation. He remained in CVICU until POD#3 for aggressive pulmonary hygiene. He was slow to progress but transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. The remainder of his hospital course was essentially uneventful. On POD#6 he was cleared for discharge to [**Hospital1 12004**]. All follow up appointments were advised. Medications on Admission: BACLOFEN 20 mg [**Hospital1 **] prn LISINOPRIL 40 mg daily METOPROLOL SUCCINATE 100 mg- 1 Tablet by mouth every morning, half a tablet every evening SIMVASTATIN 10 mg daily TRIAMCINOLONE ACETONIDE 0.1 % Ointment - Apply to surgical wound once daily with bandage change WARFARIN 2 mg daily ASPIRIN 81 mg daily FERROUS SULFATE 324 mg daily Plavix - last dose:none Last dose of Coumadin [**2155-12-19**] Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed Release (E.C.)(s) 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 4. baclofen 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 9. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 11. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours) as needed for cough. 12. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 13. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 14. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 15. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 17. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. 18. potassium chloride 20 mEq Packet Sig: One (1) PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 4 Past medical history: Hypertension Hyperlipidemia Multiple sclerosis Borderline diabetes Cervical spondylosis s/p laminectomy Severe back pain d/t osteoarthritis Atrial fibrillation on Coumadin GERD Prostate cancer s/p resection s/p skin cancer resection from left leg and nose Remote GIB requiring transfusion (None recent) Iron deficiency anemia Past Surgical History: s/p laminectomy s/p Left shin and nose s/p melanoma excision Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 2+ LE 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) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2156-1-28**] at 1:30 Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**] on [**2-13**] at 11:30am. Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Doctor Last Name **] in [**3-25**] 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** Anticoagulation Indication: Atrial Fibrillation Target INR: 2.0-3.0 Anticipated Length of Anticoagulation: Ongoing Most recent warfarin doses:Date [**2155-12-30**] [**2155-12-31**] [**2156-1-1**] Dose 2.5/2.5/2.5 Other Anticoagulants/Bridging Therapy?: No Next INR Should be Drawn On: [**2156-1-2**] Anticoagulation will be Managed by: rehab until arranged prior to discharge Completed by:[**2156-1-1**]

[ "790.29", "427.31", "512.1", "V10.83", "413.9", "V10.46", "E878.2", "530.85", "V45.89", "276.7", "V15.82", "530.81", "V70.7", "790.92", "340", "414.01", "E934.2", "280.9", "V58.61", "285.1", "272.4", "401.9" ]

icd9cm

[ [ [] ] ]

[ "34.09", "37.22", "36.13", "36.15", "39.61", "38.93", "88.56" ]

icd9pcs

[ [ [] ] ]

9041, 9201

5532, 6972

318, 586

9737, 9969

2749, 5509

10892, 11937

1950, 2004

7424, 9018

9222, 9283

6998, 7401

9993, 10869

9654, 9716

2019, 2730

235, 280

614, 1150

9305, 9631

1599, 1934

11,861

123,535

22421

Discharge summary

report

Admission Date: [**2133-2-2**] Discharge Date: [**2133-2-6**] Date of Birth: [**2105-5-5**] Sex: F Service: MEDICINE Allergies: Morphine / Prochlorperazine / Tramadol Attending:[**First Name3 (LF) 896**] Chief Complaint: N/V/diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 27 year old woman with a PMH s/f DM1, chronic back pain, anxiety and depression with multiple admissions for DKA who presents with N/V/D . Two weeks ago she was transitioned from Lantus and SS to 70/30. She says she took her last dose of insulin last night, but was unable to take it this morning secondary to the N/V/D she started to experience at 3 AM. This was initally vomtiing at 3 AM, with back pain, which subseqauently transitioned to diffuse lower back pain/abdominal pain. She also endorses several loose bowel movement, without any [**Known lastname **]. On her ROS, she endorses some eye pain above her right eye which has been prsent for the past week, tightness in her chest when she is anxiousm, cold sweats at night, and a burning in her abdomnen. Her last fingerstick was last night, and was 135. She denies any sick contacts, and had tried to use Ativan for her nausea, without great effect. She denies any sick contacts, any recent new food ingestions, or any other intoxications. She denied any fevers at home. . In the ED, initial VS were: 98.7 120 143/95 16 100%. Her labs were notable for urine with Glu 1000, Ket 150, Na 130, K 5.7, Cl 84, Bicarb 9, BUN 45, Cr 2, Glucose 824, AG 40, Calcium 10.5, Phos 8.1, and WBC count 12.2. In teh ED she received 2 L NS and 8 U insulin/hr gtt. She also received 4 mg Zofran, and 1 mg IV Dilaudid. On transfer her vitals were 98.8 119 143/80 98% RA. . On arrival to the MICU, she is AAOx3, but curled up in pain. Past Medical History: - Diabetes mellitus type I: diagnosed age 16 in [**2120**] after her first pregnancy. followed at [**Last Name (un) 387**]. - Severe anxiety/panic attacks - Previous admissions for nausea/vomiting with h/o esophagitis and with concern for diabetic gastroparesis on metoclopramide - Esophagitis / H. Pylori [**6-/2128**] and again [**8-/2130**] - Stage I diabetic nephropathy - Grade I esophageal varices seen on scope in [**2132-1-1**], negative liver ultrasound, normal LFTs, hep panel negative - Anxiety/panic attacks - Depression - Hyperlipidemia - S/P MVA [**5-4**] - lower back pain since then. - S/P MVA [**2130**], ex-lap - G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section in [**2122**], not menstruating secondary to being on Depo-Provera - Genital Herpes - H pylori, s/p 2-week triple therapy on [**2132-1-24**] . Social History: Lives with her 9 yo son. On disability. - Tobacco: quit "years ago" - Alcohol: [**12-1**] glasses wine or champagne at holidays/special occasions (none recently) - Illicits: none, denies IVDU Family History: Grandmother with diabetes, no other significant family history Physical Exam: PHYSICAL EXAM ON ADMISSION: Vitals: 98 112/68 106 20 99RA FSG 330 General: Alert, oriented, no acute distress [**Month/Day (2) 4459**]: Sclera anicteric, dry MM, 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 Back: No CVA tenderness and vertebra nontender to palpation. GU: Foley present Ext: warm, well perfused, 2+ pulses. Nonhealing and calloused right 5th toe, it is not errythematous, mildly tender. PHYSICAL EXAM ON DISCHARGE: Vitals: 98.2 160/119 100 18 100RA FSG 274 in AM General: Alert, oriented, no acute distress. [**Month/Day (2) 4459**]: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated Lungs: CTAB, no wheezes, rales, ronchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, NTND, +BS, no rebound tenderness or guarding, no organomegaly Back: No CVA tenderness and vertebra nontender to palpation. Ext: warm, well perfused, 2+ pulses. Nonhealing and calloused right 5th toe, it is not errythematous, mildly tender. Pertinent Results: [**2133-2-2**] 12:30PM [**Year/Month/Day 3143**] WBC-12.2*# RBC-4.32# Hgb-12.4# Hct-39.0# MCV-90 MCH-28.7 MCHC-31.7 RDW-13.2 Plt Ct-291 [**2133-2-2**] 12:30PM [**Year/Month/Day 3143**] Neuts-82.2* Lymphs-15.7* Monos-1.2* Eos-0.1 Baso-0.8 [**2133-2-3**] 04:02AM [**Year/Month/Day 3143**] WBC-17.6* RBC-3.41* Hgb-9.7* Hct-28.5*# MCV-84 MCH-28.3 MCHC-33.9 RDW-13.4 Plt Ct-238 [**2133-2-3**] 04:02AM [**Year/Month/Day 3143**] Neuts-82.5* Lymphs-14.7* Monos-2.3 Eos-0.3 Baso-0.2 [**2133-2-4**] 05:56AM [**Year/Month/Day 3143**] WBC-11.3* RBC-3.36* Hgb-9.8* Hct-28.7* MCV-85 MCH-29.1 MCHC-34.1 RDW-13.4 Plt Ct-189 [**2133-2-2**] 12:30PM [**Year/Month/Day 3143**] Glucose-824* UreaN-45* Creat-2.0* Na-130* K-5.7* Cl-84* HCO3-9* AnGap-43* [**2133-2-2**] 04:10PM [**Year/Month/Day 3143**] Glucose-629* [**2133-2-2**] 05:47PM [**Year/Month/Day 3143**] Glucose-456* UreaN-43* Creat-1.9* Na-140 K-4.8 Cl-101 HCO3-16* AnGap-28* [**2133-2-2**] 07:54PM [**Year/Month/Day 3143**] Glucose-289* UreaN-39* Creat-1.7* Na-135 K->10 Cl-106 HCO3-18* [**2133-2-2**] 09:39PM [**Year/Month/Day 3143**] Glucose-208* UreaN-36* Creat-1.5* Na-145 K-4.8 Cl-113* HCO3-21* AnGap-16 [**2133-2-3**] 01:12AM [**Year/Month/Day 3143**] Glucose-200* UreaN-32* Creat-1.4* Na-146* K-5.7* Cl-116* HCO3-24 AnGap-12 [**2133-2-3**] 04:02AM [**Year/Month/Day 3143**] Glucose-141* UreaN-30* Creat-1.4* Na-144 K-4.4 Cl-116* HCO3-24 AnGap-8 [**2133-2-3**] 12:18PM [**Year/Month/Day 3143**] Glucose-139* UreaN-22* Creat-1.2* Na-135 K-4.5 Cl-105 HCO3-23 AnGap-12 [**2133-2-4**] 05:56AM [**Year/Month/Day 3143**] Glucose-261* UreaN-18 Creat-1.1 Na-133 K-4.4 Cl-103 HCO3-25 AnGap-9 [**2133-2-5**] 06:00AM [**Year/Month/Day 3143**] Glucose-279* UreaN-15 Creat-1.1 Na-131* K-4.2 Cl-100 HCO3-26 AnGap-9 [**2133-2-2**] 12:30PM [**Year/Month/Day 3143**] ALT-28 AST-35 AlkPhos-109* TotBili-0.2 [**2133-2-2**] 12:30PM [**Year/Month/Day 3143**] Albumin-4.5 Calcium-10.5* Phos-8.1*# Mg-2.6 [**2133-2-2**] 05:47PM [**Year/Month/Day 3143**] Calcium-9.2 Phos-5.4*# Mg-2.8* [**2133-2-2**] 07:54PM [**Year/Month/Day 3143**] Calcium-8.6 Phos-4.1 Mg-2.3 [**2133-2-2**] 09:39PM [**Year/Month/Day 3143**] Calcium-8.8 Phos-2.7 Mg-2.2 [**2133-2-3**] 01:12AM [**Year/Month/Day 3143**] Calcium-8.5 Phos-2.0* Mg-2.3 [**2133-2-3**] 04:02AM [**Year/Month/Day 3143**] Calcium-8.4 Phos-1.8* Mg-2.1 [**2133-2-3**] 12:18PM [**Year/Month/Day 3143**] Calcium-8.3* Phos-2.1* Mg-1.9 [**2133-2-4**] 05:56AM [**Year/Month/Day 3143**] Calcium-8.7 Phos-2.1* Mg-1.8 [**2133-2-5**] 06:00AM [**Year/Month/Day 3143**] Calcium-8.6 Phos-2.3* Mg-1.7 [**2133-2-4**] 12:28AM [**Year/Month/Day 3143**] %HbA1c-13.4* eAG-338* [**2133-2-2**] 05:47PM [**Year/Month/Day 3143**] ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2133-2-3**] 04:34AM [**Year/Month/Day 3143**] Type-[**Last Name (un) **] pO2-44* pCO2-47* pH-7.31* calTCO2-25 Base XS--2 [**2133-2-2**] 05:48PM URINE [**Year/Month/Day 3143**]-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2133-2-2**] 05:48PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [**2133-2-2**] 05:48PM URINE MUCOUS-RARE . [**2-2**] CXR: Normal heart, lungs, hila, mediastinum, and pleural surfaces. No pneumonia. [**2133-2-2**] 5:48 pm URINE Source: Catheter. URINE CULTURE (Final [**2133-2-5**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE, PRESUMPTIVELY NOT S. SAPROPHYTICUS. 10,000-100,000 ORGANISMS/ML.. Brief Hospital Course: Ms. [**Known lastname **] is a 27 year old woman with a PMH of DM1, chronic back pain, anxiety, and depression with multiple admissions for DKA who presents with N/V/D and found to be in DKA. # DKA: Work up with assessment for insulin deficiency, iatrogensis, infection, inflammation, ischemia, or intoxication. She denies any non-compliance, and does not have any obvious sources which appear to be infectious. Her N/V/D are likely secondary to her DKA but could potentially be due to a viral gastroenteritis. [**Last Name (un) **] was consulted as they follow her as an outpatient. She was aggressively fluid resuscitated initially with NS and then with D5 1/2NS, placed on an insulin drip, and had electrolytes drawn every 4 hours. Potassium was repleted. Anion gap closed and the patient started taking POs at which point she was started on Novolog 70/30 with an insulin sliding scale. Subsequent chemistry panel after initiation of POs showed resolution of the anion gap. On day of discharge she was on 70/30 22units prior to breakfast and 15units at diner. Her FSG became stable. [**Last Name (un) **] was consulted and followed throughout the hospital admission. Pt was scheduled with f/u at [**Last Name (un) **]. #Nausea/vomiting/abdominal pain: [**Known firstname **] has h/o recurrent hospitalization for similar sx, has been followed by GI service. Etiology likely multifactorial, potential causes include known gastritis (+ for H pylori and will commence treatmetn with discharge), gastroparesis (previous motility studies normal but she is at risk due to h/o DM), and anxiety. She was managed symptomatically with IV zofran and ativan. She has had prior gastric motility studies that were unremarkable. Her [**Known firstname **] improved and she was scheduled for follow-up with PCP and [**Name9 (PRE) **] endocrinologist. # H. pylori: Patient is concerned that her persistent H. pylori with chronic gastritis on biopsy is the source of her N/V. Zofran was given as needed. She was started on triple therapy per her outpatient gastroenterologist, Dr. [**Last Name (STitle) **], once she is able to tolerate POs (Amoxacillin, Levofloxacin, and Omeprazole). She was given prescriptions for all three medications at the time of discharge. # [**Last Name (un) **]: Her creatinine at baseline is 1.0-1.5, but on admission was 2 likely in the setting of volume depletion from DKA. likely pre-renal in setting of persistent N/V and poor PO intake. Creatinine returned to baseline 1.2 after aggressive fluid repletion. # Depression/Anxiety: Pt has h/o sexual abuse at young age, and recently has had worsening anxiety related to the event. Social work was consulted. # Anemia: Baseline HCT is 30, admission HCT was 39, and her HCT returned at 28.5 after aggressive fluid resuscitation. # Grade I Esophageal Varcies: Seen by hepatology attending in 02/[**2131**]. Subsequent EGD on [**6-10**] showed no remarkable findings. # Hypertension: BP currently 125/75. Initially held home BP medications, but resumed prior to discharge. PENDING RESULTS: [**Month/Year (2) **] cultures x2 TRANSITIONAL ISSUES: - She is scheduled for follow-up with PCP and [**Name9 (PRE) **] endocrinologist. - She was started on H. pylori therapy. - She maintained full code status. Medications on Admission: AMOXICILLIN 500 mg [**Hospital1 **] stared [**2133-2-2**] (for 56 capsules) LEVOFLOXACIN 250 mg [**Hospital1 **] to start [**2133-2-2**] for 28 capsules NOVOLOG MIX 70-30 FLEXPEN: 12 units before breakfast, 16 units at dinner time [**Hospital1 **] as directed LISINOPRIL 10 mg QHS LORAZEPAM 0.5 mg Q8H PRN OMEPRAZOLE 40 mg [**Hospital1 **] OXYCODONE-ACETAMINOPHEN 5 mg-325 mg Tablet q8 hrs as needed for pain not relieved by Tylenol CAMPHOR-MENTHOL 1 Lotion(s) twice a day as needed for itching Discharge Medications: 1. amoxicillin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*56 Tablet(s)* Refills:*0* 2. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*28 Tablet(s)* Refills:*0* 3. Novolog Mix 70-30 FlexPen 100 unit/mL (70-30) Insulin Pen Subcutaneous 4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Diabetic Ketoacidosis (DKA) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to [**Hospital1 18**] for treatment of Diabetic Ketoacidosis. After being seen in the Emergency Department you were admitted to the ICU due concerns about your [**Hospital1 **] sugar, [**Hospital1 **] acid level and mental status. After having your [**Hospital1 **] sugars and [**Hospital1 **] acid level return to a near normal level you were transferred to a general medicine floor. There your insulin regimen was optimized and we treated your nausea/vomitting. You will see [**Name6 (MD) 58280**] [**Name8 (MD) 1726**] RN at [**Last Name (un) **] as an outpatient for follow-up treatment and optimization of your insulin regimen. The following changes were made to your meds: 1. START 70/30 Insulin 22units before breakfast 2. START 70/30 Insulin 15units at dinner 4. START Amoxicillin 500mg [**Hospital1 **] (H. pylori therapy) 5. START Levofloxacin 250mg [**Hospital1 **] (H. pylori therapy) 6. START Omeprazole 40mg [**Hospital1 **] (H. pylori therapy) No other changes were made to your medications, please continue all other previously prescribed medications It was a pleasure to take care of you. We wish you the best. Followup Instructions: [**Hospital **] [**Hospital 982**] Clinic Provider: [**Name10 (NameIs) 58280**] [**Name11 (NameIs) 1726**] RN Date/Time:[**2133-2-17**] 04:00PM [**Hospital3 **] (Primary Care at [**Hospital1 18**]) Provider: [**Name10 (NameIs) 10160**] [**Name11 (NameIs) 10161**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 2010**] Date/Time:[**2133-2-11**] 1:20 Other appointments in our system: Gastroenterologist: Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2133-3-20**] 11:00 Primary Care Physician: [**Name Initial (NameIs) 2169**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 45396**], MD Phone:[**Telephone/Fax (1) 2010**] Date/Time:[**2133-4-21**] 2:35

[ "787.01", "403.90", "250.13", "724.5", "E929.0", "041.86", "V58.67", "300.00", "272.4", "250.43", "041.19", "585.9", "787.91", "584.9", "338.29", "535.10", "309.81", "789.00", "285.9", "276.50", "709.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12244, 12250

7730, 10836

308, 314

12341, 12341

4277, 7707

13699, 14480

2937, 3001

11560, 12221

12271, 12271

11041, 11537

12492, 13676

3016, 3030

3716, 4258

10857, 11015

256, 270

342, 1849

12290, 12320

3044, 3688

12356, 12468

1871, 2711

2727, 2921

23,063

171,508

28580

Discharge summary

report

Admission Date: [**2183-10-28**] Discharge Date: [**2183-11-11**] Date of Birth: [**2123-4-11**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Back pain Major Surgical or Invasive Procedure: Lumbar Embolization L1 vertebrectomy/resection of tumor with T10 to L3 thoracolumbar fusion/instrumentation History of Present Illness: 60 female admitted after imaging at OSH revealing an L1 compression fracture and a renal mass extending into the L renal vein to the IVC and into the right atrium. Evalutated by both neurosurgery and oncology for treatment plans. The patient reports that in [**8-/2183**] she twisted her back, causing intractable pain, that prompted imaging that revealed the aforementioned abnormaliities. She reports dyspnea, back pain, leg weakness with exertion, leg swelling, transient hematuria, & constipation.. She denies any HA, CP, abdominal pain, diarrhea, melena, hematochezia. She also reports that her exercise tolerance has decreased on account of her leg pain. She says that she is not limited by her back pain of dyspnea, but that her legs "give out". Past Medical History: Epilepsy Hypothyroidism Depression HT Glaucoma Social History: Smoking: 15pk year history stopped in [**2182**], no alcohol use Married with 2 children, worked as machine operator until [**Month (only) 547**] when she fx wrist in auto accident. Family History: Noncontributory Physical Exam: 98.4 71 114/74 18 100% RA NAD, A&Ox3, comfortable, pain controlled. Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [**Last Name (un) 938**] G Sensation: Intact to light touch and propioception Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Propioception intact Toes downgoing bilaterally Pertinent Results: [**2183-10-28**] 01:40PM BLOOD WBC-10.6 RBC-4.02* Hgb-10.4* Hct-34.2* MCV-85 MCH-26.0* MCHC-30.5* RDW-16.5* Plt Ct-526* [**2183-10-30**] 06:05AM BLOOD WBC-11.3* RBC-3.78* Hgb-9.7* Hct-30.8* MCV-82 MCH-25.6* MCHC-31.4 RDW-16.9* Plt Ct-383 [**2183-11-1**] 07:10AM BLOOD WBC-9.2 RBC-3.80* Hgb-10.0* Hct-32.2* MCV-85 MCH-26.2* MCHC-30.9* RDW-16.9* Plt Ct-388 [**2183-11-4**] 06:50AM BLOOD WBC-10.4 RBC-3.80* Hgb-10.0* Hct-31.2* MCV-82 MCH-26.2* MCHC-31.9 RDW-17.3* Plt Ct-360 [**2183-10-28**] 04:53PM BLOOD PT-14.0* PTT-26.8 INR(PT)-1.2* [**2183-11-1**] 07:10AM BLOOD PT-14.7* PTT-29.3 INR(PT)-1.3* [**2183-10-28**] 04:53PM BLOOD Glucose-118* UreaN-16 Creat-1.1 Na-132* K-7.4* Cl-100 HCO3-21* AnGap-18 [**2183-10-30**] 06:05AM BLOOD Glucose-126* UreaN-16 Creat-1.1 Na-135 K-4.4 Cl-104 HCO3-21* AnGap-14 [**2183-11-2**] 04:40AM BLOOD Glucose-122* UreaN-17 Creat-1.0 Na-136 K-4.4 Cl-107 HCO3-19* AnGap-14 [**2183-10-29**] 08:05AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.2 [**2183-11-1**] 07:10AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.3 [**2183-11-4**] 06:50AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.3 [**2183-10-29**] 08:05AM BLOOD TSH-45* [**2183-10-29**] 08:05AM BLOOD Free T4-0.79* . . Imaging: MR L SPINE W/O CONTRAST [**2183-10-28**] 9:43 PM IMPRESSION: 1. Very limited study due to motion artifact. A complete diagnostic examination was not performed. 2. Collapse of the L1 vertebral body with retropulsion of bony fragments into the canal, with probable severe cord compression. 3. Left-sided paraspinal mass, and mass in the left renal fossa. These findings are not well evaluated here. . CT HEAD W/ & W/O CONTRAST [**2183-10-29**] 12:57 PM IMPRESSION: 1. Hyperdense focus in the left basal ganglia, with enhancement. Lack of mass effect and edema is more suggestive of a cavernoma than a metastasis, but an MRI is recommended in order to evaluate further and to better characterize the lesion. Alternatively, if prior outside imaging can be obtained to show long-term stability, demonstration of benignity could be achieved without further imaging. 2. Surgical clip along the posterior aspect of the left maxillary sinus, possibly due to prior surgical treatment for hemorrhage. Correlation with surgical history is recommended. . ECHO Study Date of [**2183-10-30**] Conclusions: 1. A large (4x6.5 cm), mobile mass with a large cyst is seen in the right atrium, probably starting in the IVC, filling almost all of the right atrrium, prolapsing through the tricuspid valve, and into the right ventricle. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. 3. There is a trivial/physiologic pericardial effusion. . MRA BRAIN W/O CONTRAST [**2183-10-31**] 3:21 PM IMPRESSION: Small focus of chronic blood products and enhancement in the left subinsular region adjacent to the anterior [**Doctor Last Name 534**] of the left lateral ventricle as described above. The differential diagnosis is between cavernous angioma and a metastatic disease given the patient's clinical history of a renal cell cancer. The MRI appearances and the presence of developmental venous anomaly in the adjacent brain favor cavernous malformation as suggested on the previous CT. However, if further assessment is clinically indicated, the perfusion MRI with arterial spin labeling may help for differentiation MRA OF THE HEAD: The head MRA is limited by motion. No evidence of vascular occlusion or high-grade stenosis is seen in the arteries of anterior and posterior circulation. IMPRESSION: Motion limited head MRA demonstrates no evidence of vascular occlusion. . CT PELVIS W/CONTRAST [**2183-10-31**] 10:38 AM IMPRESSION: 1. Very large left renal mass with multiple associated bulky retroperitoneal, adrenal, and left paraspinal metastases. This is again most consistent with renal cell carcinoma. 2. Destruction of the L1 vertebral body with associated epidural disease compressing the spinal canal superiorly at this level. 3. Extensive tumor thrombus within the inferior vena cava extending into the right atrium and crossing the tricuspid valve. 4. Evidence of pulmonary metastases with largest mass demonstrated in the right middle lobe. 5. Bilateral pleural effusions, ascites, and anasarca. 6. Technically successful fine needle aspiration and core biopsy of large left renal mass. . CT C-SPINE W/O CONTRAST [**2183-11-1**] 12:13 PM IMPRESSION: 1. Mild spondylytic changes, without evidence of osseous metastatic disease in the cervical spine. . CT T-SPINE W/O CONTRAST [**2183-11-1**] 12:12 PM IMPRESSION: Allowing for differences in technique compared to the prior MR, similar appearance of compression fracture of L1 with associated enhancing soft tissue mass. There is probably similar severe canal stenosis as well as involvement of the left-sided neural foramina at T12-L1 and L1-L2. . CT L-SPINE W/O CONTRAST [**2183-11-1**] 12:12 PM IMPRESSION: Allowing for differences in technique compared to the prior MR, similar appearance of compression fracture of L1 with associated enhancing soft tissue mass. There is probably similar severe canal stenosis as well as involvement of the left-sided neural foramina at T12-L1 and L1-L2. . MRA LUMBAR SPINE [**2183-11-3**] 10:37 AM IMPRESSION: Anterior spinal artery is not definitively visualized. L1 compression fracture and mass consistent with the patient's known osseous metastasis. . XRAY L SPINE [**2183-11-9**] Standing L-Spine; Hardware intact, no shift Brief Hospital Course: 60 YO F with newly diagnosed metastatic renal CA and pathologic with L1 compression fx and pain control. Patient underwent decompression and fusion surgery. . 1. L1 compression fracture: - Patient had embolization procedure on [**2183-11-4**] - Neurosurgery performed L1 vertebrectomy with T10 to L3 thoracolumbar fusion/instrumentation and tumor resection on [**2183-11-5**]. She tolerated this procedure well and was transferred to PACU post op and remained intubated overnight. On POD#1 she was extubated. She had good LE strength. She was started on PCA. Hct was followed and she did need transfusion post op. She was transferred to the floor on POD#2. Her diet and activity were advanced. PCA was transitioned to po pain med. PT evaluated pt and found her appropriate for rehab. Incision was clean dry and well healing. - On IV decadron. Patient's neuro exam has improved slightly while on steroids. - Rad Onc has seen patient and suggest that if this fracture is tumor related, then she would benefit from post-operative radiation. Outside imaging reports have been obtained. She has an old cavernous hemangioma that has been followed and is stable. Finding on CT head from [**2183-10-29**] is likely an old finding. - TLSO brace: Patient has been fitted and will require brace when OOB or greater than 30 degrees in bed. - Continue oxycontin 10 mg [**Hospital1 **] for pain. - Morphine for breakthrough pain. . 2. Renal Mass - Most likely renal CA, path pending from recent CT-guided biopsy - Given thrombus/tumor extending into IVC to Right Atrium, patient on heparin gtt . 3. Hypothyroid/epilespy- - continue synthroid. - carbamazepine . 4. FEN- - Monitor UO - replete lytes prn - regular diet 5. UTI-pt to be started on bactrim DS 1 tab po bid x 7days starting today 6. vascular recs - R/O dvt- = neg DVT on [**11-6**], will maintian sq heparin and start asa 325mg [**Last Name (un) **] day per dr [**Last Name (STitle) **]. Medications on Admission: Carbamazepine. Synthroid 0.175mg daily Hydrocodone zoloft omperazole atenolol timoptic Discharge Medications: 1. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 4. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): while on steroids. 9. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Polyethylene Glycol 3350 17 g (100%) Packet Sig: One (1) Packet PO DAILY (Daily) as needed for constipation. 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 13. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 15. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 16. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 17. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) for 3 doses: start after2 mg dosing is complete. 18. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: please start today inrehab/ this is day1. 19. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 doses. 20. Dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day) for 3 doses: start after 4mg dosing is complete. 21. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 doses: start after 3 mg dosing complete. 22. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 23. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for breakthrough pain. 24. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for anxiety, nausea. Discharge Disposition: Extended Care Facility: Life Care Center - [**Location (un) 3320**] Discharge Diagnosis: Renal Cell Carcinoma L1 Compression fracture Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating with assistance. Discharge Instructions: Call for fever or any signs of infection - redness, swelling or drainage from wound. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] for staple removal 10-14 days post op - call for appointment [**Telephone/Fax (1) 1669**]. Follow up with radiation oncology at [**Hospital3 3583**] - call for appt [**Telephone/Fax (1) 69196**]. Follow up with Dr. [**Last Name (STitle) **] in [**11-1**] days - call for appointment [**0-0-**]. Completed by:[**2183-11-11**]

[ "599.0", "189.0", "336.3", "733.13", "198.5", "453.3", "196.2", "453.2", "401.9", "041.4", "198.89", "428.0", "197.0", "345.90", "429.89", "244.9" ]

icd9cm

[ [ [] ] ]

[ "88.72", "83.39", "99.05", "81.05", "03.1", "99.04", "38.86", "84.51", "38.85", "88.47", "88.44", "03.59", "99.07", "80.99", "81.63", "55.23" ]

icd9pcs

[ [ [] ] ]

12033, 12103

7653, 9595

331, 442

12191, 12266

2127, 5511

12399, 12771

1511, 1528

9733, 12010

12124, 12170

9621, 9710

12290, 12376

1543, 1729

282, 293

470, 1224

5528, 7630

1744, 2108

1246, 1295

1311, 1495

2,962

122,216

29550

Discharge summary

report

Admission Date: [**2116-2-5**] Discharge Date: [**2116-2-15**] Date of Birth: [**2035-9-22**] Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 2901**] Chief Complaint: Bradycardia Major Surgical or Invasive Procedure: Cardiac cath, transvenous pacer placement History of Present Illness: 80 yoF with severe AS (valve area 0.6), CAD, ESRD on HD who was intially admitted to [**Hospital3 **] [**2116-2-2**] with CHF. The patient responded to dialysis. The patient was transferred to [**Hospital1 18**] CT surgery [**2116-2-5**] for consideration of cardiac catheterization and valve repair. She underwent cardiac cath on [**2-6**] revealing severe AS and 3-v CAD; plan was for OR Monday [**2-17**] for CABG/AVR. The day of transfer to the CCU, telemetry showed complete heart block without ventricular escape rhythm for 45 seconds. She was symptomatically fatigued, dizzy and nauseated. Code blue was called. The patient was trancutaneously paced and electively intubated. . On arrival to the CSRU, a transvenous pacemaker was placed. EKG after transfer showed sinus rhythm at 92, 1st degree AV block, RBBB, ST depressions in V4-V6, unchanged from previous to this episode. Echocardiogram was performed showing the pacemaker wire terminated at or within the lateral free wall of the right ventricle and not at the apex. The patient was weaned off the ventilator and extubated soon after transfer. Past Medical History: CAD status post NSTEMI [**10/2115**] Congestive heart failure, EF 40% Aortic stenosis, AV area 0.6 cm2 Left CEA [**2109**] Hypertension Right bundle branch block Diabetes mellitus, type 2 (diet-controlled) ESRD on HD since [**11-19**] Hypothyroidism Hemorrhoids Status post vein stripping Status post appendectomy Status post TAH-BSO . Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension . Cardiac History: CAD status post NSTEMI [**10/2115**] Congestive heart failure, EF 40% Aortic stenosis, AV area 0.6 cm2 Left CEA [**2109**] Hypertension . Cardiac History: CABG, none. . Percutaneous coronary intervention, none. . Pacemaker/ICD, none. . Other Past History: As above. Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death. Lives with her daughter who has medical problems of her own. Plans to move in with her other daughter within the next month. No tobacco or alcohol use. Family History: No h/o early MI or cancer. Physical Exam: Blood pressure was 90/34 mm Hg supine. Pulse was 90 beats/min and regular, respiratory rate was 12 breaths/min. Generally the patient was well developed, well nourished and well groomed. The patient was intubated. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVP of 7 cm. The carotid waveform was parvus et tardus. 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 lungs had crackles [**12-18**] bilateral lung fields. . PMI not palpated. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There was a III/VI systolic crescendo-decrescendo murmur heard at the RUSB radiating to the carotids. There were no rubs, clicks or gallops. . The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had 2+ pitting edema to knees bilaterally, but no pallor, cyanosis, or clubbing. 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 1+ Radial 2+ DP 1+ PT 1+ Left: Carotid 1+ Radial palpable DP 1+ PT 1+ Pertinent Results: [**2116-2-6**] 06:55AM BLOOD WBC-6.0 RBC-3.58* Hgb-11.1* Hct-34.8* MCV-97 MCH-31.1 MCHC-32.0 RDW-17.9* Plt Ct-140* [**2116-2-15**] 06:14PM BLOOD WBC-12.8* RBC-3.01* Hgb-9.2* Hct-30.5* MCV-102*# MCH-30.5 MCHC-30.0* RDW-17.6* Plt Ct-85* [**2116-2-6**] 06:55AM BLOOD PT-13.0 PTT-30.4 INR(PT)-1.1 [**2116-2-15**] 06:14PM BLOOD Plt Ct-85* [**2116-2-15**] 02:57AM BLOOD PT-28.3* PTT-53.2* INR(PT)-2.9* [**2116-2-15**] 02:57AM BLOOD Fibrino-310 D-Dimer->[**Numeric Identifier 961**]* [**2116-2-15**] 12:48PM BLOOD UreaN-33* Creat-4.2* [**2116-2-15**] 02:57AM BLOOD Glucose-75 UreaN-39* Creat-4.9*# Na-133 K-4.7 Cl-97 HCO3-18* AnGap-23* [**2116-2-6**] 06:55AM BLOOD Glucose-94 UreaN-41* Creat-4.8*# Na-134 K-4.8 Cl-102 HCO3-18* AnGap-19 [**2116-2-15**] 02:57AM BLOOD ALT-7690* AST-[**Numeric Identifier 70866**]* LD(LDH)-[**Numeric Identifier 70867**]* AlkPhos-116 TotBili-0.6 [**2116-2-13**] 04:15PM BLOOD CK-MB-NotDone cTropnT-1.04* [**2116-2-13**] 09:02PM BLOOD CK-MB-NotDone cTropnT-1.13* [**2116-2-14**] 03:43AM BLOOD CK-MB-NotDone cTropnT-1.31* [**2116-2-15**] 12:48PM BLOOD Calcium-11.1* Phos-4.4 Mg-2.0 [**2116-2-6**] 06:55AM BLOOD Calcium-8.3* Phos-7.5*# Mg-2.3 [**2116-2-7**] 06:55AM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE [**2116-2-14**] 03:43AM BLOOD TSH-0.70 [**2116-2-14**] 03:43AM BLOOD Cortsol-32.8* [**2116-2-15**] 08:11PM BLOOD Type-ART pO2-167* pCO2-26* pH-7.05* calTCO2-8* Base XS--22 -ASSIST/CON Intubat-INTUBATED [**2116-2-15**] 07:14PM BLOOD Type-ART pO2-121* pCO2-28* pH-7.05* calTCO2-8* Base XS--22 [**2116-2-15**] 08:11PM BLOOD Lactate-12.2* . [**2-7**] Cath COMMENTS: 1. Selective coronary angiography of this right dominant system revealed multi vessel disease. The LMCA had a 20% distal lesion. The LAD had a 60% mid vessel lesion involving a D2 branch that contained a 80% ostial lesion. The LCX gave off a large OM1 with a 70% lesion. the RCA had a 70% proximal lesion and a 60% mid lesion. 2. Left ventriculography was not performed. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. . [**2-10**] Venous duplex FINDINGS: On the right, the greater saphenous vein measured 0.42 cm proximally and 0.28 cm distally. The largest interval diameter measured 0.35 cm and the smallest interval diameter measured 0.30 cm. The right lesser saphenous vein measured 0.2 cm in the mid portion and 0.2 cm in the lower portion. The left saphenous vein has been removed previously. The left lesser saphenous vein measured 0.19 cm superiorly, 0.2 cm in its mid portion, and 0.16 cm inferiorly. . [**2-11**] Carotid U/S IMPRESSION: 1. Less than 40% stenosis of the proximal right internal carotid artery. 2. No evidence of hemodynamically significant stenosis in the left internal carotid artery, status post prior endarterectomy . [**2-13**] ECHO Conclusions: The estimated right atrial pressure is 16-20 mmHg. There is moderate to severe global left ventricular hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild to moderate ([**12-17**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. There is brief right atrial diastolic invagination. The pacemaker wire appears to terminate at or within the lateral free wall of the right ventricle and not at the apex. Dr [**Last Name (STitle) **] notified by telephone of above findings. Compared with the findings of the prior study (images reviewed) of [**2115-12-26**], a pacemaker wire is now seen in the right ventricle. The pericardial effusion is unchanged. Brief Hospital Course: Patient is a 80 yoF with severe AS (valve area 0.6), CAD, ESRD on HD who was electively admitted for CABG/AVR on [**2116-2-5**] to CT surgery. Patient coded on floor for episode of CHB and is now status post trans-venous pacer. On Transfer to CCU, she required increasing amounts of 3 pressors and increasing FiO2 and PEEP for increasing O2 requireement. Her family then decided to withdraw care and she expired within 1 hour of d/c of pressors. She was awaiting CABG/AVR on Monday. Medications on Admission: At home: ASA Metoprolol 12.5 [**Hospital1 **] Lipitor 20 QD Synthroid 175 QD Zolpidem 5 QD Meclizine 25 TID Nephrocaps . On transfer: Senna 2 TAB PO DAILY Bisacodyl 10 mg PO/PR DAILY:PRN Lanthanum 1500 mg PO TID W/MEALS Oxycodone-Acetaminophen [**12-17**] TAB PO Q6H:PRN Docusate Sodium 100 mg PO BID Sevelamer 1600 mg PO TID W/MEALS Ciprofloxacin HCl 250 mg PO Q24H Duration: 7 Days for UTI Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY Insulin SC Sliding Scale Nephrocaps 1 CAP PO DAILY Levothyroxine Sodium 175 mcg PO DAILY Aspirin EC 325 mg PO DAILY Metoprolol 12.5 mg PO BID, Hold on the morning of dialysis Atorvastatin 40 mg PO DAILY Meclizine 25 mg PO TID Acetaminophen 650 mg PO Q4-6H:PRN pain Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: Expired Discharge Instructions: n/a Followup Instructions: N/A [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "585.6", "412", "570", "458.9", "426.0", "414.01", "276.2", "250.00", "403.91", "424.1", "244.9", "525.10", "428.0", "599.0", "427.5" ]

icd9cm

[ [ [] ] ]

