ChanBeDu/relevant_section_length · Datasets at Hugging Face

28,352

154,475

48683

Discharge summary

report

Admission Date: [**2192-8-30**] Discharge Date: [**2192-9-3**] Date of Birth: [**2135-6-25**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Fatigue, Dyspnea on Exertion Major Surgical or Invasive Procedure: [**2192-8-30**] Cardiac Catheterization [**2192-8-31**] Mini-Maze Procedure(via Bilateral Mini Thoracotomies) History of Present Illness: Mr. [**Known lastname 6359**] is a 57 year old male with atrial fibrillation. He was noted to have abnormal pacemaker function in [**Country 3396**]. His symptoms are consistent exertional shortness of breath, fatigue, and two pillow orthopnea. Referred to cardiac surgery for Maze procedure. Past Medical History: Systolic Congestive Heart Failure/Cardiomyopathy(EF 30-35%) Atrial Fibrillation - s/p Multiple Cardioversions Sick Sinus Syndrome - s/p PPM Placement [**2168**] Elevated White Count - possible Chronic Lymphoctyic Leukemia Bicuspid Aortic Valve with Aortic Insufficiency Hypertension Syncope Lyme Disease Sciatica Cerebrovascular Disease Prior Neck Surgery Prior Cholecystectomy Social History: Patient lives in [**Country 3396**], married, does not smoke, is a social drinker, and does not use recreational or IV drugs Family History: Non-contributory Physical Exam: Vitals: 120-130/70-80, 70's, 16, 96% on room air General: WDWN male in no acute distress HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD Lungs: CTA bilaterally Heart: Regular rate and rhythm Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 1+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [**2192-8-30**] Cardiac Cath: 1. Coronary angiography of this right dominant system revealed no obstructive coronary artery disease. The LMCA, LAD, and LCx had no angiographically evident flow limiting stenoses. The RCA was a small vessel without flow limiting obstructive disease. 2. Resting hemodynamics revealed normal systemic systolic and diastolic pressures. [**2192-8-31**] 01:25AM BLOOD WBC-17.0* RBC-4.98 Hgb-16.1 Hct-46.8 MCV-94 MCH-32.4* MCHC-34.5 RDW-13.6 Plt Ct-140* [**2192-8-31**] 01:25AM BLOOD PT-12.7 PTT-27.2 INR(PT)-1.1 [**2192-8-31**] 01:25AM BLOOD Glucose-78 UreaN-17 Creat-1.1 Na-138 K-4.0 Cl-102 HCO3-28 AnGap-12 [**2192-8-31**] 01:25AM BLOOD ALT-36 AST-23 AlkPhos-38* Amylase-76 TotBili-1.3 [**2192-8-31**] 01:25AM BLOOD Albumin-4.0 Mg-2.2 [**2192-9-3**] 06:15AM BLOOD WBC-14.9* RBC-4.33* Hgb-14.1 Hct-40.0 MCV-93 MCH-32.5* MCHC-35.1* RDW-13.9 Plt Ct-124* [**2192-9-3**] 06:15AM BLOOD PT-12.8 INR(PT)-1.1 [**2192-9-2**] 05:38AM BLOOD Glucose-100 UreaN-12 Creat-0.8 Na-139 K-4.4 Cl-104 HCO3-30 AnGap-9 Brief Hospital Course: Mr. [**Known lastname 6359**] was admitted and underwent cardiac catheterization. Coronary angiography revealed a right dominant system and normal coronary arteries. Hematology evaluation was performed. Findings were consistent with CLL. He was otherwise cleared by the hematology service. No treatment for his possible CLL was recommended at this time. On [**8-31**], Dr. [**Last Name (STitle) 914**] performed mini-maze procedure. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. On postoperative day one, he transferred to the SDU. He remained in a normal sinus rhythm. Beta blockade and Warfarin were resumed and titrated accordingly. Over several days, he continued to make clinical improvements and was discharged to home on postoperative day four. He will follow up with Dr. [**Last Name (STitle) 914**] as directed. Medications on Admission: Atenolol, Lisinopril, Amiodarone, Aspirin, Zantac, Valium, Lomotil prn, Morphine prn Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. 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* 5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 3 doses: INR check on [**9-5**] or [**9-6**], call for cont'd dosing. Disp:*60 Tablet(s)* Refills:*0* 7. Indomethacin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) for 1 months. Disp:*180 Capsule(s)* Refills:*0* 8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 9. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Home Discharge Diagnosis: Atrial Fibrillation - s/p Maze Procedure Systolic Congestive Heart Failure/Cardiomyopathy(EF 30-35%) Sick Sinus Syndrome - s/p PPM Placement [**2168**] Elevated White Count - possible Chronic Lymphoctyic Leukemia Bicuspid Aortic Valve with Aortic Insufficiency Hypertension Syncope Lyme Disease Sciatica Cerebrovascular Disease Prior Neck Surgery Prior Cholecystectomy Discharge Condition: Good Discharge Instructions: - Call for temp > 101.5 - Patient may shower, no bathing or swimming for 1 month - Get INR checked twide weekly, and have results called to Dr. [**Name (NI) 10584**] office ([**Telephone/Fax (1) 1504**] for continued Coumadin dosing Followup Instructions: Dr. [**Last Name (STitle) 914**] [**2192-9-12**] @ 2:30PM Completed by:[**2192-9-4**]

[ "428.22", "427.31", "424.1", "414.8", "401.9", "V45.01", "724.3", "437.0", "427.81", "204.10", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.72", "37.22", "37.33", "88.56" ]

icd9pcs

[ [ [] ] ]

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2811, 3816

348, 459

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1760, 2788

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30,432

113,299

51279

Discharge summary

report

Admission Date: [**2102-3-26**] Discharge Date: [**2102-4-18**] Date of Birth: [**2021-12-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1042**] Chief Complaint: Respiratory distress. Major Surgical or Invasive Procedure: Intubation Mechanical Ventilation Arterial Line Placement History of Present Illness: 80 M with hx CAD s/p CABG presents with cough and SOB. The patient reports that about a week ago he went to [**Country 4754**] for the funeral of his brother. There he had fever/chills, and a productive cough as well as rhinorrhea for the last week. He decided to come back one week earlier and came back yesterday. TOday his SOB worsened and he decided to come into the hospital. He denied CP, pedal edema or calf pain. In the ED, the patient was hypoxic to 81% on RA on arrival. Other vitals included T 98.1, 71, 190/89, RR20. A CXR was done with no significant infiltrates. A CTA was performed without PE or infiltrate. The patient was then noted to be progressivley more wheezing and short of breath. He was given several nebs back to back with initial improvement but then continued with laboured breathing. Methylprednisolone 125mg was given x1 and Levofloxacin 750mg. The pt appeared progressively more tired and in respiratory distress. A gas showed pH 6.93 pCO2 132 pO2 113. THe patient was intubated with succinylcholin, etomidate and ativan. Lactate was 1.2. He received a total of 2L of NS. Repeat ABG: pH 7.14 pCO2 69 pO2 83. ROS: pt intubated and sedated, unable to obtain. According to nurse, pt received a double dose of his Atenolol today Past Medical History: 1. Coronary artery disease. 2. Status post myocardial infarction thirty years ago. [**2084**]- CABG: LIMA to LAD, SVG to LPL jump PDA [**2089**]- Stent to LCx, occl noted SVG at LPL-PDA segment [**2096**]- Stent SVG-OMB [**2097**]- Stent SVG-PLV [**2101**]- DES to the distal SVG-LPL and balloon angioplasty of the proximal in-stent restenosis. EF = 50%- Mild anterolateral hypokinesis 3. History of AAA, elective repair 6.6cm on [**3-19**]. 4. Hypertension. 5. Peripheral vascular disease - [**2096**] angio: Severe bilateral lower extremity peripheral vascular disease with severe bilateral SFA disease and single vessel runoff bilaterally. 6. Appendectomy 50 years ago. 7. Diverticulitis. 8. PUD 9. Hypercholesterolemia Social History: Widower, he lives with his daughter. His is a retired auto mechanic. Smokes [**7-25**] cigarettes/day. (1/2-1 PPD x 70 years) Family History: His brother died of an MI at 68 years of age. Physical Exam: T 97.2 BP 118/61 HR 102 RR 20 O2Sat 95 AC 0.3/550/20/5 Gen: NAD, comfortable and sedated HEENT: NC/AT, PERRLA, mmm, hard exophytic mass over left forehead NECK: no LAD, no JVD, no carotid bruit COR: S1S2, irregularly regular rhythm, no m/r/g PULM: moderate air movement, mild diffuse wheezing, no rhonchi ABD: + bowel sounds, soft, nd, nt Skin: warm extremities, no rash, venostasis changes EXT: 2+ DP, no edema/c/c, no CVA tenderness Neuro: moving all extremities, sedated, PERRLA, reflexes 2+ b/l Pertinent Results: EKG: NSR, HR 80, NA, NI, mild Tw changes in I, avl. (unchanged) . CXR: Single upright frontal bedside chest radiograph is compared to [**2101-11-1**]. The lungs are clear. The heart, mediastinal contours, and pulmonary vasculature are unchanged in appearance, remarkable for tortuous aorta. The patient is status post CABG. IMPRESSION: No acute cardiopulmonary process. . CT CHEST WITH CONTRAST: The pulmonary arteries opacify without filling defects. The patient is status post CABG, and there are marked coronary artery calcifications within the LAD and circumflex. The heart appears normal. There are multiple small right hilar lymph nodes as well as a more prominent 12 mm lymph node. There is no pathologic mediastinal or axillary adenopathy. There is emphysema of the lungs, but lungs are otherwise clear. Note is made of a tiny calcified granuloma in the right base. There is no pleural effusion. The airways are patent to the subsegmental level. There are multilevel degenerative changes in the osseous structures. The patient is status post median sternotomy. No suspicious lesions are identified. The visualized portions of the abdomen are unremarkable. There is atherosclerotic disease of the aorta with multiple areas of mural thrombus. IMPRESSION: 1. No evidence for pulmonary embolism. 2. Emphysema, but no evidence for pneumonia. . CT HEAD [**2102-4-11**] COMPARISON STUDY: [**2102-4-1**], head CT scan, also performed for a history of mental status changes, interpreted by Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] as revealing "No acute intracranial abnormalities detected. Unchanged expansile osseous lesion consistent with an osseous hemangioma. Destruction of the outer table suggests aggressive potential and further evaluation is indicated." FINDINGS: The images of the posterior fossa region are mildly degraded by patient motion, although a repeat imaging sequence is of reasonably good diagnostic quality in this region. There is no definite interval change in either the appearance of the brain or osseous lesion in the one-week interval between scans. There is no intracranial hemorrhage or shift of normally midline structures observed. CONCLUSION: Stable, abnormal study as noted above. If acute brain ischemia is a clinical consideration, MRI scanning, if feasible, is a more sensitive diagnostic modality. . CHEST CT [**2102-4-17**] 1. Two 3-mm left upper lobe pulmonary nodules. Statistically, these are most likely benign. However, given the patient's history, followup CT in three to six months can be obtained if clinically warranted to exclude an atypical distribution of small metastases. 2. New bilateral lower lobe dependent centrilobular opacities most likely secondary to aspiration or infectious bronchiolitis. [**2102-4-18**] 05:34AM BLOOD WBC-8.5 RBC-3.82* Hgb-12.3* Hct-36.2* MCV-95 MCH-32.3* MCHC-34.1 RDW-16.2* Plt Ct-209 [**2102-3-25**] 10:29PM BLOOD WBC-8.9 RBC-4.33* Hgb-14.0 Hct-40.1 MCV-93 MCH-32.3* MCHC-34.9 RDW-13.8 Plt Ct-185 [**2102-4-18**] 05:34AM BLOOD Glucose-152* UreaN-28* Creat-0.7 Na-137 K-3.7 Cl-98 HCO3-32 AnGap-11 [**2102-3-25**] 10:29PM BLOOD Glucose-175* UreaN-26* Creat-1.1 Na-130* K-4.4 Cl-92* HCO3-29 AnGap-13 [**2102-4-10**] 04:46AM BLOOD ALT-25 AST-21 LD(LDH)-140 AlkPhos-59 TotBili-0.3 [**2102-4-8**] 03:04AM BLOOD Lipase-57 [**2102-3-30**] 03:05AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2102-3-29**] 08:18PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2102-3-29**] 12:03PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2102-3-31**] 08:14AM BLOOD TSH-0.13* [**2102-3-31**] 08:14AM BLOOD Free T4-1.4 Brief Hospital Course: A/P: 80 y.o. M with CAD s/p CABG, PVD & COPD who p/w hypercarbic respiratory failure, likely [**2-18**] COPD exacerbation and flu, with hospital stay complicated by DTs and prolonged AMS after being off sedation. . # Hypercarbic respiratory failure: Pt presented with profound acidosis [**2-18**] hypercarbic resp failure and was intubated, found to have influenza complicated by newly diagnosed COPD. CT consistent with emphysema and long standing tobacco abuse make diagnosis very likely in the abscence of PFTs. Pt was extubated after 5 days but required reintubation [**2-18**] recurrent hypercarbic resp failure in setting of significant valium administration and MS depression. Second intubation course was prolonged due to depressed MS and likely delayed clearance of benzodiazpines. Pulm status has been stable since extubation on standing nebs, guaifenesin & pulm toilet. Pt has been afebrile, sating well on RA and secretions have decreased with mobilization. Repeat Chest CT was performed to evaluate for metastatic disease from left frontal osteohemangioma. CT reported 2 X 3mm pulm nodules that will require a follow up CT in 6mths but were thought to be likely benign. Centrilobar opacities likely c/w aspiration that have been clinically silent and may be residual from repeat intubations. Pt will need to complete last three days of Prednisone taper, Albuterol & Atrovent nebs & Guaifenesin TID. . # Altered Mental Status: Pt was initially treated with valium due to possible DTs, then required re-intubation for hypercarbic resp failure. Pt had a prolonged 2nd intubation due to sedation that responded to flumazenil (likely benzo induced MS changes). Pt was extubated on [**4-12**] and is currently alert & responding to commands but still disoriented, no focal deficits on neuro exam, though diffusely weak & deconditioned. Etiology of prolonged MS changes thought due to prolong intubation and ICU stay. Per neuro surgery, it is very unlikely that osteohemangioma mass is contributing to MS. Steroids could also be contributing to MS. Please continue with aggressive rehab. . # New onset Afib: Etiology unclear, TSH was mildly decreased but T4 was WNL. There was initial problems with HR control in the ICU, however, HR has been well controlled in 80-90s on Metoprolol with can be increased prn. Pt has a CHADS score of 2 and will need to discuss the risks/benefits of initiating anti-coagulation as an outpt. However, due to his recent h/o GI bleed, decision was made not to anti-coagulate him while in house. Pt was recently changed to Metoprolol 100mg [**Hospital1 **] & was continued on ASA 325 & Plavix 75mg. Recommend f/u thyroid function tests as outpt. . # Scull tumor: Neuro surgery was consulted for a CT read of invasive osteohemangioma. Per neuro, this was not likely contributing to any MS changes but recommended CT chest for staging which showed two different 3mm pulm nodules, unlikely to be metastatic, will need f/u CT in 6mths. . # CAD: Pt s/p CABG in [**2082**] and denied any CP throughout admission. Pt was ruled out for MI on admission and was continued on ASA, Plavix, Metoprolol, Pravastatin. Pt was switched from Captopril to Lisinopril 10mg once daily. . # PVD: Pt is s/p mult peripheral vasc interventions, denied any lower extremity pain thoughout admission, lower extremities warm & PT pulses palpable bilaterally. Pt should continue ASA & plavix. . # FEN: Pt had doboff placed on [**2102-4-12**] and has been managed with pulm nutren tube feeds. Speech & swallow recommended continuing TF for now & advancing a pureed diet with nectar thickened, strict aspiration precautions and 100% monitoring with feeds. . # Prophylaxis: Heparin sc, bowel regimen & protonix Medications on Admission: Clopidogrel 75 mg PO DAILY Aspirin 325 mg PO DAILY Atenolol 25 mg PO DAILY Lisinopril 40 mg PO once a day. Pravastatin 40 mg PO once a day. Norvasc 10 mg PO once a day. Viagra Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Pravastatin 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. 11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO TID (3 times a day) as needed for cough. 12. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: 1. Influenza B 2. Hypercarbic respiratory failure 3. Atrial fibrillation 4. Osteohemangioma of the skull 5. Hyponatremia 6. Acute renal failure 7. Incidentally noted pulmonary nodules Secondary: 1. Coronary artery disease 2. Peripheral vascular disease 3. Chronic obstructive pulmonary disease Discharge Condition: Fair Discharge Instructions: You were admitted with influenza & COPD exacerbation. You were intubated and required an ICU stay for respiratory failure and mental status changes. You were noted to develop an arrythmia called Atrial Fibrillation, this has been rate controlled with medications. You will need to discuss long term plans regarding anti-coagulation for A.Fib with your PCP and family. You will likely require a long rehabilitation stay. Upon discharge from rehab, it is important that you call Dr. [**Last Name (STitle) **] to set up a follow up appointment. You will need to obtain a follow up chest CT scan to evaluate incidentally noted nodules in your chest. This scan should be done 3-6 months from now. We would also recommend follow up thyroid function tests as outpt. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 10688**] following your rehabilitation. Please discuss with your primary care physician to obtain [**Name Initial (PRE) **] follow up chest CT scan in [**3-23**] months to evaluate pulmonary nodules. You should discuss the Atrial Fibrillation with your PCP and discuss the risks/benefits of anticoagulation.

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icd9cm

[ [ [] ] ]

[ "99.21", "99.29", "96.72", "96.71", "38.91", "96.6", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

12011, 12083

6789, 8216

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13719

Discharge summary

report

Admission Date: [**2149-5-19**] Discharge Date: [**2149-5-27**] Date of Birth: [**2081-1-9**] Sex: F Service: SURGERY Allergies: Percocet / Aspirin / Tylenol / Morphine Attending:[**First Name3 (LF) 6088**] Chief Complaint: Acute cold left foot Major Surgical or Invasive Procedure: [**2149-5-19**] Abdominal aortogram with unilateral extremity runoff, Perclose of right groin, left groin exploration with common femoral and profunda endarterectomy with bovine patch angioplasty, SFA embolectomy, below-knee [**Doctor Last Name **] exploration with vein patch angioplasty following embolectomy of anterior tibial and posterior tibial arteries; four compartment fasciotomies through 2 incisions. History of Present Illness: This is a 68-year-old female who noted the acute onset of left foot pain at 10 o'clock the prior evening and after a few hours went to [**Hospital3 **] where she was then transferred to [**Hospital1 1535**]. Upon arrival she had a palpable left femoral pulse but it was weaker than her right femoral pulse. She had no dopplerable signals in her left foot and she had mildly decreased motor and decreased sensation of the left foot. Her foot was cold and mottled at the forefoot. The decision was made for urgent arteriography with decisions for possible embolectomy versus bypass versus catheter based intervention. Past Medical History: ESRD from htn, partial colectomy for colonic polyps, and thyroid resection for benign disease, ventral hernia repair Social History: Lives with husband in home Family History: Noncontributory Physical Exam: 98.9 P:76 BP: 125/70 RR:20 Spo2: 99% NAD A&Ox4 CTAB RRR Abd soft, NT, ND Ext: LLE 3cm skin open with serous stained packing. +CSM Fem DP PT R palp palp dop L palp dop dop Pertinent Results: [**2149-5-27**] 06:15AM BLOOD WBC-12.0* RBC-2.94* Hgb-9.0* Hct-28.0* MCV-95 MCH-30.5 MCHC-32.1 RDW-17.5* Plt Ct-483* [**2149-5-27**] 06:15AM BLOOD Plt Ct-483* [**2149-5-27**] 06:15AM BLOOD Glucose-112* UreaN-48* Creat-10.3* Na-140 K-4.0 Cl-98 HCO3-29 AnGap-17 [**2149-5-27**] 06:15AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.0 OPERATIVE REPORT [**Last Name (LF) **],[**First Name3 (LF) 251**] C. Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) 251**] on TUE [**2149-5-20**] 3:10 PM Name: [**Known lastname 41311**], [**Known firstname **] Unit No: [**Numeric Identifier 41312**] Service: Date: Date of Birth: [**2081-1-9**] Sex: F Surgeon: [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 41313**] PREOPERATIVE DIAGNOSIS: Ischemic left leg. POSTOPERATIVE DIAGNOSIS: Ischemic left leg. PROCEDURE: Abdominal aortogram with unilateral extremity runoff, Perclose of right groin, left groin exploration with common femoral and profunda endarterectomy with bovine patch angioplasty, SFA embolectomy, below-knee [**Doctor Last Name **] exploration with vein patch angioplasty following embolectomy of anterior tibial and posterior tibial arteries; four compartment fasciotomies through 2 incisions. ASSISTANT: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27576**], MD. ANESTHESIA: General endotracheal anesthesia. FLUIDS: 1.6 liters of crystalloid. ESTIMATED BLOOD LOSS: 300 cc. URINE OUTPUT: Zero as the patient was on peritoneal dialysis. COMPLICATIONS: There were no complications and the patient tolerated the procedure well, was extubated and taken to the cardiovascular intensive care unit in guarded condition. A total of 128 cc of Visipaque were used and total fluoro time was 22 minutes. INDICATIONS: This is a 68-year-old female who noted the acute onset of left foot pain at 10 o'clock the prior evening and after a few hours went to [**Hospital3 **] where she was then transferred to [**Hospital1 69**]. Upon arrival she had a palpable left femoral pulse but it was weaker than her right femoral pulse. She had no dopplerable signals in her left foot and she had mildly decreased motor and decreased sensation of the left foot. Her foot was cold and mottled at the forefoot. The decision was made for urgent arteriography with decisions for possible embolectomy versus bypass versus catheter based intervention. PROCEDURE: The patient was taken to the operating room on [**2149-5-19**], laid on the table in the supine position. The patient's groins were prepped and draped in the sterile fashion. Retrograde access was obtained to the right common femoral artery using the micropuncture technique after infiltration of local anesthesia. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was placed in the abdominal aorta and a short 4-French sheath was placed. An Omni Flush was placed at the level of L1 and diagnostic abdominal aortogram was obtained. A 4-French angled glide catheter was placed into the left external iliac artery after this was accessed using the floppy angled Glidewire and then serial images were obtained of the left lower extremity down to and including the foot. At this point, the decision was made to cut down the left groin so the glide catheter was removed and the 4-French sheath was sutured into place. The anesthesia team was called and they promptly intubated the patient. She was given intravenous antibiotics. A longitudinal incision was made in the left groin and the common femoral artery was exposed. The SFA and profunda were isolated with vessel loops as well as an Aldara clamp placed on the distal external iliac artery. A longitudinal arteriotomy was made in the common femoral artery and there was a large amount of thrombus present. This was pulled out using a snap and then a #3 and #4 embolectomy catheter was passed down the superficial femoral artery with a large amount of clot removed. A #3 embolectomy catheter was passed down the profunda and there was excellent amount of clot removed. There was good back bleeding from the SFA and profunda. An endarterectomy was then performed of the common femoral going into the SFA and a plaque was pulled out of the origin of the profunda. A bovine pericardium patch was created and sewn into place using a 6-0 Prolene. Attempts were made to put a sheath through the side of the patch for further arteriography. This was not feasible so the SFA and funda were back bled and then there was good forward flow and the sutures were tied and the patch was punctured with a regular 0.018 needle and then [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was placed and a long 6-French sheath was placed into this patch. Arteriography was then performed of the left lower extremity and there was still noted to be a large amount of clot at the tibioperoneal trunk and despite multiple attempts with the export catheter over a [**Name (NI) 41314**] PT wire which had been placed into the posterior tibial artery and despite multiple passes with the excisor vacuum assisted battery-operated thrombectomy device, there was still a tremendous amount of clot in the anterior tibial and the posterior tibial so these were pulled out and the sheath was left in place. A cutdown was performed of the below-knee popliteal artery and the gastrocnemius and soleus muscle were taken off their attachments to the tibia. The proximal below-knee popliteal artery was isolated and vessel loops were placed around the anterior tibial artery, posterior tibial artery and tibioperoneal trunk. At this point a longitudinal arteriotomy was made in the below-knee popliteal artery and a #2 embolectomy catheter was passed into the anterior tibial artery all the way to approximately 60 cm and a large amount of thrombus was removed after multiple passes and ultimately there was excellent backbleeding. Attempts were made to pass the #2 embolectomy catheter down the posterior tibial artery but there was a clot lodged immediately distal to the arteriotomy and this would no come out so the arteriotomy was extended onto the posterior tibial and ultimately this clot was removed. The #2 embolectomy catheter was passed easily down into the foot and pulled back with a good amount of clot removed and excellent backbleeding. There was excellent backbleeding from the peroneal. At this point, a piece of saphenous vein was harvested from this vein incision as there had been a tremendous amount of tension put on the saphenous vein with the exposure. A patch was created and sewn into place using 6-0 Prolenes. Flow was restored and then a completion arteriogram was shot through the same sheath in the left groin patch. There was noted to be persistent thrombus in the distal anterior tibial and distal posterior tibial artery but the decision was made to stop at this point. The fascia was then incised in a deep posterior and superficial posterior compartment through the same incision as the below-knee popliteal exposure. A fasciotomy was performed of the anterior and lateral compartments through a separate incision which was 1 cm anterior to the tibia. All bleeding was checked and controlled. The skin was then closed in the fasciotomy sites using 3-0 Vicryl and then staples for the skin. The sheath was removed from the left groin and a U stitch Prolene was placed. Surgicel was placed and then hemostasis was checked for. The patient had been on heparin throughout this case and was intermittently bolused to keep her ACT's around 300. At this point 20 mg of protamine was given and the left groin was closed in layers of 2-0, 3-0 and staples for the skin. A Perclose device was deployed through the right groin after [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was placed back to the abdominal aorta. Manual pressure was held and there was excellent hemostasis from this. The dressings were applied and a Kerlix was wrapped. The patient, at the completion of the case had a dopplerable distal AT, peroneal, PT, but there was no signals in the foot. The foot was still pale. The decision was made to leave the patient on heparin as multiple attempts had been made without success to remove all the clot from the distal foot. The patient was extubated and taken to the cardiovascular intensive care unit in guarded condition. ANGIOGRAPHIC FINDINGS: Initial images of the abdominal aorta revealed patent abdominal aorta and iliac arteries bilaterally. There is patency of the external and internal iliacs bilaterally. Initial image of the left lower extremity reveal a clot sitting in the profunda which seems superimposed on the SFA. There is flow through the superficial femoral artery and then a clot sitting at the tibioperoneal trunk. There is flow through the anterior tibial but it is very sluggish and goes very slowly through the mid leg. There is very minimal flow going through the posterior tibial artery. The peroneal artery reconstitutes and is patent down to the foot. There are then images taken after there was a sheath placed through the left groin patch. This revealed excellent flow through the SFA and profunda and through the popliteal artery. There is patency of the below- knee popliteal artery and the proximal anterior tibial artery but clot sitting in the anterior tibial artery going down towards the foot. The peroneal artery is patent but there is a large clot sitting at the proximal posterior tibial artery. There is multiple images revealing attempts at export thrombectomy followed by excisor battery assisted thrombectomy. The flow through the posterior tibial artery was improved but there was still a hangup at the proximal posterior tibial artery consistent with clot. There was then the intervening portion of the operation where the below-knee popliteal artery was isolated and the tibials were thrombectomized. Completion run through the sheath shows flow continuously through the peroneal into small collaterals into the foot. There is very sluggish flow through the anterior tibial artery in the mid leg and there is no flow into the DP in the foot. There is cut-off of flow at the PT at the distal area above the medial malleolus. There is small amount of tarsal flow and collaterals into the foot from the peroneal. There is injection of papaverine followed by one completion run showing the same appearance with poor flow into the foot. CONCLUSIONS: 1. Successful removal of clot from the common femoral artery followed by bovine patch angioplasty. 2. Successful removal of clot from the tibioperoneal trunk, but there is persistent thrombus at the distal PT going into the foot as well as the very distal AT going into the foot. 3. There is continuous flow through the peroneal artery supplying collaterals to the foot. [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 41315**] Dictated By:[**Last Name (NamePattern4) 41316**] Brief Hospital Course: [**2149-5-19**] Patient transferred from [**Hospital3 4107**] for cold left foot with acute onset of [**8-29**] leg pain. Faint dopperable AT and PT and foot mottled. Heparin gtt initiated. Radial a-line placed and bear hugger applied for hypothermia. Nephrology consulted for urgent PD. Taken to the OR for revascularization (see attached Op note). Transferred to the CVICU post-op. Dopperable peripheral signals throughout and right groin perclosed. [**2149-5-20**] ICU monitoring. Extubated and vitals stable. Continued on a heparin gtt and diet advanced to regular. Continued on peritoneal dialysis per nephrology recommendations. Nitropaste to left foot for continued vasodilation. 2 units of PRBC given for hct= 29 and symptomatic hypovolemia. [**2149-5-21**] ICU monitoring. VSS Home meds restarted. Frequent pulse checks. Transferred to VICU. PT/OT evaluation recommended home vs. rehab. 7/3/08-7/408 VSS. Tolerating regular diet. Continue heparin. Coumadin started for anticoagulation with goal [**12-22**]. Continued on Q4 PD. OOB daily with PT. CXR for pleuritic pain WNL. Several staples removed from left leg incision for bleeding. Wound irrigated and packed with wet-dry dressing and ace wrap twice daily. 2 units of PRBC given for hct 24.3 which increased to 29.3 post-transfusion. [**2149-5-24**] Underwent CTA or torso. OOB with PT. Continue anticoagulation. Renal continues to follow. Continue to monitor left leg incision for bleeding and wound care. [**2149-5-25**] No acute events. VSS. Pain control with tylenol (not a true allergy). Coumadin for anticoagulation. Rehab screen. Statin started. [**2148-5-25**] VSS. Toprol DC'ed for 1st degree AV block per ECG. Continues Coumadin dosing, PD and rehab screening. [**2149-5-27**] Cleared for Rehab and accepted placement. Will follow-up with Dr. [**Last Name (STitle) **] for post-op check [**2149-6-4**]. Medications on Admission: Fosamax 35 mg once a month, Lopressor 50', calcitriol 0.25 mcg once a day, Sensipar 30', Epogen 20,000 qwk, fluoxetine 40', metolazone 5', nifedipine 60', PhosLo one tab QID, potassium chloride 20', Renagel 800''', and simvastatin 20' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO QIDWMHS (4 times a day (with meals and at bedtime)). 7. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 12. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical TID (3 times a day). 13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for post surgery pain. 15. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM: Goal PTT [**12-22**]. 16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Ischemic left leg. PMH: End Stage Renal Disease (on diaylisis) Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**12-22**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2149-9-23**] 10:50 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2149-6-4**] 9:00 Completed by:[**2149-5-27**]

[ "998.11", "585.6", "444.22", "276.7", "403.91" ]

icd9cm

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[ "38.08", "38.93", "83.14", "88.42", "38.18", "00.41", "88.48" ]

icd9pcs

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46436

Discharge summary

report

Admission Date: [**2159-9-26**] Discharge Date: [**2159-10-5**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 800**] Chief Complaint: right hip/pelvic fractures Major Surgical or Invasive Procedure: Open Reduction and Internal Fixation of Right Acetabular Fracture [**2159-9-27**] History of Present Illness: 86M H/O BPH, and DMII, s/p fall onto right side from standing while in kitchen [**9-26**]. Reports leg gave out. Patient was seen by [**Month/Day (4) **] service and found to have a right acetabular and pelvic fx's. Urology consulted for hematuria seen following Foley placement, retropubic blood collection seen on CT in setting of pelvic trauma. Pt denies abd pain pain at present, reports only hip pain. He was admitted to the [**Month/Day (4) **] service for surgical repair on [**9-27**]. He was previously living indepentenly and able to do ADL. Past Medical History: Hypertension. Type 2 diabetes, 10y duration, med managed, no insulin. Hyperlipidemia. Obesity Chronic gait instability -peripheral neuropathy? Thrombocytopenia. prev anemia. Monoclonal paraproteinemia IgM followed by hematology. GERD Chronic prostatitis/BPH. Right proximal humerus fracture. Horseshoe kidney. s/p bilateral cataract removal. Depression. Commonuted proximal humerus fracture 6th rib fracture pneumonia Social History: Retired car salesman. Lives alone in own home with supportive neighbours and daughter few minutes away. 2 daughters. Daughter does shopping and bills. He enjoys outings as able, still drives. Lost wife to lung Ca 2y ago, with subsequent depressed mood, recently improving. Smoked 2-3 packs a day for 20-30y, ceased 20-30y ago. Denied EtOH/other drugs. Family History: Mother died aged 32y hysterectomy; father died 81y Paget's disease; daughter with lung cancer Physical Exam: On Discharge- VS: afebrile, 112/50, 82, 22, 96%4LNC GEN: NAD, in chair, polite, alert HEENT: no SI, MMM, [**Last Name (un) **] OP NECK: supple, no LAD, no bruits CV: RRR, no M, S1, S3, pulses 2+ CHEST: CTA B, no wheezes, crackles or rhonchi ABD: soft, NT, ND, +BS, staple in place from surgery, surgical sites are clean, minimal erythma, no drainage, bruising along thigh and right hip GROIN: large, purple scrotal hematoma, foley in place EXT: warm, no edema, pain at hip with moving right leg NERUO: CN II-XII grossly intact, PERRLA, EOMI, strength 5/5 UE, [**5-28**] left LE, unclear strength on right LE due to pain, MS intact during interview, AXO x 3 Pertinent Results: CT abd and pelvis [**2159-9-30**] IMPRESSION: 1. Increased gaseous distention of the bowel compared to the previous study. The colon is predominantly distended with some distention of small bowel. Findings are probably due to ileus. 2. Decreased extraperitoneal hemorrhage adjacent to the bladder. There is residual blood around the right pelvic sidewall and lateral to the right psoas muscle. Generalized subcutaneous edema is seen in the inferior pelvis. The scrotum was not imaged on the current study. Findings of the study were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2159-9-29**] at 13:10 hours. Cardiology Report ECG Study Date of [**2159-9-30**] 12:37:16 PM Sinus rhythm. Right bundle-branch block. Compared to the previous tracing tachycardia has resolved and premature ventricular contractions are no longer seen. TRACING #4 Read by: [**Last Name (LF) **],[**First Name3 (LF) **] P. Intervals Axes Rate PR QRS QT/QTc P QRS T 86 132 126 382/427 10 -7 0 Cardiology Report ECG Study Date of [**2159-9-29**] 3:57:40 PM Sinus tachycardia with premature ventricular contractions. Right bundle-branch block. Compared to the previous tracing of [**2157-9-27**] the rate has increased further. TRACING #2 Read by: [**Last Name (LF) **],[**First Name3 (LF) **] P. Intervals Axes Rate PR QRS QT/QTc P QRS T 128 158 124 342/461 4 0 3 CTA [**2159-9-28**] [**Location (un) **]: IMPRESSION: 1. No pulmonary embolism to the segmental level. Motion artifacts limit the evaluation of subsegmental arteries. 2. Centrilobular emphysema 3. Suboptimal inspiration with significant collapse of bronchus intermedius and left lower lobe bronchus suggests bronchomalacia. 4. Dilation of the esophagus and small hiatal hernia. 5. Coronary artery calcifications. Scattered aortic calcification. . CT Pelvix with contrast [**2159-9-26**] IMPRESSION: 1. Comminuted, intra-articular fractures of the posterior and anterior columns of the acetabulum; the latter extends into the iliac bone. 2. Simple, oblique fracture of the inferior pubic ramus. 3. Associated lower pelvic hematoma or contained bladder rupture. Cystogram would be useful if clinically indicated. 4. No change in appearance of horseshoe kidney. 5. Bilateral fat-containing inguinal hernias. . CT cystogram without Contrast [**2159-9-26**] IMPRESSION: No bladder wall rupture. Stranding and hematoma overlying the anterior and superior margin of the bladder. Right hip comminuted fractures as described. . CXR [**2159-9-28**]: There is blunting of the left CP angle, slightly more conspicuous than on the prior study. There is some volume loss in the retrocardiac region. An early infiltrate could be present in this area. The transverse colon is slightly dilated measuring up to 8 cm. This is increased compared to the film from the prior day. . [**9-25**]: 3 views right hip IMPRESSION: Right lateral acetabular irregularity likely corresponds to an acute fracture. CT pelvis is recommended for confirmation and characterization of fracture. Findings posted to the ED dashboard at 11:30 p.m. on [**2159-9-25**]. . [**9-26**]: pelvic xray Right anterior column acetabular fracture. Please note that there is very limited evaluation due to portable technique and the other fractures seen on the CT are not as well seen. Please refer to previously performed CT report. Admission labs- [**2159-9-26**] 05:35PM WBC-10.8 RBC-2.82* HGB-10.0* HCT-28.2* MCV-100* MCH-35.4* MCHC-35.5* RDW-13.7 [**2159-9-26**] 05:35PM PLT COUNT-102* [**2159-9-26**] 11:30AM GLUCOSE-250* UREA N-28* CREAT-1.2 SODIUM-141 POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-22 ANION GAP-16 [**2159-9-26**] 11:30AM CK(CPK)-139 [**2159-9-26**] 11:30AM cTropnT-<0.01 [**2159-9-26**] 11:30AM CALCIUM-8.3* PHOSPHATE-2.7 MAGNESIUM-1.8 [**2159-9-26**] 11:30AM WBC-10.7 RBC-2.89* HGB-10.1* HCT-28.5* MCV-99* MCH-35.1* MCHC-35.6* RDW-13.8 [**2159-9-26**] 11:30AM PLT COUNT-103* [**2159-9-26**] 11:30AM PT-14.4* PTT-32.7 INR(PT)-1.3* [**2159-9-26**] 02:10AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015 [**2159-9-26**] 02:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5 LEUK-NEG [**2159-9-26**] 02:10AM URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2159-9-25**] 10:15PM GLUCOSE-186* UREA N-26* CREAT-1.1 SODIUM-140 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14 [**2159-9-25**] 10:15PM estGFR-Using this [**2159-9-25**] 10:15PM WBC-13.3*# RBC-3.68* HGB-12.8* HCT-35.7* MCV-97 MCH-34.7* MCHC-35.8* RDW-13.7 [**2159-9-25**] 10:15PM NEUTS-89.7* LYMPHS-6.9* MONOS-3.1 EOS-0.1 BASOS-0.2 [**2159-9-25**] 10:15PM PLT COUNT-125* [**2159-9-25**] 10:15PM PT-13.6* PTT-23.7 INR(PT)-1.2* Discharge labs COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2159-10-5**] 05:55AM 8.7 2.81* 9.2* 27.8* 99* 32.8* 33.1 16.3* 238 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2159-10-3**] 06:40AM 82.8* 10.9* 5.3 0.8 0.1 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2159-10-5**] 05:55AM 238 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2159-10-5**] 05:55AM 124* 19 0.9 139 3.7 103 30 10 Brief Hospital Course: Patient was admitted after fall resulting in pelvic/hip fracture. He was first admitted to orthopedics and had a ORIF of the right acetablum with pinning on [**9-27**]. On [**9-28**], he was hypoxia to and tachypnea with RR of 34. He was given lasix and had a CTA that was negative for PE. He was maintained on a high flow mask overnight and then weaned to nasal cannula in AM. Then on [**2159-9-29**], on POD#2, he continued to be tachypneic with RR about 30 and O2 sat of 93% on 3LNC. CXR showed mild blunting of left costophrenic angle and possible retrocardiac infiltrate. He was given albuterol, lasix, and subsequently developed afib with RVR rates to 140's. His SBP dropped from 110's to 80's. He was given 10 mg of IV dilt was given and he converted back to sinus with rate at 100. His SBP was 90's. His ABG was 7.44/34/80 on a non-rebreather. He was then weaned to high flow mask. He was continued on Dilt with adequate rate control, the dose of this medicaion may need to be adjusted based on his BP and HR. Given his tenuous blood pressure and oxygenation, he was transferred to the MICU. On arrival to MICU, patient was 100% on NRB mask with RR 25-28. BP stable with SBP 110s. His post op hypoxia was likely [**2-24**] atelectasis, emphysema seen on CT, and then while in ICU was diagnosed with PNA. Also likley had some fluid overload from transufsions. Was weened to first shovel mask and then NC. On discharge he is on 2L NC. He should be continued to be weaned after discharge. He was treated for hospital aquired PNA with vancomycin and levofloxacin. On discharge his Vancomycin was changed to Bactrim. His sputum only showed mixed flora. He will need to complete his 14 day treatment. Also patient having aggressive use of incentive spirometry. Received total of 5 units of pRBCs due to pelivc facture, with development of large scrotal and suprapubic hematoma. Hematocrit was stable at discharge, but should be monitored once a week initally. He was palced on cipro for foley trauma, which resulted in intial hematuria. Urology following. He has a foley in place that will need to remain until his hematoma resolves. For his acetabular fracture repair his pain was controled with tylenol and oxycodone. Patient was started on post op lovenox, Ca, vit D. PT assesed patient and recommended rehab. [**Month/Day (2) 1957**] performed a AP pelivis film for follow up on day of discharge and will see patient in 2 weeks. His staples will need to be removed in 1 week after discharge. During his admission he also had delirium, which was likely multifactorial: elderly man, in ICU, in pain, on narcotics, with infection (PNA) and constipation. Patient treateed with zyprexa 2.5mg for confusion. Also minimized narcotics and treated infection. Mental status improved before discharge. Post op patient had ileus on CT abd/pelvis. Likely post op [**2-24**] to narcotics for pain. Fleets enema helped initially. Then patient had NGT decompression and PO narcan with aggressive bowel regimen, ileus resolved. Now on less aggressive regimen, gaol [**1-24**] BMs per day. For his DM, type II, his metformin was held and his his sugar was well controlled on insulin sliding scale. His home losartan was held due to his hypotension post-op, but may need to be restarted if his BP increases. He will be discharge to rehab and will have follow up with Dr. [**Last Name (STitle) 410**]. Medications on Admission: From [**3-2**] D/C summary- Hytrin po 5 mg qhs ASA 325mg po alt days Zocor 40mg po qhs Niaspan 500mg po qpm Proscar 5mg po qhs Glucophage 500mg po qam, 1000mg qpm Trazodone 50mg po qhs Celexa 20mg po qd Cozar (losartan) 12.5 mg po qd (recently decr from 25mg qd due to decr BP) Vit D 50,000 units gel qw Sunday MVI daily Cranberry tab daily Discharge Medications: 1. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical TID (3 times a day): to penile meatus while foley in place . 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical twice a day: apply to groin rash until it resolves. 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection three times a day: use sliding scale sent from hospital. 6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours): max dose 4 g per day, for pain. 7. DILT-XR 120 mg Capsule,Degradable Cnt Release Sig: One (1) Capsule,Degradable Cnt Release PO once a day: hold for SBP<100, HR<60. Capsule,Degradable Cnt Release(s) 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for >2BMs per day. 12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 15. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO HS (at bedtime). 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stool. 19. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 20. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: do not give if sedated, rr<10, or confused. 21. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days: last day of treatment [**2159-10-12**], was started [**2159-9-29**]. 22. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 8 days: last day of treatment [**2159-10-12**]. 23. oxygen Please wean oxygen, keep oxygen saturation >92% Discharge Disposition: Extended Care Facility: [**Last Name (un) 1687**] - [**Location (un) 745**] Discharge Diagnosis: Hip facture, s/p ORIF repair Pneumonia Scrotal Hematoma Atrial fibrillation with rapid ventricular response Diabetes Mellitus, Type II Discharge Condition: Hemodynamically stable, afebrile. Discharge Instructions: You were admitted to [**Hospital1 18**] after a fall and found to have a hip fracture, you had surgery to repair your hip. After the procedure you had a rapid heart rate, this is now controlled with medication. You also had problems breathing with low blood pressure, for this you required a stay in the ICU. You were diagnosed with a pneumonia, and were treated with antibiotics. You had a fracture in you pelvis that caused bleeding into your scrotum, you will need to have a foley while this resolves. You will be going to a rehab center to improve you strength and mobility. Please keep your follow up appointments. You will need to see your PCP and the [**Hospital1 **] doctor. Please take your medications as instructed. Changed have been made to your medications. If you have chest pain, shortness of breath, fever, increased swelling in your scrotum or any other concerning symptom please seek medical attention or go to the ER. Followup Instructions: Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2159-10-16**] 3:25 Provider: [**Name10 (NameIs) **] [**First Name11 (Name Pattern1) 98650**] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2159-10-16**] 3:45, [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **] Please make an appointment with your PCP as soon as you leave the hospital to discuss your stay. PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1408**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2159-10-6**]

[ "799.02", "518.0", "996.76", "285.1", "401.9", "427.31", "E888.9", "250.00", "486", "808.0", "997.3" ]

icd9cm

[ [ [] ] ]

[ "79.39" ]

icd9pcs

[ [ [] ] ]

14004, 14082

7839, 11239

288, 372

14261, 14297

2572, 7816

15285, 16012

1783, 1879

11633, 13981

14103, 14240

11265, 11610

14321, 15262

1894, 2553

222, 250

400, 953

975, 1396

1412, 1767

76,853

158,625

4773+55610

Discharge summary

report+addendum

Admission Date: [**2114-8-6**] Discharge Date: [**2114-8-24**] Date of Birth: [**2062-6-15**] Sex: M Service: PLASTIC Allergies: Ibuprofen / Terbinafine / IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 1430**] Chief Complaint: Chest wall pain Major Surgical or Invasive Procedure: 1) IR guided fluid collection drainage X2 2) IR guided aspiration 3) PICC line placement 4) I&D by plastics 5) Chest washout by plastics 6) sternal debridement, pectoralis advancement (bilateral) and primary closure with retention sutures. History of Present Illness: 52M with a history of MI (w/stents ??????09 and CABG [**Month (only) **]. ??????09) p/w a week of reproducible [**9-24**] right sided chest pain, recently admitted for similar symptoms and ruled out for ACS in [**Month (only) 958**] [**2113**]. He reports that 5 days PTA he began to have significant right sided chest pain that is tender to palpation focally, including over the chest wound. Worse with movement and breathing. Pt noticed a swelling ??????pimple?????? in the area of his scar last week. He has had fevers to 101F w/ chills over the past two days (mostly at night) with a nonproductive cough and shortness of breath due to chest wall pain. s/p CABG course was complicated by a sternal wound dehiscence and multiple abscesses which required surgical drainage. Pt has been free of angina. At baseline, he does have some mild shortness of breath when climbing up stairs at his apartment, but he is able to make it up the five flights of stairs multiple times a day. Denies abdominal pain, n/v, SOB, LE edema, HA, stiff neck. . In the ED, vital signs as follows: HR: 88 BP: 127/71 RR: 14 O2: 99% . In the ED had a chest xray & labs drawn. He was started on IV ceftriaxone & vancomycin. Past Medical History: - Coronary Artery Disease s/p PCI [**10-24**], 2-vessel CABG [**11-23**] (LIMA to LAD, SVG to diag) c/b sternal dehiscence requiring debridment, multiple wire removals & plating, & bilateraly pectoralis flaps in [**5-25**], c/b sternal abscess s/p I&D [**7-25**] - Chronic pancreatitis - DM - HTN - Erectile dysfunction - R shoulder adhesive capsulitis s/p rotator cuff & biceps impingement, now s/p surgery - s/p C4-C5 fusion - multiple chest wall infections Social History: Patient unemployed since [**2100**]. h/o IVDU and cocaine, reports being clean x4yrs; 40+ pk-yr history of tobacco, continues to smoke Family History: Mother with lung cancer, deceased in [**2090**] and aunt and uncle with lung cancer. Father unknown, he lives in [**State 108**] and the patient is not in contact with him. Physical Exam: ADMISSION GEN: Sitting up in bed in NAD. HEENT: PERRL. EOMI. OP clear. NECK: Supple, no LAD. No JVD. COR: +S1S2, RRR, no m/g/r. PULM: CTAB, slight inspiratory crackles over right base. [**Last Name (un) **]: + NABS in 4Q, soft NTND EXT: WWP, DP + bilaterally. No c/c/e NEURO: CNIII-XII intact. MAEE. Strength 5/5 bilaterally throughout. SKIN: Area of diffuse erythema (no demarcation), warmth, & swelling over right pectoral muscle. No induration or fluctuance. Midline sternotomy scar with crusted/scabbed pustule. No dehiscence evident Pertinent Results: RADIOLOGY: CT Chest w/o Contrast [**2114-8-7**] 1.New large pre- and right parasternal collection with small intrathoracic component as described. Because of the lack of intravenous contrast administration, differentiation between and inflammatory phlegmon vs abscess was limited. 2.Previous bone changes including fragmentation, demineralization and non-united post-sternotomy changes are unchanged. 3.Multiple lung nodules stable since [**2114-4-15**]. No new lung nodules of concern. Follow-up CT is recommended at one year to monitor stability . Radiology Report PLEURAL ASP BY RADIOLOGIST Study Date of [**2114-8-8**] 3:59 PM IMPRESSION: Technically successful aspiration of midline collection containing 46 mL of purulent fluid. Aspiration of the right-sided anterior chest wall collection was not possible. Sample sent for microbiological analysis. . Radiology Report CHEST U.S. Study Date of [**2114-8-13**] 3:04 PM IMPRESSION: Resolution of the previously drained pre sternal fluid collection with a persistent right parasternal fluid collection noted more superiorly, as described. . Radiology Report GUIDANCE FOR ABSCESS ([**Numeric Identifier 10268**]) Study Date of [**2114-8-14**] 2:39 PM IMPRESSION: Uncomplicated placement of an 8 French [**Last Name (un) 2823**] pigtail catheter to the presternal fluid collection. 30 cc of frank pus was aspirated and sample was sent to the laboratory. . Radiology Report UNILAT UP EXT VEINS US RIGHT Study Date of [**2114-8-20**] 11:04 AM IMPRESSION: No DVT. . PATHOLOGY: PENDING . MICROBIOLOGY: [**2114-8-8**] 4:30 pm ABSCESS Source: chest abscess. **FINAL REPORT [**2114-8-14**]** GRAM STAIN (Final [**2114-8-9**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2114-8-14**]): WORK-UP PER DR [**Last Name (STitle) 20027**] ([**Numeric Identifier 20028**])--INCLUDING DOXY AND BACTRIM. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. Sensitivity testing performed by Sensititre. SENSITIVE TO CLINDAMYCIN MIC OF <=0.12 MCG/ML. SENSITIVE TO TETRACYCLINE MIC OF <=2 MCG/ML. 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----------- S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=2 S LEVOFLOXACIN---------- =>16 R OXACILLIN------------- =>16 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- S TRIMETHOPRIM/SULFA---- =>8 R VANCOMYCIN------------ 2 S ANAEROBIC CULTURE (Final [**2114-8-12**]): NO ANAEROBES ISOLATED. . [**2114-8-17**] 12:53 pm TISSUE 3RD RIB. GRAM STAIN (Final [**2114-8-17**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [**2114-8-21**]): Reported to and read back by DR. [**Last Name (STitle) 20029**] [**Name (STitle) 20030**] @ 1055A, [**2114-8-19**]. 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. RARE GROWTH OF FOUR COLONIAL MORPHOLOGIES. ANAEROBIC CULTURE (Final [**2114-8-21**]): NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final [**2114-8-21**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): . FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2114-8-20**]): NO FUNGAL ELEMENTS SEEN. [**2114-8-6**] 03:20PM WBC-10.2 RBC-3.62* HGB-11.1* HCT-31.3* MCV-86 MCH-30.6 MCHC-35.4* RDW-13.9 [**2114-8-6**] 03:20PM NEUTS-81.4* LYMPHS-12.1* MONOS-4.8 EOS-1.3 BASOS-0.5 [**2114-8-6**] 03:20PM PLT COUNT-423 [**2114-8-6**] 03:20PM cTropnT-<0.01 [**2114-8-6**] 03:20PM GLUCOSE-318* UREA N-19 CREAT-1.3* SODIUM-131* POTASSIUM-5.1 CHLORIDE-97 TOTAL CO2-24 ANION GAP-15 [**2114-8-6**] 03:33PM LACTATE-1.6 [**2114-8-6**] 05:22PM D-DIMER-462 Brief Hospital Course: HOSPITAL COURSE 52yo M PMHx CAD s/p CABG complicated by sternal osteomyelitis, MRSA abscess presenting w/ new anterior chest wall fluid collection, s/p drainage, course complicated by ICU stay for hypotension, IR draingage and IV abx treatment on the floor, and washout by plastics. . Neuro: Patient had no signs or symptoms of neurological impairment. He is alert and oriented during his entire hospital stay. The patient had significant pain requirements during his hospital stay. The patient was given IV Dilaudid initially for his pain. He was continued on his home dose of MS Contin 30 mg q12h. Postoperatively the patient was started on a PCA pump for approximately 24 hours. After which he was transitioned to oral opiate analgesics including p.o. oxycodone. However the patient did not do well with the oral oxycodone and chronic pain service was consulted. The patient was switched to p.o. dye lauded 46 kg q.3 h. as needed for pain the patient was discharged with a prescription for oral Dilaudid and orders to continue his prescription for oral MS Contin as directed. Cardio: Initially the patient was admitted for chest pain. His history and physical exam was atypical for acute coronary syndrome and his initial troponin was negative. During his stay, [**2114-8-7**], patient did develop hypotension in the setting of sepsis. The patient was transferred to the intensive care unit where he received IV antibiotics, IV fluids, and pressor support. The patient's blood pressure stabilized and the IV pressors were weaned off. the patient was transferred back to the floor after he was hemodynamically stable. On the floor and postoperatively the patient's vital signs were monitored and did not require interventions for hypotension. The patient was hemodynamically stable at the time of his discharge. The patient does have history of coronary artery disease status post coronary artery bypass grafting. The patient was continued on his daily aspirin regimen. Respiratory: Patient did not have any planes of respiratory distress during his admission. In the emergency department the chest x-ray was negative for infiltrate there is no evidence of pneumonia. During his ICU stay the patient did not require intubation and his O2 saturation was maintained on low levels of supplemental oxygen. Postoperatively the patient was encouraged to ambulate her early as well as use incentive spirometry to avoid atelectasis and pneumonia. Gastrointestinal: The patient did not have any gastrointestinal complaints. He was maintained on a diabetic diet and his diet was advanced as tolerated post operatively. Genitourinary: The patient was admitted with acute kidney injury most likely secondary to hypo-bulimia in the setting of sepsis. His creatinine improved with IV fluids. He had normal urinary output. Foley catheter was inserted during his ICU stay as well intraoperatively. No complications were associated with a Foley catheter. The patient was discharged with no difficulty voiding. Hematologic: During his hospital stay the patient's hematocrit decreased with a nadir of 23. Patient was transfused 2 units packed red blood cells prior to his second operation. There is no complications associated with the transfusion. The patient had appropriate increasing hematocrit was stable on discharge. The patient's etiology of his anemia is most secondary to surgery. MCV was normal. There is no evidence of gastrointestinal bleeding Infectious disease: Patient was admitted with an anterior chest wall collection suspect to be infectious in etiology. He has a history of chronic osteomyelitis in the past. During his admission he was transferred to the ICU for suspected sepsis. In emergency department the patient was given broad-spectrum antibiotic coverage. After he interventional radiologists placed a drain in the fluid collection that was sent off for culture data. The abscess culture was significant for coagulase negative staphylococcus. Infectious disease consultation was placed. Recommendations included IV vancomycin. The patient was continued on IV vancomycin and during his stay. The patient was stable after transfer from the intensive care unit. There is no further signs or symptoms of severe sepsis. The patient is being discharged home with a PICC line for anticipated 6 weeks of IV vancomycin for chronic osteomyelitis. Endocrine: Patient has a history of diabetes with insulin dependence. The patient was placed on a sliding scale insulin during his inpatient stay and was monitored closely. Hemoglobin A1c was performed which was resulted at 9. The patient has evidence of chronic uncontrolled diabetes. During his stay his blood sugars were monitored and stabilized. The patient will follow up outpatient with his primary care physician for further control of his diabetes. Psych: Patient had not had indications of suicidal or homicidal ideation. Psychiatry consultation was ordered by the medicine service for determination if the patient was competent to leave AGAINST MEDICAL ADVICE if he so desired. Patient was found to competent and has the capacity to leave AGAINST MEDICAL ADVICE during his stay, although he did not. The patient does have history of polysubstance abuse in the past. The patient was given opiate analgesics postoperatively for pain control. I recommend to the patient he continues to follow up with his chronic pain physician for appropriate control of his opiate analgesic needs. Although the [**Hospital 228**] hospital stay was quite complicated he was able to be discharged in stable condition with improvement in his anterior chest pain. The patient has a plan is to followup with his primary care physician chronic pain physician as well as the plastic surgeon who performed the patient's surgeries. Medications on Admission: - Gabapentin 800mg [**Hospital1 **] - Insulin humalog 75-25 mix 100 unit/mL (75-25) 32units qAM, 34units qPM - Lisinopril 10mg daily - Metoprolol succinate 100mg daily - MS Contin 30mg [**Hospital1 **] - Nitroglycerin 0.3mg prn - Pioglitazone 30mg daily - Ranitidine 150mg [**Hospital1 **] - Simvastatin 40mg daily - Trazodone 50mg qHS - Aspirin 81mg daily - Cyanocobalamin 500mcg daily - Ferrous sulfare 325mg daily Discharge Medications: 1. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 6 weeks. Disp:*84 gram* Refills:*0* 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 14. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). Disp:*60 Tablet Extended Release(s)* Refills:*0* 15. hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO every [**3-21**] hours as needed for pain for 1 weeks. Disp:*120 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Physician [**Name9 (PRE) **] [**Name9 (PRE) **] Discharge Diagnosis: Open wound to the chest, chronic osteomyelitis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions: Personal Care: 1. Leave your midline chest dressing in place x 48 hours after surgery. You may keep your incision/suture line open to air without a dressing OR you may cover your incision with clean, dry dressing daily. 2. Clean around the drain site(s), where the tubing exits the skin, with soap and water. 3. Strip drain tubing, empty bulb(s), and record output(s) [**1-18**] times per day. 4. A written record of the daily output from each drain should be brought to every follow-up appointment. your drains will be removed as soon as possible when the daily output tapers off to an acceptable amount. 5. You may shower daily. No baths until instructed to do so by Dr. [**First Name (STitle) **]. . Activity: 1. You may resume your regular diet. 2. DO NOT lift anything heavier than 5 pounds or engage in strenuous activity until instructed by Dr. [**First Name (STitle) **]. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 4. Take prescription pain medications for pain not relieved by tylenol. 5. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softerner if you wish. 6. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. . DRAIN DISCHARGE INSTRUCTIONS You are being discharged with drains in place. Drain care is a clean procedure. Wash your hands thoroughly with soap and warm water before performing drain care. Perform drainage care twice a day. Try to empty the drain at the same time each day. Pull the stopper out of the drainage bottle and empty the drainage fluid into the measuring cup. Record the amount of drainage fluid on the record sheet. Reestablish drain suction. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD; Please call upon discharge to make an appointment to follow up next week. [**Street Address(2) **]., [**Apartment Address(1) **], [**Location (un) **], [**Numeric Identifier 1415**] Office Phone:([**Telephone/Fax (1) 1429**] Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time: [**2114-9-3**] 9:30 The above appointment is with Infectious Disease which is located on the [**Hospital Ward Name **], [**Hospital Unit Name **], [**Location (un) 442**], [**Hospital Unit Name 6333**]. . Provider: [**First Name8 (NamePattern2) 640**] [**Last Name (NamePattern1) 2345**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time: [**2114-9-10**] 2:10 The above appointment is with [**Hospital6 733**] who are located on the [**Hospital Ward Name **], [**Hospital Ward Name 23**] building, [**Location (un) 453**]. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20031**], MD Phone:[**Telephone/Fax (1) 3736**] Date/Time: [**2114-9-19**] 1:00 This appointment is with the Spine Center who is located on the [**Hospital Ward Name **], [**Hospital Ward Name 23**] Building, [**Location (un) **]. Name: [**Known lastname 447**],[**Known firstname **] P Unit No: [**Numeric Identifier 3340**] Admission Date: [**2114-8-6**] Discharge Date: [**2114-8-24**] Date of Birth: [**2062-6-15**] Sex: M Service: PLASTIC Allergies: Ibuprofen / Terbinafine / IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 3341**] Addendum: The complications that the patient was admitted to the hospital were related to the initial sternotomy performed at [**Hospital1 8**] for his CABG. The fluid collections that were found and drained were sub pectoral. The diagnosis of chronic osteomyelitis of the ribs and sternum at the time of the surgical debridement. Discharge Disposition: Home With Service Facility: Physician [**Name9 (PRE) **] [**Name9 (PRE) **] [**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern4) 3342**] MD [**MD Number(1) 3343**] Completed by:[**2114-10-5**]

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icd9cm

[ [ [] ] ]

[ "77.61", "34.04", "83.95", "83.82", "38.97" ]

icd9pcs

[ [ [] ] ]

21049, 21287

7872, 13648

341, 582

15811, 15811

3209, 7210

19070, 21026

2461, 2635

14116, 15618

15740, 15790

13674, 14093

15986, 19047

2650, 3190

7243, 7249

7282, 7849

286, 303

610, 1809

15826, 15938

1831, 2292

2308, 2445

14,477

147,895

29764

Discharge summary

report

Admission Date: [**2178-4-29**] Discharge Date: [**2178-5-28**] Date of Birth: [**2117-11-13**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 943**] Chief Complaint: Tx from OSH for TIPS eval Major Surgical or Invasive Procedure: TIPS procedure. Therapeutic paracentesis. History of Present Illness: 60yoM with h/o HepC cirrhosis, alcohol abuse, hypertension, and type II diabetes, with recurrent ascites admitted for TIPS evaluation. The patient was initially admitted to [**Hospital 794**] Hospital in RI [**2178-4-28**] with complaint of one month worsening LE edema, weakness, increasing abdominal girth, and difficulty walking. At that time he was found to have a [Na+] 117. There he underwent 6L paracentesis with albumin replacement. Echocardiogram was performed showing EF 60%, no valvular disease. Prior to transfer [Na+] 122, HgB 8 but no transfusion given. On the floor, he reports feeling fine, but still very weak. He is a poor historian and unable to characterize symptoms. He denies chest pain, shortness of breath, fever, chills, nausea, vomiting, confusion, changes in abd girth, LE swelling. Past Medical History: Hepatitis C: 1B serotype, Dr. [**First Name4 (NamePattern1) 7306**] [**Last Name (NamePattern1) 7307**] outpatient Cirrhosis - hepatitis C with h/o grade II varices EtOH abuse HTN Type II diabetes mellitus Bipolar disorder: used to have manic episodes, now well controlled h/o tobacco use colonic polyps on colonoscopy [**7-/2176**] Social History: lives with roommate at [**Location (un) 71242**]. on disability Tob: smoked x27yrs, quit [**2176**] EtOH: h/o abuse, quit [**2168**] Illicits: h/o MJ use, quit [**2155**] Family History: F. died of stroke at 78yrs Physical Exam: VS: 100.3 98.9 126/51 70-94 18 98%RA FS 163-182 GEN: NAD, mild flat affect HEENT: PERRL, anicteric, MMM, OP clear Neck: supple, no LAD, JVP nondistended CV: RRR, no M/R/G Resp: CTA ant and laterally as pt reports too weak to sit up Abd: +BS, soft, obese, distended with fluid wave, nontender Ext: left anterior shin draining ulcer, bilateral venous stasis changes SKIN: numerous telangietasias Neuro: A&Ox3, CNII-XII intact, no asterixis Pertinent Results: Liver U/S: IMPRESSION: 1. Cirrhosis without evidence of focal lesion. 2. Ascites. 3. Splenomegaly. 4. The hepatic vessels are patent with normal waveforms. Echo: The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated. Right ventricular systolic function is normal. [Intrinsic right ventricular systolic function is likely more 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 structurally normal. Mild to moderate ([**12-9**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: # Cirrhosis: Patient was transferred from OSH for TIPS evaluation for recurrent ascites. TIPS was performed, although complicated by intraperitoneal bleeding. This was treated supportively with octreotide, FFP, and platelets, and subsequently his hematocrit stabilized. Patient continues to have recurrent ascites, although less severe. Required multiples paracenteses during admission, some of which were grossly bloody, after the TIPS. Due to falling hematocrit, there was initially concern for variceal bleed, and he was transferred to MICU for closer monitoring. However, he remained hemodynamically stable and the bleeding was attributed to slow intra-adbominal bleed due to possible capsular injury from TIPS. Prior to discharge, peritoneal fluid cleared. There was never evidence of infection, and patient is on Ciprfloxacin for SBP prophylaxis given history of varices and low total protein in ascitic fluid. Prior to discharge, patient had a 2.5 liter paracentesis. Patient's propranolol was discontinued after TIPS. He was continued on lactulose 30mL [**Hospital1 **]. Diuretics were restarted, Furosemide 40mg and Spironolactone 200mg daily prior to discharge. These had been held initially due to hyponatremia, which did not recur. Routine transplant laboratory tests were sent including Hepatitis panel, tumor markers, viral serologies. RUQ U/S was done. Echo was done to evaluate RV function and noted TR and underestimate of RV systolic function. Patient then underwent right heart cath which revealed mild pulmonary hypertension. He will continue to follow with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] in the transplant clinic for further consideration of transplant. # Wound care: High risk for developing cellulitis, given substantial lower extremity edema and diabetes mellitus. He needs daily clean dressing changes with bacitracin ointment to prevent this from worsening. Alsot, patient should schedule appointment with his podiatrist within 1-2 weeks of being discharged. Patient has bilateral stasis changes and weeping skin in both lower-extremities. He was not frankly cellulitic, given absence of warmth on skin exam, no fevers, white count, or evidence of any positive blood cultures. However, his ciprofloxacin dose for SBP, was doubled prophylactically to 500mg for 1 week course, as this will cover most likely organisms. He needs to finish 7 days of 500mg qdaily, and then resume 250mg daily afterwards for SBP prophylaxis. # Diabetes mellitus - Patient was on oral rosiglitazone prior to discharge. Due to difficult glycemic control, he was transitioned to insulin. [**Last Name (un) **] was consulted. Final regimen was insulin 70/30 30 units twice a day. Patient's primary care physician was notified and will further adjust his regimen on follow-up appointment. Patient will have VNA at [**Hospital3 **] facility to help with this. # Renal Failure: Patient had Creatinine elevation to 1.7 and felt to be elevated due to diuretic use and blood loss. Subsequently normalized, with discharge creatinine 1.1. # Pancytopenia: Likely due to splenic sequestration from portal hypertension. Patient received several peri-procedural platelet transfusions and blood transfusions as needed for blood loss. Otherwise, this was stable. Will need to be followed as outpatient. # Bipolar disorder: Continued lexapro and risperidone per outpt regimen, and discharged with refills based on this regimen. # Hypertension - patient was normotensive during this admission. He was on propranolol for portal hypertension, which was discontinued after TIPS. Can be restarted if patient develops hypertension as outpatient. # Nutrition: Patient will need to observe low-sodium fluid restricted diet as outpatient. # Hyponatremia: Secondary to diuretics, resolved. Diuretics restarted an patient tolerating. # Prophylaxis: Patient was on pantoprazole and was very ambulatory, therefore DVT prophylaxis was witheld. He was continued on lactulose for preventing encephalopathy after TIPS. # Full code Medications on Admission: Meds on Admission to [**Hospital 794**] Hospital: Avandia 4mg [**Hospital1 **] Lexapro 20mg daily Detrol LA 4mg daily Cipro 750mg qweekly MVI Vitamin K Propranolol 40mg [**Hospital1 **] Lasis 40mg daily Aldactone 100mg daily Risperdal 4mg daily Loperamide 2mg TID prn Lactulose 30mL [**Hospital1 **] . Meds on Transfer to [**Hospital1 18**]: Avandia 4mg [**Hospital1 **] Lexapro 20mg daily Detrol LA 4mg daily Cipro 750mg qweekly Propranolol 40mg [**Hospital1 **] Lasix 40mg daily Aldactone 100mg daily Risperdal 4mg daily Loperamide 2mg TID prn Lactulose 30mL [**Hospital1 **] Discharge Medications: 1. Insulin Syringe 1 mL 29 x [**12-9**] Syringe Sig: One (1) Miscellaneous Before breakfast and before dinner. Disp:*60 syringes* Refills:*2* 2. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension Sig: 30 Units Subcutaneous Before breakfast and before dinner. Disp:*2 vials* Refills:*2* 3. One Touch Ultra System Kit Kit Sig: One (1) Miscellaneous once a month. Disp:*1 kit* Refills:*2* 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:*1 months supply* Refills:*0* 5. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*2* 6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). Disp:*1800 ML(s)* Refills:*2* 7. Risperidone 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. 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* 9. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 12. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): Take 2 tablets per day for the next 7 days. Then take 1 tablet per day every day on [**2178-6-4**]. Disp:*37 Tablet(s)* Refills:*2* 13. Bacitracin 500 unit/g Ointment Sig: Moderate amount to both legs Topical once a day. Disp:*3 tubes* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] hospital VNA Discharge Diagnosis: Alcoholic Liver Disease Secondary diagnoses: Cirrhosis with grade II varices Hepatitis C History of alcohol use, none for 9 years. Hypertension Type II diabetes mellitus Bipolar disorder History of tobacco use colonic polyps on colonoscopy [**7-/2176**] Discharge Condition: Stable. Discharge Instructions: You were admitted for evaluation of fluid in the abdomen. This fluid was drained and you also received a TIPS procedure to relieve pressure in your liver. You also had some bleeding in the abdomen, and this stabilized. Please contact your physician or return to the emergency room if you notice lightheadedness, nausea, vomitting, severe abdominal pain, or any other concerning symptoms. Followup Instructions: You have an appointment scheduled with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17474**], your primary care physician on Thursday [**2178-6-11**] at 11:15 AM. Please call [**Telephone/Fax (1) 40831**] with any questions or to change your appointment. You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] in the liver transplant clinic on [**2178-6-1**] at 9:00 AM. Please call [**Telephone/Fax (1) 673**] with any questions or concerns. Please call your podiatrist to schedule an appointment within the next 1-2 weeks. Completed by:[**2178-5-28**]

[ "571.2", "998.11", "V11.3", "284.8", "593.9", "V15.82", "789.2", "276.1", "459.81", "496", "285.1", "250.00", "789.5", "070.54", "401.9", "707.19", "296.80" ]

icd9cm

[ [ [] ] ]

[ "99.04", "39.1", "99.07", "54.91", "99.05", "37.21", "88.47" ]

icd9pcs

[ [ [] ] ]

9600, 9659

3167, 4902

301, 345

9958, 9968

2259, 3144

10407, 11034

1747, 1775

7881, 9577

9680, 9705

7278, 7858

9992, 10384

1790, 2240

9726, 9937

236, 263

4914, 7252

373, 1185

1207, 1542

1558, 1731

24,579

155,526

9786

Discharge summary

report

Admission Date: [**2141-4-28**] Discharge Date: [**2141-5-8**] Service: HISTORY OF PRESENT ILLNESS: This is a 78 year-old man who developed slurred speech and left arm weakness on [**2141-4-28**]. He was transferred from [**Hospital 1474**] Hospital to [**Hospital1 346**] Emergency Department. He had no history of trauma, reportedly had some emesis a few times prior to going to the Emergency Room. The patient also developed a severe rash over his left side of his face and also with left sided eye pain over the last one to two days prior to admission. PAST MEDICAL HISTORY: Unknown at the time of admission except for back pain and incontinence. MEDICATIONS: Detrol and Vicodin. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Vital signs blood pressure 184/85. HEENT normocephalic with very impressive vesicular rash extending along the left side of the forehead to the periorbital region down to the tip of the nose and back toward the ears of the left side. No involvement of the tympanic membranes or external auditory canal. There was very sharp demarcation at the midline of the forehead. His left eye had periorbital edema and is closed. When open the sclera was injected. Pupils are equal, round and reactive to light and accommodation. Extraocular movements intact. On fluorescent examination there was a very small lesion less then 2 mm in length in the center of the portion of the cornea. This also may also represent a dendritic ulcer, however, corneal abrasion could not be completely ruled out. The patient states he is able to see throughout the eye, however, visual acuity examination is unattainable. Extraocular movements intact. Mucous membranes are moist. There is a left sided facial droop noted. The patient is unable to bluff his left cheek. Tongue was midline, although widely patent. Neck was supple, nontender. No lymphadenopathy. No jugular vein distention. Cardiovascular regular rate and rhythm. No murmurs, rubs or gallops. Chest clear to auscultation. Breath sounds are equal bilaterally. Abdomen was soft and nontender. As noted no rebound or guarding. Extremities the patient moves all of the extremities appropriately. Strength was 5 out of 5 and equal bilaterally. Sensation was intact as well as excellent strength. Reflexes were appropriate. The patient had left sided facial droop as noted. Neurological examination comprehension was intact, repetition was intact, dysarthria was present. Eyes closed, follows commands, attempts to follow eye to voice, oriented to name to [**Location (un) 86**], thinks the year was [**2111**]. Examination at [**Hospital1 188**] Emergency Room he was unable to lift his left arm off the bed. His IPs were 4 out of 5. His right face was without a droop and he again had 5 out of 5 strength. LABORATORY: His white blood cell count was 13.1. His hematocrit was 33.9, platelets 219, sodium 140, potassium 4.4, chloride 100, BUN 19, creatinine 1.1, blood sugar 168. Head CT showed a right frontal bleed on two different densities, possibly areas more acute then the other, but a bleed within the last day. No midline shift noted. The approximate size of the frontal bleed was 3 by 3 by 3.5 cm. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit to keep his blood pressure less then 140, keep his INR less then 1.4 and his platelets greater then 100,000. An ophthalmology consult was done for possible herpes zoster. He was kept fluid restricted and CT scan was going to be repeated on the morning of the 17th. Ophthalmology did see the patient on the 16th at 6:00 p.m. They felt that he had herpes zoster of his left eye area. No corneal involvement. He also had conjunctivitis and mild preseptal cellulitis. He was started on bacitracin and/or Erythromycin q.i.d. to his left eye. On the [**12-30**] the patient was arousable and oriented times one, continued with his left sided weakness and left facial weakness. He was started as per ophthalmology on Bacitracin ointment and he was monitored closely. CT on the 17th was stable with hematoma no changes. On the [**12-31**] the patient's family was spoken to. His son stated that his father requested a DNR/DNI and it was explained the patient's condition at that time. His son stated that dad and he had discussed this and would not want it to go any further. A DNR was signed again on the 18th. On the [**1-1**] the patient continued to be monitored in the Intensive Care Unit setting. He had an nasogastric tube placed and tube feedings were started. Also he was started on Lopresor and Hydralazine for his blood pressure control and Acyclovir for his herpes zoster. His medications at this time included a nitro drip, Dilantin for seizure prophylaxis, Erythromycin ointment for his herpes zoster, Hydralazine for his blood pressure, Kefzol, Acyclovir, Pepcid, Lopressor and Tylenol. Ophthalmology also followed up on the 19th and continued to state it was herpes zoster infection. No corneal involvement, positive conjunctivitis and to continue ointment in both eyes. Acyclovir switched to po. On the 19th also case management has become involved with the patient in hopes of transferring him to a facility. On the 20th the patient became more obtunded. A CAT scan was unchanged and it remained unclear why the patient became more obtunded. An LP was done and the patient was pan cultured. Also on the 20th an A line was placed and a subclavian line was placed due to insufficient peripheral access. Urology was called to place a Foley due to a history of prostate CA. The patient had pulled out his Foley. The new Foley was placed without difficulty. On the 21st it was felt that the patient was more awake. On the [**1-3**] physical therapy was consulted and he was followed for assessing a strengthening mobility, however, he was found not to be alert enough to work with them at this time. On the [**1-3**] an infectious disease consult was completed. At that time urine showed occasional bacteria, no yeast, 3 to 5 red blood cells. Cerebral spinal fluid showed in tube four 115 white blood cells, 213 red blood cells, tube one showed 75 white blood cells, 565 red blood cells, glucose 82. There was a question of possible growth of varicella PCR in the cerebral spinal fluid. Infectious disease recommended increasing Acyclovir to 1000 mg q week for best coverage of the VCV, to add VCV PCR cerebral spinal fluid to confirm the diagnosis, to consider MRI/MRA of cerebral angio as VCV vasculitis can have this characteristic of the appearance on angio. Also Levofloxacin 500 mg q 24 and Flagyl 500 mg intravenous q 8 were added for what was thought to be an aspiration pneumonia. Ophthalmology also came back on the 21st and agreed with the infectious disease recommendation. He does not appear to have preseptal cellulitis. The patient was started on Ilotycin OD t.i.d. and Lacrilube OD and Ilotycin OS t.i.d. On the 22nd an MRI and MRA of the head was ordered along with aggressive chest physical therapy and suctioning. It was felt that the patient was improving neurologically. On the 21st again it showed that VCV/PCR was pending on the cerebral spinal fluid. The patient continued on Levo and Flagyl for aspiration pneumonia and his Kefzol was stopped for what was thought to be periorbital cellulitis. On the 23rd the patient was awake and moving his right toes, squeezing his right hand, oriented times person. On the [**1-6**] the patient was afebrile, turned his head and he would open his eyes and follow single commands, he was moving the right side spontaneously. Infectious disease felt that the patient most likely had zoster encephalitis and he was getting somewhat worse from a pulmonary standpoint. Repeated aspiration, given poor mental status. Chest x-ray was also worse on the 24th. He was continued on Acyclovir, Levo and Flagyl. On the [**1-7**] the family made the patient comfort measures only and the patient passed away comfortably on [**2141-5-8**] at 7:58 a.m. His family was notified at that time. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern4) 32961**] MEDQUIST36 D: [**2141-5-8**] 11:06 T: [**2141-5-10**] 11:22 JOB#: [**Job Number 32962**]

[ "431", "376.01", "053.29", "507.0", "V10.46", "054.3" ]

icd9cm

[ [ [] ] ]

[ "38.91", "03.31" ]

icd9pcs

[ [ [] ] ]

3251, 8373

762, 3233

110, 570

593, 739

26,565

118,813

16682

Discharge summary

report

Admission Date: [**2175-3-17**] Discharge Date: [**2175-3-22**] Date of Birth: [**2108-2-29**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: crush injury to chest Major Surgical or Invasive Procedure: Bracheocephalic vein repair Fixation of sternum History of Present Illness: Pt is a 67 yo male s/p crush injury to chest after being pinned against a wall by trailer. Injuries included posterior dislocation of the right clavicle into the mediastinum. No LOC. Presented to ED with GCS 15 complaining of chest pain. Intubated for airway protection. Neurologically intact. Past Medical History: CAD, stent x 2 s/p PTCA Family History: NC Physical Exam: 98.6 73 159/88 20 100%4L HEENT: NCAT, pupils 2 mm bilat; left supraorbital abrasions Neck: clinically cleared of cervical spinal tenderness; no pain or decreased ROM trachea slightly deviated to left RRR CTAB Abdomen soft, nontender, nondistended Guaiac - LE: good pulses Pertinent Results: [**2175-3-17**] 10:39PM GLUCOSE-55* UREA N-11 CREAT-0.7 SODIUM-136 POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-22 ANION GAP-10 [**2175-3-17**] 10:39PM WBC-9.5# RBC-3.60* HGB-10.9* HCT-30.3* MCV-84 MCH-30.4 MCHC-36.1* RDW-13.4 [**2175-3-17**] 10:39PM PLT COUNT-120* [**2175-3-17**] 10:39PM PT-15.0* PTT-32.5 INR(PT)-1.4 [**2175-3-17**] 08:57PM TYPE-ART PO2-416* PCO2-40 PH-7.39 TOTAL CO2-25 BASE XS-0 INTUBATED-INTUBATED [**2175-3-17**] 03:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2175-3-17**] 03:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024 [**2175-3-17**] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2175-3-17**] 03:15PM CK(CPK)-842* AMYLASE-71 [**2175-3-17**] 03:15PM CK-MB-12* MB INDX-1.4 cTropnT-<0.01 [**2175-3-17**] 03:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2175-3-17**] 03:15PM WBC-10.2 RBC-4.52* HGB-14.1 HCT-38.9* MCV-86 MCH-31.2 MCHC-36.2* RDW-13.0 CXR: 9.5 cm mediastinum pelvis: neg CT head: neg CT cspine negative CTA chest: posterior dislocation of right clavicular head, active extrav into right SCM/pectoralis Brief Hospital Course: After initial evaluation in trauma bay and + findings on chest CT, pt brought to OR for emergent sternotomy for evaluation of great vessel injury. Pt found to have a manubrial fracture with laceration of the innominate vein at the SVC/inn. junction with posterior disclocation of the right clavicle. Extubated successfully POD#2. Chest tubes placed to water seal on POD #2 and removed on POD#5. Hospital course complicated by bouts of afib after surgery. Pt completely asymptomatic during episodes. Patient apparantly has history of Afib for which he takes anti-arrhythmic. Responded well initially to low doses of lopressor, however, SBP `90. Pt started on dilt drip which successfully got patient back into sinus rhythm. Pt then started on home dose of po 120 mg Diltiazem, after which patient remained in sinus rhythm. In addition, pt consistently had blood sugars in the 140's. Pt had never been diagnosed with diabetes, however, has many family members with Type II. Sent patient home with glucometer and strips with PCP follow up Medications on Admission: cardizem Statin Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 2. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*0* 3. Physical Therapy Sig: [**12-6**] sessions per week for as per physical therapy days. Disp:*30 * Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: s/p crush injusry to chest Posterior disclocation of right clavicular head Innominate vein tear Sternal fracture s/p median sternotomy/innominate vein patch Discharge Condition: stable Discharge Instructions: Take your medications as directed Followup Instructions: Call Dr.[**Name (NI) 1816**] office ([**Telephone/Fax (1) 170**]) for appointment in 2 weeks. You also need to follow up with Dr. [**Last Name (STitle) **] concerning your blood sugars, which have been running high in the hospital. Call the office when you get home to schedule an appointment with him. In the meantime, you need to check your blood sugars four times a day before meals.