[ "37.78", "39.95", "96.71", "88.56", "96.04", "38.91", "35.96", "37.22", "37.23" ]

icd9pcs

[ [ [] ] ]

9146, 9155

7871, 8358

286, 329

9202, 9211

4010, 5973

9263, 9398

2546, 2574

9118, 9123

9176, 9181

8384, 9095

5990, 7848

9235, 9240

2589, 3991

235, 248

357, 1466

1488, 2170

2186, 2530

6,856

143,158

6547

Discharge summary

report

Admission Date: [**2121-12-10**] Discharge Date: [**2121-12-16**] Date of Birth: [**2067-3-30**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: right upper lobe lung nodule Major Surgical or Invasive Procedure: VATS w/right upper lobectomy History of Present Illness: Pt is a 54 year old man with h/o colon cancer s/p resection who presents with a rising CEA and right upper lobe mass as well as a left lower lobe nodule. Patient underwent a cervical mediastinoscopy with lymph node biopsy on [**2121-11-27**] which revealed no evidence of malignancy. He presents for elective VATS with right upper lobectomy. He does not have any fever/weight loss/nausea or vomiting but does report mild shortness of breath with exertion. Past Medical History: rectosigmoid CA s/p resection [**2116**] and chemo/XRT HTN hyperlipidemia Social History: Seven to ten pack year history, discontinued in the [**2086**]. He has had exposure to asbestos working in a shipyard from [**2090**] to [**2095**]. He uses alcohol occasionally and socially. He denies any exposure to uranium, nickel, cadmium, or radon. Family History: Father died of cirrhosis at the age of 49. One sibling with paranoid schizophrenia. One grandparent died of TB. One grandparent had a stroke. One grandparent had an MI. Physical Exam: Gen: well appearing, NAD HEENT: PERRL, EOMI, nares patent, oropharynx clear Neck: no masses CV: RRR, no m/r/g Lung: CTA B, no w/c, incision sites bandaged c/d/i Abd: soft, NT/ND, +BS Ext: no edema/cyanosis Neuro: aao x 4 Pertinent Results: [**2121-12-15**] 09:26AM BLOOD WBC-8.0 RBC-4.11* Hgb-13.1* Hct-36.4* MCV-89 MCH-31.8 MCHC-35.9* RDW-12.8 Plt Ct-279# [**2121-12-15**] 09:26AM BLOOD Plt Ct-279# [**2121-12-15**] 09:26AM BLOOD Glucose-92 UreaN-14 Creat-0.9 Na-138 K-4.1 Cl-103 HCO3-26 AnGap-13 [**2121-12-15**] 09:26AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.8 Brief Hospital Course: Patient was admitted and underwent an uncomplicated VATS with right upper lobectomy. He was transferred to the PACU extubated and with two pleural [**Doctor Last Name **] drains in place to suction. While being transferred to the PACU, it was noted that the patient's epidural was not functioning, and he did c/o significant pain postoperatively. He remained in the PACU with poor pain control despite iv morphine and dilaudid as well as toradol. He was also noted to be hypotensive postoperatively, necessitating a neosynephrine drip overnight secondary to hypotension with decreased urine output. Overnight he remained stable with better control of his BP to the point that his neo drip was weaned. He did have adequate urine output. POD #1: cont on morphine PCA with some relief of pain. Transferred to the floor. Tolerating po's however patient demonstrated poor inspiratory effort secondary to pain. Pain service consulted who recommended reinsertion of epidural catheter, however, patient refused. [**Doctor Last Name 406**] drains put to bulb suction. POD #2: Poor pain control, patient started on q6h toradol x 6 doses with good relief of his pain in addition to his morphine PCA. One [**Doctor Last Name **] drain discontinued with no change on post-pull CXR. POD #3: Foley catheter discontinued with adequate urine output. Pain better controlled, patient remained with an oxygen requirement on 2L nasal cannula O2. POD #4: PCA discontinued, patient started on po percocet as well as iv dilaudid as needed with good pain control. POD #5: high [**Doctor Last Name **] drain output (>300cc) overnight, patient doing well. Given iv lasix 20mg x 1 for diuresis. POD#6 [**Doctor Last Name **] output minimal. Drain d/c'd - no PTX on post pull CXR. Responded well to diuresis. d/c'd to home w/ supportive sevices. Medications on Admission: Lisinopril 10', ASA 325', trazadone 50' Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*100 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for sleep. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Broctkon VNA Discharge Diagnosis: right upper lobe mass Discharge Condition: stable Discharge Instructions: Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 25078**] if you have any bleeding, pain, redness or oozing from your surgical site. Call if you have fever, nausea/vomiting, weakness or dizziness, shortness of breath or inability to eat or drink. Please do not drive while taking pain medications. take your first shower on thursday. After showering, remove your chest tube dressing and coverthe area with a clean bandaid every day until healed. If there is yellow pink drainage, this is expected and you may need to cover with a clean gauze. No tub bathing or swimming for 3 weeks. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in [**10-24**] days. Call for an appointment. Completed by:[**2121-12-17**]

[ "492.8", "V10.05", "401.9", "197.0", "272.4" ]

icd9cm

[ [ [] ] ]

[ "32.4", "40.3" ]

icd9pcs

[ [ [] ] ]

4488, 4531

2021, 3839

352, 383

4597, 4606

1680, 1998

5254, 5384

1253, 1424

3929, 4465

4552, 4576

3865, 3906

4630, 5231

1439, 1661

284, 314

411, 868

890, 965

981, 1237

63,282

151,030

44114

Discharge summary

report

Admission Date: [**2171-10-29**] Discharge Date: [**2171-11-4**] Date of Birth: [**2118-6-14**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Adhesive Attending:[**First Name3 (LF) 2969**] Chief Complaint: Sternal mass. Major Surgical or Invasive Procedure: [**2171-10-29**] Sternothoracotomy, LUL Wedge Left latissimus flap closure and pectoralis musculocutaneous flap closure. History of Present Illness: Mrs. [**Known firstname 4457**] [**Known lastname **] is a pleasant 53 year old female who was initially seen by Dr. [**Last Name (STitle) **] in [**2171-9-10**] for an ectopic bone coming out of the sternal region inferior and to left of the sternal notch. The patient had radiation 30 years ago followed by mastectomy 5 years ago. In the workup a lung cancer was found. Past Medical History: (1) hypertension (2) heart murmur (3) breast cancer (age 21 with partial mastectomy, negative lymph nodes, local recurrence at age 48 with total mastectomy) Social History: Married, smoker 1 PPD, no drinking or drugs Family History: not pertinent Physical Exam: VS: temp: 96.7, BP 116/64, HR 94 reg, RR 20, Oxygen sats on RA 95% PE: gen: pt pleasant in NAD Lungs: clear/diminished t/o bilaterally, right thoracotomy healing without redness, purulence or drainage. Left pectoralis flap warm, pink, and edges approximated without redness, purulence or drainage. Three JP's to bulb sxn. Slight erythema around all three with scant purulence surrounding apical JP, without drg. CV: RRR, S1, S2, soft HSM t/o Abd: soft, NT, ND Ext: warm 2+ BLE edema Pertinent Results: [**2171-10-31**] 06:25AM BLOOD WBC-15.6* RBC-3.26* Hgb-9.7* Hct-28.7* MCV-88 MCH-29.8 MCHC-33.8 RDW-14.5 Plt Ct-206 [**2171-10-31**] 06:25AM BLOOD Glucose-152* UreaN-17 Creat-0.6 Na-136 K-4.1 Cl-101 HCO3-26 AnGap-13 [**2171-11-2**] PA and lateral CXR The left lower chest tube has been disconnected with no interval development of pneumothorax or increase in pleural effusion. Only one chest tube is now remaining on the left. The cardiomediastinal silhouette is stable. The right mediastinal drain is in unchanged location. Brief Hospital Course: Mrs [**Known lastname **] was admitted on [**2171-10-29**] where she underwent left latissimus flap closure and pectoralis musculocutaneous flap closure by Dr. [**First Name (STitle) **] of plastic surgery. After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO, on IV fluids and antibiotics, with a foley catheter, a epidulr and IV Dilauded for pain control. The patient was hemodynamically stable. Patient with Chest tubes X 2 tp dry suction 20cm. Neuro: The patient received an epidural and iv Dilauded with good effect and adequate pain control. When tolerating oral intake, the patient's epidural was removed and she 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. Patient with chest tubes monitored daily. Chest tubes were placed to water seal after 48 hrs and apical chest tube was removed. Basilar chest tube was removed the next day. Post pull chest xray was taken after the basilar chest tube was removed. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Patient with flap and JP drains X4 monitored and cared for by plastic surgery. Prior to discahrge patient with three chest tubes to bulb suction. Patient discharge with drain teaching and VNA for drain care. 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. Discharge Medications: 1. Atenolol 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*0* 2. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation: take while on dilaudid to prevent constipation. 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 8. Tamoxifen 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO once a day: take as prescribed by PMD. 10. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain: taper down interval as able slowly every 1-2 hrs every 1-2 days then cut in half, over the next two weeks as directed. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Left upper lobe lung nodule Left breast CA [**2150**] s/p partial mastectomy c/b local recurrence [**2166**] s/p total mastectomy Hypertension Discharge Condition: stable Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] if experience: -Fevers > 101 or chills. -Increased shortness of breath, cough or sputum production -Chest pain -Incision: develops drainage, reddness increased warmth call immediately -Chest tube sites remove dressing Monday cover site with a bandaid Call Dr. [**First Name (STitle) **] if JP site becomes red, pussy or drains. Cleanse area with soap and water and cover with bacitracin ointment. If the drainage is consistently less than 30 mL per day you may call Dr. [**First Name (STitle) **] office for an earlier appointment to consider removal of drains. - No driving while taking dilaudid. - [**Month (only) 116**] shower, but keep chest tube site covered daily with bandaid. - No lifting, pushing, or pulling >10 lbs x 7 weeks. - No lifting left arm above head. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] on Thursday [**2171-11-14**] at 10 am in [**Hospital Ward Name 23**] 9 at [**Hospital1 18**] [**Hospital Ward Name **]. Please get Chest xray on [**Location (un) **] 45 minutes prior to this appointment. Call to reschedule [**Telephone/Fax (1) 4741**]. Follow up with Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 1416**] on [**2171-11-14**] at 2:45 pm at his office on 235 Cypress in [**Location (un) **].

[ "709.3", "V45.71", "196.1", "738.3", "198.89", "401.9", "162.8", "V15.3", "458.29", "305.1", "794.31" ]

icd9cm

[ [ [] ] ]

[ "34.92", "86.74", "37.31", "86.3", "85.71", "03.90", "32.29" ]

icd9pcs

[ [ [] ] ]

5786, 5869

2171, 4648

304, 427

6056, 6065

1620, 2148

6956, 7417

1086, 1101

4671, 5763

5890, 6035

6089, 6933

1116, 1601

251, 266

455, 828

850, 1009

1025, 1070

26,402

102,673

8536

Discharge summary

report

Admission Date: [**2157-1-22**] Discharge Date: [**2157-1-26**] Date of Birth: [**2091-7-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: colonoscopy History of Present Illness: The patient is a 65 year old woman with a h/o CAD, CHF and AFib presenting with bright red blood per rectum. She was watching TV on wednesday when she felt a strong urge to go to the bathroom and passed bright red blood, followed by maroon stools. In the last several weeks, her INR had been low and she had been instructed to take 5mg instead of 2.5 mg of coumadin 2/nights per week. Her INR remained low, and since [**1-7**] she had been taking the double dose 3 nights per week. This occurred 4 more times before she arrived at the OSH ED. She had a similar episode one year ago when diverticulitis was noted on colonoscopy. She denies hematochezia, no dizziness, no vomiting. She has had some slight abdominal pain that has been intermittent and sharp in the lower quadrants. No fever or chest pain. She denies constipation. . At the OSH her INR was corrected with 2U FFP and a colonoscopy was performed [**2157-1-21**] which showed blood in entire colon with diverticulosis, active bleeding from diverticular opening treated with epinephrine and endoclip. She says she has not had a bloody BM since prior to her colonoscopy. She says she received 3U of blood as well. When she was given FFP prior to the colonoscopy she had a reaction, her entire face swelled up and she had difficulty breathing. Her Hct fell after transfusion and she was transferred here for further evaluation and treatment of her unstable lower GI bleeding Past Medical History: 1. Coronary Artery disease - multiple caths with stents, last cath [**2156-3-5**], s/p MI X2 2. CHF EF 60-65%, nuclear test with small potential ischemia 3. A.fib, had been on coumadin. previously on amiodorone, but d/c following deteriorating vision in last year. 4. CVA with left upper visual field cut occurred following one of her stenting procedures. 5. Acid reflux 6. Diverticular disease 7. HTN 8. Hyperlipidemia 9. oral cancer, resection of mass on left side of tongue Social History: She does not smoke or drink EtOH. Breds and showed champion [**Doctor Last Name 2031**] horses, retired. Single with no children. Healthcare proxy is friend [**Name (NI) **] [**Name (NI) 30041**] [**Telephone/Fax (1) 30042**]. Family History: sister died of CAD, had DM2 Physical Exam: VS Temp 98.6, BP 105/54, Pulse 74, RR 17, O2 sat 98% on RA Gen A&O3, lying in bed, NAD HEENT: MM moist, OP clear, teeth absent on lower left. PERRL Lungs: CTAB CV: RRR, nl S1S2, systolic murmer at apex Abd: + BS, overweight, soft, nontender, nondistended. Ext: no edema, distal pulses 2+. Neuro: CN2-12 intact, except mild upper left visual field deficit on confrontational testing. strength 5/5 throughout, sensation grossly intact. reflexes 1+ throughout. Pertinent Results: HCT at Outside Hospital 38 -> 32.7 -> 29.3 -> 23.7 -> 29.6 -> 22.9 ->20.6 OSH CXR: low lung volumes, atelectasis. OSH CT Abd: No retroperitoneal hemorrhage, sigmoid diverticulosis. OSH EKG: a flutter 76, nl axis, nl intervals no ST T wave changnes. Brief Hospital Course: The patient is a 65 year old woman with history of CAD and Afib on coumadin transferred for treatment of an unstable GI bleed in the setting of an elevated INR to ~3.5. . -GI Bleeding. The most likely source is recurrent bleeding from the diverticuli visualized on colonoscopy at the outside hospital. Prior to transfer to our institution, her coumadin had been stopped and she had been given Vitamin K and 2U FFP to reverse her INR, however she continued to have active bleeding, was given 3U PRBCs, and was transferred here for further evaluation and possible surgical intervention. After stabilization in the MICU, she had no futher episodes of bleeding, and following the transfusion of 2 additional units of PRBC, her HCT was 29 and slowly trended upward to 33.5 over the next 3 days. Repeat colonoscopy revealed several diverticuli in the distal colon/sigmoid region, consistent with the previous report, but none were actively bleeding and no interventions were undertaken. . - Atrial Fibrillation. The patient remained in atrial fibrillation during the admission with several episodes of rapid ventricular response with heart rate elevations to the 140's. Notably, this occurred while she was not receiving her metoprolol because of concerns over possible hemodynamic issues should her bleeding recur. Once her hemodynamics proved stable, her metoprolol was restarted and titrated upwards to 50mg PO TID in order to control her heart rate. Her coumadin was held during the admission given the risk of recurrant bleeding. However, she was restarted on her aspirin and plavix given her multiple cardiac stents in place. . -CHF. Diuresis was held during most of the admission over hemodynamic concerns, however, she ultimately began to have signs of volume overload including pedal edema, pulmonary crackles, and dyspnea on exertion so her home regimen of furosemide 120 PO QD was restarted. Medications on Admission: Medications on transfer from ICU: Zantac 50mg IV q6h Nexium 40mg IV BID Metoprolol 25mg PO BID Lasix 120mg daily Lipitor 80mg daily Fish oil 1200mg daily Tylenol prn Plavix held, ASA (held in ICU) Zofran prn Discharge Disposition: Home Discharge Diagnosis: Lower GI bleed diverticulosis blood loss anemia supra-therapeutic anticoagulation atrial fibrillation history of coronary artery diesase Discharge Condition: stable, HR around 100 and normotensive and no longer orthostatic, Hct stable at 33. Discharge Instructions: Please return if you experience any further blood in your bowel movements, feel lightheaded or weak, or have difficulty breathing, palpitations or chest pain. Please followup with your cardiologist and PCP as below and take your medications as prescribed. Followup Instructions: Please call your PCP and set up a follow up appointment in [**6-13**] days. Cardiologist, Dr. [**Last Name (STitle) 11863**], [**First Name3 (LF) 5871**] Hospital [**Last Name (NamePattern1) 30043**]. [**Location (un) 5385**] [**Numeric Identifier 30044**] [**Telephone/Fax (1) 30045**] Thursday [**1-27**] 11AM [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**] Completed by:[**2157-1-28**]

[ "V10.01", "427.31", "401.9", "562.12", "272.4", "V58.61", "V45.82", "530.81", "790.92", "285.1", "414.01", "428.0" ]

icd9cm

[ [ [] ] ]

[ "45.23" ]

icd9pcs

[ [ [] ] ]

5549, 5555

3385, 5291

342, 355

5736, 5822

3111, 3362

6128, 6593

2586, 2615

5576, 5715

5317, 5526

5846, 6105

2630, 3092

275, 304

383, 1824

1846, 2326

2342, 2570

14,193

169,528

6501

Discharge summary

report

Admission Date: [**2104-5-1**] Discharge Date: [**2104-5-26**] Date of Birth: [**2051-12-12**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 5973**] Chief Complaint: LLE wound infection, pain Major Surgical or Invasive Procedure: LLE Incision and drainage [**2104-5-7**], wound debridement, and wound closure [**2104-5-15**] History of Present Illness: 52 M with poorly controlled DM1 complicated by charot's joints, gastroparesis, orthostatic hypotension, peripheral neuropathy, and retinopathy with long history of multiple orthopedic complications. He initially fractured his left midfoot in [**4-11**] that required external fixation and closed reduction. However, he ambulated on his leg and fractured the pins and had tibial fracture. On [**5-12**] pin removed and had ORIF of left tibial fracture with [**Last Name (un) 101**] plate. Again, after bearing weight on [**7-12**], he developed a non-[**Hospital1 **] fracture of his tibia and [**Last Name (un) 101**] plate fracture. He refused surgery and was treated conservatively. On [**11-11**] he developed bimalleolar fracture of his left ankle which was treated conservatively. On [**4-15**] his [**Last Name (un) 101**] plate removed, and tibial rod and nails placed. On [**4-29**], he presented to ortho clinic with nails exposed through skin and admitted. He had removal of hardware on [**5-1**] with I+D of left ankle abscess. Gram stain of abscess grew enterobacter cloacea and he has been on zosyn for treatment. Pt was to go back to OR on [**5-7**] for further debridement of his left foot wounds. Of note, he had been given 4 mg ativan PO, 3 doses of 20mg oxycodone, 5mg ambien after 18:00. He was last seen well at 03:00 AM and most recent set of floor vitals at MN 100.3 118/72 84 20 95%(RA). At 4:20 AM [**5-7**] pt found unresponsive, diaphretic, and pulseless by nurse and code blue called. On arrival, PEA arrest at 20's, given 2 rounds of epi/atropine, 1 amp of NaHCO3 with return of pulse to 140's and BP 115/p at 04:35 AM. Right femoral line placed and pt intubated. Post intubation ABG during code 7.15/85/424, K 4.0, lactate 7.1, and glucose 343. Pt transfered to ICU. On arrival to ICU, a-line place and BP 130's systolic HR 70's. Initiated on A/C 600/20 PEEP 5 FiO2 100%, ABG 7.38/44/379. CXR (my read) c/w LLL opacity, mild chf, left rib fractures. EKG shows sinus @ 75, L axis deviation, IVCD, and no ST/T wave changes compared to baseline. He was transferred to the medicine service once he became stable after extubation. Past Medical History: 1. DM1 since age 18 -retinopathy - s/p laser surgery -peripheral nerve neuropathy -gastroparesis 2. charcots joint 3. left phrenic nerve neuropathy 4. orthostatic hypotension 5. hypercholesterolemia 6. cath 00': no CAD, EF 65% 7. breathing sleep disorder ? 8. h/o penile implant Social History: Social History: Lives in [**Hospital1 3597**] with wife and kids. Disabled. no tob, no etoh, no drugs Family History: non contributory Physical Exam: PE 96.7 87 133/78 14 96% A/C 600/20 (3) PEEP 5 40% PIP 38 Plat 31; 7.42/49/60 Gen: intubated, responds to painful stimuli HEENT: pupils dilated equally bilaterally, no reflex NECK: supple CV: rrr, no m/r/g PULM: cta anteriorly ABD: obese, ventral hernia, soft EXT: left foot in [**Hospital1 **]-valve cast; right antecub PICC c/d/i NEURO: moves all 4 ext, responds to painful stimuli Pertinent Results: [**2104-5-15**] 09:17AM BLOOD WBC-11.2*# RBC-3.65*# Hgb-10.5*# Hct-32.1*# MCV-88 MCH-28.9 MCHC-32.8 RDW-15.3 Plt Ct-487*# [**2104-5-16**] 12:00AM BLOOD Hct-31.6* [**2104-5-16**] 05:41AM BLOOD WBC-11.1* RBC-3.55* Hgb-10.0* Hct-31.1* MCV-88 MCH-28.3 MCHC-32.2 RDW-14.6 Plt Ct-565* [**2104-5-17**] 05:16AM BLOOD WBC-10.0 RBC-3.90* Hgb-10.8* Hct-33.9* MCV-87 MCH-27.8 MCHC-32.0 RDW-15.0 Plt Ct-624* [**2104-5-18**] 05:02AM BLOOD WBC-9.1 RBC-3.80* Hgb-10.9* Hct-33.3* MCV-88 MCH-28.6 MCHC-32.7 RDW-15.0 Plt Ct-561* [**2104-5-19**] 05:35AM BLOOD WBC-10.5 RBC-3.77* Hgb-10.7* Hct-32.8* MCV-87 MCH-28.5 MCHC-32.7 RDW-15.1 Plt Ct-550* [**2104-5-13**] 05:25AM BLOOD Glucose-102 UreaN-14 Creat-0.8 Na-135 K-4.1 Cl-95* HCO3-30 AnGap-14 [**2104-5-14**] 05:20AM BLOOD Glucose-222* UreaN-15 Creat-0.7 Na-133 K-4.1 Cl-94* HCO3-33* AnGap-10 [**2104-5-15**] 05:06AM BLOOD Glucose-193* UreaN-15 Creat-0.8 Na-136 K-4.4 Cl-96 HCO3-33* AnGap-11 [**2104-5-16**] 05:41AM BLOOD Glucose-82 UreaN-17 Creat-0.7 Na-138 K-4.3 Cl-97 HCO3-34* AnGap-11 [**2104-5-17**] 05:16AM BLOOD Glucose-140* UreaN-17 Creat-0.7 Na-137 K-4.2 Cl-95* HCO3-33* AnGap-13 [**2104-5-18**] 05:02AM BLOOD Glucose-99 UreaN-20 Creat-0.8 Na-136 K-4.1 Cl-96 HCO3-32 AnGap-12 [**2104-5-19**] 05:35AM BLOOD Glucose-206* UreaN-20 Creat-0.8 Na-135 K-4.5 Cl-97 HCO3-31 AnGap-12 [**2104-5-8**] 10:12AM BLOOD %HbA1c-7.3* Brief Hospital Course: 52 year old man with poorly controlled DM1 and peripheral neuropathy complicated by multiple orthopedic fractures and infections s/p PEA arrest and wound debridement/closure. . # PEA arrest - Differential diagnosis was broad but most likely etiologies were PE, medication overdose, hypoxia. His body habitus and multiple medications preclude him to hypoventilation and hypoxia. His initial acidosis was likely secondary to hemodynamic collapse and hypoventilation. MI, tamponade, blood loss, sepsis, hyperkalemia were less likely etiologies. The patient did not require any pressors and was in fact hypertensive to the 200s on admission to the ICU on propofol gtt. His cardiac enzymes were mildly elevated but felt to be secondary to demand, there were no EKG changes. A stat echo was performed in the MICU on [**5-6**] which showed no effuson/tamponade. EF 55-60%. The echo had suboptimal windows given large habitus so focal wall motion could not be excluded. CTA was negative for PE but showed bilateral pulmonary infiltrates likely due to aspiration. His head CT was negative. Ultrasounds of his lower extremities were negative from venous thromboembolism. His EEG was negative for seizure activity but showed slow disorganized background and generalized slowing consistent with metabolic disorder. Therefore, most likely, his PEA arrest was secondary to hypoxic/hypercarbic resp distress from oversedation with narcotics and benzos. Since then, the amount of narcotics the patient has been receiving has been monitored closely and was slowly titrated up for optimal pain control. . # ID - Notable for growth of Enterobacter from his LLE wound, pan-sensitive to all abx. Other cx, including blood, stool and urine have all been NGTD. He did have 1+ GPC in the sputum, likely [**1-10**] aspiration PNA. He was on IV Zosyn for 2 weeks, and was recently switched to po Cipro/Flagyl to cover his LLE infection and ?aspiration PNA given his persistent left lower lobe consolidation on CXR. He needs to remain on these abx for 6-8 weeks, and will f/u with ID on [**2104-5-28**]. He will need labs checked and faxed to [**Hospital **] clinic as specified in the d/c instructions. Currently, no other source of infection has been indentified. Depending on how his LLE infection responds to abx and then off abx for at least 4 weeks, amputation is a likely possiblity if he does not clear the infection. Pt will follow with Dr. [**Last Name (STitle) 1005**] in [**Hospital 1957**] clinic. . # Respiratory failure His respiratory failure was likely due to excess fluid overload or hypoventilation secondary to overmedication with narcotics and OSA. After the patient was extubated and transferred to the medicine floor, we very cautiously titrated up his narcotics and continued to monitor his respiratory rate. We continued to diurese him with Lasix as needed. His respiratory status has been stable for several days and he has not required any supplemental oxygen in the last few days. . # Delta MS It remains unclear how long patient was unresponsive and duration of hypoxic brain injury. He appeared to have fixed and dilated pupils in ICU with a question of increased tone and dystonic movement. Therefore, an EEG was performed on [**2104-5-7**] which showed diffuse slow waves with no epileptiform movement. No paralytics were given during code. The patient's mental status improved post extubation. The patient pulled his left subclavian central line on arrival to the medicine floor but showed no signs of confusion or delirium. He remained alert and oriented x3 for the remainder of his hospitalization, and was back to his baseline status. . # DM ?????? An insulin gtt was initiated on admission to the ICU. On arrival to the medicine floor, the patient??????s blood glucose was poorly controlled at first but patient was followed by [**Last Name (un) **] and with the appropriate amounts of fixed and regular insulin, he was much better controlled during the second half of his hospitalization. His blood glucose was monitored QACHS by finger sticks and he remained on a diabetic diet when not NPO. He should be maintained on his current insulin regimen as specified in the d/c meds. . # Tachypnea: The patient became tachypneic on a couple of occasions. It was likely due to fluid overload, pneumonia, or reactive airways/bronchospasm. He responded well to albuterol nebs and diuresis. The last episode of tachypnea was due to anxiety about going to the OR. Patient reported being extremely anxious and responded to a small amount of Ativan. He did not experience tachypnea for the last 4-5 days of hospitalization after going to the OR. . #Fever/hypoxia: The patient had low-grade fevers during his hospitalization with no growth on blood and urine cultures, negative UA's, and unchanged CXRs. His fever was likely due to his LE infections or aspiration pna given his persistent CXR opacities. He has been afebrile for the last 1 1/2 weeks of his hospital course. . # HTN The patient remained on lopressor 75 mg TID, captopril was added for better control. He responded well and his SBPs were in the 110s to 130s prior to discharge. . #. FEN - His electrolytes were repleted as needed. When not NPO, he remained on a low sodium, heart healthy, diabetic diet. He tolerated POs well. . # . Prophylaxis -patient remained on Lovenox throughout his hospital course #. Code - FULL CODE #. Communication - wife, [**Name (NI) **] [**Name (NI) 4318**] [**Telephone/Fax (1) 24959**]; [**Telephone/Fax (1) 24960**] Medications on Admission: 1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day). Disp:*60 syringes* Refills:*2* 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Becaplermin 0.01 % Gel Sig: One (1) Appl Topical DAILY (Daily). Disp:*1 tube* Refills:*2* 4. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tablet Sustained Release 12HR(s)* Refills:*0* 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*50 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* Discharge Medications: 1. Outpatient Lab Work Check CBC, ESR, CRP, BUN, and Cr in one week ([**2104-5-23**]) and fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 1419**]. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*30 nebs* Refills:*2* 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:*30 nebs* Refills:*0* 6. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Disp:*60 ML(s)* Refills:*0* 8. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q8-10H () as needed. Disp:*20 Tablet(s)* Refills:*0* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Desipramine 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:*250 ML(s)* Refills:*0* 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 14. Enoxaparin 30 mg/0.3 mL Syringe Sig: 30 mg Subcutaneous Q12H (every 12 hours). Disp:*qs mg* Refills:*2* 15. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H (every 12 hours). Disp:*180 Tablet(s)* Refills:*2* 16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 17. Insulin Glargine 100 unit/mL Solution Sig: Twenty Six (26) units insulin Subcutaneous at bedtime. Disp:*qs units insulin* Refills:*2* 18. Insulin Regular Human 100 unit/mL Solution Sig: Six (6) units insulin Injection QAC. Disp:*QS Units insulin* Refills:*2* 19. Insulin Lispro (Human) 100 unit/mL Solution Sig: Per Sliding Scale Units insulin Subcutaneous QACHS. Disp:*QS Units insulin* Refills:*2* 20. Insulin Please see attached insulin regimen sheet. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Primary: LLE non [**Hospital1 **] left ankle fracture and wound infection; s/p PEA arrest Secondary: Right heel pressure ulcer, IDDM c/b retinopathy, peripheral neuropathym gastroparesis, HTN, HL Discharge Condition: stable, afebrile Discharge Instructions: -Take discharge medication as instructed -Keep wounds dry and clean -Go to emergency room if temperature greater than 101 or if purulent drainage occurs from wound -No weight bearing on left foot -Please follow up with appointments as listed below Followup Instructions: Appointments: Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2104-5-20**] 11:30 Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2104-5-28**] 9:30 Completed by:[**2104-5-26**]

[ "V54.26", "V54.19", "427.5", "507.0", "996.67", "536.3", "250.61", "428.0", "707.07", "713.5", "996.49", "357.2", "682.6", "780.50", "E937.9", "278.00", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "78.67", "78.17", "77.68", "38.91", "96.04", "84.72", "38.93", "86.22", "96.6", "78.68", "96.71", "93.59", "80.87" ]

icd9pcs

[ [ [] ] ]

13542, 13622

4832, 10347

294, 391

13862, 13881

3453, 4809

14177, 14561

3015, 3033

11101, 13519

13643, 13841

10373, 11078

13905, 14154

3048, 3434

229, 256

419, 2576

2598, 2878

2911, 2999

15,022

131,651

53291

Discharge summary

report

Admission Date: [**2175-11-22**] Discharge Date: [**2175-11-30**] Date of Birth: [**2095-11-27**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2175-11-23**] - CABGx4 (LIMA-LAD, SVG->Diag, SVG->OM1, SVG->OM2) History of Present Illness: Mr. [**Known lastname **] is a 79-year-old male who was found to have a 70% left main stenosis upon cardiac catheterization. He has a history of stenting of the right coronary artery in [**2165**]. His left anterior descending and circumflex as well as a ramus branch were involved in the disease. His right coronary artery had minimal residual 30% disease. He is presenting for coronary artery revascularization. Past Medical History: Hypercholesterolemia HTN CAD s/p PCI Mild AR Diverticulitis H/O Lymphoma Hypothyroid Bilateral rotator cuff repairs Social History: Lives with wife. Quit smoking 25 years ago. Retired farmer.Drinks 1-2 drinks on weekend. Family History: Father with PPM Mother with IHSS Physical Exam: 130/83 58 SR 20 95% RA NECK: No bruit HEART: RRR, Nl S1-S2, no murmur LUNGS: CTA ABD: Benign EXT: No edema, no varicosities, 2+ Pulses throughout NEURO: Nonfocal Pertinent Results: [**2175-11-22**] 07:21PM PT-12.4 PTT-26.7 INR(PT)-1.1 [**2175-11-22**] 07:21PM PLT COUNT-192 [**2175-11-22**] 07:21PM WBC-7.8 RBC-4.84 HGB-14.8 HCT-43.8 MCV-91 MCH-30.7 MCHC-33.8 RDW-14.1 [**2175-11-22**] 07:21PM ALT(SGPT)-21 AST(SGOT)-23 LD(LDH)-224 ALK PHOS-92 AMYLASE-54 TOT BILI-1.0 [**2175-11-22**] 07:21PM GLUCOSE-87 UREA N-19 CREAT-0.9 SODIUM-139 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-32 ANION GAP-12 [**2175-11-22**] 08:08PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2175-11-22**] 08:08PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2175-11-30**] 05:35AM BLOOD WBC-9.1 RBC-2.95* Hgb-9.6* Hct-26.4* MCV-90 MCH-32.5* MCHC-36.3* RDW-14.1 Plt Ct-272 [**2175-11-30**] 05:35AM BLOOD Plt Ct-272 [**2175-11-29**] 05:35AM BLOOD UreaN-24* Creat-1.0 Na-138 K-4.7 [**2175-11-23**] ECHO PREBYPASS No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The ascending aorta is moderately dilated. The descending thoracic aorta is moderately dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild to moderate (1+-2+) aortic insufficiency. POSTBYPASS Biventricular systolic function remains normal. No apparent aortic disection post decanulation. Study otherwise unchanged from prebypass. [**2175-11-29**] CXR 1. Interval improvement of the left-sided pleural effusion with persistent retrocardiac opacity could represent atelectasis. 2. Interval removal of the right-sided central venous line. 3. No evidence of pneumothorax. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2175-11-22**] via transfer from [**Hospital6 2910**] for surgical management of his coronary artery disease. He was worked-up in the usual preoperative manner and was found to be suitable for surgery. On [**2175-11-23**], Mr. [**Known lastname **] was taken to the operating room where he underwent coronary artery bypass grafting to four vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) **]e neurologically intact and was extubated. Over the next day, his pressors and inotropes were slowly weaned off. He developed atrial fibrillation with associated asystolic pauses. His beta blockade was decreased and the electrophysiology service was consulted. He remained on low dose beta blockade in a normal sinus rhythm. On [**2175-11-27**], Mr. [**Known lastname **] was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service worked with him daily. He continued to have bursts of paroxysmal atrial fibrillation for which his beta blockade was slowly titrated up. Coumadin was started for anticoagulation. Given his tachy-brady syndrome and possibility of needing a pacemaker, it was recommended that he be discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts monitor with follow-up with the electrophysiology service. Mr. [**Known lastname **] continued to make steady progress and was discharged home on postoperative day seven. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist, the electrophysiology service and his primary care physician as an outpatient. His coumadin dosing will be managed by Dr. [**Last Name (STitle) 141**] for a target INR of 2.0-2.5. Medications on Admission: CRestor 20mg QD Synthroid 75mcg QD Toprol 12.5mg QD Altace 5mg QD Protonix 40mg QD MVI Aspirin 81mg QD Metamucil Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 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). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 8. Procainamide 500 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO Q6H (every 6 hours). Disp:*240 Tablet Sustained Release(s)* Refills:*0* 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: Check INR [**12-1**] with results called to Dr. [**Last Name (STitle) 141**]. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: s/p CABGx4 AF Tachy-brady syndrome Past PCI Hypercholesterolemia HTN Mild AR H/O Lymphoma H/O Diverticulitis Discharge Condition: good. Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 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. 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)Coumadin to be taken as instructed by Dr. [**Last Name (STitle) 141**]. Target INR is 2.0-2.5. Please take only once daily and only as instructed. Your first blood draw will be at [**2175-12-1**]. 8)Wear [**Doctor Last Name **] of Hearts monitor as directed. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with Dr. [**Last Name (STitle) 2912**] (Cardiologist) in [**1-27**] weeks. [**Telephone/Fax (1) 25832**] Follow-up with Dr. [**Last Name (STitle) **] (Electrophysiology) in one month. Follow-up with Dr. [**Last Name (STitle) 141**] (PCP) in [**1-28**] weeks. [**Telephone/Fax (1) 142**]. Follow-up with Electrophysiology service as directed for [**Doctor Last Name **] of Hearts Monitor. Please call all providers for appointment. Completed by:[**2175-11-30**]

[ "414.01", "V45.82", "202.80", "E878.2", "427.31", "427.81", "997.1", "424.1", "272.0", "401.9", "244.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6594, 6652

3268, 5163

292, 362

6805, 6813

1300, 3245

7585, 8145

1067, 1101

5326, 6571

6673, 6784

5189, 5303

6837, 7562

1116, 1281

242, 254

390, 806

828, 945

961, 1051

21,786

186,162

3269

Discharge summary

report

Admission Date: [**2166-1-16**] Discharge Date: [**2166-1-23**] Date of Birth: [**2110-10-13**] Sex: M Service: CARDIOTHORACIC Allergies: Lisinopril Attending:[**First Name3 (LF) 1406**] Chief Complaint: Syncopal Episode Major Surgical or Invasive Procedure: [**2166-1-16**] 1. Attempted Maze procedure with pulmonary vein isolation and left atrial appendage resection. 2. Aortic valve replacement with a St. [**Male First Name (un) 923**] mechanical valve (model number 21-AGFN-756). 3. Coronary artery bypass grafting x1, with reversed saphenous vein graft to the posterior descending artery. History of Present Illness: 55 year old male with a past medical history of coronary artery disease (multiple PCI including RCA [**2158**], OM1 [**2160**], LCX [**2160**], LAD [**2163**]), bicuspid aortic valve and moderate aortic stenosis (TTE [**2163**] [**Location (un) 109**] 0.8-1.0cm2, cath [**2163**] gradient 29mm Hg and calculated [**Location (un) 109**] of 1.33 cm2), and paroxysmal atrial fibrillation not on coumadin due to bleeding risk, who presents from home following syncopal episode. He reports, when leaving a friend's house and walking to his car in the cold he developed sudden onset substernal chest pain radiating to shoulder and left arm. He drove home, 45 minutes away, and the chest pressure persisted. He noticed that when he got home he felt very weak trying to get a grocery bag out of his car. The chest pain intensified as he walked from his car to the house. At his house, he did not have enough energy to make it up the stairs into his apartment on the [**Location (un) 1773**]. He felt lightheaded and nauseous. He sat down on the third step of the stairs and then lost consciousness and postural tone. He feels that he was down for 10 minutes. After the event he felt "out of it," weak, and had difficulty calling EMS for assistance. He continued to have chest pain. EMS arrived and he was given aspirin 325mg and EKG showed Afib w/ RVR w/ rate of 150s, so was given 20 IV diltiazem with improvement initially of rate to 120s. He notes that his angina (0.5 miles) and syncopal episodes have increased in frequency over the past few months. He also notes that he has never had syncope at rest, and that is always with exertion and associated with feeling fatigue and weakness prior. He is now being referred to cardiac surgery for evaluation on Aortic valve replacement. Past Medical History: Aortic Stenosis Coronary artery disease Paroxysmal atrial fibrillation Dyslipidemia Hypertension Pulmonary hypertension GI bleed Insulin dependent Diabetes Mellitus Embolic CVA [**2158**] with residual visual field deficits in left eye Bipolar Cataracts Obstructive Sleep Apnea w/ variable compliance on CPAP Social History: Lives with: alone, widowed and has three children Occupation:retired, Used to work counseling students at international college. Tobacco:denies ETOH:Drinks 2 nights a week "at the club" but doesn't have any alcohol at home. Family History: Mother with MI in her 70's and passed away Physical Exam: Pulse:93 Resp:13 O2 sat: 97/RA B/P Right:112/78 Left:107/82 Height:6'1" Weight:168 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: [**Year (4 digits) 15262**] [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur: [**3-12**] harsh systolic ejection radiating to the left carotid area. There is also [**1-12**] diastolic murmur. Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] no Edema no Varicosities Neuro: Grossly intact Pulses: Femoral Right: 2+ (access site for cath) Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: referred murmur from the AS Pertinent Results: [**1-16**] Echo: 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. Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is no pericardial effusion. Dr.[**Last Name (STitle) **] was notified in person of the results on [**Known lastname 1349**] before bypass. POST-BYPASS: Normal RV systolic function. LVEF 40%. There is a mechanical prosthesis in the native aortic position, seated and functioning well with a residual mean gradient of 11 mm of Hg. Intact thoraic aorta. Wall motion abnormalities and other valvular findings similar to prebypass. [**2166-1-23**] 04:30AM BLOOD WBC-8.6 RBC-3.06* Hgb-9.2* Hct-26.7* MCV-87 MCH-30.0 MCHC-34.5 RDW-13.8 Plt Ct-304 [**2166-1-23**] 04:30AM BLOOD PT-37.7* PTT-35.9* INR(PT)-3.9* [**2166-1-22**] 04:30AM BLOOD PT-45.2* PTT-34.5 INR(PT)-4.9* [**2166-1-21**] 05:21PM BLOOD PT-49.2* INR(PT)-5.4* [**2166-1-21**] 10:35AM BLOOD PT-48.9* INR(PT)-5.3* [**2166-1-21**] 04:25AM BLOOD PT-48.0* PTT-32.3 INR(PT)-5.2* [**2166-1-20**] 08:50AM BLOOD PT-42.0* PTT-30.8 INR(PT)-4.4* [**2166-1-20**] 02:04AM BLOOD PT-36.1* PTT-30.5 INR(PT)-3.7* [**2166-1-19**] 04:25AM BLOOD PT-18.8* INR(PT)-1.7* [**2166-1-18**] 10:50AM BLOOD PT-15.8* INR(PT)-1.4* [**2166-1-16**] 12:30PM BLOOD PT-13.5* PTT-31.3 INR(PT)-1.2* [**2166-1-16**] 11:15AM BLOOD PT-14.9* PTT-29.0 INR(PT)-1.3* [**2166-1-23**] 04:30AM BLOOD Glucose-143* UreaN-20 Creat-1.2 Na-133 K-4.5 Cl-99 HCO3-29 AnGap-10 Brief Hospital Course: Mr. [**Known lastname 1349**] was a same day admit after undergoing pre-operative work-up during previous admission. On [**1-16**] he was brought directly to the operating room where he underwent an aortic valve replacement, coronary artery bypass graft x 1, and MAZE procedure. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later that day he was weaned from sedation, awoke neurologically intact and extubated. Beta blockers and diuretics were initiated and he was gently diuresed towards his pre-op weight. On post-op day one he was transferred to the step-down floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. During his post-op course he worked with physical therapy for strength and mobility. He developed post-op atrial fibrillation which converted to sinus rhythm with lopressor and amiodarone. He is anti-coagulated for his mechanical aortic valve. INR did rise to 5.4 following three doses of warfarin 5mg. Warfarin was held and INR trended back into goal range of 2.5-3.5. His PCP will manage coumadin/INR on discharge. The patient was discharged home with VNA on POD 7. All follow up is advised. Medications on Admission: HOME MEDICATIONS: -amlodipine 5mg daily -lipitor 80mg daily -plavix 75mg daily -aspirin 325mg daily -ranitidine 150mg PRN -lithium SR 450mg daily -insulin sliding scale -metoprolol 50mg [**Hospital1 **] CURRENT MEDICATIONS: Heparin IV Sliding Scale Metoprolol Tartrate 25 mg PO/NG [**Hospital1 **] Acetaminophen 325-650 mg PO/NG Q6H:PRN pain/fever Diltiazem 5-15 mg/hr IV INFUSION; off since 1PM Ranitidine 150 mg PO/NG DAILY Insulin SC (per Insulin Flowsheet) Lithium Carbonate 450 mg PO DAILY Atorvastatin 80 mg PO/NG DAILY Clopidogrel 75 mg PO/NG DAILY Aspirin 325 mg PO/NG DAILY Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. lithium carbonate 450 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). Disp:*30 Tablet Extended Release(s)* Refills:*0* 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then 200mg daily until further instructed. 8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2* 9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 10. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 12. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication Mechanical AVR Goal INR 2.5-3.5 First draw [**2166-1-24**] Results to Dr [**Last Name (STitle) 15263**] phone [**Telephone/Fax (1) 15271**] fax [**Telephone/Fax (1) 15272**] ([**First Name9 (NamePattern2) 5035**] [**Doctor First Name **]) Please check INR monday, wednesday and friday for two weeks then decrease frequency per PCP 13. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Mechanical AVR Goal INR 2.5-3.5 dose may change per Dr [**Last Name (STitle) 15263**] . Disp:*30 Tablet(s)* Refills:*2* 14. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: Ten (10) Subcutaneous twice a day: 10 units with breakfast and 10 units with dinner. Disp:*qs * Refills:*2* 15. insulin regular human 100 unit/mL Solution Sig: One (1) Injection four times a day: Follow Sliding Scale of Regular Insulin. Disp:*qs * Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Aortic Stenosis s/p AVR Coronary artery disease s/p CABG paroxysmal atrial fibrillation s/p attempted MAZE procedure Dyslipidemia Hypertension Pulmonary hypertension GI bleed Diabetes mellitus type 2 Embolic CVA [**2158**] with residual visual field deficits in left eye Bipolar Cataracts Obstructive Sleep Apnea Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet prn Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage. Edema- none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**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 Wound Check on [**Hospital Ward Name 121**] 6, Thursday, [**2166-1-30**], 10:15am Surgeon: Dr. [**Last Name (STitle) **] [**2-12**] at 1:15pm [**Telephone/Fax (1) 170**] Cardiologist: Dr [**Last Name (STitle) **] on [**2-6**] at 10:00am [**Telephone/Fax (1) 5068**] CVI [**Location (un) 2898**] TESTING Phone:[**Telephone/Fax (1) 5068**] Date/Time:[**2166-4-17**] 8:30 Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 15263**] in [**3-11**] weeks [**Telephone/Fax (1) 15271**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication Mechanical AVR Goal INR 2.5-3.5 First draw [**2166-1-24**] Results to Dr [**Last Name (STitle) 15263**] phone [**Telephone/Fax (1) 15271**] fax [**Telephone/Fax (1) 15272**] ([**First Name9 (NamePattern2) 5035**] [**Doctor First Name **]) Please check INR monday, wednesday and friday for two weeks then decrease frequency per PCP Completed by:[**2166-1-23**]

[ "366.8", "451.82", "V58.67", "997.1", "E878.2", "427.31", "428.23", "296.80", "564.09", "438.7", "401.9", "414.01", "428.0", "416.8", "250.00", "424.1", "746.4", "327.23", "272.4" ]

icd9cm

[ [ [] ] ]

[ "36.11", "39.61", "37.36", "35.24" ]

icd9pcs

[ [ [] ] ]

10197, 10255

5966, 7222

295, 632

10612, 10837

3915, 5943

11760, 12894

3030, 3074

7857, 10174

10276, 10591

7248, 7248

10861, 11737

3089, 3896

7266, 7452

239, 257

7473, 7834

660, 2441

2463, 2773

2789, 3014

57,476

114,743

38545

Discharge summary

report

Admission Date: [**2162-3-4**] Discharge Date: [**2162-3-25**] Date of Birth: [**2093-7-29**] Sex: M Service: SURGERY Allergies: Penicillins / Neurontin / Cyclosporine / Methotrexate And Derivatives / Levofloxacin Attending:[**First Name3 (LF) 598**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2162-3-5**] Exploratory Laparotomy, Lysis of Adhesions, resection of small bowel with anastomosis x 1. [**2162-3-18**] PICC line placement History of Present Illness: 68M with a history of recurrent SBOs requiring multiple rounds of enterolysis presented to [**Hospital3 **]recently admitted on [**Month (only) 1096**] with acute cholecystitis. Due to his multiple co morbidities he underwent percutaneous cholecystostomy tube on [**2161-10-20**]. Patient developed hypotension and oxygen desaturation with septic shock. As the cholecystotomy tube was no longer draining, patient went to the OR and underwent an open subtotal cholecystectomy [**2161-10-22**]. On [**2161-10-29**] he underwent an [**Date Range **] with sphincterotomy and stenting of the cystic duct secondary to a leak at the cystic duct stump. Patient presented today to [**Date Range **] for stent removal, but was noted to have worsening abdominal distension over several days, with no BMs x 3-4 days, and several episodes of N/V, so was sent to the ED. Patient complains of 2 weeks of mild abdominal pain, worsening during the past week in the upper abdomen mostly on the LUQ, associated with worsening constipation (last BM 3 days ago after mag citrate). Had been passing flatus until yesterday, but none noted today. ROS: (+) per HPI (-) Denies fevers chills, night sweats, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, hematemesis, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: PMH: multiple epsiodes of SBO, GERD, Barrets esophagous, CAD, CHF, MIx2, stroke, Hypertension, hyperlipidemia, OSA on BiPAP, asthma, COPD, gastroparesis, h/o GI bleed, stroke in [**2154**], polymyalgia rheumatica, polyarthralgia, chronic neck pain PSH: splenectomy, bowel resection x2, lysis of adhesions x10 Social History: Single. Never married. No children. Denies tobacco use, drinks occasionally. Family History: Father died at 85 with throat cancer and CAD. Mother died at 73 of MI Physical Exam: Upon presentation to [**Hospital1 18**]: Vitals: 97.9 76 133/106 18 100% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, severely distended, moderately tender to palpation on upper abdomen. No rebound or guarding, no palpable masses. Severe scarring of the abdominal wall. Right subcostal incision mostly healed, with a very small open area on the medial aspect, pasked with a small gauze. Ext: No LE edema, LE warm and well perfused Pertinent Results: White Blood Cells 12.4* Red Blood Cells 2.91* LAB Hemoglobin 8.2* Hematocrit 24.7* MCV 85 82 - 98 fL MCH 28.1 27 - 32 pg MCHC 33.1 31 - 35 % RDW 16.7* 10.5 - 15.5 % BASIC COAGULATION (PT, PTT, PLT, INR) Platelet Count 542* Glucose 80 Urea Nitrogen 17 Creat 0.6 Sodium 138 Potassium 4.2 Chloride 109* 96 - 108 mEq/L Bicarbonate 23 22 - 32 mEq/L Anion Gap 10 8 - 20 mEq/L Albumin 2.5* 3.5 - 5.2 g/dL Calcium, Total 8.0* 8.4 - 10.3 mg/dL Phosphate 3.2 2.7 - 4.5 mg/dL Magnesium 1.9 1.6 - 2.6 mg/dL IMAGING: [**3-4**] CT Abd/pelvis: Sequelae of multiple small bowel surgeries, w/early or partial SBO. Distal migration of CBD stent into duodenum. [**2162-3-14**] CT abd/pelvis: IMPRESSION: 1. No extraluminal contrast to suggest large anastomotic leak. Intraperitoneal gas and fluid with stranding of the small bowel mesentery is likely post-surgical. A mid abdominal incision remains open and packed. 2. Similar appearance of fluid collection in the left anterior abdomen, which is better appreciated on the contrast-enhanced study of earlier today. [**2162-3-18**] IMPRESSION: 1. Extensive occlusive deep vein thrombosis extending from the left common femoral vein to the left popliteal vein. 2. No right-sided DVT. [**2162-3-18**] IMPRESSION: 1. Enterocutaneous fistula from the mid jejunum through to the anterior abdominal wall with contrast also pooling within a likely intra-abdominal fluid collection. 2. Area of caliber change with multiple not as fully distendable bowel loops in the right lower quadrant beyond a persistent discrete, although no angulated, point of distinct caliber change; this confirms the impression that there may be mild partial obstruction due to an adhesion beyond the point of fistulization. Brief Hospital Course: He was admitted to the Acute Care Surgery service and taken to the operating room on [**3-5**] for exploratory laparotomy with extensive lysis of adhesions (> 8 hours) and small-bowel resection x1 with primary anastomosis. Intraoperatively he developed atrial fibrillation at surgical hour 8 and received amiodarone load. He was transferred to SICU post-op intubated and vented for hemodynamic monitoring and further management. He was weaned and extubated on [**3-7**] successfully. He remained hemodynamically stable and was transferred to the regular surgical floor for ongoing care. Once transferred to the floor he progressed slowly. He was given a diet and began working with Physical and Occupational therapy. On [**3-14**] he was noted with enterocutaneous fistula requiring that a wound VAC be placed over the wound. The drainage output from this was initially high; a NG tube was placed as well also initially with high output. The decision was made to place a PICC and initiate TPN. On [**3-18**] he was noted with left calf swelling and tenderness. He underwent a ultrasound which revealed extensive occlusive deep vein thrombosis extending from the left common femoral vein to the left popliteal vein bu no right-sided DVT. A Heparin drip was started and his PTT was followed closely. His NG was clamped on [**3-22**] for 6 hours with no residual and no increase in his fistula output. The NG was removed and there has not been any increase in the fistula drainage since its removal. On [**3-22**] Coumadin was started with the Heparin drip being continued as a bridge. He received 5 days of Coumadin, doses being increased every 2 days. His INR did not increase. It was felt that he was most likely not absorbing the Coumadin and the decision was made to stop the Heparin drip and initiate therapeutic Lovenox - he is currently receiving 80 mg every 12 hours. As the fistula heals restarting Coumadin should be revisited as he will require long term anticoagulation therapy. He has remained NPO allowing for fistula healing and will continue on the TPN in the meantime. He will need to follow up at least every 2 weeks in the Acute Care Clinic for wound and fistula evaluation. He has been recommended for acute rehab after hospital discharge for ongoing care. Medications on Admission: Advair 250-50mcg 2 puffs [**Hospital1 **], Albuterol INH PRN, Amitriptyline 75mg QPM, Aspirin 81mg daily, Carvedilol 6.25 [**Hospital1 **], Calcitriol 0.25mcg QMWF, Ciclopirox 8% daily, Coumadin 2mg (hasnt taken for 2 days), Cyclobenzaprine 10mg [**Hospital1 **], Furosemide 40mg QD, Vicodin PRN pain, Hyoscyamine 0.125mg daily, Isosorbide (Imdur) 30mg daily, Nitroglycerin 0.4mg PRN, Omeprazole 40mg QD, Ondansetron 4mg PRN, Miralax 17g [**Hospital1 **], Potassium Chloride 40mg [**Hospital1 **], Pravastatin 40mg daily (N), Sucralfate 1g TID, MVI Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed for SOB. 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: may rpt q 5 min x3 doses. 4. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) MG Subcutaneous Q12H (every 12 hours). 5. Metoprolol Tartrate 5 mg IV Q6H while NPO. Hold SBP <100 or HR <55 6. insulin regular human 100 unit/mL Solution Sig: One (1) dose Injection four times a day as needed for per sliding scale. 7. Pantoprazole 40 mg IV Q24H 8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 9. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 10. Heparin Flush (10 units/ml) 1 mL IV DAILY 11. Dilaudid (PF) 1 mg/mL Solution Sig: 0.5-1 MG Injection every 4-6 hours as needed for pain. 12. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**11-15**] Tablet, Delayed Release (E.C.)s PO once a day as needed for constipation. 13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 14. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 15. Ondansetron 4 mg IV Q8H:PRN nausea 16. TPN SEE ATTACHED Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Small bowel obstruction Enterocutaneous fistula Deep vein thrombosis - left lower extremity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with a small bowel obstruction requiring an operation to remove the obstruction. Your surgery was complicated by a wound fistula that has interferred with progressing you to being able to eat. You are being given intravenous nutrition called TPN that is being administered through the specialized IV called a PICC line. Once the fistula heals foods will be re-introduced. You also developed a blood clot in the veins in your left leg and initially was started on Heparin which is a blood thinner. Blood clots can commonly develop in people who have undergone major surgery and are not able to be very mobile. You are continuing to be treated with blood thinners called Lovenox which is an injection that is gien 2x/day. You were tired on Coumadin which is a pill form blood thinner but because of your medical condition your intestines were not able to absorb this medication and that is why you were changed to Lovenox. Followup Instructions: Follow up in [**11-15**] weks in Acute Care Surgery Clinic; call [**Telephone/Fax (1) 600**] for an appointment. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2162-4-14**]

[ "272.4", "285.9", "276.2", "E878.2", "438.19", "569.81", "412", "428.22", "V45.82", "567.9", "401.9", "530.81", "428.0", "493.20", "998.6", "536.3", "560.81", "414.01", "453.41", "427.31" ]

icd9cm

[ [ [] ] ]

[ "54.59", "99.15", "45.62", "38.97", "86.3" ]

icd9pcs

[ [ [] ] ]

9447, 9547

4897, 7180

357, 501

9682, 9682

3113, 4874

10837, 11087

2482, 2554

7779, 9424

9568, 9661

7206, 7756

9857, 10814

2569, 3094

303, 319

529, 2034

9697, 9833

2056, 2368

2384, 2466

24,899

196,514

12300

Discharge summary

report

Admission Date: [**2174-2-7**] Discharge Date: [**2174-2-9**] Date of Birth: [**2116-7-21**] Sex: M Service: #58 HISTORY OF PRESENT ILLNESS: The patient is a 57 year-old male with a past medical history significant for osteoarthritis of bilateral knees status post bilateral knee replacement at [**Hospital6 2910**] on [**2174-2-2**]. Surgery was uneventful and the patient was undergoing expected normal postop course until [**2-4**] when he began to complain of left sided pleuritic chest pain without shortness of breath. The patient was anticoagulated on Coumadin and had been on Venodyne. Electrocardiogram showed sinus tachycardia at 105 with T wave inversions in 3, AVF and no ST changes. He was ruled out for myocardial infarction by two serial troponin and transferred to the telemetry floor on the Medicine Service. Over the next 24 hours he had a temperature max of 101. A cardiovascular consult was requested and the patient had a workup for PE including negative lennies, but a positive D-dimer. No VQ scan or chest CT was performed at the time. Given the patient's INR of 1.8 and Venodyne since the surgery a pulmonary embolus was thought to be less likely. On the [**2-6**] he was noted to have visual and tactile hallucinations and delusions. He then reported positive alcohol abuse history with his wife reporting that he had been asked to cut down in the past. The patient reports drinking at least two drinks a day for many years. He was treated with Haldol and Ativan and given Thiamine and Folate as delirium tremors were high on the differential diagnoses. He subsequently had a CT of his head, which was negative by report. The patient required 15 Haldol and 22 of Ativan and 8 of Versed in order to have his scan completed and keep him calm during his hospitalization at [**Hospital6 **]. MEDICATIONS ON TRANSFER: Ativan and Haldol prn, Coumadin, multi vitamin, Dulcolax, iron sulfate, aspirin and Lopresor 25 mg q 8 hours. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is married and lives in [**Location 38379**] in a two level home. He is a retired CEO. He reports two Vodkas per day every day. No recollection of past episodes of seizures or delirium tremors. No cigarette use ever. On the morning of transfer to [**Hospital1 **] the patient became increasingly agitated and did not respond to Ativan or Haldol. He required elective intubation and sedation with Propofol. The presumed transfer diagnoses was delirium tremens secondary to alcohol withdraw five days postoperatively. PHYSICAL EXAMINATION ON TRANSFER: Temperature 100.2. Blood pressure 109/59. Heart rate 87 and regular. Vent settings SIMV 800 by 10, pressure support 5, PEEP of 5, FIO2 100%. His O2 sat was 100% and his arterial blood gas was 744, 39, 189. The rest of his physical examination , in general, he is a sedated male intubated and in no acute distress. HEENT normocephalic, atraumatic. Pupils are anicteric, equal, round and reactive. 2 to 1 mm bilaterally. Oropharynx is clear. There is no dried blood or lesions. Chest there is a positive air leak in the endotracheal tube. No rales or rhonchi, or wheezing appreciated. His heart is regular. No murmurs, rubs or gallops. Extremities bilateral total knee replacements, staples bilaterally at the knees, clean, dry and intact. No erythema. No fluctuance. Ecchymosis is noted on the left medial calf. There is no calf tenderness and no palpable cords. He has 2+ dorsalis pedis pulse and posterior tibial pulse bilaterally. Extremities are warm and there is no edema. Neurologically he is sedated. The patient was transferred with three radiologic reports from [**Hospital6 **]. A chest x-ray showed no acute infiltrate. CT of his head showed no bleed or intracranial process and lennies were negative. Electrocardiogram showed normal sinus at 89, normal axis and intervals, T wave inversion in 3, AVF and V1. No changes compared to electrocardiogram from [**2173-11-13**]. Laboratories on transfer, white blood cell count 8.5, hematocrit 31, platelets 283. Electrolytes sodium 138, potassium 4.2, chloride 99, bicarb 27, BUN 13, creatinine 1, glucose 107, PT 16.8, INR 1.8, D-dimer greater then 1, CPK were 187, 184 and 274. His MBs were negative. Troponins were also negative. Calcium was 8.3, magnesium 2.1, albumin 2.6, ALT 13, AST 38, alkaline phosphatase 106, total bilirubin .7, direct bili .6, amylase 78, lipase 311, GGT 125. HOSPITAL COURSE: 1. Agitation: The patient was maintained on his Propofol drip after admission until the afternoon of hospital day two at which point the Propofol was turned off. The patient was placed on Valium 10 mg q 1 to 2 hours for a CIWA scale greater then 10. He did not require any Valium during this admission as he was more persistently less then 10. On transfer the patient is calm, not hypertensive or diaphoretic, not showing signs of acute agitation. 2. Alcohol withdraw: As noted above the patient was given Valium per CIWA scale after his Propofol drip was turned off. He was also given a banana bag for nutritional supplementation. Other medications, which may have been interfering with his mental status including Haldol, Ativan, Cogentin and Vistaril were discontinued. 3. Temperature to 100: The patient's chest x-ray and chest CT demonstrated atelectasis. Culture data was negative. It was presumed that his fever was secondary to atelectasis postoperatively. 4. Hypoxia: The patient was extubated on hospital day two. Given a moderate clinical index suspicion for pulmonary embolus a high resolution chest CT was performed on the night of admission. This chest CT was of low probability for pulmonary embolus. Heparin was initially started on admission for the suspicion of pulmonary embolus, however, it was discontinued after the patient ruled out. 5. Airway protection: As mentioned earlier in this discharge summary the patient was extubated on the second day of the hospital admission. He did well and maintained good oxygen saturation 97% at the time of this dictation on 6 liters O2. 6. Bilateral knee replacements: The patient had no evidence of acute problems with his total joint replacements. He will be transferred back to [**Hospital6 **] where the Orthopedic and Physical Therapy Services will continue the rehabilitation. 7. Hypertension: The patient's hypertension was not an issue during this admission. His Lopresor was discontinued. On admission it was not restarted. 8. Fluids, electrolytes and nutrition: The patient received a banana bag as noted above. He was advanced to a regular diet on hospital day number three. He is on a regular diet as of dictation of this discharge summary. 9. Prophylaxis: The patient received Protonix and heparin on admission. The heparin was started for fear of a pulmonary embolus. This was discontinued after it was ruled out. The patient's INR was greater then 1.5. He was therefore not recontinued on Coumadin. Coumadin will be reinitiated at [**Hospital6 2910**]. 10. Vascular access: The patient was transferred with two peripheral intravenous. Venous access for blood draws was difficult. An A line was placed on [**2-8**], hospital day number two after multiple attempts and will be discontinued upon [**Hospital 228**] transfer to [**Hospital6 **]. The patient is being transferred back to [**Hospital6 1322**] on [**2174-2-9**]. His acute medical issues have resolved and he requires further orthopedic rehabilitation. DISCHARGE DIAGNOSES: 1. Alcohol withdraw resolved. 2. Osteoarthritis. 3. Herniated disc. 4. Eczema. 5. Bilateral knee replacements. DISCHARGE MEDICATIONS: Protonix 40 mg po q.d., Colace 100 mg po b.i.d., Valium 10 mg intravenous q 1 to 2 hours prn CIWA greater then 10. Tylenol 650 mg po pr q 4 hours prn pain or fever. The patient will be followed by his attending physician at [**Hospital6 2910**] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3851**] Dictated By:[**Last Name (NamePattern1) 5476**] MEDQUIST36 D: [**2174-2-9**] 07:50 T: [**2174-2-9**] 08:24 JOB#: [**Job Number 29595**]

[ "291.0", "997.3", "518.0", "401.9", "291.81", "518.81" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