[ "V45.82", "807.01", "414.01", "831.04", "807.2", "926.19", "901.3", "901.2", "E919.8" ]

icd9cm

[ [ [] ] ]

[ "78.11", "39.56", "39.61" ]

icd9pcs

[ [ [] ] ]

3887, 3936

2345, 3385

335, 384

4137, 4145

1090, 2190

4227, 4619

771, 775

3451, 3864

3957, 4116

3411, 3428

4169, 4204

790, 1071

274, 297

412, 707

2199, 2322

729, 755

32,685

109,113

30610

Discharge summary

report

Admission Date: [**2159-7-7**] Discharge Date: [**2159-7-10**] Date of Birth: [**2126-6-20**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p assault with baseball bat Major Surgical or Invasive Procedure: Chest Tube Placement (placed at OSH) History of Present Illness: 33M s/p assault with baseball bat, intubated in field for airway protection, chest tube placed at referring hospital for chest crepitus. Patient incurred multiple rib fractures, left ribs [**5-28**]; pulmonary contusion and laceration with small hemothorax. Past Medical History: None Social History: Non-contributory Family History: Non-contributory Physical Exam: AF 102 148/76 16 100 HEENT: 2mm b/l, PERRL, hematoma/laceration over L post. occiput CV: RRR S1/S2 no m/g/r LUNGS: CTA b/l, intubated, no crepitus ABD: Soft, NT, ND EXT: Abrasion LUE, RLE NEURO: grossly intact Pertinent Results: [**2159-7-7**] 02:47PM GLUCOSE-91 UREA N-12 CREAT-1.1 SODIUM-139 POTASSIUM-4.3 CHLORIDE-109* [**2159-7-7**] 02:47PM CALCIUM-7.7* [**2159-7-7**] 02:47PM HCT-30.5* [**2159-7-7**] 02:43PM TYPE-ART PO2-158* PCO2-45 PH-7.33* TOTAL CO2-25 BASE XS--2 [**2159-7-7**] 02:43PM LACTATE-0.9 [**2159-7-7**] 06:41AM GLUCOSE-83 LACTATE-5.2* NA+-138 K+-3.7 CL--113* TCO2-15* [**2159-7-7**] 06:41AM HGB-10.8* calcHCT-32 [**2159-7-7**] 06:35AM UREA N-15 CREAT-1.2 [**2159-7-7**] 06:35AM estGFR-Using this [**2159-7-7**] 06:35AM AMYLASE-38 [**2159-7-7**] 06:35AM ASA-NEG ETHANOL-65* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2159-7-7**] 06:35AM WBC-28.8* RBC-3.02* HGB-10.2* HCT-29.0* MCV-96 MCH-33.8* MCHC-35.2* RDW-14.0 [**2159-7-7**] 06:35AM PLT COUNT-177 [**2159-7-7**] 06:35AM PT-14.3* PTT-28.3 INR(PT)-1.3* [**2159-7-7**] 06:35AM FIBRINOGE-179 Brief Hospital Course: Patient was admitted from the [**Hospital1 18**] emergency department directly to the TICU. Patient was in stable condition and had pain adequately controlled with PO analgesia. On HD3 patient had the chest tube removed without complication. Follow-up CXR showed no residual pneumothorax and the patient was transferred to the regular hospital [**Hospital1 **] on HD3. Patient was evaluated by both physical and occupational therapy prior to discharge and was deemed stable for discharge. Medications on Admission: None Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Multiple Rib Fractures LT5-7 Pulmonary Contusion Hemothorax/Pneumothorax Discharge Condition: Stable Discharge Instructions: Please call physician or return to ED if any of the following occur: 1. Fever >101.5 2. Increased pain not controlled with medication 3. Intractable nausea/vomiting 4. Difficulty breathing 5. Any other concerning symptoms Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in [**1-23**] weeks. Call [**Telephone/Fax (1) 6429**] for appointment. Completed by:[**2159-7-10**]

[ "807.03", "860.4", "861.22", "958.4", "873.0", "E968.2" ]

icd9cm

[ [ [] ] ]

[ "86.59", "96.71" ]

icd9pcs

[ [ [] ] ]

2716, 2722

1914, 2408

343, 382

2839, 2848

1014, 1891

3118, 3274

748, 766

2463, 2693

2743, 2818

2434, 2440

2872, 3095

781, 995

274, 305

410, 670

692, 698

714, 732

8,296

166,628

27864

Discharge summary

report

Admission Date: [**2138-7-11**] Discharge Date: [**2138-8-9**] Date of Birth: [**2054-1-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: End stage renal failure Major Surgical or Invasive Procedure: Tunnel hemodialysis line placement on right PICC line placement in right arm Kidney biopsy History of Present Illness: Briefly, 84 year-old female with suspected cholangiocarcinoma and CKD (baseline creatinine 1.7-1.8) admitted for acute on chronic kidney failure. On day prior to presentation, patient was evaluated by Dr. [**Last Name (STitle) 1366**] in [**Hospital1 18**] renal clinic. Routine labs drawn and patient was found to have worsening creatinine, metabolic acidosis, and leukocytosis. Urine microscopy showed muddy brown casts. Patient was requested to go to ED for further managment. At [**Location (un) **], UA was suspicious for UTI. For hyperkalemia, she received Kayexylate, calcium gluconate, insulin, bicarbonate, and levofloxacin. She was transferred to [**Hospital1 18**] for further evaluation. In the ED, 98.1 92 109/58 14 93%RA. Physical examination reportedly unremarkable. Laboratory data significant for creatinine 9.8 -> 9.3 (baseline 3.8), potassium 6.6 -> 5.0, WBC 21.0 -> 18.3, hematocrit 31.4 -> 25.0, lactate 1.9. UA with blood, proteinuria and no evidence of infection. Blood and urine cultures sent. Foley placed. EKG reportedly with no acute changes. CXR 2V reportedly with no acute changes. CT abdomen/pelvis without contrast (reportedly performed to rule out urinary obstruction) remarkable for bilateral pleural effusions, small pericardial effusion, and no evidence of obstruction. Receiving NS at 150cc/hour; levofloxacin at OSH. On transfer to medicine service, afebrile, 87, 120/50, 24, 97% 2L. Had BM prior to leaving ED. On medicine service, patient reports fatigue x2 weeks. ROS otherwise negative. She denies fever, chills, cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea. Also denies decreased urine output, dysuria, or hematuria. Denies decreaed urine output. Past Medical History: - Hypertension - Hyperlipidemia - UGIB ([**2136**]) - Bell's palsy ([**2132**]) - Perforated diverticulum, s/p colectomy ([**2133**]) - Hepatic cholangioadenocarcinoma s/p resection - s/p left THR Social History: No tobacco, EtOH, drugs. Lives with brother and sister, none of whom have ever married and always have lived together. Identifies as Greek Orthodox, but not a regular church attender. Family History: Noncontributory Physical Exam: General: Laying in bed, comfortable, alert. HEENT: Sclera anicteric, MMM Neck: neck supple and nontender Lungs: Decreased breath sounds at bases. No wheezes, rales, or rhonchi. CV: RRR, normal S1/S2, no MRG Abdomen: Soft, non-tender, ostomy bag on L side, clean and dry margins. Ext: 1+ edema bilaterally in both legs Pertinent Results: ADMISSION LABS: [**2138-7-10**] 02:00PM BLOOD WBC-21.0*# RBC-3.45* Hgb-9.2* Hct-31.4* MCV-91# MCH-26.6* MCHC-29.2* RDW-15.9* Plt Ct-741*# [**2138-7-10**] 02:00PM BLOOD Neuts-86.2* Lymphs-8.4* Monos-4.1 Eos-0.7 Baso-0.6 [**2138-7-11**] 04:40AM BLOOD PT-14.4* PTT-29.0 INR(PT)-1.2* [**2138-7-10**] 02:00PM BLOOD UreaN-69* Creat-9.8*# Na-139 K-6.6* Cl-102 HCO3-11* AnGap-33* [**2138-7-11**] 04:40AM BLOOD ALT-8 AST-12 LD(LDH)-183 CK(CPK)-34 AlkPhos-69 TotBili-0.3 [**2138-7-12**] 05:05AM BLOOD CK-MB-1 cTropnT-0.04* [**2138-7-10**] 02:00PM BLOOD Albumin-3.4* Calcium-9.8 Phos-5.7*# [**2138-7-17**] 06:00AM BLOOD calTIBC-143* Ferritn-754* TRF-110* [**2138-7-23**] 09:45AM BLOOD PTH-33 [**2138-8-2**] 05:49AM BLOOD Cortsol-13.2 WORKUP FOR RENAL FAILURE: [**2138-7-14**] 02:30PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2138-7-12**] 05:05AM BLOOD ANCA-NEGATIVE B [**2138-7-12**] 05:05AM BLOOD [**Doctor First Name **]-NEGATIVE [**2138-7-12**] 05:05AM BLOOD PEP-NO SPECIFI [**2138-7-12**] 05:05AM BLOOD C3-128 C4-48* [**2138-7-22**] 08:50AM BLOOD HCV Ab-NEGATIVE [**2138-7-29**] 05:06AM BLOOD ANTI-GBM-negative [**2138-7-14**] KIDNEY NEEDLE BIOPSY: Pauci-immune crescentic glomerulonephritis Light Microscopy: The specimen consists of renal cortex and medulla, containing approximately 42 glomeruli, of which 32 are globally sclerotic (some of which show fragmentation of the [**Hospital1 **] consistent with a prior crescentic process). Of the remainder, about 4 show cellular crescents, and 4 show fibrocellular crescents. There is diffuse interstitial inflammation (mixed cellularity, eosinophils are not prominent), that makes is difficult to judge the extent of interstitial fibrosis and tubular atrophy, but it is at least moderate. Arteries show moderate-marked intimal fibroplasia. Arterioles show moderate-marked mural thickening, some with hyaline change. No active vasculitis is seen. Immunofluorescence: The specimen consists of renal cortex, containing approximately 6 glomeruli, of which 4 are globally sclerotic. There is 0-trace mesangial staining for IgG, IgA, C3, Kappa, and Lambda. IgM and C1q are negative. 1+C3 is seen along tubular basement membranes and in vessels. Albumin is non-contributory. One glomerulus shows fibrin positivity consistent with a crescent. PLEASE SEE OMR FOR CHEST X-RAY REPORTS [**2138-8-2**] BILATERAL LOWER EXTREMITY ULTRASOUNDS: Deep venous thrombosis in a single peroneal vein bilaterally [**2138-8-5**] RIGHT UPPER EXTREMITY ULTRASOUND: Deep venous thrombosis is incompletely occlusive in the right internal jugular vein, imaged above the level of the patient's right internal jugular dialysis catheter insertion site. Brief Hospital Course: Ms. [**Known lastname 67900**] is an 84 yoF with history of hepatic adenocarcinoma s/p resection and CKD (baseline creatinine 1.7-1.8) who was admitted for acute on chronic kidney failure. On day prior to presentation, patient was evaluated by Dr. [**Last Name (STitle) 1366**] in [**Hospital1 18**] renal clinic. Routine labs drawn and patient was found to have worsening creatinine, metabolic acidosis, and leukocytosis. Urine microscopy showed muddy brown casts. Patient was requested to go to ED for further managment. When Ms. [**Known lastname 67900**] was admitted, she had a Cr of 9.3. She received a renal biopsy, which showed pauci-immune crescentic glomerulonephritis. Treatment with steroids was deferred at the time of diagnosis because of multiple infections (see below) and was ultimately decided to be of little utility due to high risks in the setting of multiple infections, amount of time elapsed from the time of diagnosis, and the advanced stage of scarring seen on biopsy. HD was initiated. Complications included removal of 4 HD catheters, the first of which she pulled out while delirius, the second of which was changed for catheter failure, and the third bled from inlet site, and the fourth of which she agian pulled out while delirious. There were multiple failed attempted at HD due to hypotension/bradycardia and line malifunction. CVVH was not considered a treatment option given the Her hospital course was also complicated by UTI and two pneumonias (community acquired PNA treated on admission with levofloxacin, and later hospital-acquired pneumonia treated with flagyl, cefepime, and vancomycin). She developed bilateral lower extremity DVT's and was started on heparin ggt. Despite being therapeutic, she subsequently developed DVT in her right arm as well as her right IJ extending to the tunneled HD line. There was concern she may have Trousseau's given her history of malignancy. Given all of the above factors and her inability to tolerate hemodialysis with little chance of recovery of renal function given the degree of her RPGN, the palliative care team was consulted and goals of care were readdressed. She was made "comfort measures only" in the hospital and discharged with home hospice under her family's care. She had mild uremic symptoms on discharge, including nausea and confusion, as well as a 4L oxygen requirement thought to be from volume overload. Medications on Admission: EPO Amlodipine Metoprolol tartrate Pantoprazole Multivitamin Vitamin D Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for to back for pain. Disp:*15 Adhesive Patch, Medicated(s)* Refills:*0* 2. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO every 1 to 4 hours as needed for pain, respiratory distress. Disp:*30 ml* Refills:*0* 3. Ativan 2 mg/mL Solution Sig: One (1) mg Injection every six (6) hours as needed for anxiety. Disp:*30 ml* Refills:*0* 4. Atropine 1% Drops 2 drops sublingually every 4 hours as needed for secretions. Dispense 5 ml. 5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*0* 6. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 7. Colace 100 mg Capsule Sig: Two (2) Capsule PO twice a day. Disp:*120 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Rapidly progressive glomerulonephritis Urinary tract infection Community acquired pneumonia Hospital-acquired pneumonia Tachy-brady syndrome Bilateral lower extremity DVT's Right upper extremity DVT Discharge Condition: Patient was discharged on 4L nasal canula oxygen. She was oriented to person and place as hospital only. She had evidence of mild uremic symptoms with nausea, itching and mild confusion. Discharge Instructions: You were admitted to the hospital with acute renal failure. The cause of your renal failure is felt to be irreversible and your body did not tolerate hemodialysis because of your heart rate and blood pressure. You were also treated for pneumonia in the hospital, as well as blood clots in your legs, arm and neck. You were followed by the palliative care team in the hospital to help control your symptoms and make you comfortable. Home hospice has been arranged and will continue to help you feel more comfortable while you are at home. Followup Instructions: You will be continued to be followed by hospice while at home.

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icd9cm

[ [ [] ] ]

[ "55.23", "39.95", "34.91", "38.95", "97.49" ]

icd9pcs

[ [ [] ] ]

9235, 9284

5738, 8160

337, 430

9527, 9718

3025, 3025

10308, 10374

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274, 299

458, 2210

3041, 5715

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2446, 2631

51,039

151,578

38496

Discharge summary

report

Admission Date: [**2129-8-19**] Discharge Date: [**2129-8-25**] Date of Birth: [**2077-8-8**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor / Cefepime Attending:[**First Name3 (LF) 922**] Chief Complaint: The patient had been in rehab since last D/C unti he was seen by Dr. [**First Name (STitle) **] [**8-17**]. CT showed complex fluid collection below the lower pole of the incision which corresponded to an area of wound breakdown. He was taken to the OR for I+D. Major Surgical or Invasive Procedure: [**2129-8-22**]: Sternal debridement, removal of hardware x3, and left pectoralis muscular flap based on the thoracoacromial vessels. [**2129-8-19**] wound exploration, removal of inf plate, vac placed History of Present Illness: 51 y/o M s/p emergent CABGx4 w/ IABP on [**6-5**] with post op course complicated by Afib, LV thrombus, DVT, CVA with L sided weakness and repiratory failure requiring trach and PEG s/p sternal plating on [**7-25**] for infected sternum. The patient had been in rehab since last D/C, he was seen by Dr. [**First Name (STitle) **] [**8-17**]. Achest Ct done at that time revealed a fluid collection at the lower pole of incision and he was brought to the operating room for drainage and debridement. Past Medical History: Emergent Coronary bypass grafting [**6-5**] w/Intra Aortic ballon pump preoperatively Post-operative CVA LV thrombus lower extremity DVT Diabetes Mellitus fatty liver DM Social History: Occupation: computer tech analyst Tobacco: denies ETOH: social Family History: noncontributory Physical Exam: VS: 97.6 92/54 62 26 95% 50% trach mask, GEN: sleeping HEENT: trach in place CV: distant, RRR PULM: CTA bilat w/o wheezes/rhonchi/rales, anteriorly GI: normoactive BS, soft, non-tender, non-distended, G-tube in place MSK: no joint swelling or erythema EXT: warm and well perfused, no edema, 2+ DP pulses palpable bilaterally SKIN: no rashes, no decubiti NEURO: comfortable, according to wife alert and oriented Pertinent Results: [**2129-8-19**] 03:51PM GLUCOSE-117* UREA N-14 CREAT-0.6 SODIUM-137 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-28 ANION GAP-13 [**2129-8-19**] 03:51PM CALCIUM-9.3 PHOSPHATE-3.9 MAGNESIUM-1.9 [**2129-8-19**] 03:51PM WBC-6.7 RBC-3.72* HGB-10.1* HCT-29.9* MCV-80* MCH-27.2 MCHC-33.8 RDW-15.9* [**2129-8-19**] 03:51PM NEUTS-75.5* LYMPHS-15.8* MONOS-4.8 EOS-2.7 BASOS-1.1 [**2129-8-19**] 03:51PM PLT COUNT-423 [**2129-8-19**] 03:51PM PT-22.3* PTT-37.8* INR(PT)-2.1* Radiology Report CHEST (PORTABLE AP) Study Date of [**2129-8-22**] 4:08 PM [**Hospital 93**] MEDICAL CONDITION: 52 year old man s/p pec flap Final Report AP SEMI-UPRIGHT RADIOGRAPH OF THE CHEST: Interval removal of the sternal plating hardware is performed. The right costophrenic angle is excluded from the field of view. There is no pleural effusion. Within these limitations, there is no pneumothorax. Heart size is borderline enlarged. Hilar contours are unremarkable. There is no pulmonary edema. A left PICC is extending up to the cavoatrial junction or probably upper right atrium. There is a second looped wire projecting over the mediastinum, which could be external to the patient. Tracheostomy tube is in standard location. IMPRESSION: No evidence of pleural effusion within the limitations of a partially excluded right costophrenic angle. Radiology Report CT CHEST W/CONTRAST Study Date of [**2129-8-18**] 9:28 AM [**Hospital 93**] MEDICAL CONDITION: 52 year old man with h/o MRSA sternal osteomyelitis s/p prior CABG s/p debridement/plates placed in early [**Month (only) 216**], now with increased tenderness, erythema in inferior 3rd of sternum, elevated inflamm markers Final Report Since [**7-15**], sternal wires have been removed and transverse costosternal stabilization plates have been applied. At all levels, there is failure of fusion of the sternotomy and the extent of separation between the sternal fragments is either stable or in the lower sternum increased. At several levels the widening is due to both diastasis and bone resorption. For example at 10 cm inferior to the sternal notch, 3:33, the transverse diameter of the right fragment is 14.4 mm now, previously 16.2 mm, and the left is 12.5 mm, previously 16.6 mm while the width of separation is now 10.5 mm, previously 5.6 mm. Similar findings are present continuously from that level to the xiphoid. Apparent thickening of the caliber of the pectoralis major muscle that may be due to difference in arm position, but there is subcutaneous emphysema of the midline, anterior chest wall at several levels. In the midline presternal soft tissues, 1.5 cm inferior to the sternal notch is a collection of small gas bubbles in the thickened muscle. Although the previous midline collection that ran anterior to the manubrium and upper sternal body has been drained, starting 12 cm inferior to the sternal notch, 2:36, and running for at least 6 cm inferiorly, and adjacent to the levels of maximum sternal resorption, is a new midline fluid collection with irregular margins, and maximum transverse diameters of 37 x 23 mm, 2:38. The small volume of retrosternal fluid at these levels is inseparable from a small pericardial effusion at the junction of the lower sternal body with the xiphoid, 2:40-44. Although these intrathoracic fluid collections are unchanged since [**7-15**], since they are contiguous with the new, presumably purulent presternal collection, the transthoracic extension of infection cannot be excluded. Respiratory motion obscures some of the fine detail in the lung, but there is no pulmonary edema, consolidation, substantial atelectasis and or any nodule. Tiny bilateral pleural effusions and small pericardial effusion are unchanged. Enlargement of the upper paratracheal lymph nodes has decreased, but the right lower paratracheal complex is 22 mm across in aggregate, previously 19 mm and left lower paratracheal and prevascular nodes have grown from 5 mm to 9 and 8 mm wide respectively. Moderate enlargement of the cardiac silhouette, particularly due to a dilated left ventricle, has increased. This study is not designed for assessment of the upper abdomen, but there is no indication of extension of infection to that region. A gastrostomy tube has a normal appearance. IMPRESSION: 1. Development of new lower midline presternal collection (after drainage of the upper portion) and sternal separation, presumably infectious. Multifocal bone resorption of the sternal fragments has progressed, concerning for multilevel osteomyelitis. Edema of the lower anterior chest wall does not necessarily represent tissue infection. The only reason to presume that a small retrosternal collection and small pericardial effusion, at the levels of the new lower presternal abscess, are not infected, is that neither has enlarged or developed gas collections since late [**6-24**]. Moderate cardiomegaly, predominantly left ventricular, increased. No pulmonary edema or increase in tiny pleural effusions. 3. Tracheostomy, percutaneous gastrostomy, standard appearance. [**2129-8-19**] 2:01 pm SWAB Site: STERNUM STERNAL WOUND. GRAM STAIN (Final [**2129-8-19**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2129-8-21**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2129-8-19**] 2:21 pm TISSUE Site: STERNUM STERNAL BONE. GRAM STAIN (Final [**2129-8-19**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2129-8-22**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Brief Hospital Course: Mr. [**Known lastname **] was admitted for sternal wound debridement and hardware removal. Following the procedure a wound vac was placed and the patient was tranferred to the CVICU for further monitoring. He remained in the ICU with the VAC dressing in place until he was brought back to the operating room for further debridement and pectoralis flap advancement. He tolerated this procedure well and returned to the ICU in stable condition. The following day he was transferred to the stepdown floor for continued care. He failed a swallow evaluation and thus [**Last Name (un) 7245**] tube feeds were continued. He continued to be followed by Plastic surgery and infectious diseases services. Coumadin was resumed with a heparin drip (1600 units per hour) as his INR had not reached a therapeutic range (2.0-3.0). He received 2.5mg on [**2129-8-24**] and 5mg on [**2129-8-25**]. He will require referral back to Dr. [**Last Name (STitle) 71537**] or Dr. [**Last Name (STitle) 39975**] for coumadin follow-up upon discharge from rehab. The remainder of his hospital course was uneventful. On [**2129-8-25**] it was decided he was ready for return to rehabilitation at [**Hospital3 12564**] in [**Hospital1 3597**] NH. He will continue on vancomycin and Imipenum to total six weeks. He will require weekly labs every monday which will consist of a CBC, ESR, CRP, BUN, Creatinine, vancomycin trough and LFT's with results faxed to Infectious disease at ([**Telephone/Fax (1) 1353**]. He will remain on tube feeds until his oral intake is adequate and will benefit from close follow-up with speech and swallow. Electrolytes should be checked while receiving tube feeds. He will also require aggressive physical and occupational therapy. Medications on Admission: MEDS at rehab (from rehab tx paperwork): Coumadin - Variable ([**4-29**]), Amiodarone 200 [**Last Name (LF) 244**], [**First Name3 (LF) **] 81 QD, Colace, Lansoprazole 30 [**Hospital1 **], Simvastatin 20 QD, Lisinopril 5 QD, Oxycodone PRN, Cholecalciferol 100 QD, Albuterol [**1-28**] QID, Tylenol PRN, Lasix 40 QD, Spironolactone 25 QD, Imipenem 500 q6hr, Vanc 1 [**Hospital1 **], RISS, Reglan 10 TID, Insulin Glargine 15 [**Hospital1 **], Discharge Medications: 1. Acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for pain, fever. 2. Carvedilol 3.125 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times a day). 3. Simvastatin 20 mg Tablet [**Age over 90 **]: One (1) Tablet PO once a day. 4. Spironolactone 25 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily). 5. Furosemide 40 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Age over 90 **]: 2.5 Tablets PO DAILY (Daily). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day). 9. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO DAILY (Daily). 10. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily): hold for SBP<100. 11. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 cc PO Q4H (every 4 hours) as needed for pain. 12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**12-25**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 13. Warfarin 1 mg Tablet [**Month/Day (2) **]: as directed to maintain target INR 2-2.5 Tablets PO once a day: Target INR 2-2.5. Start [**2129-8-26**] as he received 5mg [**2129-8-25**]. 14. Insulin Glargine 100 unit/mL Solution [**Month/Day/Year **]: Twenty (20) units Subcutaneous twice a day. 15. Insulin Regular Human 100 unit/mL Solution [**Month/Day/Year **]: sliding scale Injection QAC&HS. 16. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day/Year **]: as directed ML Intravenous PRN (as needed) as needed for line flush: 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. . 17. Imipenem-Cilastatin 500 mg Recon Soln [**Month/Day/Year **]: Five Hundred (500) mg Intravenous Q6H (every 6 hours) for 6 weeks. 18. Vancomycin in D5W 1 gram/200 mL Piggyback [**Month/Day/Year **]: One (1) gm Intravenous Q 8H (Every 8 Hours) for 6 weeks. 19. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Month/Day/Year **]: [**12-25**] Puffs Inhalation Q6H (every 6 hours) as needed for dyspnea. 20. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution [**Month/Day (2) **]: 1600 (1600) units Intravenous ASDIR (AS DIRECTED): Goal PTT 60-80. Stop when INR has reached 2.0. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: [**2129-8-22**] sternal debride, washout, pectoralis flap, closure [**2129-8-19**] wound exploration, removal of inf plate, vac placed (Dr. [**First Name (STitle) **] PMH: Emergent coronary bypass grafting [**6-5**] w/ IABP preoperatively Post-op Cerebral Vascular Accident, Left Ventricle thrombus, Lower Extremity Deep Vein Thrombosis, Diabetes Mellitus, fatty liver disease, s/p tracheostomy/Percutaneous Endoscopic Gastrostomy tube placement [**6-17**] Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Incisional pain well controlled Incisions: Sternum-Clean dry and intact with JP drains. Discharge Instructions: 1)Please shower/wash daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Check incisions daily for redness or drainage 2)Please NO lotions, cream, powder, or ointments to sternal incision. Weigh yourself daily. 3)No lifting more than 10 pounds for 10 weeks from surgery date 4)Will remain on heparin drip goal PTT 60-80 until INR is >= 2.0. 5)Coumadin for atrial fibrillation, DVT, LV thrombus. Goal INR is 2.0-3.0. Please arrange for coumadin follow-up upon discharge from rehab. Dr. [**Last Name (STitle) 71537**] ([**Telephone/Fax (1) 85651**] or Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39975**]. 6)JP drains managed per plastic surgery and will be pulled in their clinic. Please apply bacitracin to JP sites daily. 7)Weekly labs while on vancomycin and imipenum. (CBC/BUN/CREAT/LFT's/Vanco trough/ESR/CRP). All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 10739**] 8)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: Dr. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**2129-9-1**] 1:45PM ([**Telephone/Fax (1) 1429**] . Dr [**Last Name (STitle) 914**] in [**2129-9-27**] @1:15PM . Provider: [**First Name4 (NamePattern1) 2482**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2129-10-10**] 11:30 . Provider: [**Name10 (NameIs) 12082**] CARE Infectious Disease Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2129-9-5**] 11:00 . Cardiologist Dr [**Last Name (STitle) 39975**] after discharge from Rehabilitation appointment. . PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] after discharge from Rehabilitation. Please call for appointment. . All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] Completed by:[**2129-8-25**]

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icd9cm

[ [ [] ] ]

[ "77.61", "78.61", "96.6", "83.82" ]

icd9pcs

[ [ [] ] ]

12606, 12653

7758, 9495

546, 750

13154, 13359

2037, 2581

14633, 15450

1568, 1585

9986, 12583

3473, 7324

12674, 13133

9521, 9963

13383, 14610

1600, 2018

7410, 7686

244, 508

778, 1278

7722, 7735

1300, 1471

1487, 1552

68,836

123,407

39984

Discharge summary

report

Admission Date: [**2142-12-4**] Discharge Date: [**2142-12-9**] Date of Birth: [**2096-2-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1945**] Chief Complaint: cough, fever, shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 87940**] is a 46 year-old man with a history of CAD s/p CABG, CHF with EF 15-20%, who presents with four days of cough, fever, shortness of breath. He states that normally he can walk around his house without shortness of breath, but for the past couple of days he has been unable to walk for more than a few steps. This is accompanied by a cough that is intermittently productive of clear sputum. He has felt feverish but his max temperature at home was 99. He has no sick contacts or recent travel. He is also newly unable to lie flat. He does not take his weight daily and has not noted any lower extremity swelling. He presented today to his PCP with all of these symptoms and was referred to the ED. . In the ED, initial VS: 98.2 130 160/119 25 100% 10L Exam notable for crackles. CXR concerning for pneumonia. EKG was unchanged from prior except for rate. He received a 500 cc fluid bolus, after which his HR fell from sinus 140s to sinus 120s. He was also given 40 mg IV lasix, vancomycin and levofloxacin. VS prior to transfer: RR 32, 132/94, 100% on 4L, HR 120 . On arrival to the ICU, Mr. [**Known lastname 87940**] has no complaints. In particular, he denies chest pain or shortness of breath at rest. He denies abdominal pain, nausea, vomitting. His cough is ongoing. Past Medical History: -CAD: s/p 6-vessel CABG in [**2134**] - LIMA to LAD. Graft stenosis in [**2134**] s/p two cypher stents to LIMA and obtuse marginal Cypher stents. -systolic CHF with EF 20% on echo [**7-1**] -ICD placement for primary preventian in [**10/2140**] -apical thrombus on echo [**7-1**], on chronic warfarin therapy -metabolic syndrome Social History: He drinks 1 glass of wine per month and smokes 10 cigarettes daily. He is self-employed as a landscaper. Family History: Both his father and paternal grandfather had heart disease. Physical Exam: VS: Temp: 102.1 BP: 143/89 HR: 126 RR: 31 O2sat: 96% on 4L GEN: pleasant, comfortable but tachypneic HEENT: neck supple, JVP at 9 cm, no LAD RESP: reduced breath sounds and faint crackles at the bases bilaterally. No wheezing. CV: regular, unable to appreciate any murmur but difficult given tachycardia ABD: nontender, nondistended EXT: trace bilateral pitting edema SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Otherwise grossly intact Pertinent Results: [**2142-12-4**] 08:32PM LACTATE-1.7 [**2142-12-4**] 08:17PM proBNP-3107* [**2142-12-4**] 11:00AM GLUCOSE-119* UREA N-14 CREAT-1.1 SODIUM-136 POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-19* ANION GAP-19 [**2142-12-4**] 11:00AM cTropnT-<0.01 [**2142-12-4**] 11:00AM LACTATE-2.7* K+-4.1 [**2142-12-4**] 11:00AM WBC-10.3 RBC-5.20 HGB-14.8 HCT-43.6 MCV-84 MCH-28.4 MCHC-33.8 RDW-15.3 [**2142-12-4**] 11:00AM NEUTS-67.2 LYMPHS-24.4 MONOS-6.1 EOS-1.7 BASOS-0.6 [**2142-12-4**] 11:00AM PLT COUNT-199 [**2142-12-4**] 11:00AM PT-32.9* PTT-34.3 INR(PT)-3.3* . [**12-4**] CXR: IMPRESSION: Markedly limited study with cardiomegaly and mild congestion. Vague right upper lung opacity could reflect pneumonia though technique is significantly limited. Consider repeat with more optimized technique to better assess. [**12-6**] ECHO The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 15 %) with anteroseptal/anterior/apical akinesis and hypokinesis elsewhere. The aortic root is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. Mitral regurgitation is present but cannot be quantified (may be mild to moderate). There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [**12-8**] CT-Chest IMPRESSION: Right greater than left ground-glass opacities without significant interlobular septal thickening appear grossly stable when the scout topogram is compared to multiple prior plain radiographic examinations, although mild progression in the left upper lobe is noted. Given the patient's history of severe cardiac decompensation, this could represent pulmonary edema. However, given the asymmetric appearance as well as the clinical presentation and the predominantly apical distribution, a community- acquired pneumonia or mycobacterial infection is likely. LABS at discharge: 7.2 4.81 13.5* 39.8* 83 28.2 34.0 14.9 282 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2142-12-9**] 07:40 119*1 21* 1.4* 135 4.4 100 25 14 Brief Hospital Course: A 46 year-old man with a history of ischemic cardiomyopathy with EF 15-20% presents with shortness of breath, fever, cough, hypoxia consistent with PNA. . # Pneumonia: Patient with fever, cough, hypoxia and evidence of infiltrate on CXR and CT-chest, all suggestive of pneumonia. He has no recent healthcare association. His sinus tachycardia on admission was most likely a manifestation of infection and fever, although difficult to assess volume status (as below), and he may have been total body overloaded as well. Continued ceftriaxone and azithromycin for community-acquired pneumonia which was completed in hospital. Sent blood and sputum cultures as well as legionella urinary antigens. # CHF: EF 15-20% in [**2138**]. ICD in place for primary prevention. CHF on admission presumably secondary to prior ischemic events. On 40 mg PO lasix but not currently taking. Volume status is difficult to assess. JVP is only slightly elevated, and hypoxia is moderate. For now we will treat infectious picture with IVF and plan to diurese as needed in the future. Home lasix was held, continued ACEI (will switch to a lower dose of short-acting captopril), beta blocker restarted at lower dose Volume status has been a big issue as he was initially given IVFs given his PNA, but then developed flash pulmonary edema and required diuresis with Lasix. He responded extremely well to IV Lasix and was net negative 4.5L. With this diuresis he also bumped his Cr and became tachycardic requiring small boluses to rehydrate. A repeat ECHO on this admission showed a similar EF: 15-20%. . # History of apical thrombus: chronically anticoagulated. Warfarin is the only medication he has actually been taking recently. INR currently 3.1. warfarin was continued during this admission with planned INR check as outpatient. . # ARF: likely [**2-27**] volume status, downtrending during admission with outpatient Creatinine follow-up scheduled. . # CAD: no evidence of ischemia on admission. continued ASA, statin, beta blocker Medications on Admission: metoprolol succinate 75 mg q24 lisinopril 10 mg daily atorvastatin 80 mg daily furosemide 40 mg daily warfarin 2.5 mg daily aspirin 81 mg daily **(patient was only taking warfarin on admission) Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 4. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Disp:*90 Tablet(s)* Refills:*2* 5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pneumonia Acute on chronic systolic heart failure Apical LV thrombus 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 worsening shortness of breath. It was likely due to a combination of a pneumonia and fluid overload. You improved symptomatically after two days, but were still having low grade fevers. Sometimes people can get fevers from new medications, and some of your lab tests suggested you were having a mild reaction to one of the medications. You completed a course of antibiotics in the hospital, so we stopped them upon your discharge. You also were found to have some elevation in your kidney function. It improved while you were here. You will needs these lab tests early next week to make sure they are still improving. We made two changes to your medications (increased your toprol and coumadin). You should restart all the medications for your heart you were supposed to be taking. You also should talk to you doctor about having borderline diabetes. You might benefit from starting a medication for your elevated sugars. This will help protect your heart and kidney in the long run. In sum, your medications will include: Aspirin 81 mg daily Coumadin 3 mg daily (this is increased from 2.5 mg daily) Lisinopril 10 mg daily Toprol XL 100 mg daily (this is increased from 75 mg daily) Lasix 40 mg daily Again, it is important to have you labs checked this week. It is also important to seek medical attention if your breathing worsens again or you are having persistent fevers. Followup Instructions: Please follow up with your cardiologist on Tues. This is already scheduled for you and has been for a while. Make sure that he checks your labs to follow your kidney function and INR. Also call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Monday morning and make an appointment to see him this week. It is important to talk to him about the above issues. He will also want to see your lab work.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7953, 7959

5027, 7053

338, 344

8072, 8072

2729, 4810

9678, 10108

2182, 2244

7297, 7930

7980, 8051

7079, 7274

8223, 9655

2259, 2710

265, 300

4831, 5004

372, 1687

8087, 8199

1709, 2042

2058, 2166

1,479

115,916

23354

Discharge summary

report

Admission Date: [**2157-11-8**] Discharge Date: [**2157-12-12**] Service: NSU MEDICATIONS ON ADMISSION: Aspirin. PAST MEDICAL HISTORY: Past medical history is remarkable for osteoarthritis, laminectomy, polymyalgia rheumatica, inclusion body myopathy and upper GI bleed. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 59937**] is an 87 year old gentleman with a history of fall. He had a fall prior to admission with neck pain and presented to an outside hospital. He had a CAT scan and MRI done of the neck which did show question of osteomyelitis and abscess at the C5-C6 level. He was transferred to [**Hospital1 188**]. PHYSICAL EXAMINATION: Heart rate was 98. Blood pressure was 132/70. Respiratory rate was 16. He was in a hard collar. Extraocular movements were intact. Lungs were clear to auscultation bilaterally. Heart showed regular rate and rhythm, no murmurs, rubs or gallops. Abdomen showed positive bowel sounds, soft, nontender, nondistended, no CVA tenderness. Neurologic exam - he opened his eyes to voice. He followed commands in all four extremities and was alert and oriented. HOSPITAL COURSE: He was admitted to the Trauma Intensive Care Unit for close neurological monitoring. He was started on IV antibiotics. Cultures were obtained. He was also seen by ORL for his posterior pharyngeal fluid collection which was evacuated. He was left intubated after this procedure. He did receive a PICC line for long term antibiotic and was also started on TPN. Dr. [**Last Name (STitle) 1327**] from Surgery did discuss with the family the patient undergoing a C5-6 anterior cervical diskectomy and fusion with allograft and screw and plate fixation. On [**2157-11-15**], he was brought to the Operating Room where he did have an anterior cervical diskectomy and fusion from C4 to C6 performed by Dr. [**Last Name (STitle) 739**]. Postoperatively, he was sedated. Vital signs were stable. Blood pressure was 142-170/53-70. His hematocrit was 31.6. He was able to move all four extremities to command. Dressing was clean, dry and intact. He remained intubated and was followed with C-spine films. He was able to have his activity increased postoperatively, but he was kept intubated. His TPN was resumed. He then had both tracheostomy and PEG tubes placed for long term management. On [**2157-11-19**], he had lower extremity Dopplers which did not show a DVT. On x-rays done on [**11-22**], a new mild retrolisthesis of C4 on C5 was seen. However, due to his degree of osteoporosis, Dr. [**Last Name (STitle) 739**] felt a posterior fusion was warranted and discussed this with the family who agreed and he was brought to the Operating Room on [**2157-11-28**] for a posterior cervical laminectomy and fusion. Prior to that day he had a tracheostomy and post-op Cspine Xrays showed that the superior plate screws had partially moved .He was placed on imipenem for Enterobacter found in sputum culture and this was continued for 14 days. Postoperatively, he was uneventful radiographically and posterior instrumentation was in good position. He was neurologically stable and his activity was once again increased and Physical Therapy and Occupational Therapy assisted. On [**11-30**], the patient was found to have upper GI bleeding and was scoped emergently and was found to have a shallow crater at the gastroesophageal junction with slight ooze. It was recommended that he be followed with serial hematocrits and transfused as needed and to have Protonix twice per day. He did require frequent suctioning while he was in the Intensive Care Unit but this did slowly subside and he was able to be transferred to the Neurological Stepdown Unit on [**12-6**]. Both Physical Therapy and Occupational Therapy worked with him closely and felt he would benefit from a rehab placement. He was seen by Dr. [**Last Name (STitle) 59938**] for question of leg movements at night and they did recommend an EEG with video monitoring for future evaluation. This could be performed as an outpatient or at the rehab facility. DISCHARGE MEDICATIONS: His medications at the time of discharge are bisacodyl 10 mg pr at bedtime prn, heparin 5000 units subcutaneously tid, miconazole 2 percent cream, one application [**Hospital1 **], lisinopril 5 mg daily, sliding scale insulin, acetaminophen 650 mg prn, oxycodone/acetaminophen elixir 5-10 mg q4h prn, pramipexole dihydrochloride 0.125 mg daily at 7 p.m., nystatin oral suspension 5 mg po qid prn, calcium carbonate 500 mg po qid, metoprolol 50 mg po bid, pantoprazole 40 mg po bid. DISCHARGE DIAGNOSES: His diagnoses include osteomyelitis, diskitis, osteoarthritis, inclusion body myopathy, upper GI bleeding. FOLLOW UP: He should follow up with Dr. [**Last Name (STitle) 739**] in his office in four weeks and should have x-rays at the time of the appointment. He should also have an EEG performed while at rehab and follow up with [**Last Name (STitle) 59938**]. [**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2157-12-12**] 11:09:05 T: [**2157-12-12**] 11:42:24 Job#: [**Job Number 59939**]

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icd9cm

[ [ [] ] ]

[ "84.52", "45.16", "03.53", "43.19", "80.51", "28.0", "38.93", "31.1", "81.62", "96.6", "84.51", "42.33", "81.02", "81.03", "99.04", "31.42", "99.15" ]

icd9pcs

[ [ [] ] ]

4577, 4685

4072, 4555

117, 127

1139, 4048

4697, 5181

668, 1121

316, 645

150, 287

3,995

157,982

46669

Discharge summary

report

Admission Date: [**2106-5-27**] Discharge Date: [**2106-6-16**] Date of Birth: [**2031-8-31**] Sex: M Service: VSURG Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: AAA Major Surgical or Invasive Procedure: AAA repair with aortobifemoral BPG [**2106-5-27**] History of Present Illness: 74 y/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4746**] with CAD, s/p CABG, h/o TIA, HTN, COPD, s/p resection esophageal tumor, resection lung tumors, s/p fem-[**Doctor Last Name **] BPG had developed a large, asymptomatic AAA. He was not a candidiate for endovascular repair because of heavy calcification of his iliac arteries. Pt was scheduled for elective, open AAA repair with aortobifemoral BPG. Past Medical History: PMH: 1.CAD: silent MI x2, s/p CABG 2.TIA [**2105-3-3**] 3.HTN 4.COPD 5.GERD 6.Gout 7.Anxiety 8.PVD PSH: 1.CABG x2 [**2105-1-31**] 2.fem-[**Doctor Last Name **] BPG 10 years ago 3.Resection right lung tumorx2 4.Resection esophageal tumor 5.Resection tumor right foreman 6.Colon polypectomy Social History: Lives with wife. [**Name (NI) **] been smoking 1ppd x 58 years. Drinks two alcoholic drinks per day. Family History: Noncontributory. Physical Exam: VS: Afebrile General: Alert,cooperative [**Male First Name (un) 4746**] in NAD Chest: Cor: RRR without murmur. Lungs clear Abd: Soft,nontender. Extremities: Feet equally warm with palpable pedal pulses bilaterally Neorological exam nonfocal Pertinent Results: [**2106-5-27**] 02:46PM GLUCOSE-113* LACTATE-2.6* NA+-138 K+-3.6 CL--113* [**2106-5-27**] 02:46PM HGB-10.7* calcHCT-32 [**2106-5-27**] 05:10PM PT-14.9* PTT-71.1* INR(PT)-1.5 Brief Hospital Course: Pt was admitted to the hospital on [**2106-5-27**] following an AAA resection. [**Name (NI) 99074**] pt received several units PRBCs. Post-op pain was managed with epidural. On POD#4 pt became unresponsive after trying to get out of bed about 30 minutes after CVL changed. He was intubated and sent ICU. Head CT was negative as well as all other studies. Pt was extubated on [**2106-6-8**] and was transferred to [**Hospital Ward Name 121**] 9. Cardiology was consulted after pt had several runs of asymptomatic, nonsustained ventricular tachycardia. Beta blocker was started. [**Doctor Last Name **] of Hearts monitor was placed [**2106-6-16**]. Physical therapy evaluated the pt and recommended short term rehab stay. At discharge pt's abdominal and groin surgical wounds were clean,dry, and intact. Pedal pulses are dopplerable bilaterally. He has a dressing over right heel blister and buttock skin breakdown. Medications on Admission: 1.Plavix 2.Metoprolol 3.Lisinopril 4.Lipitor 5.Flonase 6.Diazepam 7.Folate Discharge Medications: 1. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). 5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QD (once a day). 8. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q4H (every 4 hours). 12. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO QD (once a day). 13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a day). 14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). 15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 16. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection Q12H (every 12 hours). 17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: AAA resection Secondary DX: 1.Blood loss anemia;s/p transfusions 2.Respiratory failure postop requiring reintubation 3.Ventricular tachycardia->[**Doctor Last Name **] of Hearts placed [**2106-6-16**] 4 CAD 5.HTN 6.COPD Discharge Condition: Satisfactory Followup Instructions: Follow up with DrCampbell in the office in two weeks; call office for appoint- ment [**Telephone/Fax (1) 35309**]. Completed by:[**2106-6-16**]

[ "482.89", "496", "414.00", "599.0", "790.7", "V45.81", "428.0", "427.1", "441.4" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "33.22", "39.52" ]

icd9pcs

[ [ [] ] ]

4254, 4325

1761, 2680

316, 368

4589, 4603

1557, 1738

4626, 4771

1263, 1281

2806, 4231

4346, 4568

2706, 2783

1296, 1538

273, 278

396, 816

838, 1129

1145, 1247

27,043

162,600

32491

Discharge summary

report

Admission Date: [**2141-1-28**] Discharge Date: [**2141-2-1**] Date of Birth: [**2087-11-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Increased somnolence Major Surgical or Invasive Procedure: Bronchoscopy, central line placement, PICC placement History of Present Illness: 53 year old male with severe COPD, remote L CVA (residual R sided weakness), DM, hypercarbic respiratory failure, chronically vented was sent to ED because of worsening somnolence and hypotension. Pt usually gets his care at [**Hospital1 112**]/BU but was just recently at [**Hospital1 18**] for VAP. He has been intubated at the beginning of [**Month (only) 359**] [**2140**], reportedly at [**Hospital3 **] for hypercarbic respiratory failure in setting of severe COPD. Before that he has been O2 dependent due to severe COPD, living at a NH. At the OSH, he was found to have a RML and RLL collapse and paratracaheal LAD as well as chronic right pleural effusions. He also has questionable old granulomatous lung disease with calcified hilar LAD. He eventually required trach/PEG because of difficulties weaning from the vent. He reportedly had a bronchoscopy done ruling out malignancy. He was at rehab (Radius [**Hospital 4094**] Hospital) since [**11-9**]. He has been doing better until the middle of [**Month (only) **], when he was on CPAP transiently. However, since the end of [**Month (only) **], his respiratory status worsened again and he remained on AC. He was treated for VAP in [**Month (only) 1096**] here due to pseudomonas ESBL. Since then he was back at rehab and was weaned successfully. The day of admission, he underwent a T-piece trial and then was found to be unresponsive on the floor. The circumstances are unclear and oral report from the [**Name (NI) **] included tonic-clonic movements, while another report does not confirm that. The patient was transfered to [**Hospital1 18**] for further evaluation. In the ED, his VS were 97.9, 110, 80/46, RR 20, 98% on unclear settings. A CT head and spine were unremarkable. A CXR showed chronich RLL collapse but then subsequently after a R subclavian line placement showed almost complete R sided white-out with a [**Last Name (un) **] off at the R mainstem bronchus. The patient was given Abx, Vanco, Levo, Cefepime and he received a total 5L NS. He persisted to be hypotensive and was started on Levophed. On arrival to the ICU, his BP was 96/70 and HR 117. He was only complaining of mild R foot pain but did not recall and injury to the foot. He reports that he had a seizure, but denies any complete LOC. He denies any CP, abd pain, HA, vision changes, f,c,ns, dysuria, problems breathing or worsening secretions. Past Medical History: Past Medical History: - Chronic vent/trach/PEG for hypercarbic respiratory failure at the beginning of [**2140-10-10**], ?reportedly due to COPD exacerbation - Severe COPD, home O2 dependent in the past - Per rehab admission note, questionable old granulomatous lung disease with calcified hilar LAD - Remote L CVA with residual right sided weakness - New onset generalized TC seizures on [**2140-11-5**] per rehab neuro note, thought to be [**2-11**] post-CVA and metabolic abnormalities (on transfer from rehab on Keppra, Depakote) - Diabetes mellitus, on 16U Lantus at rehab and RISS - Depression - Schizophrenia, on effexor and risperdal - Past h/o EtOH abuse - GERD PSH: - Trach [**2140-11-2**] - PEG [**2140-11-7**] Social History: Social History: Divorced. Former smoking. Has been at a NH prior to recent admission and vent facility. Has been on home O2 before that for severe COPD. Family History: Family History: non-contributory Physical Exam: VS: Temp: 97.9 BP: 109/54 HR: 88 regular RR: 13 O2sat 96% trach mask GEN: comfortable, NAD HEENT: PERRL, EOMI, anicteric NECK: large neck, difficult to assess jvd, trach in place RESP: coarse b/l breath sounds with increased crackles at bases posteriorly CV: RRR, S1 and S2 wnl, no m/r/g ABD: obese, nd, nl b/s, soft, mildly tender to palpation in RLQ, no masses, PEG tube in place EXT: no c/c/e, warm, 1+ DP pulses SKIN: no rash NEURO: Opening eyes. Handgrip intact, unable to lift off feet from bed or dorsiflex of palmarflex feet R > L. EOMI. Pertinent Results: [**2141-1-27**] 10:15PM BLOOD WBC-14.3*# RBC-4.17*# Hgb-12.9*# Hct-37.7*# MCV-91 MCH-31.1 MCHC-34.3 RDW-15.9* Plt Ct-576* [**2141-2-1**] 06:29AM BLOOD WBC-7.5 RBC-2.86* Hgb-8.6* Hct-25.7* MCV-90 MCH-29.9 MCHC-33.3 RDW-15.2 Plt Ct-488* [**2141-1-27**] 10:15PM BLOOD PT-15.9* PTT-27.6 INR(PT)-1.4* [**2141-1-27**] 10:15PM BLOOD Glucose-212* UreaN-23* Creat-0.7 Na-139 K-5.2* Cl-91* HCO3-36* AnGap-17 [**2141-2-1**] 06:29AM BLOOD Glucose-106* UreaN-3* Creat-0.2* Na-140 K-4.1 Cl-100 HCO3-35* AnGap-9 [**2141-1-31**] 02:33AM BLOOD ALT-9 AST-9 LD(LDH)-90* AlkPhos-32* TotBili-0.1 [**2141-1-27**] 10:15PM BLOOD Calcium-9.9 Phos-4.4 Mg-2.6 [**2141-2-1**] 06:29AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.9 [**2141-1-27**] 10:15PM BLOOD Valproate-61 [**2141-1-27**] 10:28PM BLOOD pO2-68* pCO2-51* pH-7.46* calTCO2-37* Base XS-10 Intubat-INTUBATED Vent-CONTROLLED [**2141-1-31**] 04:25PM BLOOD Type-ART pO2-85 pCO2-55* pH-7.42 calTCO2-37* Base XS-8 [**2141-1-27**] 10:18PM BLOOD Lactate-2.4* [**2141-1-31**] 09:00PM BLOOD Lactate-1.4 [**2141-1-28**] 5:55 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2141-1-31**]** GRAM STAIN (Final [**2141-1-28**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2141-1-31**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. SPARSE GROWTH OROPHARYNGEAL FLORA. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. GRAM NEGATIVE ROD(S). SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES. PROTEUS SPECIES. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM------------- 1 S PIPERACILLIN---------- 16 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S [**2141-1-28**] 1:00 pm STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT [**2141-2-1**]** FECAL CULTURE (Final [**2141-2-1**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2141-1-30**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2141-1-30**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O VIBRIO (Final [**2141-1-30**]): NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [**2141-1-31**]): NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2141-1-29**]): NO E.COLI 0157:H7 FOUND. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2141-1-29**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). CHEST (PORTABLE AP) [**2141-1-27**] 10:14 PM IMPRESSION: Persistent volume loss of the right hemithorax. Right lung base opacity could be a combination of pleural fluid and atelectasis. Underlying pneumonia cannot be excluded. CT HEAD W/O CONTRAST [**2141-1-28**] 12:17 AM 1. No evidence of intracranial hemorrhage, acute major vascular territorial infarction, cerebral edema or fracture. 2. Study limited by oblique positioning. Probable remote left cerebellar infarction. CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST [**2141-2-1**] 3:51 AM IMPRESSION: 1. Short segment uncomplicated sigmoid colitis, which is non-specific and may be infectious/inflammatory in etiology. 2. Incompletely imaged bilateral pleural effusions, with partial collapse of the right lower lobe which may be post-obstructive, given the presence of fuid in the right lower lobe bronchus. Brief Hospital Course: A/P: 53M on chronic trach-mask for COPD/RLL collapse/R pleural effusions, L CVA (residual R sided weakness), DM, admitted for unresponsiveness likely [**2-11**] sepsis. # Hypoxia secondary to chronic R pleural effusions, R lung collapse, severe COPD and tracheostomy: Initial ABG revealed chronic hypercarbia and compensated respiratory acidosis. Initially suspected mucuous plug and subsequent lung collapse as possibly contributoring to hypoxia, or aspiration pneumonia given that patient was found down. CXR demonstrated rapidly evolving R lung opacification. Was continued on ipratropium, fluticasone and albuterol nebs PRN. Sputum culture revealed Pseudomonas sensitive all antibiotics except ciprofloxacin. Thus, for nosocomial pneumonia, he was started on Tobramycin Inhalation Soln 300 mg IH [**Hospital1 **] and Meropenem 1000 mg IV Q8H. Successfully transitioned to trach-mask. Initially had bronchoscopy on [**1-28**] given persistent R lung collapse with resultant suctioning and sample sent to microbiology lab that revealed PSEUDOMONAS AERUGINOSA ~[**2133**]/ML with the same sensitivities. Bronchoscopy was again peformed on [**2141-2-1**], the day of discharge, for persistent R lower lobe collapse despite clinical improvement. An additional BAL was obtained and culture data should be followed up in 48 hours. The [**Hospital1 18**] Microbiology lab can be contact[**Name (NI) **] at ([**Telephone/Fax (1) 20850**] for final results. Additionally, given his bronchoscopy the day of discharge, it would not be unusual for him to have a post-bronch fever 12-hours post-procedure. This would not represent a new infection. #Diverticulitis: New RLQ pain [**1-31**] overnight. CT-demonstrated diverticulitis without abscess or collection. No WBC count, no fever. Given that he was already on Meropenem, and no evidence of new infection, no further antibiotics were added. Recommended brief bowel rest with resolution of tubefeeding once pain resolved slightly. Pain control with IV Dilaudid. Will continue these treatements as an outpatient. # DM: Glargine (Lantus) 16units as home regimen. Initially started on insulin sliding scaled with 1/2 dose Lantus given NPO status. Once diet was advanced, this was increased to 16. Discharged with insulin sliding scale and scheduled insulin. # Seizures: STABLE. Per rehab neurology note, one GTC seizure in [**Month (only) **], thought to be due to post-CVA and metabolic abnormalities. Per discussion with nursing home staff, no sign of seizure at time of unresponsiveness. Had slight fall out of chair without injury about 2-3 days prior to admission. On day of admission was simply found lying in bed with unresponsiveness, no signs of any trauma. Therapeutic on valproic acid on admission. Continued home regimen of Levetiracetam 250 mg PO BID and Divalproex Sprinkles 875 mg TID. # Unresponsiveness: RESOLVED. Initially suspeced seizure with postictal state v. hypoxia v. sepsis. Unlikely hypoxia as is chronic at baseline, and ABGs did not show marked change. No evidence of seizure. Based on clinical picture, likely [**2-11**] sepsis, which is now resolved. Continue antibiotics as an outpatient. # H/o CVA: Right sided weakness. Seizure ppx post-CVA and GTC seizure. # Psychological Issues: STABLE. Schizophrenia and depression. Continued on Effexor, Risperdal and Trazodone. Medications on Admission: Medications at rehab: Heparin sc TID Lansoprazole 30 mg PO DAILY Senna 8.6 mg PO BID prn Acetaminophen 325 mg Q6H as needed for pain, fever. Levetiracetam 250 mg PO BID Trazodone 50 mg PO TID Folic Acid 1 mg PO DAILY Venlafaxine 75 mg PO BID Risperidone 2 mg PO HS Divalproex 875 mg TID Ipratropium Bromide Inhalation Q6H as needed for wheezing, SOB Docusate Sodium Ten ml PO BID Chlorhexidine Gluconate 0.12 % Mouthwash Miconazole Nitrate 2 % Powder Topical [**Hospital1 **] Albuterol 4-6 Puffs Inhalation Q4H Beclomethasone Dipropionate 2-4 puffs [**Hospital1 **] Bisacodyl 5 mg Tablet, Delayed Release DAILY as needed. Diltiazem HCl 30 mg 0.5 Tablet PO TID Furosemide 60 mg PO BID Lactulose Thirty ML PO Q8H as needed. Insulin scale as printed and attached. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) mL PO BID (2 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) mL Injection TID (3 times a day). 5. Levetiracetam 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 6. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Venlafaxine 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 8. Risperidone 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 9. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Hospital1 **]: One (1) Inhalation Inhalation [**Hospital1 **] (2 times a day). 10. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO TID (3 times a day) as needed. 11. Divalproex 125 mg Capsule, Sprinkle [**Hospital1 **]: Seven (7) Capsule, Sprinkle PO TID (3 times a day). 12. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: Ten (10) mL PO Q6H (every 6 hours) as needed for fever or pain. 13. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff Inhalation Q6H (every 6 hours). 14. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]: One (1) Neb Inhalation Q6H (every 6 hours) as needed. 15. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Neb Inhalation Q6H (every 6 hours). 16. Tobramycin 300 mg/5 mL Solution for Nebulization [**Hospital1 **]: Five (5) mL Inhalation [**Hospital1 **] (2 times a day) for 10 days: Tobramycin Inhalation Soln 300 mg IH [**Hospital1 **]. Please use perinebs to deliver. . 17. Pantoprazole 40 mg IV Q24H 18. 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. 19. Meropenem 1000 mg IV Q8H d1=[**1-28**], total 8 days 20. HYDROmorphone (Dilaudid) 0.5 mg IV Q6H:PRN Pain 21. Outpatient Physical Therapy To be evaluated & treated in longterm care facility 22. Outpatient Occupational Therapy To be evaluated & treated in longterm care facility 23. Insulin Sliding scale [**Known lastname **],[**Known firstname **] [**Numeric Identifier 75805**] Insulin SC - Sliding Scale & Fixed Dose Fingerstick Q6H ---Insulin SC Fixed Dose Orders: Bedtime, Glargine 16 Units ---Insulin SC Sliding Scale Q6H Humalog Glucose Insulin Dose 0-50 mg/dL [**1-11**] amp D50 51-150 mg/dL 0 0 Units 151-200 mg/dL 3 Units 201-250 mg/dL 5 Units 251-300 mg/dL 7 Units 301-350 mg/dL 9 Units 351-400 mg/dL 11 Units > 400 mg/dL Notify M.D. 24. Nutrition Tubefeeding: Start upon arrival; Probalance Full strength; Starting rate: 30 ml/hr; Advance rate by 10 ml q4h to goal rate: 70 ml/hr. Residual Check: q4h. Hold feeding for residual >= : 200 ml. Flush w/ 50 ml water q6h 25. traZODONE 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Primary: Pneumonia, diverticulitis Secondary: Hypotension, diabetes, history of stroke Discharge Condition: Hemodynamically stable & afebrile Discharge Instructions: You were admitted with worsening somnolence and poor respiratory status. You were found to have pneumonia. You have been started on antibiotics and will continue these at your longterm care facility. Please take all medications as prescribed. Your facility will be provided with a list of your current medications that you will continue taking. Please return to the ED or seek medical care if you notice increased work of breathing, shortness of breath, fever, chills, nausea, vomiting, diarrhea or for any other symptom which is concerning for you. Followup Instructions: To be followed by longterm care facility physicians while in residence.

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icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "96.72", "33.24" ]

icd9pcs

[ [ [] ] ]

15950, 16005

8550, 11931

336, 391

16137, 16173

4367, 8527

16776, 16851

3768, 3786

12742, 15927

16026, 16116

11957, 12719

16197, 16753

3801, 4348

276, 298

419, 2818

2862, 3565

3597, 3736

25,221

184,721

24145

Discharge summary

report

Admission Date: [**2179-12-17**] Discharge Date: [**2180-1-5**] Date of Birth: [**2099-2-17**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: ESRD Major Surgical or Invasive Procedure: ECD DCD Renal Transplant Exploratory Laparotomy History of Present Illness: Mr. [**Known lastname 5108**] is an 81-year-old gentleman who is on the cadaveric kidney transplant list. An ECD/ DCD kidney became available. The risks and benefits of this ECD/DCD kidney were explained in detail to the patient and he elected to go ahead with the procedure. Of note, the donor was a 58-year-old man with a history of hypertension and a total creatinine of 1.0. Past Medical History: 1. End-stage renal disease on hemodialysis for approximately four years. 2. Hypertension. 3. Coronary artery disease with history of cardiac catheterization on [**2178-2-5**] and is status post angioplasty and stent x3 in the right coronary artery. 4. Hyperlipidemia. 5. Right upper arm AV fistula. 6. Heme-positive stools status post EGD and colonoscopy in [**2179-7-23**] that showed [**Female First Name (un) 564**] esophagitis and tubular adenoma of the colon. 7. Left eye blindness and is scheduled to undergo a corneal transplant. 8. Bone mineral density test in [**2179-6-22**] showing osteoporosis. Family History: Non Contributory Physical Exam: The patient was verified to be asystolic on ECG monitoring and had no arterial waveform or blood pressure on arterial line tracing. He had no spontaneous respiration. Based on these findings, he was declared deceased at 14:45 Brief Hospital Course: Mr [**Known lastname 5108**] was admitted to [**Hospital1 18**] following the discovery of a matched kidney for transplantation. He was preoperatively evaluated and then taken to the operating room, where he underwent a successful renal transplantation in the Right retroperitoneal space. The operation was uneventful and he remained intubated overnight, requiring levophed for blood pressure support. ON POD1 he was successfully extubated and a run of hemodialysis was performed. He was transferred to the surgical floor following this. On POD2, following a dose of thymoglobumlin, he was found to be acutely SOB and hypotensive and was transferred to the SICU where he was reintubated. An ECHO showed normal L ventricular function and an swan ganz catheter was placed to optimize his fluid status. His liver function tests and CKs were markedly elevated consistent with a thymoglobulin reaction. He slowly improved over the next few days and was gently weaned from Levophed and Neo. TPN was initiated and the patient was kept NPO and his fluids were managed with CVVHD. Broad spectrum antibiotics were administered (Vanco, Zosyn). He continued to have episodes of hypotension throughout his ICU course, requiring transient increases in pressor support. Several attempts at resuming enteral nutrition were made but were not successful due to high residual volumes. Throughout the ICU course, Mr [**Known lastname 5108**] had low-grade fevers and an elevated WBC. This prompted a CT scan of the Abd and pelvis which showed multiple foci of low attenuation throughout the liver that were felt to be consistent with Hepatic abscesses. In addition, there were artherosclerotic lesions of hi s celiac trunk and SMA. The Antibiotic coverage was adjusted at this time to meropenem and Vancomycin. He continued to be stable in this state until POD9 when he had an acute rise in his WBC to 43,600. A TEE was obtained, showing no evidence of valvular vegetations. He was having diarrheal stools at this time and was empirically treated for clostridium difficile. A repeat CT scan was obtained the next day, which showed several low attenuation lesions in the liver and spleen and also a somewhat thickened loop of small bowel which appeared to be just distal to the ligament of treitz, but was similar in appearance to the prior scan. No free fluid or air was noted. The infectious disease service was consulted and felt that these CT findings in combination with the patient's history of esophageal candidiasis were worrisome for a systemic fungal infection. He was started on casprofungin and later changed to micafungin for more even renal and hepatic dosing. TPN was stopped at this time. He had a transient clinical improvement, was able to wean from sedation and was interactive enough to mouth words but did not meet criteria for extubation. ON POD15 he again had difficulty with hypotension, requiring maximum dosed of levophed and the addition of vasopressin. With fluid resuscitation, this improved somewhat and he was weaned from maximal pressor doses to minimal vasopressin. He continued to have recurrent episodes of hypotension and was supported with pressors and blood products and run even on CVVH. On the morning of POD18, succus and bile was found draining from the abdominal incision. The patient was taken back to the operating room where the incision was reopened and extended superiorly, revealing liquefaction necrosis of the entire colon, [**12-25**] of the small bowel (including the proximal extent), the L lateral segment of the liver and the gall bladder. This was felt to be a finding which was not compatible with survival and upon telephone discussion with the patient's daughter it was decided to not proceed with attempts at surgical reconstruction. The abdomen was closed and the patient was returned to the SICU where comfort care measures were instituted. He expired from cardiovasculr collapse at 1445. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Death from cardiovascular collapse due to sepsis Discharge Condition: Death

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icd9cm

[ [ [] ] ]

[ "99.15", "99.05", "38.93", "55.69", "54.11", "99.04", "00.93", "96.6", "00.17", "96.04", "99.07", "38.95", "88.72", "96.72", "39.95", "89.64" ]

icd9pcs

[ [ [] ] ]