7566, 7683

7707, 8299

4506, 7545

163, 1850

1876, 2025

2042, 4488

18,184

198,604

2969

Discharge summary

report

Admission Date: [**2142-5-3**] Discharge Date: [**2142-5-16**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 425**] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: I&D of R anterior leg hematoma Transesophageal echocardiogram History of Present Illness: 82 year-old woman with hypertrophic obstructive cardiomyopathy (HOCM) and end-stage renal disease on hemodialysis, complaining of increasing fatigue over the last 10 days. She was noted to have increasing pedal edema at this week's dialysis, and an additional 3# of fluid was removed the day prior to admission. She denies chest pain, worsening DOE, PND, or orthopnea. She does note occasional palpitations over this interval. Per report, she has a 90% ostial RCA blockage, and 50% OM2 blockage on [**2136**] cath, that was not intervened on. She had a normal EF of 70% on [**3-8**] TTE, with moderate AS (peak gradient 61, mean gradient 32, [**Location (un) 109**] 1.1-1.2cm2), 2+ MR. She had a PPM placed in the mid-[**2125**] for HOCM, originally a Thera 7960 dual chamber PPM, that was changed to a [**Company 1543**] SDR303 in [**8-6**]. She recently had Imdur 30mg PO qD added to her regimen for CP control during a recent admission for chest pain/SOB in context of two missed HD appointments, during which she was ruled out, noted to have no ECG changes, and did not have further CAD w/u done due to clean coronaries on [**2137**] cath. . Ms. [**Known lastname 14204**] saw her cardiologist on the day of admission with her complaints of fatigue. Per report, she appeared somewhat lethargic and weak. Blood pressure was 86/60mmHg left arm standing. Pulse was 110 and irregularly irregular. She was reported to have little evidence of volume overload. ECG demonstrated new AFib with rate 120, with evidence of LVH with extensive ST-T changes c/w left heart strain. Her pacer was interrogated, which indicates AF since [**4-23**] and likely chronic since [**4-28**]. Of note, however, ECGs from [**Hospital1 498**]-[**Hospital1 107**] demonstrated AF on [**4-10**] ECG, and not on previous [**3-18**] ECG. She was sent to the ED for admission for TEE/CV. In the ED, she was placed on heparin, and admitted to the cardiology service under CCU housestaff. . Of note, Ms. [**Known lastname 14204**] also has been experiencing diffuse abdominal pain over the last 2-3 months. During a recent admission at [**Hospital1 498**]-[**Hospital1 107**], a KUB, CT and mesenteric dopplers were unremarkable. She has never had a colonoscopy, and was recommended to have a colonoscopy done in the near future. She denies fever, chills, nausea, hematemesis, melena or hematochezia. She has experienced a significant weight loss, from 141lb to 106lb over the last year. Past Medical History: 1) HOCM: s/p PPM placement. No ablation done, as pt asymptomatic. On carvedilol. LVOT gradient 50mmHg at rest, 120mmHg after PVC. 2) ESRD: Unclear etiology. Apparently had ARF from acyclovir given for Shingles, along with possible contrast nephropathy. Has been receiving HD in [**Hospital1 1559**] through Hickman catheter for last six months. Anuric, has atrophic kidney. 3) HTN 4) DMII (diet controlled) Social History: No h/o tobacco or EtOH. Lives with son and daughter-in-law. [**Name (NI) 4906**] died last year. Family History: NC Physical Exam: T: [**Age over 90 **]F BP: 123/80 HR: 110 RR: 16 SaO2: 98% RA Gen: Lying flat in bed comfortably, NAD HEENT: PERRL, MMM Neck: Supple, brisk carotid upstroke, no LAD, no thyromegaly CV: Irregularly irregular, II/VI harsh SEM radiating to carotids. Could not get pt to valsalva. No S3 or S4. JVP 8cm Chest: CTAB, no w/r/r Abd: Diffusely mildly tender throughout, nondistended, +BS throughout, no HSM Extr: 2+ LE edema bilaterally Neuro: A&Ox3, no focal deficits Pertinent Results: Admission CXR: The heart size is slightly increased. There is bilateral mild to moderate pleural effusions as well as bilateral pulmonary edema. The right hemithorax pacemaker is inserted with the leads in right atrium and right ventricle. Area of linear calcification is demonstrated, the location of which could indicate mitral ring deposits. IMPRESSION: Pulmonary edema and bilateral pleural effusions. . TEE Report: GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). Local anesthesia was provided by benzocaine topical spray. No TEE related complications. 0.1 mg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe insertion. The rhythm appears to be atrial fibrillation. Echocardiographic results were reviewed by telephone with the houseofficer caring echocardiographic results by e-mail. Results were reviewed with the Cardiology Fellow involved with the patient's care. Conclusions: The left atrium is dilated. The left atrial appendage emptying velocity is extremely depressed (<0.1 m/s). Multiple large definite thrombi are seen in the left atrial appendage. There is symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch and in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is at lease moderate aortic valve stenosis, although the peak velocity across the aortic valve could not be assessed. Trace aortic regurgitation is seen. The mitral valve leaflets are moderate-to-severely thickened and myxomatous. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Pulmonary pressures could not be assessed. There is no pericardial effusion. IMPRESSION: Thrombus with associated low emptying velocities in the left atrial appendage. . CT RLE: FINDINGS: There is a large hematoma involving the anterior and lateral aspect of the right lower extremity. This large hematoma appears to extend from the level of just below the knee to the distal tibia, several centimeters above the ankle. There is no evidence of acute fracture IMPRESSION: Very large hematoma involving the anterior aspect of the right lower extremity extending from below the level of the knee towards the distal tibia. Findings were discussed with Dr. [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) 11309**] on [**2142-5-5**]. . [**5-7**] TTE: Conclusions: The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate global left ventricular hypokinesis. No resting LVOT gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is at least moderate aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral leaflets and supporting structures are thickened. Mild to moderate ([**12-4**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2141-12-22**], the rhythm is now atrial fibrillation and global left ventricular systolic function is now depressed. The aortic valve gradient is reduced (likely related to impaired LV systolic function). . Arterial Dopplers: The exam was limited. Wound in the right calf drained large amounts of bright red blood. Doppler interrogation of the posterior tibial and dorsalis pedis arteries bilaterally demonstrated monophasic waveform. IMPRESSION: Markedly limited exam. Monophasic waveform was demonstrated symmetrically in the bilateral tibial and dorsalis pedis arteries. These findings could be due to arterial insufficiency, therefore compartment syndrome cannot be diagnosed or excluded by this test. . Head CT: FINDINGS: The study is slightly limited by the fact that the patient is obliqued in the scanner. No intra- or extra-axial hemorrhage is identified. There is no mass effect or shift of normally midline structures. The ventricles and sulci are slightly prominent consistent with age-related involutional change. The basal cisterns are well visualized. There is a periventricular white matter hypodensity consistent with chronic small vessel infarction. No fractures are identified. The visualized paranasal sinuses and mastoid air cells are clear apart from a small calcification in the left frontal air cell. The orbits appear unremarkable. IMPRESSION: No evidence of intracranial hemorrhage or mass effect. . [**2142-5-16**] 09:45AM BLOOD WBC-8.9 RBC-3.92* Hgb-12.5 Hct-39.0 MCV-100* MCH-31.8 MCHC-32.0 RDW-21.5* Plt Ct-303 [**2142-5-16**] 10:45AM BLOOD PT-41.5* PTT-PND INR(PT)-4.7* [**2142-5-16**] 09:45AM BLOOD Glucose-137* UreaN-23* Creat-3.1* Na-139 K-4.7 Cl-100 HCO3-24 AnGap-20 [**2142-5-16**] 09:45AM BLOOD Albumin-3.1* Calcium-8.9 Phos-4.0 Mg-1.9 UricAcd-5.9* [**2142-5-5**] 09:00AM BLOOD VitB12-1179* Folate->20.0 [**2142-5-4**] 01:10PM BLOOD calTIBC-146* Ferritn-1113* TRF-112* [**2142-5-4**] 09:15AM BLOOD %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE [**2142-5-3**] 02:00PM BLOOD TSH-1.0 [**2142-5-4**] 01:10PM BLOOD PTH-202* Brief Hospital Course: 1) Ischemia: No evidence of active ischemia. 90% non-dominant ostial RCA lesion on previous cath, by report. Not active issue during this hospitalization. . 2) Pump: Evidence of some volume overload on initial exam and CXR, most likely [**1-4**] diastolic dysfunction in context of new AF, tachycardia, and loss of atrial kick. Kept generally euvolemic, as borderline low BPs did not allow for aggressive diuresis, and extra fluid was taken off during hemodialysis, which was continued while in-house. Switched BB to Toprol XL, and continued diltiazem SR for HOCM and diastolic dysfunction while in-house. Imdur held, so as to minimize unnecessary lowering of BP in this setting. . 3) Rhythm: New onset AF, dangerous in setting of HOCM. Had TEE, which demonstrated large clot in [**Last Name (LF) 14205**], [**First Name3 (LF) **] cardioversion not done. Kept on heparin to coumadin bridge for anticipated anticoagulation for minimum 4 weeks before repeat TEE to reconsider cardioversion. Course complicated by spontaneous R anterior compartment lower leg bleed while on heparin. Plastic surgery performed I&D, and evacuated large hematoma, which had intermittent bleeding while bridging to coumadin. Coumadin was held prior to discharge for supratherapeutic INR (4.7 on AM of discharge). INR should be checked every day, and coumadin restarted at 2mg PO qHS once INR falls below 3.5. Goal INR [**1-5**]. . 4) Abdominal pain: Concerning for malignancy, given significant weight loss. Denies F/C/NS or bowel symptoms, but will be very important to have colonoscopy as outpatient to r/o colon CA. Per OSH records, recent KUB, CT abdomen, and mesenteric doppler U/S were unrevealing. Pain control was provided as needed . 5) ESRD: Unclear etiology, possibly hypertensive nephropathy, exacerbated by episode of iatrogenic ARF during previous hospital admission. HD continued while in-house on MWF schedule. Continued nephrocaps, renal diet. . 6) s/p fall: Ms. [**Known lastname 14204**] fell while ambulating in her room, hitting her head 3 days prior to discharge. This was in the setting of supratherapeutic INR. A head CT was obtained, which demonstrated no evidence of hemorrhage. She had no neurological findings, and had no adverse sequelae from the event. Medications on Admission: Carvedilol 25mg PO bid Diltiazem SR 240mg PO qD Imdur 30mg PO qD ASA 325mg PO qD Lipitor 10mg PO qD Renalcaps qD Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 4. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QD (): Should be applied to leg with each dressing change. Disp:*1 large tube* Refills:*0* 5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 7. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 9. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 **]- Parkview Discharge Diagnosis: atrial fibrillation R lower extremity hematoma which developed in the setting of anticoagulation ESRD HOCM aortic stenosis DM II Discharge Condition: stable Discharge Instructions: You are being transferred to a rehabilitation facility for further care. . You should have your dressing changed every day, as described below. You should keep your leg elevated at all times. Followup Instructions: Please follow-up in the plastic surgery clinic on [**5-25**]. You should call ([**Telephone/Fax (1) 7138**] to make this appointment. They will examine your leg and decide if any further surgery needs to be done to promote healing of the affected area. You should continue your Clindamycin as instructed.

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icd9cm

[ [ [] ] ]

[ "39.95", "88.72", "99.04", "86.22", "86.04" ]

icd9pcs

[ [ [] ] ]

12986, 13039

9617, 11878

225, 288

13212, 13221

3842, 8257

13461, 13770

3338, 3342

12041, 12963

13060, 13191

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3357, 3823

178, 187

316, 2776

8266, 9594

2798, 3207

3223, 3322

56,394

106,350

51859

Discharge summary

report

Admission Date: [**2183-12-15**] Discharge Date: [**2183-12-22**] Date of Birth: [**2116-4-4**] Sex: M Service: ORTHOPAEDICS Allergies: Soma / Fentanyl Attending:[**Doctor Last Name 1350**] Chief Complaint: Low back and more bothersome buttock and radiating right leg pain found to be related to retrolisthesis at L3- L4, lumbar spinal stenosis, adjacent segment disease. He underwent a prolonged and multimodal course of conservative care including injections, physical therapy, medications, and activity modifications. His syndrome was refractory this. Due to the refractory nature of his syndrome, as well as the severity of the symptoms, which did limit his ability to walk, he elected to undergo surgical treatment. Major Surgical or Invasive Procedure: 1. Anterior interbody fusion with correction of spinal deformity L3-L4. 2. Interbody reconstruction with biomechanical device L3-L4 by direct lateral approach. 3. Removal of hardware L4, L5, S1. 4. Inspection of posterolateral fusion. 5. Bilateral L2 laminotomy. 6. Revision laminotomy, bilateral, L3, L4, L5. 7. Laminectomy S1. 8. Posterolateral fusion L3-L4. 9. Posterolateral instrumentation L3-L4. 10.Application of local autograft for fusion augmentation. 11.Application of allograft for fusion augmentation. History of Present Illness: back and more bothersome buttock and radiating right leg pain found to be related to retrolisthesis at L3- L4, lumbar spinal stenosis, adjacent segment disease. He underwent a prolonged and multimodal course of conservative care including injections, physical therapy, medications, and activity modifications. His syndrome was refractory this. Due to the refractory nature of his syndrome, as well as the severity of the symptoms, which did limit his ability to walk, he elected to undergo surgical treatment.weakness in his right leg. He has had right knee buckling on several occasions, particularly with prolonged walking over two minutes Past Medical History: Significant for interstitial lung disease, spine surgeries [**2172**], [**2174**], [**2176**] as described above. Hypertension, bilateral total knee replacement, gallbladder surgery in [**2146**], knee replacement in [**2153**], lung biopsy [**2179**]. Physical Exam: [**2-23**] right iliopsoas and quadriceps. Rest of BLE - hip abductors, left quad and iliopsoas [**3-24**] SILT Reflexes 2 + in knees and ankles. Plantars downgoing. Pertinent Results: [**2183-12-15**] 08:49PM TYPE-ART PO2-452* PCO2-43 PH-7.28* TOTAL CO2-21 BASE XS--6 [**2183-12-15**] 08:44PM GLUCOSE-129* UREA N-21* CREAT-1.0 SODIUM-139 POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-20* ANION GAP-13 [**2183-12-15**] 08:44PM CALCIUM-7.9* PHOSPHATE-4.0 MAGNESIUM-2.0 [**2183-12-15**] 08:44PM WBC-6.6 RBC-4.67 HGB-13.9* HCT-40.0 MCV-86 MCH-29.8 MCHC-34.8 RDW-14.3 [**2183-12-15**] 08:44PM PLT COUNT-227 [**2183-12-15**] 08:44PM WBC-6.6 RBC-4.67 HGB-13.9* HCT-40.0 MCV-86 MCH-29.8 MCHC-34.8 RDW-14.3 [**2183-12-15**] 08:44PM PT-12.7 PTT-29.0 INR(PT)-1.1 Brief Hospital Course: Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#2. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet Medications on Admission: Current medications include Tramadol 50 2 tabs twice a day, Darvocet-N 100 2 tablets q.4 hours, nabumetone 500 mg 1-1/2 tablets twice a dayisosorbide mononitrate, nitroglycerin, verapamil, aspirin 81, L-thyroxine, Senna, Advil p.r.n., Lyrica Discharge Medications: 1. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Nabumetone 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB/Wheezing. 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Actimmune 2,000,000 unit/0.5 mL Solution Sig: One (1) ML Subcutaneous Monday, Wednesday and Friday HS (). 9. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 16. Cefepime 2 gram Recon Soln Sig: One (1) Intravenous every twelve (12) hours. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: .1. Adjacent segment degeneration, adjacent segment disease L3-L4. 2. Spondylolisthesis L3-L4. 3. Spinal stenosis L3-L4, L4-L5, L5-S1. 4. Prior lumbosacral fusion L4-S1. 5. Healed posterolateral fusion L4-S1. Discharge Condition: Stable, Patient alert orientd and tolerating oral diet. Discharge Instructions: You have undergone the following operation: Lumbar anterior and posterior fusion with instrumentation. Immediately after the operation: - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. o Limit any kind of lifting. - Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. - Brace: You may have been given a brace. This brace is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. - Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Follow up: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. o We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Ambulation with assitance, Gait training. Stair climbing. Treatments Frequency: Physical therapy every day to make the patient self ambulatory. Steri strips to fall off on their own. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3736**] Date/Time:[**2183-12-31**] 2:15 Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2183-12-31**] 1:55 Completed by:[**2183-12-22**]

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icd9cm

[ [ [] ] ]

[ "78.69", "81.62", "38.93", "84.52", "81.08", "84.51", "80.51", "03.09" ]

icd9pcs

[ [ [] ] ]

5727, 5774

3068, 3937

796, 1320

6031, 6089

2470, 3045

8663, 8987

4229, 5704

5795, 6010

3963, 4206

6113, 6216

2284, 2451

8455, 8513

8535, 8640

7953, 8437

6250, 6460

242, 758

6948, 7941

1348, 1993

2015, 2269

11,043

153,424

1687

Discharge summary

report

Admission Date: [**2151-11-22**] Discharge Date: [**2151-12-6**] Date of Birth: [**2091-4-15**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 60-year-old man with a known history of congestive heart failure secondary to ischemic cardiomyopathy status post PTCA and CABG and EIV pacer. Patient has past medical history significant for type 2 diabetes and chronic renal failure. Patient was in his usual state of health (stable NYHA Class IIIb) until [**2151-10-26**] when he underwent surgery for incarcerated ventral hernia. He was D/C'd on Prandin 0.5 t.i.d. with meals. On [**2151-11-16**], the patient had an episode of hypoglycemia requiring admission to [**Hospital3 **], and was D/C'd from [**Hospital3 9717**] off all glycemic agents. Patient's PCP, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] started Glipizide 2.5 for consistently elevated serum glucose levels. On date of admission, the patient awoke diaphoretic with shortness of breath. His finger glucose at that time was measured to be 50. In the [**Hospital1 188**] ED, he received 3 amps of D50 with symptomatic improvement. The patient was without chest pain, headache, nausea, vomiting. He did have increased shortness of breath. REVIEW OF SYSTEMS: Significant for increased ascites over the past five months with no pedal edema. PAST MEDICAL HISTORY: 1. Ischemic cardiomyopathy. 2. Congestive heart failure. 3. Status post non-Q-wave myocardial infarction. 4. PTCA and SVG to LAD on 10/[**2149**]. 5. Status post CABG in [**2135**]. 6. Type 2 diabetes. 7. Chronic renal failure. 8. Status post incarcerated ventral hernia and repair. 9. Status post biventricular pacer and ICD placement on 09/[**2151**]. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Aspirin 81 mg q.d. 2. Lasix 80 mg p.o. b.i.d. 3. Plavix 75 mg q.d. 4. Lipitor 30 mg q.d. 5. Tylenol #3. 6. Toprol XL 100 mg q.d. 7. Lisinopril 2.5 mg p.o. q.d. 8. Glipizide 2.5 mg q.d. FAMILY HISTORY: Mother with diabetes and coronary artery disease. Father with coronary artery disease. SOCIAL HISTORY: The patient denies tobacco or alcohol consumption. The patient lives with his wife and two daughters. ADMISSION LABORATORIES: WBC 6.6, hematocrit 30.3, platelets 192. Chem-7 is significant for hyponatremia and hypoglycemia with sodium 129, potassium 4.7, chloride 95, bicarb 23, BUN 60, creatinine 1.6, and glucose 43. Prior studies include an echocardiogram on [**2151-10-20**] showing an ejection fraction of 15-20%, 3+ tricuspid regurgitation, and dilated right ventricle. ETT MIBI on [**4-/2151**] shows moderate septal fixed defect, moderate inferior defect which was reversible. EKG was paced at 70 beats per minute. HOSPITAL COURSE: The patient was originally admitted to the Medicine service with heart failure, Cardiology, and [**Last Name (un) **] consults. After much discussion, a consensus decision was made to take the patient for cardiac catheterization with an attempt to minimize contrast dye load. It was also suggested that the patient be started on milrinone given his decompensated CHF at the time of admission. Thus, the patient was taken on milrinone for cardiac catheterization. The findings were three vessel native coronary artery disease. Severe systolic and diastolic ventricular dysfunction with elevated right and left sided filling pressures and preserved cardiac index. It was found that the cardiac index, which was depressed, increased significantly with milrinone. There was total occlusion of the SVG to LCX graft. Total occlusion of the SVG to RCA graft. There was a patent SVG to LAD graft. In addition, a patent LIMA to diagonal graft. PA pressures were markedly elevated. The patient was then admitted to the CCU for tailored CHF therapy, and initiation of evaluation process for potential future heart transpl He was started on Natrecor and milrinone ffuture heart transmoantation.nitoring of the patient's inputs and outputs as well as his daily standing weight was obtained. The patient, [**First Name8 (NamePattern2) **] [**Last Name (un) 9718**] recommendations was started on nateglinide for his management of his diabetes. In addition, a discussion for transplant was initiated with the patient and family. The patient also underwent precardiac transplant testing which included hepatitis, HIV, and CMV serologies. Carotid and abdominal ultrasounds. Peripheral noninvasive studies and pulmonary function tests. The patient was carefully diuresed in the CCU. A Swan catheter had been placed for monitoring of the patient's pulmonary artery pressures and hemodynamics. On [**2151-12-2**], the patient underwent biventricular lead placement through a left thoracotomy for cardiac resynchronization therapy in setting of chronic NYH He tolerated this procedure well, and [**Doctor Last Name **] of chronic NYHNYHA class IIIb status despite optimal drug therapy. He was successfully extubated without difficulty. Patient was then transferred to the Medicine floor and was seen by Physical Therapy. He reported some subjective improvement. Physical Therapy was able to clear him for discharge home as he was able to perform activities of daily living. Upon discharge, extensive follow-up appointments were made for the patient. These included follow up with the Heart Failure Clinic, Device Clinic, [**Last Name (un) **] Diabetes Center, and metabolic ETT appointment. He was instructed to call the Heart Failure program if his weight increased by more than 2 pounds or if he experienced any other worrisome symptoms. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Home with services. DISCHARGE DIAGNOSES: 1. End-stage ischemic cardiomyopathy. 2. Congestive heart failure. 3. Diabetes mellitus type 2. 4. Chronic renal insufficiency. 5. SP biventricular DDD pacer for cardiac resynchronization therapy Medications and addendum will be made with the patient's medications on discharge. [**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**] Dictated By:[**Name8 (MD) 9719**] MEDQUIST36 D: [**2151-12-7**] 15:37 T: [**2151-12-8**] 06:10 JOB#: [**Job Number 9720**]

[ "412", "428.43", "250.80", "V45.82", "414.8", "428.0", "V53.32", "414.01", "403.91" ]

icd9cm

[ [ [] ] ]

[ "37.23", "37.26", "88.56", "00.13", "00.52" ]

icd9pcs

[ [ [] ] ]

1998, 2087

5693, 6236

2753, 5598

1282, 1364

157, 1262

1386, 1981

2104, 2735

5623, 5672

79,929

106,368

50815

Discharge summary

report

Admission Date: [**2173-3-20**] Discharge Date: [**2173-3-24**] Date of Birth: [**2139-3-28**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 2836**] Chief Complaint: Right leg pain, transfer from OSH r/o necrotizing fascitis Major Surgical or Invasive Procedure: none History of Present Illness: 33M with no significant PMH who punctured his leg two days ago with barbed wire after tripping and falling, later burning his legs and arms bilaterally on a space heater. The patient reports pain in his right leg that is [**11-10**] with little relief from narcotics (patient took 15 tablets of oxycodone 30mg at home). The pain is pulsatile and extends from his upper right shin to his foot. Patient is unable to bear weight on right leg. He was initially seen at [**Hospital1 **] [**Location (un) 620**], where he received vancomycin and clindamycin overnight and was given a tetanus shot. He was transferred to [**Hospital1 18**] after threatening to sign out AMA. In the [**Location (un) 620**] ED, the patient received vancomycin and clinda, he then received Zosyn at [**Hospital1 18**]. He has received Dilaudid for pain control with little effect. Past Medical History: Past Medical History: - Attention deficit disorder - Substance abuse Past Surgical History: - None Social History: Current smoker. Social alcohol use. History of snorting heroin, but no IVDU. Family History: Paternal grandmother with DM Physical Exam: On admission: Vitals: Tm/Tc 97.8, HR 81, BP 148/65, RR 18, O2 100% on RA GEN: A&O (per nurse was difficult to arouse earlier), wincing in pain HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: LLE with 2 cm healing, non-draining second-degree burn on anterior shin. RLE with circumferential edema of crus, 1+ pitting edema of foot. Poorly-demarcated erythema now extending beyond border marked earlier, extending from just below knee to ankle. Multiple 1cm x 1cm scabs and 4cm x 3cm healing, non-draining second-degree burn on upper shin. Dorsalis pedis pulses intact bilaterally. Full ROM and strength in both LE and feet. On discharge: VS: 98.1 52 (ranging 50's to low 60's) 127/62 18 98%A GEN: A&O, NAD CHEST: Lung sounds CTAB, bradycardic normal S1S2, no murmurs/rubs/gallops ABD: Soft, nontender, nondistended, +BS EXTR: LLE with multiple healing scabs 1cm x 1cm, 4cm x 3cm healing, nondraining. Very minimal errythema, inside previously outlined area. Minimal edema LLLE, +DP and TP pulses, full ROM and strength in bilateral LE. Pertinent Results: [**2173-3-20**] RLE CT: Extensive soft tissue thickening and edema consistent with cellulitis. No evidence of necrotizing fasciitis. No abscess formation. [**2173-3-22**] RLE US: No evidence of deep vein thrombosis in the right leg. Superficial thrombophlebitis is seen in the greater saphenous vein in the right calf. [**2173-3-22**] LUE US: No evidence of deep vein thrombosis in the left arm. [**2173-3-20**] 08:01AM WBC-6.6 RBC-4.02* HGB-12.1*# HCT-34.8*# MCV-87 MCH-30.1 MCHC-34.8 RDW-12.7 [**2173-3-20**] 08:01AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2173-3-20**] 08:01AM PLT SMR-NORMAL PLT COUNT-223 [**2173-3-20**] 08:01AM SED RATE-20* [**2173-3-20**] 08:01AM CRP-20.7* [**2173-3-20**] 08:01AM GLUCOSE-102* UREA N-10 CREAT-0.6 SODIUM-137 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-13 [**2173-3-20**] 08:05AM LACTATE-1.3 Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**2173-3-20**] under the acute care service for monitoring and management of his RLE cellulitis. A CT scan was obtained in the ED (see pertinent results for details) which showed no evidence of necrotizing fascitis. He was hemodynamically stable and was admitted to the surgical floor for monitoring and IV antibiotics. He was started on IV antibiotics empirically. The wound was monitored closely and showed significant evidence of improvement in errythema. He remained afebrile. Given his history of substance abuse, his pain level was routinely assessed and he was administered appropriate amounts of pain medications as needed. He was started on a clonidine patch as well. However, on HD#3 he ingested his clonidine patch because he reports he was in severe pain and his heart was racing. He became bradycardic to the 20's and 30's without hypotension and was given activated charcoal with NG tube lavage and transferred to the trauma ICU for monitoring. While observed in the trauma ICU, Mr [**Known lastname 105674**] bradycardia slowly resolved. By the afternoon his heartrate was in the low 50's and it had been 24 hours since the clonidine ingestion so he was deemed appropriate for floor transfer. During his stay there, a palpable cord in his RLE was identified, as well as an indurated/cord-like area of his LUE, so doppler exams were performed on each which showed no evidence of DVT. Chronic pain and psychiatry consults were both obtained. At that time, Chronic Pain recommended oxycodone 15mg TID based on his reported outpatient usage of 45-60mg TID. He was given one dose of methadone 20mg on [**2173-3-23**] with the understanding it would not be continued. After it was determined his cardiovascular measures were stable and he was tolerating PO intake, he was transferred back to the floor. On the floor he remained afebrile and hemodynamically stable with a HR in the 50's. He remained alert and oriented. His RLE cellulitis continued to improve. On [**2173-3-24**] he is afebrile, hemodynamically stable without leukocytosis. He is out of bed ambulating independently as tolerated. He is being discharged with a 2 week course of Bactrim for MRSA coverage for his cellulutis and a limited prescription for oxycodone until he follows up with his primary care provided on [**2173-3-30**]. Medications on Admission: Adderall 30 mg PO BID Discharge Medications: 1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): do not exceed > 4 gm of aceaminophen in 24 hours. 3. oxycodone 15 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*19 Tablet(s)* Refills:*0* 4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 6. Adderall 30 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: 1. Cellulitis of the right lower extremity 2. Clonidine ingestion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with an infection in your skin of your right leg. You have been treated with antibiotics and the infection is stable. You are being discharged home with a presciption for two more weeks of antibiotics. Please take the entire course of antibiotics as prescribed. You are being discharged on narcotic pain medication to control your pain. It is important to take this medicine as directed. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. If you are experiencing no pain, it is okay to skip a dose of pain medicine. Constipation is a common side effect of narcotics. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. Do not drink alcohol or drive/operate heavy machinery while taking narcotics. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Followup Instructions: Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER When: TUESDAY [**2173-3-30**] at 12:00 PM With: [**First Name8 (NamePattern2) 247**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Completed by:[**2173-3-26**]

[ "305.50", "300.00", "891.1", "972.6", "945.24", "724.2", "682.6", "305.60", "338.29", "E920.8", "E950.4", "E924.8", "427.89", "314.01", "305.1" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

6764, 6770

3685, 6042

330, 337

6880, 6880

2743, 3662

8980, 9397

1465, 1496

6114, 6741

6791, 6859

6068, 6091

7031, 8957

1343, 1352

1511, 1511

2325, 2724

232, 292

365, 1228

1526, 2311

6895, 7007

1272, 1320

1368, 1449

7,756

136,760

49916

Discharge summary

report

Admission Date: [**2146-2-19**] Discharge Date: [**2146-2-27**] Date of Birth: [**2059-9-19**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 2195**] Chief Complaint: gasteroenteritis, ?GIB, hypotension Major Surgical or Invasive Procedure: CVL History of Present Illness: Mr. [**Known lastname 19896**] is a 85 year old male with PMH intracranial hemorrhage with right-sided residual weakness, HTN, HLD, anemia, CKD, dementia who presents with fever. Wife states that he was complaining of abdominal pain 5-6d prior, which resolved on its own after 2 days. She felt that he was excessively tired ever since he was put on Keppra for a new-onset seizure that he suffered 1 month prior. Per nursing home report, Pt had fever of 103.7F. Pt was found lying a large pool of dark brown stool. Apparently reported vomiting x 1. No melena noted, no stomach pain. Patient did not have any complaints but has [**Known lastname 5348**] dementia. Prior to transport, Pt's vitals at nursing home were T 103.7, HR 117, R 20, BP 108/61, O2 Sat 90% on RA. He is full code per ED resident report (confirmed). On route, EMS reported that the patient was initially unresponsive. However upon questioning in the ED, the EMS denies such history. . In the ED inital vitals were temp 100.0F, hr 107, bp 137/80, rr 21, sat 97% ra. Pt's BP gradually decreased to 78/36 over 3.5 hrs at 12.50p, then 68/35 on re-test. Central line was placed, and Pt was given 4L NS, with improvement in BP to 133/59. On exam he was noted to have guaiac positive brown stool. Labs showed lactate 2.7, Na 146, Cr 1.8 ([**Known lastname 5348**] Cr 1.5-1.6), WBC 9.1 with PMN's 90.2%, Hct 37, plts 102, Coags normal, UA was negative. Cultures were sent. LFT's were unremarkable. CTAP showed no acute issues. He was initially placed on Cipro/Flagyl for concern for bowel source. NGL showed feculent material with small amounts of blood. No evidence of obstruction from CT, and therefore NGT pulled out. GI was consulted and recommended protonix gtt and plan to likely scope tomorrow. Surgery was consulted as well, and thought exam and CT were non-concerning. He had BP drop to 50s? around noon, and left IJ was palced for access. Levophed was drawn up, but never used, as pt was fluid responsive. He was given 3.5L NS with improvement in BP. Lactate improved to 1.4. Access left IJ, 2 20's PIV's. He had Tmax 101.2. VS prior to transfer T 99.2 HR 82 133/59 RR 16 91% 3LNC. . On arrival to the ICU, Pt's vitals were 99.2F, BP 145/71, Hr 96, RR 20, Sat 93% ra -> 94% 2L nc. . Pt was recently admitted in [**11/2145**] for preseptal cellulitis from [**Date range (1) 78748**]. That hospitalization was complicated by acute renal failure and UTI. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Status post right intracranial hemorrhage in [**2127**] with residual left-sided hemiparesis 2. Hypertension 3. Hypercholesterolemia 4. Falls 5. Chronic bilateral shoulder and hip pain 6. Chronic low back pain secondary to degenerative joint disease and spinal stenosis 7. Emphysema on imaging 8. Osteoporosis - The patient is on a bisphosphonate, calcium, and vitamin D. 9. Median neuropathy on the right- S/P surgery [**2142-9-21**]. 10. Anemia 11. BPH 12. Depression 13. Vascular dementia 14. thrombocytopenia of unknown source noted in [**10/2145**] 15. C7 spinous process fracture 16. Small 3rd ventricular hemorrhage in [**1-/2145**] . PAST SURGICAL HISTORY: 1. Bilateral cataract surgery. 2. Bilateral rotator cuff repair. 3. Repair of cartilage of the left knee. 4. Left mastoid surgery as a child. 5. Right pronator tendonotomy, lengthening, and right carpal tunnel release [**2142**]. Social History: Married, 2 adult daughters Retired - used to run a butcher shop Smoked 1-2ppd x30 years Former 1 glass/day alcohol, now abstinent x years [**Year (4 digits) **] MS AOX2, Forgetful but can carry on a conversation. Walks with a walker. Temporarily living in a [**Hospital1 1501**] ([**Hospital3 2558**] in [**Location (un) **], MA) because of frequent, unexplained falls at home. Family History: Mother - died of cancer in her 70's Father - died of an MI in his 60's No seizure hx No stroke hx Physical Exam: Admission Exam: Vitals: T: 100.6F, HR 86, BP 161/67, RR 20, Sat 95% 2L NC. General: Sleepy, oriented x1, no acute distress, no pain [**Location (un) 4459**]: Sclera anicteric, oropharynx dry Neck: supple, JVP not elevated, no LAD Lungs: no use of accessory muscles, bibasilar inspiratory crackles CV: Distant heart sounds, 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 present Ext: warm, well perfused, 2+ pulses in upper extremities, cool and difficult to assess pulses in bilateral lower extremities. Neuro: A&O to person, knows wife, following commands, does not state date or location, moving all extremities Discharge: VS- Tc 98.4 BP 153/76 HR 67 RR 20 98% RA Gen: Elderly man in NAD. Oriented to person and place, not time [**Location (un) 4459**]: PERRL, EOMI. MMM, OP benign. Neck: Supple, no JVD. No cervical lymphadenopathy. No carotid bruits noted. CV: RRR with normal S1/S2, holosystolic murmur best heard at RUSB Chest: Course crackles at right base Abd: +BS, soft, NTND. Ext: WWP, no edema. 2+DP/PT b/l Pertinent Results: Admission labs: WBC-9.1 RBC-4.35* HGB-11.9* HCT-37.0* PLTS 102 NEUTS-90.2* LYMPHS-6.8* MONOS-2.2 EOS-0.1 BASOS-0.7 PT-11.4 PTT-32.7 INR(PT)-1.1 LACTATE-2.4* ALT(SGPT)-21 AST(SGOT)-26 ALK PHOS-65 TOT BILI-0.5 LIPASE-25 URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE EPI-0 . Pertinent labs: TEST RESULT ---- ------ HEPARIN DEPENDENT ANTIBODIES POSITIVE (HIT test positive) Serotonin release assay PENDING On discharge: [**2146-2-27**] 07:15AM BLOOD WBC-3.7* RBC-3.09* Hgb-8.4* Hct-25.5* MCV-83 MCH-27.1 MCHC-32.8 RDW-13.3 Plt Ct-106* [**2146-2-27**] 07:15AM BLOOD Glucose-98 UreaN-20 Creat-1.4* Na-141 K-4.3 Cl-105 HCO3-27 AnGap-13 [**2146-2-27**] 07:15AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.2 [**2146-2-19**] 03:36PM BLOOD Lactate-1.4 Microbio: FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Pending): FECAL CULTURE - R/O E.COLI 0157:H7 (Pending): CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2146-2-27**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Blood cultures: Negative URINE CULTURE (Final [**2146-2-25**]): NO GROWTH. CXRay [**2-24**]: Right basilar opacification c/w aspiration. Cannot r/o infection. CXay [**2-26**]: Resolution of right basilar opacification Brief Hospital Course: Mr. [**Known lastname 19896**] is a 86 yo M w/ PMH intracranial hemorrhage with right-sided residual weakness, HTN, HLD, anemia, CKD, dementia who presented with fevers, vomiting, and diarrhea with course complicated by acute on chronic thrombocytopenia and persistent fevers. . # Hypotension: Patient was admitted to the ICU with hypovolemic shock. Blood pressure improved with fluid resuscitation. Volume loss was due to vomiting and diarrhea for 3 days prior to admission, and potential sepsis. Vomiting/diarrhea was attributed to viral gastroenteritis. Patient was initially on cipro/flagyl given instability, which was discontinued on transfer to the floor. Pressures were stable to elevated throughout the remainder of admission. . # Fevers: On admission, patient had three days of vomiting and diarrhea, concerning for gastroenteritis. U/A on admission did not show signs of infection and CXR was clear. Patient was initially on ciprofloxacin/metronidazole as he was unstable to empirically treat bacterial gastroenteritis. Patient continued to have low grade fevers on transfer to the floor. On HD3, patient spiked a fever to 101.2. Urinalysis showed moderate bacteria, with 13 WBCs, +nitrites. Patient's foley catheter was removed and he was started on ciprofloxacin as he had pan-sensitive e.coli in the past. CXR at that time showed mild consolidation in the right lower lobe. Overnight on HD3, patient again spiked a fever up to 102.6. Repeat CXR showed increased density in the right lower lobe. Antibiotics were broadened to treat health-care acquired pneumonia with vancomycin and piperacillin-tazobactam. There was also concern for aspiration pneumonitis vs pneumonia given patient's dementia and debilitated state. He was evaluated by speech & swallow who saw no overt signs of aspiration, but recommend ground solids/thin liquid diet. Video swallow also showed no signs of silent aspiration. Patient continued to spike fevers, therefore it was felt that he was likely aspirating given RLL consolidations which rapidly resolved, consistent with pneumonitis. He was changed to a pureed solid/nectar thick liquid diet and tolerated this well. . # Thrombocytopenia: On admission, as above, patient's CBC was significantly hemoconcentrated and showed platelets of 100, dropping to 60s following volume resuscitation. Patient has a history of thrombocytopenia, followed by hematology as an outpatient, which has been attributed to chronic illness and potentially medication effect. However, platelets always returned to low-normal. Platelets dropped to as low as 46 during this admission which was concerning for HIT. HIT antibody was positive, and patient was started on argatroban drip. Hematology was consulted to help better evaluate likely underlying cause of thrombocytopenia. Further information from HIT antibody revealed an optical density of 0.55, only weakly positive so low probability of being true positive. In addition, time course did not fit well with HIT. Peripheral smear showed evidence of abnormal WBCs and nucleated RBCs concerning for MDS. Hematology recommended outpatient management of the MDS with patient's primary hematologist, Dr. [**Last Name (STitle) 3759**]. Argatroban was discontinued in light of new information, and patient was placed on fondaparinux for DVT prophylaxis, however given decreased renal function this was stopped and patient was placed on mechanical DVT prophylaxis. A serotonin release assay was sent as confirmatory test of HIT. This was pending at the time of discharge. If it returns negative for HIT, the patient can safely receive heparin agents in the future. . # Acute on chronic renal failure: [**Last Name (STitle) **] Cr 1.5-1.6. Bumped to 1.8 on admission in setting of hypovolemia, but was responsive to fluid resuscitation. Creatinine remained around [**Last Name (STitle) 5348**] throughout the remainder of admission. Medication was renally dosed given low GFR of approximately 30. Losartan was held throughout admission, and hydrochlorothiazide was discontinued prior to discharge. . # HTN: On admission, amlodipine 10mg daily, hydrochlorothiazide 25mg daily, aliskiren 300mg daily, losartan 100mg daily were all held in the setting of hypotension. Amlodipine was restarted following volume resuscitation once patient became hypertensive. Losartan was reintroduced into the patient's regimen at discharge. Hydrochlorothiazide and aliskerin are still being held. . # Dementia: Remained at [**Last Name (STitle) 5348**] throughout admission, per report of wife. Continued [**Name2 (NI) **] (memantine) 10mg daily. . # Guaiac positive stool: Patient had guaiac positive stool on admission, and throughout admission. However, his hematocrit remained stable. Of note, initial CBC was significantly hemo-concentrated, as with fluid resuscitation, all cell lines returned to their normal [**Name2 (NI) 5348**] and remained stable at this level. Initial 10 point hematocrit drop was therefore not attributed to bleeding. He was evaluated by GI who felt that he did not need emergent colonoscopy, and should follow-up with GI as an outpatient. Patient has known history of polyps and diverticula on last colonoscopy in [**2143**]. # HIstory of seizure: Recent admission for witnessed seizure at rehab, placed on keppra and pyridoxine. [**Name (NI) **] wife was concerned about the sedating effect of the keppra. Outpatient neurologist reiterated the importance of continue anti-seizure medications, and felt that other options might be more sedating. Patient was continued on keppra at outpatient dose and has neurology follow-up scheduled to further discuss this medication with patient and his family. . # Hx CVA: Aspirin and statin were continued throughout admission. . # Transitional issues: - serotonin release assay is still pending to confirm true heparin allergy - blood, urine cultures pending at the time of discharge - f/u scheduled with neurology, hematology, and GI - Alter blood pressure regimen as necessary Medications on Admission: amlodipine 10mg daily aspirin 81mg daily ferrous sulfate 325mg daily hydrochlorothiazide 25mg daily omega 3,6,9 1200 capsule [**Hospital1 **] KCl 10mEq qam and 20mEq qpm daily losartan 100mg daily multivitamin 1 tab daily [**Hospital1 **] (memantine) 10mg daily calcium-vitD 500-200 x 2 tabs daily simvastatin 20mg daily aliskiren 300mg daily vitamin b-6 pyridoxine 100mg daily vit d3 400 IU daily levetiracetam 500mg [**Hospital1 **] Discharge Medications: 1. memantine 10 mg Tablet Sig: One (1) Tablet PO daily (). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. pyridoxine 100 mg Tablet Sig: One (1) Tablet PO once a day. 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Omega 3-6-9 1,200 mg Capsule Sig: One (1) Capsule PO twice a day. 11. Calcium-Vitamin D 600 mg calcium- 400 unit Tablet Sig: One (1) Tablet PO once a day. 12. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Gastroenteritis 2. Thrombocytopenia 3. Myelodysplastic syndrome 4. Pneumonia SECONDARY DIAGNOSIS: # Dementia # Hypertension # History of seizure # History of stroke # History of intracranial hemorrhage Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 19896**], It was a pleasure taking care of you during your recent admission to [**Hospital1 18**]. You were admitted because of vomiting and diarrhea causing your blood pressure to be very low. You were given fluids and your blood pressure improved. Your vomiting and diarrhea improved on their own with time. In addition, during the admission, you had inflammation in your lung which was thought to be due to food going down the wrong route, into your lung. Your diet was altered to help prevent this. The following changes were made to your medication regimen: - STOP aliskiren - STOP HCTZ Followup Instructions: Department: NEUROLOGY When: WEDNESDAY [**2146-3-2**] at 4:00 PM With: DRS. [**Name5 (PTitle) **] & [**Last Name (un) 20497**] [**Telephone/Fax (1) 3506**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: GASTROENTEROLOGY When: TUESDAY [**2146-3-15**] at 12:45 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6970**], MD [**Telephone/Fax (1) 463**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: HEMATOLOGY/BMT When: TUESDAY [**2146-3-15**] at 2:30 PM With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2146-3-15**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