5734, 5743

1718, 5682

319, 368

5835, 5843

1433, 1451

5705, 5711

5764, 5814

1466, 1695

275, 281

397, 778

800, 1417

27,232

161,552

31313

Discharge summary

report

Admission Date: [**2179-9-19**] Discharge Date: [**2179-10-12**] Date of Birth: [**2114-8-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catherterization Thoracentesis with pleurex catheter Upper Endoscopy Peripherally Inserted Central Catheter placement History of Present Illness: 65 yo male with very complicated medical history presents to [**Hospital1 18**] from OSH after developing 6/10 chest pain today at rehab. States pain began around 3 am while he was lying in bed. Located substernal, non-radiating, constant for over one hour, denies any associated nausea, diaphoresis, or SOB. Denies every having a similar pain in the past, rates the pain [**8-13**] in severity. Patient was recently admitted to [**Hospital1 18**] for a prolonged hospitalization from [**7-14**] to [**8-20**] for mesenteric ischemia complicated by myocardial infarction, respiratory failure, duodenal angioectasia, and presumed MRSA pneumonia. During that stay, he underwent an exploratory laparotomy, segmental ileal resection, and mesenteric vessel exploration, with successfuly stenting of the SMA. He also underwent resection of 8 cm distal ileum, terminal ileum and right colon resulting in ileotransverse colostomy. . Following surgery, he was found to have troponin elevation to .62, with normal CKs, ST depressions on EKG. He underwent cardiac cath on [**8-4**] which showed a right dominant system, left main and 3 vessel disease. The LMCA had a distal 70% lesion, LAD had an 80% ostial lesion with mid/distal 80% lesion, and LCx had an occluded OM2 with collateral filling. The RCA was proximally occluded with left coronary collaterals. He was evaluated by CT [**Doctor First Name **] for CABG, but thought to be a high risk candidate given his comorbidities and active illness, and the decision was made for medical management with reevaluation for CABG after recovery. He was unable to be weaned from the vent, and a trach was placed. In addition, an IVC filter was placed for DVT prophylaxis. . Today the patient was initially taken to [**Hospital3 12594**], found to have ST depressions in anterior leads on EKG, positive troponin of 1.76. He was given lasix for presumed CHF, heparin, beta-blocker, and aspirin, started on nitro gtt for persistent chest pain and subsequently became hypotensive. On arrival to [**Hospital1 18**] ED, the patient was chest pain free, EKG showed ST depressions II, V4-V5, TWI II, III, avF, V4-V5. Initial vitals were 97.6/ bp 105/92/ 72/ 24/ 98% on 3L. He became hypotensive to 70's systolically, LIJ placed and dopamine started. Cardiac enzymes here CK 386, MB 29, index 12.7, troponin 2.2. BNP [**Numeric Identifier 13168**]. One dose of Vanc given. Pt demonstrated signs of altered mental status, and the heparin was stopped until an emergent head CT could be obtained. However this was deferred as the patient was taken to cath lab. . Cardiac cath revealed 3-VD, LMCA with 80% distal, diffuse 50-60% stenosis, apical 70% stenosis. LAD showed ostial 80%, LCX diffuse 60-70% stenosis with total occlusion of distal OM1. BMS placed in LMCA/LAD, PTCA of OM1. The patient was changed to levophed for BP support and transferred to CCU for further management. . On arrival to CCU pt states he is pain free, denies any complaints. Further review of symptoms negative for prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He does note right hand tremor when he is cold and left arm weakness and numbness since his last hospitalization. Denies feeling lightheaded or dizzy. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, positive for chronic dyspnea, no orthopnea, no palpitations, syncope or presyncope. Past Medical History: PVD- s/p aorto [**Hospital1 **] fem bypass DM Bladder CA COPD s/p cholecystectomy Aorto [**Hospital1 **] Fem Bypass mesenteric ischemia s/p stenting of SMA CAD with 3 vessel disease on cath [**2179-8-4**] duodenal angioectasia respiratory failure MRSA pneumonia Social History: Pt has 75 pack/year smoking history, quit during last hospitalization, previous ETOH use about 6-12 beers/week. He is a retired highway heavy equipment operator, currently lives at [**Hospital3 **]. Family history significant for CAD, brother with MI at age younger than 50. Family History: non-contributory Physical Exam: VS: T: 98.5 BP: 125/66 P: 81 RR: 20 Sat: 96% Gen: appears older than stated age, NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Dry mucous membranes Neck: no LAD, JVP unable to be assessed as pt lying flat. Trached CV: RRR, nml s1/s2, 2/6 systolic murmur at LSB Chest: Resp were unlabored, no accessory muscle use. No crackles, + rhonchi B/L anteriorly. Abd: large open wound covered with dressing, appears CDI, NABS. Ext: 2+ pitting edema B/L up to knees. No pallor. R groin with sheath still in place, slight ooze, no hematoma, no bruit. Skin: Stage II decubitus ulcer on buttock Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; PT and DP dopplerable Left: Carotid 2+ without bruit; Femoral 2+ without bruit; DP and PT dopplerable Pertinent Results: Admission EKG demonstrated: SR, LAD, poor R wave progression, nml intervals, ST depressions II, V4,V5 . 2D-ECHOCARDIOGRAM performed on [**2179-9-20**]: The left atrium is normal in size. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is moderate to severe global left ventricular hypokinesis (LVEF = 35 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial pericardial effusion. Compared with the prior study (images reviewed) of [**2179-7-29**], global left ventricular systolic function is more depressed (but was overestimated on the prior study). . CARDIAC CATH performed on [**2179-8-4**] demonstrated: 1. Coronary angiography in this right dominant system demonstrated left main and 3 vessel disease. The LMCA had a distal 70% lesion. The LAD had an 80% ostial lesion with mid/distal 80% lesion. The LCx system had an occluded OM2 with collateral filling. The RCA was proximally occluded with left coronary collaterals. 2. Resting hemodynamics revealed normal left ventricular systolic pressure of 104 mm Hg and normal LVEDP of 12 mm Hg. Sytemic arterial systolic and diastolic pressures were normal. 3. Left ventriculography revealed no mitral regurgitation, mild global hypokinesis, and LVEF of 45%. . CARDIAC CATH on [**2179-9-19**]: 1. Three vessel coronary artery disease. 2. Normal ventricular function. 3. Acute anterior myocardial infarction, managed by acute ptca. 4. Successful PCI of the left main-left anterior descending artery. 5. Successful PCI of the mid left anterior descending artery. 6. Angioplasty of the first obtuse marginal. [**2179-10-6**] BILATERAL LOWER EXTREMITY ARTERIAL VASCULAR EXAMINATION: IMPRESSION: There is a widely patent right femoral to popliteal artery bypass graft. No evidence of thrombus is seen within the bypass graft . CXR [**9-19**]: A tracheostomy is noted in unchanged position. A new internal jugular catheter is seen with its tip in the upper superior vena cava. A feeding tube is seen with its tip in the stomach. There are bilateral pleural effusions and patchy airspace and interstitial disease bilaterally consistent with mild-to-moderate heart failure. The patient's rotation somewhat limits this study. The right lower lobe cannot be fully assessed. . LABORATORY DATA: see below, notable for leukocytosis with bandemia, anemia, hypokalemia, transaminitis, elevated BNP. [**2179-9-19**] 06:56PM CREAT-0.4* POTASSIUM-3.8 [**2179-9-19**] 06:56PM MAGNESIUM-1.5* [**2179-9-19**] 06:56PM HCT-28.0* [**2179-9-19**] 01:00PM ALT(SGPT)-45* AST(SGOT)-114* CK(CPK)-386* ALK PHOS-182* AMYLASE-42 TOT BILI-0.6 [**2179-9-19**] 01:00PM LIPASE-13 [**2179-9-19**] 01:00PM CK-MB-49* MB INDX-12.7* cTropnT-2.2* proBNP-[**Numeric Identifier 13168**]* [**2179-9-19**] 01:00PM ALBUMIN-3.0* CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-1.8 URIC ACID-3.8 [**2179-9-19**] 01:00PM WBC-14.5* RBC-3.44* HGB-11.0* HCT-32.2* MCV-94 MCH-32.1* MCHC-34.3 RDW-17.3* [**2179-9-19**] 01:00PM NEUTS-82* BANDS-2 LYMPHS-6* MONOS-9 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2179-9-19**] 01:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL [**2179-9-19**] 01:00PM PLT SMR-NORMAL PLT COUNT-188 [**2179-9-19**] 01:00PM PT-11.9 PTT-28.7 INR(PT)-1.0 Brief Hospital Course: # Cardiac- 1. Vessels- known 3-VD from previous cardiac cath, had been medically managed, now with recurrent chest pain and NSTEMI. S/P cardiac cath with BMS of LMCA/LAD and PTCA of OM1. Patient was started on aspirin, plavix, and a high-dose statin. Integrillin was held secondary to oozing at IJ and cath site. Intially beta-blocker/ACEi were held secondary to hypotension. However with improvement of hemodynamics, an ACEi was started and titrated up to captopril 50 TID. A beta blocker, metoprolol 12.5 [**Hospital1 **] was also started. The patient remained chest pain free throughout hospitalization. . 2. CHF- has a history of HF with EF >55% in [**July 2179**], a new Echo showed moderate to severe global left ventricular hypokinesis (LVEF = 35 %). During this admission, patient developed a large left right sided pulmonary effusion secondary to decompensated HF. Please see Respiratory status section below for further details. . 3. Rhythm- patient with multiple episodes of MAT during hospitalization, and one episode of atrial tachycardia with HR of 200s. This was thought to be most likely due to hypoxia vs. ischemic damage. Patient was started on metoprolol with good response and maintained a normal sinus rhythm throughout the rest of his hospital course. . # [**Name (NI) **] unclear etiology, differential included hypovolemia from overdiuresis at the OSH, cardiogenic shock, septic shock given open wound and leukocytosis although lactate normal and afebrile. BP improved after cath and with fluid resusitation. Patient was weaned off levophed which was started during catherization. Patient became hypotensive again with chest tube on [**9-30**], but these transient hypotensive episodes resolved when the chest tube was removed. . # Aortobifemoral graft thrombosis- Following catheterization, distal pulses on the right extremity, the site of femoral access, were not palapable. Pt was brought back to the catheterization lab, and was found to have an occluded aortobifemoral graft occclusion. The graft was cannulated, and he was started on heparin, with improvement of distal profusion. The patient had a b/l femoral u/s which revealed a free floating thrombus in the right fem-[**Doctor Last Name **] graft. The patient was continued on heparin as a bridge to coumadin as recommended by vascular surgery. He was treated with coumadin for 3 weeks. However following 3 weeks, his hospital course was additionally complicated by a GIB (see below) and thus a repeat ultrasound was performed to evaluate for the possibility of a persistent thrombi. The repeat ultrasound showed a patent graft and thus coumadin was discontnued. . # Leukocytosis- On admission, pt had a bandemia. His sputum Cx grew out MRSA. Patient completed 7 day course of vanc and cefipime ([**Date range (1) 73834**]), remained afebrile, and WBC resolved. Patient had repeat sputum sent in setting of questionable infiltrate on CXR. This grew MRSA and pseudomonas. He completed a 10 day course of vanco/zosyn ([**Date range (1) 73835**]). He remained afebrile following his antibiotic treatment. . # Acute upper GI bleed. Patient was found to have melena. He had an urgent EGD on [**10-5**] which revealed small AVMs in the gastric mucosa. He was started on PPI [**Hospital1 **] and sucralfate and his anticoagulation was held. He had no further episodes of GIB and he remained hemodynamically stable throughout the rest of his hospital course. . # Respiratory failure- unable to wean from vent during last admission, thought to be secondary to hypercarbia and respiratory muscle fatigue, he was s/p trach. On admission, patient had worsening CXR with complete right lung collapse, w/ pleural effusions and evidence of consolidation. Patient underwent a bronchoscopy with removal of obstructing proximal mucous plug with improvment temporarily w/ concordent chest PT and abx. Interventional pulm was consulted and the patient's effusion was then tapped with over 4L of fluid removed. Patient continued to be aggressively diuresed to prevent reaccumulation of effusion. On discharge he was switched to 120mg PO lasix daily. Of note, his creatnine was 1.3 on discharge, likely secondary to diuresis. . # Nutrition: He was continued on his tube feeds through a post-pyloric NG tube. Long-term plans for nutrition support were considered including PEG tube, however given his history of bowel surgery and recent GIB, he was continued on tube feeds through the NG tube. He was also started on megace due to persistent poor appetite. There was significant improvement of his PO intake on discharge and he was discharged with plans for weaning from tube feeding. . # Diabetes Mellitus: He was discharged home on a regimen of NPH [**12-10**]. Of note during his hospital course, he had one episode of hypoglycemia to 33 on the above NPH regimen. This was in the setting of poor caloric intake and thus his NPH dose was adjusted. However by discharge, his PO intake significantly improved and he was restarted on NPH [**12-10**]. Medications on Admission: Humulin NPH 10 units [**Hospital1 **] w/ Humalog sliding scale prevacid metoprolol 25 mg TID atrovastatin 80 mg ferrous sulfate folic acid docusate coreg 3.125 mg [**Hospital1 **] lasix 40 mg daily kcl 20 meq daily spironolactone 25 mg daily percocet ativan ambien duoneb . Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q4H (every 4 hours) as needed. 5. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) nebulizer Inhalation Q4H (every 4 hours) as needed. 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 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. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day) as needed for constipation. 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 13. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 18. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 19. Megestrol 40 mg/mL Suspension Sig: Four Hundred (400) mg PO BID (2 times a day). 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. . 21. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 22. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 23. Insulin Pt receives NPH 12 units at breakfast, 9 units at bedtime, plus fingersticks qid and a sliding scale for coverage Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: Primary: NSTEMI . Secondary: Coronary Artery Disease Peripheral Vascular Disease Mesenteric Ischemia Systolic Congestive Heart Failure Bilateral Pleural Effusions MRSA Pneumonia Sacral Decubitus Ulcer Open Surgical Abdominal Wound Duoadenal Arteriovenous Malformations Discharge Condition: stable, afebrile, chest pain-free, improved respiratory status, compensated CHF Discharge Instructions: You were admitted to the hospital with chest pain. You were found to have had a heart attack and were taken to the cath lab where you had stents placed to open 2 of the arteries supplying your heart. . While you were in the hospital you developed several complications, including a pneumonia for which you completed a course of antibiotics, a urinary tract infection for which you completed a course of antifungals, a collection of fluid around your left lung, which was drained with a catheter, and a clot in your peripheral bypass, which has completely resolved. Additionally, you had a bleed from your gastrointestinal tract, and had an upper endoscopy which showed no active bleeding. . Please take all of your medications as prescribed. Please keep all of your follow-up appointments. If you experience any further chest pain, or if you develop any trouble breathing or fevers/chills, please call your physician or go to the ED. Followup Instructions: Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2179-10-20**] 2:00 . Completed by:[**2179-10-17**]

[ "578.1", "496", "996.74", "933.1", "V10.51", "112.2", "250.00", "518.0", "V44.0", "410.71", "428.21", "V09.0", "482.41", "428.0", "707.03", "511.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "37.22", "00.42", "38.93", "34.91", "45.13", "00.66", "00.46", "88.56", "33.21", "36.06", "96.6", "34.04" ]

icd9pcs

[ [ [] ] ]

17199, 17269

9565, 14614

327, 455

17582, 17664

5594, 9542

18646, 18829

4657, 4675

14938, 17176

17290, 17561

14640, 14915

17688, 18623

4690, 5575

277, 289

483, 4062

4084, 4347

4363, 4641

32,425

112,105

28371

Discharge summary

report

Admission Date: [**2157-10-24**] Discharge Date: [**2157-11-4**] Date of Birth: [**2109-1-23**] Sex: F Service: MEDICINE Allergies: Shellfish / Flexeril Attending:[**First Name3 (LF) 949**] Chief Complaint: Hyponatremia, Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: 48yo F w/ HCV cirrhosis c/b encephalopathy, ascites, edema/TIPS [**11-8**], hydrothorax, thrombocytopenia, chronic hyponatremia (baseline 124-128), adrenal insufficiency, GERD, anxiety directly admitted for worsening hyponatremia. Diagnosis of adrenal insufficiency made [**12-12**] during hospitalization for SOB, hyponatremia, fluid overload. Cortisol [**2156-12-10**] was 0.1. At 30 min, cortisol was 1.6. at 60 min, cortisol was 2.4. ACTH < 5. CBG [**2156-12-11**] 27 (nl). Endo Inpt consulting team recommended stress dose steroids if needed but did not recommended chronic replacement steroids as outpatient since she was on inhaled steroids. Pt was seen by Dr [**Last Name (STitle) 10759**] on [**2156-12-28**]. She noted that diagnosis of AI was based on hyponatremia, relative hyperkalemia and eosinophilia. She did note that HypoNa could be [**1-7**] third spacing [**1-7**] cirrhosis and chronic diuretics. She noted that pt only had mildly orthostatic symptoms but these were unchanged whether or not patient was on oral steroids. She also noted that pt never had N, V, weight loss, decreased appetite, hypotension. She did note that off diuretics, patient became short of breath. She then repeated cortisol and ACTH levels which were persistently low and subsenquently started Prednisone 5 mg po qd. Adrenal glands were noted to be normal on abdominal US. Patient has most recently been on Hydrocortisone 20 mg po q am and 10 mg po qhs. On [**10-8**] Na 137, [**10-17**] Na 126, [**10-20**] Na 120 (OSH), [**10-24**] Na 115. On [**10-20**], her diuretics were held [**1-7**] hyponatremia. She reports good compliance with medical regimen and has been avoiding free water. She reports compliance with her low salt diet. She has had increasing dizziness, nausea, worsening LBP over the last few days. She arrived directly on the floor and labs showed the Na of 115. She was transferred to the unit for closer monitoring and potential need for hypertonic saline. On admission to the unit, she reported dizziness, nausea, and fatigue. She has had no seizure like activity or LOC. She denies [**Last Name (LF) **], [**First Name3 (LF) **], photophobia, CP, palpitations. With abdominal pain in RUQ which is unchanged from previous. She denies any fevers, chills. Denied change in BMs (normally [**1-8**] daily). No increased peripheral edema. Past Medical History: 1. HCV cirrhosis s/p TIPS [**11-8**] c/b hydrothorax, encephalopathy, and ascites 2. Hyponatremia baseline 128-133 3. Asthma 4. Adrenal insufficiency (thought to be [**1-7**] chronic advair use) 5. GERD 6. Anxiety 7. Hyperglycemia thought [**1-7**] cirrhosis 8. Recent intubation thought [**1-7**] transfusion-related acute lung injury. Led to prolonged ICU stay then rehab. Also treated for PNA 9. Recent UTI Social History: - Recreational drugs: Past IV drug use with needle sharing, last use 7 years ago. Past drug-snorting. - Alcohol: Past alcohol use, last drink at age 46. - Tobacco: Past [**Month/Day (2) 1818**] with 10 pack-year history - Personal: Single with one child. Lives with mother, who manages medications - Employment: Former waitress, unemployed on disability. Family History: Mother w/ DM2, HTN, and hyperlipidemia. Father w/ COPD and EtOH cirrhosis. Physical Exam: VS: 97.7 102 122/51 16 96% i/o 1120/805 Gen: alert to person, place, time, situation. comfortable, Neuro: fields nl to confrontation HEENT: EOMI OP clear Breast: no disharge expressed from nipple Cards: RRR + murmur Resp: Clear bilat. nl effort Abd: BS+, mildly protuberant. no rebound or guarding. soft Ext: no edema, no hyperpigmentation of scars. Pertinent Results: [**2157-10-24**] 09:31PM PT-18.9* PTT-53.9* INR(PT)-1.7* [**2157-10-24**] 09:31PM WBC-11.5* RBC-3.21* HGB-11.7* HCT-32.9* MCV-103* MCH-36.6* MCHC-35.6* RDW-18.5* NEUTS-79.8* LYMPHS-11.9* MONOS-7.0 EOS-1.0 BASOS-0.2 [**2157-10-24**] 09:31PM ALBUMIN-3.6 CALCIUM-9.3 PHOSPHATE-2.7 MAGNESIUM-2.1 LIPASE-125* [**2157-10-24**] 09:31PM ALT(SGPT)-120* AST(SGOT)-200* LD(LDH)-325* ALK PHOS-447* AMYLASE-185* TOT BILI-7.6* [**2157-10-24**] 09:31PM GLUCOSE-100 UREA N-19 CREAT-0.6 SODIUM-115* POTASSIUM-5.8* CHLORIDE-83* TOTAL CO2-27 ANION GAP-11 [**2157-10-24**] 10:24PM LACTATE-1.8 [**2157-10-24**] 11:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-NEG OSMOLAL-449 [**2157-10-24**] 11:00PM URINE [**2157-10-24**] 11:00PM URINE HOURS-RANDOM UREA N-644 CREAT-60 SODIUM-22 POTASSIUM-38 Brief Hospital Course: A/P: 48yo woman with history of HCV and ETOH induced cirrhosis complicated by encephalopathy, ascites, s/p TIPS [**11-8**], hydrothorax, thrombocytopenia, adrenal insufficiency, and chronic hyponatremia admitted for worsening hyponatremia. # Hyponatremia: Upon admission patient was noted to have sodium of 115. She has been admitted multiple times with similar problems. [**Name (NI) **] was admitted to the ICU and improved with 3%NS and fluid restriction. She has a long history of being noncompliant with fluid restriction as an outpatient. During her hospital course her sodium slowly improved from 121--> 126--> 127. Was continued on fluid restriction with continued diuresis via lasix and spironolactone. As there was also a question that some of this could be adrenal insufficiency, she was continued on [**Hospital1 **] hydrocortisone 20mg and 10mg for physiologic dosing. Briefly treated with IV lasix and albumin with good effect. Discharged on lasix, spironolactone and 1000ml fluid restriction. # Hyperkalemia: Potassium initially elevated on admission to 5.8. No ECG changes. Transtubular potassium gradient was suggestive of hypoaldosteronism at 5.6. However, it was difficult to determine TTKG in patient with decreased distal delivery of sodium. Ultimately it was unclear if patient is truly adrenally insufficienct as hyponatremia is also result of cirrhosis. Resolved with treatment as described above. Upon discharge K was 4.0 # HCV cirrhosis s/p TIPS [**11-8**] complicated by hydrothorax, encephalopathy, ascites, and thrombocytopenia. T. Bili has improved since prior admission and trending down upon this admit. ALT/AST, Alk phos, and amylase were increasingly elevated with unclear etiology. LFTs were trended and resolved to baseline. MELD calculated and found to be 20. Was continued on lactulose and rifaximin. Continued on diuresis as described above, with the brief addition of IV lasix. # Vertebral compression fractures: Evaluated by IR for vertebroplasty on last admission. IR determined that she was not to be candidate during this admission secondary to continued coagulopathy. Was continued on lidocaine transdermal patch, ice packs, and oxycodone prn. Also on MS contin [**Hospital1 **]. PT was consulted and evaluated the patient, stating she was able to discharge to home. Did have acute episodes of increase pain, but always relieved by oxycodone 5mg. Patient was concerned upon discharge that her pain would be difficult to control at home as her mother is her primary caregiver and does not give her PRNs. Discussed at great length that we could not increase scheduled as she becomes too somnolent and it is not safe. Discharged on MS contin and oxycodone for breakthrough. # History of Adrenal Insufficiency: Upon evaluation she had no sodium wasting in urine or othrostatic hypotension. Potassium levels were noted to be fluctuating. Hydrocortisone continued at physiologic dosing. To follow-up with Endocrine as an outpatient. # Asthma: Not an active inpatient issue, continued on inhalers. # Type 2, DM: Managed as on outpatient with humalog ISS and glargine. While in patient her glargine and ISS were adjusted for improved glycemic control. Discharged on both these medications. Medications on Admission: Albuterol Calcium Carbonate Clotrimazole Dexamethasone 4 mg IV bid Fluticasone-Salmeterol (100/50) FoLIC Acid Insulin Lactulose Lidocaine 5% Patch Magnesium Oxide Montelukast Sodium Morphine Sulfate Morphine SR (MS Contin) OxycoDONE (Immediate Release) Pantoprazole Rifaximin Vitamin D Discharge Medications: 1. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six (6) hours as needed for 20 doses. Disp:*20 Tablet(s)* Refills:*0* 2. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 3. Clotrimazole 10 mg Troche [**Hospital1 **]: One (1) Troche Mucous membrane 5X DAY (). Disp:*150 Troche(s)* Refills:*0* 4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device [**Hospital1 **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Folic Acid 1 mg Tablet [**Hospital1 **]: Five (5) Tablet PO DAILY (Daily). 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 7. Rifaximin 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a day). 8. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO three times a day. 9. Morphine 15 mg Tablet Sustained Release [**Hospital1 **]: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release(s)* Refills:*0* 10. Spironolactone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 12. Hydrocortisone 20 mg Tablet [**Hospital1 **]: 0.5-1 Tablet PO Twice daily, 20mg at 10AM and 10mg at 5pm: Take one tablet each morning at 10AM and [**12-7**] tablet each evening at 5pm. Disp:*45 Tablet(s)* Refills:*2* 13. Furosemide 80 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day. 14. Lactulose 10 gram/15 mL Syrup [**Month/Day (2) **]: Forty Five (45) ML PO TID (3 times a day). 15. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (2) **]: Two (2) Tablet PO once a day. 16. Insulin Lispro 100 unit/mL Insulin Pen [**Month/Day (2) **]: One (1) unit Subcutaneous four times a day as needed for glucose correction: Please give as directed on your discharge insulin sliding scale. Check fingersticks four times daily. Disp:*QS pen* Refills:*2* 17. Lancets Misc [**Month/Day (2) **]: One (1) lancet Miscellaneous four times a day. Disp:*QS lancet* Refills:*2* 18. Alcohol Prep Pads Pads, Medicated [**Month/Day (2) **]: One (1) pad Topical four times a day. 19. Insulin Syringes (Disposable) Syringe [**Month/Day (2) **]: One (1) syringe Miscellaneous twice a day. 20. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray [**Month/Day (2) **]: One (1) spray Nasal twice a day: Alternate nostrils daily. Disp:*QS unit* Refills:*1* 21. Insulin Glargine 300 unit/3 mL Insulin Pen [**Month/Day (2) **]: Thirty Four (34) unit Subcutaneous at bedtime. Disp:*1 month supply* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 6138**] Home Care Services Discharge Diagnosis: Primary: Hyponatremia, adrenal insufficiency Secondary: Hepatitis C, Cirrhosis Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: 1)You were admitted to the hospital with low sodium. You also developed worsening fluid in your legs while you were in the hospital. We increased your dose of diuretics. You were kept on a strict regimen of 1000ml (1 liter) of fluid intake. Please continue to monitor your intake of fluids and keep it within the 1 liter. 2)In the hospital you had a test to rule out tuberculosis on your arm. Please schedule an appointment with your primary care physician (you may not need an appointment, but can just stop by) on Monday to have this looked at. 3)Please take all medications as listed in the discharge instructions. Your ipratroprium bromide was held while in the hospital, please discuss this medication with your regular doctor [**First Name (Titles) 5001**] [**Last Name (Titles) 9533**] it. You have also been prescribed a new medication called Clotrimazole. Please continue to take this medication as directed. 4)Please attend all appointments as listed below. 5)If you experience any fevers, chills, chest pain, shortness of breath, dizziness or any other concerning symptoms please return to the emergency room. Followup Instructions: Please keep all your appointments. You have the following appointment scheduled to see how you are doing after discharge: Dr. [**Last Name (STitle) **] [**Name (STitle) 3628**] [**Location (un) **] [**2157-11-24**] at 8am ([**Telephone/Fax (1) 1582**] Please see you primary care physician on [**Name9 (PRE) 766**], [**2157-11-7**] to have your TB test read. This was placed on your left arm.

[ "571.5", "070.70", "287.4", "276.7", "276.1", "255.5", "493.90", "530.81", "250.00", "V49.83", "733.13", "305.93", "V58.67", "300.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11281, 11355

4922, 8187

317, 323

11478, 11517

4001, 4899

12693, 13092

3539, 3615

8524, 11258

11376, 11457

8213, 8501

11541, 12670

3630, 3982

242, 279

351, 2713

2735, 3149

3165, 3523

73,713

157,970

50322

Discharge summary

report

Admission Date: [**2150-8-25**] Discharge Date: [**2150-9-3**] Date of Birth: [**2096-10-22**] Sex: F Service: MEDICINE Allergies: Ativan Attending:[**First Name3 (LF) 4095**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: 52 y.o female with pmhx of COPD on home 2L NC, recurrent pneumonia, paraplegia, and recent admission for hypercarbic resp failure,MDR pneumonia,Proteus UTI discharged last week presenting with altered mental status. She has been noted by her caretaker to be more confused at home. In the ED she was alert and oriented X 3,with no complanits.In the ED she trigerred for a oxygen saturation of 82% RA with insp crackles and some wheezing, afebrile. She was diagnosed with recurrent RLL pnemonumona, and given Meropenem and Vancomycin. Her SBP briefly was 72 and with 500cc NS increased to SBP 100. Prior to transfer her vitals were: T-99 HR 99,107/60, RR 20 86% 6L with BIPAP being started. In the ED initial vitals were: 99 100 140/122 24 92%. She was given Meropenem and Vancomycin. On arrival to the MICU, the patient is on BIBAP and able to answer some questions. She knows its [**2150-8-2**], oriented to [**Hospital1 18**] denies chest pain, abdominal pain,diarrhea, fevers/chills,dizziness, dysuria at home. Denies headaches, syncope and vision changes at home. She does endorse tan sputum production and cough for the past few weeks. Past Medical History: # T1 to T2 paraplegia status post a motor vehicle accident. # Recurrent pneumonia - Per pulm, recurrent pneumonia likely from pulmonary toilet issues secondary to neuromuscular disease with improvement with consistent and aggressive bronchopulmonary therapy. - Prior sputum cultures + for MRSA, pan-sensitive Klebsiella, and Pseudomonas. # Recurrent UTIs in the setting of urinary retention requiring straight catheterization # hepatitis C # anxiety # DVT in [**2142**] -IVC filter placed in [**2142**] # Pulmonary nodules # Hypothyroidism # Chronic pain # Chronic gastritis # Anemia of chronic disease # S/p PEA arrest during hospitalization in [**2147-10-3**] Social History: Lives at home with husband - [**Name (NI) 1139**]: 35-pack-years, currently abusing tobacco - Alcohol: Denies. - Illicits: Denies. Family History: Mom - lung cancer Dad - healthy Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:99.1 BP:93/62 P:94 R:16 18 O2:95% BIPAP General: Alert, oriented, not retracting, has BIPAP mask on, mouthing words and nodding yes/no to questions appropiately. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: insp/ exp. wheezes difussely,insp rales in RLL, some exp ronchi diffusley. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no current foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, DISCHARGE PHYSICAL EXAM: VS - T97.8 HR 73 BP 100/60 RR 20 O2Sat 97% 2L NC GENERAL - awake, NAD LUNGS - No increased work of breathing, no wheezes or crackles HEART - RRR, S1-S2 clear, no MRG ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding GU - Foley in place NEURO - A&Ox3, CN 2-12 grossly intact Pertinent Results: ADMISSION LABS: [**2150-8-25**] 02:45PM BLOOD WBC-13.4*# RBC-3.26* Hgb-8.9* Hct-28.7* MCV-88 MCH-27.2 MCHC-30.9* RDW-16.0* Plt Ct-282 [**2150-8-25**] 02:45PM BLOOD Neuts-90.9* Lymphs-4.7* Monos-3.3 Eos-0.9 Baso-0.2 [**2150-8-25**] 02:45PM BLOOD PT-13.7* PTT-29.7 INR(PT)-1.3* [**2150-8-25**] 02:45PM BLOOD Glucose-135* UreaN-18 Creat-0.4 Na-141 K-4.2 Cl-102 HCO3-33* AnGap-10 [**2150-8-25**] 02:45PM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2 [**2150-8-25**] 02:45PM BLOOD proBNP-927* [**2150-8-25**] 05:29PM BLOOD Type-ART pO2-76* pCO2-76* pH-7.25* calTCO2-35* Base XS-2 [**2150-8-25**] 03:06PM BLOOD Lactate-1.4 [**2150-8-25**] 05:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2150-8-25**] 02:45PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG RELEVANT LABS: [**2150-8-26**] 07:37AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-POS [**2150-9-2**] 06:05AM BLOOD WBC-7.0 RBC-3.43* Hgb-8.9* Hct-29.3* MCV-85 MCH-25.9* MCHC-30.4* RDW-16.3* Plt Ct-274 [**2150-9-2**] 06:05AM BLOOD Glucose-96 UreaN-6 Creat-0.2* Na-143 K-3.6 Cl-101 HCO3-38* AnGap-8 [**2150-9-2**] 06:05AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.0 [**2150-9-2**] 08:10PM BLOOD Type-ART pO2-86 pCO2-58* pH-7.44 calTCO2-41* Base XS-12 PERTINENT MICRO: [**2150-8-27**] BLOOD CULTURE -PENDING NGTD AT DISCHARGE [**2150-8-25**] URINE Legionella Urinary Antigen -FINAL NEG [**2150-8-25**] URINE CULTURE-FINAL NEG [**2150-8-25**] BLOOD CULTURE -PENDING NGTD AT DISCHARGE [**2150-8-25**] 2:45 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [**2150-8-27**]): Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2150-8-27**] AT 0645. GRAM POSITIVE COCCI IN CLUSTERS. [**2150-8-25**] 4:45 pm SPUTUM Source: Expectorated. **FINAL REPORT [**2150-8-28**]** GRAM STAIN (Final [**2150-8-25**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2150-8-28**]): RARE GROWTH Commensal Respiratory Flora. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. HEAVY GROWTH. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested in cases of treatment failure in life-threatening infections.. STAPH AUREUS COAG +. SPARSE 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---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Blood Culture, Routine (Final [**2150-9-2**]): NO GROWTH. Legionella Urinary Antigen (Final [**2150-8-26**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. PERTINENT IMAGING: pCXR [**2150-8-25**] COMPARISONS: Multiple prior chest radiographs, most recently of [**2150-8-17**]. FINDINGS: Single frontal portable view of the chest was obtained. The heart is enlarged and its right border is silhouetted by right lung base consolidation, which is increased since [**2150-8-17**] and compatible with pneumonia, pleural effusion, or a combination of both. The left lung is clear. No pneumothorax is identified. A right central catheter terminates in the low SVC. Left humeral hardware is similar to prior and right humeral hardware is incompletely imaged. IMPRESSION: Right lung base parenchymal opacity, increased since prior, compatible with pneumonia in the correct clinical setting. Probable superimposed right pleural effusion. Brief Hospital Course: 53 y.o woman with pmhx of COPD on home 2L NC, recurrent pneumonias and UTIs, T1-T2 paraplegia , and recent admission for hypercarbic resp failure, MDR pneumonia, Proteus UTI discharged one week prior who presented with altered mental status and hypoxia, found to have new RLL Haemophilus influenzae and MRSA pneumonia. # Pneumonia: RLL pneumonia with MRSA and heavy Haemophilus influenzae on sputum cultures. Patient was initially started empirically on vancomycin, cefepime, meropenem, and was able to be narrowed to vancomycin and meropenem only following speciation of sputum cultures. Pneumonia was most likely cause of hypotension, leukocytosis, hypoxia on admission. Patient has history of recurrent pneumonias and most recently completed eight-day Vancomycin and Meropenem course for HCAP on [**2150-8-18**]. Given frequent AMS and RLL pna, high suspicion for aspiration. She was treated for a total of 10 days with Vancomycin and Meropenem. She was counseled on the contribution of underlying substance dependence/polypharmacy leading to readmissions for AMS and aspiration pneumonia. # Positive blood cultures: One of four blood cultures positive for coagulase negative staph, most likely contaminate. Patient with indwelling CVC which did not appear infected, pneumonia was treated as above. Repeat blood cultures showed no growth. #Hypotension- Most likely [**3-5**] medications or infection. Fluid responsive in the ED, lactate normal, patient did not require pressors in the MICU. SBP at baseline fluctuates between 100-150 according to past records. Infection treated as above, weaned to half doses of sedating medications. No signs of cardiogenic cause or adrenal cause. BPs were stable to elevated during her stay on the medicine floor. #Altered mental status- Patient presented with decreased responsiveness and likely aspiration pneumonia similar to prior hospitalizations, and was found to have Utox positive for methadone, which patient admitted to taking without prescription "from a friend" at unknown dose, for her chronic leg pain, as narcotics agreement was termintated with PCP. [**Name10 (NameIs) **] spoke at length with patient about this. Psychiatry consult was offered but patient declined. Patient was not treated with narcan this admission, but was known to have be responsive to narcan during the previous admission. Opioid abuse and polypharmacy are the most likely culprits for her recurrent admissions with AMS and pneumonias most likely caused by aspiration, AMS compounded by infection and poor pulmonary toilet. Sedating medication doses were decreased by half. CHRONIC ISSUES: # COPD: on 2L O2 NC at baseline; resumed tobacco use last month. -Continued home albuterol, ipratroprium, supplemental O2 # Chronic Pain: Foot and shoulder pain related to prior MVA and likely neuropathy. Narcotics contract terminated by PCP as documented in OMR. Utox positive for methadone (not prescribed) this admission as discussed above. -Lidocaine patches, baclofen, continued -Gabapentin, pregabalin intially held for AMS, pregabalin restarted, gabapentin restarted at half home dose when mental status improved. -Follow up at pain clinic as outpatient # Urinary Retention: Patient usually self-catheterizes at home but prefers to use foley when hospitalized. Foley was placed on admission and removed before discharge. Oxybutin held initially for AMS but restarted when mental status improved. # Anxiety/Depression: Continued on citalopram, sedating medications were held on admission for AMS, and were restarted at half home dose when mental status improved, including clonazepam, trazadone. Patient declined psychiatry consult but opened up to SW during this admission about home stressors, including her relationship with caregivers and husband. # Hypothyroidism: Continued levothyroxine # Hypercholesterolemia: Continued simvastatin # Hep C: Stable, no current treatment, no LFT abnormalities this admission. # GERD: Continued omeprazole Transitional issues for this patient include: - Continued investigation into options of treatment of methadone abuse and dependence Medications on Admission: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea 2. Baclofen 20 mg PO QAM, QPM 3. Baclofen 10 mg PO 4PM 4. Citalopram 40 mg PO DAILY 5. Clonazepam 1 mg PO TID:PRN anxiety 6. Lidocaine 5% Patch 1 PTCH TD DAILY feet and shoulder blade 7. Omeprazole 20 mg PO DAILY 8. Polyethylene Glycol 17 g PO DAILY 9. Simvastatin 10 mg PO DAILY 10. traZODONE 100 mg PO HS:PRN anxiety 11. Clonazepam 2 mg PO QHS 12. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN dyspnea 13. Oxybutynin 10 mg PO QAM, QHS 14. Oxybutynin 5 mg PO 4PM 15. Sucralfate 1 gm PO TID 16. Levothyroxine Sodium 112 mcg PO DAILY 17. Gabapentin 600 mg PO TID Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea 2. Baclofen 20 mg PO QAM, QPM 3. Baclofen 10 mg PO 4PM 4. Citalopram 40 mg PO DAILY 5. Levothyroxine Sodium 112 mcg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Oxybutynin 10 mg PO QAM, QHS 8. Oxybutynin 5 mg PO 4PM 9. Polyethylene Glycol 17 g PO DAILY 10. Simvastatin 10 mg PO DAILY 11. Lidocaine 5% Patch 1 PTCH TD DAILY feet and shoulder blade 12. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN dyspnea 13. Sucralfate 1 gm PO TID 14. Pregabalin 100 mg PO TID 15. Clonazepam 1 mg PO QHS 16. Clonazepam 0.5 mg PO TID:PRN anxiety hold for sedation or RR<10 17. Gabapentin 300 mg PO Q8H 18. traZODONE 50 mg PO HS:PRN insomnia Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary diagnosis: pneumonia (Haemophilus influenzae, Methicillin Resistant Staph aureus) Secondary diagnosis: opioid dependence chronic obstructive pulmonary disease T1/T2 paraplegia with neurogenic bladder 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: Dear Mrs. [**Known lastname **], It was a pleasure taking part in your care during your hospitalization at [**Hospital1 18**]. You were admitted with confusion, difficulty breathing, and low blood pressure and were found to have a pneumonia. You were briefly admitted to the intensive care unit for your symptoms, but did not require intubation. You improved with IV antibiotics and were able to be discharged. Please be aware that taking medications that are not prescribed to you can be dangerous to your health and is likely contributing to your recurrent hospitalizations. It is very important that you follow up with the pain clinic to treat your pain in a safe manner. Also please follow up with your PCP at the appointment below. Please note that the following changes have been made to your medications: 1. Your dose of gabapentin was decreased to 300 mg PO Q8HRS 2. Please only take 1 mg of clonazepam by mouth at bedtime and/or 0.5 mg by mouth up to 3 times per day as needed for anxiety Followup Instructions: Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] When: THURSDAY [**2150-9-10**] at 1:10 PM Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage NOTE: This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider Department: PAIN MANAGEMENT CENTER When: TUESDAY [**2150-9-15**] at 8:40 AM With: [**Name6 (MD) 10720**] [**Last Name (NamePattern4) 10721**], MD [**Telephone/Fax (1) 1652**] Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site Department: [**Hospital3 249**] When: TUESDAY [**2150-9-22**] at 10:40 AM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2150-9-6**]

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icd9cm

[ [ [] ] ]

[ "93.90", "38.97" ]

icd9pcs

[ [ [] ] ]

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22,098

180,946

18834

Discharge summary

report

Admission Date: [**2162-5-26**] Discharge Date: [**2162-5-29**] Date of Birth: [**2116-6-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: Lightheadedness, worsening Dyspnea on exertion Major Surgical or Invasive Procedure: Colonoscopy [**2162-5-28**] Upper Endoscopy 4/015/05 History of Present Illness: Ms. [**Known lastname **] is a 46-year old woman with cirrhosis thought to be [**3-17**] to Hep C (Ab+, VL-), ?hx of EtOH abuse, with recent admission for LGIB, hx of CHF, pulm HTN, who presents w/ lightheadedness and DOE x 2 days. Pt had recent admission [**Date range (1) 51556**] at [**Hospital1 18**]. Initially she was admitted for worsening LE edema, SOB - sx attributed to her RHF [**3-17**] pulm HTN. At the time of discharge, pt noted to have BRBPR and underwent a colonscopy which showed a rectal vessel w/ overlying clot thought to be source. Despite epi, cauterization, pt continued to bleed and went for a 2nd coloscopy which showed areas of ulceration. She was taken to colorectal surgery for ligation of area (unclear whether [**Name (NI) 24997**]??????s lesion vs bleeding rectal varix). Her course was complicated by hepatic encephalopathy requiring pt to be admitted to MICU for several days after found to be unresponsive and improved w/ aggressive lactulose Rx. Since then she was readmitted for worsening CHF and r/o??????d out for MI. At the time Hct noted to be low and was transfused 2 U PRBCs. Hct upon discharge on [**4-26**] was 30.9. Today, pt presents after noting both lightheadedness and dyspnea with exertion. At baseline, pt states that she has shortness of breath but noticed [**Month/Year (2) 766**] that it had worsened. Since then she also notes diffuse, sharp chest pain w/ activity, relieved by rest. She denies worsening of LE edema, diaphoresis, dark stools, BRBPR. In the [**Name (NI) **], pt??????s vitals were T 97.9 P 98 BP 120/63 RR 24 O2SAT 100%RA. Labs were notable for Hct 21 Tn .02 CK 630. Physical exam notable for guiac + maroon stool. NG lavage was negative. EKG demonstrated NSR 96 borderline RAD no ST-T wave changes, unchanged from previous EKG. CXR no acute cardiopulm. process. She received an ASA 325mg, Lasix 40mg, 1U PRBC. She was transferred the MICU for further management. Past Medical History: 1. Asthma 2. Pulmonary HTN - cathed [**8-/2161**], mean PA pressure 63 mmHg. Right- sided filling pressures severely elevated: RA mean 24 mmHg, RVEDP 24 mmHg). Left sided filling pressures mildly elevated: PCW 20 mmHg. 3. Thrombocytopenia 4. IDDM - unknown duration, on Lispro and NPH at home. 5. RHF - Echo in [**5-18**]. EF>55%, Global right ventricular hypokinesis. 6. Liver cirrhosis - HCV positive Ab, neg VL in [**8-/2161**], not a transplant candidate due to cor pulmonale. Social History: Unclear whether she is currently drinking. States she lives alone. Smoke 1 cigarette qd. Had heavy etOH in past -denies any etoh recently. Snorted cocaine in past but denies IVDU. Family History: HTN CAD Breast CA Physical Exam: Physical Exam: VS P 105 BP 127/50 RR 20 Sao2 General: middle-aged woman sitting comfortably in bed, no signs of resp distress HEENT: icteric sclerae, MMM, no JVD, nl JVP Chest: CTA bilaterally w/o wheezes or crackes Cardiac: sinus tach, loud P2, splitting of S2 best heard at LUSB no murmurs or rubs Abd: soft, obese, diffusely tender, + bowel sounds, no HSM Ext: 1+ pitting edema to knees, 2+ DPs, no cyanosis Neuro: alert and oriented x 3, no asterxis, grossly normal Pertinent Results: Admission Labs: HCT-22.7* PLT COUNT-71* PT-16.9* PTT-35.1* INR(PT)-1.8 GLUCOSE-155* UREA N-19 CREAT-1.0 SODIUM-139 POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-21* ANION GAP-13 CK(CPK)-630* CK-MB-4 cTropnT-0.02* ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG WBC-5.0 RBC-1.99*# HGB-6.7*# HCT-21.2*# MCV-106*# MCH-33.4* MCHC-31.4 RDW-19.3* HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+ RET AUT-6.9* Studies: Echo [**2162-5-28**]: 1. Left ventricular wall thickness, cavity size, and systolic function abnormal (LVEF>55%). Regional left ventricular wall motion is normal. 2. The right ventricular cavity is moderately dilated. There is severe global right ventricular free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. 3. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. 4. Compared with the findings of the prior report (tape unavailable for review) of [**2161-8-26**], the tricuspid regurgitation is worse, and the pulmonary pressures may be less. Colonoscopy [**2162-5-28**]: Diverticulosis of the sigmoid colon. Grade 1 internal hemorrhoids. No evidence of recent or previous bleeding noted up to the cecum. EGD [**2162-5-28**]: Erythema in the gastroesophageal junction compatible with esophagitis. Mosaic appearance in the fundus and stomach body compatible with portal gastropathy. Hypertrophied duodenal folds. CXR [**2162-5-26**]: Stable cardiomegaly. No acute cardiopulmonary process observed Brief Hospital Course: 46-year old woman with cirrhosis [**3-17**] to Hep C (Ab+, VL-), hepatic encephalopathy, CHF (right heart failure secondary to pulm HTN), h/o EtOH abuse, recent admission for LGIB p/w lightheadedness and DOE x 2 days. She notes SOB at baseline however dyspnea worsening over last 2 days. In the ED, Hct was noted to be 21. Rectal exam revealed guiac + maroon stool. NG lavage was negative. 2 [**Name (NI) 51557**] (pt refused central line). She was admitted to the MICU. She has been transfused 3 Units PRBC's. 1. GIB/anemia- Pt has hx of recent LGIB, negative NG lavage, maroon stools which are guiuac pos. Pt received 3 units of PRBCs bumping her crit from 21 to 30. She remained hemodynamically stable during her stay. Her SOB was attributed to her severe anemia. She had several small melanotic stools but there was no BRBPR. She received Golytely prep for coloscopy and EGD. Colonoscopy revealed diverticulosis of the sigmoid colon and Grade 1 internal hemorrhoids, there was no evidence of recent or previous bleeding noted up to the cecum. EGD revealed erythema in the gastroesophageal junction compatible with esophagitis, Mosaic appearance in the fundus and stomach body compatible with portal gastropathy and Hypertrophied duodenal folds. Her hct remained >28. She was discharged on protonix [**Hospital1 **]. 2. CV: Elevated troponins likely [**3-17**] to demand ischemia in setting of anemia. Serial EKG unchanged from prior and without ST-T wave changes suggestive ischemia/infarction. 3. Cirrhosis - [**3-17**] to HepC although with neg VL, hx of EtOH use? - Home diuretics were intially held since pt was intravascularly dry [**3-17**] to GIB. Lasix and spironolactone restarted on [**5-27**]. She continued on Lactulose and Flagyl. 4. RHF/cor pulmonale ?????? [**3-17**] to portopulmonary HTN. Pt demonstrated no signs of worsening CHF. LE edema remained stable, lungs were clear. Home diuretics restarted as mentioned above. Echo revealed RV cavity moderately dilated, severe global RV free wall hypokinesis. There is abnormal septal motion/position consistent with RV pressure/volume overload. Breathing at baseline by time of discharge. 5. Type 2 DM- BS well controlled on reduced regimen of NPH 3U q AM and 2U q PM. Per patient, has been having very good blood sugar control at home (~90's-100's) on her home regimen of 10U NPH qAM and 7 U NPH qPM. Therefore, she was told to resume her outpt insulin regimen. 6. Asthma - She did well on her home dose of Advair and albuterol prn. Medications on Admission: Albuterol Advair Insulin NPH 10U qam, 7U qpm Lactulose Pantoprazole 40 mg qd Spironolactone 25 mg qd Flagyl 250 [**Hospital1 **] Lasix 20mg qd Ca carbonate 500mg [**Hospital1 **] Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: Two (2) puffs Inhalation [**Hospital1 **] (2 times a day). 2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Calcium Antacid 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day with meals. 9. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1) Subcutaneous twice a day: 10 units qAM 7 units qPM. Disp:*qs * Refills:*2* Discharge Disposition: Home Discharge Diagnosis: GI bleed Anemia secondary to blood loss Discharge Condition: Fair Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please call your primary care physician or return to the hospital if you experience bleeding, chest pain, shortness of breath, or have any other concerns. Followup Instructions: You have the following appointments scheduled: 1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Where: LM [**Hospital Unit Name 7129**] CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2162-6-11**] 2:00 2. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Name8 (MD) 6121**], MD Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2162-6-3**] 3:00 Completed by:[**2162-5-29**]

[ "493.90", "562.10", "530.19", "572.3", "070.70", "416.8", "280.0", "578.9", "428.0", "571.5" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.23", "99.07", "45.13" ]

icd9pcs

[ [ [] ] ]

8936, 8942

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362, 417

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3155, 3612

276, 324

445, 2389

3648, 5209

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2909, 3090

5,774

196,401

25302

Discharge summary

report

Admission Date: [**2172-1-10**] Discharge Date: [**2172-1-21**] Date of Birth: [**2117-5-3**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: pericardial window History of Present Illness: 54 yo man with AML s/p allo-SCT (MRD) now day 370 c/b GVH of liver and skin, disseminated TB, CMV viremia, hematuria and most recently admitted for tamponade secondary to large pericardial effusion accumulation, s/p pericardial drain now with chest tube POD #4. In brief originally, he has a history of AML diagnosed in [**2169**], S/p induction and consolidation with Ara-C. During induction he developed neutropenic fever and was diagnosed with widely disseminated tuberculosis with splenic, pancreatic, and pulmonary lesions as well as bilateral pleural effusions and pericardial effusion. Cultures from blood, pleural fluid, lymph node biopsy as well as sputums to the time of his discharge all ultimately grew MTB from culture despite have negative AFB smear. At that time he was started on four drug therapy and long steroid taper. His pyrazinamide was discontinue on month 5, however shortly thereafter he was diagnosed with a tuberculous paraspinal abscess at the level of the right kidney in [**2-16**] that required drainage. Levofloxacin was added to his regimen at that time. In [**3-19**] his ethambutol was discontinued secondary to optic neuritis. He has since had drainage of pulmonary tuberculomas and pleural effusion at [**Hospital1 336**]. At the time of his allo BMT it was decided that INH, rifampin and levofloxacin would be continued for 12 months. Approximately 9 months after transplant on [**2171-10-9**] his medications were discontinued for elevated LFTs. Prior liver biopsy was consistent with GVHD, and his LFTs continued to be elevated since discontinuation of his TB meds. He was received pentostatin, rituxan and photopheresis for his GVHD which has affected his mouth, eyes, gut, skin, +/- bladder. The patient was recently admitted [**Date range (1) 63310**] for symptoms of volume overload. He was found to have a large pericardial effusion with tamponade physiology. He [**Date range (1) 1834**] pericardial drain for 1300 cc of serosanguinous fluid. Glucose level was normal, gram stain, AFB smear and culture, TB PCR and adenovirus PCR were negative. His drain was pulled. The etiology of his effusion was undetermined, however viral infection vs TB vs GVHD vs medication effect (tacrolimus?) were considered. During this admission he also had a chest CT which revealed bilaterally upper lobe infiltrates with nodules and tree-in-[**Male First Name (un) 239**] appearance. Sputums were negative for AFB smear but poor sampling precluded concentrated smear. The patient refused bronchoscopy at that time, and the plan upon discharge was repeat CT scan in one week. He was not started on TB meds. Incidentally he was diagnosed with VRE and morganella UTIs and completed a course of daptomycin and cefpodoxime. Beta D glucan checked on day prior to discharge was resulted to 170. He was seen in the [**Hospital **] clinic by Dr. [**Last Name (STitle) **] who ordered a repeat level which remained elevated to 152. She started him on treatment doses of Atovaquone for concern of smoldering PCP given worsening chest xray findings. Azithromycin was also started for atypical pathogens. Sputum cultures were negative for PCP on DFA (although these were poor samples), however bacterial cultures were positive for Stenotrophomonas. He was started on Bactrim on [**1-3**], Atovaquone was discontinued. Per the patient's wife, he was at baseline in regards to shortness of breath and had not been able to lay flat since discharge. His cough has been improving in the past few days. Yesterday he complained of fatigue and back pain, and at 3AM this morning he developed chest pain radiating to his left arm. 911 was called and the patient was taken to [**Hospital3 19345**]. CTA was performed which did not reveal PE; however a large pericardial effusion and bilateral effusions as well as mild ascites and cystic mass in pancreatic head. TTE at the OSH was reportedly negative for tamponade, although the patient did have one episode of hypotension with SBP to the 70s which responded to a 500 cc bolus. His platelet count was noted to be 17. He was transferred to the [**Hospital1 18**] ED where he was tachycardic to 110, hypotensive to 80-90s systolic. Bedside TTE at our institution revealed tamponade physiology with collapsing RV. He was taken emergently to the OR where a minithoracotomy was and pericardial window was performed. Per verbal report approximately 400 cc of dark blood was drained. A left sided chest tube was placed. He was transferred to the CT ICU where he remains intubated. He received Cefazolin perioperatively and 4 units of platelets. ROS per wife was negative for fever, chills, sick contacts, URI symptoms. Past Medical History: ONC HISTORY (per OMR): 1. Diagnosed in early [**8-/2169**] with nightly fevers. BM bx revealed AML. Flow cytometry showed aberrant expression of CD2, CD7, HLA-DR, CD 34, dim CD33, CD 117, and CD 71. CT scan revealednecrotic lymph nodes in the superior mediastinum and periportalregion, and multiple low attenuation lesions in the liver and spleen concerning for microabscesses from a disseminated infection. 2. [**2169-8-17**]: Induction chemotherapy with cytarabine and idarubicin complicated by persistent fevers and extensive workup ultimately revealing disseminated tuberculosis infection. His course was also complicated by rapid atrial fibrillation and hypotension and the development of a severe cardiomyopathy. 3. S/P one dose of high-dose ARA-C at 1.5 mg per meter squared, lowered dose due to his disseminated tuberculosis, and then he received a second course of HiDAC at 3 gram per meter squared dose and developed acute onset of gait instability. No further chemotherapy given. 4. Relapsed in 7/[**2170**]. [**Year (4 digits) **] re-induction with ME on [**2170-8-13**]. Noted for pulmonary nodules which were suspicious for aspergillus and empirically treated with Voriconazole with improvement noted on CT. 5. Admitted on [**2170-10-25**] for maintenance therapy while awaiting BMT. However, upon admit he was again found to have blasts. He proceeded with Idarubicin and Cytarabine(7+2) butdid not achieve a remission. 6. S/P High dose Ara-c with remission. 7. [**Year (4 digits) **] sibling related allo transplant on [**2171-1-8**]. Allo course c/b increased LFTs of unclear etiology, possibly from chemotherapy, renal failure attributed to CSA, and received only 1 dose of MTX due to mucositis. 8. Post transplant course complicated by asymptomatic CMV viremia and viral/URI syndromes. 9. In [**2171-5-12**] developed diarrhea with e/o GVH on endoscopy. He also had hematuria, but no evidence of BK virus. He started photopheresis. Diarrhea abated but LFTs rose. Therapy attempted for GVH of liver using pulse of prednisone and increase in CellCept with stabilization but no significant improvement. 10. Received 1mg of Pentostatin on [**2171-6-14**]. 11. Liver Biopsy c/w GVHD. Started Rituxan for 4 weeks in 5/[**2171**]. Non-onc PMH - Disseminated TB - s/p treatment with INH, levofloxacin and rifabutin - Hypertension and a heart murmur - Diabetes mellitus type 2 - Chemo related heart failure and cardiomyopathy, EF 35-40% [**12-16**] - h/o atrial fibrillation, recent EKGs in NSR - CMV viremia ([**2-17**]) Social History: He is married and lives at home with his wife & children. He is a machine operator, but is currently not working. He immigrated from [**Country 5976**] in early [**2144**]. He smoked approximately 3 cigarettes per day for 20 years and stopped 1 year ago. He does not drink alcohol. Family History: Notable for mother who passed away of myocardial infarction. His father passed away of liver disease. He has four living brothers and two living sisters, all in good health. Physical Exam: T: 96.7 P: 92 R: 18 BP: 134/72 on SIMV 16/550/100%/5 General: Chronically ill appearing, NAD HEENT: Dry MM, injected conjunctiva, ecchymosis and chronic GVHD in mouth. Neck: No LAD Cardiovascular: RRR NL S1, S2, no M/R/G. Respiratory: Atelectasis at bases bilaterally, coarse sounds lower right, otherwise CTA bilaterally. Gastrointestinal: + BS, soft, no masses Musculoskeletal: Trace edema Skin: Dry, flaky. Left thorax dressing, Left chest tube dressing intact, draining serosanguinous fluid. L SC Triple lumen line without significant erythema, bilateral EJ lines and left peripheral UE IV. Pertinent Results: [**2172-1-21**] 12:05AM BLOOD WBC-4.1 RBC-2.60* Hgb-9.6* Hct-29.4* MCV-113* MCH-36.9* MCHC-32.6 RDW-21.1* Plt Ct-32*# [**2172-1-20**] 12:00AM BLOOD WBC-2.8* RBC-2.35* Hgb-8.8* Hct-26.5* MCV-113* MCH-37.6* MCHC-33.3 RDW-21.2* Plt Ct-21* [**2172-1-15**] 12:20AM BLOOD Neuts-76.0* Lymphs-16.7* Monos-6.7 Eos-0.5 Baso-0.1 [**2172-1-14**] 12:00AM BLOOD Neuts-82* Bands-2 Lymphs-12* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 . [**2172-1-21**] 12:05AM BLOOD Plt Ct-32*# [**2172-1-20**] 12:00AM BLOOD Plt Ct-21* . [**2172-1-21**] 12:05AM BLOOD Glucose-65* UreaN-19 Creat-1.2 Na-136 K-4.7 Cl-107 HCO3-19* AnGap-15 [**2172-1-20**] 12:00AM BLOOD Glucose-96 UreaN-20 Creat-1.2 Na-136 K-4.6 Cl-107 HCO3-21* AnGap-13 . [**2172-1-21**] 12:05AM BLOOD ALT-158* AST-146* LD(LDH)-335* AlkPhos-1085* TotBili-0.9 [**2172-1-20**] 12:00AM BLOOD ALT-143* AST-131* LD(LDH)-295* AlkPhos-1024* TotBili-0.8 . [**2172-1-21**] 12:05AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.7 [**2172-1-20**] 12:00AM BLOOD Calcium-8.6 Phos-2.4* Mg-1.8 . [**2172-1-11**] 08:00PM BLOOD Hgb-9.7* calcHCT-29 O2 Sat-93 . CHEST (PORTABLE AP) [**2172-1-17**] 1:18 AM CHEST (PORTABLE AP) Reason: r/o acute process [**Hospital 93**] MEDICAL CONDITION: 54 year old man with increased serosanguenous drainage from prior CT site with pain REASON FOR THIS EXAMINATION: r/o acute process REASON FOR EXAMINATION: Increased drainage from chest tube. Portable AP chest radiograph compared to [**2172-1-16**]. There is no significant change in large left subcutaneous emphysema. There is overall improvement in bibasilar opacities, especially in the right lower lobe. There is no change in the cardiomediastinal contour and the position of the left central venous line with its tip terminating in mid-SVC. . [**1-15**] Echo: Pre-pericardial window: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Overall left ventricular systolic function is moderately depressed (LVEF= 30-35 %). 3. Right ventricular chamber size and free wall motion are collapsed due to loculated effusion. 4. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. 5. The aortic valve leaflets (3) are mildly thickened. Mild to moderate ([**2-12**]+) aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7. The tricuspid valve leaflets are mildly thickened. 8. There is a circumeferential large pericardial effusion with more around the right atrium and right ventricle. ITmeasures approximately 5.0cm in size Post-pericardial window: 1. The right ventricular chamber size and wall motion appear to be normal. 2. The size of the loculated effusion has decreased to 1.7cm after pericardial window. 3. There is improvement of LVEF (35-40%). . Brief Hospital Course: 1) Pericardial Effusion: The patient had a pericardial window placed as described in the HPI. The etiology of his effusion was thought to be secondary to GVHD as workup for other infectious etiologies was negative. After being extubated and followed without incident on the cardiac surgery service he was transferred to BMT for further management. He had a chest tube placed at the time of surgery that was removed of POD #3 after its drainage decreased. The patient had episodes of serosanguinous discharge from the site of his chest tube after the chest tube was removed but this was determined to be normal per CT surgery and resolved prior to discharge. 2) Infectious Disease: The patient was initially on vancomycin for ? GPC in his pericardial fluid, but this was discontinued once it grew staph epi. The patient complained of dysuria and was found to have VRE that was treated with a 3 day course of daptomycin per ID recommendation. He completed his Bactrim for PCP treatment and will be discharged on a prophylaxis dose. In addition he took his posaconazole and acyclovir per home regimen. 3) AML s/p all-SCT with GVHD: The patient refused to have photopheresis. His CellCept was increased from 250 [**Hospital1 **] to 500 [**Hospital1 **] per Dr. [**First Name (STitle) **]. He also continued on his prednisone 20 QD. He continued on his outpatient eye drops for eye GVHD and on dexamethasone mouthwash for mouth GVHD. 4) Pain: The patient was pain-free on Morphine SR with IR for breakthrough. 5) LFT elevations: The patient had elevated LFTs upon admission that were thought to be secondary to shocked liver in the context of his pericardial tamponade. These improved throughout his stay but never achieved baseline; they are likely a result of his chronic GVHD but should be followed as an outpatient. Medications on Admission: BACTRIM DS 800 mg-160 mg--2 (two) tablet(s) q8h ACYCLOVIR 400 mg--1 tablet(s) by mouth twice a day Artificial Saliva --30 solution(s) q2h prn BACITRACIN ZINC 500 unit/gram--topically QID prn penile pain BENZONATATE 100 mg--1 capsule(s) PO TID prn cough DEXAMETHASONE 0.5 mg/5 mL--5 mlPO [**Hospital1 **] swish and spit. DOCUSATE SODIUM 100 mg--1 capsule(s) by mouth twice a day Ergocalciferol (Vitamin D2) 50,000 unit--1 q fri FOLIC ACID 1 mg--2 (two) tablet(s) by mouth once a day HUMALOG 100 unit/mL--per sliding scale Insulin Glargine 100 unit/mL--14 units sq daily LUMIGAN 0.03 %--1 drops(s) in the right eye at bedtime both eyes METOPROLOL TARTRATE 25 mg--3 tablet(s) by mouth twice a day MYCOPHENOLATE MOFETIL 250 mg--1 capsule(s) by mouth twice a day NYSTATIN 100,000 unit/mL--5 ml by mouth q6h swish and spit OMEPRAZOLE 20 mg--1 capsule(s) by mouth once a day OXYCODONE 5 mg--1 tablet(s) by mouth q6h prn pain OXYCONTIN 10 mg--2 (two) tablet(s) by mouth twice a day PRED MILD 0.12 %--1 (one) drop in each eye [**Hospital1 **] PREDNISONE 20 mg--1 tablet(s) by mouth once a day PYRIDIUM 200 mg--1 (one) tablet(s) by mouth once a day Posaconazole 200 mg/5 mL--1 suspension(s) by mouth TID Pyridoxine 50 mg--2 tablet(s) by mouth once a day RESTASIS 0.05 %--1 (one) drop in each eye twice a day Saliva Substitution Combo No.2 --30 ml to mucous membrane q2 VITAMIN E 400 unit--1 capsule(s) by mouth daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 3. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Posaconazole 200 mg/5 mL Suspension Sig: One (1) PO TID (3 times a day). 6. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Humalog 100 unit/mL Cartridge Sig: One (1) unit Subcutaneous four times a day: per sliding scale. 10. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous QAM. 11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-12**] Drops Ophthalmic PRN (as needed). 12. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 13. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 14. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-12**] Drops Ophthalmic PRN (as needed). 15. Dexamethasone 0.1 % Drops, Suspension Sig: One (1) Drop Ophthalmic Q6H (every 6 hours). 16. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO Monday-Wednesday-Friday. Disp:*15 Tablet(s)* Refills:*2* 17. Cyclosporine 0.05 % Dropperette Sig: [**2-12**] Dropperettes Ophthalmic [**Hospital1 **] (2 times a day). 18. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 19. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 20. Petrolatum Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 21. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 22. Dexamethasone 0.5 mg/5 mL Solution Sig: One (1) 5ml swish PO BID (2 times a day): spit out solution, do not swallow. Disp:*1 bottle* Refills:*2* 23. Heparin Flush (100 units/ml) 2 ml IV DAILY:PRN Flush with 10 cc NS followed by 2ml of 100u heparin to each lumen. Blue and Red ports for [**Hospital1 **] only but need daily flush if not used. 24. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 25. Artificial Saliva 0.15-0.15 % Solution Sig: One (1) swish Mucous membrane PRN as needed for dry mouth. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: cardiac tamponade vancomycin resistant enterococcus urinary tract infection s/p allogenic BMT chronic GVHD of gut, skin, mouth, bladder chemotherapy-induced cardiomyopathy Discharge Condition: stable Discharge Instructions: You were admitted to the hospital with cardiac tamponade. You had a surgery that opened up the pericardium (a tissue surrounding your heart) to drain the fluid. This surgery relieved the pressure on your heart and improved your shortness of breath. You had a chest tube after the surgery to drain the fluid from your chest. This tube was removed once the drainage from your chest decreased. In addition you were treated with daptomycin for a urinary tract infection. You will need to follow up with your physicians as directed below. Please take your medications as prescribed. If you develop shortness of breath, fevers, chills, or any other concerning symptom please contact a physician [**Name Initial (PRE) 2227**]. Followup Instructions: Please follow up with your physicians: Oncology: [**2172-1-29**] 11:00a [**Last Name (LF) 3919**],[**First Name3 (LF) **] E. [**Hospital6 29**], [**Location (un) **] HEMATOLOGY/ONCOLOGY-SC [**2172-1-29**] 11:00a [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Hospital6 29**], [**Location (un) **] HEMATOLOGY/ONCOLOGY-SC Eye: [**2172-1-31**] 01:00p BALL,[**Doctor First Name **] L. [**Hospital6 29**], [**Location (un) **] OPTOMETRY Heart Surgeon: [**2172-2-19**] 01:00p CT,[**Doctor First Name **] LM [**Hospital Unit Name **], [**Location (un) **] CARDIAC SURGERY LMOB 2A Completed by:[**2172-1-25**]

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Discharge summary

report

Admission Date: [**2153-9-18**] Discharge Date: [**2153-9-23**] Date of Birth: [**2080-2-28**] Sex: F Service: MEDICINE Allergies: ice cream / Penicillins Attending:[**First Name3 (LF) 1145**] Chief Complaint: exertional angina Major Surgical or Invasive Procedure: Cardiac catheterization with stent placement to stenosis of right internal carotid artery History of Present Illness: 73 y/o with a history of COPD, CAD, s/p mid RCA and OM PTCA [**2133**], tobacco abuse, HTN was referred for cardiac cath done for exertional angina done on [**9-18**]. Cath showed LCX 70%, complete RCA occlusion with collaterals, right axillary 95%, right carotid 90%. She was admitted to NP service and on [**2153-9-19**]-> s/p axillary PTA, RRA appoach. She was placed on ASA/Plavix. On [**9-21**] she returned to OR for right carotid stent. . The patient was noted to have an RCA that fills well via collaterals in [**8-11**]. Stress testing on [**2152-10-25**] showed a small reversible inferior defect in the AC non-corrected images. In [**7-12**], she was referred for aortoiliac ultrasound, carotid study that showed severe stenosis of the R internal carotid artery and moderate stenosis of the L internal carotid artery. She developed exertional pain in her arms and chest and back recently, and so she was referred to Dr. [**Last Name (STitle) **] here at [**Hospital1 18**]. Neurology was consulted pre-procedurally prior to the carotid intervention. Neuro and patient note a baseline left facial flattness/mouth edge droop. . She states that she was refered for cardiac catheterization because she has had anginal sxs of chest pain to her left arm, particularly after an hour of working/sanding her deck this summer. She states that she can ride her exercise bike for 10 minutes but has to stop because of hip pain. She is able to climb her stairs at home and do oher activitiy without difficulty. The sxs she reported this summer were relieved with 15 minutes of rest and did not go away with nitro. . She notes that she has a dry cough from her COPD at baseline but is not on home oxygen. Reports no recent CP or dyspnea. No BM since Monday. She does occassionally have zigzags in her vision, more in her right eye than her left, due to cataracts. Upon arrival to the floor she noted neck pain, which quickly improved. Further, upon being on the floor she twice stated that upon awakening from sleep she had feelings of being dissoriented with the "bed vertical, feeling higher in the air, the clock and the calendar sideways." She denies having this before but states that this feeling/vision was in both eyes and resolved in less than 1 minute. She denies feeling/seeing it upon evaluation. On review of systems, s/he denies any prior history of 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. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes on insulin, +Dyslipidemia,+ Hypertension 2. CARDIAC HISTORY: - PERCUTANEOUS CORONARY INTERVENTIONS: [**2133**]: s/p cardiac cath with PTCA of mid RCA and OM [**2134**] showed chronically occluded RCA [**2137**] & [**2139**] showed no significant change -- see above for today LHC) - PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: -Emphysema, no home oxygen -GERD -Degenerative lumbar spine disease -S/P left and then right parotidectomy, "the mass was benign" -History of ? TIA in [**2131**] -Osteoporosis -h/o Cholecystectomy -?afib/arrythmia -- this is not documented on the available notes, but the patient endorses it, without knowing any details. She denies any h/o anticoagulation. -?h/o DVT in [**2111**] -- also not documented, also no A/C, also does not recall details other than her leg hurt and it came on all of a sudden, and it went away with some sort of short-term treatment. Denies PE, but unsure. Social History: Lives alone, from [**Location 90637**]near Wolfeboro. Husband died last New Years Eve after a long illness of COPD. - Tobacco: 40 pack year history; recently smokes 10 cigs/day, but desires to quit. Smoked 6 of the last 20 days. Declined nicotine patch. - Ethanol: denies. - Illicit / recreational drug use: Denies Family History: - Mother: never knew birth mother - Father: CAD/CVA Physical Exam: Admission exam VS: 96.7, 62, 113/62, 99/RA, 14 GENERAL: NAD. Oriented x3. Anxious affect. Slow slightly slurred-speaking (baseline per interventional fellow). Tangential but appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6cm. CARDIAC: Distant heart sounds. 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 from anterior. ABDOMEN: Soft, NT, mild distention. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No edema. Femoral artery catheter in place right groin. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Discharge exam: 96.5 116/44 57 15 98%RA GENERAL: NAD. Oriented x3. Normal mood and affect. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP to earlobe (assessed on the right side) when lying flat. CHEST: 0.5 cm hyperpigmented seborrheic keratosis on upper part of left breast CARDIAC: Distant heart sounds. 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 w/ slightly decreased breath sounds at the bases R >L ABDOMEN: Soft, NT, mild distention. No HSM or tenderness. +BS. EXTREMITIES: No edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+Radial 2+ DP 1+ Left: Carotid 2+ Radial 1+ DP 1+ Pertinent Results: Admission Labs [**2153-9-20**] 03:15PM BLOOD WBC-9.2 RBC-4.30 Hgb-13.9 Hct-41.6 MCV-97 MCH-32.3* MCHC-33.4 RDW-13.1 Plt Ct-174 [**2153-9-20**] 03:15PM BLOOD Glucose-197* UreaN-20 Creat-0.9 Na-139 K-4.8 Cl-104 HCO3-27 AnGap-13 [**2153-9-22**] 02:50AM BLOOD ALT-15 AST-20 AlkPhos-65 TotBili-0.4 [**2153-9-22**] 06:29PM BLOOD CK-MB-2 cTropnT-<0.01 [**2153-9-19**] 07:05AM BLOOD %HbA1c-7.0* eAG-154* [**2153-9-19**] 07:05AM BLOOD Triglyc-98 HDL-39 CHOL/HD-3.9 LDLcalc-92 . Relevant Labs: [**2153-9-22**] 06:29PM BLOOD CK(CPK)-57 [**2153-9-23**] 04:42AM BLOOD CK-MB-2 cTropnT-<0.01 . Discharge Labs: [**2153-9-23**] 04:42AM BLOOD WBC-6.7 RBC-3.72* Hgb-11.5* Hct-34.8* MCV-94 MCH-30.9 MCHC-33.0 RDW-13.2 Plt Ct-180 [**2153-9-23**] 04:42AM BLOOD Glucose-105* UreaN-16 Creat-0.8 Na-142 K-3.7 Cl-108 HCO3-24 AnGap-14 [**2153-9-23**] 04:42AM BLOOD CK(CPK)-47 [**2153-9-23**] 04:42AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0 . Cardiac cath [**9-19**]: 1. Severe right axillary stenosis with pressure gradient indicating severe stenosis. 2. Successful PTA alone of right axillary stenosis with 4.0x20mm NC balloon and then 5.0x15mm NC balloon with 10% residual stenosis and virtual elimination of gradient. 3. Successful hemostasis of right radial arteriotomy with TR band. FINAL DIAGNOSIS: 1. Severe right axillary stenosis. 2. Successful PTA alone of right axillary artery with 5.0mm NC balloon. 3. Successful RRA TR band. 4. Continue ASA, plavix. . Cardiac cath [**9-21**]: Angiography and PTA COMMENTS: After clearing the guide, first the right brachiocephalic artery was engaged and then the right common carotid artery. Cerebral angiography showed patent RMCA and RACA. Angiography of the right carotid confirmed a severe stenosis in the right internal carotid artery just after the bifurcation. A 7.0mm [**Doctor Last Name **] Freedom embolic filter wire crossed the [**Country **] stenosis with minimal difficulty and was deployed distal to the stenosis. The stenosis was predilated with a 2.5x20mm NC Quantum Apex MR balloon at 8 and 10 atms. Nitroglycerin was started for hypertension. A [**8-8**] x 40mm XACT RX Carotid Stent was then deployed in the [**Country **] across the bifurcation. The stent was then postdilated with a 4.5x20mm NC Quantum Apex MR balloon at 10 atms with 1 amp of atropine given immediately prior to post balloon inflation. The [**Doctor Last Name **] freedom filter was then retrieved. Final angiography showed the [**Country **] stent with no residual stenosis, excellent flow. At the end of the case the patient's blood pressure was low and IVF and neosynephrine was started. Cerebral angiography at end of case showed the RMCA and RACA patent. The patient's neurologic exam was unchanged and the patient tolerated the procedure well. She was transferred to the CCU in stable condition. . COMMENTS: 1. Severe [**Country **] stenosis. 2. Successful stenting of [**Country **] with 9-7x40mm XACT RX stent with [**Doctor Last Name **] filter distal protection. Stent postdilated with 4.5x20mm NC Quantum Apex balloon. 3. Transient hypertension and then hypotension treated with IVF and neosynephrine. . FINAL DIAGNOSIS: 1. Severe [**Country **] stenosis. 2. Successful stenting of [**Country **] with 9-7x40mm XACT stent. 3. Goal SBP 100-120 mmHg. 4. Monitor in CCU. Brief Hospital Course: Patient is a 73 y/o with a history of CAD, exertional angina, initially referred for cardiac catheterization done on [**9-19**] which showed LCX 40-60%, right axillary 95%, right carotid 90%, now s/p axillary ballooning [**9-20**] and carotid stenting [**9-21**]. . . ACTIVE ISSUES: #. S/P right carotid stenting: Patient with 90% right carotid stenosis s/p stent [**9-21**]. Neuro examination stable without any gross motor or sensory defects. Neurologic exam was performed every four hours and was not concerning cfor any changes, noting baseline left facial droop and visual sxs of zigzags which she occasionally gets with migraines. Her SBP were tightly controlled with phenylephrine and nitroglycerin intermittlently to a goal of 90-120s. She was started on aspirin 325mg and plavix 75 mg daily. The patient will need to f/u with study team by returning to holding area on [**10-22**] Monday, at 11am. . # CAD: Pt had non occlusive CAD of LCX at OM1 bifurcation of 70% and RCA chronically occluded with collaterals. This was not intervened upon. She was having intermittent episodes of [**4-10**] dull pain that is substernal, in both arms, and radiates through to back. These were similar to prior episodes of angina, but more intense than usual, and relieved by SL NTG x1 each time. She was started on ASA and plavix as above. She was continued on her home atorvastatin. Her Atenolol was held while in-house due to bradycardia secondary to vagal stimulation after carotid stenting. This can be started as an outpatient as heart rate allows. . . CHRONIC ISSUES: # Pump: NL EF at 70% on recent pharmacologic nuclear stress. . # RHYTHM: Currently in sinus with PVCs though notes hx of afib. Due to bradycardia, her atenolol was held on discharge. This can be restarted by her PCP. . # HTN: Her SBP goal was kept at 90-120 as above. She was restarted on her Imdur before discharge, but her home Atenolol was held due to bradycardia. . # HLD : LDL was measured at 92 here, and she was continued on her home Atorvastatin. . # DM: Pts current A1c at goal of 7. She was continued on her home long acting insulin with sliding scale while in-house, and was restarted on her home metformin upon discharge. . # COPD: currently stable on RA, but was continued on her home Fluticasone-Salmeterol 250/50 IH [**Hospital1 **] and albuterol prn. . . TRANSITIONAL ISSUES: 1.) PCP can restart atenolol if bradycardia resolves. 2.) PCP can follow up on seborrheic keratosis noted on left breast. Medications on Admission: Albuterol inhaler Q6H prn (not used 3 weeks) - Alendronate 70mg weekly - Atneolol 50mg daily - Atorvastatin 50mg QHS - Advair 250/50 mcg daily (not using) - Humulog 5U am, 5U before dinner - Imdur 60mg ER daily - Metformin 500mg [**Hospital1 **] - Nitro 0.4mg SL prn (not using) - Omeprazole 40mg daily - ASA 81 mg daily - Vitamin D - NPH 15U in am, 7U at dinner Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 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. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for abdominal discomfort. 5. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1) Inhalation twice a day. Disp:*2 inhaler* Refills:*2* 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. NPH insulin human recomb 100 unit/mL Suspension Sig: Fifteen (15) units Subcutaneous QAM. 8. NPH insulin human recomb 100 unit/mL Suspension Sig: Seven (7) units Subcutaneous at dinner. 9. Humalog 100 unit/mL Solution Sig: Five (5) units Subcutaneous QAM and again before dinner. 10. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tab Sublingual PRN as needed for chest pain: can take a 2nd dose after 5 minutes if still having chest pain. Can take a 3rd dose after 5 more minutes if still having chest pain. . 12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 13. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Right internal carotid stenosis of 90% Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 2433**], You were admitted to [**Hospital1 69**] because you were having pain with exertion. You were found to have a blockage in your right carotid (neck) artery. This blockage was treated with catheterization and stent placement. You had several important changes to your medications. Please take all medications EXACTLY as prescribed, as failure to do so can cause acute stent blockage, which can be life threatening. The following changes were made to your medications: ** CHANGE atorvastatin to 80mg by mouth once daily (lowers cholesterol) ** START plavix 75mg by mouth once daily. This is EXTREMELY IMPORTANT to take as prescribed, to keep your stents open. No one except your cardiologist can tell you to stop it, including other doctors. ** CHANGE aspirin to 325mg by mouth once daily (up from 81mg). This will also help keep your stents open. ** STOP taking atenolol until your primary care provider tells you to restart this medication ** STOP taking omeprazole ** START taking pantoprazole 40mg by mouth once daily. This is similar to omeprazole (for acid-reflux), but interacts with your heart medications less. Wishing you all the best! Followup Instructions: Dr. [**Last Name (STitle) 59323**] [**2153-10-5**] 8:30AM For your follow-up study, you will need to return to the Catheterization Lab holding area at 11am on Monday [**10-22**].