14728, 14798

7306, 13105

312, 317

15076, 15076

5872, 5872

15909, 17210

4570, 4670

13841, 14705

14819, 14819

13382, 13818

15260, 15886

3928, 4159

4685, 5853

6457, 7283

2791, 3238

236, 274

345, 2772

14944, 15055

5888, 6241

14838, 14923

15091, 15236

6263, 6443

13128, 13356

3260, 3905

4175, 4554

6,268

175,664

26837

Discharge summary

report

Admission Date: [**2128-1-3**] Discharge Date: [**2128-1-27**] Date of Birth: [**2081-11-3**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 4219**] Chief Complaint: 46 M w/ h/o metastatic colorectal CA with widespread mets including spinal mets w/ h/o radiographic cord compression at T5 p/w sensation/sensory changes below the nipple line corresponding to the T5 level, and progressive lower extremity weakness. Major Surgical or Invasive Procedure: 1. Transpedicular decompression, T5 and L1. 2. Multiple thoracic laminotomies. 3. Fusion of T1 to L3. 4. Segmental instrumentation T1 to L3. 5. Autograft. 6. Epidural catheter placed. History of Present Illness: 46 M with h/o metastatic colorectal CA and prior radiation to the spine who has sudden onset of sensation changes from the nipple level down and loss of ability to ambulate after a fall. Prior to this the patient was ambulating with a cane and assistance. Pt was admitted to [**Hospital6 204**] and spine MRI was performed, whose images we have reviewed. There is a dominant lesion at approximately T5 in the right posterior/lateral pedicle and invading into the spinal cord. There are areas of metastatic disease throughout the spine. Per patient report, he and neurosurgery were hesitant to operate because of his low platelet count previously. Patient was transferred to [**Hospital1 18**] for further management. Of note, the patient had already received ~4000cGy to the T5 spine and his cervical, lumbar, and S1 levels. He received cyperknife to L1 level late [**7-14**]. Past Medical History: --Metastatic Colon CA with extensive bony metastases to his spine, ribs, left humerus, right humerus (dx [**2123**]). --- s/p XRT --- s/p stereotactic cingulotomy. --- s/p Cyberknife treatment(at [**Hospital1 18**]) at L1 --- s/p Avastin and 5-fluorouracil treatment. Followed by Radiation Oncology at [**Hospital6 204**](Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] -- Falls -- s/p humeral fracture (bilat) s/p ORIF -- Thrombocytopenia (platelet count on admit [**12-31**] to LGH 12) -- Ulcerative colitis Social History: Married w/ 3 children, former home constructor, no tob, rare ETOH. His children are 18,11,7. He has a great support system at home. Family History: GM with breast CA GF with skin CA Physical Exam: On arrival to [**Hospital1 18**] 97.5 110/70 70 20 97% RA patient lying in bed in NAD OP clear without evidence of bleeding or oral lesions neck supple Regular nl S1 S2 no MRG CTA bilaterally soft NT/ND +BS colostomy site c/d/i no HSM +staples along left humerus with bruising down left arm to hands, no swelling, staple site c/d/i Upper extremity strength 5/5 bilaterally LE weak bilaterally Decreased sensation to light touch below the nipple level Pertinent Results: Imaging: [**2128-1-20**] RUQ U/S - Limited study. Multiple likely metastatic lesions in the liver. No biliary ductal dilation. Gallbladder suboptimally visualized, but no evidence to suggest cholecystitis. [**2128-1-20**] CT Head - Probable metastatic lesions bilaterally in the deep frontal white matter. See prior MRI with gadolinium for better assessment. Multiple lytic and sclerotic lesions involving the skull, skull base, and cervical spine, highly suspicious for metastases. [**2128-1-20**] CXR - Lungs clear. Heart size normal. There is no pleural effusion. Expansile left lower posterior rib and pleural thickening around healed left lateral rib fracture are unchanged. Spinal stabilization rods in place. [**2128-1-20**] MRI - Skull base metastatic foci, including a locale adjacent to the right trigeminal ganglion. Status-post cingulotomies, but no evidence for brain parenchymal metastases Cultures: [**2128-1-19**] Blood - pending [**2128-1-19**] Urine - contaminated [**2128-1-19**] Blood - pending [**2128-1-17**] Blood - no growth [**2128-1-17**] Urine - enterococcus [**2128-1-19**] Blood - NGTD [**2128-1-19**] Urine - NGTD Brief Hospital Course: At [**Hospital6 204**], lumbar CT scan showed diffuse osteopenia and lesions at L4-5 with compression fracture at L1 and fracture at L5. He reportedly had a T5 cord compression of which no reports were sent. Neurosurgery (OSH) felt he was not a good operative candidate secondary to his thrombocytopenia, he was transferred here for possible gamma knife treatment. Patient's platelet count was 12 on admission -->6 units of platelets. He has been febrile intermittently and neutropenic. He was started on tequin 400 mg IV qd for his bandemia. He continued steroids. He has required 11 units of packed red blood cells. and multiple units of platelets: good response in plt count (max 140), but not sustained. He received decadron 6mg IV q 6 hours for cord compression. Patient was taken to the OR on [**2128-1-4**] for. Multiple thoracic laminotomies, fusion of T1 to L3, segmental instrumentation T1 to L3, autograft, epidural catheter placement. Patient received ancef x 48 hours peri-operatively and Prednisone 10 q 8. Pain service was consulted for epidural management.His postoperative exam on transfer to the ICU was as follows: IP Q HS TA [**Last Name (un) 938**] GS R 4 4+ 4+ 5 5 4+ L 4 4+ 4+ 5 5 4+ SILT L2-S1 bilaterally. The epidural was d/c'd on [**1-5**]. By POD #3, patient continued to improve, was out of bed sitting in a chair and pain [**Last Name (un) 19692**] well controlled with a PCA. On POD #4 patient was fit with a TLSO brace and continued to make progress slowly with physical therapy. On [**2128-1-9**] his drains were discontinued. On [**2128-1-10**] patient was transfused 2 units of PRBC for hematocrit = 22 and symptomatic with tachycardia. On [**2128-1-11**] he was transfused 6 pack of platelets for plt=25. He recovered well until [**1-11**] when he developed SOB/CP/EKG changes and was transferred to the ICU. Trop x 3 was negative and CTA was negative. He was noted to have an epidrual hematoma and underwent I and D on [**1-12**] (POD 3). The hemovac drain was d/c'd [**1-14**] and he has had no further bleeding episodes. The patient was transferred to the medical service on [**2128-1-16**]. From a cord compression standpoint, he remained stable s/p laminectomy and epidural hematoma evacuation. His bilateral asymetrical LE motor deficits improved slowly with physical therapy. PT worked with the patient almost daily until discharge to a rehab facility. He was originally on a PCA for pain control. We were able to successfully switch the patient to a fentanyl patch with liquid oxycodone for breakthrough pain. The patient continued to complain of trigeminal neuralgia that had been worsening over the past month. A CT head was ordered to evaluate for any signs of metastatic disease. It showed numerous skull mets, but no parychemal involvement. There were skull mets close to the trigeminal nucleus but it remained unclear if this was the cause of his pain. Radiation Oncology felt there was no need for treatment at this time. The patient also had new findings of horners syndrome. A neurooncology consult was called. They requested MRI imaging of the orbits and an LP to look for spread of the cancer to the CSF. The MRI of the orbits was unremarkable. Because the patient is not currently a candidate for chemotherapy (low counts, advanced disease), he opted against the LP because it would not change our current management. He was started on neurontin for the trigeminal neuralgia but it was discontinued because it was not providing relief. Further, during his stay on the medical service, the patient continued to spike low grade fevers. He was treated with vanco and switched to levo when sensitives showed pansensitive enterococcus UTI. He was treated with a full 10 day course. He continued to spike fevers which were eventually attributed to hematoma breakdown (he had numerous large hematoma throughout his body). All cultures (other than the Urine showing enterococcus) remained negative to date. We decided to not empirically treat unless he spiked greater than 101. During the time on the medicine service he was only neutropenic for 24 hours. Because of the UTI, we removed the patients foley and gave him several voiding trials. He continued to retain ([**2-12**] effects of the cord compression) and he was discharged with a foley in place. Throughout his hospital course the patient was thrombocytopenic. He had the extensive hematoma formation at his surgical site with a platelet count of 24. Because of this, it was decided that the transfusion threshold would be to keep plts >50. His thrombocytoenia was likely multifactorial with a significant contribution from marrow suppression from XRT and chemotherapy. Other contributors include prolonged illness and drug effect. Every 2-3 days his platelets would drift to <50 and require transfusion. He will need continual platelet tranfusions at rehab and at home (will be under bridge to hospice) to keep plts>50. The patient also was anemia which again was thought to be multi-factorial from: 1) bone marrow suppression from XRT and chemotherapy (note retic=0.6) 2) anemia of chronic disease (note alb=2.8) 3) peri-operative blood loss 4) marrow infiltration by cancer (significant bony destruction on imaging, although no nucleated RBCs on smear). His threshold for transfusion was to keep hct>28. He required much less frequent PRBC transfusion than platelets. He required only 1 unit PRBC during his week on the medical service. His hct will need to be checked every few days after discharge and transfused for hct<28. There was concern that the patient might have been hemolyzing because his labs showed an elevated LDH, low haptoglobin, and increased bilirubin. His hct remained relatively stable and his LDH slowly trended down. The LDH was attributed to hematoma breakdown (hematomas on left arm and right flank). Because the patients TBil continued to rise, a RUQ U/S was obtained and showed multiple liver mets. The primary oncologist confirmed that these lesions were new. He showed no signs of biliary obstruction. The patient will follow up after discharge with his primary oncologist at [**Hospital3 **] for further treatment. Because of the new metastatic disease that was identified in the skull and liver, we consulted [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] to discuss hospice care. The patient was made aware that his disease had progressed and there may not be any further treatement available. He understood and continued to want aggressive management. He expressed his desire to get stronger at rehab and get home to his family. He remained full code throughout his hospital admission. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] contact[**Name (NI) **] the patients [**Name (NI) 269**] service at home and his nurse is a hospice nurse. The patient will leave rehab with bridge to hospice so that he can continue transfusion and other treatment options. Medications on Admission: Dilaudid Oxycodone 30mg PO q4Hr Bowel regimen PRN Prednisone 4mg PO daily Zofran PRN Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q3H (every 3 hours) as needed for pain. 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q3H (every 3 hours) as needed for pain. 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 8. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane QID (4 times a day). 11. Fentanyl 100 mcg/hr Patch 72HR Sig: Two (2) Patch 72HR Transdermal Q72H (every 72 hours). 12. Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea 13. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: One (1) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 **] OF [**Hospital1 **] Discharge Diagnosis: # Metastatic colon cancer to the spine and paraparesis. # Cord Compression s/p laminectomy ([**1-3**]) # Epidural Hematoma s/p evacuation ([**1-11**]) # Colorectal Cancer with known bony mets and new Liver and skull Mets # Horner's syndrome: (patient defers LP to look for malignant etiology as not currently a chemo candidate) # Pancytopenia: ([**2-12**] large doses of chemo + XRT) # Neutropenia # Intra-hepatic cholestasis: [**2-12**] liver mets # Trigeminal Neuropathy: skull bony mets may be etiologic # Urinary retention # Pain Syndrome # HTN # Enterococcus UTI # Hyponatremia Discharge Condition: stable, progressing with physical therapy Discharge Instructions: **[**Name8 (MD) 138**] M.D. for redness or drainage from wound, breakdown of wound, fever, severe headache, change in neurological status, dizziness, weakness, sensory changes, questions or concerns. **Please take all medications as prescribed. Followup Instructions: **Follow-up with Dr. [**Last Name (STitle) 363**] in the orthopaedic spine surgery clinic within 1 week of leaving rehab. Please call clinic to schedule [**Telephone/Fax (1) 1228**]. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 66052**] Call to schedule appointment **Please followup with Dr.[**Last Name (STitle) 26683**] within 1-2 weeks of leaving rehab. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]

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icd9cm

[ [ [] ] ]

[ "03.09", "81.05", "99.05", "99.07", "03.02", "81.64" ]

icd9pcs

[ [ [] ] ]

12341, 12404

4026, 11076

519, 705

13031, 13075

2851, 4003

13368, 13883

2330, 2365

11211, 12318

12425, 13010

11102, 11188

13099, 13345

2380, 2832

232, 481

733, 1612

1634, 2162

2178, 2314

72,940

197,461

36045

Discharge summary

report

Admission Date: [**2166-4-10**] Discharge Date: [**2166-4-15**] Date of Birth: [**2098-9-8**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: Bilateral aorto-iliac disease Major Surgical or Invasive Procedure: Aortobifemoral bypass. History of Present Illness: Mr. [**Known lastname 37742**] is a 68-year-old gentleman who is severely limited in daily activities by his peripheral vascular disease. He is only able to walk approximately 20 yards before he has very painful claudication. Past Medical History: PMH: Chol, DM PSH: s/p Tonsillectomy Social History: He is married with two grown children. He continues to smoke but does not drink. He works as a manager at the [**Location (un) **] Airport. Family History: Father with CAD Physical Exam: On discharge: VS T 98.5 HR 88 BP 158/72 RR 18 98% O2 saturation on ra gen: A&O x 3 CVS: RRR no m/r/g/ Pulm: clear bilaterally Abd: S/NT/ND, Well healing abdominal surgicla site without erythema or induration with staple in place Groin: Bilateral groin wound C/D/I with staple in place Ext: WWP Pul: DP PT R D D L D D Pertinent Results: [**4-15**]: TTE: Normal regional and global biventricular systolic function. [**2166-4-15**] 05:37AM BLOOD WBC-7.7 RBC-3.38* Hgb-10.6* Hct-30.0* MCV-89 MCH-31.2 MCHC-35.2* RDW-15.0 Plt Ct-157 [**2166-4-10**] 08:00PM BLOOD WBC-11.6* RBC-3.40*# Hgb-10.9* Hct-30.4* MCV-89 MCH-32.2* MCHC-36.0*# RDW-13.8 Plt Ct-169 Brief Hospital Course: [**2166-4-10**]: Pt admitted to the vascular service for aortobifemoral bypass. As the incision was being closed the patient went into a rapid V-tach. This was stopped with cardioversion. He went into it 1 more time which was again stopped with cardioversion. Intraoperative transesophageal echocardiogram showed what looked to be a decreased ejection fraction of apical ventricle. The patient did stay in sinus rhythm for the rest of the closure. He was transferred to the ICU still intubated. Cardiology was consulted. Pt was observed overnight in the ICU without further incident. Epidural was capped and pain control with IV medications. Beta blockade started for HR control as tolerated by patient's BP. hemodynamic monitoring achieved with PA catheter and a line. Foley in place. [**2166-4-11**] PT was extubated in the a.m. Pt was started on Plavix after epidural removed at the recommendations of cardiology. He was kept NPO. Electrolytes replaced as necessary. PTS tropon ins were followed with slight bump c/w demand ischemia from hypotension intra op. Pt also had increase in his Creatinine which trend ed down over the course of his stay and was thought to be due to ATN. DM was managed with insulin GGT. PT was started on vancomycin for wound erythema. [**4-12**] -[**4-13**] Pt was transferred to the VI CU. His swan catheter was exchanged to a triple lumen CVL. PT consulted. PT did well over the weekend. Diet was advanced to clears. PT was transfused a total of 3 units of blood to keep HCT at 30 given cardiac issues. [**4-14**] Foley removed at midnight with normal voiding. CVL discontinued. HCT stable at 30. Patient cleared by physical therapy for home.Vancomycin discontinued. Will be discharged on metoprolol, Plavix per cardiology. His metformin was held for Cr on 1.8 with follow up scheduled with PCP for further DM management. PT will follow up with Dr. [**Last Name (STitle) 1391**] in 2 weeks for staple removal. Medications on Admission: Meds: Metformin 1000mg [**Hospital1 **], Actos 30mg daily, Simvastatin 80mg daily, ASA 325mg daily. Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:*30 * Refills:*0* 3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*35 Tablet(s)* Refills:*0* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Outpatient Lab Work Please draw chem 10. Discharge Disposition: Home Discharge Diagnosis: [**Hospital1 **]-iliac Vascular disease. Discharge Condition: VSS, tolerating a regular diet, pain well controlled on PO meds, ambulating. Discharge Instructions: Continue plavix for 9 months per cardiology reccomendations. Please follow up with cardiology for further recs. Incision Care: Keep clean and dry. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. -If you have staples, they will be removed during at your follow up appointment. . Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([**11-6**] lbs) until your follow up appointment 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 [**2-25**] 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 to schedule appointment with Dr [**Last Name (STitle) 1391**] ([**Telephone/Fax (1) 29063**] in 2 weeks for post procedure follow up and staple removal. Please call Dr [**First Name (STitle) **] [**Name (STitle) 1911**] ([**Telephone/Fax (1) 9410**] to schedule follow up at [**Hospital3 **]. Please follow up with Dr. [**Last Name (STitle) 1159**] ([**Telephone/Fax (1) 1160**] Friday, 1:45 pm [**4-18**]. Please get your blood drawn prior to arrival at [**Hospital6 **]. Completed by:[**2166-4-15**]

[ "276.2", "427.1", "E849.7", "272.0", "E878.2", "997.1", "440.21", "250.70" ]

icd9cm

[ [ [] ] ]

[ "88.72", "38.93", "99.69", "39.25" ]

icd9pcs

[ [ [] ] ]

4516, 4522

1589, 3548

344, 369

4607, 4686

1251, 1566

9303, 9822

859, 876

3698, 4493

4543, 4586

3574, 3675

4710, 4823

8896, 9280

4839, 8870

891, 891

905, 1232

274, 306

397, 625

647, 685

701, 843

17,857

141,869

10276

Discharge summary

report

Admission Date: [**2131-4-4**] Discharge Date: [**2131-4-12**] Date of Birth: [**2065-6-28**] Sex: M Service: MEDICINE Allergies: Oxycontin Attending:[**First Name3 (LF) 1865**] Chief Complaint: hypotension, GI bleeding Major Surgical or Invasive Procedure: intubation bronchoscopy History of Present Illness: This is a 65 year old man with a history of colon cancer metastatic to lung, liver, abdominal wall, and ureter who presents with N/V, hypotension. History is obtained from the patient's daughter and from the medical record. According to the daughter, the patient had been having N/V for several days and she was worried that he was becoming dehydrated. Apparently today he was less alert and had decreased urine output. His BP at home was 70/40 and he appeared to be having trouble breathing. He was also having trouble swallowing his pills, due to being more somnolent. . In the ED, VS: 99.9, HR 130s, SBP 60s, O2sat not initially recorded, but per ED resident 70s-80s. He was reportedly unresponsive at that time. R groin cordis was placed emergently due to inability to obtain BP. Patient was intubated due to concern that he was aspirating on bloody emesis. OGT placed, immediately post intubation, draining 2500cc dark red blood, which did not clear with lavage. Rectal revealed guaiac + brown stool. He was started on IVF (5L NS) and levophed and dopamine. L IJ was later placed for additional access. He was transfused 3U PRBC and 2U FFP. He was also given vitamin K and protamine (to reverse lovenox), as well as protonix IV. He was given vancomycin and ceftriaxone. . His abdomen was noted to be rigid (in the setting of known extensive mets and GI bleed), so he underwent CT abdomen/pelvis (in addition to CTA chest). He was then transferred to the MICU for further management. GI was also made aware of the patient. Past Medical History: PAST ONC HISTORY: The patient initially presented in [**2125**] for evaluation of mild hematuria when a CT abd showed thickening of the sigmoid colon. A sigmoidoscopy showed a large non-bleeding mass and he underwent sigmoid colectomy which showed moderately differentiated ulcerated adenocarcinoma reaching the serosa with [**5-18**] lymph nodes were positive for metastasis. Since his initial presentation of stage III colon CA, he has progressed to metastatic disease to the lung, liver, abd wall, ureter. 1. He is status post 5-FU, leucovorin as adjuvant therapy. 2. He is status post 5-FU, irinotecan, and Avastin with disease progression. 3. Status post oxaliplatin and Xeloda. 4. He is status post Erbitux and irinotecan. 5. He is status post Avastin, 5-FU, and mitomycin. He has not received therapy in several months. He has progressed on all these therapies. 6. He developed a PE in [**9-17**] and is being anticoagulated with Lovenox daily. 7. He was recently placed on a phase 1 Reata clinical trial, which has since been held due to progression of disease. . Other PMH: 1) Metastatic colon cancer as above 2) HTN 3) Hypercholesterolemia 4) Depression 5) CRI 6) GERD Social History: Lives with wife. Smokes [**5-17**] cig/day for the past 50 yrs. Previously was a heavier smoker, up to 1 PPD. Denies EtOH, illicits, IVDA. Family History: No family h/o colon CA. Aunt with rectal CA at the age of 85. Physical Exam: VS: T 97.9, HR 102, BP 127/76, RR 18, O2sat 100% Vent: AC 600/18, PEEP 5, FiO2 100% Gen: intubated, sedated, chronically ill appearing HEENT: PERRL, ETT and OGT in place Lungs: CTA anteriorly Heart: RRR, no m/r/g Abd: +BS, firm palpable masses in epigastric and suprapubic areas. Otherwise nondistended. Rectal: guaiac + brown stool per ED Extrem: No edema, warm. Pertinent Results: admission labs: [**2131-4-4**] 07:35PM NEUTS-54 BANDS-17* LYMPHS-18 MONOS-8 EOS-0 BASOS-0 ATYPS-1* METAS-2* MYELOS-0 [**2131-4-4**] 07:35PM WBC-7.0 RBC-2.97* HGB-8.9* HCT-26.7* MCV-90 MCH-30.0 MCHC-33.4 RDW-15.4 [**2131-4-4**] 07:35PM CK-MB-7 cTropnT-0.09* [**2131-4-4**] 07:35PM ALT(SGPT)-88* AST(SGOT)-237* CK(CPK)-507* ALK PHOS-90 AMYLASE-180* TOT BILI-0.4 [**2131-4-4**] 07:43PM PH-7.19* INTUBATED-INTUBATED . reports: ct pelvis [**4-4**]: IMPRESSION: 1. Endotracheal tube tip is located at the carina. 2. Left lower lobe consolidation may reflect pneumonia. 3. No pulmonary embolism or thoracic aortic dissection. 4. Extensive metastatic disease has progressed compared to [**2131-1-12**], with increased hepatic and pulmonary metastases as well as increased right pleural disease. Abdominal wall disease appears similar. 5. Unchanged right hydronephrosis and hydroureter with multiple nodules in the right ureter suggestive of tumor. . [**4-4**] cxr: IMPRESSION: 1. Endotracheal tube and nasogastric tube in appropriate positions. 2. Persistent pulmonary vascular congestion. 3. Multiple pulmonary nodules which were better assessed on a CT chest from [**2131-1-12**]. 4. Worsening retrocardiac left lower lobe opacity could be consolidative in nature. . echo [**4-5**]: Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is moderate global left ventricular hypokinesis, without regional wall motion abnormalities. The right ventricular cavity is markedly dilated. There is severe global right ventricular 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 regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: Moderate global left ventricular systolic dysfunction. Dilated right ventricle with severe systolic dysfunction and evidence of pressure/volume overload. Moderate pulmonary hypertension. . Liver US [**4-6**]: IMPRESSION: 1) No cholelithiasis. Normal son[**Name (NI) 493**] appearance to gallbladder. No intra- or extra-hepatic biliary ductal dilatation. 2) Multiple unchanged liver metastases. Unchanged right hydronephrosis. Brief Hospital Course: 65M with metastatic colon cancer admitted with hypotension, GI bleed, pneumonia, and NSTEMI. Hospital Course described below by problems: . 1. Hypotension: Felt to be primarily secondary to sepsis. Possible septic sources included UTI and LLL pneumonia (seen on chest CT). Blood cultures and BAL came back positive for [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**]. GI bleed was felt to be a less likely etiology as his Hct was stable. Possible aspiration event prior to intubation. There may have also been a component of cardiogenic shock given biventricular dysfunction on TTE. He had no PE on CTA. He received aggressive IVF and blood products without improvement in his blood pressure. He was started on norepinephrine and vasopressin. ID was consulted for fungemia, and he was treated with caspofungin. He was also maintained on broad spectrum antibiotics. Bronchoscopy [**4-5**] ruled out endobronchial obstruction. His antimicrobials and pressors were discontinued when he was made CMO. . 2. GI bleed: Possible upper GI bleed given + NGL in ED. Could be related to metastatic disease vs. PUD, etc. GI aware. EGD was deferred as hematocrit was stable and GI bleed was felt unlikely to be the primary issue. His Lovenox was held. He received vitamin K and FFP to correct coagulopathy. His hematocrit remained stable. He was maintained IV PPI [**Hospital1 **], which was discontinued when he was made CMO. . 3. Respiratory Failure: Patient intubated due to concern for mental status, aspiration. Also has pneumonia, underlying pulmonary mets. The patient was to be continued on ventilation until his mental status and sepsis resolved, though the patient was extubated on [**4-9**] after being made CMO. . 4. ARF: Creatinine improved to 2.9 from 4.2, baseline 1.1-1.3. Most likely pre-renal azotemia due to dehydration +/- ATN due to hypotension. He also received IV contrast for CTA, so might expect renal function to worsen further despite aggressive hydration he has received so far. CT showed known R hydronephrosis and hydroureter, stable. . 5. Elevated CEs/NSTEMI: Resolving. CK and TnT initially elevated in setting of hypotension and acute renal failure. EKG with lateral ST depressions, and his trop peaked at 0.99. We could not give asa, plavix, or heparin given GI bleed. Not treated with BB given hypotension. . 6. CHF: EF 30% with moderate global LV dysfunction and RV dilatation and severe dysfunction. No prior studies for comparison. . 7. Coagulopathy: Patient on lovenox at home. Liver function also abnormal, with rising LFTs, low albumin - could be contributing as well. Received protamine and FFP in ED, as well as vitamin K. DIC panel negative. . 8. LFT abnormalities: Improving. Likely related to progression of liver mets as well as component of shock liver in the setting of hypotension. RUQ U/S unremarkable . 9. Contrast infiltration into axilla: Notified by radiology resident of infiltration of 30cc of CT contrast into axilla. There is some risk of skin necrosis from this, although it was a relatively small amount of contrast. He was evaluated by Plastic Surgery who recommended elevation of his arm and monitoring for development of compartment syndrome. No further intervention was required. . 10. Code: He was initially maintained as Full Code, which was confirmed with daughter (HCP). Family meeting on [**4-5**] --> daughter wished to continue aggressive care 24-48hrs; family meeting [**4-7**] --> daughter believed her father's wishes were to have aggressive care and live as long as possible. The patient's primary oncologist spoke with the family on [**4-9**] and explained the patient's very poor prognosis given his advanced disease, multiorgan system failure, and lack of further oncologic treatment options. His family decided to make him comfort measures only. He was extubated and started on morphine drip for comfort. On the floor the patient was maintained on morphine drip, scopalamine and seen by palliative care. He was comfortable and passed away without problems. His family was aware and an autopsy was declined Medications on Admission: lovenox 80mg daily morphine SR 100mg [**Hospital1 **] protonix 40mg daily lorazepam 1mg hs ambien 5-10mg colace [**Hospital1 **] senna [**Hospital1 **] lisinopril 40mg (no longer taking) zofran Discharge Medications: none patient passed away Discharge Disposition: Expired Discharge Diagnosis: metastatic colon cancer sepsis hypotension GI Bleed Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased

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icd9cm

[ [ [] ] ]

[ "96.72", "00.17", "96.04", "99.07", "99.04" ]

icd9pcs

[ [ [] ] ]