[ "V58.67", "458.29", "E879.8", "V45.82", "413.9", "V14.0", "401.9", "305.1", "440.20", "414.2", "433.10", "V70.7", "433.30", "V15.02", "250.00", "272.4", "530.81", "721.3", "496", "733.00", "V17.49" ]

icd9cm

[ [ [] ] ]

[ "39.50", "00.45", "00.40", "37.22", "88.44", "00.61", "00.63", "88.56", "88.41" ]

icd9pcs

[ [ [] ] ]

14144, 14150

9658, 9926

302, 394

14233, 14233

6347, 6926

15592, 15777

4372, 4427

12560, 14121

14171, 14212

12173, 12537

9487, 9635

14384, 15569

6942, 7603

4442, 5415

3171, 3405

5431, 6328

12023, 12146

245, 264

9941, 11212

422, 3053

14248, 14360

3436, 4022

11228, 12002

3075, 3151

4038, 4356

49,205

185,409

35301

Discharge summary

report

Admission Date: [**2125-11-8**] Discharge Date: [**2125-11-21**] Date of Birth: [**2101-5-4**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: 24M s/p GSW to left-ant neck Major Surgical or Invasive Procedure: L neck exploration, trap door(limited sternotomy), LIJ/L subclavian vein ligation. History of Present Illness: 24M s/p GSW to left-ant neck, zone I, w/ vascular injury to confluence of LIJ/L subclavian veins, including injury to thoracic duct. L 1st & 2nd rib fx's. No other injuries identified. Massive EBL/transfusions, likely TRALI. No tracheal injury seen on IO bronch, no esoph injury. Past Medical History: unknown Social History: unknown Family History: n/c Physical Exam: Physical exam: Vitals- T 96.6, HR 112, BP 97/65, RR 27, O2sat 100% Vent- AC 80% 420/26 PEEP 20 Gen- edematous Head and neck- incision to L neck and upper chest, JP in neck with serosanguinous output Heart- sinus tach, no murmurs Lungs- bilateral coarse breath sounds, decreased at L apex, L CT with serosanguinous output Abd- soft, distended, ? NT Ext- warm, well-perfused, no edema Pertinent Results: [**2125-11-8**] 02:39PM TYPE-ART TEMP-36.9 RATES-26/ TIDAL VOL-420 PEEP-14 O2-60 PO2-157* PCO2-44 PH-7.37 TOTAL CO2-26 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2125-11-8**] 02:39PM GLUCOSE-83 LACTATE-1.3 [**2125-11-8**] 02:39PM freeCa-1.19 [**2125-11-8**] 02:21PM VoidSpec-[**First Name9 (NamePattern2) 21799**] [**Male First Name (un) **] [**2125-11-8**] 01:56PM GLUCOSE-98 UREA N-12 CREAT-1.1 SODIUM-143 POTASSIUM-4.8 CHLORIDE-110* TOTAL CO2-26 ANION GAP-12 [**2125-11-8**] 01:56PM CALCIUM-8.7 PHOSPHATE-5.5* MAGNESIUM-2.0 [**2125-11-8**] 01:56PM HCT-35.0* [**2125-11-8**] 01:56PM PLT COUNT-171 [**2125-11-8**] 01:56PM PT-13.1 PTT-30.4 INR(PT)-1.1 [**2125-11-8**] 12:11PM TYPE-ART TEMP-36.9 RATES-26/ PEEP-14 O2-70 PO2-136* PCO2-48* PH-7.34* TOTAL CO2-27 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2125-11-8**] 12:11PM freeCa-1.26 [**2125-11-8**] 10:15AM TYPE-ART TEMP-35.9 RATES-/26 TIDAL VOL-420 PEEP-18 O2-80 PO2-178* PCO2-52* PH-7.31* TOTAL CO2-27 BASE XS-0 AADO2-368 REQ O2-63 -ASSIST/CON INTUBATED-INTUBATED [**2125-11-8**] 08:22AM GLUCOSE-84 UREA N-12 CREAT-1.3* SODIUM-144 POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-28 ANION GAP-10 [**2125-11-8**] 08:22AM CALCIUM-8.7 PHOSPHATE-6.5* MAGNESIUM-1.8 [**2125-11-8**] 08:22AM WBC-9.5 RBC-4.07* HGB-12.1* HCT-34.7* MCV-85 MCH-29.7 MCHC-34.9 RDW-14.5 [**2125-11-8**] 08:22AM NEUTS-68 BANDS-8* LYMPHS-9* MONOS-15* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2125-11-8**] 08:22AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2125-11-8**] 08:22AM PLT SMR-NORMAL PLT COUNT-194 [**2125-11-8**] 08:22AM PT-13.9* PTT-30.9 INR(PT)-1.2* [**2125-11-8**] 07:43AM TYPE-ART TEMP-36.8 RATES-/27 PEEP-20 O2-100 PO2-112* PCO2-63* PH-7.26* TOTAL CO2-30 BASE XS-0 AADO2-572 REQ O2-90 -ASSIST/CON INTUBATED-INTUBATED [**2125-11-8**] 07:43AM GLUCOSE-94 [**2125-11-8**] 05:18AM TYPE-ART PO2-88 PCO2-57* PH-7.18* TOTAL CO2-22 BASE XS--7 [**2125-11-8**] 04:44AM TYPE-ART PO2-48* PCO2-70* PH-7.20* TOTAL CO2-29 BASE XS--2 [**2125-11-8**] 04:44AM LACTATE-1.6 [**2125-11-8**] 04:44AM freeCa-1.27 [**2125-11-8**] 04:34AM GLUCOSE-183* UREA N-11 CREAT-1.2 SODIUM-145 POTASSIUM-4.3 CHLORIDE-111* TOTAL CO2-28 ANION GAP-10 [**2125-11-8**] 04:34AM CALCIUM-8.9 PHOSPHATE-5.7* MAGNESIUM-1.8 [**2125-11-8**] 04:34AM WBC-11.7* RBC-3.77* HGB-11.6* HCT-32.7* MCV-87 MCH-30.7 MCHC-35.3* RDW-14.2 [**2125-11-8**] 04:34AM PLT COUNT-200 [**2125-11-8**] 04:34AM PT-15.4* PTT-36.8* INR(PT)-1.4* [**2125-11-8**] 04:34AM FIBRINOGE-406*# [**2125-11-8**] 03:02AM TYPE-ART PO2-54* PCO2-59* PH-7.20* TOTAL CO2-24 BASE XS--5 [**2125-11-8**] 03:02AM GLUCOSE-255* LACTATE-3.8* NA+-141 K+-4.3 CL--107 [**2125-11-8**] 03:02AM HGB-9.9* calcHCT-30 [**2125-11-8**] 03:02AM freeCa-1.02* [**2125-11-8**] 03:02AM WBC-9.9 RBC-3.04* HGB-9.4* HCT-26.4* MCV-87 MCH-30.9 MCHC-35.7* RDW-14.3 [**2125-11-8**] 03:02AM PLT COUNT-194 [**2125-11-8**] 02:06AM TYPE-ART PO2-41* PCO2-62* PH-7.18* TOTAL CO2-24 BASE XS--7 INTUBATED-INTUBATED [**2125-11-8**] 02:06AM GLUCOSE-250* LACTATE-4.2* NA+-137 K+-5.4* CL--107 [**2125-11-8**] 02:06AM HGB-8.4* calcHCT-25 [**2125-11-8**] 02:06AM freeCa-0.94* [**2125-11-8**] 01:46AM TYPE-ART PO2-66* PCO2-57* PH-7.19* TOTAL CO2-23 BASE XS--6 INTUBATED-INTUBATED [**2125-11-8**] 01:46AM GLUCOSE-244* LACTATE-4.1* NA+-140 K+-4.9 CL--109 [**2125-11-8**] 01:46AM HGB-8.7* calcHCT-26 [**2125-11-8**] 01:46AM freeCa-1.52* [**2125-11-8**] 01:20AM WBC-18.2*# RBC-2.84* HGB-8.5* HCT-25.7* MCV-90 MCH-29.8 MCHC-33.0 RDW-14.1 [**2125-11-8**] 01:20AM PLT COUNT-258 [**2125-11-8**] 01:20AM PT-18.3* PTT-67.0* INR(PT)-1.7* [**2125-11-8**] 01:20AM FIBRINOGE-128* [**2125-11-8**] 01:05AM TYPE-ART PO2-79* PCO2-71* PH-7.04* TOTAL CO2-21 BASE XS--13 INTUBATED-INTUBATED [**2125-11-8**] 01:05AM GLUCOSE-283* LACTATE-6.3* NA+-141 K+-4.1 CL--110 [**2125-11-8**] 01:05AM HGB-10.1* calcHCT-30 [**2125-11-8**] 01:05AM freeCa-1.01* [**2125-11-8**] 12:21AM URINE HOURS-RANDOM [**2125-11-8**] 12:21AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2125-11-8**] 12:21AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2125-11-8**] 12:21AM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2125-11-8**] 12:21AM URINE RBC-[**4-18**]* WBC-[**4-18**] BACTERIA-MOD YEAST-NONE EPI-0-2 [**2125-11-8**] 12:21AM URINE MUCOUS-FEW [**2125-11-8**] 12:14AM UREA N-14 CREAT-1.8* [**2125-11-8**] 12:14AM estGFR-Using this [**2125-11-8**] 12:14AM LIPASE-42 [**2125-11-8**] 12:14AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2125-11-8**] 12:14AM GLUCOSE-340* LACTATE-14.2* NA+-144 K+-3.9 CL--108 TCO2-12* [**2125-11-8**] 12:14AM HGB-11.6* calcHCT-35 [**2125-11-8**] 12:14AM WBC-11.6* RBC-3.49* HGB-10.3* HCT-33.2* MCV-95 MCH-29.4 MCHC-30.9* RDW-13.3 [**2125-11-8**] 12:14AM PLT COUNT-305 [**2125-11-8**] 12:14AM PT-17.9* PTT-61.3* INR(PT)-1.6* [**2125-11-8**] 12:14AM FIBRINOGE-177 Brief Hospital Course: 24M was admitted on [**2125-11-8**] with GSW to Left neck was intubated at the scene. Thoracic and vascular surgery was consulted. Pt was immediately taken to OR for left neck exploration, trap door(limited sternotomy), LIJ/L subclavian vein ligation. Please see Op note for details. Pt experienced hypoxia in OR and on arrival to Surgical ICU. Pt was able to oxygenate with 100% FIO2 and Peep of 25. CXR with apparent RUL collapse and LUL contusion. Esophageal baloon was used to titrate PEEP to transpulmonary pressures.Pt was taken to surgical ICU for recovery. Chest tube was inserted and output was followed daily. Nutrition was given via OG tube. Chest tube was to suction. POD1 2U PRBC for falling hct. HCt 31->26 POD2 TPN was given. Began vent wean POD3 PEEP was weaned as tolerate. On POD4 patient developed fever and fever work up was started and antibiotics were given. POD5 thick secretions were producted from ETT and CT sinuses was ordered (which showed fluid in sinuses). continued vent wean. POD6 BAL was performed to determine whether patient had pneumonia. Pt was on Meropenum. POD7. Collar was taken off. Continued vent wean trial. Diuresis was started in preparation for extubation. Patient failed spontaneous breathing trial. TPN was discontinued. tube feeds were continued. Diuresis was continued and venting was intubated. POD8 Tube feeds was stopped and TPN continued for high residual. CT of chest showed resolving pneumothorax, no effusion. POD9 pt failed extubation attempt. Continued to diurese. Patient did not have BM after surgery. Mag citrate given. POD10 Patient extubated. Pt started on Heparin gtt for PE that was seen on PE protocol CT. Ultrasound was negative for DVT. POD12 Patient was stable to be transferred to floor POD13. Patient is being transferred to prison facility afebrile, on heparin gtt. Started on Coumadin. Patient to continue heparin until INR therapeutic ([**3-18**]). Medications on Admission: unknown Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for fever. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 5. Glycerin (Adult) Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 6. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 8. Lorazepam 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2 hours) as needed for agitation. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM for 2 doses. 12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 13. Meropenem 1000 mg IV Q8H 14. Morphine Sulfate 2-6 mg IV Q4H:PRN pain 15. Ondansetron 4 mg IV Q8H:PRN 16. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 17. Vancomycin 1000 mg IV Q 8H 18. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: 2300 (2300) units/hr Intravenous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Gunshot wound to the left base of neck with: Hemorrhagic Shock Laceration of subclavian and internal jugular veins Disruption of thoracic duct Brachial plexus injury Adult Respiratory Distress Syndrome Pulmonary Embolus Discharge Condition: Good. Discharge Instructions: Call your doctor or return to the Emergency Department right away if any of the following problems develop: * Watch carefully for signs of infection: redness, warmth, increasing pain, swelling, drainage of pus (thick white, yellow or green liquid) or fevers. * If you have numbness, pins-and-needles or pain in the area of your injury. * Your chest pain or chest discomfort lasts longer than 5 minutes. * Your chest pain or chest discomfort gets worse in any way. * You have angina and your chest pain or chest discomfort is worse, lasts longer than usual or comes on with less activity than usual. * You have angina and your chest pain or chest discomfort is not relieved by your usual medicines. * You develop any shortness of breath, sweats, dizziness, throwing up or nausea with your chest pain or chest discomfort. * Your chest pain or chest discomfort moves into your arm, neck, back, jaw or stomach. * Anything else that worries you. Followup Instructions: To follow up in trauma clinic in 2 weeks: [**Telephone/Fax (1) 6429**] Completed by:[**2125-11-21**]

[ "958.4", "874.9", "518.5", "E965.1", "997.4", "901.3", "560.1", "953.4", "E878.8", "900.1", "415.11", "862.39", "860.5" ]

icd9cm

[ [ [] ] ]

[ "96.72", "39.32", "38.85", "99.15", "99.09", "40.69", "96.05", "99.07", "34.04", "38.91", "33.24", "99.04" ]

icd9pcs

[ [ [] ] ]

9870, 9943

6353, 8291

343, 427

10215, 10223

1231, 6330

11315, 11418

808, 813

8349, 9847

9964, 10194

8317, 8326

10247, 11292

843, 1212

275, 305

455, 736

758, 767

783, 792

58,229

120,778

52170

Discharge summary

report

Admission Date: [**2177-12-19**] Discharge Date: [**2177-12-30**] Date of Birth: [**2111-6-1**] Sex: M Service: MEDICINE Allergies: Coumadin / Heparin Agents Attending:[**First Name3 (LF) 4654**] Chief Complaint: s/p cardiac arrest Major Surgical or Invasive Procedure: intubated History of Present Illness: 66M with PMH notable for DM2, AVRx2, tracheobronchomalacia s/p tracheal Y stenting earlier this year presents with witnessed PEA arrest at friend's workplace. Per family, friend reported that patient "appeared to be asleep." This did not immediately raise concern because the patient falls asleep frequently during the day, even in social situations. His wife notes that he was more somnolent than usual this morning; he had a hard time getting out of bed. He went to breakfast with friends as per his usual routine, and he actually fell asleep at the restaurant as well. Once he slumped forward EMS was called. He was down for approximately four minutes prior to initiation of CPR. Apparently, his initial rhythm on EMS arrival was PEA, and he received 1 mg epinephrine and 1 mg atropine. He also received 300 mg amiodarone but it is unclear whether this was given first or subsequent to other medications. On tracings from EMS, appears that patient is intermittently paced which is wide complex and this may have been mistaken for VT. Reportedly, he had return of pulses after 6 minutes of CPR. Two IVs were placed and the patient was intubated in the field. Unfortunately, the actual EMS documentation is no longer with his chart. He was initially cooled in the field by report. [**Hospital **]hospital EKG also concerning for inferior STEMI, but on my review, this appears only on paced beats with ST elevations in II and III and ST depressions in I. . On arrival to the ED, the patient's initial vitals were T 95.1, HR 60 (paced), BP 80/40, O2 100%. Blood pressures decreased to the 60s; cooling was stopped. Right femoral CVL was placed for IV access. He was placed on dopamine gtt with persistent hypotension and levophed was added. FAST exam was negative. He also required epinephrine gtt to maintain blood pressures in the 90s systolic. CT head/neck/chest/abdomen/pelvis revealed bilateral lower lobe infiltrates concerning for aspiration versus pneumonia. He received IV ceftriaxone 1 g X 1 (but not vancomycin which was also ordered in the ED). A left radial arterial line as placed. On CT scan, his ETT was noted to be anterior to his tracheal stent. IP and anesthesia/critial care were called to the bedside where bronchoscopy was used to reposition the tube; the ETT is now located within the stent about 2.5 cm above the carina. Cardiology was consulted from the ED; they did not feel that his presentation was consistent with acute STEMI. ECHO performed at the bedside showed preserved EF (> 55%) with no regional wall motion abnormalities. . On arrival to the ICU, the patient is not sedated but is intubated and unresponsive to voice and painful. On further questioning, the patient's wife notes that the patient has had a cough productive of sputum for the past few months; he has been treated intermittently with antibiotics for this. She reports no recent fevers at home. The patient did not have any other particular complaints in the past few days. As above, he was more somnolent on the morning of this incident. Overall, the patient's family admits that they know little about his medical history because the patient did not share his medical problems. The most recent medication list that the patient's wife can find is from 9/[**2175**]. . Past Medical History: Type II DM, on insulin (since [**2161**]) * Tracheobronchomalacia s/p tracheal Y stenting at [**Hospital **] Hospital ([**2177**]) * CAD with "small" MIs in past per family, no CABG & no stents * h/o pacemaker (unknown indication) * AVR X 2, porcine then cadaveric, no longer on coumadin - ? prior endocarditis * history of sleep apnea (noncompliant with cpap, has home O2 but does not wear it per family) * h/o TIAs per family * history of alcoholism * history of restless leg syndrome * HTN * hypercholesterolemia * h/o depression, * h/o BPH versus prostate cancer * h/o colon cancer managed medically (patient travelled to [**Country 6607**] for experimental therapy which he is now getting at [**Hospital1 2025**]) * h/o multiple orthopedic procedures for arthritis (bilateral knee replacements, shoulder replacement) * h/o chronic back pain on narcotics * h/o staph bacteremia (s/p 6 weeks antibiotics in [**2174**] or [**2175**] per family) Social History: Lives with wife. [**Name (NI) 3003**] [**Name2 (NI) 1818**] (cigars). Prior alcohol use. Does not work. Family History: noncontributory Physical Exam: PE: T: 91.5 oral BP: 87/53 HR: 60 RR: 24 O2 98% on a/c 500X24, peep 5, FiO2 100% Gen: intubated, sedated, no response to voice or painful stimuli. HEENT: pupils minimally reactive, sluggish, right pupil smaller than left pupil, tongue moist, ETT in place. NECK: R ej iv in place, jvd not easy to appreciate given habitus CV: RRR, no appreciable murmur but difficult to hear given coarse breath sounds. LUNGS: rhonchi at bases, no wheezing ABD: soft, obese, no tenderness to palpation, no rebound, no guarding EXT: warm, trace peripheral edema SKIN: no rashes NEURO: sedated, intubated, no corneal reflex, - oculocephalic reflex, no gag, does not withdraw to pain in all 4 extremities, toes mute bilaterally, limbs flaccid, DTRs not appreciated at patella and biceps Pertinent Results: [**2177-12-19**] 01:45PM FIBRINOGE-370 [**2177-12-19**] 01:45PM PLT COUNT-207 [**2177-12-19**] 01:45PM PT-13.0 PTT-29.8 INR(PT)-1.1 [**2177-12-19**] 01:45PM NEUTS-83.4* LYMPHS-12.4* MONOS-3.8 EOS-0.2 BASOS-0.2 [**2177-12-19**] 01:45PM WBC-19.4* RBC-3.62* HGB-11.4* HCT-33.7* MCV-93 MCH-31.6 MCHC-34.0 RDW-14.1 [**2177-12-19**] 01:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2177-12-19**] 01:45PM cTropnT-0.05* [**2177-12-19**] 01:45PM CK-MB-5 [**2177-12-19**] 01:45PM LIPASE-16 [**2177-12-19**] 01:45PM CK(CPK)-420* [**2177-12-19**] 01:45PM estGFR-Using this [**2177-12-19**] 01:45PM UREA N-30* CREAT-2.7* [**2177-12-19**] 01:57PM freeCa-1.09* [**2177-12-19**] 01:57PM GLUCOSE-262* LACTATE-3.9* NA+-140 K+-4.6 CL--98* TCO2-25 [**2177-12-19**] 01:57PM PH-7.08* COMMENTS-GREEN TOP [**2177-12-19**] 02:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2177-12-19**] 02:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2177-12-19**] 02:20PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2177-12-19**] 02:20PM URINE HOURS-RANDOM [**2177-12-19**] 03:03PM freeCa-1.10* [**2177-12-19**] 03:03PM GLUCOSE-254* LACTATE-2.8* NA+-138 K+-3.7 CL--101 [**2177-12-19**] 03:03PM TYPE-ART PO2-116* PCO2-74* PH-7.11* TOTAL CO2-25 BASE XS--7 [**2177-12-19**] 05:12PM PLT SMR-NORMAL PLT COUNT-231 [**2177-12-19**] 05:12PM PT-14.1* PTT-27.1 INR(PT)-1.2* [**2177-12-19**] 05:12PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ TARGET-OCCASIONAL STIPPLED-OCCASIONAL PAPPENHEI-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2177-12-19**] 05:12PM NEUTS-66 BANDS-21* LYMPHS-9* MONOS-0 EOS-0 BASOS-0 ATYPS-2* METAS-2* MYELOS-0 [**2177-12-19**] 05:12PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ TARGET-OCCASIONAL STIPPLED-OCCASIONAL PAPPENHEI-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2177-12-19**] 05:12PM NEUTS-66 BANDS-21* LYMPHS-9* MONOS-0 EOS-0 BASOS-0 ATYPS-2* METAS-2* MYELOS-0 [**2177-12-19**] 05:12PM WBC-24.5* RBC-4.05* HGB-12.3* HCT-36.8* MCV-91 MCH-30.3 MCHC-33.4 RDW-14.0 [**2177-12-19**] 05:12PM ALBUMIN-3.4 CALCIUM-7.2* PHOSPHATE-6.4* MAGNESIUM-2.3 [**2177-12-19**] 05:12PM CK-MB-5 cTropnT-0.06* [**2177-12-19**] 05:12PM ALT(SGPT)-31 AST(SGOT)-43* LD(LDH)-236 CK(CPK)-266* ALK PHOS-98 TOT BILI-0.6 [**2177-12-19**] 05:12PM GLUCOSE-355* UREA N-30* CREAT-2.3* SODIUM-136 POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15 [**2177-12-19**] 05:23PM freeCa-1.04* [**2177-12-19**] 05:23PM LACTATE-2.6* [**2177-12-19**] 05:23PM TYPE-ART TEMP-31.5 RATES-24/ TIDAL VOL-500 PEEP-5 O2-100 PO2-65* PCO2-52* PH-7.21* TOTAL CO2-22 BASE XS--7 AADO2-603 REQ O2-98 INTUBATED-INTUBATED VENT-CONTROLLED [**2177-12-19**] 07:29PM TYPE-ART TEMP-33.1 RATES-28/ TIDAL VOL-500 PEEP-10 O2-100 PO2-92 PCO2-49* PH-7.23* TOTAL CO2-22 BASE XS--7 AADO2-579 REQ O2-94 INTUBATED-INTUBATED VENT-CONTROLLED [**2177-12-19**] 09:43PM TYPE-ART TEMP-34.2 RATES-28/ TIDAL VOL-500 O2-100 PO2-183* PCO2-39 PH-7.33* TOTAL CO2-21 BASE XS--4 AADO2-498 REQ O2-83 INTUBATED-INTUBATED VENT-CONTROLLED . [**2177-12-20**] 4:35 am SPUTUM Site: ENDOTRACHEAL GRAM STAIN (Final [**2177-12-20**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Preliminary): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. MODERATE GROWTH. GRAM NEGATIVE ROD(S). SPARSE GROWTH. . [**2177-12-23**] 10:33 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2177-12-23**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. SPARSE GROWTH. GRAM NEGATIVE ROD(S). SPARSE GROWTH. . Echo: The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is higher than expected for this type of prosthesis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate symmetric LVH with probably normal LV systolic function. Aortic valve prosthesis is not well seen but appears to have a higher than expected velocity. [**2177-12-25**] 04:50AM BLOOD WBC-10.8 RBC-3.83* Hgb-11.9* Hct-33.8* MCV-88 MCH-31.0 MCHC-35.1* RDW-13.9 Plt Ct-233 [**2177-12-25**] 02:32PM BLOOD Glucose-162* UreaN-26* Creat-1.0 Na-141 K-3.5 Cl-102 HCO3-35* AnGap-8 [**2177-12-23**] 04:06AM BLOOD CK(CPK)-669* [**2177-12-25**] 04:50AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.2 Brief Hospital Course: 66M with a past medical history notable for DM2, AVR X 2, and TBM s/p tracheal stent who presented status post PEA arrest. The patient was initially admitted to the medical ICU and then transferred to the general medical floor on [**12-25**]. # PEA arrest: Circumstances surrounding the arrest are unclear. From family history, the patient falls asleep frequently during the day, likely secondary to chronic hypercarbia in the setting of not using CPAP and exacerbated by patient multiple narcotic pain medications. It was felt likely that additional narcotics may have depressed his already-tenuous respiratory drive leading to hypercarbia and hypoxia which led to PEA arrest. Other possibilities for PEA arrest, including MI, electrolyte abnormalities, PE, hypothermia were felt to be unlikely after further investigation. It is unclear what type of neurologic deficits, if any, he will have following this event. He was not cooled per protocol with arctic sun due to the length of time between his arrest (~ 1315) and arrival to the MICU (~1815) as well as the instability of his blood pressure on arrival (he was initially on 3 pressors on arrival to MICU). He was rapidly weaned off of the pressors. During his admission he had continuous firing of his a/V pacer with frequent pacer spikes on the QRS. EP re-evaluated the patient on [**12-23**] and shortened a sensing interval so that the patient is now continuously V paced. A repeat ECHO was performed, showing an EF greater than 55 % and high transaoritc valve pressure gradiant, largely unchanged since his echo on presentation. The patient also had a brief period of atrial flutter on telemetry that resolved spontaneously during his MICU stay. At the time of his discharge, medications which could adversely affect his respiratory status were discontinued or weaned down. Specifically, his flexeril, seroquel and oxycodone were discontinued. His oxycontin dose was decreased to 10mg by mouth three times daily. He was instructed regarding the importance of wearing his CPAP machine as instructed, and the risks of a recurrent episode of PEA arrest should he not do so. Given his ongoing narcotic use, he was instructed as to the risks of driving, and told not to drive until instructed that this was safe by his primary care physician. # Respiratory failure: The primary precipitant remains unknown, though the patient has multiple pulmonary issues including sleep apnea (likely obesity hypoventilation syndrome), tracheobronchomalacia with recent tracheal stenting, and recurrent pneumonias (antibiotics almost continuously per wife due to sputum production). He also takes multiple narcotics and other sedating medications which could contribute to altered mental status and exacerbate hypoventilation. On arrival, the patient was intubated with difficulty, complicated by the presence of his existing tracheal stent. Pulmonary was called to replace the endotracheal tube under bronchoscopic guidance because of the existing stent. The ventilator settings were weaned and the patient was extubated on [**12-23**], sating well on 4L NC. Urine Legionella antigen was negative. Sputum on [**12-20**] grew Coag + Staph aureus and the patient was treated with vancomycin and cefepime for and 8 day course. Gram stain on repeat sputum on [**12-23**] was concerning for 4+ GNRs, however, only Staph aureus eventually grew out. The patient's oxygen requirement improved and he did not spike any additional fevers while on antibiotics or after they were stopped. The patient also received aggressive fluid resuscitation on initial presentation. He was diruesed with furosemide, and was eventually placed back on his home regimen of lasix 40mg po qdaily at the time of discharge. # Renal insufficiency: Resolved. Baseline creatinine 0.9 to 1.1 per OSH. Cr 2.7 on admission in setting of shock and arrest, improved with IVF and resuscitation and returned to [**Location 213**] range. He was discharged home on his home regimen of lasix 40mg po qdaiy. # Mental status: The patient was noted to have memory deficits (unable to remember the events surrounding his arrest as well as both antegrade and, to a lesser extent, retrograde memory difficulty). He may have had an anoxic brain injury as a result of his arrest. The patient continued to improve during his hospitalization, but memory remained sluggish at discharge, thoug hpt clearly understood his surroundings, his indication for hospitalization, treatment recommendations and instructions for follow-up. It was recommended that if his memory difficulties persist that he see a behavioral neurologist as an outpatient. No additional neurologic deficits were noted. # Diabetes mellitus: The patient had a FSBS in the 300s on arrival to the ICU. He was placed on an insulin gtt and blood sugars were monitored q1h until they were under better control. He was eventually transitioned back to Lantus to 20 [**Hospital1 **] with a sliding scale. # Hypertension: The patient's home antihypertensive regimen was held on presentation given his pressor requirement. He was gradually started back on metoprolol, ACE, isordil and furosemide. # Hypercholesterolemia: pt was continued on his statin. # Chronic pain: On presentation all of the patient's chronic pain medications were stopped due to altered mental status. Following transfer to the general medical floor, the patient was restarted on oxycodone 5 mg Q6H and gradually advanced to oxycontin 10 mg Q8H with prn oxycodone as above. The patient was noted to be very somnolent on this regimen which included frequent prn oxycodone. PRN oxycodone was stopped and the patient gradually became more alert. On discharge he was advised to use a lower dose of oxycontin (10mg po tid) at home to prevent sedation and further respiratory difficulties. . # CK elevation: Unlikely cardiac source given low MB and MBI. Troponin slightly elevated but in setting of renal insufficiency and stress from hypotension. These enzyme elevations resolved quickly and pt was restarted on his statin. . # h/o BPH - pt on ditropan and urecholine on admission. his urecholine was continued. his ditropan was held [**2-8**] concerns that anticholinergic effects could have contributed to his hypercarbic respiratory failure. his flomax and proscar were continued. . # psych - pt continued on effexor. . # h/o CAD - pt continued on aspirin, metoprolol, ACE, and statin. he is s/p pacemaker for unclear indication per his cardiologists note on [**2177-12-2**]. he remained v-paced in the 60s during his hospitalization. . # h/o AVR x 2 - pt not on coumadin, as discussed in his last cardiologist note [**2177-12-2**]. he had AVR [**2156**], which the patient states is for AI. In [**2162**], his mechanical valve was switched to a bioprosthetic valve due to poorly controlled INRs. He was on a heparin pump at some point, but this was complicated by heparin induced osteoporosis as well as infection. he was clinically euvolemic at time of discharge, and discharged home on home regimen of lasix 40mg po qdaily. . # disposition - home VNA was set up, but would not be able to start services until Friday, [**2178-1-2**] given the holiday. Given his lack of acute medical issues (IV medication requirement, cardiopulmonary monitoring) this was felt reasonable. pt was evaluated by physical therapy on and prior to the day of discharge. he was felt safe for discharge home with home physical therapy. given his impulsivity, it was suggested that he be at home with 24 hour supervision. pt's wife was planning to be home on [**12-31**] and 12/25 per conversations with family. plan for discharge was discussed with pt's son [**First Name8 (NamePattern2) **] [**Name (NI) 107937**]) at 11AM. Follow-up phone call made at 3PM, but unable to reach, and again at 4:50PM, at which time phone message was left. discharge plan was also communicated by case management and physical therapy on day of discharge. Medications on Admission: MEDS at home (list from [**2175**], family cannot confirm): effexor 37.5 daily nexium 40 mg daily cyclobenzaprine 10 mg tid ditropan xl 20 mg qam accupril 20 mg [**Hospital1 **] imdur 60 mg qhs celebrex 200 mg daily lipitor 10 mg daily lasix 80 mg daily oxycontin 40 mg tid advair 250/50 [**Hospital1 **] flonase 0.05% tid prn spectazole cream prn lantus 37.5 [**Hospital1 **] humulin sliding scale urecholine 50 mg four times daily proscar 5 mg daily flomax 0.8 mg daily oxycodone/apap 5/325 four times daily for breakthrough pain valium 10 mg at bedtime seroquel 100 mg at bedtime toprol 25 mg daily Meds from H&P from [**8-/2177**] All the same as [**2175**] with the following changes: Cyclobenzaprine 20mg TID Lipitor 20mg QDaily Urecholine 25mg QID Flomax 0.4mg [**Hospital1 **] No valium No seroquel ASA 81mg QDaily ---------- LIST RECEIVED FROM CARDIOLOGIST ([**First Name9 (NamePattern2) **] [**Doctor Last Name **]) FROM [**2177-12-2**] VISIT: Medications (Confirmed) Accupril 20 mg daily Advair aspirin 81 mg po daily cyclobenzaprine hydrochloride 10 mg tid Ditropan XL 10 mg daily Effexor XR daily Flomax Flonase Humalog sliding scale isosorbide dinitrate 60 mg Lantus 37.5 units [**Hospital1 **] Lasix 40mg po daily Lipitor 10 mg daily Nexium 40 mg daily oxycodone daily Oxycontin 40 mg tid Proscar 5 mg daily Seroquel 75 at bedtime Toprol XL 25 mg daily Urecholine 25 mg 2 tabs qid Discharge Medications: 1. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Quinapril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours) for 2 weeks. Disp:*42 Tablet Sustained Release 12 hr(s)* Refills:*0* 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 8. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 9. Insulin Glargine 20 units twice daily and insulin sliding scale, or as directed 10. Urecholine 25 mg Tablet Sig: One (1) Tablet PO four times a day. 11. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO twice a day. 12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Disp:*1 bottle* Refills:*1* 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: [**1-9**] Adhesive Patch, Medicateds Topical DAILY (Daily): please wear patches for 12 hours, then remove patches for 12 hours. . Disp:*90 Adhesive Patch, Medicated(s)* Refills:*0* 14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 15. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-8**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*3* 16. Humalog 100 unit/mL Solution Sig: as per sliding scale Subcutaneous four times a day. 17. Lantus 100 unit/mL Solution Sig: as per sliding scale Subcutaneous twice a day. 18. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day. 19. Isordil 40 mg Tablet Sig: 1.5 Tablets PO once a day. 20. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary Diagnoses: 1. Pulseless electrical activity cardiac arrest 2. Hypercarbic respiratory failure 3. Pneumonia 4. Acute renal failure Secondary Diagnoses: 1. Diabetes mellitus, type 2 2. Coronary artery disease 3. Hypertension 4. Tracheobroncheomalacia with tracheal stent 5. Chronic pain 6. Obstructive sleep apnea 7. Hypercholesterolemia 8. Depression Discharge Condition: Vital signs stable. Discharge Instructions: You were admitted to the hospital because you had stopped breathing and your heart had stopped. Not wearing your CPAP and too much narcotic pain medication likely contributed to this event by causing too much carbon dioxide to accumulate in your blood. . On admission you were also found to have a pneumonia that was treated with antibiotics. . To prevent a recurrence of this episode and improve your alertness, we strongly recommend that you wear your BiPAP/CPAP at night and that you decrease the amount of oxycontin that you take. . You are having some difficulties with memory that should continue to improve gradually over the next few weeks. Please see a behavioral neurologist if you are still having memory difficulties after this time. . You still had a cough on discharge, likely left over from your resolving pneumonia. It may take a few weeks for this cough to completely go away. You can take an over the counter cough syrup to help with this. Please eat and drink sitting upright to avoid swallowing food down your trachea. . Please verify your discharge list with your primary care physician. . The following changes were made to you medications: 1. your oxycodone, seroquel, and ditropan were discontinued, these can contribute to somnolence, and my have led to your passing out. 2. your oxycontin dose was decreased to 10mg taken 3 times daily. 3. your lasix dose was continued at 40mg once daily. 4. you were given a prescription for an albuterol inhaler. . You will need to arrange for 24 hour home supervision given impulsiveness. . Please follow-up as directed below. . Please call your physician or return to the hospital if you have fevers, worsening shortness of breath, chest pain, or have other concerning symptoms. Followup Instructions: Please follow-up with your primary care physician. [**Name10 (NameIs) 28867**],[**Name11 (NameIs) 107938**] [**Telephone/Fax (1) 28868**]. please arrange for an appointment within 2 weeks of your discharge. . Please follow-up with your cardiologist Dr. [**Last Name (STitle) 41196**] [**Name (STitle) **], [**Telephone/Fax (1) 107939**]. An appointment could not be made for you, so please call and arrange an appointment for within 3-4 weeks of your arrival home. . Please follow-up with a behavioral neurologist if you continue to have memory difficulties. You can see one at [**Hospital1 2025**] or at [**Hospital1 18**] ([**Telephone/Fax (1) 1690**]). [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]

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icd9cm

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icd9pcs

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129,013

33821

Discharge summary

report

Admission Date: [**2161-2-4**] Discharge Date: [**2161-2-12**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2234**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 86 year old male with little known past medical history presented to ED with chest pain, nausea, abdominal pain and general malaise. He is visiting his daughter from [**Name (NI) 15158**], NY. He is a poor historian, and his family was unavailable for details during our visit. In the emergency room, he was found to have Crt of >3.0, hyperkalemia, and indeterminant troponin, and was subsequently admitted to the medicine service for further evaluation. Past medical history below obtained from outside records the second day of admission. Past Medical History: 1. Stroke with residual left arm weakness 2. Hypertension 3. BPH 4. Chronic Renal Insufficiency (previous creatinine in [**2153**] of 3.9) 5. Coronary Artery Disease s/p angioplasty 5 years ago 6. elevated PSA Social History: +tobacco, no EtoH, illicts. Lives in [**Location 15158**] with his wife. Daughter, granddaughter and great-granddaughter live in [**Name (NI) 86**]. Family History: noncontributory Physical Exam: GEN NAD EYE Anicteric ENT Moist OP CV RRR RESP CTA GI SNT NABS GU Foley, gross hematuria MSK Warm, no LE edema SKIN No rash NEURO A&Ox3, no asterixis PSYCH Calm HEME/[**Last Name (un) **] no LN Pertinent Results: Admit labs: [**2161-2-3**] 11:50PM BLOOD WBC-5.1 RBC-4.59* Hgb-10.8* Hct-33.5* MCV-73* MCH-23.5* MCHC-32.2 RDW-17.4* Plt Ct-104* [**2161-2-3**] 11:50PM BLOOD PT-12.2 PTT-28.3 INR(PT)-1.0 [**2161-2-3**] 11:50PM BLOOD Glucose-93 UreaN-58* Creat-3.2* Na-145 K-6.1* Cl-118* HCO3-14* AnGap-19 [**2161-2-3**] 11:50PM BLOOD cTropnT-0.06* [**2161-2-4**] 06:31AM BLOOD cTropnT-0.07* [**2161-2-4**] 01:00PM BLOOD CK-MB-8 cTropnT-0.06* [**2161-2-3**] 11:50PM BLOOD Calcium-9.2 Phos-3.1 Mg-2.0 [**2161-2-7**] 08:25AM BLOOD calTIBC-242* Ferritn-305 TRF-186* [**2161-2-4**] 01:00PM BLOOD TSH-2.9 ============================================================ CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: ABD PAIN HTN, RENAL FAILURE. ? INFECTION Field of view: 32 [**Hospital 93**] MEDICAL CONDITION: 86 year old man with hypertension, new renal failure, abd pain REASON FOR THIS EXAMINATION: enlarged aorta? evidence of infection? not able to take PO contrast and no IV vontrast b/c arf CONTRAINDICATIONS for IV CONTRAST: elevated cr INDICATION: 86-year-old man with hypertension and new renal failure and abdominal pain. Please evaluate for aortic pathology or evidence of infection. No comparisons available. TECHNIQUE: Axial MDCT images were obtained from the lung bases to the pubic symphysis with no IV or oral contrast administration. Sagittal and coronal reformatted images were then obtained. CT OF THE ABDOMEN WITHOUT IV CONTRAST: The visualized portion of the lung bases demonstrates panlobular emphysema. No pulmonary nodule, parenchymal opacity, or pleural effusion is noted. Dependent atelectatic changes are noted at both lung bases. The aorta is diffusely ectatic and contains calcification. The heart has normal appearance. The liver contains a small hypodense lesion within its dome measuring 6 mm which is too small to characterize. The gallbladder contains multiple stones. The common bile duct is not dilated. The pancreas has normal appearance. The adrenal glands, stomach, duodenum, and loops of small bowel and large bowel appear normal. Both kidneys contain multiple hypodense lesions which most likely represent simple cysts. Both the left and right renal midpoles contain 15mm round, hyperdense lesions measuring [**Doctor Last Name **] 50-80, which have the appearance of hyperdense cysts. No hyronenephrosis is noted. No free air or fluid is noted within the abdomen and pelvis. No pathologically enlarged mesenteric or retroperitoneal node is noted. The descending thoraco-abdominal aorta is tortuous and ectatic throughout; however, there is a focal area of aneurysmal dilatation at the level of the infrarenal aorta measuring 29 x 28 mm. There is apparent aneurysmal dilatation of the celiac artery at its origin which also shows some foci of calcification. Diffuse calcification is noted throughout the course of abdominal aorta and the iliac arteries. CT of the pelvis with no contrast: The urinary bladder has normal appearance. The distal ureters are also normal. The prostate gland is massively enlarged and its markedly hypertrophied median lobe protrudes into the base of the bladder measuring 5.3 x 4.6 in a transverse dimension and 7.2 cm in craniocaudal dimension. The part of the prostate gland that protrudes into the base of the bladder demonstrates multiple round hyperdense foci, suggesting hemorrhage; no blood is seen to layer dependently within the bladder. No free air or fluid is noted within the pelvis. No pathologically enlarged pelvic or inguinal nodes are noted. The rectum and sigmoid colon have normal appearance. BONE WINDOWS: No concerning lytic or sclerotic lesions are identified. IMPRESSION: 1. Diffusely calcific and tortuous abdominal aorta with infrarenal aortic aneurysm measuring approximately 2.8 x 2.9 cm, with no evidence of intramural hemorrhage or perianeurysmal leak. 2. At least three larger and two smaller hyperdense cysts are noted within both kidneys. In this setting of renal failure and numerous cysts, the differential diagnosis favors hemorrhagic (or superinfected) cysts, or less likely, primary renal malignancy. Further characterization (as cystic rather than solid) by US may be useful. 3. Cholelithiasis with no evidence of cholecystitis. 4. Diffusely enlarged median lobe, prostate gland which protrudes into the base of the bladder and contains hemorrhagic foci. Of note, the bladder appears smooth-walled with no free clot,and there is no hydronephrosis. 5. Diffuse panacinar emphysema. 6. 8-mm hypodense lesion within the dome of the liver which cannot be further characterized. COMMENT: Please note that son[**Name (NI) 867**] may be helpful for further evaluation of hyperdense renal cysts, prostate gland with hemorrhage and bladder PVR, and evaluation of the liver lesion. =============================================================== Stress-MIBI:INTERPRETATION: This 86 year old man with a history of renal failure and CAD was referred to the lab for evaluation of chest pain. The patient was infused with 0.142 mg/kg/min of dipyridamole over 4 minutes. No arm, neck, back or chest discomfort was reported by the patient throughout the study. There were no ST segment changes during the infusion or in recovery. The rhythm was sinus with occasional isolated vpbs and apbs. Appropriate hemodynamic response to the infusion. The dipyridamole was reversed with 125 mg of aminophylline IV. IMPRESSION: No anginal type symptoms or ischemic EKG changes. Nuclear report sent separately. PERSANTINE MIBI [**2161-2-11**] PERSANTINE MIBI Reason: 86 YEAR OLD MAN WITH HYPERTENSION, NEWLY DEPRESSED EF, INFER OLATERAL HYPOKINESIS RADIOPHARMECEUTICAL DATA: 10.9 mCi Tc-[**Age over 90 **]m Sestamibi Rest ([**2161-2-11**]); 33.0 mCi Tc-99m Sestamibi Stress ([**2161-2-11**]); HISTORY: 86-year-old man with a hsitory of HTN referred for evaluation of a newly discovered cardiomyopathy with depressed systolic function and a wall motion abnormality on echocardiography SUMMARY OF DATA FROM THE EXERCISE LAB: Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 mg/kg/min. He had no ischemic symptoms or ECG changes. METHOD: Resting perfusion images were obtained with Tc-[**Age over 90 **]m sestamibi. Tracer was injected approximately 45 minutes prior to obtaining the resting images. Following resting images and two minutes following intravenous dipyridamole, approximately three times the resting dose of Tc-[**Age over 90 **]m sestamibi was administered intravenously. Stress images were obtained approximately 45 minutes following tracer injection. Imaging protocol: Gated SPECT. This study was interpreted using the 17-segment myocardial perfusion model. INTERPRETATION: The image quality is adequate but limited due to patient motion and activity adjacent to the heart. Left ventricular cavity size is increased. Rest and stress perfusion images reveal a fixed, severe reduction in photon counts involving the mid and basal anterolateral and inferolateral walls and the distal lateral wall. There is also a fixed, severe reduction in photon counts involving the apex. There is also a partially reversible, severe reduction in photon counts involving the entire inferior wall and the basal inferoseptum. Gated images reveal hypokinesis of the entire inferior wall and akinesis of the mid and basal inferolateral and anterolateral walls and the apex. The calculated left ventricular ejection fraction is 27% with an EDV of 107 ml. IMPRESSION: 1. Paritally reversible, medium sized, severe perfusion defect involving the PDA territory. 2. Fixed, large, severe perfusion defect involving the LCx territory. 3. Fixed, small, severe perfusion defect involving the LAD territory. 4. Incresed left ventricular cavity size with severe systolic dysfunction due to multiple wall motion abnormalities described above. ============================================== Echo: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with inferior and infero-lateral hypokinesis. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. ================================================ US ABD LIMIT, SINGLE ORGAN [**2161-2-5**] 9:14 AM US ABD LIMIT, SINGLE ORGAN; RENAL U.S. Reason: evaluate hyperdensities seen on CT scan (kidney and liver) f [**Hospital 93**] MEDICAL CONDITION: 86 year old man with acute renal failure, urinary retention, hyperkalemia. REASON FOR THIS EXAMINATION: evaluate hyperdensities seen on CT scan (kidney and liver) for cyst versus malignancy. INDICATION: 86-year-old male with acute renal failure and multiple hyperdense cysts seen on recent CT examination. An 8 mm hypodensity was also noted in the dome of the liver. COMPARISON: CT abdomen and pelvis dated [**2161-2-4**]. RIGHT UPPER QUADRANT ULTRASOUND: The liver demonstrates no focal or textural abnormalities. The 8-mm hypodense lesion seen on the recent CT scan is not clearly visualized. There is no intra- or extra-hepatic biliary ductal dilatation. The gallbladder contains numerous shadowing stones. There is no gallbladder wall edema or pericholecystic fluid to indicate acute cholecystitis. Common bile duct measures 2 mm. The main portal vein is patent with hepatopetal flow. There is no hepatic ascites. The pancreas and midline retroperitoneal structures are obscured by overlying bowel gas. RENAL ULTRASOUND: The right kidney measures 9.4 cm and the left kidney measures 7.5 cm in length. There are multiple bilateral renal cysts, some with increased internal echogenicity reflecting hemorrhage or proteinaceous material. No solid renal mass, hydronephrosis or calculus is seen. The largest right renal cyst arising from the lower pole measures 5.5 x 5.4 x 5.5 cm, and demonstrates benign features with a thin wall and anechoic center. The largest discrete left renal cyst is seen in the upper pole, measuring 2.4 cm. No perirenal fluid collections are seen. IMPRESSION: 1. Cholelithiasis without evidence for acute cholecystitis. 2. Hypodense lesion in the hepatic dome seen on the recent CT is not clearly visualized. 3. Multiple bilateral renal cysts, some demonstrating internal echogenicity, most consistent with internal hemorrhage or proteinaceous material. No solid renal mass, hydronephrosis or calculi are identified. Brief Hospital Course: 1. CKD stage IV:--elevated creatinine determined to be consistent with chronic baseline. Follow up with outpatient renal arranged. Sodium bicarb, calcitriol initiated. 2. Chest pain/Coronary Artery Disease/Chronic Systolic heart failure -- On admission, in setting of hypertension, had three troponins that were negative for acute ischemia. Echo demonstrated Ef o 40% with focal wall motion abnormalities. Patient reports cardiac cath in [**Location (un) 7349**] about 5 years ago with stenting. Stress here demonstrated multiple abnormalities including one reversible defect. Evaluated by cardiology who recommended maximal medical management and outpatient follow up. Complicated by CKD stage IV. Aspirin, statin, beta blocker maintained throughout. 3. urinary obstruction with BPH/Hematuria-->Acute blood loss Anemia: -- Had traumatic foley placement with frank hematuria. Three way foley was placed, [**Location (un) **] consulted for recommendation on BPH, hemmorhagic foci in prostate, renal lesions, and recommendations on prostate cancer work up and outpatient follow up. Please see their note in OMR. Alpha blockade, proscar initiated. Discharged with foley, [**Location (un) **] follow up. Required 2 units of blood. 4. Episode of hypotension: Combination of titration of BP meds, blood loss. Resolved with blood, fluids and holding BP meds. (Overnight ICU stay). 5. Hypertension, malignant: BP to 200's in emergency department. Unclear meds prior to admit, had missed doses. New regimen initiated here with control. BP 130's to 150's on this regimen by discharge. . 6. elevated PSA -- outside records show PSA elevated in [**8-25**]. Per [**Date Range **], he should have outpatient follow up with discussion of biopsy. 7. hyperkalemia -- he was monitored on telemetry, given kayexalate and Lasix, and potassium came down to normal limits. No further over course of stay. Unclear if taking ace/[**Last Name (un) **] as outpatient in setting of renal failure 8. renal lesions -- Seen on CT, concerning for malignancy. U/S showed lesions were likely hemmorhagic cysts. [**Last Name (un) 159**] follow up ======================================= Medications on Admission: Pt cannot remember medications or doses, but he ran out of his blood pressure pills several days ago. On day 2 of hospitalization, daughter brought in meds, as follos: [**Name (NI) 8863**] XL Diltiazem ER 180 mg po qday aspirin 81 mg po qday simvastatin 20 mg po qday Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 2. [**Name (NI) 8863**] XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: can substitute generic. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 8. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*2* 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. Malignant hypertension 2. coronary Artery disease 3. Episode of Hypotension 4. Chronic Systolic Heart Failure 5. Urinary retention 6. BPH with obstruction 7. Hematuria 8. Acute blood loss anemia 9. chronic kidney disease Stage IV 10. Thrombocytopenia 11. Stroke with late effects 12. [**Last Name (un) **] Cancer s/p resection Discharge Condition: Stable, BP under better control, good PO Discharge Instructions: Follow up as below, it is important you keep all of your appointments. All medications as prescribed. Do not take any medications that you were previously taking, take only those we have given you until you see your new doctors. If you develop fevers, chills, chest pain, shortness of breath, abdominal pain, headaches or any other new concerning symptoms, contact your doctor or go to the emergency room. Keep the foley urinary catheter in until you are seen by the urologist on [**2-18**]. Followup Instructions: Follow up with the kidney doctor: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2161-2-17**] 11:00 Follow up with the urologist for your urinary catheter: Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2161-2-18**] 10:00 FOllow up with cardiology: Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] office to schedule a follow up appointment. He is the heart doctor who saw you in the hospital. He gave you his number to call. We scheduled an appointment with another cardiologist before Dr. [**Last Name (STitle) **] saw you. If you decide to follow up with Dr. [**Last Name (STitle) **], please cancel the following appointment. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**] Date/Time:[**2161-3-11**] 9:40 Follow up with your new primary care doctor: [**2161-3-20**] 03:00p [**Last Name (LF) **],[**First Name3 (LF) 21154**] K. [**Hospital6 29**], [**Location (un) **] [**Hospital 191**] MEDICAL UNIT

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icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

16192, 16250

12396, 14578

276, 282

16623, 16665

1519, 2279

17210, 18346

1272, 1289

14898, 16169

10423, 10498

16271, 16602

14604, 14875

16689, 17187

1304, 1500

222, 238

10527, 12373

310, 856

878, 1089

1105, 1256

16,860

102,399

45139

Discharge summary

report

Admission Date: [**2120-7-2**] Discharge Date: [**2120-7-23**] Date of Birth: [**2064-12-26**] Sex: M Service: CARDIOTHORACIC Allergies: Motrin / Glyburide / Glucophage Attending:[**First Name3 (LF) 1267**] Chief Complaint: Diarrhea, confusion, fever. Major Surgical or Invasive Procedure: L BKA/Guillotine [**2120-7-4**] AVR(21mm St. [**Male First Name (un) 923**]) [**2120-7-9**] L BKA Closure [**7-17**] History of Present Illness: 55 yo male w/PMHx sx for DM2 presents with abdominal discomfort, nausea, vomiting, altered mental status, and hyperglycemia. Patient originally presented to his PCP this am with complaints of GI upset. He reported that he had been having abdominal pain for the past seven days, with nonbloody watery diarrhea x3 days, with associated nausea. He has had a 1 day hx of nonbloody emesis as well. He has had diminished po intake secondary to nausea, and self-decreased insulin dose from 25U --> 20U qam and 20U --> 15U qpm. [**Name (NI) **] wife stated that patient has also had AMS for approx 8 days, with confusion and difficulty carrying out commands. She also notes labored breathing and chills, as well as fevers at home to 101 over the last three days. He states that he does not believe that his foot is infected because when his left foot gets infected, it swells and becomes tender, and currently it is at baseline. He does have a sick child at home, and several children who live at home who are in daycare. He also notes some nasal congestion. Patient denies any headache, vision changes (but does note some burning in his eyes), numbness, tingling, dysuria, hematuria, dizziness, lightheadnesses, neck stiffness, or back pain. He denies any recent travel, rashes, cough, unusual food consumption, melena, hematochezia, bloody emesis, or sputum production. In the ED, patient was found to be febrile to 101, with WBC 34.0, with elevation in creatinine to 1.9 (baseline 1.0) with glucose 459, with UA positive for mild ketones. He had an LP done as well, which showed elevated WBC count. He received 3L NS, and was given 10u regular insulin, and was initially started on vancomycin, ceftriaxone, and metronidazole, and transferred to the floor. Past Medical History: DM2 Charcot left foot Hx cellulitis, ?osteomyelitis s/p amputation of foot Nonproliferative retinopathy Left conductive hearing loss Hx MRSA Anemia of chronic disease Recent admit for gallstones Social History: Currently on disability. Lives at home with his partner, Ms. [**Name13 (STitle) **] [**Telephone/Fax (1) 96486**]. Denies alcohol, drugs, or tobacco. Has young children at home, who go to daycare. No pets. Family History: Family ALW. No hx of MI, CAD, or DM. Physical Exam: On Admission: VS: Tm 101.9 HR 120 BP 123/85 RR 30 O2sat 100% Gen: sleepy but arousable. Alert and oriented x3. Responds appropriately to questions. HEENT: PERRLA. Scerla not injected. Clear discharge from eyes. No nasal erythema. Oral mucosa moist with no ulcers. White exudate on tongue. No cervical LAD. Neck supple. Lungs: CTAB from front. Limited exam [**1-24**] recent LP. Hrt: Tachycardic. No MRG. Distant heart sounds. Abd: S/NT/ND +BS. Obese. No palpable masses. No HSM. Ext: Right extremity - Charcot foot. No ulcers or drainage. No tenderness or erythema. Left extremity - Thickened skin over dorsal surface with hyperpigmentation. Linear scar over left medial malleolar region with no tenderness or drainage at site. Swollen. No erythema or open ulcers. Amputation of three toes on left foot. 2+radial pulses. Neuro: CN2-12 intact. 2+DTRs. 5/5 strength throughout. Sensation to light touch and pinprick diminished over plantar surface of both feet, L>R. Negative Brudzinski's. Negative Kernig's. Pertinent Results: [**2120-7-22**] 01:41AM BLOOD WBC-16.7* RBC-3.40* Hgb-9.7* Hct-28.0* MCV-82 MCH-28.5 MCHC-34.6 RDW-15.6* Plt Ct-460* [**2120-7-23**] 06:33AM BLOOD WBC-18.5* Hct-29.2* Plt Ct-533* [**2120-7-22**] 04:07PM BLOOD PT-17.6* PTT-114.6* INR(PT)-2.0 [**2120-7-22**] 01:41AM BLOOD Glucose-102 UreaN-18 Creat-1.7* Na-128* K-4.5 Cl-98 HCO3-22 AnGap-13 [**2120-7-23**] 06:33AM BLOOD WBC-18.5* Hct-29.2* Plt Ct-533* [**2120-7-23**] 06:33AM BLOOD Plt Ct-533* [**2120-7-23**] 06:33AM BLOOD Glucose-114* UreaN-19 Creat-1.6* Na-128* K-4.8 Cl-95* HCO3-22 AnGap-16 [**2120-7-23**] 06:33AM BLOOD PT-17.5* INR(PT)-2.0 Brief Hospital Course: 55 yo w/hx of DM2 presents with 7d episode of abdominal upset, AMS, fever, nausea, vomiting, and diarrhea. LP shows 29 WBCs, normal to low glucose, and normal protein, concerning for a viral meningitis, esp in context of AMS and immunocompromised state. Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a guillotine amuptation of his LLE on [**2120-7-4**]. He then had a TEE which showed aortic valve endocarditis. He had a mechanical AVR on [**2120-7-9**], after which he was transferred to the ICU in critical but stable condition on Neo. He was extubated and his drips were weaned by post op day one. His L BKA was revised on [**2120-7-17**]. He continued to have a slightly elevated white count, with no fever or signs of sepsis, and is to remain on vancomycin until followup with infectious diseases on [**2120-8-20**]. He was anticoagulated with heparin and coumadin for his mechanical valve. Medications on Admission: Moxepril 7.5 mg po qd Percocet 5-325 1-2 tabs q4-6h prn pain Fluticasone inh. NPH insulin 100U Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. 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. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 6. Erythromycin 5 mg/g Ointment Sig: One (1) gtt Ophthalmic QID (4 times a day). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 9. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 11. Vancomycin HCl 1000 mg IV Q 24H check trough after 3rd dose 12. 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. 13. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR goal of [**2-22**].5. 14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) unit Subcutaneous twice a day: 25 U qAM 20 u qPM. unit Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Aortic valve endocarditis L foot infection Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Do not use lotions, creams, or powder on wounds. Call our office for sternal drainage, temp.>101.5 Followup Instructions: Make an appointment with Dr. [**First Name (STitle) **] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2505**] (Infectious Diseases) [**2120-8-20**] at 9:30. LMOB Suite GB ([**Telephone/Fax (1) 6732**] See Dr. [**Last Name (STitle) **] (podiatry) after discharge for shoe fitting Completed by:[**2120-7-23**]

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icd9cm

[ [ [] ] ]

[ "83.13", "88.72", "84.15", "84.12", "35.22", "39.61", "03.31", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

7026, 7096

4384, 5292

326, 445

7183, 7190

3764, 4361

7532, 7974

2684, 2722

5438, 7003

7117, 7162

5318, 5415

7214, 7509

2737, 2737

259, 288

473, 2226

2751, 3745

2248, 2445

2461, 2668

3,073

131,648

10895

Discharge summary

report

Admission Date: [**2165-12-4**] Discharge Date: [**2165-12-11**] Date of Birth: [**2110-7-17**] Sex: F Service: [**Company 191**] MED ADMITTING DIAGNOSIS: 1. DKA/HONC 2. Pancreatitis. HISTORY OF THE PRESENTING ILLNESS: The patient is a 55-year-old woman with a past medical history of diabetes, pancreatitis, alcohol abuse, who presented on [**2165-12-4**] with complaints of shortness of breath and abdominal pain. The patient reports that two days prior to admission she had dinner with a friend and had two drinks. That evening she felt nauseous and vomited. She then developed shortness of breath and abdominal pain. On the day of admission, she experienced increase in abdominal pain so she presented to the Emergency Department. The patient stated that she had a nonproductive cough. She denied fevers, chills, sweats, chest pain. In the ED, her glucose was 475 with an anion gap of 34. An arterial blood gas showed a pH of 7.11, C02 16, and an 02 of 154. She was started on IV fluids and an insulin drip. A repeat anion gap was 24 with an ABG of 7.18/19/120. Her urinalysis showed ketones and glucose. There was a large amount of acetone in the blood. The patient was admitted to the ICU for management of her DKA. PAST MEDICAL HISTORY: 1. Alcoholic pancreatitis. 2. Type 2 diabetes, on insulin. 3. Depression. 4. Hypertension. 5. Status post total abdominal hysterectomy. 6. Status post appendectomy. 7. Alcohol abuse. MEDICATIONS AT HOME: 1. Climara q.h.s. 2. Zyrtec 10 q.d. 3. Nexium 40 q.d. 4. Lisinopril 10 q.d. 5. Celexa 60 q.d. 6. Trazodone 150 q.d. 7. Nasonex. 8. Lantus 70 units q.h.s. 9. Humalog sliding scale. 10. Vioxx p.r.n. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient lives in [**State 531**]. She smokes one- half a pack per day. The patient states that she is currently not drinking alcohol. She states that she has a history of alcohol abuse. PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.9, heart rate 109, blood pressure 155/62, respiratory rate 24, saturating 100% on room air. The head and neck examination was unremarkable. The heart sounds were normal. There were no murmurs. The chest was clear to auscultation bilaterally. Bowel sounds were present. There was epigastric tenderness. The extremities were warm and dry. There was no peripheral edema. Peripheral pulses were palpable. The patient was alert and oriented times three with no focal neurological deficits. LABORATORY DATA: White count 9.4, hematocrit 40.5, platelets 297,000. Sodium 132, potassium 5.0, chloride 91, bicarbonate 7, BUN 27, creatinine 1.4, glucose 205. Albumin 4.6. There was large acetone. A tox screen was negative for alcohol. ALT 13, AST 11, lipase 338, amylase 133. CK 60, troponin less than 0.3. A urinalysis showed 500 glucose, greater than 80 ketones. The first ABG was 7.11/16/154/5. Repeat ABG was 7.18/19/120/7. An EKG showed sinus tachycardia at 120. There was normal axis. There was no change when compared with EKG from [**2164-7-13**]. An abdominal ultrasound showed no stones in the gallbladder. There was no intrahepatic dilation. A chest x-ray showed no acute intrathoracic process. HOSPITAL COURSE: 1. DKA: The patient was admitted to the Medical ICU for management of her DKA. She was maintained on IV fluids, insulin drip. Her anion gap was monitored q. 2 h. On the fourth day of admission, she was transferred to a sliding scale insulin. She was transferred to the Medical Floor. She was restarted on her Lantus q.h.s. as well as an insulin sliding scale. Her blood sugars were monitored q.i.d. Her anion gap was monitored q.d. At the time of discharge, the patient's anion gap is 11. Her glucose in the morning of discharge was 97. 2. PANCREATITIS: The patient's amylase peaked at 133 and lipase at 338. The patient was kept n.p.o. She was maintained on IV fluids. Her amylase and lipase trended down throughout her stay in the hospital. The patient was slowly transitioned to clear liquids and then to a low-fat, low-sugar diet. She was tolerating this well at the time of discharge. 3. ALCOHOL ABUSE: The patient was monitored for signs of alcohol withdrawal. She showed no signs of withdrawal during her stay in the hospital. She did not require any Ativan. The patient states that she will not drink alcohol again. 4. HYPERTENSION: The patient was maintained on lisinopril while in the hospital. Her blood pressure control was fair. 5. PSYCH: The patient was maintained on her outpatient psychiatric medications. DISCHARGE DIAGNOSIS: 1. Diabetic ketoacidosis. 2. Pancreatitis. 3. Type 2 diabetes, on insulin. 4. Depression. 5. Hypertension. 6. Status post total abdominal hysterectomy. 7. Status post appendectomy. 8. History of alcohol abuse. DISCHARGE MEDICATIONS: 1. Lisinopril 10 mg p.o. q.d. 2. Nexium 40 mg q.d. 3. Celexa 60 mg q.d. 4. Trazodone 150 mg q.h.s. 5. Climara patch 0.1 mg q. week. 6. Insulin Glargine 70 units q.h.s. 7. Humalog sliding scale. 8. Vioxx p.r.n. 9. Ambien 5 mg p.o. q.h.s. DISCHARGE FOLLOW-UP: The patient lives in [**State 531**]. She will follow-up with her PCP there, Dr. [**First Name (STitle) 35449**], [**Telephone/Fax (1) 35450**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Last Name (NamePattern1) 222**] MEDQUIST36 D: [**2165-12-11**] 10:16 T: [**2165-12-11**] 13:49 JOB#: [**Job Number 35451**]

[ "577.0", "276.2", "311", "401.9", "276.8", "250.10", "577.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4862, 5520

4620, 4839

3247, 4599

1489, 1750

1996, 3230

171, 1255

1277, 1468

1767, 1981

83,292

101,616

2369

Discharge summary

report

Admission Date: [**2171-1-24**] Discharge Date: [**2171-1-26**] Date of Birth: [**2103-9-18**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 3556**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Colonoscopy with polypectomy site clipping [**2171-1-25**] History of Present Illness: 67 y/o M CAD who presents with bright red blood per rectum. Patient had a colonoscopy [**2171-1-17**] and underwent a cecum polypectomy (final pathology adenoma). He restarted his Aspirin/Plavix on [**1-19**] and had one episode of bloody stool on the morning of admission ([**1-24**])with several clots. and consequently presented to the ED. Past Medical History: - CAD. Last catheterization was [**5-/2170**], which showed one-vessel disease of the main coronary artery of 30 to 50%. There was diffuse narrowing. He also had two patent stents in his LAD. His circumflex showed 70% stenosis which underwent pressure wire, but no new stent was placed. Cath [**2169-11-15**] mid-LAD had a 80% lesion at the D2 which was small and had an ostial 70% lesion. The Lcx had a 60-70% ostial lesion. Two DES placed in the mid-LAD. - Prostate cancer status post brachytherapy, followed by Dr. [**Last Name (STitle) **] in radiation oncology. Last visit was in [**10-8**], at which time PSA was normal. - External hemorrhoids - Erectile dysfunction - Hypertension - Low back pain for status post lumbar surgery at [**Location (un) **] [**Location (un) 1459**] approximately 12 years ago. Social History: He lives in [**Hospital1 392**], [**State 350**]. He is married and his wife works as a clerk. He retired from his job as an airline mechanic in [**2160**]. He has history of 60 pack years tobacco use - he quit 30 years ago smoked two packs a day. Denies any illicit substances. He has no drug use. Family History: His father had cirrhosis at age 47. His mother had a stroke in her 90s. He has three brothers. Two brothers with carotid stenosis and CAD. One brother is healthy. He has three healthy children and numerous grandchildren who are also healthy. No history of GI cancer. Physical Exam: on admission to the ICU: GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - pale conjunctiva, NC/AT, PERRLA, EOMI, sclerae anicteric, dryMM NECK - no thyromegaly, no JVD, no carotid bruits LUNGS - CTA b/l HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-3**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric Pertinent Results: [**2171-1-24**] 04:25PM Hct-37.2* [**2171-1-24**] 09:58PM Hct-33.6* [**2171-1-25**] 04:23AM Hct-35.7* [**2171-1-25**] 07:44AM Hct-34.4* [**2171-1-25**] 01:29PM Hct-34.1* [**2171-1-25**] 09:14PM Hct-33.7* [**2171-1-26**] 05:30AM Hct-34.0* . [**2171-1-24**] 04:25PM WBC-6.8 Plt Ct-167 [**2171-1-25**] 04:23AM BLOOD WBC-9.4 Plt Ct-127* [**2171-1-25**] 01:29PM WBC-6.3 Plt Ct-122* [**2171-1-25**] 09:14PM WBC-6.4 Plt Ct-115* [**2171-1-26**] 05:30AM WBC-5.8 Plt Ct-111* . [**2171-1-26**] 05:30AM Glucose-95 UreaN-10 Creat-0.9 Na-143 K-3.8 Cl-113* HCO3-25 AnGap-9 [**2171-1-25**] 04:23AM ALT-16 AST-25 LD(LDH)-297* AlkPhos-43 TotBili-2.5* DirBili-0.2 IndBili-2.3 [**2171-1-25**] 04:23AM Hapto-94 Brief Hospital Course: #Acute blood loss anemia from lower GI bleed: Patient's presenting vitals were T 97.1, BP 114/77, HR 58, RR 20, Sa 99%. Patient's HCT was found to be 37 from baseline 41. Patient was initially admitted to the general medicine floor with plan to prep overnight for colonoscopy in the morning. Aspirin and plavix were stopped and his anti-hypertensives were held. . After starting prep he had a large bright red bloody bowel movement and became hypotensive with a blood pressure of 80/palpable. His repeat hematocrit was 33 (from 37) Patient was started on 1 L with mild improvement in BP (SBP 104). Given the concern for inability to control the site of bleeding, he was transferred to the MICU to complete the prep and have a colonoscopy. . In the ICU, the patient received a total of 3 units of PRBCs. His HCT did not increase appropriately but did increase to 35.7. He had a colonoscopy the next morning by GI who found ulceration with 2 visible vessels at prior polypectomy site. 2 clips were placed for hemostasis, they also saw small rectal ulcers; grade 2 internal hemorrhoids. . His HCTs were checked q4 hours for 24 hours and remained stable 33-35. He tolerated clears and then on the morning of diacharge ate a full breakfast. He had no more bowel movements, no abdominal pain and he remained normotensive without any more fluids or blood products. His atenolol and aspirin were restarted on the day of discharge. He was instructed to restart his lisinopril on the day after discharge (Sunday) and come to the clinic for a CBC on Monday. After the results of his CBC, if HCT is stable, he was instructed to restart his plavix after discussion with his PCP and his cardiologist. His cardiologist wand PCP were not [**Name9 (PRE) 12304**] during his admission but an email was sent to let them know the patient was off his plavix (had DES in [**2168**]). . # Indirect Hyperbilirubinemia: Patient with T. Bili of 2.5 and I. Bili of 2.3, LDH was increased and platelets were decreased so there was concern for hemolysis or DIC but it was then realized that these were checked on a hemolyzed sample of blood which would falsely elevate these tests. Haptoglobin was normal and reticulocyte count was 1.8. . # Thrombocytopenia: Platelets trended down from 167 to 111. It was felt most likely dilutional from IVF and packed RBCs. The patient did not receive any heparin products. He will have an outpatient CBC on Monday [**1-28**]. . # h/o CAD s/p DES: No chest pain during admission. EKG was unchanged. As above, Aspirin and plavix were held, aspirin restarted. Patient was continued on his simvastatin. . # HTN: Patient's anti-hypertensives were held during admission given hypotension and GI bleed. . Medications on Admission: - ATENOLOL - 25 mg by mouth daily - CLOPIDOGREL [PLAVIX] - 75 mg Tablet by mouth once a day do NOT stop this medication without to speaking to your cardiologist - LISINOPRIL - 10 mg by mouth once a day - NITROGLYCERIN - 0.4 mg prn as needed for chest pain - SIMVASTATIN - 40 mg Tablet by mouth once a day - ASPIRIN - 81 mg by mouth daily - OMEGA-3 FATTY ACIDS-VITAMIN E 1,000 mg Capsule - 2 Capsule(s) by mouth once a day ** Currently on hold due to hypotension: HYDROCHLOROTHIAZIDE - 25 mg by mouth daily ** Currently on hold ISOSORBIDE MONONITRATE - 30 mg Sustained Release 24 hr by mouth daily Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omega-3 Fatty Acids-Vitamin E 1,000 mg Capsule Sig: Two (2) Capsule PO once a day. 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day: Please restart this medication today upon arriving home. 6. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet Sublingual once a day as needed for chest pain. Discharge Disposition: Home Discharge Diagnosis: Primary: Gastrointestinal bleeding after polypectomy Discharge Condition: Mental status intact, ambulating freely without difficulty. Discharge Instructions: You were admitted with bleeding from your rectum and blood in your stool This was due to bleeding from your recent polyp removal in your colon. You were transfused 3 units of blood cells. The GI specialists put clips on your prior polyps sites and there was no further evidence of bleeding. You need to get a repeat blood test done on Monday, [**1-28**] to check your blood levels. This can be done at your primary care office. You should not take your Clopidogrel (Plavix) until instructed to do so. Please continue your prior outpatient medications. Please keep all your outpatient appointments. Followup Instructions: You should call and schedule a follow-up appointment for the next 1-2 weeks post-discharge with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Her office can be contact[**Name (NI) **] at [**Telephone/Fax (1) 250**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

[ "458.9", "E879.8", "455.0", "414.01", "E849.8", "569.82", "V10.46", "413.9", "V45.82", "998.11", "285.1", "569.41", "401.9", "455.3" ]

icd9cm

[ [ [] ] ]

[ "45.43" ]

icd9pcs

[ [ [] ] ]

7497, 7503

3576, 6298

314, 375

7600, 7662

2857, 3553

8316, 8690

1922, 2196

6945, 7474

7524, 7579

6324, 6922

7686, 8293

2211, 2838

247, 276

403, 747

769, 1584

1600, 1906

62,717

100,077

46241

Discharge summary

report

Admission Date: [**2140-2-29**] Discharge Date: [**2140-3-4**] Date of Birth: [**2069-7-18**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: C2 type II dens fracture s/p HALO placement Major Surgical or Invasive Procedure: [**2140-2-29**]: Open reduction and internal fixation of type II C2 dens fracture. History of Present Illness: Pt is a 79 year old woman with a known C2 fracture sustained after a fall in [**2139-10-22**]. She was placed in a halo at that time, then discharged to [**Hospital 100**] Rehab, and is here today for follow up. She has not yet been discharged from rehabilitation. She complains of pain related to the halo at times, and feels that she has had a decrease in mobility especially when getting out of bed or a chair. No additional complaints. No HA, numbness/tingling. Past Medical History: CAD Hiatal hernia SVD Vaginal hysterectomy Post colporrhaphy and bladder neck suspension, R breast lumpectomy L mastectomy for Breast Ca C2 type II dens fracture. Social History: widowed Family History: Father - CAD, [**Name (NI) **] Ca. Mother - PE Physical Exam: GENERAL: She is alert and oriented x 3, pleasant, and in no acute distress. NEUROLOGIC: She has a halo on and it is intact. She is able to rise from her seat, but is tentative, uses her arms for additional strength. Full strength throughout, [**3-25**]. Deep tendon reflexes 2+ throughout. Sensation is intact. Halo pin sites, no erythema, edema, or drainage. C-spine CT from [**2-2**] - Again seen is an oblique fracture involving the base of the odontoid process (type 2). Fracture fragments appear in unchanged alignment. Multiple small osseous fragments, also unchanged in appearance, are noted. There is slight cortication of the still-evident fracture line margins. However, the lack of change in alignment suggests development of fibrous [**Hospital1 **]. Pertinent Results: [**2140-3-3**] 06:45AM BLOOD WBC-8.9 RBC-4.32 Hgb-12.9 Hct-38.4 MCV-89 MCH-29.9 MCHC-33.6 RDW-14.0 Plt Ct-99* [**2140-3-3**] 06:45AM BLOOD Glucose-87 UreaN-11 Creat-0.6 Na-145 K-4.3 Cl-105 HCO3-32 AnGap-12 [**2140-3-3**] 06:45AM BLOOD Calcium-8.5 Phos-2.8# Mg-1.8 RADIOLOGY Final Report CT C-SPINE W/O CONTRAST [**2140-3-1**] 12:03 PM CT C-SPINE W/O CONTRAST Reason: please evaluate post op at 0800 on [**2140-3-1**]. thank you. [**Hospital 93**] MEDICAL CONDITION: 70 year old woman s/p ORIF of C2 type II dens fx. REASON FOR THIS EXAMINATION: please evaluate post op at 0800 on [**2140-3-1**]. thank you. CONTRAINDICATIONS for IV CONTRAST: None. CT scan of the cervical spine with multiplanar reformatted images. Exam compared to previous examination of [**2140-2-2**]. FINDINGS: There has been intramedullary fixation of the fracture of C2 and the odontoid with a metallic device extending from the body of C2 into the odontoid process. There is no evidence of abnormal calcification within the spinal canal. The retropharyngeal mass is again demonstrated and is unchanged from prior studies. There is no alteration in alignment. IMPRESSION: Status post internal fixation of odontoid fracture. Stable appearance of retropharyngeal mass. DR. [**First Name (STitle) 23303**] [**Doctor Last Name **] Approved: TUE [**2140-3-1**] 3:57 PM Brief Hospital Course: Pt admitted to the neurosurgery service s/p ORIF type II C2 dens fracture. Pt keep in the PACU overnight for q1 hr neurochecks. Post operatively she was awake, alert and orientated X3 moving upper extremeties with good strength. She had a post op CT scan: FINDINGS: There has been intramedullary fixation of the fracture of C2 and the odontoid with a metallic device extending from the body of C2 into the odontoid process. There is no evidence of abnormal calcification within the spinal canal. The retropharyngeal mass is again demonstrated and is unchanged from prior studies. There is no alteration in alignment. She was seen by PT and found to be hypotensive so she was observed additional day. Social work was also involved with her discharge planning and Ms [**Known lastname 98305**] agreed to return to rehab. Medications on Admission: protonix 40mg qd triethanolamine/water (shampoo) Th@10 to scalp. neosporin triple antibiotic ointment to pin sites tylenol 650 q4h prn tylenol 650 [**Hospital1 **] fosamax 70mg qSat lipitor 80mg qPM dulcolax 10mg PR prn calcium/vit D 500 tid celexa 40 qhs colace 250 qAM [**Doctor First Name 130**] 30 qd prn robitussin syrup 5ml q6prn MOM 30ml qd prn MVI oxycodone hcl 5 q4 prn senna 2 tabs qHS trazodone 25 daily prn lasix 40 qod Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Use while on Percocet. Disp:*30 Tablet(s)* Refills:*1* 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every Saturday). 5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain/fever. 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: Use while on Percocet. Disp:*60 Capsule(s)* Refills:*2* 10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 8 days. Disp:*32 Capsule(s)* Refills:*0* 12. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): to pin sites. Disp:*1 500unit/g* Refills:*2* 13. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: C2 type II dens fracture. Discharge Condition: neurologically stable. Discharge Instructions: Restart you home medications as usual. Please take newly prescribed medications as instructed. Must wear collar at all times except when bathing No heavy lifting Diet low in cholesterol and high in fiber. Do not get steristrips wet until tomorrow, may shower starting tomorrow. Watch incision for redness, drainage, bleeding, swelling, or if you develop a fever greater than 101.5 call Dr [**Last Name (STitle) 17511**] office You may shower but please keep incision covered with tegaderms during shower. Please keep incision clean, dry, intact till you see Dr. [**Last Name (STitle) **] clinic. * Increasing pain * Fever (>101.5 F) or Vomiting * Inability to eat or drink * Reddness/swelling/discharge from wounds * Anything that concerns you. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 8 weeks. Please call [**Telephone/Fax (1) 1669**] to make an appointment. Please keep the following appointments: Provider: [**Name10 (NameIs) 326**] [**Name11 (NameIs) **] DX RM2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2140-3-4**] 1:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 98306**], [**Name12 (NameIs) 16569**] RNC Date/Time:[**2140-4-4**] 1:20 Provider: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern1) 21**], M.D. Date/Time:[**2140-4-11**] 3:30

[ "272.4", "413.9", "V10.3", "733.00", "553.3", "414.01", "733.82", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "02.95", "03.53" ]

icd9pcs

[ [ [] ] ]

6057, 6142

3400, 4232

362, 447

6212, 6237

2023, 2459

7034, 7611

1171, 1220

4714, 6034

2496, 2546

6163, 6191

4258, 4691

6261, 7011

1235, 2004

279, 324

2575, 3377

475, 943

965, 1129

1145, 1155

26,944

185,766

7657

Discharge summary

report

Admission Date: [**2108-9-21**] Discharge Date: [**2108-9-24**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: melena Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [**Age over 90 **] yo F with a h/o recurrent UTIs and recent posterior rib fractures who presented with melena x1 today. The patient reports that she had a large, black bowel movement this morning that was noted at her rehab facility. She denies any recent history of tarry stools, however per the chart her family has noted prior black BMs. She denies any history of blood in the stool. She denies recent N/V, diarrhea or abdominal pain. She also denies CP, SOB, lighheadedness or dizziness. She denies taking NSAIDS other than her usual dose of aspirin. She denies any recent fever or chills. She reports that her appetite has been decreased for the last 2-3 months and does not eat much more than soup. . Of note the patient was recently admitted to [**Hospital1 18**] with flank pain. CT abdomen showed biliary ductal dilatation. In ED flank pain completely resolved spontaneously. She underwent EGD/EUS which showed normal esophagus/stomach and cysts in the uncinate process of the pancreas without gallbladder stones. . In ED VS were T 98.2 BP 120/49 HR 92 RR 20 91% RA. She was given 1L of NS and transferred to the ICU. On arrival to the ICU the patient denied abdominal pain, dizziness, SOB. She was incontinent of a small amount of black stool, guaiac positive. Past Medical History: Tremor Recurrent UTIs posterior rib fractures s/p fall Pancreatic cysts Social History: Previously lived with her son. Moved into [**Hospital 1820**] rehab today. Son involved in care and lives in [**Hospital1 8**]. Walks with walker. Denies tobacco and alcohol use. Family History: Non-contributory Physical Exam: VS T 96.5, 130/60, 75, 18, 94% GEN: Elderly F pleasant, in NAD HEENT: PERRL, EOMI, mmm Neck: Supple, no carotid bruits CV: RRR nl S1 S2, III/VI SEM at RUSB PULM: CTAB ABD: Soft, NT/ND, +BS, guaiac positive stool EXTR: No c/c/e, wram, well-perfused NEURO: AAO x 3, moves all extremities equally Pertinent Results: EKG: NSR, rate 92, no ST or T wave changes from prior [**2108-9-24**] 06:15AM BLOOD WBC-11.3* RBC-4.03* Hgb-11.8* Hct-35.0* MCV-87 MCH-29.2 MCHC-33.7 RDW-15.1 Plt Ct-342 [**2108-9-23**] 06:05AM BLOOD PT-12.6 PTT-23.2 INR(PT)-1.1 [**2108-9-24**] 06:15AM BLOOD Glucose-102 UreaN-10 Creat-0.7 Na-139 K-3.4 Cl-102 HCO3-26 AnGap-14 [**2108-9-21**] 05:45PM BLOOD CK(CPK)-47 [**2108-9-21**] 05:45PM BLOOD cTropnT-<0.01 [**2108-9-23**] 06:05AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.2 Brief Hospital Course: Assessment/Plan: [**Age over 90 **] yo F with a h/o recurrent UTIs and recent posterior rib fractures who presented with melena from her [**Hospital1 1501**]. . 1. Acute blood loss anemia/Gastrointestinal bleeding: - Crit 38 to 34 on [**9-21**] and then stabilized at 34 over [**Date range (1) 24744**]. - No further melena - Hemodynamically stable - Monitored in [**Hospital Unit Name 153**] on [**9-21**] through [**9-22**], to floor night of [**9-22**] - GI Consultation - Recent EGD [**9-10**] without bleeding source - Decision made to defer scope given no further bleeding to outpatient setting. Patient needs outpatient EGD and colonoscopy - Outpatient aspirin held throughout and not re-started until endoscopy 2. Rib fractures: - Patient has known posterior rib fx s/p fall recently - Pt has been taking tylenol and using lidocaine patch for pain control - Pain currently well-controlled. 3. Biliary ductal dilatation: - Asymptomatic, no gallstones - Pancreatic cysts noted on EUS - Will need repeat imaging as outpatient. To [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] Medications on Admission: MVI Ecotrin 81mg daily Tylenol prn Lidocaine 5% patch Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Capsule, Delayed Release(E.C.)(s) 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): for 12h/day. 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] Discharge Diagnosis: 1. Acute Blood Loss Anemia 2. GI bleeding, unspecified site Secondary 1. Rib fracture Discharge Condition: Good Discharge Instructions: Follow up as below. You will need Endoscopy/colonoscopy for your gastrointestinal bleeding as an outpatient. Followup Instructions: Follow up with [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5004**] [**Telephone/Fax (1) 250**] as needed The Gastroenterology department should arrange for an endoscopy within the next 2-3 weeks. If you do not get a call, contact Dr. [**First Name (STitle) **] for assistance in arranging this. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2108-10-4**] 11:00 Provider: [**Name10 (NameIs) **] RADIOLOGY Phone:[**Telephone/Fax (1) 10164**] Date/Time:[**2108-11-8**] 1:30

[ "285.1", "578.1", "577.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4331, 4427

2752, 3865

269, 275

4557, 4563

2256, 2729

4721, 5321

1909, 1927

3970, 4308

4448, 4536

3891, 3947

4587, 4698

1942, 2237

223, 231

303, 1601

1623, 1696

1712, 1893

8,498

100,336

44984

Discharge summary

report

Admission Date: [**2144-8-25**] Discharge Date: [**2144-9-11**] Date of Birth: [**2063-8-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: Cardiogenic shock. Major Surgical or Invasive Procedure: Intra-aortic Balloon pump placement Impella - Left Ventricular Assist Device Cardiac catheterization PICC placement Left Groin Central Venous Catheter. SWAN catheter placed, Left groin History of Present Illness: This is an 81 year old gentleman with a past history of coronary artery disease (CAD), status-post coronary artery bypass grafting (CABG) (SVG to OM, SVG to RCA and LIMA, [**7-/2140**]) who underwent elective right total hip replacement on [**2144-8-25**]. His post-operative course was complicated by anginal symptoms during physical therapy ([**2144-8-26**]). The patient was noted to have dynamic ECG changes and CK 667, MB 12, Trop 0.11. Conservative management, including heparin was initiated, with plan for possible catheterization and some future point. Over the course of the day, the patient remained borderline hypotensive and was noted to have a decrease in urine output. Urine electrolytes suggested a pre-renal etiology. The patient received several litre boluses on the floor. Subsequently, the patient continued to have low blood pressures and was transferred to the [**Hospital Unit Name 153**], where he continued to received IV fluid boluses. He was later found to have a fall in his hematocrit from 29 to 24 and was transfused 2 units PRBC. The patient continued to become progressively hypotensive to systolic in 50s, despite running saline through 2 IVs as well as PRBCs through a third. He became progressively distressed, diaphoretic, and began complaining of substernal chest discomfort. Code blue was called and patient was intubated. Prior to intubation, patient had a large emesis that he was witnessed to aspirate. He received a total of 9 litres fluid, and had progressively escalating vasopressor requirement, needing maximum doses of first dopamine, then neosynephrine, then levophed. This maintained his blood pressure in systolic of 90s. ECG initially was similar to prior tracings earlier in the day, but the patient subsequently evolved a rhythm that appeared to be accelerated idioventricular with RBBB morphology. Cardiology was called and bedside echocardiogram was performed. This demonstrated some focal wall motion abnormality and possibly some evidence of right-heart strain. Bedside LENIs were obtained to assess for source of possible source of PE, and these were negative. Decision was made to transfer the patient to the cardiac catheterization laboratory for further evaluation and management. Past Medical History: - CAD, status-post CABG X 3 '[**40**], - Hypertension, - Hypercholesterolemia - Chronic Renal Insufficiency, - Gallstone pancreatitis status-post cholecystectomy [**6-11**], - Status-post lumbar laminectomy (L4-5) in [**2140-2-4**] for - spinal stenosis. - R-hip degenerative arthritis s/p elective total hip replacement [**2144-8-25**] - Benign prostatic hyperplasia - Gastroesophageal reflux disease. - History of a difficult intubation. - History of torn cartilage in the right knee. Social History: Patient lives with wife, has 3 children. He is retired and his previous occupation was as a mens' apparel businessman and CFO for his son's construction buisiness. No tobacco, rare social EtOH, and no other drug use. Family History: Father: 1st MI early 60's; Mother: CVA; No siblings with CAD Physical Exam: T: 33 C, HR 94, BP 105/55 (IAMP: systoly 98, augmented diastoly 109, IABP mean 80), respiratory on AC 550/26 PEEP 20 witgh an ABG 7.19/40/75/15 SPO2 78 General: intubated and sedated, pupils areactive and at 2mm Neck: difficult to assecc JVD Lungs: clear anteriorly Heart: soft s1, RRR, no holosystolic murmur appreciable Abdomen: distended and w/o bowelsounds Extremities: patient warm as on heating blanket, pulses dopplerable, trace edema Pertinent Results: Labs on admission: [**2144-8-26**] 07:00AM BLOOD WBC-12.1*# RBC-3.12* Hgb-9.9* Hct-29.3* MCV-94 MCH-31.8 MCHC-33.8 RDW-13.4 Plt Ct-173 [**2144-8-27**] 06:55AM BLOOD Neuts-85* Bands-10* Lymphs-4* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2144-8-27**] 01:30AM BLOOD PT-18.8* PTT-150* INR(PT)-1.7* [**2144-8-26**] 07:00AM BLOOD Glucose-156* UreaN-25* Creat-1.4* Na-136 K-4.7 Cl-103 HCO3-23 AnGap-15 [**2144-8-27**] 01:30AM BLOOD ALT-15 AST-49* LD(LDH)-152 CK(CPK)-667* AlkPhos-42 TotBili-0.4 [**2144-8-26**] 07:00AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.7 [**2144-9-1**] 06:37AM BLOOD calTIBC-129* Ferritn-858* TRF-99* [**2144-9-2**] 04:40AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [**2144-8-25**] 05:52PM BLOOD Glucose-112* Lactate-1.5 Na-137 K-4.3 Cl-105 Labs on discharge: [**2144-9-11**] 05:42AM BLOOD WBC-8.4 RBC-2.91* Hgb-8.8* Hct-26.6* MCV-92 MCH-30.4 MCHC-33.2 RDW-14.9 Plt Ct-438 [**2144-9-6**] 06:53AM BLOOD Neuts-81.1* Lymphs-11.7* Monos-4.8 Eos-1.9 Baso-0.4 [**2144-9-11**] 05:42AM BLOOD PT-33.7* PTT-43.4* INR(PT)-3.5* [**2144-9-11**] 05:42AM BLOOD Glucose-113* UreaN-52* Creat-2.3* Na-138 K-3.8 Cl-102 HCO3-30 AnGap-10 [**2144-9-11**] 05:42AM BLOOD Calcium-7.8* Phos-3.9 Mg-2.3 Cardiac enzymes: [**2144-8-29**] 05:49AM BLOOD CK-MB-51* MB Indx-2.1 cTropnT-6.58* [**2144-8-28**] 12:49PM BLOOD CK-MB-186* MB Indx-4.7 cTropnT-9.19* [**2144-8-27**] 09:18PM BLOOD CK-MB-GREATER TH cTropnT-7.29* [**2144-8-27**] 05:04PM BLOOD CK-MB-GREATER TH cTropnT-6.58* [**2144-8-27**] 06:55AM BLOOD CK-MB-343* MB Indx-19.6* cTropnT-1.42* [**2144-8-27**] 01:30AM BLOOD CK-MB-55* MB Indx-8.2* cTropnT-0.36* [**2144-8-26**] 07:21PM BLOOD CK-MB-17* MB Indx-2.5 cTropnT-0.11* Cardiac cath #1 on [**2144-8-27**]: COMMENTS: 1. Selective coronary angiography in this right dominant system revealed three vessel coronary disease. The LMCA had a 50% in the midsegment. The LAD had a mid-vessel occlusion with a 70% diag1 lesion. The proximal LCX had a 60% lesion, a 70% mid lesion and an 80% OM1 stenosis with diffuse disease noted. The RCA was not engaged but was known to be occluded. 2. Selective conduit arteriogrpahy revealed a patent LIMA to LAD with good collaterals to the RCA. 3. Venous conduit angiography was not performed as the SVG to RCA and SVG to OM were known to be occluded from prior cardiac catheterization. 4. Resting hemodynamics revealed systemic hypotension with SBP of 109 mmHg on three IV pressor agents. Right sided and left sided filling pressures were elevated with RVEDP of 29 mmHg and mean PCWP of 46 mmHg. There was pulmonary arterial hypertension with PASP of 57 mmHg. Cardiac index was preserved with CI of 3.88 l/min/m2. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent LIMA to LAD. 3. Elevated right and left sided filling pressures 4. Successful insertion of IABP. Cardiac cath #2 on [**2144-8-27**]: COMMENTS: 1. Pulmonary angiography of the right and left pulmonary artery demonstrated normal filling of contrast with no obvious flow limiting pulmonary emboli. 2. Selective angiography of the abdominal arteries demonstrated a patent celiac, superior mesenteric artery and inferior mesenteric artery - no obvious source for mesenteric ischemia. 3. Successful placement of the Impella cardiac support unit following successful removal of the intraortic balloon pump. 4. Towards the conclusion of the case the patient experienced an PEA cardiac arrest and was successfully resuscitated. 5. Limited resting hemodynamics demonstrated elevated right and left heart filling pressures along with depressed cardiac output with an index of 1.8 L/min/m2. 6. Pt with increasing ventilator requirements with poor oxygenation. Switched from oxygen to nitric oxide with improved oxygenation. FINAL DIAGNOSIS: 1. No evidence of pulmonary emboli. 2. No evidence of mesenteric emboli. 3. Cardiogenic shock requiring multiple pressors along with placement of an Impella cardiac support pump. Removal of the IABP. 4. PEA cardiac arrest with successful resuscitation. Lower ext. ultrasound [**2144-8-27**]: IMPRESSION: No deep vein thrombosis in bilateral lower extremity. Please note that right common femoral could not be evaluated due to line and bandages. ECHO [**2144-9-1**]: The left and right atrium are moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis (LVEF 45%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. A small vegetation on the non-coronary leaflet cannot be fully excluded (clip #[**Clip Number (Radiology) **]). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2144-8-28**], bitventricular systolic function has markedly improved and mild pulmonary artery systolic hypertension is now identified. Trace aortic regurgitation is also now seen (the aortic valve was previously distorted and is better defined on the current study). Brief Hospital Course: 81 year old male with extensive cardiac hx on POD1 c/o of CP/back pain, who came in for Right total hip repalcement and on POD#1 from Right Total hip replacement He started having chest pain and hypotension with ECG changed consistent with an NSTEMI. he was started on a heparin drip and his blood pressure medications were held. His urine output decreased and he was transferred to the MICU. His condition continued to worsen, he became more hypotensive and required intubation for respiratory support. His hematocrit also dropped and he required 2 units of blood. An ECHO showed an EF of 25% and he was taken to the cath lab. There was no obvious cardiac lesion. A balloon pump was placed to maintain cardiac output, he was started on pressors and he was transferred to the CCU. He developed a fever and was started on broad spectrum antibiotics. He was cathed again and the intra-aortic balloon pump was exchanged for an Impella device. There was no evidence of a pulmonary embolism. He developed cardiogenic shock and went into a PEA arrest requiring CPR. He had another PEA arrest a few hours after and was again resuscitated. He required three pressors for blood pressure support. His pressures improved and the impella device was removed. His blood cultures grew out Vancomycin resistant enteroccocus and he was started on Linezolid. His swan was pulled and a PICC was placed. His blood pressures normalized and he was weaned off of pressors. He begain to improve and was able to be extubated. He tolerated PT well over the next few days and was able to be tranfered to the general medical floor. He was stable on room air at rest, although he did require O2 (2L nasal cannula) when ambulating. He is stable for discharge. On discharge his Imdur and doxasosin were held. He requires coumadin for 6 weeks for his hip replacement with an INR goal of [**3-7**].5. He was resumed on his home medication regimine. His staples will need to come out between [**Date range (1) **]. This can be done at a rehabilitation hospital or PCP [**Name Initial (PRE) 3726**]. Medications on Admission: Milk of Magnesia 30 ml PO Multivitamins 1 CAP PO DAILY Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP 150 mEq Sodium Bicarbonate/ 1000 mL D5W Continuous at 150 ml/hr for [**2136**] ml Order date: [**8-27**] @ 0815 19. Phenylephrine 0.5-5 mcg/kg/min IV DRIP TITRATE TO MAP 60 Allopurinol 300 mg PO DAILY Piperacillin-Tazobactam Na 2.25 g IV Q8H Aspirin 325 mg PO DAILY Atorvastatin 40 mg PO DAILY Ranitidine 150 mg PO BID Calcium Carbonate 500 mg PO TID Senna 1 TAB PO BID:PRN Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days DOPamine 5-20 mcg/kg/min IV DRIP TITRATE TO MAP 60 Docusate Sodium 100 mg PO BID Famotidine 20 mg PO BID Vancomycin 1000 mg IV Q48H Ferrous Sulfate 325 mg PO DAILY Vitamin D 1000 UNIT PO DAILY traZODONE 50 mg Insulin SC Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO four times a day. 6. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours). 9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 10. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) as needed for pain. 11. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). 14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**] Discharge Diagnosis: Cardiac Arrest Acute on Chronic Renal Failure VRE Bacteremia Acute Respiratory Failure Cardiogenic Shock Ileus Status-post total right hip replacement [**2144-8-25**] Discharge Condition: Vital signs stable. afebrile. Ok to go to rehab. Discharge Instructions: You had an infection in your blood and acute respiratory and kidney failure that is now resolving. You are still receiving an oral antibiotic to treat the blood infection. You had a catheterization that showed some moderate blockages in your coronary arteries but they were not severe enough to get a balloon procedure or a stent. Your bowel function slowed because of your illness, however there is no evidence of infection in your stool. Medication changes: Please stop taking Imdur and Doxazosin. Your staples will need to come out between [**9-20**] and [**9-23**]. This can be done at your [**Hospital **] Hospital or at your primary care phycisian's office. 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: Orthopedic surgery: Provider: [**First Name8 (NamePattern2) 4599**] [**Last Name (NamePattern1) 9856**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2144-9-22**] 4:00 Cardiology: Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) 122**], MD Phone: [**Telephone/Fax (1) 5068**] Date/Time:Thursday [**9-24**] at 11:00am Primary Care: Provider: [**First Name8 (NamePattern2) 4559**] [**Last Name (NamePattern1) 58**], MD Phone: [**Telephone/Fax (1) 3329**] Date/Time: Wednesday [**10-14**] at 11:30am. Opthamology: Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2144-11-10**] 10:00

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icd9cm

[ [ [] ] ]

[ "00.12", "37.23", "37.61", "00.14", "81.51", "96.04", "37.62", "88.56", "38.93", "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

13452, 13594

9338, 11421

333, 519

13805, 13856

4091, 4096

14915, 15616

3551, 3613

12214, 13429

13615, 13784

11447, 12191

7852, 9315

13880, 14321

3628, 4072

5313, 6747

14341, 14892

275, 295

4879, 5296

547, 2791

4110, 4860

2813, 3301

3317, 3535

29,035

154,213

18067

Discharge summary

report

Admission Date: [**2156-10-12**] Discharge Date: [**2156-11-6**] Date of Birth: [**2089-12-13**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Indomethacin / Actonel / Reglan / linezolid / meropenem / atenolol / biphosphates / macrolids / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / prazoles / Prochlorperazine / risedronate sodium Attending:[**Last Name (NamePattern1) 293**] Chief Complaint: Acute on chronic renal failure Major Surgical or Invasive Procedure: None History of Present Illness: 66 yo female with a very extensive past medical history including severe AS, ESRD s/p cadaveric renal transplant in [**2153**], stage IV NASH cirrhosis c/b portal HTN, ascites, encephalopathy, grade I-II esophageal varices s/p banding s/p TIPS [**8-/2152**], s/p OLTx [**2153-7-21**], presenting from OSH with worsening anemia and [**Last Name (un) **] on CKD. Pt was initially on [**Female First Name (un) **] psych service at [**Hospital3 5097**] for ECT. She was noted to have bruising on her abdomen and bloody lips. Lips thought to be [**3-11**] biting but due to abdominal ecchomyses a Hct was checked and found to be down (28.2). Transferred to medical floor where further labs revealed Creatinine 3.4 (elevated) and WBC 11.7. Medical team was initially concerned about DIC, however fibrinogen was 551 and D-Dimer was 1.08/plt 404K, and INR was 1.2. Bleeding of her lip was thought to be attributed to self induced trauma. Given her renal failure, intial workup showed a positive UA growing GNRs. She was started on levofloxacin on [**2156-10-10**], switched to fosfomycin due to her cultures growing ESBL presumably resistant to FQ's. With her HCT drop, she was guiaced reportedly several times, all which were negative. She had a Renal US which showed no evidence of hydronephrosis or lithiasis in either kidney. Her txplt kidney was 11 cm with no evidence of hydroneprhosis. Given her new worsening renal failure, she was transferred to [**Hospital1 18**] for further care and potential renal biopsy. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: severe aortic stenosis s/p aortic valvuloplasty in [**7-/2156**] ([**2156-8-6**] TTE showed [**Location (un) 109**] 0.9cm2, pressure gradient 34) Atrial fibrillation - High-degree AV block, s/p PPM [**2154-2-5**] ([**Company 1543**] Sensia DDD pacemaker), now pacer dependent - Diastolic heart failure, NYHA II-[**Last Name (LF) 1105**], [**First Name3 (LF) **] >70-75% on TTE [**5-/2155**] - Moderate mitral annular calcification and mitral regurgitation - Mild tricuspid regurgitation - Moderate pulmonary hypertension 3. OTHER PAST MEDICAL HISTORY: - Diabetes Mellitus Type 2, on Insulin, c/b retinopathy, nephropathy, and neuropathy - End-stage renal disease, [**3-11**] diabetes & contrast-induced nephropathy, s/p cadaveric transplant [**2153-7-21**] - Hx frequent MDR UTIs - Dyslipidemia - Hypertension - Non-alcoholic steato-hepatitis cirrhosis (Stage IV, Grade 2), c/b portal HTN, ascites, encephalopathy, grade I-II esophageal varices s/p banding s/p TIPS [**8-/2152**], s/p OLTx [**2153-7-21**] - Saphenous vein interposition graft repair of the hepatic artery and harvesting of the left saphenous vein graft [**2154-3-14**], Hepatic artery s/p stent [**2154-4-25**] - [**3-/2155**]: Exploratory laparotomy, evacuation of intra-abdominal blood, exploration of retroperitoneal hematoma, left salpingo-oophorectomy for RP bleeding - s/p VATS decortication [**11/2153**] - Splenic vein thrombosis, no longer on coumadin - Anemia - Thrombocytopenia - h/o C.diff - h/o Seizures - headaches ?[**3-11**] occipital neuralgia - Meningioma, small left frontal lobe - GERD - OSA has CPAP at home but does not use - Cervical DJD - Dermoid cyst - Right adrenal mass - osteoporosis - Status post cholecystectomy followed by tubal ligation - Status post left oopherectomy - Status post appendectomy - ? Restless legs syndrome - hypothyroid - gout - hip surgery, discharged [**2156-2-8**] Social History: Widowed, lives in [**Hospital3 **] facility in [**Hospital1 6930**], MA. Uses a walker for ambulation. Has 4 children, 3 in MA, one in [**State 3908**]. Previously worked as a nurse [**First Name (Titles) **] [**Last Name (Titles) **]. No tobacco, alcohol or drugs ever Family History: father died of stroke, mother died of cerebral hemorrhage. Her sister has diabetes. Physical Exam: Admission PE: VS: T98.2 | BP 120/49| HR 70| RR 20| satting 97% 3L GENERAL: Chronically ill and pale. Obese. Flat affect NAD. Baseline tremor/jitteriness HEENT: Sclera icteric. PERRL, EOMI. Crusted blood on lips and evidence of traumatic injury on lower lip on the right. NECK: Supple. JVP difficult to assess. CARDIAC: [**4-13**] crescendo decrscendo murmur loudest in the parasternal region with radiation to the carotids bilaterally. Obliteration of S2. No thrills. LUNGS: ULF's are CTABL. Crackles L>R laying on left side in the basilar lung fields. No wheezes present. No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well symmetrically. ABDOMEN: Obses abdomen. Hypoactive bowel sounds. Multiple abdominal scars consistent with prior transplant surgeries. Eccymoses present in RLQ where patinet was receiving heparin at the OSH. Mild TTP over kidney transplant site (RLQ). Otherwise NT to palpation. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. Trace lower extremity edema. Neuro: Flat affect but AOx3. Tremulous without asterixis. RUE remains flexed but can extend and follow commands if asked. No facial droop or focal CN deficits. Can do finger to nose testing without past pointing. Can wiggle toes and squeeze hands. Discharge PE: Pertinent Results: Admission Labs: [**2156-10-12**] 10:19PM URINE HOURS-RANDOM UREA N-441 CREAT-101 SODIUM-12 POTASSIUM-39 CHLORIDE-11 [**2156-10-12**] 10:19PM URINE OSMOLAL-312 [**2156-10-12**] 10:19PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.012 [**2156-10-12**] 10:19PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG [**2156-10-12**] 10:19PM URINE RBC-2 WBC->182* BACTERIA-FEW YEAST-NONE EPI-2 TRANS EPI-1 [**2156-10-12**] 10:19PM URINE HYALINE-7* [**2156-10-12**] 10:19PM URINE EOS-NEGATIVE [**2156-10-12**] 08:40PM GLUCOSE-78 UREA N-110* CREAT-3.4*# SODIUM-133 POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-23 ANION GAP-20 [**2156-10-12**] 08:40PM ALT(SGPT)-6 AST(SGOT)-11 LD(LDH)-121 ALK PHOS-93 TOT BILI-0.3 [**2156-10-12**] 08:40PM CALCIUM-8.9 PHOSPHATE-5.4* MAGNESIUM-2.5 [**2156-10-12**] 08:40PM tacroFK-7.7 [**2156-10-12**] 08:40PM WBC-10.4 RBC-3.12* HGB-9.9* HCT-30.1* MCV-97# MCH-31.9 MCHC-33.0 RDW-17.8* [**2156-10-12**] 08:40PM NEUTS-85.9* LYMPHS-7.2* MONOS-4.2 EOS-2.1 BASOS-0.6 [**2156-10-12**] 08:40PM PLT COUNT-473* [**2156-10-12**] 08:40PM PT-13.9* PTT-29.4 INR(PT)-1.3* CXR [**2156-10-13**]: Mild pulmonary edema, as manifested by an increase of interstitial markings and a slight increase in diameter of the pulmonary vessels. No evidence of consolidations suggesting pneumonia. No parenchymal opacities. No pleural effusions, no pneumothorax. The pacer leads are in unchanged position. TTE [**2156-10-14**]: - Peak Ao grad 39, mean grad 20, peak velocity 3.1, Ao area 1.1 cm2 -There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is moderately depressed (LVEF = 35 %) secondary to extensive severe apical hypokinesis/akinesis with focal dyskinesis. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with depressed free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets are severely thickened/deformed. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. There is moderate functional mitral stenosis (mean gradient 9 mmHg) due to mitral annular calcification. Severe (4+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. -Compared with the findings of the prior study (images reviewed) of [**2156-8-6**], there has been significant worsening of left ventricular and right ventricular contractile function. [**10-15**] NCHCT- No evidence of acute intracranial process. [**10-16**] NCHCT- No evidence of acute intracranial process. CT abd without contrast [**10-19**]: 1. Normal appearance of transplanted kidney in the right lower quadrant. Minimal ascites. 2. No acute process to explain patient's symptoms identified. -The mass in the left lower quadrant, though called a hematoma on prior studies, has the appearance of a rejected prior transplanted kidney, clinical correlation recommended. TEE [**10-20**]: negative for endocarditis . [**10-27**] Tagged WBC scan: 1. Focus of uptake in the nose. 2. Focus of uptake within the right hemipelvis which may be within the region of the transplanted kidney. The transplant could be further [**Month/Year (2) 6349**] with an ultrasound to determine presence of infectious process such as and focal infection of abscess in the region of the transplanted right kidney. . Transplant renal U/S [**10-28**]: Normal appearance of renal transplant, apart from mild elevation of RI's. . MICRO: - OSH Klebsiella ESBL >100,000 CFU -- sensitive to carbapenems and cefotetan -- SENSITIVE TO TIGECYCLINE - [**2156-10-12**] Ucx-Klebsiella [**Last Name (un) 36**] to [**Last Name (un) 2830**] and gent. (10,000-100,000 ORGANISMS/ML) - [**10-14**] Stool culture- negative for c.diff, campylobacter, salmonella, shigella - [**10-16**], [**10-17**] Blood culture- no growth - [**10-18**] ucx - klebsiella sensitive to gent (10,000-100,000 ORGANISMS/ML) - CMV viral load- pending - [**10-23**] ucx: GNR, pending - [**10-24**] CSF: gram stain 1+ PMNs, cryptococcal Ag neg, HSV PCR neg HHV6 pending - [**10-24**] bl cx: pending - [**10-25**] ucx: ESBL Klebsiella >100,000 ORGANISMS/ML - [**10-26**] ucx: ESBL Klebsiella >100,000 ORGANISMS/ML - [**10-26**] bl cx: pending . Initial EEG interpretation [**2156-10-22**]: Diffuse theta slowing with superimposed bursts of delta slowing. Some epileptiform waveforms. No seizures visualized during study. . Discharge Labs: Brief Hospital Course: 66 yo female with extensive past medical history including severe AS, AFIB, ESRD s/p cadaveric renal transplant, s/p OLTx [**2153-7-21**], presenting from OSH with worsening anemia and [**Last Name (un) **] on CKD. . >> Active Issues: #Comfort Measures: Pt had PEA cardiac arrest on [**11-2**] during HD. She was successfully resuscitated after 2 rounds of CPR and epinephrine and transferred to the MICU. She stabilized for several days and mental status returned to baseline. Pt's blood pressure remained lower than baseline, most likely secondary to worsening cardiac function and developing sepsis. On [**11-6**], the patient developed worsening sepsis most likely secondary to known UTI and PNA. Her platlets and RBC counts dropped dramatically most likely due to DIC. Fibrinogen continued to drop as well. She required dopamine for blood pressure support. At this time, the patient's family made her [**Last Name (LF) 3225**], [**First Name3 (LF) **] the patient's previously writen wishes. She expired on the night of [**11-6**] with family at bedside. # [**Last Name (un) **] on CKD: Creatinine 3.4 on adm from baseline of approx 1.3-1.5. DDx includes prerenal azotemia from some combination of dehydation from poor PO, poor forward flow from systolic heart failure (possibly with some contribution from clinically severe AS), and lasix use. Also considered possibility of AIN vs ATN vs late rejection though these seem less likely. No new medications per patient or medical history to suggest cause of AIN and urine eos negative. Ulytes c/w prerenal etiology and hyaline casts on UA. S/p gentle IVF daily. Cr improved slowly but plateaued in 2.5 range; Cr subsequently bumped back to 3.2. Renally dosed meds. Lasix held. Gave daily MIVF at 100cc/hr for 1 L daily until pt starting to develop signs of volume overload and increased O2 requirements. Pt with persistently elevated BUN in 120s. Pt started on temp HD [**10-26**] via L AVF x3d. Pt's BUN downtrended and signs of uremia improved, most notably AMS. Pt's UOP steadily declined. . # ESBL Klebsiella UTI: Longstanding history of multi drug resistant UTI's in the past. Pt discharged from last adm [**8-/2156**] on fosfomycin weekly ppx for recurrent UTIs, but not clear if taking this. Was put on fosfomycin at OSH for planned 14 day course per OSH report started on [**2156-10-11**]. Was previously on fluoroquinolone but discontinued after senstivities returned. OSH sensitivities only to carbapenems and cefotetan. Pt with carbapenem allergy. UA on adm positive and ucx on adm with klebsiella growth. Pt started on tigecycline [**10-13**]. ID consulted. Obtained ucx from OSH, which was sensitive to tigecycline with MIC 2.0. Pt completed 10d course of tigecycline for complicated UTI. Repeat ucx on [**10-18**] showed persistence of multi-drug resistant Klebsiella likely colonization in the setting of clearing of pyuria on UA. Pt had again repeat UA [**10-23**] which was neg. Pt with repeat UAs on [**10-25**] and [**10-26**] with significant pyuria and many bacteria. UCx from [**10-25**] and [**10-26**] returned with >100K Klebsiella, so pt restarted on tigecycline [**10-27**] with plan for 3wk course of complicated UTI. . # Leukocytosis: Chronic leukoctyosis dating back to [**2153**] with baseline WBC count [**12-24**] rarely into 9-11 range. Etiology of persistent leukocytosis unclear but could be related to chronic prednisone use vs chronic infection, including possibility of recurrent UTIs with low-grade pyelo. Pt initially admitted with UTI with clearing on UA, then recurrent positive UA from [**10-25**] and [**10-26**] after completing 10d course of tigecycline. Pt with CXR neg for infiltrate, negative cdiff, stool cx neg, no acute process on CT abd/pelvis and no evidence of endocarditis on TEE. Bl cx NGTD. Lipase WNL. CSF not c/w infection. CMV VL and BK virus neg. Tagged WBC scan showing focus in nose and RLQ. Concern for focal infection of transplant kidney like abscess but no evidence of such on renal U/S. Pt afebrile during course. WBC persistently elevated in 13-16 range; WBC count normalized [**10-31**]. . # AMS: Pt had dizziness while toileting and fell and hit head against wall reportedly (unwitnessed) on [**10-15**]. Head CT neg. Pt with increased AMS later in evening. Repeat head CT neg. MS improved. Pt's keppra was discontinued at OSH in setting of ECT. Per OP neurologist, restarted Keppra 500 [**Hospital1 **] on [**10-21**]. Pt subsequently had worsening of MS on [**10-22**] during which she became more lethargic, A&Ox1-2 and increased myoclonus and twitches. Neurology was consulted. EEG was attached and showed moderate diffuse background slowing c/w encephalopathy. There were no electrographic seizures. EEG showed increased sharp wave activity suggestive of brain irritability. AMS thought likely to be result of uremia vs infection vs med-related. Thought that may also be component of severe depression with catatonia as pt perseverating and some waxy flexibility on exam. Psych [**Month/Year (2) 6349**] the pt and agreed may be component of catatonia but treatment would be benzos; held off on benzos in the setting of lethargy. Pt also noted to have elevated TSH to 6.9 and low T4 and T3, but free T4 WNL so did not adjust levothyroxine dose per endocrine recs. Pt had fluoro-guided LP on [**2156-10-24**] after failed attempt at bedside on [**10-23**] per above. CSF studies not suggestive of infection. Pt started on temp HD [**10-26**] for uremia mgmt. MS slowly improved with HD suggesting AMS most likely [**3-11**] uremia; pt became more alert and returned to baseline MS. Neuro recommended continuing keppra as no good alternative. Keppra dose was decreased [**10-26**] to 500 daily and 250 supplement after HD sessions. . # Hypoxia: on ABG [**10-25**]. CXR c/w volume overload and vascular congestion, pulm edema and pleural effusions. Provided supplemental O2 2-3L. HD for fluid removal. Pt weaned from supplemental O2. . # Drop in plts in the setting of abnormal RBC smear: Plt count has decreased from 500-600s to low 200s where stable. 1+ schistocytes on smear [**10-25**] as well as 8% nRBCs. H/H stable but elevated MCV and RDW with nRBCs. DIC and hemolysis labs unremarkable. Heme consult for assistance in interpretting smear and believes abnormal smear most likely result of chronic infection causing persistent leukocytosis. Schistocytes likely from severe valvular disease. . # Lymphocytopenia: 2-3% lymphocytes on smear. Unclear etiology but could be related to chronic steroid use vs chronic infection. Heme consult for assistance. . # Failure to thrive: pt initially with poor PO intake from depression, which worsened in setting of AMS. Dobhoff placed [**10-29**] but pt pulled tube out and refused another tube. Encouarged PO. . # Diarrhea: C diff and stool cultures negative. Diarrhea resolved. . # H/o diastolic HF (past EF45%), clinically severe Aortic Stenosis s/p AO valvuloplasty: Cards consulted. TTE showing decrease in EF to 35% with apical hypokinesis. Cardiology reviewed previous caths and does not feel there are areas that potentially could be intervened on. They think the AS gradient is not severe enough to be driving her difficult volume status, more likely to be overall EF. Cards recommends slow bolusing with close monitoring of volume status. No evidence of volume overload on CXR or exam initially. Continued [**Month/Year (2) **], atorvastatin. Continued coreg, then restarted imdur per cards recs. Pt had PPM interrogation which was unremarkable. Cards said that pt is not candidate for revascularization after review of cath from [**8-/2156**] and valvular disease gradients not severe enough to merit valvular repair. Imdur discontinued in the setting of restarting HD to allow more room with BPs for fluid removal. . >> Chronic issues: # S/p Renal/Liver Transplant: on tacrolimus and prednisone. Monitored daily tacro levels. Continued vitamin D/Calcium Carbonate for prevention osteopenia. Held on PCP [**Name9 (PRE) **] for now (prev on Bactrim ppx). Continued ursodiol. Pt continued on [**Name9 (PRE) **] and [**Name9 (PRE) 4532**] for hepatic artery stent. . # DM: continue SSI. Decreased glargine to 8U qhs for bottoming out fingersticks in 70s. SSI. . # Anemia: chronic, not significantly different from baseline. Normocytic, normochromic. No signs of active bleeding. Low iron in setting of normal ferritin and transferrin may suggest some component of iron deficiency anemia though seems less likely in setting of normal MCV and MCHC. Likely some degree of anemia of chronic disease. Started trial iron supplementation in setting of low iron sat. H/H remained stable. PO iron changed to QOD IV iron in setting of nausea, which was subsequently discontinued in the setting trying to reduce medications that could contribution to AMS. . # Major Depression: Had been receiving ECT at [**Known firstname **]. Will likely benefit from further ECT per psych recs. Psych consulted. Continued venlafaxine at 150 mg XR given [**Last Name (un) **]. Continued Haloperidol qam/qhs. Continued aripiprazole, which was then discontinued in setting of AMS. Psychiatry followed. Pt intermittently expressive passive SI. Psych felt pt would benefit from further ECT but deferred in setting of AMS. . # History of AFIB s/p PPM. Pt had PPM interrogation in preparation for ECT clearance by cardiology, which was unremarkable. . # Gout: uric acid of 12 on check. Allopurinol dose increased to 300 po daily . # Hypothyroidism: Continued levothyroxine 50 mcg qday. TSH elevated with low T4 and T3. Endocrine consulted in re: to mgmt of hypothyroidism in setting of AMS. In setting of normal free T4, maintained pt on 50mcg daily per endocrine recs. . Transitional Issues: # Family present at time of death, autopsy deferred Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR OSH Record. 1. Venlafaxine XR 225 mg PO DAILY 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/SOB 3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing/SOB 4. PredniSONE 5 mg PO DAILY Start: In am 5. Ondansetron 4 mg PO Q8H:PRN nausea 6. Allopurinol 200 mg PO DAILY Start: In am 7. Atorvastatin 10 mg PO HS 8. Haloperidol 0.5 mg PO QAM Start: In am 9. Haloperidol 1 mg PO HS 10. HydrOXYzine 12.5 mg PO Q6H:PRN pruritus 11. Sarna Lotion 1 Appl TP QID:PRN pruritus 12. Lorazepam 0.5 mg PO HS:PRN anxiety Hold for sedation 13. Carvedilol 25 mg PO BID Hold for SBP<100/ HR<60 14. Docusate Sodium 100 mg PO BID 15. Senna 1 TAB PO BID:PRN constipation 16. Polyethylene Glycol 17 g PO DAILY:PRN constipation 17. Ursodiol 300 mg PO BID 18. Furosemide 80 mg PO DAILY hold for SBP<100 19. Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 20. Multivitamins 1 TAB PO DAILY 21. Aspirin 325 mg PO DAILY Start: In am 22. OxycoDONE (Immediate Release) 5 mg PO QHS:PRN pain hold for SBP<100/ Somnolence/ RR<10 23. OxycoDONE (Immediate Release) 5 mg PO QAM pain Patient may refuse. Hold for somnolence/ RR<10 24. Clopidogrel 75 mg PO DAILY Start: In am 25. Aripiprazole 5 mg PO DAILY Start: In am 26. Fosfomycin Tromethamine 3 g PO Q24H Start: In am Dissolve in [**4-11**] oz (90-120 mL) water and take immediately. Day 1 = [**2156-10-11**] at OSH for planned 14 day course 27. Lidocaine 5% Patch 1 PTCH TD DAILY 12 hours on / 12 hours off. Apply to affected hip area. 28. Tacrolimus 0.5 mg PO Q12H 29. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Start: In am Hold for SBP<100 30. Vitamin D 400 UNIT PO DAILY Start: In am 31. Calcium Carbonate 500 mg PO Q24H 32. Levothyroxine Sodium 50 mcg PO DAILY Start: In am 33. Lactulose 30 mL PO Q8H:PRN constipation Discharge Disposition: Expired Discharge Diagnosis: Primary diagnoses: Acute on chronic renal failure Complicated UTI Secondary diagnoses: s/p renal-liver transplant Chronic diastolic heart failure Systolic heart failure Severe aortic stenosis Discharge Condition: Deceased

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icd9cm

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48450+48451

Discharge summary

report+report

Admission Date: [**2153-3-19**] Discharge Date: [**2153-3-21**] Date of Birth: [**2086-12-19**] Sex: F Service: [**Hospital Unit Name 153**] CHIEF COMPLAINT: Hypotension and fever. HISTORY OF PRESENT ILLNESS: This is a 66-year-old female with a history of end-stage renal disease on hemodialysis, diabetes mellitus, with recent [**Hospital6 2018**] admission from [**2153-1-29**], through [**2153-3-5**], for sepsis, mental status changes, and respiratory failure. The patient's sepsis etiology was never determined but was thought to be a right AV fistula graft infection for which she received six weeks of Vancomycin but which was not revised. Her infectious work-up at that time included gallium scan, MRI of the brain, abdomen CT, LP, blood cultures, sputum cultures, urine culture, echocardiogram, all of which were negative except for one urine culture which showed [**Female First Name (un) **] and was treated with Caspofungin for ten days. Of note, an ultrasound of the AV fistula never showed clot or fluid collection, but the skin over it was superficially inflamed. The patient required pressors for greater than two-weeks and had a prolonged course complicated by hemodialysis. The patient was intubated for airway protection and later had failure to wean and had a trachea and PEG placed on [**2153-2-22**]. Her mental status did not improve after the sedation was discontinued, and this was thought to be related to active seizure on EEG, at which point the antiseizure medications were adjusted by the Neurology group at that time and lingering benzodiazepines in her system in the setting of hemodialysis and possibly anoxic brain injury. MRI was normal on [**3-5**] however. On discharge, the patient was able to move all four extremities and opened eyes to voice but was not following commands. The hospital course was also complicated by atrial fibrillation and a CK/troponin leak which was thought to be demand ischemia. Her atrial fibrillation was ultimately controlled by Digoxin and Lopressor, and but she was not anticoagulated because she had a GI bleed on Heparin. Since her discharge to rehabilitation at [**Hospital1 **], the patient went off her ventilator but was still trached and was generally improving in terms of her mental status. She was started on Flagyl on [**2153-3-16**], due to positive C-diff at [**Hospital1 **] per their notes. On the day of admission to rehabilitation, the patient was found to be tachycardiac to the 160s in atrial fibrillation with a blood pressure of 65/palp, with a temperature up to 100.6??????. At rehabilitation the patient received 750 cc normal saline and was transferred to [**Hospital 8**] Hospital where she received an additional 1800 cc normal saline and was still hypotensive to 100/50, at which point she was transferred to [**Hospital6 256**] for further work-up. On transfer, her temperature was 101?????? rectally, blood pressure 84/28, and she had an oxygen saturation of 100% on room air. The patient received 900 cc normal saline in the Emergency Room. Of note, she had a right IJ placed on [**2153-2-13**], which was still in place at the time of her Emergency Department admission here. This was discontinued, and the tip was sent for culture, and a new left subclavian triple-lumen catheter was placed in the Emergency Room. A Foley was placed and drained purulent-appearing urine, and the patient was unable to answer questions about her history. MEDICATIONS ON ADMISSION: Heparin 3000 U with hemodialysis, Epogen 8000 U IV with hemodialysis, Calcitriol, Metoprolol 100 mg t.i.d., Digoxin 0.125 mg Monday, Wednesday, and Friday, Insulin sliding scale, Keppra 250 Monday, Wednesday, and Friday, Sodium Bicarbonate 10 cc, Colace 100 mg b.i.d., Bisacodyl 10 q.d. p.r.n., Multivitamin, Lactulose 20 q.d. p.r.n., Tylenol 650 q.4 hours p.r.n., Valproate 500 mg t.i.d., Glargine Insulin 12 U q.p.m., Heparin subcue 5000 t.i.d., Lansoprazole 30 mg b.i.d., Aspirin 325 mg q.d., Ipratropium inhaled q.4 hours, Albuterol p.r.n., Ipratropium nebs, Albuterol nebs, Flagyl 500 mg p.o. t.i.d. started [**2153-3-16**], ................. PAST MEDICAL HISTORY: 1. End-stage renal disease on hemodialysis, Tuesday, Thursday, and Sunday. 2. Diabetes mellitus. 3. Hypertension. 4. History of brain abscess, stopped with evacuation in [**2147-2-9**], complicated by subsequent seizure disorder. 5. Otitis media and mastoiditis status post tympanomastoidectomy. 6. Laminectomy in L5-S1. 7. Atrial fibrillation. 8. Status post tracheotomy in [**2153-2-8**], for failure to wean on recent Intensive Care Unit admission. 9. Status post G-tube placement in [**2153-2-8**]. 10. Hypothyroidism. 11. Status post gastrointestinal bleeding on Heparin in [**2153-2-8**]. 12. History of VRE in her urine in [**2147**]. ALLERGIES: PENICILLIN, LOVASTATIN, MIRIPENIM, CEPHAZOLIN, CIPROFLOXACIN LEADS TO RASH. FAMILY HISTORY: Father died of myocardial infarction at 38. SOCIAL HISTORY: She was at [**Hospital1 **] since recent discharge. She has one son. PHYSICAL EXAMINATION: Vital signs: Temperature 101.1?????? rectally, pulse 86, blood pressure 108/33, respirations 19, 100% oxygen saturation 10 L via trach. CVP above 5 after 250 cc normal saline bolus. General: She opened eyes to voice and followed simple commands. She moved head and answered yes/no questions. She was in no apparent distress. HEENT: pupils equal, round and reactive to light. Anicteric sclera. Oropharynx clear. Neck: Obese. No jugular venous distention. No lymphadenopathy. Trachea midline without excessive secretions. Lungs: Decreased breath sounds at the bases, otherwise clear. Cardiovascular: Regular, rate and rhythm. There was a soft holosystolic murmur at the left lower sternal border. Abdomen: Obese, soft, nontender, nondistended. Normal abdominal bowel sounds. PEG site clean, dry, and intact, ................., erythema, or TTP. Extremities: Cool dry skin with flaking. No clubbing. No edema. No peripheral stigmata of SBE. There was a fungal toe infection with multiple cracks in the skin of her feet bilaterally. There was a stage I decubitus ulcer. LABORATORY DATA: Initial data showed a white count of 14.7, however 56% polys, hematocrit 24.6, MCV 102, platelet count 331; INR 1.2; CHEM7 with a sodium of 139, potassium 4.7, chloride 102, bicarb 22, BUN 61, creatinine 6.2, glucose 105, anion gap 15; calcium 10.1, magnesium 2.4, phosphate 4.9, ALT 7, AST 10, amylase 96, total bilirubin 0,3, lipase 62; urinalysis was with a specific gravity of 1.014, large blood, negative nitrite, 100 protein, moderate leukoesterase, RBCs greater than 50, WBCs greater than 50, bacteria many, no yeast, [**7-19**] epis, [**7-19**] renal epis; initial lactate 2.1. Chest x-ray showed successful placement of the left subclavian line and left lower lobe collapsing consolidation, known to be chronic. Electrocardiogram was atrial fibrillation at 100 beats per minute, normal axis, dense looking ST segment with T-wave inversions in II-AVF and V4-V6, which is consistent with Digoxin affect. Her Digoxin level was 0.8; valproic level was 30. HOSPITAL COURSE: This is was a 66-year-old female with end-stage renal disease on hemodialysis, diabetes mellitus, recent prolonged complicated hospital course, transferred to [**Hospital6 256**] for decreased blood pressure, low-grade temperature, dehydration, and presumed sepsis. ................. lactate elevation was a positive anion gap acidosis, decreased hematocrit and leukocytosis. 1. Hypotension/sepsis versus dehydration: The potential sources for the sepsis included the central line which was discontinued, her urine, failed treatment for C-diff, and skin breakdown. The patient was started on Vancomycin, Gentamicin, and Clindamycin, and a sepsis protocol was undertaken. A cord stem test was done and was negative for adrenal insufficiency. She was transfused to keep her hematocrit greater than 30, and fluid boluses were kept to keep her CVP between 8 and 12. The patient did have ............. less than 70; however, we thought that this may be deceptive given her history of autonomic instability and wildly labile blood pressures. As she received fluid, her mental status began to become clearer, and she was speaking coherently and interacting normally after 24 hours. Multiple sets of blood cultures, urine cultures, and wound tip cultures had no growth by the time of this discharge summary. After cultures were negative for 72 hours, all antibiotics except for Flagyl were discontinued, as the patient did have a history of C-diff. Her antihypertensive medications were held while she was acutely hypotensive. 2. Anion gap/metabolic acidosis: This was probably secondary to underlying infection versus uremia. She did skip her dialysis session. Lactate did come down after she received fluid, and her anion gap acidosis resolved after hemodialysis. 3. Anemia: This was probably due to rapid volume expansion in the field. The patient was transfused to keep her hematocrit greater than 30. LFTs were within normal limits; however, since she had a macrocytosis, vitamin B12 and folate were checked, and these were both normal. Epogen was continued on hemodialysis, and it was presumed that she had anemia of chronic disease related to her renal failure. 4. End-stage renal disease: The patient received hemodialysis on Tuesday and Wednesday. She was started on .................. per Renal Team recommendations here in the hospital. 5. Diabetes mellitus: All standing Insulin was held while the patient was NPO initially. Once her tube feeds were restarted, she was started again on her Glargine. Fingersticks q.i.d. and regular Insulin sliding scale were done at all times through the hospitalization. 6. Seizure disorder: The patient exhibited no seizure activity while in the hospital. Her antiepileptics were continued. 7. Atrial fibrillation: The patient was not on any anticoagulation, as she was prone to GI bleed. Digoxin was initially held. Her initial Digoxin level was 0.8. Beta-blocker was held. The patient was noted to have a troponin of 0.17 on her first check in the hospital. Two subsequent troponins were 0.14 and 0.14, at 12 hours and 24 hours afterward. She had CKs done with later troponins of 24 and 23. It was presumed that she had a troponin leak from demand ischemia due to her rapid atrial fibrillation which is now resolved. 8. Hypothyroidism: The patient had a TSH of 37 with a free T4 of 0.7. She was switched initially from p.o. Levothyroxine to one IV dose. She is to resume her p.o. dose of Levothyroxine and have it further adjusted as an outpatient. 9. Fluids, electrolytes, and nutrition: The patient was mostly kept NPO; however, tube feeds were restarted once her mental status had cleared. 10. Electrocardiogram changes: This was presumed to be drug affect. This should be rechecked again once back at rehabilitation. DISPOSITION: The patient rapidly turned around with fluids and with further hemodialysis. Her antibiotics were discontinued, as it was presumed that she did not have sepsis but in fact had dehydration, and she was deemed safe to go back to rehabilitation by her second hospital day. Physical Therapy and Occupational Therapy were asked to evaluate her in the hospital. DISCHARGE DIAGNOSIS: 1. Hypotension secondary to dehydration. 2. End-stage renal disease on hemodialysis. 3. Diabetes mellitus. 4. Hypertension. 5. Brain status post evacuation. 6. Seizure disorder. 7. Atrial fibrillation with demand ischemia and troponin leak. 8. Hypothyroidism. DISCHARGE MEDICATIONS: Same as admission medications with the exception of discontinued of Calcitriol and the addition of ................. 800 mg t.i.d. DISCHARGE STATUS: Back to [**Hospital **] Rehabilitation to continue her strengthening and eventual weaning from trach and PEG. CONDITION ON DISCHARGE: Fair. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**Name8 (MD) 6867**] MEDQUIST36 D: [**2153-3-20**] 13:44 T: [**2153-3-20**] 14:12 JOB#: [**Job Number 102010**] Admission Date: [**2153-3-19**] Discharge Date: [**2153-3-22**] Date of Birth: [**2086-12-19**] Sex: F Service: [**Hospital Unit Name 153**] ADDENDUM - HOSPITAL COURSE FROM [**2153-3-21**] TO [**2153-3-22**]: 1) HYPOTENSION: The patient was deemed to have hypotension as a result of dehydration rather than sepsis, as all of her culture data was negative by the time of discharge. She had her vancomycin, gentamicin and clindamycin discontinued on [**3-21**] and remained only on Flagyl to treat her underlying C. diff infection. She became hypotensive several times during the hospital course and all of the times responded to 250 cc normal saline boluses. The hemodialysis fellow was aware of her volume sensitivity and made adjustments with hemodialysis accordingly. 2) METABOLIC ACIDOSIS: Resolved after hemodialysis. 3) ANEMIA: The patient received 2 units of packed red blood cells throughout her hospital course for hematocrit less than 30. The rest as previously dictated. 4) END-STAGE RENAL DISEASE: The patient received hemodialysis on Tuesday, [**3-20**], and on Thursday, [**3-22**], as per renal team recommendations. She was started on Sevelamer, and her calcitriol was discontinued, as per their recommendations. 5) DIABETES MELLITUS: The patient was kept on regular insulin sliding scale. 6) SEIZURE DISORDER: The patient exhibited no seizure activity while in the hospital. Her usual antiepileptic drugs were continued. 7) ATRIAL FIBRILLATION: The patient had EKG changes which were reflective of digoxin effect. The patient went into rapid atrial fibrillation with rapid ventricular response with heart rates in the 120s-150s which quickly responded to volume and normal saline boluses. The cardiology team evaluated her in house, and they recommended discontinuing digoxin at this time and simply increasing her beta blocker as tolerated. Should her increase in beta blocker in the future prove to be insufficient to control her atrial fibrillation, they recommended starting amiodarone. They recommended anticoagulation for AFIB; however, this could not be done for this patient, as she has a history of GI bleeding while on heparin. The patient had several troponins drawn during the hospital course and peak was 0.17, low was 0.14, and CKs were all flat. It was deemed that she probably had prior demand ischemia from AFIB with RVR, and no further work-up was done. DISCHARGE DIAGNOSES: Same as previous discharge summary. DISCHARGE MEDICATIONS: 1. Keppra 250 mg via NG q Monday, Wednesday and Friday. 2. Regular insulin sliding scale. 3. Multivitamin capsule 1 via NG qd. 4. Tylenol 325, 1-2 tabs NG q 4-6 h prn. 5. Heparin 5,000 U subcu q 8 h. 6. Lansoprazole 30 mg via NG po bid. 7. Aspirin 325 mg NG qd. 8. Ipratropium nebulized q 6 h prn. 9. Albuterol nebulized q 6 h prn. 10.Metoprolol 25 mg NG [**Hospital1 **]--hold for blood pressure less than 100, heart rate less than 55. 11.Levothyroxine 100 mcg via NG qd. 12.Sevelamer 800 mg via NG tid. 13.Metronidazole 500 mg via NG [**Hospital1 **] to be continued for 7 more days, so last day would be [**3-28**]. 14.Valproate 500 mg via NG tid. 15.Epogen 8,000 U IV q hemodialysis. DISCHARGE STATUS: To [**Hospital **] Rehabilitation facility. DISCHARGE INSTRUCTIONS: 1. Please have PICC placed in left upper extremity and DC left subclavian triple-lumen catheter afterward. She should not have the PICC in for more than 1 week due to infection risk, and should have her fluids managed appropriately through hemodialysis. 2. She is having diarrhea and should have her stool output monitored and make sure that fluid is replaced at hemodialysis, and she should have her weights run even from the time of discharge. 3. If she should get tachycardic, or drop her blood pressure to systolic of less than 90, she should be bolused with 250 cc of normal saline prn. Her beta blocker should be titrated up as needed to control blood pressure. 4. Her glargine insulin should be restarted once on a stable diet. She should follow-up with her PCP as previously scheduled. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ADV Dictated By:[**Name8 (MD) 6867**] MEDQUIST36 D: [**2153-3-22**] 11:35 T: [**2153-3-22**] 11:40 JOB#: [**Job Number 102011**]

[ "285.21", "780.39", "250.00", "403.91", "276.5", "V45.1", "707.0", "008.45", "427.31" ]

icd9cm

[ [ [] ] ]

[ "39.95", "96.6" ]

icd9pcs

[ [ [] ] ]

4951, 4996

14709, 14746

14769, 15522

11416, 11685

3509, 4158

7202, 11395

15546, 16563

5106, 7184

180, 204

233, 3482

4181, 4934

5013, 5083

11996, 14687

6,173

147,383

27719

Discharge summary

report

Admission Date: [**2118-9-8**] Discharge Date: [**2118-9-18**] Date of Birth: [**2065-11-6**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4533**] Chief Complaint: Progressive hematuria Major Surgical or Invasive Procedure: L radical nephrectomy w/ IVC thrombectomy; R nostril packing by ENT after significant nosebleed History of Present Illness: 52 y/o male POD 1 s/p. radical Left nephrectiomy. Patient presented with hematuria back on [**2118-6-25**] which progressed to gross hematuria 10 days later. MRI revealed caval tumor thrombus and other masses consistent with metastatic disease. Past Medical History: Hypertension Gout Asthma Deviated Septum Social History: Alcoholism Works as an electrician Family History: Rectal CA (father) myasthenia [**Last Name (un) 2902**] (mother) Pertinent Results: [**2118-9-17**] 06:55AM BLOOD WBC-9.6 RBC-2.82* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.3 MCHC-33.4 RDW-14.9 Plt Ct-426 [**2118-9-16**] 06:30AM BLOOD WBC-8.7 RBC-2.74* Hgb-8.6* Hct-25.2* MCV-92 MCH-31.3 MCHC-34.0 RDW-14.7 Plt Ct-369 [**2118-9-15**] 11:30AM BLOOD WBC-9.9 RBC-2.34* Hgb-7.1* Hct-21.7* MCV-93 MCH-30.2 MCHC-32.6 RDW-14.2 Plt Ct-409 [**2118-9-14**] 09:50AM BLOOD WBC-11.8* RBC-2.56* Hgb-8.1* Hct-23.6* MCV-92 MCH-31.6 MCHC-34.3 RDW-14.1 Plt Ct-420 [**2118-9-13**] 07:15AM BLOOD WBC-9.4 RBC-2.56* Hgb-8.1* Hct-24.3* MCV-95 MCH-31.6 MCHC-33.2 RDW-13.6 Plt Ct-294 [**2118-9-12**] 06:55AM BLOOD WBC-10.6 RBC-2.47* Hgb-7.8* Hct-22.9* MCV-93 MCH-31.8 MCHC-34.3 RDW-13.9 Plt Ct-224 [**2118-9-11**] 01:10PM BLOOD WBC-12.0* RBC-2.69* Hgb-8.3* Hct-24.7* MCV-92 MCH-31.0 MCHC-33.8 RDW-14.3 Plt Ct-189 [**2118-9-11**] 06:05AM BLOOD WBC-11.3* RBC-2.56* Hgb-8.2* Hct-23.9* MCV-93 MCH-32.1* MCHC-34.4 RDW-14.3 Plt Ct-190 [**2118-9-10**] 02:43AM BLOOD WBC-15.4*# RBC-2.84* Hgb-9.3* Hct-26.5* MCV-94 MCH-32.6* MCHC-34.9 RDW-13.9 Plt Ct-166 [**2118-9-9**] 03:23PM BLOOD Hct-28.8* [**2118-9-9**] 04:38AM BLOOD WBC-9.5 RBC-3.40* Hgb-10.9* Hct-31.1* MCV-91 MCH-31.9 MCHC-35.0 RDW-13.6 Plt Ct-188 [**2118-9-9**] 12:20AM BLOOD WBC-10.1 RBC-3.46* Hgb-11.3* Hct-31.6* MCV-91 MCH-32.6* MCHC-35.8* RDW-13.6 Plt Ct-184 [**2118-9-8**] 08:56PM BLOOD WBC-12.7*# RBC-3.50*# Hgb-11.3*# Hct-32.7* MCV-93 MCH-32.3* MCHC-34.6 RDW-13.6 Plt Ct-187 [**2118-9-17**] 06:55AM BLOOD Glucose-95 UreaN-20 Creat-1.4* Na-136 K-4.1 Cl-102 HCO3-27 AnGap-11 [**2118-9-16**] 06:30AM BLOOD Glucose-102 UreaN-26* Creat-1.5* Na-136 K-3.7 Cl-103 HCO3-27 AnGap-10 [**2118-9-15**] 11:30AM BLOOD Glucose-133* UreaN-30* Creat-1.4* Na-141 K-3.8 Cl-105 HCO3-26 AnGap-14 [**2118-9-14**] 09:50AM BLOOD Glucose-110* UreaN-26* Creat-1.4* Na-143 K-4.1 Cl-107 HCO3-26 AnGap-14 [**2118-9-13**] 01:30PM BLOOD Glucose-158* UreaN-25* Creat-1.4* Na-137 K-3.2* Cl-104 HCO3-25 AnGap-11 [**2118-9-13**] 07:15AM BLOOD Glucose-115* UreaN-25* Creat-1.5* Na-142 K-3.3 Cl-108 HCO3-26 AnGap-11 [**2118-9-12**] 06:55AM BLOOD Glucose-110* UreaN-23* Creat-1.2 Na-137 K-3.6 Cl-106 HCO3-26 AnGap-9 [**2118-9-11**] 06:05AM BLOOD Glucose-109* UreaN-25* Creat-1.3* Na-141 K-3.9 Cl-109* HCO3-25 AnGap-11 [**2118-9-10**] 02:43AM BLOOD Glucose-114* UreaN-22* Creat-1.5* Na-141 K-4.4 Cl-114* HCO3-23 AnGap-8 [**2118-9-9**] 03:06PM BLOOD Glucose-147* UreaN-22* Creat-1.4* Na-139 K-4.1 Cl-113* HCO3-21* AnGap-9 [**2118-9-9**] 04:38AM BLOOD Glucose-131* UreaN-19 Creat-1.3* Na-139 K-4.3 Cl-114* HCO3-18* AnGap-11 [**2118-9-9**] 12:20AM BLOOD Glucose-149* UreaN-16 Creat-1.3* Na-139 K-4.7 Cl-114* HCO3-18* AnGap-12 [**2118-9-8**] 08:56PM BLOOD Glucose-136* UreaN-16 Creat-1.3* Na-139 K-5.1 Cl-112* HCO3-19* AnGap-13 [**2118-9-17**] 06:55AM BLOOD Calcium-8.5 Mg-2.1 [**2118-9-16**] 06:30AM BLOOD Calcium-8.1* Mg-2.1 [**2118-9-15**] 11:30AM BLOOD Calcium-7.9* Mg-2.2 [**2118-9-14**] 09:50AM BLOOD Albumin-3.0* Calcium-8.4 Mg-2.1 [**2118-9-13**] 01:30PM BLOOD Calcium-8.4 Mg-2.1 [**2118-9-13**] 07:15AM BLOOD Calcium-8.4 Mg-2.2 [**2118-9-12**] 06:55AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.2 [**2118-9-11**] 06:05AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.2 [**2118-9-10**] 02:43AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.2 [**2118-9-9**] 03:06PM BLOOD Calcium-8.0* Phos-2.1* Mg-2.2 [**2118-9-10**] 03:05AM BLOOD Type-ART pO2-82* pCO2-44 pH-7.35 calTCO2-25 Base XS--1 Brief Hospital Course: Patient underwent nephrectomy and was transferred to the SICU where he did very well. He had an epidural catheter placed for pain management. On post op day 1, he was successfully extubated and had no problems ventilating. On post op day 2, patient transferred to 12 [**Hospital Ward Name 1827**]. On the way over, the epidural catheter was uncapped requiring it to come out per the pain service. Patient started on a dilaudid PCA for pain management which worked very well. Patient underwent blood cultures, sputum cultures and got a chest XRay to rule out any infection. On post op day 3, patient fared ok overnight. His crit was around 23 and he was consented for another transfusion, but blood was held as the low crit was thought to be hemodilutional. ON post op day 5, his oxygen requirements remained higher than expected at 5L NC. On post op day 6, a trigger event was called due to uncontrolled epistaxis. ENT was consulted and successfully stopped the bleeding and left surgicel in the right nare. Patient transfused 2 units of blood as crit had dropped. Psychaitry was also consulted and had several useful imputs regarding pain medications and the patient's mental status. Patient started on Keflex for 7 days per the ent team. During the epistaxis event, the patient's blood pressure got up to 190 systolic and the team had difficulty controling his pressure on a daily basis with it running around 160 systolic. We consulted the hospitalist service who recommended PO metoprolol and po hydralazine. On [**2118-9-17**], staples were removed and steri strips were applied. Patient discharged home and will follow up with Urology, transplant surgery, and ENT. Medications on Admission: Diltiazem Allopurinol Albuterol inhaler prn Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for nasal packing for 3 days. Disp:*12 Capsule(s)* Refills:*0* 3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety/insomnia. Disp:*28 Tablet(s)* Refills:*0* 4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): HOLD SBP<110. Disp:*28 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): Hold SBP<110, HR<60. Disp:*14 Tablet(s)* Refills:*0* 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: L renal mass Discharge Condition: stable Discharge Instructions: 1. No driving while taking narcotic pain medications. 2. [**Name8 (MD) **] MD and come to ED if increasing nausea, vomiting, fevers, chills, night sweats, wound redness/discharge, or other signs of infection. 3. You may shower at home, letting the water run over your incision. Do not scrub your incision. No soaking/bathtubs/hottubs/swimming for 4 weeks. 4. No heavy lifting for 4 weeks. 5. Visiting nurse to check blood pressure and wound at home. Followup Instructions: Call Dr.[**Name (NI) 24219**] office to schedule urology F/U appt. Call PCP's office to schedule F/U appt for Tuesday to evaluate medical regimen and assess general medical condition after recent hospitalization. Call Dr.[**Name (NI) 18353**] office to schedule ENT F/U appt for 1 week ([**Telephone/Fax (1) 2349**]). Call Dr.[**Name (NI) 67657**] office to schedule psychiatry F/U appt. Completed by:[**2118-9-20**]

[ "300.00", "784.7", "305.03", "189.0", "458.29", "198.89", "V70.7", "E939.4", "584.9", "285.1", "292.81", "276.2" ]

icd9cm

[ [ [] ] ]

[ "21.03", "38.07", "88.72", "99.04", "94.62", "38.87", "55.51", "40.11", "00.17" ]

icd9pcs

[ [ [] ] ]

6888, 6939

4305, 5994

335, 433

6996, 7005

924, 4282

7505, 7927

839, 905

6088, 6865

6960, 6975

6020, 6065

7029, 7482

274, 297

461, 707

729, 771

787, 823

7,373

130,585

16972

Discharge summary

report

Admission Date: [**2141-6-9**] Discharge Date: [**2141-6-14**] Date of Birth: Sex: Service: SURGICAL SERVICE: Blue Surgery. HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old female who presented for the seventh time to [**Hospital1 346**] with history of coronary artery disease, hypertension and cerebrovascular attack, who had recently been discharged from [**Hospital1 188**] on [**2141-5-1**] for partial small bowel obstruction which had spontaneously resolved and who now is presenting with abdominal pain, nausea, and vomiting for 12 hours. The patient had complained of nausea and vomiting and no bowel movements for several days. She denies fever or chills. She had passed some flatus in the morning of her presentation. She is complaining of some diarrhea several weeks ago. PAST MEDICAL HISTORY: Significant for H. Pylori. A 4-cm abdominal aortic aneurysm. Hypothyroidism. Congestive heart failure. Hypertension. Cerebrovascular accident. Atrial fibrillation. Depression. Left internal carotid artery aneurysm. PAST SURGICAL HISTORY: Significant for total abdominal hysterectomy and she is status post ventral hernia repair and cholecystectomy. MEDICATIONS ON ADMISSION: 1. Plavix 75 mg q.d. 2. Levoxyl 75 mcg q.d. 3. Imdur 120 mg q.d. 4. Lisinopril 40 mg b.i.d. 5. Flovent 1-2 puffs twice a day. 6. Celebrex 200 mg b.i.d. 7. Lipitor 10 mg q.d. 8. Remeron 15 mg q.d. 9. Protonix 40 mg q.d. 10. Aspirin 81 mg q.d. 11. Procardia XL 60 mg b.i.d. 12. Lopressor 100 mg b.i.d. 13. Also p.r.n. took Dulcolax, milk of magnesia, and senna. PHYSICAL EXAMINATION: Vitals: Temperature 99.0 degrees, blood pressure 151/76, heart rate of 70, respirations of 24, and saturating 100 percent. She had an NG tube in place at the time of examination, which had an output of 1000 cc recorded. On exam, she was awake, alert, and in no acute distress. Her lung exam revealed some rales at the right bases and her heart rate was irregular but no murmurs, rubs, or gallops are auscultated. Her abdomen was distended, soft, tympanitic. There was some tenderness in the epigastric region in the right upper quadrant. There was no rebound, no hernia was palpated. Her pelvic exam did not reveal any masses. Rectal examination, no masses and guaiac negative. There was no clubbing, edema, or cyanosis of the extremities. LABORATORY DATA: Sodium was 142, potassium 4.7, chloride 102, bicarbonate 26, BUN 49, creatinine 1.4. Her glucose is 123. White count was 18, hematocrit 35, and platelets 270,000. A KUB which had been done on the [**10-9**] revealed dilated small bowel loops with air fluid levels. HOSPITAL COURSE: The patient was admitted to the Blue Surgical Service under the care of Dr. [**Last Name (STitle) **]. She was made n.p.o and an NG tube was placed. She was administered IV antibiotics and stool specimens were sent for C. difficile cultures. Routine preoperative labs were ordered. The patient underwent serial abdominal examinations. On hospital day number 3, a PICC line was placed so that the patient might receive parenteral nutrition. On hospital day number 4, the patient developed some increased work of breathing with the respiratory rate in the 30s. A chest x-ray the day previous to this had revealed interstitial findings consistent with CHF. On hospital day number 5, the patient continued to exhibit signs of difficulty breathing consistent with pneumonia versus CHF. She was treated with Lasix and did respond, but it was decided that she be transferred to the Intensive Care Unit for further management. In addition, cardiac enzymes had been ordered and her troponin was elevated at 0.9. It was decided that the patient would not undergo any surgery due to her present cardiopulmonary situation. She was transferred to the Trauma Surgical Intensive Care Unit on hospital day 5. Due to continued decompensation, the patient required intubation and for respiratory support. At this time, the family held a conference and made the decision that they would withdraw care. This occurred on hospital day 6. The patient passed away on hospital day 6 at 21:00. Her family members were present at bedside. CAUSE OF DEATH: Respiratory failure. DATE OF DEATH: [**2141-6-14**] at 21:00. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4007**] Dictated By:[**Last Name (NamePattern1) 15009**] MEDQUIST36 D: [**2141-10-1**] 16:10:31 T: [**2141-10-2**] 08:53:15 Job#: [**Job Number 47757**]

[ "593.9", "560.9", "518.81", "412", "428.0", "427.31", "244.9", "276.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "99.15", "96.07", "96.04", "89.64", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

1257, 1630

2708, 4599

1119, 1231

1653, 2690

188, 848

871, 1095

25,326

186,963

4925

Discharge summary

report

Admission Date: [**2119-1-4**] Discharge Date: [**2119-1-12**] Date of Birth: [**2058-5-23**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2290**] Chief Complaint: Fever and hypotension Major Surgical or Invasive Procedure: Tunneled line removal History of Present Illness: 60 year old male with h/o seizure disorder, ESRD on HD with persistent tunneled line infection (changed over wire in [**11-2**]), nonischemic cardiomyopathy (EF30-35%), remote h/o MI and CVA, and hepatitis B who presented to the ED from HD after fever to 103F. Per records patient had persistent purulent drainage from his tunnel site unresponsive to antibiotic treatment, but without systemic signs of infection or bacteremia. In [**11-2**] the catheter was changed over a wire. Subsequently he developed a contact dermatitis at the line site treated with clobetasol per dermatology recs. He was in his USOH until this morning when he arrived at HD and had a fever to 103F. He was given Vanc/Gent at HD after cultures were drawn. he was also hypotensive prior to HD but he completed treatment at HD with 4.3kg removed. After HD was hypotensive to the 60s and thus transferred to the ED at [**Hospital1 18**]. On arrival to the ED VS: T:98.6 HR:110 BP:93/61 RR:18. Also had EJ placed and then right CVL placed in groin. Per renal ok to use HD line in groin for pressors. Currently on levophed for BPs 85/46 prior to coming to floor. Otherwise mentating well, afebrile while in the ED. . On arrival to the floor: patient has no complaints except he is hungry and tired. . Review of systems: Denies any recent shortness of breath, dizziness, cough, abdominal pain, diarrhea. Past Medical History: - Seizure disorder since mid [**2097**]'s after starting dialysis - MSSA HD line infection with septic lung emboli [**9-1**] with left pleural effusion - H/o Hepatitis B, treated - Non-ischemic cardiomyopathy, last EF 30-35% - MI [**2086**] per pt - CVA [**2086**] per pt (?residual LE weakness) - ESRD on hemodialysis [**1-25**] HTN. EDW 80 kg as of [**2118-1-3**]. - Multiple thrombectomies in LUE and R thigh AV fistula - Graft excision for infected thigh graft [**2117-5-26**] - Hungry bone syndrome status post parathyroidectomy - Pituitary mass - Anemia of chronic disease - s/p PEG tube placement [**2117-10-29**] - Admission to MICU in [**10-2**] for seizure and hypotension - Swab positive for MRSA and VRE at left groin site in [**10-2**] and MRSA positive from same site [**11-2**] Social History: (per OMR) Retired piano and organ teacher. Has 2 PhDs (history and music) and prefers to be called "Dr. [**Known lastname 2026**]." Walks with a walker at baseline. Never smoker, no other drug use. Drinks 1 drink/week. Has 2 sisters that live out of state, son died 3 years ago ("was shot to death"). Family History: (per OMR) Father with DM, mother died at age 41 of renal failure. . Physical Exam: VS: 98,6 BP 105/60 on levophed 0.05, HR 70s, O2 sat 100 on RA GEN: Tall, thin, African American male with slight temporal muscle wasting in NAD HEENT: anicteric, MMM RESP: Mild rales at the right base, otherwise clear bilaterally CV: Mildly tachycardic with 2/6 systolic murmur at LLSB not radiating to axilla Abd: Soft, BS+, not tender or distended. Ext: Left groin HD line without tenderness or erythema. R groin line in place with dressing C/D/I Neuro: A+Ox3 Pertinent Results: Na:145 K:4.0 Cl:99 Glu:96 freeCa:1.04 Lactate:1.6 pH:Pnd BUN: 22 Cr: 5.5 CK: 89 MB: 1 Trop-T: 0.17 WBC: 5.7 HGB:12.0 PLT: 306 HCT: 36.9 N:88.6 L:7.9 M:2.7 E:0.2 Bas:0.5 PT: 13.7 PTT: 31.3 INR: 1.2 [**2119-1-4**] 9:25 am BLOOD CULTURE Blood Culture, Routine (Preliminary): STAPH AUREUS COAG +. PRESUMPTIVE IDENTIFICATION. DEFINITIVE IDENTIFICATION TO FOLLOW. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. Aerobic Bottle Gram Stain (Final [**2119-1-5**]): REPORTED BY PHONE TO DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 20488**] ON [**2119-1-5**] AT 0035. GRAM POSITIVE COCCI IN CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2119-1-5**]): GRAM POSITIVE COCCI IN CLUSTERS. Brief Hospital Course: MICU COURSE [**Date range (3) 20489**] # Septic Shock: Patient is usually hypertensive and on last admission to MICU he had BP 120s/70s so definitely not at his baseline on admission. He was presumed initially to have septic shock given the fevers at HD. He was started on levophed in the ED and Vancomycin + gent. He remained hypotensive and febrile and on [**1-5**] his tunneled HD line was removed. After this his blood pressures were better and he was able to be weaned off levophed. Blood cultures from the HD line grew staph aureus, that was ultimately found to be oxacillin resistant. He was continued on Vanco dosed by levels and gentamycin was discontinued per renal recommendations. A TTE was done which did not reveal any vegetations but did have AR so patient was ordered for a TEE to be done after transfer to the floor. Pt was transferred to the floor for further management. His femoral line was pulled on [**2119-1-8**] to give the patient a true line holiday until [**2119-1-10**]. Daily vancomcyin troughs were drawn and he was given small boluses of vancomycin 750mg PRN to keep Vancomycin trough close to 20. The patient remained afebrile and his serial cultures continued to be negative. ID was consulted and they recommended Continuing IV vancomycin to be dosed by HD protocol. Lab results would be faxed to [**Hospital **] clinic and they will be adjusted as needed. . # ESRD on HD: Last had HD on day of admission and while in the ICU had no acute need for HD, electrolytes currently within normal limits. Dialysis fellow was aware of admission and followed patient while in the ICU. After the HD line was pulled pt had a line holiday until [**2119-1-10**] when a temporary line was placed. Daily labs and volume status were closely monitored, but the patient did not require urgent dialysis during his line holiday. On [**2119-1-11**] a permanent tunnelled line was placed and the patient was ready for discharge with scheduled dialysis as before. # cardiomyopathy and h/o MI: Patient's TTE (done to assess for vegetations) shows slightly worsening ejection fraction and regional wall motion abnormality than prior. Although was hypotensive is HD dependent for fluid balance so did not bolus fluids given would not be able to dialyze off with line holiday. ACE inhibitor was held. Zocor 20mg po daily was restarted when eating. # History of seizure disorder: Continued oxcarbazepine and levtiricetam. This was not an active issue during the course of his admission. Medications on Admission: (From Discharge Medications [**10-2**] and confirmed with patient) bisacodyl 5 mg Two Tablet PO DAILY senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day PRN calcium acetate 667 mg Capsule Sig: Four (4) Capsule PO TID W/MEALS folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY ferrous sulfate 300 mg PO DAILY lanthanum 500 mg PO BID sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q24H levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID levetiracetam 500 mg Tablet Sig: One (1) Tablet PO MWF oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID aspirin 81 mg PO DAILY oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO MWF simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY omeprazole 20 mg PO DAILY (Daily). digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H PRN . Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. calcium acetate 667 mg Capsule Sig: Four (4) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 6. sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours). 8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 10. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK (MO,WE,FR). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 16. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 17. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 18. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gm Intravenous HD PROTOCOL (HD Protochol) for 6 weeks: Until [**2119-2-15**]. 19. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 20. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) application Topical once a day: Apply liberally to hands and feet. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: MRSA bacteremia [**1-25**] infected HD line . Secondary Diagnosis: - Seizure disorder since mid [**2097**]'s after starting dialysis - MSSA HD line infection with septic lung emboli [**9-1**] with left pleural effusion - H/o Hepatitis B, treated - Non-ischemic cardiomyopathy, last EF 30-35% - MI [**2086**] per pt - CVA [**2086**] per pt (?residual LE weakness) - ESRD on hemodialysis [**1-25**] HTN. EDW 80 kg as of [**2118-1-3**]. - Multiple thrombectomies in LUE and R thigh AV fistula - Graft excision for infected thigh graft [**2117-5-26**] - Hungry bone syndrome status post parathyroidectomy - Pituitary mass - Anemia of chronic disease - s/p PEG tube placement [**2117-10-29**] - Admission to MICU in [**10-2**] for seizure and hypotension - Swab positive for MRSA and VRE at left groin site in [**10-2**] and MRSA positive from same site [**11-2**] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You are being discharged from [**Hospital1 **]. It was a pleasure taking of care of you while you were in the hospital. You were admitted from your hemodialysis center with fevers and low blood pressure and were found to have an infected hemodialysis line. You were admitted to the intensive care unit where antibiotics were started and you were monitored closely until your blood pressures stabilized and you were felt ready to go to the general medicine floor. Blood cultures from admission showed you were growing MRSA and you were treated with the proper antibiotics. Your hemodialysis line was pulled and you were given a period when you had not line for dialysis. On [**2119-1-10**] you had a new hemodialysis line placed. You are doing much better and are ready for discharge from the hospital with follow up with your nephrologist, infectious disease and your PCP. [**Name10 (NameIs) **] will receive Antibiotics for a total of 6 weeks. You will get your antibiotics at your dialysis center. . The following medications were STARTED during this admission: Vancomycin 1gm IV to be dose at hemodialysis until [**2119-2-15**] . The following medication was CHANGED: lisinopril 10mg --> lisinopril 2.5mg by mouth Daily . The following medication was STOPPED: Lanthanum 500 mg by mouth two times a day Dilaudid . Please take your other medications as prescribed. . You will need weekly safety labs including CBC with differential, ESR, CRP, Chem 7, and vanco trough. Please have the dialysis center fax the results to the infectious disease clinic at [**Telephone/Fax (1) 1419**]. Followup Instructions: Department: [**Hospital3 249**] When: MONDAY [**2119-1-23**] at 3:45 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: INFECTIOUS DISEASE When: MONDAY [**2119-1-16**] at 9:50 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2119-2-7**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "428.0", "038.12", "V12.09", "V45.11", "428.22", "996.62", "425.4", "345.90", "414.01", "785.52", "729.89", "403.91", "438.89", "585.6", "412", "E879.1", "995.92" ]

icd9cm

[ [ [] ] ]