10570, 10579

6140, 10277

294, 319

10674, 10684

3738, 3738

10741, 10752

3275, 3338

10521, 10547

10600, 10653

10303, 10498

10708, 10718

3353, 3719

230, 256

347, 1891

3754, 6117

1913, 3102

3118, 3259

52,898

108,336

41103

Discharge summary

report

Admission Date: [**2163-4-20**] Discharge Date: [**2163-5-3**] Date of Birth: [**2098-1-5**] Sex: M Service: SURGERY Allergies: Penicillins / Heparin Agents Attending:[**First Name3 (LF) 2597**] Chief Complaint: ? wound ischemia. Major Surgical or Invasive Procedure: Quentin Catheter removal PROCEDURE: Sharp debridement of sacral decubitus wound at the bedside. History of Present Illness: This is a 65 y/o gentleman s/p TAAA repair on [**2163-2-15**], complicated by mesenteric ischemia and paraplegia, s/p exlap, left colectomy, open abdomen on [**2163-2-22**], s/p washout, resection of proximal rectum on [**2163-2-23**], s/p trans seg colectomy, end colostomy, GJ, closure w mesh on [**2163-2-24**], s/p perc trach on [**2163-3-4**], s/p STSG on [**2163-3-17**]. The patient was discharged to [**Hospital3 **] on [**2163-3-25**]. Over the past month, the patient has improved clinically, including stopping HD 2 weeks ago. The patient now presents to the [**Hospital1 18**] ED with a ? bullous area of the upper pole of the abdominal wound and hypotension. The patient was taken off midodrine at Rehab and was then started on lopressor. With the new medication change, the patient had low blood pressure. The patient is afebrile, mentating, and is no acute distress. Past Medical History: PAST MEDICAL HISTORY: HTN, Inc chol, pos smoker, COPD, osteoarthritis Homocystine, increase PSA PAST SURGICAL HISTORY: s/p prostate bx - [P] Social History: SOCIAL HISTORY: NA. Pos smoker, pet dog, married with children, wine distrubuter, retired a yr ago Family History: FAMILY HISTORY: father and Uncle pos AAA Physical Exam: Vital Signs: Temp: 98.1 RR: 20 Pulse: 52 BP: 104/54 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, abnormal: Open abdominal wound with good granulation, visible peristalsis, RLQ ostomy pink. Rectal: Not Examined. Extremities: No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. LUE Radial: P. RLE Femoral: P. PT: P. LLE Femoral: P. DP: P. PT: P. DESCRIPTION OF WOUND: Abdomen: good granulation, visible peristalsis, packing at LLQ, 3cm area of bluish bullous area at upper pole of wound Pertinent Results: [**2163-5-3**] 07:10AM BLOOD WBC-14.9* RBC-3.25* Hgb-10.1* Hct-30.6* MCV-94 MCH-31.1 MCHC-33.0 RDW-16.8* Plt Ct-422 [**2163-5-3**] 07:10AM BLOOD PT-12.9 PTT-27.8 INR(PT)-1.1 [**2163-5-3**] 07:10AM BLOOD Glucose-103* UreaN-31* Creat-0.8 Na-138 K-4.8 Cl-105 HCO3-28 AnGap-10 [**2163-5-3**] 07:10AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0 [**2163-4-22**] 01:46PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2163-4-22**] 9:13 am TISSUE Site: ULCER Source: sacral ulcer. GRAM STAIN (Final [**2163-4-22**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). Reported to and read back by [**First Name8 (NamePattern2) 89585**] [**Last Name (un) 89586**] #[**Numeric Identifier 89587**] @1446, [**4-22**]. TISSUE (Final [**2163-4-26**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. PROBABLE ENTEROCOCCUS. MODERATE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH. ANAEROBIC CULTURE (Final [**2163-4-26**]): NO ANAEROBES ISOLATED. [**2163-4-26**] 3:55 am STOOL CONSISTENCY: LOOSE Source: Stool. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2163-4-26**]): Feces negative for C.difficile toxin A & B by EIA. CTA: Endoscopy capsule is seen within the cecum. Other findings, including open abdomen, subcapsular liver hematoma/seroma, pleural effusions, and bibasilar atelectasis are unchanged. As seen previously, the [**Female First Name (un) 899**] does not fill but the SMA and Celiac axes are patent. VIDEO SWALLOW: FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was no gross aspiration or penetration. For details, please refer to speech and swallow division note in OMR. IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy. Brief Hospital Course: [**2163-4-20**] 65M s/p TAAA repair, c/b paraplegia and mesenteric ischemia requiring left colectomy and colostomy, abdominal wall closure with split-thickness skin-grafts. Presents with concerns of discoloration at the superior aspect of his wound felt to be benign and hypotension likely discontinuation of his midodrine and initiation of beta-blockers. Pt. otherwise stable Pt admitted to VICU Resumed cipro / fluconazol / flagyl through out the hospital course. Pan cx'd CT SCAN obtained: IMPRESSION: 1. Stable appearance of the thoracoabdominal aortic graft, with a small amount of fluid collection surrounding the graft. 2. Status post total colectomy and right lower quadrant ileostomy, without bowel obstruction or secondary signs of mesenteric ischemia. Evaluation for ischemia is limited due to the lack of intravenous contrast. 3. The tracheostomy tube and central lines are in optimal position. 4. Secretions within the trachea, concerning for aspiration. Complete collapse of the left lower lobe with abrupt cutoff of the left lower lobe bronchus, question mucous plug versus aspiration. 5. Bilateral moderate-sized pleural effusions, with associated right basilar atelectasis, slightly larger since the prior study. With the discontinuation of BB and middorone hypotension resolved. Pt abdominal wound not infected Transplant consulted for abdominal wound. Nothin to do. [**2163-4-21**] Wound / Ostomy consult obtained for osteo care Nutrition Consult obtained for TF Pace maker interrogated Pt noticed to have large decubitus ulcer. Plastic Surgery Consulted. Dr [**Last Name (STitle) **]. Pt found to be anemic, 2 units PRBC's given. Free water given for Na. [**2163-4-22**] Plastic Surgery recommended q 2hr turns, nutrtion optimization, [**Last Name (un) **] Air Bed, Performed sharp debridment bedside, CX taken. DOES NOT LOOK INFECTED. Recommended wet to dry dressing changes [**Hospital1 **]. Free water given for Na. PT evaluation SQ heperin stopped, fundaperinox started. [**4-23**] cx's pending bp stable off midarone hypernatremia - c/w flushes speech and swallow consult - recommended video swallow IV antibiotics continued [**4-24**] cx's STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. PROBABLE ENTEROCOCCUS. MODERATE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH. ID consulted, keep same antibiotics, no change BP stable off midarone hypernatremia - c/w flushes [**2163-4-25**] HIT negative, pt with low platelets. [**Doctor First Name **] sent NA improving TF clamped for egd vs scope HCT still low, blood at osteum site. GI consulted. TF held for possible scope. Pt recieved CTA to rule out aortic enteric fistula, fundaperinox held for scope. Pt given NAHCO3 for renal protection CTA: 1. Moderate bilateral pleural effusions. 2. Limited evaluation for contrast exacerbation into the bowel due to the presence of oral contrast from a prior examination. 3. Unchanged left flank simple fluid collection. 4. The balloon of the GJ tube appears to be inflated outside the stomach wall. Clinical correlation recommended. Hypernatremia improving with free water flushes. Pt found tohave increase in BUN to 120, Renal consulted Video swallow completed: IMPRESSION: Normal oropharyngeal swallowing videofluoroscopy. B/L lower extremity swelling, LENIS ordered IMPRESSION: No evidence of deep vein thrombosis in either leg. [**2163-4-26**] GI EGD: Mild diffuse gastritis G-J tube without abnormality at internal bumper Otherwise normal EGD to second part of the duodenum Pt hct stable IV antibiotics pt preped for GI scope TF clamped for GI scope NA improving with fresh water flushes HIT positive [**4-27**] GI SCOPE: Few flecks of melena in the right colon Normal colonic mucosa Normal ileal mucosa to 20cm from IC valve Otherwise normal colonoscopy to terminal ileum NA improving with fresh water flushes BUN decreaseing HCT low 2 units PRBC's given TF resumed IV antibiotics continued renal recs: for NA D5, BUN improving GI do to capsule study. [**2163-4-28**] Melena remains in ostomy, both EGD and colonoscopy negative. Capsule study (p) IV antibiotics continued TF held untill capsule passes, reglan started to help motility [**2163-4-29**] Pt does not pass capsule, KUB obtained LUQ can see capsule IV antibiotics continued Perma cath removed per renal, no longer requiring dialysis Decided to restart TF to help pass the capsule. Repeat KUB, capsule in RLQ. GI thinks capsule is lodged near stricture. This was probably the site of GI bleed HCT stable, Tagged redblood scan if pt rebleeds [**2163-4-30**] IV AB continued TF awaiting capsule to pass HCT stable, Tagged redblood scan if pt rebleeds GI recommend CT Enterogram to check capsule, slowly passing [**5-1**] - [**5-2**] CT enterogram: Endoscopy capsule is seen within the cecum. Other findings, including open abdomen, subcapsular liver hematoma/seroma, pleural effusions, and bibasilar atelectasis are unchanged. As seen previously, the [**Female First Name (un) 899**] does not fill but the SMA and Celiac axes are patent. GI signs off, awaiting capsule to pass, No need to retrieve, slowly passing IV AB continued TF HCT stable, Tagged redblood scan if pt rebleeds [**5-3**] Pt stable for DC Medications on Admission: ASA 81', Symbicort 2 puffs [**Hospital1 **], Chlorhexidine swish and spit [**Hospital1 **], Cipro 250 [**Hospital1 **] MW, Santyl qdaily to coccyx, Ferros sulfate 300BID, Diflucan 400 MWF, Lasix 20 [**Hospital1 **], Insulin 10U qAM, Insulin Regular Ativan 1mg qHS/0.5mg prn, Nephlex daily, Juven 1 pkt [**Hospital1 **], ranitidine 150', Tiotropium 18mcg IH daily, trazodone 100 qHS, Xenaderm ointment [**Hospital1 **], Flagyl 250 TID, Tylenol 650 elixir Q6hr prn, Mucomyst prn, Benadryl 10ml [**Hospital1 **], Lipase/Protease/Amylase [**Hospital1 **] Discharge Medications: 1. chlorhexidine gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 2. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for . 7. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for . 8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. paroxetine HCl 10 mg/5 mL Suspension Sig: One (1) PO DAILY (Daily). 10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for . 11. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for . 12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. insulin Sliding Scale Fingerstick q6h Insulin SC Sliding Scale Q6H Humalog Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-119 mg/dL 0 Units 120-159 mg/dL 2 Units 160-199 mg/dL 4 Units 200-239 mg/dL 6 Units 240-279 mg/dL 8 Units > 280 mg/dL Notify M.D. 14. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Flagyl 250 mg Tablet Sig: One (1) Tablet PO three times a day. 16. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO every other day: Mon / Wends / Fri. 17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 18. fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) Subcutaneous once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital for Continuing Care Discharge Diagnosis: Dehydration Hypotension Hypernatremia HTN, inc chol, COPD, Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Please adhere to rehab protocol Please call if you have any of the following: Abdominal pain Abdominal swelling Nausea and vomiting Vomiting blood Difficulty swallowing Diarrhea Constipation Blood in stool Black stool Followup Instructions: Provider: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2163-6-13**] 9:00 Please call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 3121**]. Schedule an appoinment when you are safely able to come to the office. Completed by:[**2163-5-3**]

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icd9cm

[ [ [] ] ]

[ "86.05", "45.19", "45.13", "45.23", "86.28", "96.6" ]

icd9pcs

[ [ [] ] ]

12456, 12527

4699, 10012

305, 405

12631, 12631

2449, 4676

13013, 13345

1633, 1660

10613, 12433

12548, 12610

10038, 10590

12768, 12990

1459, 1483

1675, 2430

247, 267

433, 1317

12646, 12744

1361, 1436

1515, 1601

23,568

113,930

54162

Discharge summary

report

Admission Date: [**2106-6-28**] Discharge Date: [**2106-7-4**] Date of Birth: [**2047-6-23**] Sex: F Service: CCU, FAR 3. HISTORY OF THE PRESENT ILLNESS: This is a 59-year-old female with a history of coronary artery disease status post cardiac catheterization at [**Hospital1 69**] in [**2091**]; hypertension; and anxiety. The patient presented to an outside hospital with four days of chest pain and right arm pain. EKG showed nonsignificant ST changes in lead V4 through V6. The first set of enzymes with CK of 62, MB 1.5 index, 2.4 troponin less than 0.1. The patient was transferred to the [**Hospital1 69**] for cardiac catheterization, which showed left main coronary artery 30 to 40 distal stenosis, LAD mild irregularities, left circumflex small [**Last Name (LF) 12425**], [**First Name3 (LF) **] mild diffuse disease, RCA large [**First Name3 (LF) 12425**] with 95% mid stenosis. PCI stent was placed in the RCA. Post cardiac catheterization, the patient was found to be hypotensive with systolic blood pressures in the 60s to 70s. She had nausea and vomiting. She complained of right lower quadrant pain and tenderness. The hematocrit was 31 from 39 precatheterization. CT showed large right retroperitoneal bleed with compression of bladder. IV protamine was given, and the patient was transferred to the Coronary Care Unit Team with Vascular Surgery notified. SOCIAL HISTORY: The patient is a smoker of one half of a pack per day for 40 years. She has a history of hypertension, high cholesterol, with total cholesterol of 191 and LDL of 108, and positive family history, father with [**Name (NI) 110991**] with less than 55. PAST MEDICAL HISTORY: 1. Coronary artery disease. In [**2101-12-25**], cardiac catheterization showed a proximal left circumflex 60% stenosis, EF 86% and no interventions were done. 2. The patient had an ETT MIBI in [**2101-2-22**], which was negative. 3. The patient also has a history of hypertension, anxiety, on Zoloft, but the patient denies depression. SOCIAL HISTORY: The patient lives at home [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3146**] with her husband and son. She is a smoker. REVIEW OF SYSTEMS: Noncontributory. FAMILY HISTORY: History is as above. PHYSICAL EXAMINATION: Examination revealed the following: VITAL SIGNS: Heart rate 75, blood pressure 108/63, respiratory rate 26, 93% on two liters nasal cannula. GENERAL: The patient is anxious and in no acute distress. HEENT: Mucous membranes were moist. NECK: Could not assess secondary to body habitus. LUNGS: Lungs revealed decreased breath sounds at the bases, otherwise, clear. COR: Normal, S1 and S2, no murmurs appreciated. ABDOMEN: Obese. Positive tenderness in the right lower quadrant; firm, normoactive bowel sounds. EXTREMITIES: No clubbing, cyanosis or edema; 2+ PT/DP pulses bilaterally. LABORATORY DATA: Laboratory data revealed the following: CBC, WBC 26.2, hematocrit 37.7, status post transfusion of two units RBCs. Platelet count 145,000. CT of the abdomen: Please see history of present illness. HOSPITAL COURSE: #1. CAD, status post RCA stent. She she was started on Plavix, aspirin, and Integrilin was discontinued secondary to the bleed. The Plavix and aspirin were held and restarted on [**2106-6-30**]. Vascular Surgery was consulted for the retroperitoneal bleed and recommended continuing to monitor. The hematocrit was drawn serially q.6h. and remained stable after serial blood transfusions. She received a total of seven units throughout the hospital course. She was also started on Pravastatin 20 mg PO q.d. Rate and rhythm stable. #2. PULMONARY: Stable. #3. RENAL: Stable. #4. GI/FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was tolerating clear liquids. The patient was started on Pantoprazole. Electrolytes were checked and repleted as normal. Code was full. #5. PROPHYLAXIS; Pneumoboots, Pantoprazole. #6. GENITOURINARY: The patient complained of urinary discomfort. The Urinalysis was significant for positive nitrites. She was started on Bactrim double strength, one tablet PO b.i.d. times five days. She was discharged to home for follow up to Dr. [**Last Name (STitle) 1147**] and the primary care physician. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg PO q.d. 2. Plavix 75 mg PO q.d. times 30 days, last dose [**7-28**]. 3. Ativan 0.5 mg PO q.8h. p.r.n. times ten days. 4. Ranitidine 150 mg PO b.i.d. 5. Sublingual nitroglycerin one tablet sublingual q.5 minutes times three doses p.r.n. 6. Aspirin 325 mg q.d. 7. Vitamin E 400 mg q.d. 8. Zoloft 75 mg PO q.d. 9. Metoprolol XL 100 mg PO q.d. 10. Bactrim double strength one tablet PO b.i.d. times five days. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Discharge to home. FINAL DIAGNOSIS: Diagnosis revealed acute coronary syndrome with retroperitoneal bleed. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], M.D. [**MD Number(1) 37596**] Dictated By:[**Last Name (NamePattern1) 41557**] MEDQUIST36 D: [**2106-7-4**] 13:06 T: [**2106-7-4**] 13:14 JOB#: [**Job Number 110992**]

[ "401.9", "305.1", "E878.8", "414.01", "300.00", "411.1", "496", "998.11", "272.0" ]

icd9cm

[ [ [] ] ]

[ "36.01", "88.56", "37.22", "99.20", "36.06", "88.53" ]

icd9pcs

[ [ [] ] ]

2252, 2274

4301, 4734

3130, 4278

4822, 5175

2297, 3112

2217, 2235

1700, 2042

2059, 2197

4759, 4805

6,901

193,108

16224

Discharge summary

report

Admission Date: [**2133-3-14**] Discharge Date: [**2133-3-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 134**] Chief Complaint: Weakness. Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] y year old man w/ pmh sinus node dysfunction s/p pacemaker placement, afib, HTN, called 911 earlier today after slipping off of his chair and falling to the ground. The patient was unable to get up, and lay on the ground for several hours before he was able to reach a phone. The patient reports fatigue and weakness over the past several days. He lives by himself and cares for himself, depending primarily on meals for wheels for nutrition. The patient [**Age over 90 **] chest pain, shortness of breath, fever, chills, brbpr, melena, dysuria. . In the ED, vitals were HR 124, BP 95/65. 97% RA. EKG showed afib w/aberrancy vs. Vtach. CK was 1589, Trop was .05 (baseline). INR was 12.9. Creatinine was 1.7, up from baseline 0.8. UA was positive for UTI. Pt received 150 amiodarone. Also ceftriaxone, 2.5 SC vitamin K and 1 unit FFP. Past Medical History: HTN GERD Sinus node dysfunction --> DDD pacer Atrial fibrillation s/p cardioversion ORIF right leg Cholecystectomy Cataract removal TURP Aortic stenosis s/p AVR (St. [**Male First Name (un) 923**] porcine valve, [**10-8**]) Carpal tunnel syndrome s/p release Allergic rhinitis Social History: Mr. [**Known lastname 46286**] is a retired window cleaner. He quit smoking 20 years ago and reports having smoked 1.5 packs per day for sixty years. He estimates drinking about 3 alcoholic drinks per month. He lives alone. Family History: Mr. [**Known lastname 46286**] [**Last Name (Titles) **] any contributory family history. Physical Exam: VS: T 99.6, BP 105/70 , HR 120-130 , RR 18 , O2 96 % on RA Gen: Elderly male Caucasian. Tired appearing but Oriented x3 and pleasant. Head: NCAT. Eyes: Sclera anicteric. PERRL, EOMI. Conjunctiva pale. Mouth furrowed, red tongue, no ulcerations seen. Neck: Supple with JVP of 8 cm. CV: Irregularly irregular, normal S1, S2. No S4, no S3. Chest: Resp were unlabored, no accessory muscle use. Scattered crackles, wheeze, rhonchi. Abd: Obese, soft, NTND. No abdominial bruits. Ext: [**12-3**]+ edema bilaterally. No femoral bruits. Skin: 3x3 erythematous shallow ulcer on lateral RLE. Red rash throughout perineal area. Pulses: DP pulses 2+ bilaterally Pertinent Results: [**2133-3-13**] 09:25PM BLOOD WBC-13.2* RBC-4.82 Hgb-14.1 Hct-42.4 MCV-88 MCH-29.3 MCHC-33.4 RDW-14.7 Plt Ct-219 [**2133-3-19**] 06:20AM BLOOD WBC-9.1 RBC-4.27* Hgb-12.4* Hct-37.3* MCV-87 MCH-29.0 MCHC-33.2 RDW-14.5 Plt Ct-161 [**2133-3-13**] 09:25PM BLOOD PT-97.9* PTT-46.1* INR(PT)-12.9* [**2133-3-19**] 06:20AM BLOOD PT-19.6* PTT-35.5* INR(PT)-1.8* [**2133-3-13**] 09:25PM BLOOD Glucose-86 UreaN-79* Creat-1.7* Na-141 K-5.5* Cl-105 HCO3-21* AnGap-21* [**2133-3-19**] 05:59PM BLOOD Glucose-96 UreaN-17 Creat-0.8 Na-136 K-4.1 Cl-101 HCO3-28 AnGap-11 [**2133-3-13**] 09:25PM BLOOD ALT-181* AST-142* CK(CPK)-1589* AlkPhos-162* TotBili-2.0* [**2133-3-17**] 03:44AM BLOOD ALT-93* AST-42* LD(LDH)-422* AlkPhos-127* TotBili-0.7 [**2133-3-13**] 09:25PM BLOOD CK-MB-32* MB Indx-2.0 [**2133-3-13**] 09:25PM BLOOD cTropnT-0.05* [**2133-3-15**] 05:02AM BLOOD CK-MB-8 cTropnT-0.05* [**2133-3-14**] 05:03AM BLOOD CK-MB-22* MB Indx-2.2 [**2133-3-13**] 09:25PM BLOOD Calcium-9.5 Phos-4.7*# Mg-3.0* [**2133-3-19**] 05:59PM BLOOD Calcium-7.6* Phos-2.0* Mg-1.9 [**2133-3-13**] 09:25PM BLOOD TSH-5.0* [**2133-3-13**] 09:25PM BLOOD Free T4-1.1 [**2133-3-18**] 04:34AM BLOOD Digoxin-1.5 [**2133-3-14**] 05:02AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010 [**2133-3-14**] 05:02AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2133-3-14**] 05:02AM URINE RBC-21-50* WBC->50 Bacteri-MOD Yeast-NONE Epi-[**2-4**] RenalEp-0-2 [**2133-3-13**] 09:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2133-3-13**] 09:40PM URINE Blood-LG Nitrite-POS Protein-TR Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2133-3-13**] 09:40PM URINE RBC-[**10-22**]* WBC-21-50* Bacteri-MOD Yeast-NONE Epi-0-2 [**2133-3-14**] 09:10AM URINE Hours-RANDOM Creat-64 Na-12 [**2133-3-14**] 05:02AM URINE Hours-RANDOM Creat-32 Na-83 [**2133-3-14**] 09:10AM URINE Osmolal-632 . CT HEAD W/O CONTRAST [**2133-3-14**] 12:10 AM CT HEAD W/O CONTRAST Reason: please assess for bleed [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] yo M presents with weakness. found to be in afib. anticoagulated INR 12 REASON FOR THIS EXAMINATION: please assess for bleed CONTRAINDICATIONS for IV CONTRAST: creat INDICATION: [**Age over 90 **]-year-old male with weakness and AFib with an INR of 12. COMPARISON: [**2133-3-2**]. TECHNIQUE: Non-contrast head CT. FINDINGS: There is no hemorrhage, edema, mass effect, hydrocephalus, or evidence of acute vascular territorial infarct. The ventricular and sulcal prominence remains unchanged. Hypodensities in the external capsule bilaterally are stable and suggestive of lacunar infarct. The osseous structures demonstrate no fractures. There is mucosal thickening within multiple ethmoid air cells, the frontal air cells, as well as maxillary sinuses with an 8-mm retention cyst in the left maxillary sinus. The middle ear cavities and mastoid air cells are clear. The soft tissues are unremarkable. IMPRESSION: No hemorrhage or mass effect. . CHEST (PORTABLE AP) [**2133-3-13**] 9:28 PM CHEST (PORTABLE AP) Reason: chf, pna [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old man with tachy, wide compl, rales REASON FOR THIS EXAMINATION: chf, pna CHEST RADIOGRAPH PERFORMED ON [**2133-3-13**] Compared with prior study from [**2132-1-20**]. CLINICAL HISTORY: [**Age over 90 **]-year-old man with tachycardia, rales, evaluate for CHF or pneumonia. FINDINGS: Portable upright chest radiograph is obtained. Midline sternotomy wires are again noted as is the dual-lead right chest pacemaker with lead tips in the proximal location of the right atrium and right ventricle. The patient is slightly rotated to the left, which somewhat limits evaluation. The cardiomediastinal silhouette is stable with mild cardiac enlargement again noted. There is a layering left pleural effusion noted. Bibasilar atelectatic changes are noted as well. There is no overt CHF. No definite pneumothorax is seen, although the patient's chin overlies the left lung apex, somewhat limiting evaluation. The visualized osseous structures appear stable and intact. IMPRESSION: 1. Stable cardiomegaly with left pleural effusion and bibasilar atelectasis. . Atrial fibrillation with rapid ventricular response and intraventricular conduction defect with secondary ST-T wave abnormalities. Compared to the previous tracing of [**2131-12-28**] atrial fibrillation is new. TRACING #1 Intervals Axes Rate PR QRS QT/QTc P QRS T 118 0 160 354/455 0 -56 122 . The left atrium is moderately dilated. The right atrium is markedly dilated. The estimated right atrial pressure is 10-20mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis (LVEF = 25-30 %). Right ventricular chamber size is normal. with mild global free wall hypokinesis. The ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis has normal transvalvular gradients. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. There is a minimally increased gradient consistent with trivial mitral stenosis. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Moderate [2+] tricuspid regurgitation is seen. There is mild estimated pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2132-1-17**], biventricular function is worse and the trans-aortic gradient has decreased, possibly due to decreased cardiac output. . CHEST (PORTABLE AP) [**2133-3-19**] 7:44 AM CHEST (PORTABLE AP) Reason: interval change of effusion and pulm edema? [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old man with new CHF, vol overload. REASON FOR THIS EXAMINATION: interval change of effusion and pulm edema? PORTABLE CHEST COMPARISON: [**2133-3-17**]. INDICATION: CHF. Congestive heart failure has [**Year (4 digits) 27836**] with increasing vascular engorgement, perihilar edema, and enlarging pleural effusions. Left pleural effusion is now moderate-to-large in size, and the right effusion is small-to-moderate. Brief Hospital Course: [**Age over 90 **] y.o. male w/ pmh afib on coumadin, HTN, AS s/p porcine valve replacement, dementia, found down at home, presenting with UTI, ARF, rhabdomyolysis, and atrial fibrillation w/ aberancy. . #)Chronic systolic CHF: Patient presented with CHF exacerbation, being total body fluid overloaded while being intravascularly fluid depleted. His rhythm was atrial fibrillation with heart rates of 120-130's. He was treated initially with fluids, as his JVP was flat and he had negligible PO intake over the preceeding three days. He was also started on amiodarone in an attempt to cardiovert his rhythm. Echo showed LVEF 25-30% with severe global LV hypokinesis. By hospital Day #2, he began to develop crackles on lung exam and he was begun on a lasix drip in an attempt to diurese his excess fluid. His amiodaorne was discontinued as it was unsuccessful in cardioverting him to sinus rhythm. The patient was then begun on digoxin. He was on a lasix drip for three days and diuresed a total of 8L. The patient maintained adequate blood pressure throughout diuresis. The patient also had a pacer set at a rate of 80. EP was asked to interrogate the pacer and lower his rate to 70, in an effort to improve his symptoms of congestive heart failure. Interrogation revealed that he spends the majority of his time in atrial fibrillation. He is currently diuresing without diuretics. Please monitor ins and outs. When he begins to get even or positive/euvolemic (currently 2L negative without diuretics), please start 20mg PO lasix and titrate for euvolemia. He will need a follow-up ECHO in the next 6-8 weeks. . #)Atrial Fibrillation: Patient presented in atrial fibrillation with rates up to 120-130's. His INR was also at 12.1. He was administered fluids. He was initially begun on amiodarone, but was discontinued after two days because it was unsuccessful in cardioverting his rhythm. he was also administered ffp and vitamin k to reverse his INR. Echo showed dilated left atrium with a globally hypokinetic left ventricle with LVEF 25-30%. Given his left atrial dilation, he was not considered a good condidate for electrical cardioversion. He was next begun on digoxin. After fluid administration and initiation of digoxin, the patient's heart rate gradually slowed to 80-100. After three days, he was restarted on coumadin to maintain a therapeutic INR. His INR climbed to 2.9 on 5mg coumadin on the day of discharge, so he should be given 4mg qday starting on the evening of [**2133-3-23**]. Please check INR [**2133-3-28**]. Please give results to staff physician and fax to PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**First Name3 (LF) **] A, Fax: [**Telephone/Fax (1) 6443**] Phone: [**Telephone/Fax (1) 1144**]. Titrate coumadin to INR goal [**1-4**]. . #)Nutritional Status: patient is dependent on meals on wheels for his nutrition. He reported not eating for several days prior to admission. He was initially treated with thiamine, folate, glucose, vitamin C, zinc supplements, along with a multivitamin. He also received daily meals. After eating, his phosphate decreased to 1.5. This was thought to be a manifestation of refeeding syndrome and he was given phosphate supplements TID. chem 10 on [**2133-3-28**]. Please give results to staff physician and fax to PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**First Name3 (LF) **] A, Fax: [**Telephone/Fax (1) 6443**] Phone: [**Telephone/Fax (1) 1144**]. Titrate neutra phos to replete phosphate, can discontinue when refeeding syndrome is improved. . #) Acute renal failure: Baseline cr 0.8. On admission Cr 1.7, trended back to 0.9 atfer fluid administration. His ARF was thought secondary to hypovolemia. . #) UTI: positive UA upon admission. he also presented with a leukocytosis. He was begun on ceftriaxone for a UTI, and was treated for 7 days. . #) Valvular disease, s/p AVR with [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] porcine valve. Patient's INR was initially reversed with ffp and vitamin K. His coumadin was then restarted to maintain a therapeutic INR. . #) Elevated LFTs: AST and ALT elevation may be explained by mild shock liver in setting of hypotension, no good explanation for alk phos and elevated t bili. His liver enzymes an bilirubin trended down to normal with stabilizing his hemodynamic status. . #) Lower Extremity Wounds: the patient had several ulcers on his lower extremities. he was evaluated by wound care and treated with daily dresing changes. . #) Code: FULL Medications on Admission: Nystatin - 100,000 unit/gram Powder - apply to rash twice a day Warfarin [Coumadin] - 5 mg Tablet - one Tablet(s) by mouth as directed Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet Sig: One (1) Powder in Packet PO TID WITH MEALS (). 10. labwork INR and chem 10 on [**2133-3-28**]. Titrate coumadin to INR goal [**1-4**]. Titrate neutra phos to replete phosphate, can discontinue when refeeding syndrome is improved. Please give results to staff physician and fax to PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**First Name3 (LF) **] A, Fax: [**Telephone/Fax (1) 6443**] Phone: [**Telephone/Fax (1) 1144**] 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: - acute on chronic systolic congestive heart failure - atrial fibrillation - UTI - hypophosphatemia . Secondary: HTN GERD Sinus node dysfunction --> DDD pacer ORIF right leg Cholecystectomy Cataract removal TURP Aortic stenosis s/p AVR (St. [**Male First Name (un) 923**] porcine valve, [**10-8**]) Carpal tunnel syndrome s/p release Allergic rhinitis Dementia Discharge Condition: good, stable Discharge Instructions: Mr. [**Known lastname 46286**] was seen at [**Hospital1 18**] for heart failure and atrial fibrillation. He was significantly fluid overloaded and he was diuresed during his stay. His afib was control with digoxin after amiodarone failed. He also had his pace maker changed to pace at 70 bpm and his warfarin titrated for goal INR [**1-4**]. He was also given a course of ceftriaxone for UTI. His potassium, phosphate and calcium was being repleted for likely refeeding syndrome. . He should be followed for: - INR, titrate coumadin to goal INR [**1-4**] - cardiopulmonary monitoring, specifically heart rate and blood pressure - weight gain - PT/OT - monitor phosphate, titrate or discontinue phosphate supplement accordingly . INR and chem 10 on [**2133-3-28**]. Titrate coumadin to INR goal [**1-4**]. Titrate neutra phos to replete phosphate, can discontinue when refeeding syndrome is improved. Please give results to staff physician and fax to PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**First Name3 (LF) **] A, Fax: [**Telephone/Fax (1) 6443**] Phone: [**Telephone/Fax (1) 1144**] . Please monitor ins and outs. When he begins to get even or positive/euvolemic (currently 2L negative without diuretics), please start 20mg PO lasix and titrate for euvolemia. . His primary care provider should be called or he should return to the emergency department if he experiences shortness of breath, chest pain, lightheadedness, palpitations, fever greater than 101.5 degrees F, or any other concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2133-4-30**] 3:30 . Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2133-4-30**] 4:00. - Please call Dr. [**Last Name (STitle) 1911**] for closer follow-up in the next 2-3 weeks. . Please follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in the next 1-2 weeks. His number is [**Telephone/Fax (1) 1144**]. Please call for an appointment.