[ "88.72", "39.95", "97.49", "38.95", "38.93" ]

icd9pcs

[ [ [] ] ]

9791, 9849

4372, 6876

325, 348

10773, 10773

3477, 3735

12540, 13441

2907, 2977

7964, 9768

9870, 9870

6902, 7941

10924, 12517

2992, 3458

3779, 4349

1669, 1754

264, 287

376, 1650

9956, 10752

9889, 9935

10788, 10900

1776, 2572

2588, 2891

26,650

104,796

14678+14714

Discharge summary

report+report

Admission Date: [**2188-6-4**] Discharge Date: [**2188-7-4**] Date of Birth: [**2135-12-20**] Sex: M Service: [**Company 191**] Medicine NO dictation for this report [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Last Name (NamePattern1) 6834**] MEDQUIST36 D: [**2188-7-4**] 15:44 T: [**2188-7-4**] 16:06 JOB#: [**Job Number 43210**] Admission Date: [**2188-6-4**] Discharge Date: [**2188-7-4**] Date of Birth: [**2135-12-20**] Sex: M Service: [**Company 191**] Medicine HISTORY OF PRESENT ILLNESS: The patient is a 52 year old male with a history of ethyl alcohol abuse, cirrhosis, chronic obstructive pulmonary disease and depression who presents to an outside hospital on [**2188-6-29**] with complaints of periods of nausea, vomiting, diaphoresis, decreased p.o. intake, chills, bloody stools, chest pain and shortness of breath. The patient was admitted and diagnosed with a right lower lobe pneumonia and started on antibiotics. On [**6-2**], he had an abdominal computerized tomography scan consistent with colitis and was started on Vancomycin which was subsequently changed to intravenous Flagyl. Clostridium difficile came back negative. On [**6-4**], the patient was noted to be tachypneic with saturations to 80% on room air. A chest x-ray showed worsening right and left-sided infiltrates. The patient was also noted to have a bilirubin elevation to 8.1 and a slight bump in the white blood cell count of 9.2 to 12.2. He was transferred to [**Hospital6 1760**] on Imipenem, Ciprofloxacin, Vancomycin, Ceftriaxone and Levaquin. PAST MEDICAL HISTORY: Significant for ethyl alcohol abuse, gastritis, cirrhosis, esophageal varices, upper gastrointestinal and lower gastrointestinal bleed, diverticulosis, depression, anxiety, chronic obstructive pulmonary disease and peptic ulcer disease. MEDICATIONS ON ADMISSION: Medications on admission to [**Hospital6 1760**] were Imipenem, Vancomycin, Ciprofloxacin, Flagyl, Carafate, metered dose inhalers, Folate and Protonix, Fluticasone. MEDICATIONS AT HOME: Zoloft 100 mg; Prilosec 20 mg b.i.d., Trazodone 150 mg q.d.; Valium 5 mg p.o. t.i.d. prn; Folic acid; Advair; Vanceril; Azmacort. PHYSICAL EXAMINATION: On physical examination the patient's temperature was 98.4, pulse 80 to 102, blood pressure 70s to 90s/40s to 50s, respiratory rate 26, 95% on 100% oxygen. In general he was a chronically ill-appearing male in moderate distress secondary to shortness of breath, abdominal pain and nausea. Head, eyes, ears, nose and throat, pupils equal, round, and reactive to light, extraocular muscles intact, sclera icteric, oropharynx dry. Lips were cracked. No jugulovenous distension and neck was supple. Heart was regular, normal S1 and S2 without a murmur. Pulmonary had rare crackles on the left, diffuse crackles on the right, good air movement with tachypnea. Abdomen, positive bowel sounds, soft, nondistended, no masses, nontender, mildly and diffusely mainly in the right upper quadrant and epigastrium. The skin had no with positive palmar erythema. Extremities showed no edema. LABORATORY DATA: Laboratory data no transfer showed white blood cell count of 13.4, hematocrit 33.8, MCV 98, platelets 128. Urinalysis was negative. Chem-7 showed sodium 139, potassium 3.0, chloride 109, bicarbonate 23, BUN 6, creatinine .4, glucose 73. Total bilirubin was 7.1, ALT 36, AST 60, alkaline phosphatase 69, amylase 9, albumin 1.0, calcium 6.7, phosphorus 1.2, magnesium 1.2, and arterial blood gas was 7.42/34/97/96. Negative stool cultures, ova and parasite and Clostridium difficile. Studies - Computerized tomography scan of the abdomen showed diffuse wall thickening throughout the colon, a likely infectious process with shrunken liver, gallstones, ascites small, bilateral pleural effusions and consolidation of the lung bases. Chest computerized tomography scan showed dense consolidation of the lung parenchyma consistent with bilateral pneumonia, mild emphysematous changes in the apices and magnetic resonance cholangiopancreatography of the abdomen showed cholelithiasis without evidence of cholecystitis, no choledocholithiasis, no intrahepatic ductal dilatation, normal common bile duct, liver with cirrhotic ascites and bilateral pleural effusions. HOSPITAL COURSE: Gastrointestinal - The patient was admitted with a colitis, presumed to be Clostridium difficile and significantly increased bilirubin. His antibiotics were changed to Levofloxacin, Flagyl and Vancomycin. Abdominal ultrasound was performed which showed no ductal dilatation with gallbladder sludging and wall thickening. On [**6-7**], the patient's bilirubin went from 9.4 to 5.9. Gastroenterology and Surgery were consulted for colitis and pericolonic fat surrounding on the computerized tomography scan. There was no suspicion for ischemic colitis. The Vancomycin was changed to p.o. dosing. On [**6-9**] the stool was negative for Clostridium difficile. KUB was negative for megacolon. Total parenteral nutrition was started the next day. Upon transfer to the floor, the patient completed a total seven day course of p.o. Vancomycin and intravenous Flagyl for presumed Clostridium difficile colitis. He had diarrhea throughout the remainder of his admission. His bilirubin continued to be in the 8 to 10 level. The patient was then received a video swallow study which showed clear aspiration and a percutaneous endoscopic gastrostomy tube was placed. After placement the patient began to have increased abdominal pain, bloating and decreased bowel sounds. A diagnostic paracentesis was performed which showed secondary bacterial peritonitis with coagulase negative Staphylococcus. A magnetic resonance cholangiopancreatography of the liver was performed with biopsy planned that was ultimately deferred. He received a one week course of Vancomycin. On the day of discharge the patient had a repeat video swallow study which showed much improved swallow function. He was started on pureed foods under supervision. Increased bilirubin which was treated with HC exacerbation was trending down upon discharge. Pulmonary - Upon transfer the patient had a right lower lobe pneumonia. Antibiotics were trimmed to Levofloxacin, Flagyl and Vancomycin. On [**6-6**], he was intubated for a low pH and high pCO2. Bronchoscopy and chest computerized tomography scan were performed. On [**6-7**], the patient was diagnosed with adult respiratory distress syndrome with bilateral infiltrates on chest x-ray and treated with increased positive end-expiratory pressure and recruitment breaths. On [**6-10**], the bilateral infiltrates were improving. On [**6-12**], the patient was weaned from positive end-expiratory pressure. On [**6-12**] he tolerated pressure support ventilation of 14 and 7.5. On [**6-15**], the patient was extubated. He was transferred to the floor and pulmonary issues were stable since. Cardiovascular - On [**6-7**], the patient was intubated for one day and became hypotensive. He was started on Levophed. On [**6-8**], he was weaned off pressors and was hemodynamically stable since. Infectious disease - See above systems for full details. The patient was treated for pneumonia, presumed Clostridium difficile colitis and secondary bacterial peritonitis. He had finished all antibiotic courses upon discharge. Renal - No issues. Heme - The patient has been coagulopathic throughout the admission despite multiple doses of Vitamin K, mostly attributed to his liver disease. He required fresh frozen plasma for percutaneous endoscopic gastrostomy tube placement. He also had low platelets throughout the admission most likely due to splenic sequestration. On the day of discharge his platelet count was in the 70s and H2 blockers were discontinued. He had no gastrointestinal bleeding events. Fluids, electrolytes and nutrition - The patient had hyponatremia throughout much of his admission. It was likely due to syndrome of inappropriate diuretic hormone and was treated with free water restriction. The patient was discharged on total parenteral nutrition but had just started pureed foods prior to discharge. Neurological - Psyche, the patient suffers from post traumatic stress disorder, depression and anxiety. He was sedated throughout much of his Intensive Care Unit stay with Propofol to increase ventilator compliance. He was given Ativan for his anxiety but was discontinued due to concomitant liver disease. His Zoloft was restarted and should be increased to his outpatient dosage. DISCHARGE CONDITION: Stable. DISCHARGE DISPOSITION: To [**Hospital **] Rehabilitation. DISCHARGE DIAGNOSIS: 1. Cirrhosis of the liver 2. Pneumonia 3. Colitis 4. Chronic obstructive pulmonary disease 5. Bacterial peritonitis 6. Depression/anxiety 7. Aspiration risk DISCHARGE MEDICATIONS: 1. Aldactone 50 mg p.o. q. day 2. Flovent 220 mcg, metered dose inhaler 2 puffs b.i.d. 3. Albuterol 2 puffs q.h.s. prn 4. Atrovent 2 puffs q.i.d. 5. Reglan 5 mg intravenously prn 6. Zoloft 60 mg p.o. q.d. 7. Lasix 20 mg p.o. q.d. 8. Protonix 40 mg p.o. intravenously q. day 9. Dilaudid .5 to 1 mg subcutaneously q. 4-6 hours prn 10. Miconazole powder 11. Tylenol 12. Haldol 1 to 2 mg p.o. intravenous, intramuscular prn [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Last Name (NamePattern1) 6834**] MEDQUIST36 D: [**2188-7-4**] 15:51 T: [**2188-7-4**] 16:09 JOB#: [**Job Number 43304**]

[ "253.6", "571.2", "507.0", "008.45", "518.81", "287.5", "567.2", "511.9", "789.5" ]

icd9cm

[ [ [] ] ]

[ "33.24", "96.72", "38.93", "44.32", "99.15", "96.04", "54.91" ]

icd9pcs

[ [ [] ] ]

8726, 8762

8693, 8702

8971, 9665

8783, 8948

1978, 2145

4413, 8671

2167, 2298

2321, 4395

643, 1690

1713, 1951

23,893

171,761

20020

Discharge summary

report

Admission Date: [**2136-11-26**] Discharge Date: [**2136-11-28**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old gentleman with coronary artery disease (status post coronary artery bypass graft), hypercholesterolemia, hypertension, type 2 diabetes mellitus, and multi-infarct dementia who presents with intermittent chest pain times two to three days. The pain changes location and is not associated with shortness of breath; although, it is associated with an increase in fatigue and decreased oral intake. In the Emergency Department, the patient was found to have an irregular rhythm. On electrocardiogram he was found to be flipping from a heart rate of 30 to a heart rate of 140 to 160. The patient remained completely asymptomatic during these episodes without complaints of chest pain, palpitations, or shortness of breath. His blood pressure was for the most part in the 90's-100's, but with rates in the 30's was occasionally transiently in the 80's. PAST MEDICAL HISTORY: 1. Coronary artery disease. (a) Status post myocardial infarction. (b) Coronary artery bypass graft in [**2125**]. 2. Type 2 diabetes mellitus; complicated by peripheral neuropathy. 3. Hypertension. 4. Hypothyroidism. 5. Hypercholesterolemia. 6. Multi-infarct dementia. 7. History of transient ischemic attacks. 8. Gout. 9. Diverticulitis. 10. History of colonic polyps. MEDICATIONS ON ADMISSION: 1. Glyburide 5 mg by mouth twice per day. 2. Levoxyl 50 mcg by mouth once per day. 3. Reminyl 8 mg by mouth twice per day. 4. Aspirin 81 mg by mouth once per day. 5. Lopid 600 mg by mouth twice per day. 6. Zocor 50 mg by mouth once per day. 7. Ferrous sulfate 320 mg by mouth twice per day. 8. Nitroglycerin patch 0.6 mg as needed. ALLERGIES: 1. SULFA. 2. BENZODIAZEPINES. SOCIAL HISTORY: The patient lives in the [**Location (un) 86**] Alzheimer's Center (which is an [**Hospital3 **] facility). The patient denies any history of tobacco smoking or alcohol use. He has a granddaughter who is very dedicated to him. She assists him with his medications. The patient has a very poor memory, but is otherwise independent. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed the patient was afebrile, his heart rate was 69, his blood pressure was 105/51, his respiratory rate was 16, and his oxygen saturation was 97% on room air. Physical examination was notable for a normal first heart sounds and second heart sounds, and there were clear lung sounds bilaterally. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission were notable only for a creatinine of 1.4. The remainder of the patient's laboratories were within normal limits. Thyroid-stimulating hormone was within normal limits. PERTINENT RADIOLOGY/IMAGING: Multiple electrocardiograms obtained in the Emergency Department showed bradycardia with a rate in the 30s and a pattern consistent with atrial bigeminy with blocked APBs as well as episodes of atrial fibrillation and episodes of typical atrial flutter with a heart rate in the 150s. A chest x-ray was clear. CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Coronary Care Unit for close monitoring due to his irregular rhythm and intermittent hypotension. The patient received a [**Company 1543**] SDR303B dual-chamber rate-responsive pacemaker. The patient tolerated the procedure extremely well. At the time of the pacemaker placement, the patient was in a sinus rhythm. However, it was decided since he did have episodes of atrial fibrillation/atrial flutter that he would be amiodarone loaded and started on Coumadin. The patient was started on Coumadin following a Physical Therapy evaluation which showed very minimal fall risk. The patient also received 48 hours of vancomycin intravenously prophylactically. The patient was to be continued on clindamycin prophylactically as an outpatient for several more days. The patient's creatinine, which was elevated at 1.4 on admission, decreased back down to his baseline with some hydration. The patient's thyroid-stimulating hormone was also checked and was found to be within normal limits, and he was continued on his home dose of levothyroxine. Prior to discharge, the patient was also started on a low dose of Toprol-XL due to his history of coronary artery disease. CONDITION AT DISCHARGE: Condition on discharge was stable, with a stable heart rate in the 70s to 80s, and feeling well. DISCHARGE STATUS: The patient was to be discharged back to his extended care facility (which is [**Location (un) 86**] Alzheimer's Center). The patient was to receive [**Hospital6 1587**] to assist with medication management and for blood pressure checks as well as INR checks. DISCHARGE DIAGNOSES: 1. Sick sinus syndrome. 2. Status post pacemaker placement. 3. Atrial fibrillation. 4. Atrial flutter. 5. Coronary artery disease. 6. Type 2 diabetes mellitus. 7. Hypertension. 8. Hypothyroidism. 9. Hypercholesterolemia. 10. Multi-infarct dementia. 11. Cerebrovascular disease. MEDICATIONS ON DISCHARGE: 1. Levothyroxine 50 mcg p.o. q.d. 2. Galantamine hydrobromide (Reminyl) 8 mg by mouth twice per day. 3. Aspirin 81 mg by mouth once per day. 4. Gemfibrozil 600 mg by mouth twice per day. 5. Simvastatin 50 mg by mouth once per day. 6. Sertraline 25 mg by mouth once per day. 7. Docusate 100 mg by mouth twice per day. 8. Ferrous sulfate 320 mg by mouth twice per day. 9. Glyburide 5 mg by mouth twice per day. 10. Clindamycin 300 mg by mouth q.6h. (for a total of six doses). 11. Amiodarone 200 mg by mouth three times per day times one month; followed by amiodarone 200 mg by mouth once per day after the one month. 12. Multivitamin one tablet by mouth every day. 13. Metoprolol sustained release 25 mg by mouth once per day. 14. Coumadin 2.5 mg by mouth at hour of sleep (to be started on the Friday after discharge; [**11-30**]). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with the Cardiology Electrophysiology Device Clinic on [**12-6**] at 10 p.m. 2. The patient was instructed to follow up with his primary care physician (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 53928**]) in one to two weeks; he was asked to make a follow-up appointment. 3. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] in the Cardiology Center on [**2136-12-31**] at 3 p.m. [**First Name8 (NamePattern2) 610**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Dictated By:[**Name8 (MD) 4993**] MEDQUIST36 D: [**2136-11-28**] 17:00 T: [**2136-12-1**] 04:46 JOB#: [**Job Number 53929**]

[ "427.31", "427.81", "V45.81", "414.00", "401.9", "412", "427.32", "272.0", "250.00" ]

icd9cm

[ [ [] ] ]

[ "37.72", "37.83" ]

icd9pcs

[ [ [] ] ]

4810, 5108

5135, 5990

1441, 1826

6023, 6820

3176, 4394

4409, 4788

118, 1000

1023, 1415

1843, 3147

14,460

163,907

27950

Discharge summary

report

Admission Date: [**2142-10-17**] Discharge Date: [**2142-10-21**] Date of Birth: [**2097-6-12**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: DOE Major Surgical or Invasive Procedure: Pericardiectomy via sternotomy [**2142-10-17**] History of Present Illness: 45 y/o male w/recurrent pleural effusions, recent MR [**First Name (Titles) 654**] [**Last Name (Titles) 68071**]e pericarditis Past Medical History: Question of Lyme disease, completed 3 week course of antibiotics No history of rheumatologic/pulmonary/cardiac complaints. Social History: SocHx: Lives at home in [**Location (un) 12670**] with wife and children, works in sales from home. No tob, social alcohol, no drugs. Family History: FamHx: Both parents alive and well (mother with HTN), all siblings alive and well, three children alive and well. No history of sudden cardiac death in family. Physical Exam: unremarkable pre-op exam Pertinent Results: [**2142-10-20**] 05:22AM BLOOD WBC-6.2 RBC-3.88* Hgb-12.5* Hct-35.3* MCV-91 MCH-32.2* MCHC-35.3* RDW-14.4 Plt Ct-241 [**2142-10-17**] 01:11PM BLOOD PT-15.8* PTT-27.1 INR(PT)-1.4* [**2142-10-17**] 01:11PM BLOOD PT-15.8* PTT-27.1 INR(PT)-1.4* [**2142-10-20**] 05:22AM BLOOD Glucose-101 UreaN-25* Creat-0.9 Na-134 K-4.1 Cl-99 HCO3-28 AnGap-11 PATIENT/TEST INFORMATION: Indication: Pericarditis. Intra-op TEE for Pericardial Stripping. Height: (in) 71 Weight (lb): 185 BSA (m2): 2.04 m2 Status: Inpatient Date/Time: [**2142-10-17**] at 10:32 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW01-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.2 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 4.5 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.4 cm (nl <= 5.0 cm) Left Ventricle - Ejection Fraction: 40% to 50% (nl >=55%) Aorta - Valve Level: 2.4 cm (nl <= 3.6 cm) Aorta - Ascending: 3.4 cm (nl <= 3.4 cm) Aorta - Arch: 2.6 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: *2.6 cm (nl <= 2.5 cm) Aortic Valve - LVOT VTI: 9 Aortic Valve - LVOT Diam: 2.3 cm INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Mild spontaneous echo contrast in the body of the RA. Depressed RAA ejection velocity (<0.2m/s). Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Normal regional LV systolic function. Mild global LV hypokinesis. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV wall thickness. Moderately dilated RV cavity. Severe global RV free wall hypokinesis. AORTA: Normal aortic root diameter. Focal calcifications in aortic root. Normal ascending aorta diameter. Normal aortic arch diameter. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. No MS. Trivial MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: Small pericardial effusion. Pericardium appears thickened. Pericardial calcifications. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally Conclusions: 1. The left atrium is mildly dilated. Mild spontaneous echo contrast is seen in the body of the right atrium. The right atrial appendage ejection velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. The interatrial septum bulges into the LA. 2. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is mildly depressed (40-50). Septal bounce is noted consistent with RV pressure variation with respiration. 3. The right ventricular cavity is moderately dilated. There is severe global right ventricular free wall hypokinesis. 4. MV inflow and TV inflow patterns show respiratory variation consistent with restrictive physiology. 5. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 6. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. 7. The mitral valve leaflets are structurally normal. Trivial mitral regurgitation is seen. 8. There is a small pericardial effusion (3-4mm). The pericardium appears thickened (3-4mm) and calcified. 9. Post pericardial stripping, LVEF 50%. RV free wall motion improved to moderate to severe hypokinesis. 10. Remaining exam unchanged. All findings discussed with surgeons at the time of the exam. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2142-10-18**] 07:34. [**Location (un) **] PHYSICIAN: Brief Hospital Course: Direct admission to OR on [**2142-10-17**], underwent pericardiectomy, post-op was taken to the CSRU in stable condition. He initially had ventricular ectopy, requiring IV amiodarone, but his rhythm has remained stable, and the amiodarone was subsequently d/c'd. He stayed in the ICU for PA monitoring with aggressive diuresis. He was transferred to the telemetry floor on post-op day # 2. He has remained hemodynamically stable, and ready to be discharged home today, POD #4 Medications on Admission: Lasix 40 mg [**Hospital1 **] Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 2 weeks: Take with food. Disp:*56 Tablet(s)* Refills:*0* 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: Constrictive pericarditis Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wound, pat dry with a towel. Call our office for temp>101.5, sternal drainage. Do not use creams, lotions, or creams on wounds. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 11907**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2142-10-21**]

[ "511.9", "423.2" ]

icd9cm

[ [ [] ] ]

[ "34.09", "37.31" ]

icd9pcs

[ [ [] ] ]

6934, 6996

5311, 5790

327, 377

7066, 7074

1070, 1411

7400, 7575

849, 1010

5869, 6911

7017, 7045

5816, 5846

7098, 7377

1437, 5250

1025, 1051

284, 289

405, 534

5288, 5288

556, 681

697, 833

12,537

138,457

18126+56914

Discharge summary

report+addendum

Admission Date: [**2120-8-9**] Discharge Date: [**2120-8-12**] Service: BLUE SURGERY HISTORY OF THE PRESENT ILLNESS: The patient is a 79-year-old male with a complex past medical history transferred from [**Hospital3 3583**]. The patient had a UTI for which he had received a course of Levaquin. During the course of antibiotics he developed lower abdominal pain, dry heaves, and significant diarrhea. At [**Hospital3 3583**], the patient was found to be slightly hypotensive. He had a KUB and it showed a dilated colon. Abdominal CT performed at [**Hospital3 6265**] also demonstrated a dilated transverse colon. He was felt to need surgical intervention and was transferred to the [**Hospital1 **] for further management. PAST MEDICAL HISTORY: 1. Colon cancer, status post a colectomy 16 years ago. 2. Cancer cancer. 3. Atrial fibrillation, off Coumadin due to a history of GI bleed. 4. Cardiomyopathy with an EF of around 25%. 5. History of peptic ulcer disease. 6. Previous sternotomy with resection of a thymoma. 7. Status post left lower lobe wedge resection for cancer, status post TURP. ADMISSION MEDICATIONS: 1. Amiodarone. 2. Carafate. 3. Protonix. 4. Lopressor. 5. Lasix. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient was afebrile at 97.5 with a heart rate of 75 and blood pressure of 111/44, saturating 96% on 2 liters. He was alert and oriented, clear to auscultation. He had a significant murmur, grade IV. Abdomen: Soft, but distended and tender to palpation profusely. He also had guarding. LABORATORY/RADIOLOGIC DATA: A KUB showed a dilated cecum and small bowel. His white count on admission was 38. Troponin positive at 136. LFTs were normal. Amylase and lipase were normal. A BUN and creatinine were 52 and 3.4. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit with a preliminary diagnosis of C. difficile colitis. Due to a murmur, PTE was obtained. PTE demonstrated an aortic dissection. The Vascular Service was consulted and an MRA was obtained. MR demonstrated a type A dissection involving the root of the aorta and the left brachycephalic. The aortic dissection continued down to the level of the SMA. The SMA and the celiac access were supplied by the true lumen. The Thoracic Service was consulted for intervention regarding this aortic dissection. The Cardiothoracic Service felt that he was not a surgical candidate due to his age, elevated creatinine, and risk of bleeding. Given this, the patient was placed on an Esmolol drip which he did not tolerate and subsequently a Diltiazem drip for rate control. It was decided not to intervene his aortic dissection. His abdominal examination improved and his white count trended downwards being 29 at the time of discharge. He was kept on broad spectrum antibiotics, ampicillin, ceftriaxone, and Flagyl as treatment for his ischemic or C. difficile colitis. After three days in the hospital, the patient's renal function was worsening with his creatinine peaking at 4.2 on the 15th. After a discussion with the family, they decided that the patient would not want hemodialysis and they decided that making him CMO would be the most appropriate measure. It was decided after discussion with the patient's primary care physician to then make him CMO at that institution. DISCHARGE DIAGNOSIS: 1. Clostridium difficile versus ischemic colitis, with sepsis. Respiratory Failure 2. Type A aortic dissection. 3. Cardiomyopathy with an EF of 25%, Congestive heart failure 4. Acute on chronic renal failure. 5. Prostate cancer. 6. History of Colon cancer 7. History of Lung Cancer 8. History of Thymoma DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. b.i.d. 2. Sucralfate 1 gram p.o. q.i.d. 3. Heparin subcutaneously. 4. Ampicillin 1 gram IV q. six hours. 5. Ceftriaxone 1 gram IV q. 24 hours. 6. Flagyl 500 mg IV q. eight hours. 7. Protonix 40 mg IV q. 24 hours. 8. Atrovent. 9. Albuterol. 10. Haldol p.r.n. 11. Lorazepam 0.5 to 1 mg IV q. four hours. 12. Tylenol. 13. Diltiazem. [**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**] Dictated By:[**Last Name (NamePattern1) 40667**] MEDQUIST36 D: [**2120-8-12**] 03:55 T: [**2120-8-12**] 18:02 JOB#: [**Job Number 50139**] Name: [**Known lastname 3654**], [**Known firstname **] Unit No: [**Numeric Identifier 9260**] Admission Date: [**2120-8-9**] Discharge Date: [**2120-8-13**] Date of Birth: [**2041-3-19**] Sex: M Service: BLUE SURGERY DISPOSITION: Deceased. After family discussion as well as with the health care team, it was decided the patient would be made comfort measures only. He was placed on Morphine and expired on the morning of [**8-13**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 3676**] Dictated By:[**Last Name (NamePattern1) 799**] MEDQUIST36 D: [**2120-8-13**] 06:43 T: [**2120-8-13**] 06:46 JOB#: [**Job Number 9261**]

[ "038.9", "585", "518.82", "008.45", "427.5", "410.91", "441.03", "557.0", "785.59" ]

icd9cm

[ [ [] ] ]

[ "38.91", "89.64", "38.93" ]

icd9pcs

[ [ [] ] ]

3753, 5087

3420, 3730

1867, 3399

1146, 1292

1307, 1849

766, 1123

47,448

190,637

37409

Discharge summary

report

Admission Date: [**2157-6-8**] Discharge Date: [**2157-6-21**] Date of Birth: [**2103-10-10**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: exploratory laparotomy lysis of adhesions reduction of internal henia History of Present Illness: This is a 53 year old male with a longstanding history of Chron's colitis s/p ileocecal anastomosis who has had increasing peri-umbilical abdominal pain associated with weight loss and anorexia for the past two months. Patient is here today for exploratory laparotomy. Past Medical History: UPJ resection for stenosis, ileocecal resection with ileocolic anastomosis for Chron's disease Social History: smokes half pack per day, 4 beers daily, worked at paper mill Family History: No history of irritable Bowel disease, paternal cardiac disease Physical Exam: VS: Gen: alert and oriented x3 CV: regular,rate, rhtymn, no murmur, gallops or rub, normal s1, s2 Resp: lungs clear bilaterally GI: abdomen Soft, non-tender, mildly distended, passing flatus,bowel movements. Tolerating a regular diet. No nausea or vomitting Extremities: no edema 2+ pulses GU:voiding adqeuate amount Incision: Abdominal incision with staples clean, dry intact, mild erythema at incision line Pertinent Results: [**2157-6-8**] 06:15PM HCT-40.6 [**2157-6-8**] 06:15PM SODIUM-139 POTASSIUM-3.3 CHLORIDE-104 [**2157-6-8**] 06:15PM MAGNESIUM-1.7 [**2157-6-8**] 06:15PM HCT-40.6 Brief Hospital Course: Patient was admitted to the East general surgery service under the care of Dr. [**Last Name (STitle) **] following an uncomplicated exploratory laparotomy and reduction of internal hernia. Pain was controlled with Dilaudid patient care analgesia and patient was kept nothing by mouth. On Post operative day 1 patient was given three 500 cc NS boluses for low urine output, which improved following the third bolus. Abdomen was soft, non distended, tender to palpation. He was hypokalemic and hypomagnesemic and was repleted accordingly. He was started on clear sips and tolerated it well. His abdominal incision was noted to have serosanguineous drainage but no odor. He did complain of severe abdominal pain and while he was on Dilaudid patient care analgesia received boluses intravenously. On post operative day two his home medications were re-started and patient was advanced to limited clears. At this point the patient was recovering well. On post operative day three his pain was well controlled and patient care analgesia Dilaudid dose was decreased. Patient did not tolerate the decrease in pain medication and subsequently was changed back to previous settings. At this time he complained of severe abdominal pain, worse ever and nausea. His abdomen was also noted to be firm and distended , no flatus and decreased bowel sounds. At that time his diet was changed to nothing by mouth. Patient became hypertensive to 190/110, tachypneic 32, anxious, diaphoretic with tremors. He reported feeling agitated and light headed. He denied chest pain, dizziness or palpitations. Abdominal xray was done to rule out postoperative ileus versus small bowel obstruction. He continued to have increase abdominal pain, distension and nausea. Patient also became agitated and diaphoretic with tremors. Given his history of alcohol abuse was started on a CIWA scale. Despite receiving multiple doses of Ativan intravenously his agitation worsened. Patient was then triggered for unstable vital signs and marked nursing concern. A Nasogastric tube was also placed to decompress his abdomen which had bilious output. Patient was transferred to the intensive care unit for further monitoring of alcohol withdrawal and Delirium Tremens. While in the intensive care unit the patient was aggressively management on CIWA protocol for alcohol withdrawal. Patient became febrile and Cat scan of abdomen/pelvis was completed to rule out intra-abdominal causes. Patient was started on Vancomycin, Cipro floxacillin and Flagyl for empiric coverage. Patient continued to output .Patient be febrile and CTA of chest was completed to rule out pulmonary embolism. In order to complete the study however the patient required large amounts of sedation. To protect his airway for the study, the patient was intubated. Patient was successfully weaned off the ventilator thereafter and extubated approximately 24 hours after intubation. Post-extubation, patient was no longer agitated and did not require any Ativan per CIWA protocol. He did not remember why he had come to the hospital however acknowledged that he has a problem with alcohol. He expressed interest in seeing the social worker for this issue. Patient no longer required intensive care unit level care and was safely discharged back to his primary team for further management. Patient post operatively continued was slow to progress a Nasogastric tube remained in place for abdominal decompression. He continued to require electrolyte repletion for hypokalemia and hypomagnesemic. Nasogastric tube was subsequently discontinued on [**2157-6-15**] after patient abdominal distension was improving. His electrolytes improved shortly thereafter. Patient was also fluid volume overloaded and was given Lasix intravenously and his Lisinopril was restarted. Patient was having bowel movements but denied having flatus. He was given Dulcolax suppository on [**2157-6-16**] and [**6-17**]. Patient continued to have bowel movements with more flatus, abdomen was softly distended. Patient complaint of intermittent nausea but no emesis and was receiving Zofran intravenously. He was tolerating clear sips to clear liquids. Patient was afebrile and intravenous antibiotics, Vancomycin, Ciprofloxacin, and Flagyl was discontinued. He was tolerating clear liquids with no nausea and his diet was advanced to regular. His intravenous fluids and intravenous Dilaudid were also discontinued. He was started on oral Dilaudid with complaints of abdominal pain. On [**2157-6-20**] Tylenol around the clock was started. Mr. [**Known lastname 84089**] is doing well, continues to report mild abdominal cramping after eating, abdomen is soft and distended but unchanged. His pain is better controlled and he will be discharged home on [**2157-6-21**]. His staples were removed today and steri strips were placed, incision is clean dry and intact with mild erythema around incision line. He will resume his home dose of Humira and Entocort. He will follow up with Dr. [**Last Name (STitle) **] in [**11-20**] weeks. Medications on Admission: Lisinopril 5mg QD Hydrochlorothiazide 25mg QD Humira dosage unknown Asacol 400mg PO BID Entocort 3 capsules QD Discharge Medications: 1. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain for 1 weeks: do not drive while taking pain medication. do not exceed more than 4000mg of tylenol (acetaminophen) daily. Disp:*25 Tablet(s)* Refills:*0* 4. Hydrochlorothizide 25 mg daily 5. Humira (dosage unknown) 6. Entocort 3 capsules daily Discharge Disposition: Home Discharge Diagnosis: Reduction of internal hernia,lysis of adhesions, reduction of internal hernia. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the East general surgery service under the care of Dr. [**Last Name (STitle) **]. You underwent an exploratory laparotomy, lysis of adhesion, and reduction of internal hernia. You have an abdominal incision with staples, please monitor for redness and swelling. Please call Dr. [**Last Name (STitle) **] office or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until cleared by your surgeon. You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry.Your staples will be removed at your follow up appointment with Dr. [**Last Name (STitle) **] in [**11-20**] week [**Telephone/Fax (1) 9011**]. 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 wheeze. *You are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You 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. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. You will be given a prescription for Dilaudid to help with your pain. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. When you get home please schedule a follow up appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks [**Telephone/Fax (1) 9011**]. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in [**11-20**] week [**Telephone/Fax (1) 9011**]. Completed by:[**2157-6-21**]

[ "552.8", "560.81", "291.0", "555.9", "E878.8", "997.4", "303.91", "305.1", "275.2", "560.1", "518.0", "E849.7", "276.8" ]

icd9cm

[ [ [] ] ]

[ "96.71", "54.59", "53.9", "99.77", "96.04" ]

icd9pcs

[ [ [] ] ]

7383, 7389

1615, 6684

326, 398

7512, 7512

1421, 1592

10211, 10337

911, 976

6845, 7360

7410, 7491

6710, 6822

7663, 9257

991, 1402

9289, 10188

272, 288

426, 698

7527, 7639

720, 816

832, 895

31,381

117,080

23816

Discharge summary

report

Admission Date: [**2101-9-16**] Discharge Date: [**2101-9-19**] Date of Birth: [**2039-3-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1580**] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: none History of Present Illness: 62 yo male with Hep C cirrhosis and HCC who presented to OSH today after noting several weeks of worsening abd girth and associated diffuse pain, as well as new lower extr edema. The pt also experienced two episodes of BRBPR on the day of admission, which is what prompted him acutely to seek medication attention. Pt's HCT at the OSH was found to be 29 (unclear baseline) and he was noted to be hypotensive with an SBP first in the 80s-90s (close to baseline per pt) and then lower to the 70s. The pt was started on a dopamine gtt to support his BP and was transferred to [**Hospital1 18**] for further care. In the [**Hospital1 18**] ED, initial vitals were HR 98, R 16, 92/58, 96% RA. The pt had an NG levage which was negative and a transfusion of 2 units pRBCs was initiated. On ROS, the endorses occasional chills but no fevers. No chest pain or SOB. Abd pain as above but no nausea or vomiting. No urinary sxs. Blood per rectum as described above but otherwise no change in stool. No neuro or MSK sxs. Past Medical History: Hep C complicated by HCC CAD s/p LAD stenting and ICD impant COPD, 35 pack year smoking hx psoriasis Social History: Former construction worker, now diabled. Prior smoker. Denies EtOH. Family History: Pt is adopted and thus not aware of FH. Physical Exam: Gen: Adult male, chronically ill appearing but no acute distress. HEENT: PERRL, EOMI. MMM. Conjunctival icterus. Neck: Supple, without adenopathy or JVD. No tenderness with palpation. Chest: CTAB anterior and posterior. Cor: Normal S1, S2. RRR. No murmurs appreciated. Abdomen: Firm and distended with minimal diffuse tenderness. +BS, no HSM. Extremity: Warm, pitting edema to mid thighs bilat. 2+ DP pulses bilat. Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all extremities. Sensation intact grossly. Pertinent Results: [**2101-9-16**] 08:21PM WBC-11.5* RBC-3.18* HGB-9.8* HCT-29.6* MCV-93 MCH-30.9 MCHC-33.2 RDW-19.2* [**2101-9-16**] 08:21PM GLUCOSE-70 UREA N-87* CREAT-4.2* SODIUM-130* POTASSIUM-6.4* CHLORIDE-98 TOTAL CO2-13* ANION GAP-25* . CT Abd/Pelvis 1. Very limited examination due to no IV contrast and a minimal amount of oral contrast within loops of bowel. No CT findings to suggest obstruction. Gas-filled loops of large bowel, predominantly the transverse may suggest ileus. 2. Diffusely heterogeneous and enlarged liver consistent with patient's known cirrhosis and multifocal HCC. Mild-to-moderate amount of ascites within the abdominal cavity. 3. Atherosclerotic disease within the coronary circulation and aorta. 4. Known left renal cyst. 5. Small bilateral pleural effusions. Mild ascites. . Abd Ultrasound 1. Multiple confluent nodules in the right lobe of the liver. Multiple confluent solid masses identified in the left lobe of the liver. The liver is markedly enlarged but no biliary dilatation. 2. Patent hepatic vasculature. Brief Hospital Course: The pt was admitted to the medical ICU for closer care and monitoring. Although initial attempts were made to wean him from the dopamine he had arrived with, his pressor requirements actually increased, his renal failure worsened and his overall clinical status deteriorated. Radiologic evaluation of the abdomen demonstrated a markedly enlarged liver but no ascites that could be tapped. With clinical deterioration, the pt's mental status also declined. He and his family members made clear that he would not want aggressive measures to prolong his life in the face of a poor overall prognosis, and thus the pt's goals of care were transitioned to comfort. Pressors were stopped and morphine was used to relieve the pt's abdominal pain. Approximately one day after making this transition, the patient expired with his family at his side. The pt's PCP and oncologist were notified of his passing. An autopsy was declined. Medications on Admission: spironolactone 25 mg daily Coreg 3.125 mg [**Hospital1 **] trazodone 50 mg daily Lipitor 80 mg daily Altace 5 mg [**Hospital1 **] Plavix 75 mg daily Advair daily Spiriva daily Requip 2 mg daily Oxycodone 20 mg PRN Ativan 0.5 mg PRN Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: liver failure hepatocellular carcinoma renal failure Discharge Condition: expired [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1583**] MD, MSC, MPH[**MD Number(3) 1584**]

[ "456.8", "584.9", "560.1", "V45.02", "276.7", "428.0", "155.0", "789.59", "428.22", "570", "070.44", "276.2", "496", "572.3", "571.5", "276.1", "414.01", "578.1", "458.9", "537.89" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

4515, 4524

3277, 4201

343, 349

4620, 4767

2217, 3254

1615, 1656

4483, 4492

4545, 4599

4227, 4460

1671, 2198

276, 305

377, 1389

1411, 1513

1529, 1599

19,626

190,506

21082

Discharge summary

report

Admission Date: [**2120-5-23**] Discharge Date: [**2120-5-26**] Date of Birth: [**2043-7-14**] Sex: F Service: Cardiac Care Unit HISTORY OF PRESENT ILLNESS: The patient is a 76 year-old female with hypertension and hyperlipidemia who presents with acute inferoposterior myocardial infarction. The patient reports she has had stuttering chest pain for the past two weeks but was constant since 8 P.M. on the day of admission. The patient reports that the pain was in her left arm and was associated with diaphoresis. The patient went to [**Hospital3 418**] Emergency Room where an EKG showed 2 to [**Street Address(2) 2051**] elevations in 2, 3 and F and posterior ST elevations. Patient was noted to be bradycardic to the 40s, was given Atropine with rate to the 90s. Patient was also given aspirin, heparin and a 2B3A. Patient was pain free on transfer. Cardiac catheterization at [**Hospital3 **] revealed single vessel disease. A stent to the RCA was attempted but they were unable to cross the RCA lesion and the procedure was aborted. The ST elevations persisted but the patient remained pain-free. REVIEW OF SYSTEMS: The patient denied dyspnea on exertion, denied paroxysmal nocturnal dyspnea or orthopnea. She had reported chest pain as previously described. Patient also reported any syncopal or presyncopal episodes. Patient reported past medical history of hypercholesterolemia and hypertension but no other known coronary artery disease. PAST MEDICAL HISTORY: 1) Total abdominal hysterectomy. 2) Status post appendectomy. 3) Mastoid surgery. 4) Hypertension. 5) Hypercholesterolemia. SOCIAL HISTORY: The patient has three daughters and one son. She currently smokes [**1-26**] pack per day for the past 50 years. Denies alcohol and denies drug use. MEDICATIONS ON ADMISSION: Lescol XL 40 q day. No known drug allergies. PHYSICAL EXAMINATION: On admission the patient was afebrile, blood pressure 190/106, heart rate in the 80s, respirations 16. She was a well appearing female in no acute distress. Her cardiac examination was regular rhythm with no murmurs. There was an S4 but no rubs. The lungs were clear to auscultation. Her abdomen was soft, nontender, nondistended. There was no lower extremity edema and her pulses were intact bilaterally. An EKG on presentation was normal sinus rhythm at 92, ST elevations in 2, 3 and F with elevations in 3 greater than 2. She had ST depressions in 1, L and V1 through V4. Post cardiac catheterization she had persistent ST elevations. LABORATORY VALUES ON ADMISSION: White count 9.9, hematocrit 32, platelets are 214, INR 1.0. Chem-7: sodium 140, K of 3.6, chloride 105, bicarb 24, BUN 27, creatinine 1.2. Chest x-ray at the outside hospital revealed a calcified aorta, no evidence of congestive heart failure. It did show a hiatal hernia. SUMMARY OF HOSPITAL COURSE: 1. Cardiac, coronary artery disease: The patient had an inferoposterior myocardial infarction with ST elevations. She was brought to the catheterization laboratory but there was an unsuccessful attempt at revascularization of the RCA. The patient had persistent ST elevations post cardiac catheterization. Also at cardiac catheterization she was found to have a PA pressure of 20/7. Cardiac output was 4.9, cardiac index 2.6. She had a wedge of 7. The patient was given aspirin and a statin. She was also started on aggressive beta blockade and this was increased as tolerated. She was initially started on an ACE inhibitor. However, she had a rising creatinine at the time during the hospitalization and therefore the ACE inhibitor was held at the time of discharge. Patient had no residual lesions, no LAD or left circumflex lesions and the patient will follow up with Dr. [**Last Name (STitle) 284**] for her cardiology care. 2. Blood pressure: The patient was very hypertensive on admission. She was started on a nitro drip at 4 mcg per kilogram per minute. The patient was given intravenous Lopressor as well as p.o. Lopressor and the nitroglycerine was successfully titrated off. The patient's blood pressure was well controlled on her beta blocker. 3. Vascular: The patient was noted to have a bruit over her right groin after the cardiac catheterization. Femoral ultrasound revealed a small common femoral AV fistula on the right. Vascular surgery was consulted. Per their report the patient will follow up in six weeks time for a repeat ultrasound and will follow up with Dr. [**Last Name (STitle) 43230**] for further monitoring. 4. Anemia: The patient has a baseline anemia with a hematocrit on admission of 31. Her iron studies reveal anemia of chronic disease. The patient's hematocrit dropped to 26 on [**5-24**] for an unclear reason. The patient was given 2 units of packed red blood cells with appropriate bumps. She had no evidence for active bleeding. Patient's hematocrit bumped appropriately and should be further monitored as an outpatient. 5. Chronic renal insufficiency: The patient had an elevated creatinine to 1.5 on the day of discharge. This was likely due to a component of dehydration as well as post cardiac catheterization after receiving [**Male First Name (un) **]. The patient was given a 500 cc bolus and her creatinine decreased to 1.4 just prior to discharge. The patient will follow up with her primary care physician in the week following discharge for further monitoring of her hematocrit as well as her creatinine. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: ST elevation myocardial infarction. Total occlusion of RCA. Anemia. AV femoral fistula. DISCHARGE MEDICATIONS: Aspirin 325 q day, Atorvastatin 80 q day, Toprol XL 150 q day, Ambien p.r.n.. FOLLOW UP PLANS: Patient will follow up with her primary care physician in the week following discharge for further monitoring of her hematocrit as well as her renal function. The patient will follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] in four weeks time for cardiology follow up. The patient will also follow up with vascular surgery with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in six weeks times. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**] Dictated By:[**Name8 (MD) 12502**] MEDQUIST36 D: [**2120-5-26**] 17:30 T: [**2120-5-28**] 07:51 JOB#: [**Job Number 55969**]

[ "285.9", "272.0", "998.2", "305.1", "410.31", "401.9", "414.01", "593.9", "997.2" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5558, 5647

5671, 6460

1828, 1875

2880, 5474

1898, 2560

1153, 1482

179, 1133

2575, 2852

1505, 1634

1651, 1801

5499, 5537

3,559

194,942

6316

Discharge summary

report

Admission Date: [**2161-6-14**] Discharge Date:[**2161-6-24**] Date of Birth: [**2096-12-10**] Sex: F Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: This is a 64-year-old female that was a preoperative admission for a right foot/ankle reconstruction with external fixation secondary to Charcot deformity caused by diabetes. The patient states that her recent health history has been much improved. The patient states she has chronic anemia which has been well controlled with her last hematocrit check of 35 on [**2161-6-10**]. The patient is also status post panniculectomy by approximately two months and states she has been doing well since that procedure. The patient has no other events or complaints. PAST MEDICAL HISTORY: Status post panniculectomy times approximately two months. Severe bilateral lower extremity lymphedema. Bilateral Charcot deformities. Diabetes mellitus type 1. Hypertension. Status post myocardial infarction. Status post coronary artery bypass graft times two. Glaucoma. Hypothyroidism. Hyperlipidemia. Gout. Hypercholesterolemia. Coronary artery disease. Methicillin resistant Staphylococcus aureus history. ALLERGIES: The patient denies any known drug allergies. MEDICATIONS: 1. Rhinocort inhaler. 2. Timoptic eyedrops. 3. Humalog NPH insulin 28 units in the morning, 12 units at night. 4. Amaryl 2 mg q day. 5. Actose 45 mg q day. 6. Xalatan. 7. Atenolol 50 mg q day. 8. Levoxyl 75 mcg q day. 9. Lasix 120 mg in the morning and 120 mg at night. 10. Allopurinol 300 mg q day. 11. Lipitor 20 mg q day. 12. K-Dur 20 mg in the morning, 20 mg at night. 13. Isosorbide 60 mg q day. 14. Detrol LA 4 mg q day. 15. Lisinopril 10 mg q day. 16. Procrit 10,000 units subq every Tuesday. PHYSICAL EXAMINATION: On admission the patient is generally alert and oriented times three and in no apparent distress but is obese. The patient's head, eyes, ears, nose and throat examination shows pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Mucosal membranes are supple and intact. There is no lymphadenopathy. The patient's chest examination shows lungs are clear to auscultation bilaterally with no wheezing, crackles or rales. The patient's cardiovascular examination shows a heart with a regular rate and rhythm. No murmurs, gallops or rubs. The patient's abdominal examination shows the abdomen is soft, nontender, nondistended with no organomegaly. Bowel sounds are times four. The patient is obese and is status post panniculectomy. The patient's neurological examination shows cranial nerves 2 through 12 are intact. The patient's lower extremity examination shows she has severe lymphedema bilaterally. There are signs of previous ulceration on the plantar aspect of the right foot that is now healed. There are no signs of infection. The patient has a Charcot deformity mostly at the ankle and right foot which is inverted. Her dorsalis pedis and posterior tibial pulses are nonpalpable, most likely secondary to lymphedema. Protected sensations are diminished. There are small keratosis on the lateral aspect around the lateral malleolus due to pressure. There is no sign of infection currently in the foot. HOSPITAL COURSE: On hospital day one the patient was admitted and was preoped accordingly for the pending procedure. The patient received CBC, Chem 7 studies as well as chest x-ray and foot films. The patient also had antibiotic therapy initiated consisting of Vancomycin and Levaquin. On hospital day two, the patient had her Charcot foot reconstruction with external fixation of the right foot. The corresponding operative note can be found within the [**Hospital 228**] medical record. The patient did however tolerate the procedure and anesthesia well and without apparent complications. The patient following the procedure remained intubated and was transferred to the SICU for the first night. The patient remained intubated simply because of the length of the procedure and the patient did receive approximately three liters of fluid to compensate for a large volume loss during the procedure. At the patient's postop check she had no events or complications and her vital signs were stable and intact. The patient's lungs were clear to auscultation bilaterally and her heart had a regular rate and rhythm. The patient's dressings were clean, dry and intact. The patient had a JP drain intact and functioning properly. External fixation device was also in place and stable. The foot was warm and had good coloration. On hospital day three the patient was extubated and was doing quite well postoperatively. She was alert, oriented times three at the time of her examination and denied any nausea, vomiting, fevers, chills, diarrhea, as well as headache, chest pain, shortness of breath or abdominal pain. The patient states that she felt well and denied any pain or discomfort. The patient's CBC and Chem 7 studies were stable and within normal limits for this patient. Her dressings remained clean, dry and intact with some moderate strike through. Dressings were left in place. Her neuromuscular and vascular functions were intact and the external fixation was firmly in place and stable. Lungs were clear to auscultation bilaterally and her heart had a regular rate and rhythm. The remainder of the [**Hospital 228**] hospital course remained uneventful with her vital signs stable and intact. The patient was in no apparent distress. Her CBC and Chem 7 studies well within normal ranges for this patient. The following exceptions to this hospital course should be noted. On hospital day five, the patient was noted to be slightly shortness of breath during the examination. She also appeared to have some mild distress with her breathing while using her accessory muscles to assist. The patient's lungs had some slight rales detected bilaterally at the basal levels. There was no wheezing or crackles upon the lung examination. A chest x-ray was performed that showed some lower lobe atelectasis bilaterally. Also showed an indication of mild congestive heart failure. Since the patient's surgical procedure she was being hydrated aggressively because of her volume loss during the procedure. It was felt that the patient had received enough fluid and that this was causing her shortness of breath and mild congestive heart failure per x-ray. It was determined to discontinue the patient's fluids and also to aggressively continue incentive spirometry. On hospital day four it is noted that the patient had hematocrit drop to 24.8. It was determined that this was due to a combination of patient's chronic anemia and a large volume loss during the procedure so the patient received a transfusion of one unit of packed red blood cells which resulted in her hematocrit bumping up to 26.6 the following day. On hospital day eight, it was noted that the lateral incision site had a small area of necrosis which was felt to be secondary to skin tension during the closure procedure. At this time two of the sutures were removed to allow for some extra skin relaxation. The patient also had some mild serous drainage coming from this opened area so the dressing changes were changed to have 1/4 strength Betadine soaked gauze packed into this open area. In addition it was noted that there were some mild serous drainage coming out of the medial incision so as well 1/4 strength Betadine dressing was placed on this wound as well. In addition with the patient's mild congestive heart failure by chest x-ray and shortness of breath the patient was also diuresed with Lasix and continued to draw for approximately one to two liters of fluid in excess per day. The patient's shortness of breath improved with the removal of the fluid and the patient claimed that she was feeling much better and breathing much easier. The patient was also removed from her breathing mask so that she was sating at 97% on room air. In addition would cultures taken intraoperatively showed a resistant species of Enterobacter cloacae so the patient's antibiotics were changed to Meropenum which sensitivity showed the bacteria species was sensitive to. The remainder of the [**Hospital 228**] hospital course continued uneventfully. The patient was followed by the [**First Name4 (NamePattern1) 3208**] [**Last Name (NamePattern1) **] for her diabetes care and she also received a PICC line for outpatient antibiotic therapy. The patient was also examined by physical therapy which concluded that she would need several more sessions of physical therapy. This would be scheduled as an outpatient. The patient suffered from no other events or complications during her hospital course. The patient's condition of discharge will be to a rehabilitation facility. DISCHARGE DIAGNOSIS: Status post panniculectomy times two months. Severe bilateral lower extremity lymphedema. Bilateral Charcot deformities. Diabetes mellitus type I. Hypertension. Status post myocardial infarction. Status post coronary artery bypass graft times two. Glaucoma. Hypothyroidism. Hyperlipidemia. Gout. Hypercholesterolemia. Coronary artery disease. Methicillin resistant Staphylococcus aureus history Status post Charcot reconstruction of the right foot with external fixation. DISCHARGE MEDICATIONS: 1. Atenolol 50 mg q day. 2. Levoxyl 75 mcg q day. 3. Furosemide 120 mg twice a day. 4. Allopurinol 300 mg q day. 5. Atorvastatin calcium 20 mg q day. 6. Isosorbide mononitrate 60 mg q day. 7. Fludarabine Tartrate 2 mg q day. 8. Pantoprazole sodium 40 mg q day. 9. Lisinopril 10 mg q day. 10. Procrit 10,000 units subcutaneously every Tuesday. 11. Coumadin 5 mg q day. 12. Meropenum 1 gram every 8 hours. . 13. Colace 100 mg q day p.r.n. 14. Percocet 3/325 one to two tablets every four to six hours. 15. Glargine insulin 35 units at bedtime. 16. Humalog sliding scale taken four times a day p.r.n. DISCHARGE STATUS: Stable/good. FOLLOW UP: The patient is instructed to follow-up with Dr. [**Last Name (STitle) **] within 10 to 14 days following discharge. In addition the patient will be discharged to a rehabilitation facility for approximately one to two weeks and will be reviewed at that time. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Numeric Identifier 24462**] Dictated By:[**Last Name (NamePattern4) 24463**] MEDQUIST36 D: [**2161-6-24**] 10:03:11 T: [**2161-6-24**] 11:44:24 Job#: [**Job Number 24464**]

[ "414.00", "713.5", "250.61", "428.0", "041.85", "272.4", "V45.81", "401.9", "707.15" ]

icd9cm

[ [ [] ] ]

[ "78.48", "83.11" ]

icd9pcs

[ [ [] ] ]

9415, 10086

8905, 9392

3310, 8883

10098, 10667

1827, 3292

183, 746

769, 1804

57,774

106,996

7541

Discharge summary

report

Admission Date: [**2148-12-2**] Discharge Date: [**2148-12-11**] Date of Birth: [**2066-10-30**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 2186**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: HD catheter placed [**2148-12-4**] PICC line placed [**2148-12-4**] Intubation History of Present Illness: The patient is an 82 year old male with a history of CRI being set up for HD, DM, and HTN who presented after a syncopal episode. The patient is being transitioned to HD due to continually worsening renal function. He is followed by Dr. [**Last Name (STitle) **] of nephrology, with daily kayexalate and frequent electrolyte monitoring. By report, the patient has not had his usual daily bowel movements for 3 days and had missed a scheduled lab check on the day of presentation due to a major snowstorm that was blanketing the [**Location (un) 86**] metropolitan area at the time. On the morning of presentation, the patient awoke nauseous and not feeling well, got up to go to the bathroom and felt dizzy. He was witnessed by his family to syncopize, and was unresponsive for a few minutes. Following the event, he continued to feel light headed and nauseous. The patient complained of low back pain throughout the day. It was unclear if this was due to trauma. EMS was called, evidently after a pre-syncopal event (per second-hand account of patient??????s grandson) on the evening of presentation; he had not clearly worsened during the day before that according to his grandson. When EMS arrived the patient continued to vomit, his HR was 80, BP 90/50, and he was taken to [**Hospital3 **]. At [**Hospital3 **], the patient was found to be in a junctional bradycardia as low as 15; he had a BP 105/70, Cr of 3.5, and K was 6.5. He got 0.5 of atropine, then 1mg of atropine without effect. Transcutaneous pacer pads were used, but due to concern of low blood pressure, no sedation was given, and shocks were discontinued when they did not capture. The patient was transferred to [**Hospital1 18**] CCU for transvenous pacing. On transport, Mr [**Known lastname **]??????s HR remained 18-20 with SBP of 105-147, with an oxygen saturation of 92% on a NRB. On arrival to the floor, the patient was found to be minimally responsive with labored breathing. An ABG was obtained, with a gas of 7.02/43/102, potassium of 7.3, and lactate of 7.0. Ten (10) units of insulin and 50ml of dextrose were administered. The patient's breathing became increasingly agonal, and bag ventilation was intiated. His pulse became thready and systolic blood pressures dropped into the 60s. Dopamine was started, and quickly up titrated to 20. The patient was by this time in PEA arrest and a code blue was called. The patient was ultimately intubated. With absent pulse, chest compressions were intiated. The patient received a total of 3 amps of atropine, 2 pushes of epi, 2g of calcium, and 2 amps of bicarb. The patient regained a normal HR at 80 and BP of 120/50. Renal was emergently consulted. A temporary HD line was placed and CVVH was initiated. He was difficult to ventilate initially until it was recognized that he had a right mainstem bronchus intubation; his ETT was pulled back and his oxygenation improved. Since then, by report he has remained stable on the ventilator. He had a CT scan of his abdomen for which a preliminary read suggested colitis and pancreatitis without contrast extravasation into the peritoneum. When he was transferred to the MICU he remained on dopamine as a pressor but the nursing staff were soon able to stop this, after which his pressures remain stable and MAPS remained >65. Past Medical History: Diabetes Hypertension CRI for last 3 year, now nearing dialysis, believed [**1-13**] to DM, HTN, - LUE AV fistula placed [**6-18**] with poor maturation - s/p fistulogram and balloon angioplasty of mid outflow vein stenosis on [**8-19**] BPH s/p TURP Anemia [**1-13**] to CKD (baseline Cr 31) Renal Osteodystrophy Gout Social History: Occupation: Former construction worker in [**Country 3992**] Drugs: unk Tobacco: smoked in past, quit 20 yrs ago per family Alcohol: v occasional EtOH per family Other: Pt [**Name (NI) 27558**]; lives with daughter in [**Name (NI) 5110**] Family History: Father: Died in 50's, unsure of cause Mother: Died in 80's of MI, no history of renal disease Physical Exam: Tmax: 36.6 ??????C (97.8 ??????F) Tcurrent: 36.5 ??????C (97.7 ??????F) HR: 84 (33 - 93) bpm BP: 116/46(69) {86/37(-29) - 171/54(90)} mmHg RR: 22 (17 - 23) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 56.6 kg (admission): 56 kg Respiratory O2 Delivery Device: Endotracheal tube Ventilator mode: CMV/ASSIST/AutoFlow Vt (Set): 400 (400 - 400) mL RR (Set): 22 RR (Spontaneous): 0 PEEP: 8 cmH2O FiO2: 60% RSBI Deferred: Hemodynamic Instability PIP: 20 cmH2O Plateau: 18 cmH2O Compliance: 40 cmH2O/mL SpO2: 100% ABG: 7.42/42/200/27/3 Ve: 8.2 L/min PaO2 / FiO2: 333 Physical Examination General Appearance: Well nourished Head, Ears, Nose, Throat: Endotracheal tube, OG tube Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Distended Non-tender, Bowel sounds faintly present Extremities: Right: Trace, Left: Trace Skin: No rashes/petichiae in limited exam Neurologic: Responds to: voice, intermittently Pertinent Results: On Admission: [**2148-12-2**] 02:50AM BLOOD WBC-13.7*# RBC-2.91* Hgb-8.6* Hct-26.2* MCV-90 MCH-29.4 MCHC-32.6 RDW-14.7 Plt Ct-193 [**2148-12-2**] 03:30AM BLOOD Neuts-66.3 Lymphs-29.3 Monos-0.4* Eos-3.4 Baso-0.4 [**2148-12-2**] 03:30AM BLOOD Glucose-606* UreaN-62* Creat-3.4* Na-140 K-5.9* Cl-109* HCO3-20* AnGap-17 [**2148-12-2**] 06:11AM BLOOD ALT-328* AST-293* LD(LDH)-587* AlkPhos-50 TotBili-0.6 [**2148-12-2**] 03:30AM BLOOD Calcium-13.5* Mg-2.1 [**2148-12-2**] 02:58AM BLOOD Type-ART pO2-103 pCO2-48* pH-7.02* calTCO2-13* Base XS--19 [**2148-12-2**] 02:58AM BLOOD Lactate-7.0* K-7.3* [**2148-12-2**] 03:40AM BLOOD freeCa-1.62* . Imaging: ECHO on Admission: Normal global and regional biventricular systolic function. Diastolic dysfunction. Trace aortic regurgitation. . Body CTA: 1. Very severe atherosclerosis of the aorta with multiple ulcerated plaques and eccentric thrombus. 40% stenosis of the origin of the celiac artery. Very severe stenosis of the right common iliac artery. Very severe stenosis of the right renal artery with atrophic right kidney. Moderately severe left renal artery stenosis. 2. Edema of the right and transverse colon, could be related to colitis. No pneumatosis and no free air. 3. Peripancreatic edema with retroperitoneal free fluid, could be related to pancreatitis in the appropriate clinical setting. Gallbladder enhancement and common bile duct enhancement could also be related to pancreatitis. 4. Small amount of ascites. 5. Large third duodenum diverticulum. 6. Nonobstructive right vesicoureteral junction ureterolithiasis. 7. Right upper lobe peribronchial nodules, likely postinflammatory or postinfectious. Scattered lung nodules, should be followed in one year to ensure stability. 8. Signs of anemia. 9. ETT tip less than 1 cm above the carina, should be pulled back for optimal placement. Foley catheter balloon inflated in the prostate. . CXR: Right PICC terminates in the mid superior vena cava. Heart size, mediastinal, and hilar contours are within normal limits. The lungs demonstrate no focal areas of consolidation. No definite pleural effusion. Minimal relatively symmetrical biapical thickening. Bones are diffusely demineralized with slight decrease in height of several vertebral bodies. IMPRESSION: No evidence of pneumonia. . Right upper extremity ultrasound: Thrombus within the right cephalic vein. No evidence of deep venous thrombus within the right upper extremity. . Right knee: No signs for acute fractures or dislocations. Mineralization is within normal limits. There are mild degenerative changes with spurring of the medial and lateral compartments as well as of the patellofemoral and tibial spines. There is no significant joint effusion. No bony erosions are present. Vascular calcifications are seen. . Micro: URINE CULTURE (Final [**2148-12-5**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=1 S . Labs on Discharge: [**2148-12-11**] 04:21AM BLOOD WBC-13.3* RBC-3.08* Hgb-8.8* Hct-24.9* MCV-81* MCH-28.6 MCHC-35.3* RDW-19.9* Plt Ct-411 [**2148-12-10**] 04:48AM BLOOD Neuts-83.9* Lymphs-9.1* Monos-5.8 Eos-1.1 Baso-0.1 [**2148-12-11**] 04:21AM BLOOD Glucose-144* UreaN-63* Creat-2.5* Na-135 K-3.7 Cl-99 HCO3-24 AnGap-16 [**2148-12-4**] 02:51AM BLOOD ALT-100* AST-57* LD(LDH)-246 AlkPhos-30* TotBili-0.6 [**2148-12-3**] 04:40AM BLOOD Lipase-68* [**2148-12-11**] 04:21AM BLOOD Calcium-7.5* Phos-4.4 Mg-2.3 [**2148-12-7**] 03:18AM BLOOD calTIBC-207* Ferritn-205 TRF-159* [**2148-12-5**] 07:27AM BLOOD Vanco-4.5* Brief Hospital Course: 82 yo M with T2DM, HTN, CKD near ESRD, admitted with syncope, found to be hyperkalemia with junctional bradycardia, s/p PEA arrest now recovered after CVVH and HD. . MICU/CCU Course according to problem: # Hypotension: Mr [**Known lastname **] was hypotensive in the CCU, even after his hyperkalemia and bradycardia were corrected. He had a high lactate. His CT scan included findings of possible pancreatitis (supported by high pancreatic enzymes) and colitis (which might be source of high but now lower lactate). His lactate is declining which is reassuring; however, his pancreatic enzymes are rising and fluid balance will need to be watched closely. Sepsis may have been an underlying issue; cultures are pending. In the MICU: * hypotension resolved [**12-2**]-> pt hypertensive * restarted [**First Name9 (NamePattern2) 3782**] [**Last Name (un) **] and hydralazine, imdur * persistent hypertension, was started on nitro gtt [**12-4**]. * titrated up PO BP meds and nitro gtt turned off [**12-7**] early AM. . # Bradycardia: Mr [**Known lastname **] was transferred to the [**Hospital1 18**] CCU from [**Hospital3 **] originally because of bradycardia refractory to transcutaneous pacing attempts. The bradycardia was in the setting of severe hyperkalemia, and although he first had a PEA cardiac arrest requiring resuscitation, his arrythmias resolved after correction of potassium in the [**Hospital1 18**] CCU. Agree with CCU assessment that potassium level is likely source of his original bradycardia and likely his syncopal and pre-syncopal events described by his family. * resolved [**12-2**], no new episodes in the MICU; continued to hold nodal blockers . # Hyperkalemia: Patient had failed to get labs checked and kayexelate was not producing usual BM. Presented with K of 7.3, and likely etiology of patients arrythmia, which had corrected with short term interventions. Patient??????s symptoms of dizziness, nausea, and vomiting likely secondary to uremia/hyperkalemia given timing, though underlying infection is a possibility. HD line was placed in CCU and dialysis was conducted. . # CKD: Secondary to DM/HTN and being transitioned to HD with ESRD. Likely contributing to hyperkalemia [**1-13**] ineffective kayexalate. * tunneled line placed [**12-4**], last RRT 12/24 . * [**12-4**] HCT drop in setting of self discontinuation of fem line (patient pulled out) - CT abd/pelvis negative for intra or retroperitoneal bleed, received 2 units of PRBCs. Anemia stable . # Respiratory Distress: Patient with agonal breathing on presentation, poor oxygenation with large A-a gradient. Intubated in setting of PEA arrest. * extubated w/o complication [**12-3**] # DM: Patient on glyburide as an outpatient. Patient had glucose of 606 in CCU with consistent hyperglycemia; may be secondary to pancreatic injury. Resolved. . Hospital course on general medicine floor by problem: . # Leukocytosis: Elevated to 17, unclear etiology. Patient developed low grade fever (T max 100.2). Urine, CXR and blood culture negative growth. HD and PICC line pulled prior to d/c. Asymptomatic other than right knee pain. Patient with history of gout, no erythema or warmness on exam, but uric acid elevated to 8.8. Leukocytosis could have been related to mild gout flare (see below). Patient was afebrile > 48hr with negative cultures and decreasing leukocytosis prior to discharge. . # Hypertension : Moderately well-controlled 130-40s. Avoiding increasing nodal blockade in the setting of recent bradycardia. Started Amlodipine 5 mg this admission. Patient was discharged on Amlodipine plus prior outpatient medications. . # Knee pain: Symptoms have improved. Right knee without warmth, erythema or tenderness. Full range of motion on exam. Patient does have history of gout and uric acid is elevated. Avoid any NSAID treatment for gout due to unstable renal function. Knee film demonstrated no abnormalities. Pain improved prior to discharge. . # Anemia: The patient dropped his Hct in the setting of losing his femoral HD line. After 2 units PRBCs has stabilized at 26. No other evidence of bleeding. Chronic anemia most likely due to renal disease. Patient on EPO [**2139**] units [**Hospital1 **]/ 2 x weekly while in house. Discharged on outpatient EPO dose. . # Enterococcus UTI: Treated with Ampicillin for 7 day course. . # CKD: Acute elevation in creatinine most likely ATN related to hypovolemia. Chronic renal disease secondary to DM/HTN. Last HD session on [**12-4**]. Good urine output (> 2 L), lytes in normal limits therefore temporary HD line was removed. However, was slowly increasing since stopping dialysis (from 2 to 2.5 over three days). Mild creatinine increase could have been due to ibuprofen dose 12/28 for ? gout (ibuprofen was discontinued). Patient will require very close follow-up with Renal. . # PEA Arrest: Likely related to hyperkalemia, presumably from ESRD. Has recovered very well with no obvious morbidity. Underlying rhythm was a junctional bradycardia. Patient was monitored on tele while on the floor. Medications on Admission: ALLOPURINOL - 200 mg daily CALCITRIOL - 0.25 mcg Capsule every Monday and Friday CINACALCET - 30 mg Tablet once a day EPOETIN ALFA [PROCRIT] 6000 units (s/c q 6 weeks FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth daily FUROSEMIDE - 40 mg Tablet [**Hospital1 **] GLIPIZIDE - 5 mg daily LACTULOSE - PRN constipation LOSARTAN [COZAAR] - 100 mg daily SEVELAMER HCL [RENAGEL] - 800 mg three times a day with meals SIMVASTATIN - 20 mg daily VERAPAMIL - 240 mg Cap,24 hr once a day Discharge Medications: 1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO every monday and friday. 2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 6. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three times a day: with meals. 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Verapamil 240 mg Cap,24 hr Sust Release Pellets Sig: One (1) Cap,24 hr Sust Release Pellets PO once a day. 10. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 11. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 12. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic Q8H (every 8 hours). 13. Homatropine HBr 2 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 14. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 15. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. Epoetin Alfa 4,000 unit/mL Solution Sig: 6,000 units Injection every 6 weeks. Discharge Disposition: Home Discharge Diagnosis: PEA arrest Bradycardia Acute on chronic renal failure requiring emergent dialysis Hyperkalemia Urinary tract infection Hypertension Discharge Condition: Good, ambulating. Discharge Instructions: You were admitted for passing out. During your hospital stay you had a cardiac arrest, and was consequently intubated and transferred to the medical ICU. You were found to have renal failure and high potassium and was consequently started on dialysis. Your renal failure improved and you no longer required dialysis. You were treated for a urinary tract infection. . Review your medication list closely. The following changes were made to your medications: 1. Imdur 90mg daily should be taken for your blood pressure every day 2. You should also take amlodipine 5mg daily for your blood pressure . Attend all follow up appointments. It is very important you follow your kidney function closely with your kidney doctor and primary care doctor. . Return to the ER if you experience dizziness, passing out, chest pain, difficulty breathing, fever, chills or any other concerning symptoms. Followup Instructions: You have an Appt with Dr [**Last Name (STitle) **]: Sunday [**12-15**] at 11:45 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2148-12-18**] 8:30 Provider: [**Name10 (NameIs) **] OPTOMETRY Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2149-1-16**] 2:45 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] AV CARE AV CARE [**Location (un) **] Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2149-2-3**] 8:30 Completed by:[**2148-12-14**]

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icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "38.95", "39.95", "99.04" ]

icd9pcs

[ [ [] ] ]

16457, 16463

9442, 14490

285, 366

16639, 16659

5593, 5593

17593, 18122

4320, 4416

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145,945

34283

Discharge summary

report

Admission Date: [**2129-2-19**] Discharge Date: [**2129-2-25**] Date of Birth: [**2061-2-18**] Sex: F Service: MEDICINE Allergies: Penicillins / Iodine / Adenosine Attending:[**First Name3 (LF) 1936**] Chief Complaint: FUO Major Surgical or Invasive Procedure: Joint Tap of the wrist History of Present Illness: 67 female with a history of CAD s/p stent, DM, and ESRD on HD, who presented to [**Hospital3 25148**] Center on [**2129-2-11**] with bilateral foot pain. The patient reports a mechanical fall 2 weeks ago onto her left hip, then a second fall onto that same hip a few days later. She had significant ecchymoses and was told to use hot compresses by her HD physicians. The next day ([**2129-2-10**]), she developed severe left foot pain, followed by left wrist pain, then right foot pain, all characterized as burning and associated with erythema. She presented to the ED for evaluation and was discharged without intervention. The next day, her pain was so severe she could not rise to the bathroom so was BIBA to [**Hospital3 25148**] on [**2129-2-11**]. She was afebrile at that time but started on vancomycin and colchicine for a question of cellulitis v. gout without improvement. She was then started on Neurontin on [**2129-2-12**]. She remained afebrile until several days later, with her first documented fever of 102.2 on [**2129-2-15**]. Levofloxacin was started. Ortho tapped her wrist, cx returned neg; no crystals sent. she remained febrile, so wrist and ankle films and a bone scan were done on [**2129-2-16**] which showed some increased uptake in bilateral feet and left wrist and lumbar spine, but appeared to be degenerative pattern. On [**2-17**], her right IJ HD line was removed and a tunnelled left IJ line was placed. TEE was performed and no vegetations seen. On [**2-19**], her levofloxacin was discontinued. Her fever work-up so far has been notable for leukocytosis, ESR 100 -> 130 on [**2-18**], CRP 31 on [**2-18**]. Negative studies have included serial bcx (NGTD), cath tip cx (NGTD), Ucx, CXR, left wrist joint fluid cx, MRSA screen, Lyme Ab, hep B and C serologies, RF, and [**Doctor First Name **]. . Pt was accept for transfer here for further work-up of her fevers, with a concern for ID v. Rheum process. Prior to her transfer this evening, the covering MD (Dr. [**Last Name (STitle) 78911**] was called to evaluate the pt for acute MS changes. Per her daughters, she received some medications including dilaudid and became very difficult to arouse with confused speech. Per her daughters, she had been "loopy" with narcotics in the past few days but not to this extent. She was noted to have a fever of 103. She received Narcan around 6:30pm without improvement and a tylenol suppository at 7:30pm. Around 9:30pm, the pt "woke up," and returned almost back to baseline. [**Name6 (MD) **] the MD [**First Name (Titles) 1023**] [**Last Name (Titles) 6349**] her, she seemed debilitated, listless, and lethargic but was not confused on his evaluation; she responded to voice without difficulty and neuro exam was grossly nonfoccal. ABG did not show hypercarbia. He did order a stat CT head which only noted cerebral atrophy on prelim read. A CBC was repeated at time which showed an increase in WBC from 10 to 18.5 with 87% polys. . Summary of hospital course: [**2-11**]: to ED with left wrist and left foot pain, admitted. vanco and colchicine started. T99.4. [**2-12**]: HD. Neurontin started. CXR neg. [**2-13**]: T99.3. [**2-14**]: HD. T100.1. [**2-15**]: T102.2. levofloxacin IV started. Wrist tap done by ortho, sent for culture. [**2-16**]: T100.4. HD. Wrist and ankle films done and had a bone scan - some increased uptake in bilateral feet and left wrist and lumbar spine, but appeared to be degenerative pattern. [**2-17**]: T99.7, Tmax 101.9R IJ HD line removed, tunnelled L IJ HD line placed. TEE performed, no vegetations seen. [**2-18**]: T101.7. HD. [**2-19**]: levofloxacin dced. Tmax 103.4. . On the floor, patient currently is "much better" per her daughters. Although her speech is still a little slurred, she is oriented x 3 and able to provide a good history. She complains only of burning wrist and bilateral foot/lower leg pain, worse with movement, which is unchanged. . Her daughters note that she had a recent admission in [**9-/2128**] for FUO which resolved after several days. Per the OSH notes, this admission was from [**10-9**] to [**2128-10-14**] for febrile illness with 4 days of fever up to 103.7 but negative infectious workup (neg blood cultures, urine cultures, Cdiff, CXR). Oral HSV was questioned as the etiology at that time. She was started on ceftaz and given oral valtrex. Notes state she completed 5 days of IV azithromycin and ceftriaxone and was discharged on 2 more days of azithro and vantin. . Review of systems: Denies recent weight loss or gain. Denies headache or sinus tenderness, does have mild jaw pain when chewing. No rhinorrhea or congestion. Denies neck pain or stiffness. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. Intermittent dysuria. Back soreness "from lying in bed." No new rash other than erythema of left wrist and BLE. Up to date on routine cancer screening with recent normal mammogram, pap smear, and colonoscopy (within past couple years per daughter). Pt tested negative for HIV in the past year. No new medications other than antibiotics (pt reports has not been on vanco in the past). Past Medical History: Hypertension Hyperlipidemia DM CAD s/p PCI with unknown type of stent (?BMS), [**2127**]. ESRD secondary to diabetes on HD MWF S/p cataract removal GERD Anemia Social History: She lives with her 2nd husband. She is a retired school teacher. She quit smoking over 40 years ago. She denies alcohol, drug, or herbal medicine use. Family History: Mother had HTN and CAD in her 80s. Her mother died at 87 and her father at 93 of "old age." She has one sister who died after esophageal bleed and one sister with breast cancer in her 60s and bladder cancer in her 80s, still living. She also had an aunt with breast cancer in her 60s. She has two healthy daughters. [**Name (NI) **] family history of connective tissue disease. Physical Exam: Vitals: T 102.1, BP 129/53, P 92, RR 20, O2sat 92 RA, FSG 155 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, no focal c-spine tenderness, JVP not elevated, no LAD Back: Diffuse tenderness over lumbar region involving L4-S1 spine and paraspinal muscles. Lungs: Minimal crackles at the bases, improved with coughing, otherwise clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, +systolic mm loudest at base, no rubs or gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses. Left wrist and hand swollen with erythema and TTP but able to move. Erythema and ?increased warmth over bilateral feet with patch over lower shin, superficial tenderness extending over pedal/dorsal foot and shin. Minimal edema of both feet, nonpitting. Tenderness on palpation of right 1st-4th PIPs with pain on movement of right ankle but not left ankle. + Calf tenderness b/l. Neuro: Lethargic but easily arousable and responds appropriately to questions, oriented to person, hospital (initially [**Hospital1 66332**] but recalled [**Hospital1 18**] when requestioned later), and date. Speech clear at times, slightly gargled when drifting off to sleep. CN II-XII grossly intact, UE strength 5/5, LE strength. Unable to maintain outstretched arms (L worse than R) with ?asterixis but no clear pronator drift. Sensation to LT intact b/l (?hyperesthesia of LE as noted above). Patellar reflexes symmetric. Negative Kernig and Brudzinski. Gait not assessed. Pertinent Results: Other notable OSH labs: WBC max 15.5 on [**2-15**], although reportedly 18.5 on [**2-19**] prior to transfer ferritin 1619 [**2-18**] CRP 31 on [**2-18**] ESR 100 on [**2-14**] -> >130 on [**2-18**] RF 13 (negative) on [**2-15**] [**Doctor First Name **] negative on [**2-15**] Lyme Ab negative on [**2-17**] Heb B sAb, sAg, cAb negative Fe 21, TIBC 155 on [**2-12**] LFTs all normal on [**2-11**] (except albumin 2.6) UA [**2-13**]: 3+ protein, >100 WBCs, [**1-28**] RBCs, >15 epis HgbA1C 5.8 on [**2-11**] . Micro: blood cultures: [**2-13**] x2, [**2-14**] x2, [**2-16**] x1, [**2-18**] all NGTD cath tip culture [**2-17**] NGTD urine culture [**2-13**] < 10K mixed skin flora; [**2-15**] < 10K mixed skin flora L wrist joint fluid [**2-15**] NGTD MRSA screen negative [**2-12**] . Images: TEE [**2-17**]: EF 60-65%. Mild concentric LVH. Trace AI, mild MR, mild TR. No vegetations. . TTE [**2-15**]: EF 60-65%. MAC, mild MR. technically difficult study. . Wrist films [**2-16**]: extensive vascular calcifications. No evidence for osteomyelitis. . Foot films [**2-16**]: diffuse osteopenia. Vascular calcifications. Mild left sided soft tissue swelling. no osteomyelitis seen. . Ankle films [**2-16**]: no fracture. No radiographic evidence of osteomyelitis. . Bone scan [**2-16**]: abnormal uptake in both feet, predomiantly involving the hindfoot and midfoot regions. no clear focal area of radiotracer accumulation within the visualized tarsal bones. Findings are probably degenerative rather than being secondaryh to multifocal osteomyelitis. Degenerative appearing uptake in the visualized left wrist and lumbar spine. . Portable CXR [**2-13**]: R sided cathter. Heart size upper normal. Clear lungs. Some R hemidiaphragm elevation (unchanged from prior) Brief Hospital Course: 68 yo F with CKD on HD, CAD, DM presents with bilateral foot and left wrist pain, persistant fevers, with waxing and [**Doctor Last Name 688**] mental status and elevated inflammatory markers transferred back to floors from MICU. . # Gout: Rheumatology [**Doctor Last Name 6349**] patient and did repeat wrist tap that revealed small amount of crystal negative fluid. However, presentation, signs and symptoms were highly consistent with gout. Initially fever work up was conducted (see below) and steroids were held. Patient treated w/ narcotics, but developed AMS (see below) which were then held. Infectious w/o was negative and fevers were thought to be secondary to gout. Patient was ultimately started on prednisone taper from 30mg->20mg->10mg->5mg over 12 days. Patient improved with steroid therapy. . # Fevers: On transfer patient had persistant fevers with a leukocytosis that was downtrending. Inflammatory markers ESR and CRP were elevated. Further infectious work was undertaken and unrevealing. LFTs were normal, Hep serologies were repeated and negative, HIV ab and viral load, CMV, fungal cx and blood cx were neg. Septic arthritis was felt to be unlikely given negative work up at OSH. MRI spine that was unrevealing for infectious process. Patient had episodes of AMS (see below), however given the lack of meningeal signs and symptoms and resolution of mental status with holding of narcotics LP was not performed. Patient had unrevealing SPEP. LENI's were checked bilaterally and were negative. Hematology also consulted, who thought BM biopsy was unlikely to yield diagnosis. Rheumatology was consulted and tapped the left wrist, crystals were not identified but given presentation Rheumatology felt that the likely etiology to the fevers was gout. Other rheumatologic markers [**First Name9 (NamePattern2) 78912**] [**Doctor First Name **], RF, ANCA were negative. Patient defervesced with gout treatment see above. . # AMS: On transfer patient appeared somnolent with AMS. On [**2-20**] patient triggered for AMS, head CT was normal, and ABG was unremarkable. Patient was transferred to the MICU. MRI head was w/o any acute findings, MRI C/T/L spine w/o evidence of cord compression or epidural abcess though the study was limited by motion artifact, and EEG w/o epileptiform acitivity. TSH within normal limits. B12/folate normal. AMS resolved by holding narcotics and patient was transferred to the floors where she remained A&Ox3 throughout. . # ESRD: On transfer patient arrived with a tunneled HD line, that was left in place to allow for maturation of her fistula line. She was continued on her HD sessions M/W/F and continued on calcium acetate, nephrocaps. - Tunnelled line to be d/c'd by outpatient nephrologist, pending maturation of fistula . # CAD: Pt remained chest pain free. OSH TEE was unremarkable. Plavix was held at OSH given concern for serum sickness, however this was restarted. She was continued on ASA 81, imdur, statin, carvedilol. . # HTN: Continued home carvedilol and Imdur. Hydral, dilt, and lisinopril had been held at OSH however these were restarted. . # HL: Continued statin and fenofibrate . # DM: Continue HISS. Medications on Admission: Medications at home (per OSH records): B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] once a day CALCIUM ACETATE 667 mg capsules - 3 tabs TID with meals CARVEDILOL 3.125 mg twice a day CLOPIDOGREL 75 mg once a day DILTIAZEM HCL 240 mg, Sust. Release [**Hospital1 **] FENOFIBRATE 145 mg once a day FLUVASTATIN 40 mg every other day HYDRALAZINE - 100 mg Tablet [**Hospital1 **] INSULIN LISPRO sl sc as needed ISOSORBIDE MONONITRATE 30 mg once daily LISINOPRIL 30 mg once a day ASPIRIN 81 mg once a day Darvocet N100 1 tab Q6H prn Omeprazole 20 mg daily . Medications (on transfer): Heparin 5000 UNIT SC TID Insulin SC (per Insulin Flowsheet) Acetaminophen 325-650 mg PO/NG Q4H:PRN pain, fever Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Aspirin 81 mg PO/NG DAILY Nephrocaps 1 CAP PO DAILY Calcium Acetate [**2119**] mg PO TID W/MEALS Omeprazole 20 mg PO DAILY Carvedilol 3.125 mg PO/NG [**Hospital1 **] Pravastatin 40 mg PO QODHS Docusate Sodium 100 mg PO Senna 1 TAB PO/NG [**Hospital1 **]:PRN Fenofibric Acid *NF* 145 mg Oral daily Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Primary: Gout Flare AMS secondary to narcotics Discharge Condition: Reduced functional mobility and activity tolerance secondary to pain. Oriented times three Discharge Instructions: We had the pleasure of taking care of you at [**Hospital1 18**] for your foot pain and fevers. These were secondary to your gout flare. We treated you with prednisone and tylenol. While you were here you became confused and we performed imaging of your brain and spine that did not show any acute changes. We also performed an infectious work up which did not show any sign of infection in your body. We believe your confusion was from the narcotics and you improved when we stopped your narcotics. We have made the following changes to your medications: 1. We have started you on prednisone. You should take 20mg Fri ([**2-25**]), Sat ([**2-26**]), Sun ([**2-27**]); 10mg Mon ([**2-28**]), Tues ([**3-1**]), Wed ([**3-2**]); 5mg Thurs ([**3-3**]), Fri ([**3-4**]), Sat ([**3-5**]). 2. We have also started you on stool softners senna/colace to be taken as needed for constipation. 3. We have stopped darvocet, you can take tylenol instead. Followup Instructions: Please follow up with rheumatology: [**2129-3-4**] at 10am in [**Hospital **] Clinic with [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **] Please schedule an appointment with your PCP and nephrologist. Your nephrologist will decide when your temporary hemodialysis line can come out. Completed by:[**2129-2-25**]

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icd9cm

[ [ [] ] ]

[ "39.95", "81.91" ]

icd9pcs

[ [ [] ] ]

14107, 14154

9821, 13015

297, 322

14245, 14338

8033, 9798

15334, 15671

5969, 6349

14175, 14224

13041, 14084

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4851, 5600

254, 259

351, 3319

5622, 5784

5800, 5953

45,542

140,428

37704

Discharge summary

report

Admission Date: [**2165-3-2**] Discharge Date: [**2165-3-8**] Date of Birth: [**2135-8-29**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Epigastric pain and nausea. Major Surgical or Invasive Procedure: None History of Present Illness: 29 year old male admitted last night with sudden onset of epigastric pain and nausea. Patient states had some wine last night. No fever or chills. States he had a similar episode and was hospitalized for pancreatitis [**2164-11-16**] where he was admitted with 1 day h/o abdominal pain, initial elevation of lipase and amylase consistent with gallstone pancreatitis. The CT scan obtained during that admission revealed a peripancreatic fluid without evidence of pancreatic ductal dilatation or pancreatic necrosis. No gallstones were identified on CT scan. During the same admission within three days, his hyperamylasemia and hyperlipasemia returned to [**Location 213**]. Ultrasound examination at that time revealed a 3-mm common duct. No peripancreatic or pericholecystic fluid. Past Medical History: PMHx: GERD - Patient had EDG done at [**Hospital6 5016**] in early [**2164**] after which his PCP started [**Name Initial (PRE) **] PPI, no Ulcer disease per pateint. Pericarditis in [**2158**] of unknown etiology treated with Indocin. Pancreatitis [**11-9**] initially admitted to Dr. [**Last Name (STitle) 1120**], followed by Dr. [**Last Name (STitle) **]. . PSHx: None Social History: EtOH: [**11-12**] drinks spaced throughout the week. No tobacco use. Lives with girlfriend, currently unemployed. Did not ask regarding illicit drugs as family present. Family History: Paternal grandmother with pancreatic CA, gallbladder disease. Physical Exam: On Admission: Gen: resting comfortably HEENT: no jaundice, PERRL, trachea midline Abd: soft, mildly distended, no rebound or guarding, tenderness over epigastrium, positive bowel sounds CVS: tachycardic, positive S1 and S2, no S3 or S4 Chest: clear to auscultation bilaterally Ext: no edema, positive distal pulses Pertinent Results: On Admission: [**2165-3-2**] 05:18PM AMYLASE-530* [**2165-3-2**] 05:18PM LIPASE-1654* [**2165-3-2**] 08:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG [**2165-3-2**] 08:18AM LACTATE-3.5* [**2165-3-2**] 04:15AM GLUCOSE-173* UREA N-16 CREAT-0.8 SODIUM-139 POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-26 ANION GAP-20 [**2165-3-2**] 04:15AM ALT(SGPT)-48* AST(SGOT)-43* ALK PHOS-119 TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1 [**2165-3-2**] 04:15AM LIPASE-4605* [**2165-3-2**] 04:15AM ALBUMIN-4.9 [**2165-3-2**] 04:15AM WBC-20.5*# RBC-4.93# HGB-15.9# HCT-45.3# MCV-92# MCH-32.3* MCHC-35.1* RDW-12.9 [**2165-3-2**] 04:15AM NEUTS-83.5* LYMPHS-13.5* MONOS-2.3 EOS-0.2 BASOS-0.4 [**2165-3-2**] 04:15AM PLT COUNT-413# . Date of Discharge: [**2165-3-8**] 06:45AM BLOOD Glucose-107* UreaN-6 Creat-0.8 Na-142 K-4.1 Cl-102 HCO3-29 AnGap-15 [**2165-3-8**] 06:45AM BLOOD Amylase-171* [**2165-3-8**] 06:45AM BLOOD Lipase-664* . IMAGING: [**2165-3-2**] Liver/Gallbladder U/S: 1. Limited visualization of pancreas. No fluid seen in right upper quadrant. 2. No findings of acute cholecystitis. Tiny 1.5-mm nonmobile echogenic focus probably represents a tiny adherent stone. . [**2165-3-2**] AP CXR: Bedside AP radiograph of the chest shows normal cardiac, mediastinal and hilar contours. A left retrocardiac consolidation is noted, non-specific, possibly atelectasis or a focus of aspiration or infection. There is no pleural effusion or pneumothorax. There is no evidence of pneumoperitoneum. . [**2165-3-2**] ABD CT W&W/O CONTRAST: 1. Inflammatory change and fluid surrounding the pancreas, consistent with acute pancreatitis. No evidence of necrotizing pancreatitis, pancreatic pseudocyst, or vascular involvement. 2. No biliary obstruction or biliary stones. . [**2165-3-7**] MRCP: **PRELIMINARY REPORT**: Findings consistent with acute pancreatitis, no evidence of complications, such as no necrosis or peripancreatic fluid collection. No cholelithiasis or choledocholithiasis. . MICROBIOLOGY: [**2165-3-2**] MRSA SCREEN: NEGATIVE. [**2165-3-2**] BLOOD CULTURE: NO GROWTH - FINAL. [**2165-3-2**] BLOOD CULTURE: NO GROWTH - FINAL. Brief Hospital Course: The patient was admitted to the General Surgical Service in the TSICU on [**2165-3-2**] for evaluation and treatment of epigastric pain and elevated pancreatic enzymes, initially consistent with gallstone pancreatitis. Admission abdominal ultra-sound showed no fluid seen in right upper quadrant and no findings of acute cholecystitis. A tiny 1.5-mm nonmobile echogenic focus probably represents a tiny adherent stone was appreciated. Abdominal CT revealed inflammatory change and fluid surrounding the pancreas, consistent with acute pancreatitis. There was no evidence of necrotizing pancreatitis, pancreatic pseudocyst, vascular involvement, or biliary obstruction or biliary stones. Findings now consistent with recurrent pancreatitis. He was made NPO, given IV fluid rescusitation, a foley catheter was placed, and Dilaudid IV PRN for pain with good effect. He was hemodynamically stable. Transferred to floor on [**2165-3-4**]. Neuro: The patient was changed to a Dilaudid PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications with continued good pain control. . CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. . GI/GU/FEN: Upon admission, the patient was made NPO and received aggressive IV fluid rescusitation. Hyperamylasemia and hyperlipasemia significantly improved over the next three days. On [**3-5**], he was started on sips, which was advanced to low fat regular by [**3-6**]. On [**3-7**], diet was returned to clears as he experienced a moderate increase in lipase to 502, and mild increase of amylase to 117. He did not experience any abdominal pain, fever, nausea. An MRCP was performed, which demonstrated findings consistent with acute pancreatitis, no evidence of complications, such as no necrosis or peripancreatic fluid collection. No cholelithiasis or choledocholithiasis. Pancreatic enzymes were again mildly elevated on [**3-8**] with an Amylase of 171 (up from 115) and a lipase of 664 (up from 475). Diet was maintained at clear liquids. Foley was discontinued on [**3-5**]; he was subsequently able to void without peoblem. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. He was discharged on a clear liquid diet. . ID: The patient's white blood count and fever curves were closely watched for signs of infection. Admission blood cultures revealed no growth. . Endocrine: The patient's blood sugar was monitored throughout his stay; sliding scale insulin dosing was administered when required. He did not require exogenous insulin at discharge. . 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 clear diet, ambulating, voiding without assistance, and pain was well controlled. As he was feeling well and was asymptomatic despite the increase in the pancreatic enzymes, he was cleared for discharged home without services. He will return on Monday, [**2165-3-11**] for repeat pancreatic enzymes and LFTs, and then will follow-up with Dr. [**Last Name (STitle) **] on Friday, [**3-15**]. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. He specifically agreed to return to the [**Hospital1 18**] Emergency Department if he experiences fever, abdominal pain, nausea, vomiting, jaundice, or other concerning symptoms. Medications on Admission: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day Discharge Medications: 1. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Recurrent pancreatitis Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-10**] 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. Followup Instructions: Please return to [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**] on Monday, [**2165-3-11**] for repeat labwork. Please bring the Outpatient Lab Requisition with you. . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Surgery). Phone: ([**Telephone/Fax (1) 2828**]. Date/Time: [**2165-3-15**] at 11:45AM. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]. . Please arrange a follow-up appointment with your Primary Care Provider (PCP) in [**3-6**] weeks. If you do not have a PCP and would like to establish with one here at [**Hospital1 18**], please call ([**Telephone/Fax (1) 1921**]. Completed by:[**2165-3-8**]

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icd9cm

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54569

Discharge summary

report

Admission Date: [**2163-1-31**] Discharge Date: [**2163-2-11**] Date of Birth: [**2109-7-1**] Sex: F Service: MEDICINE Allergies: Nsaids / Aspirin / Influenza Virus Vaccine Attending:[**First Name3 (LF) 2291**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: PICC line insertion History of Present Illness: Ms. [**Known lastname 3646**] is a 53-year-old woman with a history of asthma, severe pulmonary htn, GBS, chronic nausea/abdominal pain, hx of substance abuse, who p/w complaints of dyspnea, productive cough x3 days. The pt states that over the past that she has felt increased baseline dyspnea for the past couple of weeks with a more noticeable increase since Saturday, though she has been stable on home O2 3L. She also endorsed chills, some substernal, left sided chest and abdominal aching since Friday (worse since yesterday), increased lacrimation, and congestion. She also has nausea which is chronic. The pt is unable to receive flu shots due to prior hx of GBS. Yesterday she developed a cough productive of yellow sputum and noted increased body aches. She has been taking her flovent and proair without significant relief so she presented to the hospital as she felt she'd be unable to sleep and is tired of being sick. . Of note per recent PCP note, the pt was seen in the emergency department [**1-21**] for shortness of breath, abdominal pain, foot and leg pain. She complained of progressive swelling in her legs, right greater than left. In the emergency department, they did both plain films and ultrasound of her right lower extremity, which did not show a clot or other abnormalities. Per pcp records, compared to a year ago at 177, she is now weighing at 223 lbs. She was increased from lasix 10mg daily to 20mg daily. At that point she also reported a small increase in shortness of breath, although not markedly so. Urine tox was taken [**1-25**] and returned positive for cocaine, though the patient adamantly denies use since last [**Month (only) 956**]. . In the ED, initial VS: 99.2 86 121/37 15 97%. She was found to have a K+ 2.9 so was given 60meq KCL PO, and 10meq IV. SHe was given albuterol/ipratropium neb x1 with some improvement, oxycodone 5mg x1. EKG showed aflutter at a rate of 89bpm, upright twaves in v3 (last inverted) otherwise unchanged. . Currently, the pt is 98.7 151/94 94 22 100%3L. She is complaining of total body discomfort, occasional chills, nausea and cough. Past Medical History: Pulmonary hypertension - Thought secondary to cocaine abuse vs. [**First Name9 (NamePattern2) 7816**] [**Location (un) **] Active tobacco use Restrictive lung disease Chronic hepatitis Hypertension Perforated duodenal ulcer [**12/2159**], attributed to NSAID use [**Last Name (un) 4584**]-[**Location (un) **] syndrome - with residual sensory neuropathy Polysubstance abuse (smoked cocaine) Depression Rheumatoid arthritis, seronegative Chronic severe back pain C-sections x 4 History of secondary syphilis, treated Seizures in childhood Social History: Has four children and several grandchildren. Smokes tobacco. Has glass of wine several times per week. History of cocaine use, but denies currrent use. Family History: Father with COPD. Sister with diabetes. Physical Exam: Admission: Vitals: T: 101.9, BP: 98/doppler, P: 120, R: 18, O2: 50% Venti mask General: Obese African-American lady lying with HOB 45 degrees, using accessory muscles of respiration, able to speak in full sentences HEENT: Sclera anicteric, dry MM, pupils 3mm and equally reactive to light Neck: supple, no JVD (though neck obese) CV: parasternal heave, tachycardic, S1 + S2, regular, no murmur, no muffled heart sounds Lungs: Poor air movement bilaterally, end-expiratory wheezes diffusely, no focal rhonchi except for region in R axilla Abdomen: soft, non-distended (+)bowel sounds, liver edge palpable 1cm below costal margin Ext: warm, 1+ DP pulses, no clubbing, or cyanosis; RLE>LLE size with 1+ edema to the knees bilaterally Neuro: drowsy but arousable to voice, oriented x3, grossly normal sensation Discharge Exam: [**2163-2-11**] VS: Tm 97.9, Tc 96.8, 119-130/76-83, 80-85, 17, 96-99 2L General: no acute distress, resting in bed HEENT: MMM, oropharynx clear Neck: supple Lungs: good air movement, occasional diffuse expiratory wheezes, decreased breath sounds at bases. CV: regular rate and rhythm, no m/r/g Abdomen: obese, nodistended, tender to palpation in periumbilical area, bowel sounds present. No rebound, no guarding. Ext: Warm, well perfused, no cyanosis or clubbing. 1+ LE edema bilaterally. Wearing [**Male First Name (un) **] stockings. Neuro: A&O x3 Pertinent Results: [**2163-1-31**] 08:30PM BLOOD WBC-6.3 RBC-4.10* Hgb-12.3 Hct-38.1 MCV-93 MCH-30.1 MCHC-32.4 RDW-14.2 Plt Ct-188 [**2163-2-1**] 10:30PM BLOOD WBC-10.7# RBC-4.04* Hgb-12.2 Hct-37.1 MCV-92 MCH-30.3 MCHC-33.0 RDW-14.5 Plt Ct-168 [**2163-2-5**] 09:05AM BLOOD WBC-7.4 RBC-3.61* Hgb-11.1* Hct-33.7* MCV-94 MCH-30.8 MCHC-32.9 RDW-14.5 Plt Ct-136* [**2163-2-11**] 04:25AM BLOOD WBC-7.9 RBC-3.49* Hgb-10.4* Hct-31.9* MCV-91 MCH-29.6 MCHC-32.5 RDW-15.3 Plt Ct-338 [**2163-1-31**] 08:30PM BLOOD Neuts-59.2 Lymphs-27.5 Monos-5.5 Eos-6.8* Baso-1.1 [**2163-2-11**] 04:25AM BLOOD Neuts-44.3* Lymphs-40.7 Monos-7.5 Eos-6.5* Baso-1.0 [**2163-2-5**] 09:05AM BLOOD PT-16.7* PTT-40.2* INR(PT)-1.6* [**2163-2-11**] 04:25AM BLOOD PT-15.0* PTT-36.9* INR(PT)-1.4* [**2163-2-7**] 02:06AM BLOOD Ret Aut-0.7* [**2163-2-1**] 10:30PM BLOOD ESR-17 [**2163-2-7**] 04:00AM BLOOD Fibrino-230 [**2163-1-31**] 08:30PM BLOOD Glucose-89 UreaN-4* Creat-0.8 Na-143 K-2.9* Cl-103 HCO3-29 AnGap-14 [**2163-2-11**] 04:25AM BLOOD Glucose-73 UreaN-4* Creat-0.7 Na-139 K-3.5 Cl-105 HCO3-23 AnGap-15 [**2163-2-1**] 10:30PM BLOOD ALT-20 AST-36 CK(CPK)-224* AlkPhos-66 TotBili-1.9* [**2163-2-5**] 09:05AM BLOOD ALT-17 AST-35 LD(LDH)-364* CK(CPK)-134 AlkPhos-85 TotBili-1.3 [**2163-2-11**] 04:25AM BLOOD ALT-18 AST-35 LD(LDH)-359* AlkPhos-126* TotBili-0.9 [**2163-1-31**] 08:30PM BLOOD cTropnT-<0.01 proBNP-[**2060**]* [**2163-2-5**] 09:05AM BLOOD CK-MB-2 cTropnT-<0.01 . Micro [**2163-2-4**] 8:08 am SPUTUM Source: Expectorated. GRAM STAIN (Final [**2163-2-4**]): [**10-27**] PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2163-2-6**]): RARE GROWTH Commensal Respiratory Flora. YEAST. SPARSE GROWTH. LEGIONELLA CULTURE (Final [**2163-2-11**]): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final [**2163-2-7**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. . [**2163-2-10**] [**2163-2-10**] 11:42 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2163-2-11**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2163-2-11**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . Imaging . [**2163-1-31**] CXR IMPRESSION: Moderate-to-severe cardiomegaly, mild vascular congestion . [**2163-2-1**] CTA Chest IMPRESSION: 1. No evidence of pulmonary embolism. 2. Pulmonary arterial hypertension and moderate cardiomegaly. 3. Pneumonia in right lower lobe posterior basal segment and mild to moderate atelectasis in left lower lobe. 4. Mediastinal and bilateral hilar lymphadenopathy leading to mild narrowing but without occlusion of the central airways. . [**2163-2-2**] ECHO The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is normal (LVEF>55%). Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is markedly dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. Compared with the prior study dated [**2162-11-8**], findings are similar. A bubble study was performed on the current echocardiogram without evidence of PFO/ASD . [**2163-2-7**] Head CT IMPRESSION: Study limited by motion artifact. No abnormalities are detected. . [**2163-2-9**] Abdominal Ultrasound IMPRESSION: Unremarkable abdomen ultrasound. No ascites identified. Please note that this is a limited study due to the patient's body habitus. Brief Hospital Course: Ms. [**Known lastname 3646**] is a 53 year old woman with COPD, severe pulmonary hypertension, GBS, and polysubstance abuse who presented with dyspnea and productive cough x3 days. . Her hospital course by problem is as follows: . # Dyspnea/productive cough: Ms. [**Known lastname 3646**] presented with chills, wheezing, and cough. Her imaging was consistent with a pneumonia. In the MICU it was also felt she had a significant flare of her underlying pulmonary hypertension and COPD along with some volume overload. She was treated with vancomycin and cefepime (later switched to Zosyn) for presumed pneumonia given imaging findings. She was initially admitted to the floor, but then required transfer to the MICU for hypoxia. She was briefly on a non-rebreather, but did not require intubation. Her sildenafil was increased and spiriva was added in addition to a regimen of nebulizers to optimize her underlying lung disease. She was connected with social work to discuss her positive utox and ongoing use of cocaine (though patient denies this). She was again transferred to a regular medicine floor, where her symptoms continued to improve. She was stable on her home O2 oxygen requirement of 2-3L. . #Delirium: The patient developed confusion on the floor and she was transferred back to the ICU. Her altered mental status was more consistent with delirium as it waxed and waned. This was thought to be due to medications so her cefepime was discontinued (can cause confusion) and switched to zosyn. Benzos, opiates, and H2 blockers were limited. Her delirium eventually improved. After transfer back to the floor, the medical team continued to avoid using morphine, phenergan, oxycodone, pregabalin, or flexeril. Her delirium continued to improve and she was back to her baseline at discharge. . #Hypotension: Her blood pressures remained low in the 80s-90s systolic throughout her MICU stay but were never associated with changes in mental status so she never required pressor support. This was felt to be due to her underlying pulmonary hypertension and not a sign of septic physiology. After transfer to the floor, systolic pressures were 110s-120s and she did not have further episodes of hypotension. . #Pain: Neuropathic chronic pain in her right foot and chronic abdominal pain. She was started on pregabalin with oxycodone prn, but these medications were discontinued due to delirium. After discussion with her PCP it was determined that she would not be prescribed narcotics as an outpatient. Therefore, her chronic pain was not treated with narcotics as an inpatient. Her pain was then treated with Gabapentin and Tylenol. She was started on low dose Seroguel at night. . # [**Last Name (un) **]: Likely due to hypovolemia in the setting of infection. Improved with treatment of infection and gentle fluid boluses. # Pulmonary Hypertension: Chronic, severe pulmonary hypertension probably exacerbated by cocaine use. Her sildenafil was increased to 60mg. We encouraged cessation of cocaine and offered social work services. The MICU team discussed her current management with her pulmonologist, Dr. [**Last Name (STitle) **], and she will follow-up as an outpatient. Physical and Occupation Therapy evaluated and worked with her during this hospitalization. At discharge she was breathing well on her home O2 requirement of 2-3L. #CHF: She has right heart failure secondary to severe pulmonary hypertension. Her Lasix was held in the context of hypotensive episodes in the MICU. After transfer to the floor, we restarted her home dose (20mg) lasix and monitored her Is and Os and weight. #Diarrhea: She developed several episodes of diarrhea on the medical floor. Her C. diff was negative. The diarrhea resolved by discharge. #CODE: FULL Medications on Admission: Medications - Prescription ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 puffs every 4 to 6 hours as needed COMP STOCKING,KNEE,REGULAR,SML [T.E.D. KNEE LENGTH-S-REGULAR] - Misc - Wear on both legs daily CYCLOBENZAPRINE - 5 mg Tablet - 1 Tablet(s) by mouth every eight (8) hours as needed for muscle cramps/spasm DESONIDE - 0.05 % Cream - To areas of eczema on groin twice a day No more than 2 weeks per month to avoid skin thinning. Not for chronic use. FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs twice a day FUROSEMIDE - (Dose adjustment - no new Rx) - 20 mg Tablet - 1 Tablet(s) by mouth daily HYDROCODONE-ACETAMINOPHEN - 7.5 mg-500 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for severe pain LIDOCAINE - (Not Taking as Prescribed) - 5 % (700 mg/patch) Adhesive Patch, Medicated - Apply [**1-4**] patches to affected area daily as needed for PRN 12 hours on and 12 hours off LIDOCAINE HCL - 5 % Ointment - apply to both hand as directed three times a day as needed for pain OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth twice a day ONDANSETRON - 8 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth every 8 hours as needed POLYETHYLENE GLYCOL 3350 - (Not Taking as Prescribed) - 17 gram/dose Powder - 1 packet by mouth daily Mix with 8 ounces of juice/water PREGABALIN [LYRICA] - 75 mg Capsule - 1 Capsule(s) by mouth three times a day PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for nausea SHOES - - extra-depth shoes, multi-density insoles wear daily as needed for neuropathy related to [**Month/Day (3) 30065**]-[**Location (un) **] SILDENAFIL [REVATIO] - 20 mg Tablet - 2 Tablet(s) by mouth three times per day - No Substitution STATIONARY AND PORTABLE OXYGEN - - Use 2L oxygen daily as needed for Port. oxygen req. for daily appoint./errands 3-6 hrs. a wk. for rest O2 sat of 88% in the setting of pulmonary hypertension (416.0) and restrictiv SUCRALFATE - 1 gram/10 mL Suspension - 1 gm by mouth three times a day TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth hs Medications - OTC CAMPHOR-MENTHOL [SARNA ANTI-ITCH] - 0.5 %-0.5 % Lotion - Apply to skin itchy skin MICONAZOLE NITRATE [MITRAZOL] - 2 % Powder - Apply to affected skin three times a day MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day RANITIDINE HCL [ZANTAC MAXIMUM STRENGTH] - 150 mg Tablet - 1 Tablet(s) by mouth at night - No Substitution SODIUM CHLORIDE - 0.65 % Aerosol, Spray - 1 spray each nostril three times a day as needed for dry nose Ranitidine 150mg QHS Zofran 8mg Q8H PRN Compazine 10mg Q6H PRN Sucralfate 1g TID Miralax PRN Sarna lotion MTV daily Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 8. sildenafil 20 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*1* 9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*30 caps* Refills:*2* 10. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-3**] Sprays Nasal TID (3 times a day). 11. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 12. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis Pneumonia Delirium Pulmonary Hypertension Secondary Diagnosis Polysubstance Abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Thank you for allowing us to take part in your care. On [**1-31**] you came to the emergency department of [**Hospital1 771**] because you had been having trouble breathing, a cough, chills, and congestion. You also had pain in your abdomen and in your right foot. A urine test in the ED was positive for cocaine. A CT scan showed that you had pneumonia. You received antibiotics to treat pneumonia. In the ICU you became very confused and delirious. All medications which can worsen delirium were stopped. Over the course of a few days, your condition slowly improved and we transferred you back to a regular medical floor. Your breathing improved until you were back at your baseline condition. You continued to experience some pain in your abdomen and in your right foot. An ultrasound of your abdomen was normal. We treated your pain with Gabapentin and with Tylenol. Physical therapy evaluated you and after working with you for a few days they determined that you were safe to go home and follow up with [**Hospital 111618**] rehab as an outpatient. When you go home, make the following changes to your medications: STOP taking Lyrica (Pregabalin) STOP taking Trazodone STOP any narcotics START taking Gabapentin twice a day START taking Quetiapine (Seroquel) at bedtime We strongly advise avoiding all narcotics, alcohol, and illicit drugs. These substances will worsen your breathing and thinking. Followup Instructions: You have the following appointments already scheduled: Department: RADIOLOGY When: MONDAY [**2163-10-31**] at 10:30 AM [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: OBSTETRICS AND GYNECOLOGY When: TUESDAY [**2163-11-1**] at 2:30 PM With: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 15653**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You should follow up with Dr. [**First Name (STitle) 31365**] in one week after you leave the hospital. We tried to make an appointment for you, but could not make one before you left the hospital. Please call the office at [**Telephone/Fax (1) 7976**] on Monday for an appointment. We would also like you to a lung doctor. You should call the office on Monday to schedule an appointment. Please call [**Telephone/Fax (1) 612**]. Please ask for [**Doctor First Name 8125**] at Dr.[**Name (NI) 6005**] office.

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2132-6-4**] Discharge Date: [**2132-6-19**] Date of Birth: [**2067-11-19**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 695**] Chief Complaint: Here for surgical debulking of insulinoma including distal pancreatectomy and splenectomy, left hepatic lobectomy, and resection of the left supraclavicular mass Major Surgical or Invasive Procedure: -[**2132-6-4**]: Left lateral segmentectomy, (extended) cholecystectomy, distal pancreatectomy, splenectomy, intraoperative ultrasound, intraoperative cholangiogram and resection of left neck mass. - PICC line placement History of Present Illness: 64 yo M with metastatic insulinoma confirmed by liver biopsy scheduled for surgical debulking of insulinoma including distal pancreatectomy and splenectomy, left hepatic lobectomy, and resection of the left supraclavicular mass with Dr. [**Last Name (STitle) **]. He first presented in [**3-13**] lower extremity edema, arthralgias, fatigue, chills and night sweats, a persistent dry cough, dyspnea on exertion, and diarrhea. He was seen by his PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], and was found to have abnormal LFT's. Liver U/S obtained on [**2132-3-18**] demonstrated multiple heterogeneous, predominantly hyperechoic masses throughout the liver. An U/S guided liver biopsy ([**2132-3-26**]) demonstrated a metastatic malignant well-differentiated endocrine tumor (carcinoid). The tumor + for cytokeratin-AE1/AE3, chromogranin, synaptophysin, and [**Last Name (un) **]-31, and was negative for HepPar-1. Most recent CT on [**2132-5-28**] demonstrated a single 5 x 8mm nodule in the anterior right middle lobe. The liver contained multiple heterogeneous lesions in both lobes, with the largest lesion occupying the left lobe and measuring 16.9 x 13.7 x 12.7cm (enlarged from [**2132-4-10**] CT). The primary tumor has resulted in splenic vein thrombosis and the development of left-sided varices along the stomach and spleen. In addition, he has a large mass replacing the left lobe of his liver and occluding the portal vein. He also has metastatic disease in the right lobe of the liver. Octreotide scan ([**2132-4-22**]) demonstrates a 4 cm left supraclavicular lymph node. His symptoms have been very difficult to control, even with this current medical therapy. He is up several times during the night checking his glucoses and eating to try to prevent severe hypoglycemic episodes. Past Medical History: Oncologic history: -metastatic neuroendocrine tumor of the liver confirmed with liver biopsy. Octreotide scan showed involvement of liver and pancreas. Could not identify bowel source. Liver biopsy showed metastatic malignant well-differentiated endocrine tumor (carcinoid); with staining positive for cytokeratin AE1/AE3, chromogranin, synaptophysin, and [**Last Name (un) **]-31. Lesional cells are negative for HepPar-1. PMH: -HTN -hypothyroidism -OSA on CPAP -GERD -pernicous anemia on montly vit B12 injections -s/p 2 inguinal hernia repairs Social History: Married and lives with his wife. Smoked 1ppd for many years and quit when he was 30 years old. Smoke about 3 cigars per month. Has not had alcohol since his carcinoid diagnosis. Family History: Mother had [**Name2 (NI) 499**] cancer and his father had leukemia. Also family history of Alzheimer's. Physical Exam: Gen: well appearing, NAD, sitting up in bed HEENT: MMM, no scleral icterus, trachea midline, large mobile L supraclavicular mass consistent with known mets CVS: RRR Lungs: CTAB no w/r/r Abd: Soft, NT, ND. Large solid, palpable abdominal mass in epigastrium approx. 15 cm in width and 5 cm extending from below xiphoid to umbilicus. Dull to percussion over mass. Ext: No lower limb edema Neuro: grossly intact, no focal deficits Pertinent Results: On Admission: [**2132-6-4**] WBC-3.4* RBC-3.82* Hgb-10.6* Hct-32.5* MCV-85 MCH-27.8 MCHC-32.7 RDW-16.7* Plt Ct-267 PT-12.5 PTT-28.1 INR(PT)-1.1 Glucose-34* UreaN-21* Creat-1.1 Na-130* K-4.1 Cl-96 HCO3-28 AnGap-10 ALT-46* AST-89* AlkPhos-238* TotBili-0.4 Albumin-3.6 Calcium-8.9 Phos-3.4 Mg-2.0 At Discharge: [**2132-6-19**] WBC-7.7 RBC-3.70* Hgb-10.6* Hct-32.4* MCV-88 MCH-28.5 MCHC-32.6 RDW-14.8 Plt Ct-599* Glucose-107* UreaN-14 Creat-0.6 Na-127* K-4.6 Cl-96 HCO3-25 AnGap-11 ALT-50* AST-26 AlkPhos-278* TotBili-0.3 Albumin-2.7* Calcium-8.3* Phos-3.1 Mg-1.9 Triglyc-37 HDL-36 CHOL/HD-2.7 LDLcalc-55 TSH-9.8* T4-6.9 T3-81 rapmycn-2.7* Brief Hospital Course: 64 y/o male with insulinoma taken to the OR with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Left lateral segmentectomy, (extended)cholecystectomy, distal pancreatectomy, splenectomy, intraoperative ultrasound, intraoperative cholangiogram and resection of left neck mass. Per Dr [**Last Name (STitle) 4727**] note, at the time of surgery he had a small amount of ascites. He had a large mass occupying what was mostly the left lateral segment and extended into the medial segment superiorly. He had multiple large masses in the right lobe of the liver. He had a mass in the tail of his pancreas. He had no peritoneal disease. Intraoperative ultrasound confirmed these findings. Please see the operative note for surgical detail. He received 4000 mL of crystalloid, 2 units of fresh frozen plasma, 8 units of packed red cells, 1000 mL of albumin and made 395 mL of urine with an EBL of 4100 mL. He was transferred to the SICU post op for close management. Initially blood sugar management was achieved with D10NS and hourly fingersticks, D50 given for BS < 60 which was occurring frewuently in the immedicate post op period. He also had an inital period of oliguria responsive to fluid bolus. The endocrinology service followed the patient closely throughout the hospitalization. Recommendations included restarting the proglycem, which was increased to TID and then discontinued on POD 12. Slowly the D50 was weaned back, but an attempt to fully allow diet to cover blood sugars was not successful and it was determined that at least at night he would be requiring some D50 supplementation IV through a PICC line. POs were started on POD 4 and he was tolerating diet well enough to start full diet by POD 6, but he is not able to take enough orally to keep blood sugars consistently above 60. Discussion was started on the use of immunosuppressive medication in this patient. It was decided to start sirolimus at 2 mg daily. It was felt that levels should not be allowed to go over 10. Dose was set at 2 mg at discharge but level was 2.7 on discharge so dose was increased to 3 mg daily with labs to be checked Monday [**6-23**] and thereafter every Monday. Sodium was noted to be decreased towards the end of the hospitalization. Lasix and Spironolactone were discontinued and HCTZ left at 25 mg daily. He had slight bilateral lower extremity edema, weight was 86 kg at discharge which was 6 kg lower than admission weight. The patient was discharged to home on D50NS at 25cc/hour for 12 hours overnight. PLan was to check blood sugars four times daily and to be checked during the night. Surgically the patient did very well. Incision remained C/D/I and JP drains were removed by the day of discharge. He was ambulating, had return of bowel function and was tolerating diet without nausea or vomiting. He remained afebrile throughout. Medications on Admission: CPAP - 17CM - USE NIGHTLY CYANOCOBALAMIN - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - Dosage uncertain DIAZOXIDE (DIABETIC USE) [PROGLYCEM] - (Prescribed by Other Provider) - 50 mg/mL Suspension - 100 mg by mouth three times a day FLUTICASONE - (Prescribed by Other Provider) - 50 mcg Spray, Suspension - 1 sprays nasally daily FOLIC ACID - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 1 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth daily GABAPENTIN - 300 mg Capsule - 2 Capsule(s) by mouth at bedtime HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth daily LEVOTHYROXINE [LEVOXYL] - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 75 mcg Tablet - 1 Tablet(s) by mouth once a day OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day SPIRONOLACTONE - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth daily TESTOSTERONE CYPIONATE - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - Dosage uncertain Medications - OTC MULTIVITAMIN WITH IRON-MINERAL [CENTRUM] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Fluticasone 50 mcg/Actuation Disk with Device Sig: One (1) IH Inhalation once a day. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 5. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever: Maximum 6 tablets daily. 8. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 9. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): New dose. Have TSH checked in one month. Disp:*30 Tablet(s)* Refills:*2* 10. Diazoxide (Bulk) 100 % Powder Sig: One [**Age over 90 1230**]y (150) mg Miscellaneous Q8H (every 8 hours) as needed for hypoglycemia. 11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 13. D50NS IV Dextrose 50% in Normal saline-infuse at 25cc/hour from 8pm to 8am every day supply: 7 bags refill: 4 14. Multivitamin with Iron-Mineral Tablet Sig: One (1) Tablet PO once a day: Take separately from Thyroid medication. 15. Testosterone Cypionate 100 mg/mL Oil Sig: One (1) Intramuscular per pre-hospital regimen: Continue home regimen. 16. Outpatient Lab Work Weekly Labs CBC, Chem 7, Ca, Phos, Mg, AST, ALT, Alk Phos, T Bili Trough Rapamycin level Please Fax results to [**Telephone/Fax (1) 697**] Discharge Disposition: Home With Service Facility: [**Location (un) **] HOME THERAPIES Discharge Diagnosis: Insulinoma of the distal pancreas with metastases to the liver and left neck. Discharge Condition: Stable/good Discharge Instructions: Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, increased abdominal pain or issues with the abdominal wound incision such as redness, drainage or bleeding. Please call the endocrine Fellow at [**Telephone/Fax (1) 70484**] and ask for the endocrine fellow on call to be paged. Please call them if issues with very low blood sugars arise in the overnight hours Check blood sugars before each meal and before going to bed. Have a snack with mixed protein, carbohydates and fat at 10 PM. Set alarm for 4 hours after going to bed to check blood sugar and have a snack if indicated. The D50NS at 25 cc/hrwill be running continuously at night from 8 PM to 8AM via the PICC line. VNA will be assisiting with this [**Location (un) 511**] Home Therapies is providing supplies You may shower, pat incision dry and leave open to air Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2132-6-25**] 1:40 [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2132-6-25**] 3:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. Phone:[**Telephone/Fax (1) 6856**] Date/Time:[**2133-2-16**] 9:00 [**Last Name (LF) 7476**],[**First Name3 (LF) **] [**Telephone/Fax (1) 7477**] Call to schedule appointment [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2132-6-20**]

[ "281.0", "452", "157.8", "530.81", "244.9", "401.9", "575.11", "196.2", "197.7", "327.23", "198.89" ]

icd9cm

[ [ [] ] ]

[ "41.5", "87.53", "50.22", "83.39", "38.93", "52.59" ]

icd9pcs

[ [ [] ] ]

10523, 10589

4582, 7451

442, 664

10711, 10725

3922, 3922

11666, 12386

3348, 3454

8762, 10500

10610, 10690

7477, 8739

10749, 11643

3469, 3903

4230, 4559

240, 404

692, 2564

3936, 4216

2586, 3136

3152, 3332

4,395

102,935

46588

Discharge summary

report

Admission Date: [**2174-5-4**] Discharge Date: [**2174-5-20**] Date of Birth: [**2102-3-31**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 905**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Thorocentesis IR guided permatcath [**5-13**] History of Present Illness: 72yo M with metastatic squamous cell lung CA s/p chemo, XRT, photodynamic therapy and tumor debulking to obstructing LLL tumor and pleurodiesis for recurrent Left pleural effusion. In addition, the patient has a history of AFib, HTN, DMII with diabetic nephropathy and emphysema. Day prior to admission, he was sob with climbing stiars. The following night, he presented with orthopnea and PND associated with dry cough. The patient admits to mild chest discomfort. He denied any palpitations, paresthesias, LE edema, hemoptysis. On arrival of EMS, the patient had SaO2 in 80% on RA which improved to 90% on 100% NRB. The pateint was given nebs, lasix in the ED with improvement in sx. He was also given 1 SL nitro with resolution of chest discomfort. Past Medical History: 1. Metastatic squamous cell lung CA s/p chemotherapy with [**Doctor Last Name **]/taxol, photodynamic therapy for obstructing LLL tumor. 2. Recurrent L pleural effusion s/p thoracoscopy with talc pleurodiesis on [**2174-3-26**]. 3. HTN 4. Afib with embolic CVA in [**September 2172**] 5. DMII with nephropathy 6. SCC of skin 7. Emphysema 8. Mild CHF - EF 50-55% by TTE [**9-/2172**], mild regional left ventricular systolic dysfunction with focal severe hypo/akinesis of the basal inferior wall and inferior septum. [**1-23**]+ MR. 9. Nephrotic Syndrome by renal biopsy [**9-/2173**] Social History: The patient lives with his wife. [**Name (NI) **] is a retired baseball player and telephone company worker He admits to smoking 60+ pack years but reports he quit in '[**71**] He denies any significant alcohol consumption. Family History: non contributory Physical Exam: In the ED: VS: 96 119 119/109 20 92% on 5L Gen: elderly male sitting at 90 degress in no respiratory distress HEENT: mm dry, no JVD at 90 degrees, unable to tolerate lying at any lower angle Chest: [**Month (only) **]. BS throughout, with rales at left base CV: tachy, regular rhythm, no murmurs, rubs, gallops Abd: soft, NT, ND, +BS Ext: right leg with 1+ edema, no cords, no calf tenderness Pertinent Results: [**2174-5-4**] 01:10AM WBC-18.5* RBC-4.25* HGB-11.1* HCT-35.6* MCV-84 MCH-26.1* MCHC-31.1 RDW-14.9 [**2174-5-4**] 01:10AM PT-24.3* PTT-35.1* INR(PT)-3.7 [**2174-5-4**] 01:10AM GLUCOSE-358* UREA N-59* CREAT-3.0* SODIUM-140 POTASSIUM-5.2* CHLORIDE-105 TOTAL CO2-20* ANION GAP-20 [**2174-5-4**] 07:54PM CK(CPK)-72 [**2174-5-4**] 07:54PM CK-MB-NotDone cTropnT-0.44* [**2174-5-4**] 10:33PM TYPE-ART PO2-50* PCO2-36 PH-7.41 TOTAL CO2-24 BASE XS-0 [**2174-5-4**] 10:33PM LACTATE-1.8 . [**2174-5-4**] CXR: - IMPRESSION: 1) Worsening asymmetrical alveolar pattern, most likely due to worsening pulmonary edema. 2) Moderate to large loculated left pleural effusion. 3) Stable abnormal appearance of left hilum and perihilar region, in keeping with history of lung cancer." . [**2174-5-5**] TTE: Conclusions: The left atrium is dilated. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed. Resting regional wall motion abnormalities include basal to mid inferior/inferolaterlal hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. There is no pericardial effusion. Compared with the prior study (tape reviewed) of [**2172-9-29**], left ventricular systolic function appears similar and mitral regurgitation appears similar." . [**2174-5-6**] Bilateral Lower Extremity Doppler US: "No DVTs bilaterally. . [**2174-5-6**] Non-contrast Chest CT - IMPRESSION: 1. Left lower lobe consolidation, with air fluid levels concerning for an empyema vs recent procedure. Clinical correlation is requested. 2. Moderate sized right-sided pleural effusion. 3. Loculated left pleural effusion at prior chest tube insertion site. 4. Diffuse paraseptal emphysematous change bilaterally. 5. Honeycombing and interstitial air space disease, predominantly within right upper lobe. Given the acute increase, this most likely represents a pneumonic infiltrate. Given the asymmetry, congestive heart failure is less likely. Clinical correlation is requested. 6. Diffuse mediastinal lymphadenopathy consistent with the patient's history of lung cancer. 7. Atherosclerotic disease. Brief Hospital Course: 72yo M with squamous cell lung CA s/p chemo, XRT, and photodynamic therapy, recurrent left pleural effusion s/p pleurodiesis, CHF, HTN, Afib, Emphysema, who presents with progressively worsening DOE and hypoxia. . PULMONARY - The etiology of the patient's hypoxia was somewhat unclear. [**Name2 (NI) **] had evidence of both pulmonary edema as well as a primary pulmonary process. Multiple CT scans noted evidence of PNA, and possible multilobar PNA. He completed a 10 day course of Levofloxacin for this. He was admitted to CCU intially for diuresis, and then to the [**Hospital Unit Name 153**] for further w/u of his pulmonary process. He was briefly intubated for hypoxia/respiratory distress s/p extubation in the [**Hospital Unit Name 153**]. He thorough w/u for infectious etiology of his pulmonary process including right thoracentesis and brochoscopy which did not show etiology of these findings. All viral and bacterial cultures returned negative. PE was felt less likely given his CT findings, negative LE U/S, and therapeutic INR on Coumadin. Attempts at aggressive diuresis with IV diuretics were unsuccessfull given his Cr in the 3's and known renal disease. His creatinine began to rise with IV diuretics, and he begun on hemodialysis because of his volume overload and continued hypoxia. His oxygen requirement continued to decrease to room air currently. . CARDIOVASCULAR: Coronaries - the patient c/o some atypical chest discomfort on admission, and was noted to have flat CK's but positive Troponins as high as 0.5 in setting of ARF. He had new EKG's with lat STD's and TWI's at low rates, which became more diffuse at higher heart rates. He has likely CAD based on focal WMA's on previous and current TTE's. Cardiology was consulted and recommended medical management of CAD at this time. Pt was continued on ASA, statin, BB. Pump - repeat TTE noted stable EF. Pt required hemodialysis for adequate diuresis. Pt was thought to have a component of diastolic dysfunction in setting of CAD, as well as Afib when in RVR. [**Name (NI) **] - pt presented on Amiodarone but clearly continued to be in Afib. His rate was slighly elevated in high 90's on admission, which was controlled with BB. His Amiodarone was d/c's given his ongoing pulmonary infiltrates and continued Afib despite Amio. He was anticoagulated with Heparin and then restarted on coumadin. Goal INR [**2-24**]. . ARF: The patient has very poor basline renal function, with significant renal damage by recent renal biopsy. This is thought be secondary to nephrotic syndrome b/o diabetes. After he was started on hemodialysis, it was felt that he would likely require long-term dialysis given his poor baseline. He had an IR-guided permacath placed for access. . ONCOLOGY: After discuss with pt's primary Oncologist Dr [**Last Name (STitle) 3274**], it was felt that the status of the patient's lung Ca was unknown. He likely has local recurrence in the location of his previous treatments, but there is no evidence of current metastasis. Since his has had an indolent course of tumor progression and since his mortality is unknown, it was decided that his lung cancer not preclude treatment of his other medical issues. . DM: patient was placed on ISS. Glipizide was discontinued given his renal failure. . ANEMIA: anemia studies c/w anemia of chronic inflammation, with no evidence of GIB. He was started on epogen with hemodialysis. FEN: Cardiac, diabetic diet. UTI: Patient on 7 day course of Levofloxacin. Attempts to remove foley were unsuccessful secondary to retention. [**Month (only) 116**] may have trial of removal in 3 days. Started on flomax. Medications on Admission: 1. Norvasc 10mg once daily 2. Toprol XL 75mg once daily 3. Amiodarone 200mg once daily 4. Lasix 40mg [**Hospital1 **] 5. Coumdain 5mg QHS 6. Glipizide 7. ASA . . Allergies: Percocet -> N/V Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit Injection ASDIR (AS DIRECTED): per insulin sliding scale 151-200, 4 units 201-250, 6 units 251-300, 8 units 301-350, 10 units 351-400, 12 units. 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every six (6) hours. 9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 14. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 15. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 2 days. 16. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**Location (un) 4480**] [**Hospital 4094**] Hospital - [**Location (un) 38**] Discharge Diagnosis: Pulmonary Edema CHF Metastatic Lung cancer Recurrent Pleural effusion DM SCC of skin Emphysema Nephrotic syndrome Discharge Condition: good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Next Hemodialysis on Monday. Check INR 3x per week, goal INR [**2-24**]. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D.[**MD Number(3) **]: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2174-6-8**] 10:00 Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTI-SPECIALTY MULTI-SPECIALTY THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI Date/Time:[**2174-6-9**] 11:30 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2174-5-20**]

[ "414.01", "599.0", "584.9", "518.82", "250.42", "403.91", "581.81", "511.9", "427.31", "428.30", "V58.61", "486", "410.71", "197.0", "492.8", "788.20", "518.81", "V10.83" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.95", "00.13", "93.90", "38.91", "33.22", "99.04", "99.07", "34.91", "96.6", "39.95", "96.04" ]

icd9pcs

[ [ [] ] ]

10373, 10478

4874, 8531

287, 335

10636, 10642

2454, 4851

10863, 11394

2000, 2018

8777, 10350

10499, 10615

8557, 8754

10666, 10840

2033, 2435

228, 249

363, 1126

1148, 1743

1759, 1984

43,749

129,564

45499

Discharge summary

report

Admission Date: [**2118-4-21**] Discharge Date: [**2118-4-24**] Service: MEDICINE Allergies: Penicillin G / Morphine Sulfate / Procardia / Cimetidine / Lopid / Sulfa (Sulfonamide Antibiotics) / Tetracycline Analogues / Clindamycin / Zetia / Compazine / Augmentin / Plavix / Paxil / Lipitor / Levsin / Epinephrine / Lidoderm / Tagamet / Zocor / Lyrica / Tizanidine / Flomax / Colchicine / Avelox / Tramadol / Zydone / Amitriptyline Attending:[**First Name3 (LF) 2698**] Chief Complaint: Chest pain radiating to the neck Major Surgical or Invasive Procedure: none History of Present Illness: 89 year old female with past medical history of coronary artery disease, peripheral vascular disease and hypertension who was recently admitted to [**Hospital1 18**] ([**2118-3-21**] - [**2118-3-22**]) with similar complaint of chest pain radiating to the neck along with palpatations. With nonobstructive coronaries on cardiac catheterization in [**2113**] and normal pMIBI in [**8-/2117**], she was ruled out with three sets of enzymes. She was noted to be in her known atrial fibrillation with conversion to sinus rhythm after four second pause without symptoms. She did not prefer anticoagulation with coumadin and was discharged home on aspirin. . She presented to her PCP today with chest pain radiating to the neck. She received nitro x 1 at PCP's office and transferred to [**Hospital1 18**] ED. . In the ED, she was noted to be in and out of coarse atrial fibrillation with slow ventricular response and long conversion pauses with longest being 12 seconds. Labs with negative troponin t, normal renal function, normocytic anemia. CXR within normal limits. She received IV morphine/zofran/ativan x 1 in the ED which resolved her chest pain. She was admitted to CCU for further evaluation and management. Vitals prior to transfer: 85, 20, 96 2L, 125/66, 98.7. . On the floor, she had no complaints. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - CAD. Most recent cardiac cath [**6-19**] which did not reveal any flow limiting disease. Has had 9+ cardiac catheterization, s/p PTCA [**2090**]. - PVD. Doppler eval [**6-19**] showed miderate right SFA and tibial artery occlusive disease with ABI 0.58. Carotids 11.06 b/l <40% stenosis. - HTN - Functional bowel disease, Gastritis, Nutcracker esophagus - Peripheral neuropathy - Spinal stenosis, Lumbar degenerative disease - Anxiety/personality disorder - Chronic small vessel infarcts on brain MRI in [**2112**] - Chronic rhinitis - Seizure d/o - Chronic cystitis - R gluteal coccygeal pressure ulcer - Osteopenia - [**Female First Name (un) 564**] vaginitis - Hyponatremia, has been noted in past, attributed to primary polydipsia, has resolved with water restriction - Abdominal aortic ectasia - Migraines - Colon adenoma - S/p hysterectomy Social History: Widowed. Lives alone with 2 sons in the area. Walks sometimes with the assistance of a cane. -Tobacco history: None -ETOH: None -Illicit drugs: None Family History: Noncontributory Physical Exam: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple neck. 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, NTND. 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: [**2118-4-21**] 05:30PM BLOOD WBC-6.4 RBC-3.82* Hgb-11.9* Hct-33.3* MCV-87 MCH-31.2 MCHC-35.8* RDW-14.4 Plt Ct-260 [**2118-4-21**] 05:30PM BLOOD PT-12.5 PTT-22.2 INR(PT)-1.1 [**2118-4-21**] 05:30PM BLOOD Glucose-151* UreaN-32* Creat-1.0 Na-137 K-4.9 Cl-100 HCO3-24 AnGap-18 [**2118-4-21**] 05:30PM BLOOD cTropnT-<0.01 [**2118-4-22**] 12:30AM BLOOD CK-MB-5 cTropnT-0.02* [**2118-4-22**] 06:28AM BLOOD CK-MB-6 cTropnT-0.04* [**2118-4-21**] 05:30PM BLOOD Phenyto-7.7* . CXR: IMPRESSION: Low lung volumes, but otherwise no acute pulmonary process. Brief Hospital Course: 89 year old female with past medical history of non obstructive coronary artery disease, peripheral vascular disease and hypertension who was recently admitted to [**Hospital1 18**] ([**2118-3-21**] - [**2118-3-22**]) with similar complaint of chest pain radiating to the neck along with palpitations, found to have aflutter with variable conduction and long conversion pauses. 1. Atrial flutter with variable conduction and long conversion pauses. Likely due to diffuse conduction disease from age related fibrosis with underlying LBBB and prolonged AV delay on previous EKGs. Chronic atrial flutter/fibrillation can cause sinus node dysfunction as well. Unsure how much of the long conversion pauses are due to diltiazem given in the ambulance or if it is due to nicardipine which patient has been taking prn. Pt's AV nodal blockers and diltiazem were held and she had no subsequent pauses. She was instructed to discontinue nicardipine and dilantin on dispo however it is unclear if she will be adherent to this recommendation. She was very histrionic about taking nicardipine to the point that she took 2 tabs of her own prescription despite being advised not to by housestaff and nurse. She should follow-up wtih with outpt cardiologist for further management and ongoing discussion regarding pacemaker. She refused to stop taking dilantin. She was instructed to talk to her primary care physician regarding alternative seizure medications. 2. HTN: Pt on nitro patch and nicardipine at home which she titrates herself. Nicardipine was held and pt was started on Losartan as above - 12.5 mg [**Hospital1 **]. She complained of chest pain and choking after initiating this medication with negative cardiac enzymes and unchanged EKG. 3. Chest pain: Likely GERD, responsive to maalox and lorazepam. No EKG changes or evidence of ACS. 4. Non-obstructive CAD: s/p PTCA in [**2090**]. Has 50% mid LAD, 40% distal RCA and mild Left Cx disease which are all nonobstructive. TTE recently with normal LVEF. Not on optimal medical management. Only on aspirin. Reportably cannot tolerated statin but last LDL was 61 in 05/[**2117**]. Not on BB due to AV delay. Started on [**Last Name (un) **]. f/u with cardiologist. 5. Abnormal UA: Has had history of recurrent UTI with treatment with ciprofloxacin recently. Removed foley. Initial urine culture mixed flora. Subsequent urine cx pending at time of dispo. No signs of infection. Afebrile, without leukocytosis. 6. Complex migraine with aura: Dced dilantin bc sodium blockade confers cardiac risk. Can follow up with neurologist re: alternative tx. She refused to stop taking dilantin. She was instructed to talk to her primary care physician regarding alternative seizure medications. 7. Anxiety/Insomnia: Continue diazepam and diphenhydramine as needed. Very poorly controlled anxiety. Would benefit from outpatient therapy. Medications on Admission: alum-mag hydroxide-simethicone four times a day prn chest pain aspirin 325 mg po qdaily budesonide 32 mcg inhalation qdaily Conjugated estrogens 0.3 mg Tablet po 2x week ([**Last Name (un) 766**] and Thursday) Diazepam 5 mg po BID prn anxiety Diphenhydramine HCl prn hives Gabapentin 100 mg po qhs Hyoscyamine sulfate 0.125 mg SL QID prn pain Nitroglycerin 0.2 mg/hr Patch 24 hr omeprazole 40 mg po BID Phenytoin sodium extended 300 mg Capsule 2x week ([**Last Name (un) 766**] and Thursday)and 200 mg 5x Week ([**Doctor First Name **],TU,WE,FR,SA) polyethylene glycol 3350 17 gram/dose Powder qdaily pyridoxine 10 mg po qdaily Nicardipine 10 mg po qdaily Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. budesonide Inhalation 3. diazepam 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 4. diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: 12.5 mg PO prn as needed for hive. 5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 6. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for indigestion. 7. nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours). 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 9. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1) tab Sublingual four times a day as needed for pain. 10. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 11. pyridoxine Oral 12. losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*20 Tablet(s)* Refills:*2* 13. phenytoin 50 mg Tablet, Chewable Sig: Three Hundred (300) mg PO 2x week (mon and thursday). 14. phenytoin 50 mg Tablet, Chewable Sig: 200 mg Tablet, Chewables PO 5x week (Tuesday, Wednesday, Friday, Saturday and Sunday). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Atrial flutter with variable conduction and long conversion pauses Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname 97077**], It was a pleasure participating in your care. You were admitted for chest pain and found to have pauses in your heart rhythm. Your nicardipine and dilantin were held as they were likely causing these pauses and you were without subsequent problems. We recommend that you do not take any more nicardipine as this could put your heart at risk for pauses and may lead to the need for pacemaker in the future. You have been started on a new medication, Losartan, to help control your blood pressure. Please call or return to the hospital if you have any other symptoms that concern you. ------------------- Please START the following medications: - Losartan 12.5mg daily Please STOP the following medications: - Nicardipine Followup Instructions: Please call your PCP to schedule an appointment in the next [**11-14**] weeks . Please call your cardiologist, Dr. [**Last Name (STitle) **], to schedule an appointment in the next [**11-14**] wks. . Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2118-5-4**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7937**], 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

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9415, 9473

4581, 7459

578, 585

9584, 9584

4013, 4558

10524, 11094

3168, 3185

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3001, 3152

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139,651

29396

Discharge summary

report

Admission Date: [**2128-11-22**] Discharge Date: [**2128-11-23**] Date of Birth: [**2086-9-25**] Sex: M Service: MEDICINE Allergies: Lipitor / Codeine Attending:[**First Name3 (LF) 3984**] Chief Complaint: GIB Major Surgical or Invasive Procedure: Endoscopy [**2128-11-22**] History of Present Illness: 42 yom with PMH of HTN, hyperchol admitted to OSH 1 day ago with black tarry stools X 2 days. Patient states that he had chronically had loose stools but over 2 preeceeding days noticed the stool to be dark and tarry. +Epigastric discomfort, gurgling gas-like pain, no association with food. +lightheadedness when he stood up prompting him to go to OSH ED. He states that he takes ASA daily and takes motrin 800 mg tid sometimes for pain, last use 2 wks PTA. Denies BRBPR, n/v/d. Denies recent fevers, chills. Denies any hemetemesis. At OSH initial Hct= 26, and 22 upon repeat. He was also orthostatic given 3 units PRBC and IVF. EGD attempted but pt unable to tolerate. He is now transferred to [**Hospital1 18**] for futher workup and Rx. . On transfer pt denies any complaints. States that lightheadedness is resolved. Past Medical History: HTN Hyperchol h/o A. fib 6 yrs ago -> cardioverted. Social History: Social Hx: Works as a police oficer, married, denies smoking, etoh. Family History: Family Hx: father with lung ca. Physical Exam: Physical Exam: Vitals: . T: 98 P:66 R: 15 BP:122/51 SaO2:100%RA . General: young male in nad, awake alert oriented HEENT: MMM, eomi, OP clear Neck: supple, no JVD Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: obese, soft, mild epigastric tenderness, NABS Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Rectal: no hemrroiids, guiac positive brown stool. Pertinent Results: OSH 27.5 hct at 2:50 AM [**11-22**]. . EKG: OSH - sinus tach at 108, nl axis, nl intevals. No st-t abnormalities. . [**2128-11-22**] 06:17AM PT-13.2* PTT-27.2 INR(PT)-1.1 [**2128-11-22**] 06:17AM PLT COUNT-259 [**2128-11-22**] 06:17AM WBC-9.3 RBC-3.21* HGB-9.6* HCT-27.3* MCV-85 MCH-29.9 MCHC-35.2* RDW-15.6* [**2128-11-22**] 09:50PM WBC-8.0 RBC-3.20* HGB-9.6* HCT-27.8* MCV-87 MCH-30.1 MCHC-34.7 RDW-15.7* [**2128-11-22**] 09:50PM PLT COUNT-264 [**2128-11-22**] 12:38PM WBC-7.4 RBC-3.38* HGB-10.1* HCT-29.2* MCV-86 MCH-29.8 MCHC-34.5 RDW-15.5 Brief Hospital Course: Assessment and Plan: 42 yom with h/o NSAID use transferred from OSH with black tarry stools at home. Patient was admitted to MICU with tid Hct check. GI was consulted and performed Endoscopy under general anesthesia which revealed a non bleeding ulcer and gastritis. Patient was continued on [**Hospital1 **] PPI, H. Pylori serology checked (pending at time of discharge). His antihypertensives were held given concern for GI bleed and should be restarted at follow up appointment with PCP. [**Name10 (NameIs) **] was discharged with goal PPI twice day for 1 month followed by once a day. He is scheduled to follow up with daughter in 2 days. Medications on Admission: Medications on transfer: esmopreazole 40 mg iv bid hydrochlorthiazide 25 mg daily lisinopril 5 mg daily loratadine 10 mg daily metprolol 150 mg daily multivitamin niacin 500 mg daily - Medications at home: ASA 325mg daily motrin 800 mg tid lisinopril 5 mg daily hydrochlorthiazide 25 mg daily toprol xl 150mg daily niaspan 500 mg daily loratidine 10 mg daily. Discharge Medications: 1. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): Twice a day for one month, followed by one tablet per day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: GI Bleeding Peptic Ulcer disease Gastritis Hypertension Hypercholestrolemia Discharge Condition: Good Discharge Instructions: Please continue to take all your medicaitons and follow up with your appointments as below. You should avoid aspirin, motrin or any other nonsteroidal antiinflammatory agents. You should restart your BP medications after you see your PCP. If you have any further black stools, bleeding, lightheadedness or any other concerning symptoms please contact your PCP or return to the emergency room. Followup Instructions: Please call your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 10113**] at [**Telephone/Fax (1) 70592**] to set up an appointment by Friday this week. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2128-11-23**]

[ "401.9", "280.0", "272.0", "780.57", "535.50", "531.40", "E935.9" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

3851, 3857

2425, 3076

284, 313

3977, 3984

1843, 2402

4428, 4751

1350, 1383

3486, 3828

3878, 3956

3102, 3102

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3308, 3463

1413, 1824

241, 246

341, 1173

3127, 3287

1195, 1248

1264, 1334

28,201

114,725

34192

Discharge summary

report

Admission Date: [**2185-5-5**] Discharge Date: [**2185-5-14**] Date of Birth: [**2105-12-13**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 79 year-old right-handed man with a past medical history significant for alzheimer's disease, hypercholesterolemia, and hypothyroidism who was found at around 4:30pm this evening to be behaving oddly. Though he has moderate alzheimer's at baseline he clearly was acting differently. He was clearly more agitated. He was found at one point in the bathroom folding and unfolding towels. He did this with a napkin and a handkerchief as well. He was much more fidgety than normal. The patient's wife called her daughter who phoned their Neurologist. A decision was made to call EMS and have the patient brought to [**Hospital **] hospital. Blood pressure there was 149/78 There a CT scan showed a right frontal hemorrhage. The white blood cell count was slightly elevated at 10.8. The patient was transferred here for neurosurgical intervention. Past Medical History: Hypothyroidism Hypercholesterolemia Alzheimer's Dementia Social History: Lives with wife. [**Name (NI) **] a daughter in neighborhood. [**Name2 (NI) **] smoking or drugs. Drinks a glass of red wine every evening. Functioned minimally with advanced dementia, but was conversation and pleasant. Needed prompting and cueing for most ADLs, and needed help with dressing and personal hygiene. When put in chair with book/newspaper he would read happily. Was able to join family on small outings. Family History: NC Physical Exam: Vitals: T:97.9 P:78 R:19 BP:133/68 SaO2:100% General: Eyes closed. Arrousable. NAD HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA anteriorly. Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Eyes closed. Opens to his name if repeated loudly and often. Variably following commands. Didn't open and close right hand to command. Did close his eyes to command. Didn't open his eyes to command. Wasn't able to tell where he was. Correctly identified his wife as "[**Name2 (NI) **]" when I asked him who she was. He doesn't move his limbs to command, but he does keep them up. -Cranial Nerves: Olfaction not tested. Pupils equal at 1mm and minimally reactive. Unable to obtain fundoscopic exam. Corneal reflex intact bilaterally. No facial droop. Patient actively opposed eye opening. He was able to hear my questions. -Motor: All four limbs are antigravity. The patient does not comply with a formal motor test. He can keep both arms up for 10 seconds and both legs up for 5 seconds. -Sensory: Intact to noxious stimuli in the upper and lower extremities bilaterally. -Coordination: Nt tesed. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach C5 C7 C6 L4 S1 L 1 1 1 1 0 R 1 1 1 1 0 Plantar response was extensor bilaterally. -Gait: In no condition to test Pertinent Results: MRI [**5-5**] Again demonstrated is a large right frontal intraparenchymal hemorrhage, measuring approximately 5.5 cm x 5 cm, not significantly changed in size from three hours prior. This lesion demonstrates mostly T2 hyperintensity and T1 isointensity, compatible with an acute hemorrhage. There is associated mass effect on the frontal [**Doctor Last Name 534**] of the right lateral ventricle with mild subfalcine herniation, not significantly changed. Additionally, a moderate amount of layering intraventricular hemorrhage within the occipital horns of the lateral ventricles is stable. Thre is no evidence of hydrocephalus. On gradient-echo sequences, scattered punctate foci of susceptibility are seen within the sulci, likely reflecting blood products from a small amount of associated subarachnoid hemorrhage. No definite enhancement is seen within the right frontal region to suggest a large mass or vascular malformation. However, given the relatively large size of this, assessment is somewhat limited. Additionally, there is no evidence of an acute infarct within any particular vascular territory. No convincing evidence of amyloid angiopathy is identified. Minimal mucosal thickening of the ethmoidal sinuses is seen. No abnormal enhancement is identified after contrast administration. IMPRESSION: 1. Large right frontal intraparenchymal hemorrhage, with associated subarachnoid and intraventricular hemorrhage. Overall size and appearance is largely unchanged from three hours prior. 2. Mild leftward subfalcine herniation and effacement of the right frontal [**Doctor Last Name 534**] and lateral ventricle is not changed. 3. No definite evidence of underlying mass, vascular malformation, or infarct. No convincing evidence of amyloid angiopathy. However, due to the large size of this hemorrhage, assessment is limited for an underlying lesion, and a followup study after resolution of acute symptoms is recommended to exclude any underlying mass or vascular malformation. CT [**5-5**] Again is noted a large right frontal intraparenchymal hemorrhage, slightly larger than the study conducted at 3:00 a.m. this morning. There is associated subarachnoid hemorrhage, comparable to the prior study. Unchanged bilateral intraventricular extension is again noted. There is extensive vasogenic edema surrounding the hemorrhage causing mass effect and effacement of the frontal and occipital horns of the lateral ventricle. There is a 4.9 mm leftward subfalcine herniation compared to prior 4.4 mm. There is no uncal or downward transtentorial herniation. There is diffuse global atrophy, unchanged. There are no acute major vascular territorial infarcts or obvious masses. There is no hydrocephalus. No other interval changes are noted. IMPRESSION: 1. Slight interval increase in the right frontal intraparenchymal and bilateral subarachnoid hemorrhage. 2. Stable intraventricular hemorrhage and minimal leftward subfalcine herniation. CT [**5-6**] Again is noted a large right frontal intraparenchymal hemorrhage, slightly larger than the study conducted at 3:00 a.m. this morning. There is associated subarachnoid hemorrhage, comparable to the prior study. Unchanged bilateral intraventricular extension is again noted. There is extensive vasogenic edema surrounding the hemorrhage causing mass effect and effacement of the frontal and occipital horns of the lateral ventricle. There is a 4.9 mm leftward subfalcine herniation compared to prior 4.4 mm. There is no uncal or downward transtentorial herniation. There is diffuse global atrophy, unchanged. There are no acute major vascular territorial infarcts or obvious masses. There is no hydrocephalus. No other interval changes are noted. IMPRESSION: 1. Slight interval increase in the right frontal intraparenchymal and bilateral subarachnoid hemorrhage. 2. Stable intraventricular hemorrhage and minimal leftward subfalcine herniation. CT [**5-10**] The large right intraparenchymal hemorrhage with associated edema, mass effect and effacement of the right frontal [**Doctor Last Name 534**] of the lateral ventricle have shown expected evolution from prior study without any evidence of new hemorrhage or infarct. The 4-mm leftward midline shift is unchanged. The diffuse subarachnoid blood within the cortical sulci is similar, although the confluent area in the left parietal lobe is less apparent. There is slightly less blood within the occipital horns of lateral ventricles than on prior. The mild ventriculomegaly and dilated temporal horns is similar to prior. There is new opacification of the left sphenoid sinus. The mastoid air cells are normal. There are no fractures. IMPRESSION: 1. Expected evolution of right intraparenchymal hemorrhage and diffuse subarachnoid hemorrhage and intraventricular blood without evidence of new infarct or intracranial hemorrhage. 2. Persistent midline shift. 3. No change in the mild ventriculomegaly. Brief Hospital Course: The patient was admitted to the ICU. Neurosurgery was consulted but no intervention. Repeat CT next day no interval change. Exam remained poor. Transferred to floor. Patient became febrile, no focus found, CXR read as possible infiltrate around L hemidiaphragm but no change after 3 days of ABx, no white count, no labored breathing so likely central fever. Exam remained extremely poor and patient deteriorated slowly over 9 day stay, despite stable vital signs and only mild fever, with no evidence of systemic infection. EEG negative for seizures, did show mild to moderate encephalopathy, consistent with exam. 3rd CT scan on [**5-10**] showed further blossoming of R parietal contusion, entrapment of ventricles with balooning, large R frontal evolution of bleed. Towards the 2nd half of hospitalization, daily conversations were held with family. Grim prognosis was stressed, given age, extensive frontal lobe involvement, deterioration during hospital stay, and perhaps most importantly his pre-morbid advanced dementia. The patient has expressed clearly that he wanted no supportive measures in absence of a meaningful life, and the family has respected his wishes after the prognosis became more evident over time. First they chose not to give him a PEG tube, and with continued lack of recovery quite understandingbly made him CMO. Medications on Admission: Asa 81 qd Namenda 10mg [**Hospital1 **] Aricept 10mg daily Levothyroxine 112mcg daily Simvastatin 20 daily Vit E 1200 IU daily Ginko 120mg daily Discharge Medications: Scopolamine patch Morphine drip PRN at discretion of hospice medical team Discharge Disposition: Home with Service Discharge Diagnosis: Intracranial hemorrhage Discharge Condition: comfort measures only Discharge Instructions: You will be transferred to a hospice facility. You have had a large R frontal and a smaller L parietal bleed. Followup Instructions: none [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2185-5-13**]