[ "427.31", "428.0", "728.88", "530.81", "707.12", "401.9", "599.0", "275.3", "584.9", "V45.01", "428.23", "V42.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15000, 15070

8861, 13412

271, 277

15484, 15499

2498, 4538

17086, 17633

1722, 1813

13598, 14977

8391, 8451

15091, 15463

13438, 13575

15523, 17063

1828, 2479

222, 233

8480, 8838

305, 1160

1182, 1461

1477, 1706

7,681

175,048

17128

Discharge summary

report

Admission Date: [**2167-1-5**] Discharge Date: [**2167-1-9**] Date of Birth: [**2117-1-14**] Sex: M Service: MICU/BLOOM Admitted to the Medical Intensive Care Unit then transferred to the [**Hospital 48098**] Medical Service. HISTORY OF PRESENT ILLNESS: This is a 49-year-old male with a history of hepatitis C and alcoholic cirrhosis also with a history of transjugular intrahepatic portosystemic shunt done in [**5-/2166**] secondary to variceal bleeding who presents with bright red blood per rectum times two episodes that "filled the toilet." Patient reports lightheadedness as well. The blood is mixed with brown stool. Patient complains of having constipation for the previous two days and thus leading to increased straining, which then resulted in the bloody stool. In the Emergency Department the patient was hemodynamically stable with a blood pressure of 108/56, pulse 91, hematocrit 28, and INR of 2.3. His baseline hematocrit is around 33 and then three hours later his hematocrit dropped to 25. In addition, he had recurrent episodes of bright red blood per rectum while in the Emergency Department. He did not tolerate nasogastric tube placement, thus did not undergo nasogastric lavage. He was admitted to the Medical Intensive Care Unit on [**2167-1-5**]. HIS MEDICAL INTENSIVE CARE UNIT COURSE: Transfused three units of packed red blood cells and four units of fresh frozen plasma. An EGD was performed as the most worrisome cause of gastrointestinal bleeding in his case would be recurrent gastric variceal bleeding. He was found to have gastropathy and esophageal varices with no active bleeding. Several varices were banded. He had a right upper quadrant to evaluate TIPS which showed stenosis and, thus, he underwent revision of his TIPS on [**2167-1-7**]. In addition, he had alcohol-ablated varices during his TIPS revision. He was started on Octreotide the day before the TIPS. PAST MEDICAL HISTORY: 1. Child's class C cirrhosis secondary to alcohol and hepatitis C; on the transplant list. 2. Hepatitis C diagnosed in [**2159**]. 3. Multiple upper gastrointestinal bleeds secondary to varices. 4. Peptic ulcer disease. 5. TIPS in [**5-/2166**] with revision in [**5-/2166**] complicated by local hepatic infarctions. 6. Known hemorrhoids. 7. Diabetes type 2. 8. Lumbar disc herniation. HOME MEDICATIONS: 1. NPH, 22 units in the morning, 22 units at night. 2. Regular insulin, four units in the morning. 3. Ursodiol 600 mg two times a day. 4. Spironolactone 50 mg once a day. 5. Protonix 40 mg two times a day. 6. Lactulose one teaspoon three times a day. 7. Caltrate. 8. Mycelex troches, five, a day. FAMILY HISTORY: Significant for his mother with diabetes and his father with alcoholic cirrhosis. He died at the age of 68. SOCIAL HISTORY: He lives with his mom, is unemployed, has a history of smoking one pack per day times 20 years. Has now weaned himself to a cigarette p.r.n. Denies current alcohol use. Has a history of marijuana use and intravenous drug use back in the '70s. PHYSICAL EXAMINATION UPON TRANSFER TO THE FLOOR: Vital signs: Temperature is 100.8, heart rate ranges from 81 to 100, blood pressure 104 to 131/31 to 62, breathing 20, satting 95% on room air. Fingersticks are anywhere between 110 and 120 on a regular insulin sliding scale. In general, he is in no acute distress, slightly jaundiced, answering questions appropriately. HEENT is positive for scleral icterus. Pupils equal, round, and reactive to light. Extraocular muscles are intact. Clear oropharynx. Internal jugular triple lumen in his right internal jugular. No lymphadenopathy in his neck. Chest: He has spider angiomata. His lungs are clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm without murmur. Abdomen: Positive bowel sounds; quite distended; nontender; difficult to appreciate hepatosplenomegaly; positive fluid wave; almost a tense belly but nontender. Extremities: A very slight slap; has asterixis on the left; Pneumoboots in place with trace pedal edema. Dorsalis pedis pulse is 2+ bilaterally. Cranial nerves II-XII intact. Strength 5/5 throughout. Sensation to light touch intact bilaterally. Gait not tested, although later on patient is observed walking up and down the hallways and does not have difficulty. LABORATORY DATA: This patient's hematocrit Nadired at 25 and was 35 upon discharge. White blood cells were within normal limits. Patient consistently had low platelets in the 40s to 50s range. INR was 2.3 upon admission and went down with administration of fresh frozen plasma and one dose of vitamin K but then went back up on the day of discharge. Chem-7 within normal limits and calcium 7.5 but corrected for the low albumin. Phosphorous 3.3, magnesium 1.6. LFTs: ALT 82, AST 143, alkaline phosphatase 187, amylase 75, total bilirubin 9.4, albumin 2.0. STUDIES: On [**2167-1-5**] EGD: Three cords of grade 2 varices on the lower esophagus, banded. Portal hypertensive gastropathy. On [**2167-1-5**] right upper quadrant ultrasound showed ascites with left portal vein thrombosis, TIPS stenosis, and hepatopetal flow in the portal vein. [**2167-1-7**] TIPS revision with embolization of varices supplying the splenorenal shunt, enlarged gastric varices with absolute alcohol. There was balloon angioplasty of the TIPS and also a stent across the existing TIPS stent. Pre-procedure portal hepatic gradient was 18 mm/Hg; post procedure was 9 to 10 mm/Hg. EKG on [**2167-1-5**] showed normal sinus rhythm, normal axis and intervals, no ST-T wave changes or Qs. No changes compared to 02/[**2165**]. HOSPITALIZATION COURSE: Please refer to the Medical Intensive Care Unit course described above in the History of Present Illness. 1. Bright red blood per rectum: The EGD revealed portal gastropathy with no evidence of bleeding and had grade 2 esophageal varices times four with no bleeding. Varices were banded. Right upper quadrant ultrasound revealed narrowing of the TIPS, and thus patient underwent TIPS revision, as described above. Right upper quadrant ultrasound on [**2167-1-8**] showed wall-to-wall flow in the TIPS. Patient did have episodes of melena on [**2167-1-6**] and [**2167-1-7**] although no episodes of melena or bright red blood per rectum on the day of discharge and the day prior to discharge. He was kept on Sucralfate and proton pump inhibitor. Hematocrits were checked two times a day and were stable as of midnight the night prior to discharge through discharge. He has a colonoscopy scheduled as an outpatient on [**2167-1-27**] by Dr. [**Last Name (STitle) 497**]. Additionally, Nadolol was added on the day of discharge to decrease portal hypertension, which may have led to bleeding of the varices. It is unclear exactly what caused his bright red blood per rectum at this time. 2. Anemia: Patient had no significant coronary artery disease on recent exercise stress test and MIBI. He was transfused for hematocrit less than 27. He was given a total of five units of packed red blood cells and four units of fresh frozen plasma. Hematocrit upon discharge was 35, although this may reflect some hematoconcentration secondary to beginning diuretics on the day of discharge. 3. Coagulopathy: INR of 2.3. He was transfused four units of fresh frozen plasma and given vitamin K times one at the beginning of his hospitalization course. His goal INR was 1.1 to 1.2 while bleeding. 4. Ascites: Spironolactone was held until his hematocrit was stable. The patient did spike a temperature to 101.7 at midnight on [**2167-1-8**]. Blood and urine cultures were sent, and a chest x-ray was done, and a paracentesis was performed on [**2167-1-8**] by ultrasound which showed 100 red blood cells. This patient never displayed any mental status changes or abdominal pain with the spike in his fever to suggest spontaneous bacterial peritonitis. Cultures at the time of discharge include no growth seen on fluid culture of the peritoneal fluid. Blood cultures were pending at the time of discharge. Urine culture showed mixed bacterial flora consistent with scant anterogenital contamination. He was started on Nadolol, Aldactone, and Lasix on the day of discharge. 5. Cirrhosis: Patient is on the transplant list and was continued on his Lactulose and Clotrimazole troches. 6. Fluid, electrolytes, nutrition: He was transitioned to a soft solids diet, [**Doctor First Name **] diet, low salt. His electrolytes were followed closely. He was seen by Nutrition, which recommended no supplements as of right now as his weight has been unchanged over the past two months. Patient was educated on dietary issue. 7. Diabetes: He was maintained on a regular insulin sliding scale with two fingersticks while in house. He was informed not to go back to his regular outpatient regimen of insulin as it may be too much as it may lead to hypoglycemia. He has a good understanding of diabetes and his diabetic regimen and is followed at [**Last Name (un) **], and he checks his fingersticks four times a day at home. 8. Lines: The patient had a right internal jugular triple lumen which was needed for his TIPS revision and pulled on [**2167-1-8**]. Good hemostasis was obtained, and the TIPS was sent for culture, which is pending at the time of discharge. DISCHARGE DIAGNOSES: 1. Gastrointestinal bleed. 2. Esophageal varices. 3. Hepatitis C. 4. Alcoholic cirrhosis. 5. Ascites. 6. Diabetes mellitus. DISCHARGE INSTRUCTIONS: 1. He should check in with the transplant coordinator on Monday, [**2167-1-12**]. 2. He should have labs drawn on Monday, [**2167-1-12**], a CBC, INR, LFTs, Chem-7, and fax those to [**Telephone/Fax (1) 697**]. 3. Colonoscopy by Dr. [**Last Name (STitle) 497**] on [**2167-1-27**] at 10:30 a.m. 4. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22924**] on [**2167-2-4**] at 2 p.m. 5. Primary care physician with Dr. [**First Name (STitle) **] [**Name (STitle) **] on Friday, [**2167-1-16**], at 1:30 p.m., [**Hospital Ward Name 23**], Sixth Floor. 6. Otorhinolaryngology appointment with Dr. [**First Name (STitle) **] on [**2167-2-6**] at 8:45 a.m. 7. Dr. ................... at the [**Last Name (un) **] Diabetes Center on [**2167-1-15**] at 2:30 p.m. DISCHARGE CONDITION: Improved. DISPOSITION: To home. DISCHARGE MEDICATIONS: 1. Lactulose 10 grams/15 ml. He should take 38 ml. p.o. four times a day, titrate to three to four loose stools a day. 2. Ursodiol 600 mg two times a day. 3. Pantoprazole 40 mg two times a day. 4. Clotrimazole troches five times a day. 5. Sucralfate 1 gram four times a day. 6. Calcium carbonate 500 mg four times a day. 7. Nadolol 20 mg a day. 8. Spironolactone 100 mg a day. 9. Furosemide 40 mg a day. 10. Insulin regimen: He checks his fingersticks four times a day, and based on his fingersticks and the rise of his fingersticks, he will contact his [**Name (NI) **] physician for changes in his regimen. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7619**] Dictated By:[**Last Name (NamePattern1) 9789**] MEDQUIST36 D: [**2167-1-9**] 16:32 T: [**2167-1-10**] 16:41 JOB#: [**Job Number 48099**] cc:[**Name8 (MD) 48100**]

[ "070.54", "996.74", "578.9", "285.1", "287.5", "456.21", "572.3", "789.5", "571.2" ]

icd9cm

[ [ [] ] ]

[ "39.90", "45.13", "99.04", "99.07", "39.50", "54.91", "42.33", "39.79" ]

icd9pcs

[ [ [] ] ]

10354, 10389

2699, 2809

9399, 9530

10412, 11316

9554, 10332

2376, 2682

273, 1940

1962, 2358

2826, 9378

73,322

136,087

41512

Discharge summary

report

Admission Date: [**2127-3-27**] Discharge Date: [**2127-4-4**] Date of Birth: [**2050-10-13**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 668**] Chief Complaint: Bloody ostomy output Major Surgical or Invasive Procedure: Upper Endoscopy with clipping and epinephrine injection at ulcerated/bleeding portion of Stomach History of Present Illness: 76 y/o male s/p EVAR [**3-3**] complicated by colonic ischemia necessitating exploratory laporotomy and Left colectomy on [**2127-3-5**]. Pt was subsequently discharged to rehab in good condition on [**2127-3-26**] tolerating a regular diet, Tube feeds cycled at night for nutritional supplementation. The patient had a recent J-tube change on [**3-25**]. Yesterday, the patient had fallen out of his wheelchair without apparent injury or issue while at the facility. Later that evening, his nurse [**First Name (Titles) 13431**] [**Last Name (Titles) 90292**] stool from the ostomy. The patient was then transferred to the [**Hospital1 18**] ED today for further assessment. Pt states having pain in his lower back and hips; and, specifically denies any pain in his chest or SOB. He denies further any fevers/chills/nausea or emesis. He feels thirsty/hungry. Past Medical History: PMH: AAA, htn, ^lipids PSH: s/p EVAR + L renal stent [**3-3**] ([**Doctor Last Name **] + [**Doctor Last Name **]), Lt colectomy w/ end colostomy; CABG x1, L CEA, R Fem-->[**Doctor Last Name **] + SFA stent [**2-10**], CCY Social History: Retired, multiple children in the area. Family History: noncontributory Physical Exam: 96. 75 159/54 26 96RA Gen - Obese male, A&O x 3, NAD CV - rrr no m/g/r Pulm - CTAB Abd - soft, ND, TTP near miline incision. 2.5 cm of inferior incision packed with wet to dry dressing, tissue granulating well. Lt end colostomy patent with stool in bag, G tube site with foley in place, no surrounding erethema or induration Extrem - no cce Pertinent Results: [**2127-3-27**] Hct-23.1* [**2127-3-27**] Hct-23.6* [**2127-3-27**] Hct-27.8* [**2127-3-28**] Hct-29.8* [**2127-3-28**] Hct-30.6* [**2127-3-28**] Hct-29.7* [**2127-4-2**] Hct-30.5* Impression: Old blood seen in esophagus. No ulceration visualized. End of feeding tube noted in GE junction. Clotted blood and fresh blood visualized in the stomach obscuring view of the mucosa. Bolster of G tube visualized with large cratered circumferential ulcer beneath balloon with oozing of red blood from periphery. Small black spot potentially visible vessel seen along periphery of ulcer. Balloon deflated with visualization of deep ulceration. (injection, endoclip) No red blood noted in duodenum. No ulcers or other lesions noted. Otherwise normal EGD to second part of the duodenum Brief Hospital Course: The patient was admitted to the West 1 General Surgery service on [**2127-3-27**] for treatment of melena from his ostomy site and an acute drop in his Hct. Neuro: While NPO the patient received IV morphine, with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient was hypertensive once his HCt stabalized and he was slowly started on his antihypertensive medications once he tolerated PO. He was otherwise sable from a CV standpoint; vital signs were routinely monitored. Pulmonary: The patient was intubated for the endoscopy and was intubated through HD 3. He was then extubated and remained stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Upon admission to the surgical ICU a gastric lavage was done which was negative. The patient was transfused 7 units pRBC and 2 units of platelets. GI was consulted and melena extracted from J-G tube site. CTA Abdomen indeterminate for source of bleed. EGD showed large ulcer at duodenal bulb. The GJ tube was removed, the ulcer site clippend and epinephrine was infused across bleed and bleed stabilized. A foley was placed into the G tube tract and secured in place with a stat-lock to keep the tract open. His HCt nadir was 23 and then it trended up toward 30, where he was at the time of discharge. The patient was kept NPO through this and TPN was started on HD 2. On HD 3 the patient had LENI's and was found to have b/l peroneal vein & L right post tibial vein thromboses. Due to the high risk of anticoagulation in the setting of an UGI bleed an IVC filter was placed on HD 4. On HD 5 the patient was transferred to the floor. Hcts remained stable and the patient was started on thickened liquids, which he tolerated well. He was advanced to a diabetic diet on HD 6 and due to poor intake he was started on tube feeds through the foley at the G tube site, which the patient tolerated well. The patient has a history of urinary retention and was transferred to the hospital with a foley in place. He will be discharged to a nursing facility with a foley in place. ID: The patient was started on was started on a seven day course of vanc/zosyn during this admission, which he completed this hospitalization. The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received an IVC filter on HD 4 and was restarted on his ASA and plavix on HD 5, once he was hemodynamically stable. The patient worked with physical therapy while he was hospitalized. At the time of discharge on PPD 8, the patient was doing well, afebrile with stable vital signs, tolerating a diabetic diet and tube feeds, OOB with assistance, and pain was well controlled. Medications on Admission: plavix 75mg daily, ASA 325mg daily, lopressor 100mg daily, norvasc 5mg daily, benicar-HCTZ 40-25mg daily, zocor 60mg daily, allopurinol 300mg daily, metformin 500mg daily, quinapril 20mg daily Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: [**2-2**] Adhesive Patch, Medicateds Topical DAILY (Daily). 4. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Benicar HCT 40-25 mg Tablet Sig: One (1) Tablet PO once a day. 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 3 weeks. 10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. simvastatin 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 12. quinapril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for rash. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Upper gastrointestinal bleed bilateral DVTs (filter placed) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office [**Telephone/Fax (1) 673**] if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or coming out of the ostomy. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. . General 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 [**6-10**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. * Moist dressings will be placed onto the open parts of your incision, as done while you were in the hospital. General 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). *If the drain is connected to a collection container, please 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. *Wash the area gently with warm, soapy water or 1/2 strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2127-4-14**] 10:30 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2127-6-3**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2127-6-3**] 1:30 Completed by:[**2127-4-4**]

[ "532.40", "V44.3", "401.9", "280.0", "272.4", "453.42", "414.00" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "44.43", "38.7", "99.15" ]

icd9pcs

[ [ [] ] ]

6993, 7059

2833, 5587

323, 422

7163, 7163

2032, 2810

9944, 10381

1637, 1654

5831, 6970

7080, 7142

5613, 5808

7339, 8394

9020, 9921

1669, 2013

8426, 9005

263, 285

450, 1316

7178, 7315

1338, 1564

1580, 1621

28,939

122,073

45724+58848

Discharge summary

report+addendum

Admission Date: [**2154-6-26**] Discharge Date: [**2154-7-16**] Date of Birth: [**2085-3-29**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: Abdominal pain with nausea Major Surgical or Invasive Procedure: [**2154-7-5**] Laparoscopy converted to laparotomy, small-bowel resection, and jejunostomy. History of Present Illness: Ms. [**Known lastname 805**] is 4 months after an esophago- gastrectomy for an esophageal cancer, which was treated with neoadjuvant treatment. She has had a jejunostomy tube in place. She has had some progressive nausea and now vomiting with dilatation of the bowel proximal to the jejunostomy site. There is no clear-cut evidence of cancer on a CT scan. The patient has not responded to conservative treatment, and therefore operation was advised and accepted by the patient. Originally, we thought that a laparoscopic revision of the jejunostomy would be feasible. Past Medical History: Diabetes Mellitus Hypertension Hyperlipidemia COPD Esophageal Cancer s/p minimally invasive esophagectomy Breast Cancer s/p Right mastectomy Social History: She has been a nonsmoker for the past year, having started at the age of 14 and smoked up to one pack per day. She drinks an occasional alcoholic beverage, but they are so rare she cannot remember when her last one was. Family History: Her family history is negative for breast or ovarian cancer. She had a maternal uncle with [**Name2 (NI) 499**] cancer and a maternal grandmother with some type of cancer that spread; she is unsure whether this could have been ovarian. There has been no prostate or pancreatic cancers. Physical Exam: PE: 98.1 76 110/54 16 96/RA NAD, A&Ox3, interactive and pleasant RRR, no m/r/g CTAB, no w/c/r Abd mildly distended, soft, diffusely tender to deep palpation, local rebound, no guarding, normal bowel sounds Pertinent Results: Upon admission: [**2154-6-26**] 11:33AM GLUCOSE-199* LACTATE-1.2 NA+-135 K+-4.4 CL--91* TCO2-31* [**2154-6-26**] 11:33AM HGB-10.9* calcHCT-33 [**2154-6-26**] 10:00AM GLUCOSE-207* UREA N-23* CREAT-0.8 SODIUM-133 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-30 ANION GAP-12 [**2154-6-26**] 10:00AM CK(CPK)-18* [**2154-6-26**] 10:00AM cTropnT-<0.01 [**2154-6-26**] 10:00AM CALCIUM-9.3 PHOSPHATE-3.4 MAGNESIUM-2.0 [**2154-6-26**] 10:00AM WBC-14.4* RBC-3.43* HGB-10.2* HCT-31.1* MCV-91 MCH-29.8 MCHC-33.0 RDW-14.6 [**2154-6-26**] 10:00AM PLT COUNT-355 [**2154-6-26**] 10:00AM PT-13.8* PTT-27.8 INR(PT)-1.2* [**2154-6-25**] 11:20AM ALT(SGPT)-35 AST(SGOT)-27 ALK PHOS-141* [**2154-6-25**] 09:55AM URINE RBC-2 WBC-7* BACTERIA-FEW YEAST-NONE EPI-3 [**2154-6-26**] CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Post-surgical changes related to esophagectomy is present with large amount of debris and fluid within the distal neoesophagus. Note is made of air layering in dependent portion of the esophagus, which is probably intraluminal, however close followup is recommended as pneumatosis may have a similar appearance. The lung bases show bibasilar atelectasis, right greater than left. Small right pleural effusion is unchanged. Within the limitations of a non-contrast exam no focal hepatic lesion is identified. The gallbladder is distended and there is mild intrahepatic biliary dilatation which may be related to fasting. There is no gallbladder wall thickening or pericholecystic fluid. The spleen, adrenal glands, and kidneys are unremarkable. The pancreas is atrophic. The duodenum is fluid filled and dilated measuring up to 4.8 cm with abrupt caliber change at the anterior abdominal wall (series 2A, image 47), worrisome for an obstruction. Given that the oral contrast was administered via the jejunostomy, it is difficult to determine the degree of obstruction. The bowel loops distal to this and the jejunostomy remain relatively collapsed. There is no free air or free fluid. The abdominal aorta shows atherosclerotic calcification however maintains a normal caliber. CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: The rectum, sigmoid [**Month/Day/Year 499**] and bladder are within normal limits. The vagina contains soft tissue material which is of uncertain etiology. Direct visualization is recommended as a fistulous connection to the adjacent bowel is not entirely excluded. Small amount of free fluid is present within the pelvis. There is no lymphadenopathy. BONE WINDOWS: No suspicious lytic or sclerotic lesion is identified. Degenerative changes are seen involving the lower lumbar spine and bilateral hips. IMPRESSION: 1. The distal neoesophagus and duodenum are fluid filled and dilated with abrupt caliber change at the anterior abdominal wall proximal to the jejunostomy, worrisome for obstruction. Note is made of gas layering in the dependent portions of the distal esophagus, which is likely intraluminal, however close follow up is recommended as pneumatosis may have a similar appearance. 2. Soft tissue material within the vaginal canal, which is of uncertain significance. Recommend direct visualization as fistulous connection to bowel is not entirely excluded. 3. Small amount of pelvic free fluid. 4. Bibasilar atelectasis and small right pleural effusion. [**2154-7-14**] FINDINGS: There are dilated loops of small bowel measuring approximately 7 cm at its greatest diameter. There are associated air-fluid levels noted in the small bowel. There is no intraperitoneal free air noted. There are post-surgical clips noted in place. There is a nasogastric tube with its tip overlying the gastric shadow. These findings are consistent with small-bowel obstruction. There is slight increase distention from supine portable radiograph from [**2154-7-9**]. The visualized osseous and soft tissue structures are unremarkable. IMPRESSION: Dilated loops of small bowel, slightly worse from [**2154-7-9**] concerning for possible small-bowel obstruction. Brief Hospital Course: Pt admitted to Surgical Floor on [**2154-6-26**] under Dr. [**Last Name (STitle) **]. She was status post esophagogastrectomy with J tube placement for adenocarcinoma and was admitted with question of bowel obstruction after experiencing nausea, vomiting and abdominal pain. She was made NPO and given morphine for pain control as well as anti-emetics for nausea/vomiting. An NG tube was placed for gastrointestinal decompression, which was later removed. A urinalysis specimen came back positive for UTI and she was treated with a three day course of Ciprofloxacin. She had also reported some vaginal bleeding when initially seen in the emergency department. Gynecology was consulted after pelvic matter was seen in the vaginal on CT. She declined an exam in the hospital and it was felt that outpatient follow up with her regular gynecologist would be appropriate to further evaluate the bleeding and pelvic matter on imaging. For nutrition, tube feed were provided through her J tube, however, she continued to experience intermittent nausea and vomiting throughout the early days of her hospital stay. IV fluids were provided for hydration. Potassium and magnesium were provided for correction of hypokalemia and hypomagnesemia respectively. After her nausea and vomiting failed to improve, the decision was made to return to the operating room on [**2154-7-5**] for small bowel resection and J tube revision. Intraoperatively, she was found to have widespread cancer throughout her abdomen. Her J tube was involved by tumor; the affected portion of the jejunum was resected and a new J tube insertion site was created. Atrial fibrillation: HOD 8 ([**2154-7-5**]) Prior to going to the OR the patient developed a-fib with RVR [**12-29**] her afternoon dose of Lopressor was held. The pt was converted to NSR with Lopressor 10mg IVP. The pt went to OR for laparoscopy converted to laparotomy, small-bowelresection, and jejunostomy. Pt tolerated the operation well, but developed a-fib with rapid ventricular response. Loressor was used with success for a few hours, but the patient continued to convert to a-fib and dropped her SBP to 90s (MAP 50s). An amiodarone drip was started and the patient was transferred to the ICU where she did well for the next few days. She was transferred out of the ICU with no further episodes of a-fib. She continued to have further episodes of nausea and vomiting after transfer back to the floor and the NG tube was replaced again. Reglan was tried to promote gastric motility and Pantoprazole was provided for stomach acid reduction without any symptomatic improvement. Nystatin was provided for oral candidiasis. Because of the operative findings of carcinomatosis, there were no further surgical options which were likely to be of substantial curative benefit to the patient. Tube feeds were restarted to the new J tube. A palliative care consult was obtained, which resulted in a family meeting being held. At the family meeting, the patient's diagnosis and prognosis were discussed. After considering all the information, the family chose to proceed with a planned discharge to home with hospice services. NG clamp trials were attempted in an effort to remove the NG, but she always had substantial residual volumes and felt more comfortable with the NG tube in place for decompression since she quickly became nauseated without it. On [**2154-7-16**] after home hospice had been arranged, she was discharged to home with a plan for further palliative and comfort care per hospice. Medications on Admission: Albuterol, fentanyl 100 mcg/72h patch, advair, lasix 20', lansoprazole 30', ativan, reglan, lopressor 25'', zofran, oxycodone elixir, roxicet, colace Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol [**Date Range **]: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath. Disp:*1 * Refills:*2* 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Date Range **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): via j-tube. Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 4. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ML's PO BID (2 times a day). Disp:*600 ML's* Refills:*2* 5. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 6. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID (4 times a day) as needed for oral thrush. Disp:*400 ML(s)* Refills:*0* 7. Fentanyl 100 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) as needed for pain. Disp:*10 Patch 72 hr(s)* Refills:*0* 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply to affected area as directed. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 9. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day): via j-tube. Disp:*60 Tablet(s)* Refills:*2* 10. Scopolamine Base 1.5 mg Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr Transdermal Q72H PRN () as needed for secretions. Disp:*10 Patch 72 hr(s)* Refills:*0* 11. Oxycodone 20 mg/mL (1 mL) Concentrate [**Last Name (STitle) **]: 1/4-1 ML's PO Q3H:PRN as needed for pain. Disp:*60 * Refills:*0* 12. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Ten (10) ML's PO Q6H (every 6 hours) as needed for fever. Disp:*500 ML's* Refills:*0* 13. Prochlorperazine Maleate 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*60 Tablet(s)* Refills:*1* 14. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1) Tablet, Sublingual Sublingual Q4-6H () as needed for secretions. Disp:*30 Tablet, Sublingual(s)* Refills:*1* 15. Prochlorperazine 25 mg Suppository [**Last Name (STitle) **]: One (1) Rectal every 6-8 hours as needed for nausea: use if unable to give via j-tube. Disp:*30 * Refills:*1* 16. Dexamethasone 4 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 17. Ativan 1 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every 4-6 hours as needed for anxiety: [**Month (only) 116**] use as alternate Ativan liquid 5mg/ml; 1-2 mg every 4-6 hours prn. Disp:*60 Tablet(s)* Refills:*1* 18. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month (only) **]: Five (5) ML Intravenous PRN (as needed) as needed for line flush: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. . Disp:*60 ML(s)* Refills:*1* 19. Morphine Concentrate 20 mg/mL Solution [**Month (only) **]: 0.25 ML's PO every four (4) hours as needed for pain: give sublingually as needed for moderate to severe pain. Disp:*15 ML's* Refills:*0* 20. Zofran 4 mg/5 mL Solution [**Month (only) **]: [**4-6**] ML's PO every 6-8 hours as needed for nausea. Disp:*300 ML's* Refills:*0* 21. Intravenous fluids Normal saline continuous at 100 ml/hour Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: Esophageal Cancer w/ recurrnece Small bowel obstruction carcinomatosis Discharge Condition: Hemodynamically stable, pain adequately controlled Discharge Instructions: Contact [**Hospital 2188**] 24 hours a day/7 days a week [**Telephone/Fax (1) 97440**] if there are any concerns pertaining your health status and you will be directed accordingly. Followup Instructions: Follow up in 2 weeks with Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **], call [**Telephone/Fax (1) 2981**] to make that appoinment. You will need to call for an appointment with Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]. You have an appoinment with Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2154-9-18**] 11:00 Name: [**Known lastname 183**],[**Known firstname 15548**] Unit No: [**Numeric Identifier 15549**] Admission Date: [**2154-6-26**] Discharge Date: [**2154-7-16**] Date of Birth: [**2085-3-29**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 203**] Addendum: Additional secondary diagnosis for Ms. [**Known lastname **]: Nursing documentation towards the end of the admission reveals Stage II Ulcer of the Buttocks/Rxd. The pressure ulcers were not noted to be present at admission. They developed during Ms. [**Known lastname **]' long hospitalization and were treated with Aloe Vista and an air mattress. Discharge Disposition: Home With Service Facility: [**Location (un) 15504**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**] Completed by:[**2154-7-30**]

[ "560.89", "V64.41", "496", "197.6", "V66.7", "599.0", "427.31", "272.4", "276.8", "V10.03", "250.00", "401.9", "707.05", "197.4", "275.2" ]

icd9cm

[ [ [] ] ]

[ "46.39", "54.23", "45.62", "96.6", "45.91" ]

icd9pcs

[ [ [] ] ]

15027, 15238

6020, 9554

341, 435

13501, 13553

1989, 1991

13782, 15004

1455, 1743

9755, 13313

13408, 13480

9580, 9732

13577, 13759

1758, 1970

275, 303

463, 1036

2006, 5997

1058, 1201

1217, 1439

1,882

132,824

10933

Discharge summary

report

Admission Date: [**2161-4-6**] Discharge Date:[**2161-4-17**] Date of Birth: [**2110-12-1**] Sex: M Service: HEPATOBILIARY SURGERY SERVICE CHIEF COMPLAINT: Abdominal pain, weakness. HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old, Asian male, with a history of metastatic hepatocellular carcinoma and hepatitis B infection who presented to [**Hospital1 1444**] on [**2161-4-5**] with complaints of abdominal pain and weakness. PAST MEDICAL HISTORY: Significant for hepatitis B infection and metastatic hepatocellular carcinoma. PAST SURGICAL HISTORY: Liver biopsy times two. Radio frequency ablation times three. MEDICATIONS AT HOME: Herbs, tea and Acupuncture. SOCIAL HISTORY: The patient is married. He lives at home with his wife. [**Name (NI) **] does not smoke tobacco, drink alcohol or use illicit drugs. REVIEW OF SYSTEMS: The patient reports the acute onset of abdominal pain, diaphoresis, weakness and dyspnea. HOSPITAL COURSE: As above, the patient presented to [**Hospital1 1444**] on [**2161-4-5**] with complaints of weakness and abdominal pain. On presentation, the patient was notably diaphoretic and dyspneic. He was tachycardiac with a heart rate in the 120's. His blood pressure remained stable. LABORATORY DATA: Values obtained emergently revealed a hematocrit of 28.5. The patient was resuscitated with intravenous fluids. A CT scan was obtained which revealed a large amount of blood adjacent to the liver, in the area of a large hepatoma. The blood extended into the pelvis. The CT scan also noted, in addition to the hepatoma, multiple pulmonary metastases, predominantly in the right lower lobe with an associated effusion. The patient was admitted to the surgery service. The patient rapidly was transfused with packed red cells. A repeat hematocrit obtained was 25.5. He patient was transferred to the surgical ICU. He continued to be resuscitated aggressively with packed red blood cells and fresh frozen plasma, for an INR of 2.0. Mr. [**Known lastname 35520**] hematocrit stabilized at 40.6 after four units of packed red cells. He became noticeably more comfortable. His abdominal distention decreased. His shortness of breath subsided. After four units of FFP as well his INR became stable at 1.4. Mr. [**Known lastname **] would remain in the ICU under close observation. Serial hematocrits were checked. His vital signs were monitored diligently and serial physical examinations were made. Mr. [**Known lastname **] was eventually transferred to the floor after several days in stable condition in the ICU. He did well on the floor until the day of [**4-9**], when again he began to complain of severe abdominal pain, associated with abdominal distention and shortness of breath. Vital signs were expeditiously obtained and revealed a drop in systolic blood pressure of nearly 60 points. Two units of packed red blood cells were ordered emergently. A stat hematocrit checked revealed a drop in the patient's hematocrit from 31.7 to 26.9 over a several hour period. He was transferred to the ICU. He received 2 units of packed red cells and 2 units of FFP. His hematocrit stabilized at 33.2 and would remain stable thereafter. Palliative care consult was obtained. Intimate discussions with the patient and his family were initiated and the patient requested to be made CMO (comfort measures only). The patient remained in the care of the hepatobiliary surgical service. His physical state began to decline. He began to show signs of hepatic encephalopathy. His respiratory status as well began to decline. On [**2161-4-17**], Mr. [**Known lastname **] passed away from complications of metastatic hepatocellular carcinoma and respiratory failure. TIME OF DEATH: 5:11 p.m. The [**Location (un) 511**] Organ Bank was notified and the patient was declined for organ transplantation by the [**Location (un) 511**] Organ Bank. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PHD[**Numeric Identifier **] Dictated By:[**Last Name (NamePattern1) 16264**] MEDQUIST36 D: [**2161-4-17**] 17:44:25 T: [**2161-4-17**] 18:43:22 Job#: [**Job Number 35521**]

[ "276.7", "570", "276.1", "070.32", "568.81", "197.0", "286.7", "518.81", "197.2", "155.0" ]

icd9cm

[ [ [] ] ]

[ "99.07", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

985, 4212

674, 703

588, 652

876, 967

178, 205

234, 461

484, 564

720, 856

27,597

117,860

34483

Discharge summary

report

Admission Date: [**2201-3-14**] Discharge Date: [**2201-3-22**] Date of Birth: [**2139-4-7**] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 4854**] Chief Complaint: Weakness, [**First Name3 (LF) 7186**] of breath Major Surgical or Invasive Procedure: None History of Present Illness: 61 y/o male with history of Wegener's granulomatosis and autoimmune lymphopenia, on immunosuppression complicated by multiple infections as detailed in HPI below presents with weakness and [**First Name3 (LF) 7186**] of breath. He has been maintained on long term azathioprine with a recent taper of his immunosuppresion over the past several months. He has complained of dizziness and headaches but this has thought to be related to his antihypertension medications. Most recently he has not had any evidence of active pulmonary vasculitis and stable emphysema. Today he developed lethargy and was brought to the ED by his nephew. [**Name (NI) **] was noted to be hypotensive with SBP 78 and tachycardic and was started on an NRB. A CXR demonstrated a LLL PNA. A central line was placed and he was started on levofloxacin and Zosyn. A CT chest/abdomen without contrast was performed that demonstrated multiple anomalies including: 1. Multiple new small nodules, many of which are cavitating, within the right lung, which may be consistent with patient's known Wegener's granulomatosis. However, infectious process, including fungal or septic emboli, cannot be excluded. 2. Extensive consolidation in the left lower lobe, consistent with pneumonia. 3. Limited examination for mesenteric ischemia; however, there is loss of normal haustra and mild bowel wall thickening of the colonic wall starting from the hepatic flexure extending to the proximal descending colon. This could represent an infectious/inflammatory colitis. Ischemia is thought to be less likely due to the distribution of the abnormality, spanning different vascular territories. . He was paralyzed, intubated, and sent to the ICU for further care. Past Medical History: - cANCA+ vasculitis - renal bx [**7-5**]; pulmonary-renal disease; s/p plasmapheresis x 1 week, IVP steroids; PO Cytoxan x1 month with neutropenia; AZA since [**1-6**] with slow pred taper. - Prolonged neutropenia in [**9-4**] and [**12-6**]. - Aspergillus fumigatus PNA in [**7-5**] (sputum+, galactomannan+), voriconazole x 6 wks in [**8-5**]. - Stenotrophomonas PNA while neutropenic in [**9-4**] (BAL+), completed Bactrim course x 3 wks. - ?Latent TB (right-sided apical pulmonary scar on chest CT + h/o exposure from father; PPD neg, 3x induced sputum neg in [**7-5**]), INH [**Date range (1) 79239**] completed. - Parainfluenza in [**12-6**]. - Pseudomonas PNA in [**12-7**]. - ACD, Aflutter, emphysema/COPD. - Presumed autoimmune lymphopenia. - Steroid-induced osteoporosis. - Primary hypogonadism. Social History: He lives by himself. He works as a machine operator and currently not working. He does not smoke. He does not drink alcohol. Family History: No family history of osteoporosis. His brother has coronary artery disease and his twin brother has heart disease. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: LABS ON ADMISSION: [**2201-3-14**] 06:10PM PT-11.1 PTT-20.7* INR(PT)-0.9 [**2201-3-14**] 06:10PM PLT COUNT-255 [**2201-3-14**] 06:10PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-2+ POLYCHROM-2+ OVALOCYT-1+ STIPPLED-OCCASIONAL TEARDROP-1+ PAPPENHEI-1+ BITE-1+ [**2201-3-14**] 06:10PM NEUTS-18* BANDS-41* LYMPHS-5* MONOS-17* EOS-7* BASOS-1 ATYPS-3* METAS-5* MYELOS-1* YOUNG-2* NUC RBCS-14* [**2201-3-14**] 06:10PM WBC-4.1 RBC-3.97* HGB-13.5* HCT-39.3* MCV-99* MCH-34.0* MCHC-34.3 RDW-18.6* [**2201-3-14**] 06:10PM HGB-14.0 calcHCT-42 [**2201-3-14**] 06:10PM GLUCOSE-239* LACTATE-7.5* K+-5.7* [**2201-3-14**] 06:10PM ALBUMIN-3.2* [**2201-3-14**] 06:10PM cTropnT-0.11* [**2201-3-14**] 06:10PM ALT(SGPT)-27 AST(SGOT)-19 ALK PHOS-82 TOT BILI-0.3 [**2201-3-14**] 06:10PM GLUCOSE-253* UREA N-140* CREAT-3.8* SODIUM-133 POTASSIUM-6.0* CHLORIDE-95* TOTAL CO2-15* ANION GAP-29* [**2201-3-14**] 06:35PM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [**2201-3-14**] 06:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2201-3-14**] 06:35PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2201-3-14**] 07:29PM GLUCOSE-129* LACTATE-4.2* NA+-136 K+-4.3 CL--117* TCO2-12* [**2201-3-14**] 10:29PM freeCa-1.04* [**2201-3-14**] 10:29PM O2 SAT-86 [**2201-3-14**] 10:29PM GLUCOSE-201* LACTATE-3.3* NA+-133* K+-4.9 CL--111 [**2201-3-14**] 10:29PM TYPE-ART RATES-16/ TIDAL VOL-450 O2-100 PO2-72* PCO2-54* PH-7.06* TOTAL CO2-16* BASE XS--15 AADO2-601 REQ O2-96 -ASSIST/CON INTUBATED-INTUBATED [**2201-3-14**] 11:34PM O2 SAT-80 [**2201-3-14**] 11:34PM LACTATE-1.8 [**2201-3-14**] 11:34PM TYPE-ART TEMP-35.8 RATES-/24 TIDAL VOL-450 PEEP-16 O2-100 PO2-54* PCO2-47* PH-7.08* TOTAL CO2-15* BASE XS--16 AADO2-626 REQ O2-100 -ASSIST/CON INTUBATED-INTUBATED ======== MICROBIOLOGY: - [**2201-3-14**] Urine culture: no growth - [**2201-3-14**] Blood culture: no growth - [**2201-3-15**] Blood culture: no growth - [**2201-3-15**] Blood culture: no growth - [**2201-3-15**] MRSA screen: no MRSA isolated - [**2201-3-16**] Blood culture: PENDING ** - [**2201-3-16**] Urine legionella antigen: negative - [**2201-3-17**] Sputum: Gram stain - <10 PMNs and <10 epithelial cells/100X field, 2+ microorganisms consistent with oropharyngeal flora; culture - sparse growth commensal respiratory flora, moderate growth yeast, rare growth Aspergillus fumigatus. - [**2201-3-19**] C. difficile toxin: negative - [**2201-3-20**] CMV viral load: PENDING ** - [**2201-3-20**] Cryptococcal antigen: negative - [**2201-3-21**] Sputum: Gram stain - <10 PMNs and <10 epithelial cells/100X field, 1+ GNR, 1+ budding yeast with pseudohyphae; culture - PENDING **; fungal culture - PENDING ** ======== IMAGES/STUDIES: [**2201-3-14**] ECG: Atrial flutter with rapid ventricular response. ST-T wave abnormalities are non-specific. Since the previous tracing of [**2200-11-26**] ventricular rate is faster and further ST-T wave changes are present. [**2201-3-14**] CXR: UPRIGHT AP VIEW OF THE CHEST: Dense consolidation within the left lung base is concerning for pneumonia. There is likely a small left effusion. Right internal jugular central venous catheter tip terminates within the SVC. Focal ill-defined patchy and nodular opacities within the right upper lobe appear similar to the prior study. Relative lucency of the lung apices reflects underlying emphysema. Cardiac, mediastinal and hilar contours are unremarkable. There is no pneumothorax. IMPRESSION: New consolidation in left lung base concerning for pneumonia. Followup radiographs after treatment are recommended to ensure resolution. [**2201-3-14**] CT torso: IMPRESSION: 1. Multiple new small nodules, many of which are cavitating, within the right lung, which may be consistent with patient's known Wegener's granulomatosis. However, infectious process, including fungal or septic emboli, cannot be excluded. 2. Extensive consolidation in the left lower lobe, consistent with pneumonia. 3. Limited examination for mesenteric ischemia; however, there is loss of normal haustra and mild bowel wall thickening of the colonic wall starting from the hepatic flexure extending to the proximal descending colon. This could represent an infectious/inflammatory colitis. Ischemia is thought to be less likely due to the distribution of the abnormality, spanning different vascular territories. 4. Avascular necrosis of the right femoral head. 5. New L2 compression deformity, and unchanged T12 wedge compression fracture. [**2201-3-16**] Abdominal x-ray: IMPRESSION: A solitary overhead view of the abdomen excludes the lower pelvis. As far as one can tell with the patient in this position, there is no appreciable distention of the GI tract, with the exception of the stomach which is fluid filled, despite a nasogastric tube in place. Upright views would be helpful. [**2201-3-16**] Head CT: IMPRESSION: 1. No acute intracranial abnormality. 2. Sinus disease as above. [**2201-3-17**] CXR: Of note the left CP angle was not included on the film, The visualized left lower lobe with ill-defined opacities is unchanged. This is more likely due to hemorrhage. Otherwise there are no changes in the right lobe with pleural parenchyma scarring in the right apex. Lines and tubes remain in place. [**2201-3-18**] CXR: FINDINGS: In comparison with the study of [**3-17**], the monitoring and support devices are essentially unchanged. Areas of increased opacification persist in the lower half of the left hemithorax. This could be due to pulmonary hemorrhage or superimposed pneumonia. Apical pleural changes are again seen. Respiratory motion somewhat obscures the sharpness of the image. [**2201-3-18**] RUQ ultrasound with Doppler: FINDINGS: Extremely limited views of the liver demonstrate no focal or textural abnormality. There is no intra- or extra-hepatic biliary dilatation. The gallbladder is normal without evidence of stones. The common bile duct is not dilated measuring up to 3 mm. There is no evidence of splenomegaly with spleen measuring up to 9.9 cm. DOPPLER EXAMINATION: The main portal vein, right anterior and posterior, and left portal branches are patent with appropriate directions of flow and Doppler waveforms. The right, middle, and left hepatic veins are patent. The IVC is patent. The main hepatic artery is patent with appropriate arterial waveforms. No appreciable ascites. IMPRESSION: 1. Limited study with no gross abnormalities of the liver. 2. Patent hepatic vasculature. [**2201-3-19**] CXR: FINDINGS: As compared to the previous radiograph, the monitoring and support devices are unchanged. Unchanged extent of the predominantly left basal parenchymal opacities, combined to some degree of retrocardiac atelectasis. Unchanged borderline size of the cardiac silhouette without evidence of pulmonary edema. No newly occurred opacities. The presence of a small left pleural effusion cannot be excluded. [**2201-3-19**] IVC filter placement: [**2201-3-19**] CT torso: IMPRESSION: 1. Worsening of pulmonary abnormalities in right lower lobe and left upper lobe but improvement in left lower lobe. 2. Findings consistent with bleeding in the internal adductor muscles of the left hip. 3. Small amount of perihepatic fluid. [**2201-3-20**] CXR: Bibasilar consolidation, left greater than right, worsened since [**3-17**], stable since [**3-19**], consistent with bilateral pneumonia, possibly due to aspiration, alternatively pulmonary hemorrhage. Left lung base is excluded from the examination, probable small persistent left pleural effusion. Heart size normal. ET tube, right internal jugular lines in standard placements, nasogastric tube passes below the diaphragm and out of view. No pneumothorax. [**2201-3-21**] CXR: FINDINGS: As compared to the previous radiograph, the monitoring and support devices are unchanged. The pre-existing bilateral apical and bilateral basal opacities that are slightly more severe on the left than on the right, have mildly improved. New parenchymal opacities are not seen. Normal size of the cardiac silhouette. Brief Hospital Course: 61 y/o male with a history of Wegener's granulomatosis admitted with respiratory failure thought to be due to pneumonia. He was intubated and admitted to the MICU for further management. The suspicion was highest that he developed respiratory failure due to pneumonia in a patient with emphysema and [**Month/Day/Year **] lung damage from repeated infections and Wegener's granulomatosis. Given his history of multiple past pulmonary infections he was started on broad spectrum antibiotic coverage. His hospital course was complicated by sepsis requiring multiple vasopressors, oliguric renal failure with hyperkalemia, acidosis, and volume overload requiring CVVH, lower extremity deep vein thrombosis, atrial tachyarrhythmia, ileus, and anemia with CT scan showing internal adductor muscle bleed. Regarding his DVT, given his bleeding and evidence of coagulopathy he underwent a temporary IVC filter placement by interventional radiology. Multiple services were consulted including the infectious disease team regarding management of his pulmonary infection, the renal service for management of oliguric renal failure, and rheumatology given his Wegener's disease. Despite out combined efforts, his respiratory status declined as he developed an increasing FiO2 requirement with agonal breathing, also with worsening hemodynamic status and acidemia, and deterioration in his neurological status. With the family's urging, the decision was made to transition the patient towards comfort measures. The vasopressors were stopped, CVVH was held, and he was extubated with the family by his side. He expired on [**2201-3-22**]. The family accepted our offer for post-mortem. Medications on Admission: Medications (per OMR): - Tylenol #3 1 Tab Q8 Hrs - Azathioprine 150 daily - Aransep 60mg every other week - Diltiazem XR 120 daily - Ergocalciverol 50,000U weekly - Furosemide 40 [**Hospital1 **] - Combivent 1-2 puffs Q 4 hours - Lisinopril 5 daily -- stopped on [**3-13**] - Toprol XL 100 daily - Nystatin 100,000 2 tablespoons by mouth QID for thrush - Predinsone 2mg daily - Sertraline 50mg daily - Simvastatin 20mg daily - Sodium Polystyrene Sulfonate 30g as needed for elevated K - Bactrim DS 1 Tab TIW - Androgel 1% gel apply one packet to back daily - Spirival 18mcg Capsule 1 capsule daily - ASA 325 daily - CaCO3 500mg TID - Ferrous Sulfate 324 Tab 1 tab daily - Ranitidine 150 daily - Sodium Bicarbonate 650 1 tab [**Hospital1 **] Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Wegener's granulomatosis Pneumonia Sepsis DVT Anemia Acute renal failure Ileus Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**] MD, [**MD Number(3) 4858**]

[ "584.9", "453.40", "279.49", "276.2", "250.00", "782.3", "518.81", "733.42", "492.8", "285.1", "582.1", "257.2", "558.9", "446.4", "V66.7", "E932.0", "585.4", "995.92", "288.00", "276.7", "427.32", "560.1", "733.09", "486", "038.9", "785.52", "728.89", "286.9" ]

icd9cm

[ [ [] ] ]

[ "38.7", "96.04", "96.6", "96.72", "38.95", "39.95", "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

14357, 14366

11858, 13536

318, 324

14488, 14498

3687, 3692

14555, 14699

3068, 3186

14328, 14334

14387, 14467

13562, 14305

14522, 14532

3201, 3668

231, 280

352, 2077

8638, 11835

3706, 8629

2099, 2906

2922, 3052

25,107

131,511

15462

Discharge summary

report

Admission Date: [**2195-5-13**] Discharge Date: [**2195-5-21**] Date of Birth: [**2135-10-2**] Sex: M Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 59-year-old man with cardiac risk factors of hypertension, tobacco use, positive family history, and PTCA in the past who had two episodes of chest pain over the weekend; both happened while he was at rest and were relieved by sublingual nitroglycerin. He has been pain-free since that time. However, since he had a PTCA of the left main in [**Month (only) 359**] of last year, it was felt that he should be re-catheterized with the onset of this chest pain. PAST MEDICAL HISTORY: 1. Hypertension. 2. CAD. 3. Hypercholesterolemia. 4. Paroxysmal atrial fibrillation. ALLERGIES: The patient has no known drug allergies. MEDICATIONS PRIOR TO ADMISSION: 1. Aspirin 325 once a day. 2. Lopressor 25 twice a day. 3. Lipitor 20 mg once a day. 4. Wellbutrin 150 mg twice a day. 5. Plavix 75 mg once a day. 6. Coumadin 5 mg once a day. FAMILY HISTORY: Both parents died in their 70s from an MI. He has one brother who has had a CABG in the past. SOCIAL HISTORY: Formerly worked laying carpets. He has been disabled since [**2194-10-14**]. Positive tobacco use, currently one pack per day, previously two packs per day times 40 years. Remote alcohol use. He has quit since [**Month (only) 359**]. STUDIES: As stated previously, the patient was admitted to [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] to undergo cardiac catheterization. Please see the catheterization report for full details. In summary, the cath showed left main with diffuse moderate in-stent restenosis up to 90%, LAD was normal, left circumflex was normal, and RCA was normal. He had no mitral regurgitation and mild global hypokinesis. Following catheterization, CT Surgery was consulted. The EKG at the time of catheterization was sinus brady at a rate of 54, intervals 0.18, 0.82, 0.40, with Qs in III and aVF. The laboratory data revealed a white count of 9.4, hematocrit 44.9, platelets 354,000. Sodium 139, potassium 4.6, chloride 103, C02 24, BUN 17, creatinine 0.7, glucose 89, INR 1.4. PHYSICAL EXAMINATION: Height 5' 4", weight 170 pounds. Vital signs: Heart rate 54, sinus rhythm, blood pressure 132/80, respiratory rate 20, 02 saturation 98% on room air. General: The patient was in no acute distress. HEENT: Pupils were equally round and reactive to light with extraocular movements intact, anicteric, noninjected. OP and mucous membranes were moist. There was no erythema or exudate. Positive dental caries. Neck: Supple with no lymphadenopathy, no thyromegaly, no bruits. Chest: Clear to auscultation. Coronary: Regular rate and rhythm, S1, S2, with no murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly. Extremities: Warm and well perfused with no clubbing, cyanosis or edema. No varicosities. Pulses: Carotids 2+ bilaterally with no bruit. Radial 2+ bilaterally. Femoral 2+ bilaterally. Dorsalis pedis and posterior tibial 1+ bilaterally. HOSPITAL COURSE: The patient was seen by CT Surgery and accepted for coronary artery bypass grafting. On [**2195-5-15**], the patient was brought to the Operating Room where he underwent coronary artery bypass grafting times two. Please see the OR report for full details. In summary, the patient had a CABG times two with LIMA to LAD and saphenous vein grafts to the OM. He tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient had a mean arterial pressure of 80, CVP 13. He was A paced with a heart rate of 88. At the time of transfer, he had propofol at 20 micrograms/kilogram per minute and Neo-Synephrine at 0.3 micrograms/kilogram per minute. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from sedation and then weaned from the ventilator, successfully extubated within several hours of arrival to the Cardiothoracic Intensive Care Unit. On postoperative day number one, the patient remained hemodynamically stable. His chest tubes were removed and he was transferred to the floor for continued postoperative care and cardiac rehabilitation. Once on the floor, the patient was noted to be in a rapid atrial fibrillation with a heart rate up to 147. He was treated with IV Lopressor followed by a bolus of Amiodarone. The Lopressor controlled his rate and eventually he converted to a normal sinus rhythm. He did, however, continue to have episodes of intermittent atrial fibrillation throughout his hospitalization and was subsequently anticoagulated. Over the next several days, the patient remained hemodynamically stable. His activity level was increased with the assistance of physical therapy and the nursing staff. As stated previously, he was ultimately anticoagulated with heparin and Coumadin. On postoperative day number five, it was felt that he was getting close to his goal INR and would be ready for discharge to home within the next day or two. DISCHARGE PHYSICAL EXAMINATION: At this time, the patient's physical examination is as follows: Vital signs: Temperature 98, heart rate 64, sinus rhythm, blood pressure 121/66, respiratory rate 18, 02 saturation 98% on room air. Weight preoperatively 77 kilograms, at discharge 74.5 kilograms. The laboratories revealed a white count of 9.6, hematocrit 31.9, platelets 385,000. Sodium 137, potassium 4.8, chloride 102, C02 20, BUN 19, creatinine 0.9, glucose 110. The INR on [**2195-5-20**] is 1.3. DISCHARGE MEDICATIONS: 1. Lasix 20 mg q.d. times seven days. 2. Potassium chloride 20 mEq q.d. times seven days. 3. Metoprolol 50 mg b.i.d. 4. Bupropion 75 mg q.d. 5. Enteric coated aspirin 81 mg q.d. 6. Coumadin over the past two days has been dosed with 5 mg, goal INR was 2.0. 7. Amiodarone 400 mg b.i.d. times two weeks and then 400 mg q.d. times two weeks and then 200 mg q.d. P.R.N. MEDICATIONS: Percocet 5/325 one to two tablets q. four hours p.r.n. CONDITION AT THE TIME OF DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Coronary artery disease, status post coronary artery bypass grafting times two with left internal mammary artery to the left anterior descending artery and saphenous vein graft to the obtuse marginal. 2. Hypertension. 3. Hypercholesterolemia. 4. Paroxysmal atrial fibrillation. FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] for his Coumadin dosing and follow-up with Dr. [**Last Name (STitle) 70**] in four to six weeks. Anticipated date of discharge is [**2195-5-21**] or [**2195-5-22**]. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2195-5-20**] 07:37 T: [**2195-5-20**] 20:45 JOB#: [**Job Number 44852**]

[ "V58.61", "996.72", "411.1", "401.9", "V45.82", "427.31", "272.0", "414.01" ]

icd9cm

[ [ [] ] ]

[ "88.55", "39.61", "36.11", "36.15", "37.22", "88.53" ]

icd9pcs

[ [ [] ] ]

1040, 1135

5726, 6216

6237, 7054

3173, 5208

840, 1023

5231, 5703

664, 808

1152, 2208

42,950

168,075

42490

Discharge summary

report

Admission Date: [**2110-1-14**] Discharge Date: [**2110-1-17**] Date of Birth: [**2055-10-25**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 922**] Chief Complaint: mitral regurgitation, atrial septal defect Major Surgical or Invasive Procedure: Minimally invasive mitral valve repair, resection of P2, (34mm ring), closure of atrial septal defect [**2110-1-14**] History of Present Illness: This 54 year old white male has had known mitral regurgitaion for some time. Several months ago he noted fatigue and inability to run as he had been Echocardiography revealed worsening regurgitation and he was referred for surgical evaluation. Coronaries were clean and operation was scheduled. Past Medical History: head trauma after MVA [**2097**]/MRSA eye surgery secondary to above h/o basal cell carcinoam s/p tonsillectomy Social History: Race: Caucasian Last Dental Exam: 2-3 months ago Lives: Alone Occupation: Self employed, landscape designer Cigarettes: Denies ETOH: < 1 drink/week [x] [**2-4**] drinks/week [] >8 drinks/week [] Other: Occasional marijuana - last use over one year ago Family History: Family History: Denies premature coronary artery disease. Great grandparents with sudden cardiac death - unknown cause. Physical Exam: Pulse: 61 Resp: 16 O2 sat: 100% room air B/P Right: 128/73 Left: 124/72 70" 79.8 kg General: WDWN male in no acute distress 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 [x] grade [**4-4**] holosystolic murmur radiating throughout his precordium and carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: None Varicosities: None Neuro: Grossly intact 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: transmitted murmur noted - right > left Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 91962**] (Congenital) Done [**2110-1-7**] at 10:33:37 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Outpatient DOB: [**2055-10-25**] Age (years): 54 M Hgt (in): 70 BP (mm Hg): 115/72 Wgt (lb): 172 HR (bpm): 62 BSA (m2): 1.96 m2 Indication: Mitral valve prolapse. Shortness of breath. ICD-9 Codes: 745.5, 786.05, 424.0 Test Information Date/Time: [**2110-1-7**] at 10:33 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Test Type: TEE (Congenital) Son[**Name (NI) 930**]: Cardiology Fellow Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2012W012-0:00 Machine: Q-2 Vivid Sedation: Versed: 1 mg Fentanyl: 50 mcg Patient was monitored by a nurse throughout the procedure Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: >= 60% >= 55% Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Aneurysmal interatrial septum. Left-to-right shunt across the interatrial septum at rest. Small secundum ASD. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV systolic function. AORTA: No atheroma in aortic arch. No atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate/severe MVP. Eccentric MR jet. Moderate to severe (3+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the patient. A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). The posterior pharynx was anesthetized with 2% viscous lidocaine. 0.2 mg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe insertion. No TEE related complications. Results were reviewed with the Cardiology Fellow involved with the patient's care. Conclusions The interatrial septum is aneurysmal. A left-to-right shunt across the interatrial septum is seen at rest with a small secundum atrial septal defect (measuring 7 mm). Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is moderate/severe [**Hospital1 **]-leaflet mitral valve prolapse (P2 most severe) with an eccentric, septally directed jet of moderate to severe (3+) mitral regurgitation. There is no clear flow reversal in the left upper pulmonary vein. There is no pericardial effusion. IMPRESSION: Small (7 mm) secundum atrial septal defect with left-to-right flow at rest. Severe posterior (particularly P2) > anterior leaflet mitral valve prolapse with moderate to severe mitral regurgitation. I certify that I was present for this procedure in compliance with HCFA regulations. [**2110-1-17**] 05:07AM BLOOD WBC-9.4 RBC-3.39* Hgb-11.3* Hct-31.8* MCV-94 MCH-33.3* MCHC-35.6* RDW-11.9 Plt Ct-185 [**2110-1-17**] 05:07AM BLOOD Glucose-124* UreaN-16 Creat-1.0 Na-140 K-4.2 Cl-106 HCO3-28 AnGap-10 Brief Hospital Course: Following same day admission he went to the operating room where the valve and the atrial septal defect were repaired using a minimally invasive technique. See operative note for details. He weaned from bypass easily, was weaned from the ventilator and extubated. He remained stable, chest tubes were removed on POD 1 and he transferred to the floor. Pain was controlled with Percocet and Ibuprofen and much better controlled after chest tube removal. Diuresis and beta blockade were instituted. He did have a first degree AV block with a PR interval of .32 but he was hemodynamically stable in this rhythm. Physical Therapy was consulted for mobility. On POD 3 he was ambulating in the halls without difficulty, his incision was healing well and he was tolerating a full oral diet. He continued to make good progress and was cleared for discharge to home with VNA on POD #3. All follow up appointments were advised. Medications on Admission: Multivitamin daily, Cod liver oil 3x weekly, Melatonin daily Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 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:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 3 months. Disp:*360 Tablet(s)* Refills:*2* 4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*1* 5. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily) for 5 days. Disp:*10 Tablet Extended Release(s)* Refills:*1* 6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: mitral regugitation atrial septal defect s/p mitral valve repair & closure of atrial septal defect s/p tonsillectomy h/o basal cell cancer prior MVA with prolonged hospitalization/MRSA Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Right mini thoracotomy incision- healing well, no erythema or drainage No 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 3 weeks 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 2-3 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon:Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**2-24**] at 1:00pm Cardiologist:Dr. [**First Name (STitle) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **] on [**2-5**] at 11:15am wound check on [**1-23**] at 10:00am Please call to schedule appointments with: Primary Care: Dr.[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 19961**] ([**Telephone/Fax (1) 52959**]in [**4-3**] 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**x Completed by:[**2110-1-17**]

[ "V10.83", "518.52", "285.1", "414.10", "458.29", "426.11", "424.0", "745.5", "V12.04" ]

icd9cm

[ [ [] ] ]

[ "35.71", "35.12", "39.61" ]

icd9pcs

[ [ [] ] ]

7973, 8032

6120, 7043

341, 461

8261, 8475

2106, 6097

9315, 10031

1226, 1332

7155, 7950

8053, 8240

7069, 7132

8499, 9292

1347, 2087

259, 303

489, 788

810, 923

939, 1194

29,221

157,580

31982

Discharge summary

report

Admission Date: [**2156-11-25**] Discharge Date: [**2156-12-1**] Date of Birth: [**2082-6-15**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Angina Major Surgical or Invasive Procedure: CABG X 6 ([**2156-11-26**]- LIMA to LAD, SVG to DIAG, SVG to PDA to PLV, SVG to OM, with Y graft to RAMUS) History of Present Illness: 74 yo M with history of angina, diaphoresis that has progressed to crescendo in the last 2 weeks. Past Medical History: CAD bph, ^chol, HTN, Angina Social History: retired quit tob [**2115**] - 10 pack year history 3 etoh/week Family History: 2 brothers and sister with CABG at unknown age Physical Exam: HR 56 RR 18 BP 142/58 WD elderly M in NAD Upper and lower dentures Lungs CTAB RRR no murmur Abdomen soft, NT, ND Extrem warm, no edema, 2+ dp/pt pulses No carotid bruits Pertinent Results: [**2156-11-30**] 06:40AM BLOOD WBC-8.2 RBC-3.31* Hgb-10.0* Hct-29.1* MCV-88 MCH-30.3 MCHC-34.4 RDW-15.5 Plt Ct-171 [**2156-11-30**] 06:40AM BLOOD Plt Ct-171 [**2156-11-30**] 06:40AM BLOOD Plt Ct-171 [**2156-11-29**] 01:35AM BLOOD PT-13.5* PTT-29.4 INR(PT)-1.2* [**2156-11-30**] 06:40AM BLOOD Glucose-133* UreaN-22* Creat-1.0 Na-140 K-4.0 Cl-103 HCO3-30 AnGap-11 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2156-11-29**] 9:22 AM CHEST (PORTABLE AP) Reason: r/o ptx [**Hospital 93**] MEDICAL CONDITION: 74 year old man s/p CABG and chest tubes removal REASON FOR THIS EXAMINATION: r/o ptx CHEST PORTABLE AP. CHEST PORTABLE AP [**2156-11-28**]. HISTORY: Evaluate for pneumothorax. FINDINGS: There is poor inspiration with elevated hemidiaphragms. There are sternotomy wires in place. There has been interval removal of drains. There is no pneumothorax identified. There are bilateral pleural effusions. There is a sharpness to the right cardiophrenic angle, likely representing a pleural reaction. The lung fields are otherwise clear. IMPRESSION: No evidence of pneumothorax. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**] DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Approved: MON [**2156-11-29**] 8:45 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 8032**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 74929**] (Complete) Done [**2156-11-26**] at 1:51:59 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2082-6-15**] Age (years): 74 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Right ventricular function. Valvular heart disease. ICD-9 Codes: 440.0, 424.1, 396.9, 424.0 Test Information Date/Time: [**2156-11-26**] at 13:51 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD Test Type: TEE (Complete) 3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: *6.0 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Aorta - Annulus: 1.9 cm <= 3.0 cm Aorta - Sinus Level: 3.5 cm <= 3.6 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mildly depressed LVEF. RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of mitral valve chordae. Torn mitral chordae. [**Male First Name (un) **] of the mitral chordae (normal variant). No resting LVOT gradient. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is mildly depressed (LVEF= XX %). The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Torn mitral chordae are present. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IABP 5 cm. below the origin of the left subclavian artery. Post CPB: Improved biventricular systolic function. Trace MR/Trazce TR/+ chordal [**Male First Name (un) **]. IABP positioned under TEE guidance. Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting physician ?????? Brief Hospital Course: He was transferred from [**Hospital 9464**] Hospital for CABG. He underwent preop carotid ultrasound which showed < 40% stenosis bilaterally. He had chest pain at rest, and A balloon pump was placed in the cath lab preoperatively. He was taken to the operating room urgently on [**11-26**] where he underwent a CABG x 6. He was transferred to the ICU in critical but stable condition. His IABP was dc'd and he was extuabted on POD #1. He was transferred to the floor on POD #3. He had atrial fibrillation for which he was started on amiodarone with conversion to SR. Chest tubes and pacing wires removed without incident. Cleared for discharge to rehab on POD #5. Pt. is to make all followup appts. as per discharge instructions. Medications on Admission: folate, finasteride 5', simvastatin 40', diltiazem ER 300', Terazosin 10', ASA 325', NTG prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days: then 200 mg [**Hospital1 **] for 7 days until [**12-11**], then 200 mg daily ongoing. 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days: hold for K > 4.5. Discharge Disposition: Extended Care Facility: [**Doctor Last Name 74930**]Rehab Discharge Diagnosis: CAD bph, ^chol, HTN, Angina postop A Fib 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) 37217**] (PCP) 2 weeks Dr. [**Last Name (STitle) 55499**] (Cardiologist) 2 weeks Dr. [**Last Name (STitle) 914**] (Cardiac surgery) 2 weeks [**Telephone/Fax (1) 170**] ****[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] PA at VA Fax # [**Telephone/Fax (1) 74931**] - Fax all prescriptions and d/c summary to him and pt will pick up at VA pharmacy - we need to do this if he goes home. Completed by:[**2156-12-1**]

[ "E878.2", "414.01", "427.31", "997.1", "272.0", "600.00", "411.1", "V15.82", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.14", "37.22", "36.15", "88.56", "88.53", "37.61" ]

icd9pcs

[ [ [] ] ]

8731, 8791

6605, 7337

328, 437

8876, 8884

964, 1437

9184, 9644

711, 759

7480, 8708

1474, 1523

8812, 8855

7363, 7457

8908, 9161

5422, 6310

774, 945

282, 290

1552, 5373

465, 564

586, 615

631, 695

6320, 6582

41,738

184,992

33918

Discharge summary

report

Admission Date: [**2171-1-7**] Discharge Date: [**2171-1-14**] Date of Birth: [**2087-6-13**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: aortic stenosis/cornary artery disease Major Surgical or Invasive Procedure: left heart catheterization, coronary angiogram, left ventriculogram, right heart catheterization [**2171-1-7**] Aortic valve replacement (21mm [**Doctor Last Name **] pericardial), coronary artery bypass grafts x3(LIMA-LAD,SVG-OM,SVG-PDA) [**2171-1-9**] History of Present Illness: This 83 year old white male has known aortic stenosis being followed with serial echocardiograms. He has had progressive symptoms of dizziness and exertional dyspnea over the past few months. The stenosis has worsened and he had ischemic changes on a recent stress echo. He was referred for angiography. Past Medical History: Aortic stenosis Hypertension Hyperlipidemia Chronic bronchitis Polymyalgia rheumatic Prostate cancer s/p prostatectomy Gout Osteoarthritis Carpal tunnel repair, right Ganglionic cyst behind knee Open Aortic aneurysm repair Ulnar nerve entrapment surgery Hernia repair Carpal tunnel repair, right Social History: Last Dental Exam: Full upper and lower dentures, edentulous Lives with: Lives alone. Widowed. Retired. Contact: [**Name (NI) 78363**], [**Name (NI) **] [**Name (NI) **] available locally for an emergency. [**Telephone/Fax (1) 78364**] Cigarettes: Smoked no [] yes [x] last cigarette 45 years ago Hx: 1 ppd x 35 years ETOH: < 1 drink/week [] [**2-5**] drinks/week [] >8 drinks/week [x] for several years - quit 2 months ago Illicit drug use - none Family History: Family History:No premature coronary artery disease Father MI < 55 [] Mother < 65 [] Race: Caucasian Physical Exam: Physical Exam Pulse:65 Resp:17 O2 sat:98% RA B/P Right: 170/87 Left: Height:5'8" Weight: 150# General: AAOx 3 in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Bibasilar wheezing Heart: RRR [x] Irregular [] Murmur [x] grade III/VI______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Well healed mid abdominal scar Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: sheath Left: 2+ DP Right:1+ Left:1+ PT [**Name (NI) 167**]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right: Left: transmitted murmur bilaterally Pertinent Results: [**2171-1-14**] 04:40AM BLOOD WBC-6.2 RBC-3.26* Hgb-9.6* Hct-28.3* MCV-87 MCH-29.4 MCHC-33.9 RDW-14.3 Plt Ct-74* [**2171-1-13**] 05:45AM BLOOD WBC-6.2 RBC-3.22* Hgb-9.6* Hct-27.6* MCV-86 MCH-29.9 MCHC-34.8 RDW-14.4 Plt Ct-72* [**2171-1-7**] 10:45AM BLOOD WBC-5.4 RBC-3.74* Hgb-11.3* Hct-32.9* MCV-88 MCH-30.1 MCHC-34.3 RDW-12.8 Plt Ct-128* [**2171-1-14**] 04:40AM BLOOD UreaN-46* Creat-1.6* Na-138 K-4.0 Cl-99 [**2171-1-13**] 05:45AM BLOOD Glucose-94 UreaN-44* Creat-1.6* Na-138 K-3.4 Cl-98 HCO3-30 AnGap-13 [**2171-1-7**] 10:45AM BLOOD Glucose-104* UreaN-23* Creat-1.2 Na-137 K-4.4 Cl-102 HCO3-24 AnGap-15 [**2171-1-9**] 06:38AM BLOOD %HbA1c-5.6 eAG-114 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. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. There are complex (mobile) atheroma in the descending aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results before surgical incision. POST-BYPASS: Preserved biventricular sytolic function. Intact thoracic aorta. LVEF 55%. There is a bioprosthesis in the native aortic position, stable and functioning well with a residual mean gradient of 10 mm of Hg. Brief Hospital Course: He was referred for surgical evaluation after catheterization. The usual preoperative workup was completed and on [**1-9**] he was taken to the Operating Room where valve replacement ansd bypass grafting were performed. He weaned from bypass on Neo Synephrine and Propofol. He awoke intact, remained stable and weaned and extubated. Pressor was weaned off and the CTs and pacing wires were rmoved per protocols easliy. He was begun on beta blockers and diuresed towards his properative weight. physical Therapy worked with him for strength and mobility. He was discharged on POD 5 to [**Location (un) 1036**] for further recovery. Follow up appointments and discharge medications are as listed elsewhere. Medications on Admission: ALENDRONATE 70 mg Tablet once a week on Sat BUDESONIDE-FORMOTEROL [SYMBICORT] 160 mcg-4.5 mcg/actuation HFA Aerosol Inhaler - two puffs inhaled once a day in am COLCHICINE 0.6 mg Tablet daily HYDROCORTISONE - dose uncertain IPRATROPIUM-ALBUTEROL 18 mcg-103 mcg (90 mcg)/Actuation Aerosol -one puff inhaled four times a day as needed METOPROLOL SUCCINATE 25 mg tablet Extended Release 24 hr one Tablet once a day PREDNISONE 2.5 mg Tablet once a day SIMVASTATIN 80 mg Tablet daily at bedtime SULFACETAMIDE SODIUM - Dosage uncertain TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] 18 mcg Capsule, w/Inhalation Device - one capsule inhaled once a day ASPIRIN 81 mg Tablet daily CYANOCOBALAMIN (VITAMIN B-12) 500 mcg Tablet daily Discharge Medications: 1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 2. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation q am (). 3. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. 4. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-31**] Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath. 5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. sulfacetamide sodium Topical 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: aortic stenosis Coronary Artery Disease s/p aortic valve replacement s/p coronary artery bypass grafts polymyalgia rheumatica chronic bronchitis urinary retension h/o prostate ca s/p prostatectomy hypertension s/p open abdominal aortic aneurysmectomy degenerative joint disease gouty arthritis Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema: trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon:Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) office will call w/ appointment Cardiologist:Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 4105**]) office will call Please call to schedule appointments with: Primary Care: Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 696**] ([**Telephone/Fax (1) 4105**]) in [**4-4**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2171-1-14**]

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icd9cm

[ [ [] ] ]

[ "36.12", "39.61", "37.23", "34.04", "88.56", "35.21", "36.15" ]

icd9pcs

[ [ [] ] ]

7009, 7086

4472, 5183

348, 605

7424, 7653

2631, 4449

8577, 9264

1761, 1858

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7107, 7403

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1873, 2612

270, 310

633, 940

962, 1261

1277, 1730