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icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

9993, 10012

8355, 9700

338, 345

10080, 10104

3397, 8332

10262, 10413

1752, 1756

9895, 9970

10033, 10059

9726, 9872

10128, 10239

2682, 3378

1771, 2267

277, 300

373, 1217

2282, 2665

1239, 1298

1314, 1736

53,835

174,399

48127

Discharge summary

report

Admission Date: [**2116-8-4**] Discharge Date: [**2116-8-21**] Date of Birth: [**2031-8-15**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: Exertional dyspnea and occassional chest pain Major Surgical or Invasive Procedure: [**2116-8-5**]: 1. Aortic valve replacement with a 21-mm [**Last Name (un) 3843**]-[**Doctor Last Name **] Magna Ease aortic valve bioprosthesis. Model number 3300TFX. Serial number [**Serial Number 101479**]. 2. Coronary artery bypass grafting x1 with left internal mammary artery to left anterior descending coronary artery. History of Present Illness: History of Present Illness: 84 year old active gentleman with history of aortic stenosis which has been followed by serial echcardiograms. More recently he has noticed increased symptoms of exertional dyspnea and mild chest pain. He has also noticed that he is considerably more fatigued. A recent echocardiogram revealed critical aortic stenosis with mild left ventricular hypertrophy with a normal left ventricular ejection fraction. He was admitted today after catherization for AVR/CABG Past Medical History: [**2116-8-5**] AVR CABG x 1 LIMA->LAD Past Medical History: Aortic stenosis GERD Depression Hypertension Eosinophilia since [**2113**] Pruritis BPH Past Surgical History: Hemicolectomy [**2076**] c/b infection and prolonged recovery Multiple bowel surgeries for adhesions/obstruction Right knee arthroscopy MOH's surgery x2 on head for Basal cell Recent varicose vein repair after trauma Social History: Race: Caucasian Last Dental Exam: Every 6 months - Last exam [**2116-7-28**] with dental clearance obtained Lives with: Wife in [**Name2 (NI) **] Occupation: Retired Physics professor [**First Name (Titles) **] [**Last Name (Titles) **] Cigarettes: Smoked no [] yes [X] last cigarette [**2076**] Hx: [**12-1**] ppd x20 years ETOH: < 1 drink/week [] [**1-6**] drinks/week [X] >8 drinks/week [] Illicit drug use: None Family History: Family History: Father died at age 56 of heart disease Physical Exam: Physical Exam Pulse: 50 SB Resp: 16 O2 sat:100% RA B/P Right:162/79 Left: 162/77 Height: 64" Weight: 145lb General: AAO x 3 in NAD Skin: Warm, Dry and intact. Multiple well healed abdominal incisions. Infraumbilical incisional hernia. HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Missing multiple teeth - poor repair Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] IV/VI Systolic Murmur Abdomen: Soft[X] non-distended[X] non-tender [X] + bowel sounds[X] Extremities: Warm [X], well-perfused [X] Trace Edema Varicosities: Right below knee grossly varicosed laterally. No appreciable varicosities in thigh. Neuro: Grossly intact [X] Pulses: Femoral Right:cath site Left:2 DP Right:2 Left:2 PT [**Name (NI) 167**]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit Transmitted vs. Bruit bilaterally Pertinent Results: [**2116-8-18**] 04:54AM BLOOD WBC-19.0* RBC-4.22* Hgb-12.3* Hct-36.0* MCV-85 MCH-29.0 MCHC-34.0 RDW-13.4 Plt Ct-420 [**2116-8-17**] 03:09AM BLOOD WBC-17.7* RBC-4.27* Hgb-12.6* Hct-36.4* MCV-85 MCH-29.6 MCHC-34.7 RDW-13.4 Plt Ct-420 [**2116-8-18**] 04:54AM BLOOD PT-18.9* INR(PT)-1.7* [**2116-8-17**] 03:09AM BLOOD PT-24.1* INR(PT)-2.3* [**2116-8-16**] 04:04AM BLOOD PT-23.5* INR(PT)-2.2* [**2116-8-15**] 05:25AM BLOOD PT-18.8* PTT-27.6 INR(PT)-1.7* [**2116-8-14**] 05:51AM BLOOD PT-19.2* INR(PT)-1.7* [**2116-8-13**] 04:08AM BLOOD PT-21.3* PTT-43.8* INR(PT)-2.0* [**2116-8-12**] 01:59AM BLOOD PT-23.0* INR(PT)-2.1* [**2116-8-11**] 12:09AM BLOOD PT-16.5* PTT-35.0 INR(PT)-1.5* [**2116-8-10**] 01:04AM BLOOD PT-13.4 INR(PT)-1.1 [**2116-8-9**] 01:08AM BLOOD PT-12.5 INR(PT)-1.1 [**2116-8-18**] 04:54AM BLOOD UreaN-41* Creat-1.1 Na-139 K-4.8 Cl-107 [**2116-8-17**] 03:09AM BLOOD Glucose-132* UreaN-43* Creat-1.0 Na-139 K-4.4 Cl-108 HCO3-24 AnGap-11 [**2116-8-16**] 04:04AM BLOOD UreaN-46* Creat-1.0 Na-142 K-4.4 Cl-109* [**2116-8-20**] 05:33AM BLOOD WBC-15.2* RBC-4.35* Hgb-12.4* Hct-36.4* MCV-84 MCH-28.5 MCHC-34.0 RDW-13.2 Plt Ct-484* [**2116-8-19**] 01:58AM BLOOD WBC-17.3* RBC-4.00* Hgb-11.8* Hct-33.9* MCV-85 MCH-29.4 MCHC-34.7 RDW-13.1 Plt Ct-414 [**2116-8-20**] 05:33AM BLOOD PT-16.8* INR(PT)-1.5* [**2116-8-19**] 01:58AM BLOOD PT-20.0* INR(PT)-1.8* [**2116-8-20**] 05:33AM BLOOD Glucose-116* UreaN-32* Creat-1.0 Na-134 K-4.9 Cl-99 HCO3-27 AnGap-13 [**2116-8-19**] 01:58AM BLOOD Glucose-123* UreaN-36* Creat-0.8 Na-137 K-4.8 Cl-104 HCO3-26 AnGap-12 Echo: [**2116-8-5**] PREBYASS: -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. -There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. -Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. -Right ventricular chamber size and free wall motion are normal. -There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. -There are three aortic valve leaflets. 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. Mild (1+) mitral regurgitation is seen. -The left ventricular inflow pattern suggests impaired relaxation. -The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. POSTBYPASS: The patient is AV paced on low dose phenylephrine infusion. There is a well seated prosthetic valve in the aortic position. Peak Gradient=48mmHg. There is trace AR. Biventricular function remains intact. The aorta remains intact. [**2116-8-21**] 06:43AM BLOOD WBC-14.5* RBC-4.16* Hgb-12.3* Hct-35.0* MCV-84 MCH-29.5 MCHC-35.0 RDW-13.6 Plt Ct-444* [**2116-8-21**] 06:43AM BLOOD PT-17.7* INR(PT)-1.6* [**2116-8-20**] 05:33AM BLOOD PT-16.8* INR(PT)-1.5* [**2116-8-19**] 01:58AM BLOOD PT-20.0* INR(PT)-1.8* [**2116-8-21**] 06:43AM BLOOD Glucose-102* UreaN-28* Creat-0.9 Na-131* K-4.5 Cl-99 HCO3-29 AnGap-8 [**2116-8-20**] 05:33AM BLOOD Glucose-116* UreaN-32* Creat-1.0 Na-134 K-4.9 Cl-99 HCO3-27 AnGap-13 Brief Hospital Course: Mr [**Known lastname **] has known aortic stenosis, he was admitted one day prioor to suregy for cardiac catheterization. On [**8-5**] he was brought to the operating room for aortic valve replacement and coronary bypass grafting, please see operative report for details. In summary he had: Aortic valve replacement with a 21-mm [**Last Name (un) 3843**]-[**Doctor Last Name **] Magna Ease aortic valve bioprosthesis. Model number 3300TFX. Serial number [**Serial Number 101479**]. And coronary artery bypass grafting x1 with left internal mammary artery to left anterior descending coronary artery. His bypass time was 110 minutes with a crossclamp time of 89 minutes. He tolerated the operation and was brought from the operating room to the cardiac surgery ICU on Neosynephrine and Propofol. Post-operatively he experienced significant bleeding and requiried multiple units of fresh frozen plasma, platelets and packed red blood cells. He stopped without returning to the operating room but was kept sedated on the day of surgery. His chest xray showed moderate pulmonary conjestion requiring aggressive diuresis prior to weaning from the ventilator. He finally extubated on POD3, he remained somewhat lethargic after extubation and failed a speech and swallow evaluation. A feeding tube was placed on POD 5. His mental status improved slowly and steadily. He was evaluated at the bedside by speech and swallow pathology and was cleared for ground solids and thin liquids. He continued to progress and a video swallow was done and he was cleared for soft solids and thin liquids. His appetite remains fair with patient consuming ~50% meals and supplements were ordered. He pulled his dobhoff multiple times and it was decided that it would left out with encouragement with meals. He continued to need supervision and assistance with meals. He remains on calorie counts. He experienced post-operative afib which was managed with lopressor and amiodarone. While on Lopressor 25 [**Hospital1 **] and Amiodarone 400 [**Hospital1 **] he developed complete heart block with a stable blood pressure. He was transferred back to the CVICU for closer monitoring. Electrophysiology was consulted and recommended decreasing the Amiodarone to 200 daily. Once rhythm was stable, his Lopressor was added back and titrated up to 25 mg [**Hospital1 **]. He remained in a sinus rhythm with PAC's in the 70-80's throughout the remainder of his hospital course. Coumadin was initiated for Atrial fibrillation with 1-2 mg doses for INR goal 2.0-2.5. He will need coumadin follow up arranged post discharge from rehab. He is discharged to the [**Hospital 100**] Rehab MACU on POD 16 in stable condition. All follow up appointments were arranged. Medications on Admission: Active Medication list as of [**2116-7-13**]: Amoxicillin 2grams dental prophylaxis LEXAPRO - 10MG Tablet - ONE TABLET EVERY DAY LOSARTAN - 25 mg Tablet - 1 Tablet(s) by mouth once a day RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth twice a day TRIAMCINOLONE ACETONIDE - 0.5 % Ointment - apply to affected area twice a day # 30 gm Medications - OTC ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day - No Substitution MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication afib Goal INR 2.0-2.5 First draw [**2116-8-22**] Results to phone fax : plaese arrange coumadin follow up with PCP upon discharge from rehab 2. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Month/Day/Year **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. acetaminophen 325 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 4. magnesium hydroxide 400 mg/5 mL Suspension [**Month/Day/Year **]: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. bisacodyl 10 mg Suppository [**Month/Day/Year **]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 6. losartan 50 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY (Daily). 7. amiodarone 200 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day. 8. escitalopram 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 9. simvastatin 10 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY (Daily). 10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 11. amlodipine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 12. furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily) for 7 days. 13. potassium chloride 20 mEq Packet [**Last Name (STitle) **]: One (1) Packet PO once a day for 7 days. 14. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 15. warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: MD to dose daily for goal INR 2-2.5, dx: afib. 16. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Two (2) PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: [**2116-8-5**] AVR CABG x 1 LIMA->LAD PMH: Aortic stenosis, GERD, Depression, Hypertension, Eosinophilia since [**2113**], Pruritis, BPH, Hemicolectomy [**2076**] c/b infection and prolonged recovery, Multiple bowel surgeries for adhesions/obstruction, Right knee arthroscopy, MOH's surgery x2 on head for ?Basal cell, Recent varicose vein repair after trauma Discharge Condition: Alert and oriented x3 nonfocal Transfers from bed to chair with assistance, deconditioned Incisional pain managed with tylenol Incisions: Sternal - 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**] **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: Surgeon: Dr.[**Last Name (STitle) 914**], [**First Name3 (LF) **] #[**Telephone/Fax (1) 170**] on [**9-15**] at 1:30pm in the [**Hospital **] medical office building [**Hospital Unit Name **] Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2116-9-3**] on 10:00am Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2116-9-21**] 10:10 **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 afib Goal INR 2.0-2.5 First draw [**2116-8-22**] Results to phone fax : please arrange coumadin follow up with PCP upon discharge from rehab Completed by:[**2116-8-21**]

[ "424.1", "288.3", "285.1", "518.5", "998.11", "E878.2", "780.09", "600.00", "401.9", "530.81", "311", "427.32", "251.2", "458.29", "287.5", "426.0", "414.01", "427.31", "276.69", "511.9" ]

icd9cm

[ [ [] ] ]

[ "34.04", "36.15", "96.6", "35.22", "88.56", "39.61", "96.71", "37.23", "38.97" ]

icd9pcs

[ [ [] ] ]

11583, 11649

6412, 9148

355, 685

12053, 12252

3078, 6389

13093, 13937

2084, 2125

9746, 11560

11670, 12032

9174, 9723

12276, 13070

1398, 1617

2140, 3059

269, 317

741, 1205

1287, 1375

1633, 2052

5,750

175,176

49871+49872

Discharge summary

report+report

Admission Date: [**2134-11-20**] Discharge Date: Date of Birth: [**2072-3-5**] Sex: F Service: [**Company 191**] CHIEF COMPLAINT: Shortness of breath HISTORY OF PRESENT ILLNESS: 62-year-old African-American female with a history of diabetes, rheumatoid arthritis, hypertension, and Stage IV non-small cell lung carcinoma, who breath. The patient had been doing well until she had sudden onset of shortness of breath at rest that was unresponsive to her bronchodilator metered dose inhalers. The patient called EMS, where she was noted to be tachypneic and tachycardic as well as hypoxic, with oxygen saturation approximately 82% on [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] Emergency Department. In the Emergency Department, she had electrocardiogram demonstrating new right heart strain, and CT angiogram was performed, demonstrating evidence of bilateral pulmonary emboli. The patient was started on heparin, and echocardiogram was performed at the bedside, demonstrating right ventricular dilatation and paroxysmal subtotal wall motion. The patient was then transferred to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Stage IV non-small cell lung carcinoma, diagnosed in [**2134-8-8**]. The patient had right upper lobe mass with right-sided pleural effusions, for which she underwent pleuroscopy and pleurodesis. She has been on gemcitabine/cisplatin chemotherapy three times, last on [**2134-11-19**]. Also has metastases to the contralateral lung as well as to the left adrenal gland. 2. Diabetes mellitus Type 2 3. Rheumatoid arthritis 4. Obesity 5. Asthma 6. Hypercholesterolemia 7. History of tobacco use ALLERGIES: No known drug allergies. MEDICATIONS: 1. Cozaar 100 mg by mouth once daily 2. Folate 2 mg by mouth once daily 3. Lipitor 10 mg by mouth once daily 4. Glyburide 10 mg by mouth once daily 5. Naproxen as needed 6. Methotrexate 2.5 mg four times per week 7. Serevent 8. Albuterol 9. Azmacort 10. Actos SOCIAL HISTORY: The patient is a 20 pack year smoker, but quit 16 years ago. No history of drug or alcohol use. FAMILY HISTORY: Significant for two brothers with [**Name2 (NI) 499**] cancer. PHYSICAL EXAMINATION: Vital signs: Heart rate 120 to 145, blood pressure 152/62, oxygen saturation 100% on 100% non-rebreather, respiratory rate 26 to 40. General: Morbidly obese African-American female, lying in bed, tachypneic. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light and accommodation, extraocular movements intact, no lymphadenopathy, no jugular venous distention. Cardiovascular: Tachycardic but regular. Lungs: Dullness to percussion at the right base, and decreased breath sounds. Abdomen: Soft, nontender, nondistended, positive bowel sounds, no masses. Extremities: No cyanosis, clubbing or edema, 2+ dorsalis pedis pulses bilaterally. Alert and oriented x 3. LABORATORY DATA: CT of the head was negative for bleed or metastases. CT angiogram showed bilateral pulmonary emboli. Electrocardiogram was sinus tachycardia, normal axis, new S1 Q3, intraventricular conduction delay with right bundle morphology. Chest x-ray with right basilar opacity consistent with right pleural effusion. HOSPITAL COURSE: 1. Pulmonary embolism: The patient had a right internal jugular placed and was started on heparin. The patient developed right neck hematoma and bleed on heparin. She consequently had thrombocytopenia (plt to 30k). The patient's heparin was discontinued. This occurred at a supratherapeutic level of heparin. Also noted to have stranding in the superior mediastinum, consistent with mediastinal hemorrhage. The patient underwent lower extremity Dopplers to find the source of the clot. She had small thrombus in the proximal left superficial femoral vein, as well as more occlusive thrombus in the popliteal vein on the left. The patient then underwent inferior vena cava filter placement with Trap-Ease type filter. The patient remained clinically stable and improved her oxygenation as well as her tachypnea. The patient was then transferred to the regular hospital floor. Heparin was continued to be held secondary to bleeding and thrombocytopenia risk. Heparin-induced thrombocytopenia antibody was negative. 2. Anemia: The patient suffered bleed on heparin at supratherapeutic level. Hematocrit decreased to 22. The patient was transfused four units of packed red blood cells with increase of hematocrit to 26. The patient had right neck hematoma as well as mediastinal bleed. There was some bruising over the left flank, consistent with retroperitoneal hematoma, although PT was not performed to validate this. The patient's hematocrit then rose on its own. No further blood transfusions were required. 3. Thrombocytopenia: The patient's platelet count on admission was 164. This decreased to a nadir of 33 on hospital day number five. It was unclear if this was due to heparin or to the chemotherapy the patient had received several days earlier. Heparin-induced antibody was negative, as well as other medications such as TPI were stopped. The patient's platelets gradually increased and are increasing at the time of this dictation. 4. Hypotension: The patient initially was hypotensive, probably secondary to her pulmonary embolism. The patient's blood pressure slowly increased during time. The patient was started on metoprolol 12.5 mg by mouth twice a day, with close attention to her blood pressure. 5. Diabetes mellitus: The patient was discontinued on her oral antihyperglycemics, and she was followed with a regular insulin sliding scale. She remained in fair control on this regimen. 6. Code: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**], the patient's primary care physician, [**Name10 (NameIs) 28822**] the patient's code status with her and her family. The patient decided to become Do Not Resuscitate/Do Not Intubate. 7. Non-small cell lung carcinoma: The patient had been receiving outpatient chemotherapy. Secondary to her acute illness and her thrombocytopenia, these were not performed in-house. Consideration may be given to this in the future. A discharge summary addendum will be performed by the next intern. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 26586**] Dictated By:[**Name8 (MD) 104195**] MEDQUIST36 D: [**2134-11-28**] 00:45 T: [**2134-11-28**] 01:40 JOB#: [**Job Number **] Admission Date: [**2134-11-20**] Discharge Date: [**2134-12-2**] Date of Birth: [**2072-3-5**] Sex: F Service: [**Company 191**] Prior discharge summary ends dictation on events through [**2134-11-29**]. Notable events since that discharge summary include the following: The patient's thrombocytopenia continued to improve off heparin products. The patient's final level at the time of this dictation was a platelet count of 503. The patient's hematocrit had decreased somewhat from 28 to 24.7 and should be followed in her extended care facility stay. The patient was noted to have some burning on urination on the [**9-1**]. A urinalysis was noted to have 38 white blood cells and less then 1 epithelial cell with many bacteria. The patient was started on Ciprofloxacin 500 mg po b.i.d. to treat a presumed urinary tract infection. The patient did spike a temperature on the evening of [**2134-11-30**] as well. This was largely thought to be due to her severe clot burden, however, blood cultures were drawn as well as a urine culture, which were no growth to date. The patient was started on Coumadin 5 mg q.h.s., which was increased subsequently to 10 mg q.h.s. given slow increase in the patient's INR, however, dose again was decreased to 5 mg po q.h.s. when Ciprofloxacin was started due to interaction of Warfarin with floxacin drugs. It is recommended that the patient's hematocrit and INR be checked every day until therapeutic level of Coumadin can be established and dose regulated and also to watch for any signs or symtpoms of bleeding since the patient had severe bleeding in the Intensive Care Unit during prior days of this hospitalization. DISCHARGE MEDICATIONS: Ciprofloxacin 500 mg po b.i.d. to be taken through [**2134-12-4**]. Metoprolol 12.5 mg po b.i.d., sliding scale regular insulin, Zolpidem 5 mg po q.h.s. prn, Folic acid 2 mg po q day, Salmeterol inhaler two puffs b.i.d., Albuterol inhaler two puffs q 6 hours prn, Colace 100 mg po b.i.d., Coumadin 5 mg q.h.s. The patient was to have a pneumatic boot to her right lower extremity when not ambulating. Physical therapy and intensive ambulation encouraged at rehab. As noted previously the patient's code status has been changed to DNR/DNI. The following outpatient appointments have been made for the patient and she should be transported from rehab to the [**Hospital Ward Name 23**] Clinical Center at [**Hospital1 346**] for both appointments. First appointment is for chest CAT scan on [**2134-12-17**] at 10:00 a.m. This will take place at the [**Location (un) 861**] of the [**Hospital Ward Name 23**] Clinical Center. The patient is to have no food or drink three hours prior to that study and is best to be NPO after midnight the prior evening. The second follow up appointment is with Dr. [**First Name (STitle) 3459**] and Dr. [**Last Name (STitle) 24028**] of oncology on [**2133-12-23**] at 10:00 a.m. That will take place on the 7th Flor of the [**Hospital Ward Name 23**] Clinical Center. The patient has a previously scheduled appointment with her primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] in [**2135-1-8**]. DISCHARGE DIAGNOSES: 1. Pulmonary embolus. 2. Left lower extremity deep venous thrombosis. 3. Resolving thrombocytopenia possibly due to Gemcitabine or heparin therapy. 4. Diabetes type 2. 5. Rheumatoid arthritis. 6. Asthma. 7. Hypertension. 8. Stage four nonsmall cell lung cancer. The patient is being discharged to the [**Hospital3 105**] [**Location (un) 104196**] in [**Location (un) 86**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 26586**] Dictated By:[**Last Name (NamePattern1) 104197**] MEDQUIST36 D: [**2134-12-2**] 10:32 T: [**2134-12-2**] 10:36 JOB#: [**Job Number **] cc:[**Last Name (NamePattern1) 104198**]

[ "998.12", "162.3", "285.1", "511.9", "287.5", "415.19", "197.0", "198.7", "453.8" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.7", "38.91" ]

icd9pcs

[ [ [] ] ]

2196, 2260

9856, 10555

8316, 9835

3325, 8292

2283, 3308

150, 171

200, 1214

1236, 2064

2081, 2179

81,893

180,910

43972

Discharge summary

report

Admission Date: [**2141-12-1**] Discharge Date: [**2141-12-5**] Date of Birth: [**2078-6-29**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Name (NI) 9308**] Chief Complaint: Hyperglycemia Major Surgical or Invasive Procedure: atrial fibrillation ablation History of Present Illness: 63 yom with history of IDDM Type 2, hypertension, hyperlipidemia, paroxysmal afib/atrial flutter on coumadin, CAD s/p Cypher stenting of the PDA in [**2134**], diastolic heart failure EF 55%, initally presented today for elective atrial flutter ablation, but was found to have blood sugars in the 800s. He was subsequently transferred to the CCU team for management of hyperglycemia, hydration given diastolic heart failure. The patient denies any complaints of chest discomfort, shortness of breath, fevers/chills, palpitations or significant fatigue, although he is fairly sedentary due to an ulcer on his right great toe that is limiting his walking. . The patient was first diagnosed with atrial flutter in [**2138**]. He had a recurrence earlier this year and has been in persistent atrial flutter for several months with a difficult to control heart rate. He is currently on Toprol 250mg qd and Coumadin. . 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: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: [**2134**] PTCA/stenting of PDA - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - Past Medical History: Diastolic dysfunction Hypertension, severe Diabetes mellitus, type II c/b retinopathy, nephropathy, and neuropathy Chronic infected diabetic ulcer PAF on coumadin OSA Peripheral edema Hyperlipidemia BPH Obesity GERD Social History: Lives with girlfriend. Retired; formerly worked as bus driver with [**Company 2318**]. Denies alcohol, tobacco, or illicit drug use. Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Brother with diabetes mellitus. Physical Exam: VS: T= 96.1 BP= 161/106 HR= 100 RR= 18 O2 sat= 100% 2L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Irreg Irreg, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. 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: . [**2141-12-1**] 07:25AM BLOOD WBC-7.8 RBC-4.66 Hgb-12.0* Hct-39.4* MCV-85 MCH-25.8* MCHC-30.5* RDW-16.1* Plt Ct-125* [**2141-12-1**] 07:25AM BLOOD PT-21.2* INR(PT)-2.0* [**2141-12-1**] 07:25AM BLOOD Glucose-807* UreaN-67* Creat-3.4* Na-122* K-5.0 Cl-87* HCO3-27 AnGap-13 [**2141-12-1**] 12:24PM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0 [**2141-12-1**] 02:06PM BLOOD CK-MB-5 cTropnT-0.03* [**2141-12-1**] 07:25AM BLOOD %HbA1c-13.6* eAG-344* . TEE [**12-1**]: Moderate to severe spontaneous echo contrast is seen in the body of the left atrium and left atrial appendage. No mass/thrombus is seen in the left atrium or left atrial appendage. Moderate to severe spontaneous echo contrast is seen in the body of the right atrium and right atrial appendage. No mass or thrombus is seen in the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated with moderate global free wall hypokinesis. 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. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No atrial thrombus seen. Moderate to severe spontaneous echo contrast in the left and right atria and left and right atrial appendages. Normal left ventricular systolic function. Dilated right ventricle with depressed right ventricular systolic function. Brief Hospital Course: 63 yom with history of IDDM Type 2, hypertension, hyperlipidemia, paroxysmal afib/atrial flutter on coumadin, CAD s/p Cypher stenting of the PDA in [**2134**], diastolic heart failure EF 55%, initally presented today for elective atrial flutter ablation, now admitted to CCU with hyperglycemia to 800. . # DM - HOCM vs DKA, no anion gap present on admission. Patient was resusitated with IVFs and put on an insulin drip. Once sugars returned to < 250 patient was transitioned to home regimen. Based on high blood sugars in the hospital, home regimen was increased on discharge to 14 units NPH qam and qpm, with 4 units NPH with insulin sliding scale at meals. Patient was counseled extensively about insulin and diet compliance, as A1c was > 13. . # RHYTHM: Aflutter successfully ablated. Patient discharged on Metoprolol 100 XL [**Hospital1 **] and home dose of coumadin. . # CAD: Patient continued on statin, B blocker, discharged with metoprolol 100 XL [**Hospital1 **]. . # CHF: Once patient rehydrated and euvolemic, he was continued on home lasix 80 [**Hospital1 **]. Medications on Admission: CALCIUM ACETATE 667 mg tid before meals ERGOCALCIFEROL 50,000 qwk vs 1000u daily FUROSEMIDE 80 mg [**Hospital1 **] HYDRALAZINE 50 mg tid HUMALOG 4 units before each meal IPRATROPIUM-ALBUTEROL neb, 2-3 times daily ISOSORBIDE MONONITRATE 30 mg qAM METOPROLOL SUCCINATE 250 mg daily OMEPRAZOLE 20mg daily SIMVASTATIN 80mg daily WARFARIN 5 mg qhs weekdays, 4 mg on weekends ASPIRIN 81 mg daily NPH 6 units twice a day Discharge Medications: 1. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 2. calcium acetate 667 mg Tablet Sig: One (1) Tablet PO three times a day: with meals. 3. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 4. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 6. Humalog 100 unit/mL Solution Sig: 0-12 units Subcutaneous four times a day: per sliding scale. 7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-26**] Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 8. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO twice a day. 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: on weekdays Take 4 mg on weekends (Sat and Sun). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. NPH insulin human recomb 100 unit/mL Suspension Sig: Fourteen (14) units Subcutaneous once a day: Take before breakdast, take 10 units of NPH before dinner. 14. Outpatient Lab Work Please check INR, Chem-7 on tursday [**2141-12-7**] and call results to coumadin clinic and Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 38275**] Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Atrial Fibrillation Hyperglycemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a successful atrial fibrillation ablation, you are now in a normal heart rhythm. Please watch your right groin site for oozing or pain/swelling. You may take off the dressing at home. You should continue your home regimen of coumadin and get an INR checked on [**2141-12-7**] by the VNA. We made the following changes to your medicines: 1. Decrease you Metoprolol to 100 mg twice daily 2. Increase your NPH insulin to 14 units in the morning and 10 units in the evening. 3. Continue your warfarin at the previous schedule. . Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Followup Instructions: Name: [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 15824**], NP-wound care check in Dr [**Last Name (STitle) 94434**] office Location: [**Location (un) 2274**]-[**Location **] Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 3883**] Phone: [**Telephone/Fax (1) 28551**] Appt: Tomorrow, [**12-6**] at 2:40pm Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] -PCP [**Name Initial (PRE) 69975**]: [**Location (un) 2274**]-[**Location **] Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 3883**] Phone: [**Telephone/Fax (1) 28551**] Appt: [**12-12**] at 2pm Name: [**Name (NI) **], [**Name (NI) **]: Cardiology Location: [**Hospital1 641**] Address: [**Street Address(2) 34126**] [**Location 1268**] ,[**Numeric Identifier 6425**] Phone: [**Telephone/Fax (1) 38275**] Appt: [**1-1**] at 10:50 AM Name: Pat [**Doctor Last Name 7984**] Location: [**Location (un) 2274**]-[**Location **] Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 3883**] Phone: [**Telephone/Fax (1) 7985**] Pat's office will call you at home with an appt in 2 weeks.

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icd9cm

[ [ [] ] ]

[ "88.72", "38.93", "37.34" ]

icd9pcs

[ [ [] ] ]

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17,580

170,305

6610

Discharge summary

report

Admission Date: [**2127-10-2**] Discharge Date: [**2127-10-10**] Date of Birth: [**2077-9-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5644**] Chief Complaint: 50M w/ hx obesity, CHF p/w lower abdominal/groin erythema, swelling. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [**Known lastname 25267**] is a 50 year-old gentleman with history significant for obesity and CHD who presents with chief complaint of abdominal and scrotal swelling and pain. Mr. [**Known lastname 25267**] stopped taking his Lasix several months ago, as he did not appreciate the frequency with which it caused him to urinate. Since that time he has noted gradually increasing swelling in his lower abdomen. The region of swelling has appeared irritated and hard to Mr. [**Known lastname 25267**] at times; he has used Vitamin E lotion, which sometimes helps. During the last several weeks, the area has become increasingly irritated, hard, and painful, and during the last two nights the swelling extended to his R scrotal sac > L. He has felt slightly feverish during the last several weeks, with occasional mild nausea. He also notes increased shortness of breath during the last several months, with no acute worsening. He denies chest pain, orthopnea, or PND. He sleeps on 2 pillows at night, a requirement that has not changed. Of note, Mr. [**Known lastname 25267**] had a surgery on his R groin approximately 20 years ago at the [**Location (un) **] Hospital. He recalls that he had injured a blood vessel while straddling a fence, followed by erectile dysfunction. He had what sounds like a vascular graft bypass repair to restore blood flow to the penis, followed by resolution of his dysfunction. On ROS, the patient denies chills, abdominal pain other than superficially at the irritated region, changes in appetite, constipation, or diarrhea, dysuria, changes in vision, hearing, any coriza or sore throat. He notes seeing some blood in his stool one week ago, which he attributes to his chronic hemorrhoids. Past Medical History: - DM II - Obesity - HTN - CHF - on CPAP for OSA - Chronic leg ulcers - Torn cartilage in R knee PSH: - splenectomy s/p MVA in late teens - Bypass surgery for R testicle, as noted above (Dr. [**First Name4 (NamePattern1) 25268**] [**Last Name (NamePattern1) **], [**Location (un) **] Hospital) Social History: Lives in [**Hospital1 8**] with wife and two children. Works several days/week as a property manager. Denies significant smoking history; did smoke "a little bit," for "a few years, a few years back." Denies EtOH or drug use. Gets little exercise. Family History: Father died at age 72 from complications of DM. Mother is still alive at 83, no significant health problems. Four brothers and two children, all in good health. Physical Exam: VS: T 97.5, Pulse 80, BP 134/92, RR 28, sats 94% on 5L GEN: obese, NAD, cheerful HEENT: PERRL. EOMI. Non-icteric. OP clear, but back of throat not well visualized [**2-17**] habitus. NECK: Supple. No LAD appreciated. Extremely thick neck. PULM: Reduced breath sounds throughout. Some soft end-expiratory wheezes in mid-lung fields. Fremitus equal throughout. CV: JVD could not be assessed [**2-17**] habitus. Distant heart sounds. NSR, no MRG appreciated. No heave. ABD: Obese. Upper [**2-18**] abdomen soft, NT. Lower [**1-18**] abdomen indurated, reddened, tender, with puckering at hair follicles. Two well-healed abdominal scars noted; at midline (deviating to left inferiorly), and R groin; the latter incision was raised, hardened, and tender. GENITAL: bilateral scrotal swelling, R > L. Per patient, the swelling has decreased since diuresis last night. EXT: 1+ edema bilaterally. Sensation to light touch and position sense intact to distal extremities. 1+ pulses B. Changes of chronic venous stasis noted. Pertinent Results: [**2127-10-2**] 03:22PM GLUCOSE-88 UREA N-21* CREAT-0.9 SODIUM-143 POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-34* ANION GAP-13 [**2127-10-2**] 03:22PM WBC-12.1* RBC-5.41 HGB-16.3 HCT-50.4 MCV-93 MCH-30.1 MCHC-32.3 RDW-14.7 [**2127-10-2**] 03:22PM NEUTS-65.3 LYMPHS-23.0 MONOS-8.7 EOS-2.2 BASOS-0.8 [**2127-10-2**] 03:22PM HYPOCHROM-3+ [**2127-10-2**] 03:22PM PLT COUNT-324 Brief Hospital Course: A/P: 50M with history of CHF, DM, and morbid obesity who presented with several months of abdominal swelling and intermittant lower abdominal tenderness, increasing shortness of breath, and scrotal swelling. The patient was diuresed aggressively, with resolution of the scrotal swelling, and treated with oxacillin for a presumed cellulitis. While in-house, two additional issues came to light: (1) a significant hypoxia and (2) night-time delerium. The first was deemed consistent with obesity hypoventillation syndrome, and the second was thought related to either Seroquel, hypoxia, or hypercapnia. The [**Hospital 228**] hospital course by problem is discussed below. 1. Volume status The patient's report of stopping diuretics several months prior to presentation, along with increasing SOB and lower abdominal/scrotal edema, suggests that the patient was fluid overloaded. JVD is unreliable in a patient with this habitus. His volume overload might have contributed to his low saturations if there were pulmonary congestion. CXR was difficult to assess, also due to habitus, but suggestive of some pulmonary edema. The patient was diuresed with Lasix, with initial doses of 40 early in his stay, and 20 later. His scrotal edema resolved with diuresis. Other factors likely contributing to the scrotal edema could include the patient's habitus, compressing the IVC; and a history of R vascular insufficiency due to an old injury, addressed through a bypass procedure 20 years ago -- which might explain why the patient's scrotal edema is R > L. The patient was fluid restricted and ran approximately 1-1.5 L negative each day. By the end of the stay, the patient's weight had declined by approximately 10 kg. 2. Hypoxia Mr. [**Known lastname 25267**] [**Last Name (Titles) 3780**] significant baseline hypoxia, with sats on RA in the low 80s. He appeared perfectly comfortable at these saturations, likely indicating a chronic hypoxia. When pressed to breath deeply, his saturations on room air would increase to mid-90s, suggesting a strong hypoventillatory component to his hypoxia. On [**2-18**] L O2 by nasal canula, his sats would go to the low 90s. At night, Mr. [**Known lastname 25267**] [**Last Name (Titles) 3780**] concerning desaturations, occasionally to the 70s or 60s. He was poorly rousable at these times. He was attempted on CPAP/biPAP at night, but often ripped the mask off his face. Aggressive oxygenation, in fact, seemed to worsen his mental status at night. Serial ABGs during his stay [**Last Name (Titles) 3780**] the following: 10 L O2 by FM: pH 7.29, pCO2 85, pO2 61, HCO3 43. 3 L O2 by NC: pH 7.35, pCO2 71, pO2 57, HCO3 41. RA: pH 7.37, pCO2 64, pO2 39, HCO3 38. These data implicated that aggressive oxygenation caused hypercapnia, consistent with a chronic obesity hypoventillation syndrome. Pulmonary was consulted, and suggested a sleep study. A parital study to assess for biPAP goals was conducted on the evening of [**2127-10-9**], and results are commented on in the MICU discharge addendum. We strongly recommend pulmonary follow-up with a formal outpatient sleep study and biPAP for Mr. [**Known lastname 25267**], and have arranged several appointments to this effect. 3. Cellulitis/panniculitis Mr. [**Known lastname 25269**] lower abdominal pannus was red, hot, and painful on admission, implying a cellulitis. He was afebrile and his white could was unimpressive. He was treated with oxacillin. While the erythema and induration did resolve somewhat during the hospital stay, some tenderness remains. He might have had a cellulitis, or simply chronic congestions secondary to regional lymphatic or venous drainage in the region. He will complete a 10 day course of oxacillin --> diclox as an outpatient. 4. Mental status Mr. [**Known lastname 25267**] had several concerning episodes of night-time somnambulation and delerium. He is on a home regimen of Seroquel 200 mg PO TID for unclear reasons. We noticed that, on the nights when Seroquel was held, there were fewer desaturations and less delerium and agitation. Consequently, Seroquel was d/ced. Additional contributory factors to his delerium were thought to include hypoxia and hypercapnia. We have suggested that he might benefit from psych f/u, but he has thus far been unresponsive to that suggestion. 5. Cardiac Rythym: the patient was in NSR throughout his stay. Ischemia: the patient's EKG was somewhat low-amplitude but not suggestive of ischemia. Echo was limited by habitus, but showed no indication of either failure or significant wall motion abnormalities. Pump: The patient's blood pressures were stable throughout his stay, with systolics from 104 to 130 and diastolics from 62 to 84. The patient was on Lipitor for prophylaxis. 6. FEN Mr. [**Known lastname 25269**] labs during his stay were significant for elevated bicarbonate (ranges 30 to 40) and low chloride (as low as 91). His elevated bicarbs were thought partly metabolic compensation for a chronic respiratory acidosis, and partly due to aggressive diuresis. There may have been a contribution from hypochloridemia secondary to aggressive diuresis as well. He was repleted with KCl, with decreasing bicarb from 40 on the 19th to 32 on the 23rd. Mr. [**Known lastname 25267**] [**Last Name (Titles) 8337**] POs well throughout his stay. We strongly recommend dietary follow-up, perhaps including calorie-counting. He is potentially interested in a gastric bypass procedure. 7. DM: the patient's sugars were controlled with Glipizide 10 mg PO BID and sliding scale insulin with Lantus and Humolog throughout his stay. His sugars were occasionally labile to the low 200s, but largely within the 120 - 150 range. 8. PPX: SQ heparin, PO diet. 9. Pain control: Mr. [**Known lastname 25269**] slight abdominal pain was well-controlled on acetominophen. 10. Disposition: Mr. [**Known lastname 25267**] is being discharged to home with close follow-up with his new PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and the pulmonology service. We would further recommend outpatient follow-up with a dietician, at Dr.[**Name (NI) 2056**] discretion. A sleep study is planned for the near future. Mr. [**Known lastname 25267**] will require arrangement for a new biPAP device at home, to be discussed at his PCP [**Name Initial (PRE) **]. Medications on Admission: [**First Name8 (NamePattern2) **] [**Last Name (un) 25270**] Apothocary: [**Telephone/Fax (1) 25271**] Lantus 50 Qhs Humulog 50 units TID Glipizide 10 TID Furosemide 40 [**Hospital1 **] Zesteretic 10/12/5 "as directed" Neurontin 300 [**Hospital1 **] (for "leg pain") Lipitor 20 [**Hospital1 **] Seroquel 200 TID Celebrex 200 mg QD Viagra PRN Discharge Medications: 1. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. glargine Sig: Forty (40) units at bedtime. Disp:*qs * Refills:*2* 5. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 6. Dicloxacillin Sodium 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 4 days. Disp:*16 Capsule(s)* Refills:*0* 7. Lipitor 20 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Celebrex 200 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 9. Humalog 100 unit/mL Solution Sig: 0.5 ml Subcutaneous three times a day. Disp:*qs * Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Cellulitis Obstructive Sleep Apnea with Obesity Hypoventilation Syndrome Diabetes mellitus, type 2 Hypertension Discharge Condition: Stable Discharge Instructions: Please wear your home BiPAP as much as you can tolerate. It is EXTREMELY important that you use this machine, even though it is uncomfortable at times. Please adhere to 2 gm sodium diet Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2127-10-16**] 3:00 Please also call [**Company 191**] Registration (use the main # listed above) and ask for Registration, so that you can update your information You have an appointment scheduled with the Sleep [**Hospital **] Clinic in [**Location (un) 745**] for a sleep study on Saturday, [**11-15**], at 8:30 pm. They are going to send you all of the information regarding this.

[ "278.01", "514", "428.0", "682.2", "401.9", "786.09", "276.4", "780.57", "238.4" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

11949, 11955

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384, 391

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12355, 12904

2759, 2921

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11976, 12090

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12143, 12332

2936, 3967

276, 346

419, 2160

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174,241

9587

Discharge summary

report

Admission Date: [**2165-1-15**] Discharge Date: [**2165-1-22**] Date of Birth: [**2100-11-15**] Sex: M Service: C-MED HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old male with a past medical history significant for end-stage renal disease (on hemodialysis) who was admitted on [**1-15**] to the Surgical Transplant Service for arteriovenous fistula revision and thrombectomy. PAST MEDICAL HISTORY: 1. End-stage renal disease (on hemodialysis on Monday, Wednesday, and Friday). 2. History of pancreatitis. 3. Status post cerebrovascular accident in [**2149**] with residual left hemiparesis. 4. History of gout. 5. Multiple Escherichia coli bacteremia infections. 6. Diverticulosis. 7. Chronic obstructive pulmonary disease. 8. Hypertension. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Enalapril 20 mg p.o. q.d. 2. Labetalol 200 mg p.o. q.d. 3. Isosorbide dinitrate 20 mg p.o. t.i.d. 4. Clonidine TTS #3 patch every Thursday. 5. Sevelamer 800 mg p.o. t.i.d. 6. Nephrocaps one tablet p.o. q.d. 7. Lipitor 40 mg p.o. q.d. SOCIAL HISTORY: The patient is an emigrant from [**Country 2045**]. The patient is married and lives with his wife. The patient speaks Haitian Creole as well as some English. The patient denies a history of tobacco, alcohol, as well as illicit drug use. FAMILY HISTORY: Family history unknown. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on transfer from the Surgery Service to Cardiology Service revealed temperature was 98.6, blood pressure was 140/70, heart rate was 91, respiratory rate was 16, and oxygen saturation was 98% on room air. In general, the patient was a well-developed and well-nourished male complaining of chest pain. In moderate distress. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. Sclerae were anicteric. Pupils were equal, round, and reactive to light and accommodation. The oropharynx was clear. Mucous membranes were moist. The neck was supple. No jugular venous distention or lymphadenopathy appreciated. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sound and second heart sound. A systolic murmur at the right upper sternal border with no third heart sound or fourth heart sound appreciated. Pulmonary examination was clear to auscultation bilaterally without wheezes, rhonchi, or rales. Abdominal examination revealed soft and nondistended. Diffusely tender without guarding or rebound. Normal active bowel sounds. Extremity examination revealed no edema. Dorsalis pedis and posterior tibialis pulses were 2+. Right arm arteriovenous fistula dressing was clean, dry, and intact with a palpable thrill. PERTINENT LABORATORY VALUES ON PRESENTATION: Admission laboratories revealed complete blood count with a white blood cell count of 5.2, hematocrit was 31.3, and platelets were 121. INR was 1.1. Chemistry-7 revealed sodium was 138, potassium was 4.2, chloride was 99, bicarbonate was 19, blood urea nitrogen was 76, creatinine was 3.3, and blood glucose was 126. Calcium was 9.4, magnesium was 2.1, and phosphate was 9.5. The patient had multiple sets of cardiac enzymes with negative creatine kinase (peak of 90) and an evaluated troponin I with a peak of 29. She also had a cholesterol panel during her hospitalization with a total cholesterol of 118, triglycerides were 87, high-density lipoprotein was 34, and low-density lipoprotein was 67. Hemoglobin A1c was 5.8. RADIOLOGY/IMAGING: The patient's electrocardiogram on hospital day two demonstrated a normal sinus rhythm at 68 with atrioventricular conduction delay. New T wave inversions in leads I, aVL, V4 through V6. Q waves in leads in III and aVF. HOSPITAL COURSE: The patient underwent arteriovenous fistula repair and thrombectomy on hospital day one without complications. However, on postoperative day one, the patient developed the acute onset of substernal chest pain with diaphoresis, nausea, and vomiting. An electrocardiogram demonstrated new T wave inversions in the anterolateral leads, and the patient was sent for emergent cardiac catheterization. Cardiac catheterization revealed 3-vessel disease with 70% proximal and 95% mid left anterior descending artery stenosis, 70% proximal left circumflex stenosis, 80% second obtuse marginal stenosis, and 75% proximal and 80% mid right coronary artery stenosis. The patient underwent percutaneous transluminal coronary angioplasty and stenting (times two) of the left anterior descending artery with good results. The patient had a stable post catheterization course until [**1-17**]; when, during hemodialysis, the patient complained of abdominal pain with nausea and vomiting. Hemodialysis was discontinued early, and the patient was returned to the floor where the nausea and vomiting continued, and the patient complained of recurrent chest pain. A repeat electrocardiogram demonstrated anteroinferior ST elevations, and the patient went for emergent re-look catheterization. Catheterization was without evidence of acute thrombosis or change in anatomy, and no intervention was required. However, immediately status post catheterization, the patient developed large hematemesis; initially coffee-grounds emesis followed by bright red blood per rectum. The patient was hemodynamically stable and without chest pain at the time and was transferred to the Cardiothoracic Intensive Care Unit for further management. The patient's blood pressure medications were held, and the patient was transfused one unit of packed red blood cells for a hematocrit of 25.6 (down from 31 twelve hours prior). The patient refused a nasogastric lavage and was started on high-dose proton pump inhibitor without further episodes of hematemesis. The patient continued to remain hemodynamically stable without further episodes of chest pain. An echocardiogram was performed which demonstrated mild left and right atrial dilatation, symmetric left ventricular hypertrophy, normal right and left ventricular size and function, with an ejection fraction of 55%, moderate aortic root dilatation, and 1+ aortic regurgitation, and trivial tricuspid regurgitation. The patient was transferred to the Cardiac Medicine floor where he remained for 48 hours. The patient's hematocrit remained stable with a discharge hematocrit of 33.4. There was no further need for a transfusion. The patient remained hemodynamically stable, and blood pressure medications were restarted without complications. The patient has a history of end-stage renal disease (on hemodialysis three times per week). The patient was continued on hemodialysis throughout the hospitalization via a temporary port while the arteriovenous fistula matured. The arteriovenous fistula remained dressed and without signs of infection. CONDITION AT DISCHARGE: Condition on discharge was good; ambulating without difficulty, chest pain free, and without further evidence of bleeding. DISCHARGE DIAGNOSES: 1. Non-ST-elevation myocardial infarction. 2. Status post cardiac catheterization with percutaneous transluminal coronary angioplasty and stenting of the left anterior descending artery. 3. Upper gastrointestinal bleed (no intervention). 4. Status post arteriovenous fistula repair and thrombectomy. 5. End-stage renal disease (on hemodialysis). 6. Cerebrovascular accident with residual left hemiparesis. 7. Chronic obstructive pulmonary disease. 8. Gout. 9. Diverticulosis. 10. Multiple Escherichia coli bacteremia infections. MEDICATIONS ON DISCHARGE: 1. Plavix 75 mg p.o. q.d. (times three months). 2. Enalapril 20 mg p.o. q.d. 3. Labetalol 200 mg p.o. q.d. 4. Protonix 40 mg p.o. b.i.d. 5. Isosorbide dinitrate 20 mg p.o. t.i.d. 6. Sevelamer hydrochloride 800 mg p.o. t.i.d. 7. Nephrocaps one tablet p.o. q.d. 8. Sublingual nitroglycerin 0.3 mg tablet as needed (for chest pain). 9. Clonidine patch TTS #3 every week. DISCHARGE STATUS: The patient was discharged to home with [**Hospital6 407**] services for medication teaching and compliance reinforcement. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to continue hemodialysis as per usual on the day status post discharge. 2. An appointment with Vascular/Transplant Surgery; follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**1-31**] at 2 p.m. at [**Last Name (NamePattern1) 21589**]. 3. The patient was scheduled with primary care physician (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**]) for an initial appointment on [**2-11**] at 3:30 p.m. in the [**Last Name (un) 469**] Building, sixth floor, [**Hospital6 6613**] Clinic. 4. The patient was scheduled for an initial Gastroenterology appointment with Dr. [**Last Name (STitle) **] on [**2-12**] at 1:20 in the [**Hospital 12053**] Clinic. 5. The patient was scheduled for an initial Cardiology appointment with Dr. [**Last Name (STitle) **] on [**2-13**] at 9 a.m. at [**Last Name (NamePattern1) 21589**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. [**MD Number(1) 4992**] Dictated By:[**Name8 (MD) 4935**] MEDQUIST36 D: [**2165-1-25**] 12:48 T: [**2165-1-29**] 07:53 JOB#: [**Job Number 32513**]

[ "414.01", "274.9", "410.91", "996.73", "E878.8", "578.9", "438.20", "496", "403.91" ]

icd9cm

[ [ [] ] ]

[ "36.06", "37.22", "88.56", "36.01", "88.53", "39.95", "39.42", "38.93" ]

icd9pcs

[ [ [] ] ]

1363, 3758

7031, 7579

7605, 8126

842, 1087

3777, 6870

8159, 9337

6885, 7009

164, 404

426, 816

1104, 1346

53,739

126,125

10097

Discharge summary

report

Admission Date: [**2141-4-13**] Discharge Date: [**2141-4-26**] Date of Birth: [**2092-4-10**] Sex: M Service: CT SURGERY CHIEF COMPLAINT: The patient presents with coronary artery disease. HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old male who has a history of an anterior myocardial infarction approximately 16 years ago, without any intervention done at that time. The patient presented to his cardiologist and primary care physician approximately two weeks ago, after a gradual increase in shortness of breath and dyspnea on exertion. The patient noted decreased exercise tolerance in his usual walk home up a [**Doctor Last Name **]. The patient never reported any chest pain, but did not exactly feel right. The patient went on a standard [**Doctor First Name **] protocol with an exercise Thallium test, which showed 1 to [**Street Address(2) 1766**] depressions in Leads II, III and V5 through V6. A MIBI scan showed large, fixed, intraseptal, apical and septal perfusion deficits, consistent with old infarction. It also showed an anteroapical ischemia that was new. There was moderate akinesis of the anteroseptal and apical regions. Ejection fraction measured at 41%. A cardiac catheterization done at [**Hospital6 3426**] showed an 80% proximal LM, 70% proximal left anterior descending, right coronary artery 70% mid-stenosis, a 60% distal stenosis, and a question of an anterior aneurysm. The patient was therefore transferred to [**Hospital1 1444**] for surgical intervention. PAST MEDICAL HISTORY: Includes a myocardial infarction 16 years ago, Hodgkin's disease 15 years ago with XRT to the chest wall and splenectomy, hypercholesterolemia, hypothyroidism, and depression. MEDICATIONS: Depakote 250 mg twice a day, Paxil 20 mg once daily, Levoxyl .125 mg once daily, Zestril 5 mg by mouth once daily, Lipitor 10 mg once daily, and aspirin 325 mg once daily. ALLERGIES: None. SOCIAL HISTORY: 25 year pack smoker, quit ten days prior to admission, and occasional alcohol use. PHYSICAL EXAMINATION: The patient is a pleasant male, appearing his stated age, and in no apparent distress. The head was normocephalic, atraumatic, with equal and reactive pupillary responses. The neck was supple, without jugular venous distention, lymphadenopathy or bruits appreciated. The chest was clear to auscultation bilaterally. The heart was regular rate and rhythm, normal S1 and S2, without murmurs, gallops or rubs appreciated. The abdomen was soft, nontender, nondistended, with present bowel sounds. The extremities were warm and well perfused, and there was no peripheral edema. Neurologically, the patient was alert and oriented x 3, moving all extremities, with intact cranial nerves. HOSPITAL COURSE: The patient was admitted to the Cardiothoracic Surgery service and underwent a three vessel coronary artery bypass graft on [**2141-4-14**]. The vessels involved were a left internal mammary artery to the left anterior descending, saphenous vein graft to the obtuse marginal, and a saphenous vein graft to the posterior descending artery. The patient tolerated the procedure well, and was transferred in a stable condition to the Cardiothoracic Intensive Care Unit. Postoperatively, the patient spiked a fever to 101.4, but otherwise had stable vital signs. The patient was extubated without difficulty, and was started on his oral medications. A moderate amount of purulent drainage was noted from the mid-incision line, as well as peri-incisional erythema. There was no sternal click, however. The patient continued to spike low-grade temperatures, and therefore was pancultured. One blood culture showed coag-negative staphylococcus. Therefore, the patient was started on vancomycin 1 gram intravenously every 12 hours. Wound cultures from the sternal wound also grew out coag-negative staphylococcus. On postoperative day number two, the patient was transferred to the floor in stable condition, and did well with Physical Therapy and ambulation, took a regular diet, and was voiding on his own. The patient continued to do well over the following few days, but did have an elevated white count, which was noted to be 16 on [**2141-4-18**]. The patient was ambulating well, and denied having any symptoms of fevers, chills or sweats. The patient was continued on wet-to-dry twice a day dressing changes to the sternal wound site. The patient was also continued on intravenous vancomycin for therapy of both the wound site and also the blood culture x 1. The patient's white blood cell count reached a [**Location (un) **] of 19.9 on [**2141-4-22**], and then progressively improved over the following days to 17.3 on the day of discharge. The last few days of the admission, the patient was afebrile, with stable vital signs. The patient had clear lung and heart sounds. The sternal wound appeared to be clean, dry and intact, with good fibrinous and granulation tissue on the wound margins. The patient had no complaints of fevers, chills or sweats. The patient was ambulating well, taking a full diet, and voiding on his own. A PICC line was placed by Interventional Radiology on [**2141-4-25**] secondary to inability for venous access team to place PICC line. On [**2141-4-26**], the patient was felt to be stable from a medical and surgical standpoint to be discharged home with VNA care for home antibiotics. DISCHARGE CONDITION: Stable DISCHARGE DISPOSITION: To home with VNA care DISCHARGE MEDICATIONS: Include lasix 20 mg twice a day, potassium chloride 10 mEq twice a day, Nystatin swish and swallow 5 mg three times a day, ciprofloxacin 500 mg twice a day, Paxil 20 mg once daily, Levoxyl .125 mg once daily, vancomycin 1 gram twice a day, Depakote 250 mg twice a day, Lipitor 10 mg once daily, Colace 100 mg twice a day, aspirin 81 mg once daily, Lopressor 25 mg twice a day, Percocet one to two tablets by mouth every four to six hours as needed, albuterol and Atrovent nebulizers every four to six hours as needed. DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient is to receive his vancomycin 1 gram every 12 hours intravenously through his PICC line for the next two weeks total. The patient is to follow up with his primary care provider in one week for medical management. The patient is to follow up with Dr. [**Last Name (Prefixes) 2545**] of the Cardiothoracic Surgery service within two to three weeks, and is to call the office to make a follow up appointment. The patient is also to have his staples removed within three weeks of surgical date. The patient is to continue taking medications as outlined above, and is to report to the Cardiothoracic Surgery service if he has any concerning symptoms of wound infection, including fevers, chills, sweats, purulent discharge, redness, warmth, or odor. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 13463**] MEDQUIST36 D: [**2141-4-26**] 22:06 T: [**2141-4-27**] 00:48 JOB#: [**Job Number 33728**]

[ "272.0", "411.1", "V15.82", "414.01", "V10.72", "244.9", "998.59" ]

icd9cm

[ [ [] ] ]

[ "38.93", "36.15", "39.61", "36.12" ]

icd9pcs

[ [ [] ] ]

5472, 5495

5440, 5448

5520, 7113

2781, 5418

2074, 2762

161, 213

243, 1539

1563, 1948

1966, 2050

18,846

157,080

6076

Discharge summary

report

Admission Date: [**2136-9-12**] Discharge Date: [**2136-9-16**] Date of Birth: [**2074-2-1**] Sex: F Service: MEDICINE Allergies: Penicillins / Ceftriaxone Attending:[**First Name3 (LF) 458**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Cardiac catheterization with pericardial drain placement -- [**2136-9-12**] History of Present Illness: Ms. [**Known lastname **] is a 62 yo female with a h/o IDDM, ESRD on HD, diastolic CHF, multiple thrombi on coumadin, s/p recent admission for HD catheter infection who presents with a complaint of abdominal pain x 1 week. She describes anorexia and vomiting with any PO intake. She localizes the abdominal pain to the RLQ, radiating to the RUQ. Per report from The [**Hospital3 2558**], morning vitals were notable only for a HR 122. Patient requested transfer to [**Hospital1 18**]. . On arrival to ED, T 95.6 PO, HR 122, BP 104/55, RR 17. Morphine 4 mg IV and Zofran 4 mg IV were administered on arrival for symptom control. Following a stat lactate of 6.3 she received Vancomycin 1 gram and Ceftazadime 2 g IV. Patient became hypotensive to 63/31 and a CVL was placed in the right groin. Levophed was started. CT abdomen was performed given her complaint of abdominal pain which revealed large pericardial effusion. Cardiology was called, and stat TTE was performed at bedside, indicating tamponade physiology. She received Vitamin K 10 mg PO, and 1 mg IV. 4 units FFP were transfused, and she received Profil nine 1120 units IV x 1. . She was taken urgently to the cath lab where 700 cc of bloody fluid was drained. Initial pericardial pressure in 40's down to 11 s/p drainage. Patient was started on Dopamine gtt at 5mcg/kg/min and transferred to the CCU for further management. . On review of symptoms, she denies any prior history of stroke, TIA, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: - Bilateral internal jugular thromboses, restarted on coumadin [**8-24**] - h/o bilateral lower extremity DVT's - ESRD on HD T, Th, Sat - IDDM - Diastolic heart failure - Pulmonary hypertension - Hypercholesterolemia - OSA, noncompliant with CPAP as outpatient - OA - h/o C. Diff - GERD - Depression - Morbid obesity - Fibroid uterus; vaginal bleeding - h/o Osteomyelitis at the T9 Vertebrae [**5-24**]; tx with Vanc - h/o Multiple line infections **[**2135-12-17**]: Providencia, treated with 4 wk course of aztreonam **[**2135-4-17**]: Staph coag positive, sensitive to both vancomycin and gentamicin **[**2136-5-17**]: Staph bacteremia tx with vanc x 6 weeks **[**2136-8-17**]: Proteius mirabilis and MSSA, treated with ceftaz and vanc . PAST SURGICAL HISTORY: - L forearm radial-basilic AV graft, s/p infection, thrombosis and abandonment ([**12-21**]) - Multiple lines in L upper arm with AV graft - 1/07 L femoral PermaCath placed - L upper arm thrombectomy, revision, of LUE AV graft ([**3-23**]) - [**4-23**] Excision of left upper arm infected AV graft; associated MRSA bacteremia treated with 6 weeks vancomycin. - Right upper extremity AV fistula creation [**10-23**] s/p revision - [**2135-12-14**] Right AV fistula repair, Right IJ PermaCath rewiring and IVC filter removed Social History: Patient denies a tobacco, alcohol or illicit drug use. She lives in a nursing home (?[**Hospital3 2558**]) Family History: Not obtained. Physical Exam: VS: T 96.7, BP 127/53, HR 102, RR 16, O2 97% on 1 L NC Gen: obese black female, supine in bed, in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 8 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: Tunneled HD cathter in left anterior chest wall with dressing intact. No scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, with tenderness in all 4 quadrants. + [**Doctor Last Name 515**] sign. No abdominial bruits. Ext: Trace lower extremity edema. No femoral bruits. TLC in left groin with clean dry dressing intact. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Pertinent Results: ADMISSION LABS: . [**2136-9-12**] 09:20AM BLOOD WBC-9.6 RBC-4.14* Hgb-13.3 Hct-42.6 MCV-103* MCH-32.1* MCHC-31.2 RDW-16.0* Plt Ct-509* [**2136-9-12**] 01:50PM BLOOD Neuts-87.6* Lymphs-9.3* Monos-2.7 Eos-0.1 Baso-0.3 [**2136-9-12**] 09:20AM BLOOD PT-129.1* PTT-44.3* INR(PT)-18.2* [**2136-9-12**] 09:20AM BLOOD Plt Ct-509* [**2136-9-12**] 09:20AM BLOOD Glucose-176* UreaN-36* Creat-4.8* Na-133 K-GREATER TH Cl-92* HCO3-21* [**2136-9-12**] 01:50PM BLOOD Glucose-260* UreaN-34* Creat-4.3* Na-133 K-4.4 Cl-92* HCO3-21* AnGap-24* [**2136-9-12**] 09:20AM BLOOD ALT-450* AST-496* AlkPhos-957* TotBili-0.8 [**2136-9-12**] 01:50PM BLOOD CK(CPK)-35 [**2136-9-12**] 09:20AM BLOOD Lipase-25 [**2136-9-12**] 01:50PM BLOOD CK-MB-NotDone cTropnT-0.09* [**2136-9-12**] 09:20AM BLOOD Albumin-4.1 Calcium-7.7* Phos-5.0*# Mg-3.1* [**2136-9-12**] 02:02PM BLOOD pH-7.22* [**2136-9-12**] 09:35AM BLOOD Lactate-6.3* [**2136-9-12**] 11:39AM BLOOD K-5.3 [**2136-9-12**] 02:02PM BLOOD freeCa-0.67* . . PERTINENT LABS/STUDIES: Hct: 42.6 ([**9-12**]) -> 33.2 ([**9-12**]) -> 31.9 -> 30.9 -> 32.1 ([**9-15**]) INR: 18.2 ([**9-12**]) -> 6.4 -> 3.5 -> 4.1 -> 3.3 -> 2.8 ALT: 627 ([**9-13**]) -> 470 -> 352 ([**9-15**]) AST: 627 ([**9-13**]) -> 258 -> 137 ([**9-15**]) Alk Phos: 669 ([**9-13**]) -> 618 -> 557 ([**9-15**]) Calcium: 7.7 ([**9-12**]) -> 7.0 ([**9-15**]) Free Ca: 0.67 -> 0.91 EKG performed on arrival to CCU demonstrated NSR, HR 100 with no significant change compared with prior dated [**2136-8-27**]. Left axis deviation with normal intervals. Normal voltages. Left anterior fascicular block and delayed R wave progression. . TELEMETRY demonstrated: NSR, HR 80 . CARDIAC CATH performed on [**2136-9-12**] demonstrated: 1. Cardiac tamponade. 2. Successful pericardiocentesis with drainage of approximately 700 cc of bloody fluid. . CT ABDOMEN/PELVIS [**2136-9-12**]: 1. Large pericardial fluid collection with enhancement of the pericardium is consistent with pericarditis. Pericardial fluid causes mass effect on the atria and ventricles. Emergent pericardiocentesis should be considered. Right basal effusion. 2. Enlarged gallbladder and common duct. Recommend HIDA scan to rule out acute cholecystitis. 3. Normal appendix without evidence of obstruction or ischemia. 4. There is an AV fistula in the right groin with contrast in the right iliac vein and IVC . PRE-PROCEDURE TTE [**2136-9-12**]: Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is a large pericardial effusion. Stranding is visualized within the pericardial space c/w organization. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. . POST-PROCEDURE TTE [**2136-9-12**]: Overall left ventricular systolic function is normal (LVEF>55%). There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2136-9-12**], the pericardial effusion has nearly resolved. RV and RA diastolic collapse are no longer seen (tamponade resolved post-pericardiocentesis). . . DISCHARGE LABS: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2136-9-16**] 03:26AM 6.3 3.20* 9.9* 32.4* 101* 30.9 30.5* 15.7* 366 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2136-9-16**] 03:26AM 83 19 3.3*# 136 4.2 94* 32 14 ENZYMES ALT AST LD(LDH) AlkPhos TotBili [**9-16**] 281* 103* 222 532* 0.3 Brief Hospital Course: Ms. [**Known lastname **] is a 62 yo female with a history of insulin-dependant diabetes, ESRD on HD, and multiple thrombi on coumadin, who presents with cardiac tamponade in the setting of supratherapeutic INR. . #. Pericardial effusion: Patient presented to the ED with abdominal pain. A CT performed in the ED demonstrated a large pericardial effusion. Patient had a TTE performed at the bedside which demonstrated tamponade physiology, with a pericardial pressure in the 40s. 700 ccs of bloody fluid was drained from the pericardium, which was shown to have a Hct of 35, PMNs, and no growth of organisms. Patient was found to have an INR of 18.2 on admission, and it was thought that this effusion was a spontaneous pericardial bleed in the setting of a supratherapeutic INR. The pericardial drain remained in place for 24 hours and it was pulled after a repeat TTE demonstrated that there was no reaccumulation of pericardial fluid. Patient's aspirin and coumadin were both held and her hematocrit remained stable for the duration of this admission. Patient's INR had decreased to 2.3 prior to discharge. . #. Coagulopathy: Patient has a remote h/o bilateral DVT's and was found to have bilateral thrombi of her internal jugular veins during a recent admission. She was not on Coumadin from [**2136-5-17**] until discovery of IJ occlusion in [**2136-8-17**]. According to [**Location (un) **] Corner, patient had INRs of 1.0, 1.22, and 1.87 on the three days prior to admission. She thus received 7 mg, 8 mg, and 8 mg of Coumadin the days prior to admission. These supratherapeutic levels also occurred in the setting of recent coumadin reinitiation, antibiotic use, and liver failure. Patient presented with acute life-threatening bleed and INR was reversed with Vitamin K, factor IX, and FFP. Patient's coumadin was held during this admission until her INR decreased to 2.8. She thus was restarted on 2 mg daily. She should continue to have her INR checked at [**Hospital3 2558**], and she should be monitored for signs of bleeding. . #. Transaminitis: Patient presented with a complaint of abdominal pain and RUQ pain on physical exam. Patient had a new elevation of her transaminases and alk phos. A CT of her Abdomen showed an enlarged gallbladder and common bile duct. A HIDA scan was then performed which showed evidence of chronic cholecystitis. Patient's statin was held, and her transaminases are now trending down. Hepatitis serologies were all repeated and are still pending at time of discharge. The use of simvastatin was discontinued in the setting of her elevated liver enzymes. Restarting this medication should be addressed with her PCP. . # R. Leg Pain: Pt. developed right lower extremity pain during this admission. On physical exam, the lateral aspect of her right quadricept is tense, warm, and she experiences pain with light palpation. Patient had a CT of her lower extremity performed which did not show a marked difference from a previous R lower extremity CT performed in [**Month (only) 547**]. There was no hematoma or compartment syndrome noted on CT and only slight edema of the interstitial fat. Given that this appeared to be a chronic symptom, no further intervention was made and it was felt that the pain should be followed by her outpatient care providers. . #. ESRD: Patient has a history of ESRD and undergoes HD on Tues, Thurs, Saturday. Patient was admitted with hypocalcemia, so her Cinacalcet was held on admission. Patient was initially continued on Sevelamer during this admission, but this was discontinued in the setting of her lowered phosphorus. She received HD on Thursday and Saturday. She should follow up with her Nephrologist in the next 1-2 weeks. . #. Hypotension: Patient has relative hypotension at baseline with [**Name (NI) 5462**] regularly in 80's-90's. She was continued on her home dose of Midodrine, and she did not experience any acute events during this hospital stay. . #. Diabetes: Patient has a history of insulin-dependent Diabetes. She was continued on her home dose of Glargine and her home insulin sliding scale. She did not have any acute events during this hospital stay. . #) Obstructive Sleep Apnea: Patient has a history of OSA requiring BIPAP. Patient was continued on her BIPAP during this hospital stay. She had one episode where she desatted to 60% overnight. It was found that her BIPAP mask was not tightly secured on her face. This was adjusted, and the patient's oxygen saturation increased appropriately. . #. Code status: full code. Medications on Admission: CURRENT MEDICATIONS: 1. Warfarin 2 mg daily 2. Simvastatin 20 mg daily 3. Paroxetine 20 mg daily 4. Sevelamer 2400 mg [**Hospital1 **] 5. Ascorbic acid 500 mg [**Hospital1 **] 6. Colace 100 mg [**Hospital1 **] 7. Cinacalcet 30 mg daily 8. Albuterol neg q6 PRN 9. Midodrine 10 mg TID 10. Folic acid 1 mg daily 11. Glargine 10 units qHS 12. RISS 13. Reglan 5 mg IV q6h PRN 14. ASA 81 mg daily 15. Senna 1-2 tabs [**Hospital1 **] PRN 16. Dulcolax 10 mg daily PRN Discharge Medications: 1. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 2. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulization Inhalation Q6H (every 6 hours) as needed for shortness of breath. 6. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) Units Subcutaneous at bedtime. 9. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: use as directed per sliding scale Units Subcutaneous qachs. 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**1-18**] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for constipation. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Reglan 5 mg/mL Solution Sig: One (1) injection Injection every six (6) hours as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary: Pericardial effusion Transaminitis Coagulopathy Secondary: Type 2 Diabetes End-stage renal disease Discharge Condition: Good. Patient's vital signs are stable and she is mentating at baseline. Discharge Instructions: You were admitted to the hospital because you bled into the area around your heart. We found that your dose of Warfarin had been too high. We drained this area around your heart, and then you were monitored in the CCU for three days. While you were here, we made the following changes to your medication: 1. We have discontinued your Sevelemer per the recommendation of our dialysis team. You should continue to follow-up with your nephrologist regarding restarting this medication. . 2. We have discontinued your use of simvastatin due to elevations in your liver function tests. Please address this issue with your Primary care doctor. Please take all medications as prescribed. Please keep all previously scheduled appointments. Please return to the ED or your healthcare provider if you experience shortness of breath, chest pain, fatigue, pain in your shoulder or jaw, fevers, chills, or any other concerning symptoms. Please weigh yourself every morning, call your doctor if your weight increases more than 3 lbs in one week. Please adhere to a low sodium (<2 gm daily) diet. Followup Instructions: Continue to receive hemodialysis on Tuesday, Wednesday, and Saturday. Please follow up with your nephrologist, Dr. [**Last Name (STitle) 7473**], in [**1-18**] weeks. Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-18**] weeks. Your liver function tests should be repeated with your PCP. Completed by:[**2136-9-16**]

[ "272.0", "403.91", "250.00", "V58.67", "327.23", "286.7", "790.4", "423.0", "275.41", "428.0", "585.6", "575.11", "416.0", "E942.2", "428.30", "E934.2", "423.3" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93", "37.0" ]

icd9pcs

[ [ [] ] ]

14783, 14853

8334, 12902

299, 377

15006, 15082

4813, 4813

16222, 16563

3762, 3777

13413, 14760

14874, 14985

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245, 261

12949, 13390

405, 2288

4829, 7925

2332, 3073

3637, 3746

28,611

195,335

29185

Discharge summary

report

Admission Date: [**2123-2-11**] Discharge Date: [**2123-2-17**] Date of Birth: [**2056-4-30**] Sex: F Service: MEDICINE Allergies: Heparin Agents / Ceftriaxone Attending:[**First Name3 (LF) 30**] Chief Complaint: Kinked HD line Major Surgical or Invasive Procedure: IR evaluation of HD line History of Present Illness: 66yoF ESRD-HD [**1-30**] SLE, multiple failed vascular accesses, hx DVT/PE, HIT+, h/o CVA, tardive dyskinesia, transferred from [**Hospital1 **] for question clogged HD line and concern for infection at line site. Pt was discharged [**2123-2-10**] after having HD line changed for fungemia (previous line tip positive for yeast) with plan to continue 4 weeks of caspofungin as per ID recs. In [**Hospital1 18**] ED, vital signs stable, SBP 180, exam baseline. Guiac negative brown stool, cxr with no acute pathology, ekg unchanged. Renal evaluated pt, HD line locked with heparin or PICC line with heparin given her HIT+ history. Hct found to be 19, down from baseline - renal suggested 1u pRBCs slowly. Blood cultures sent. Transferred to MICU in stable condition. Past Medical History: 1. s/p CVA ([**5-4**], with left facial drop) 2. HIT Ab + ([**2120**], s/p treatment with argatroban and Coumadin, PF4+ in [**4-5**]) 3. TTP (s/p plasmapheresis *10) 4. ESRD on HD (first HD, [**2121-9-5**], HD three days/week) 5. VRE septic thrombophlebitis in IJ ([**1-4**]) s/p linezolid) 6. C. difficile colitis with h/o failed flagyl 7. SLE (diagnosed [**2119**]) 8. HTN 9. ACD (baseline Hct from [**Date range (1) 70208**], 26---37) 10. Bowel and bladder incontinence 11. Peripheral vascular disease 12. Diverticulosis 13. Peptic ulcer disease 14. s/p Billroth II gastrectomy ([**2118**]) 15. Gout 16. ETOH abuse 17. Depression 18. s/p hysterectomy 19. h/o PE Social History: Pt worked as a nurse for [**Hospital6 70211**] in [**Location (un) 86**], but is currently retired. She came from [**Hospital1 **] prior to this admission. Her husband passed away 3 years ago. She has a son and two daughters, [**Name (NI) 24592**] and [**Name (NI) **]; daughter [**Name (NI) **] [**Last Name (NamePattern1) **] is her HCP. [**Name (NI) **] son lives locally with his wife, and they are supportive. She smoked for 8 years, [**1-31**] cigs/day, but quit ~40 years ago. She quit EtOH ~1 year ago, with previously heavy use. She denies illicit drug use. Pt states that she can obtain support from her relatives and friends. Family History: Non-contributory; daughter has scleroderma Physical Exam: T 96.6 BP 147/70 HR 92 RR 22 98%RA Gen: Cachectic woman with tardive dyskinesia movements (but able to communicate) and constant scratching [**1-30**] pruritus Skin: R sclavian dialysis catheter nontender, no erythema; WWP, no rashes/lesions/discolorations HEENT: NCAT, anicteric, no conjunctival suffusion, PERRLA, EOMI, MMM, OP clear; marked repetitive facial contractions with rhythmic movements and tongue involvement Neck: Supple, no thyromegaly/[**Doctor First Name **]/carotid bruits, no JVD (difficult to examine as pt in constant motion) Pulm: CTAB CV: Mildly tachycardic, nl S1 and S2, no M/R/G Abd: scaphoid, +BS, soft, NT/ND, no masses or organomegaly Ext: No C/C/E, warm, 2+ DP pulses bilat Neuro: A&O x 3; able to answers questions but severely dysarthric, tardive dyskinesia w/ constant motion CN III-XII intact throughout; sensory and motor intact throughout; reflexes 2+ throughout; coordination intact Pertinent Results: [**2123-2-11**] 06:15PM GLUCOSE-79 LACTATE-0.8 NA+-136 K+-3.9 CL--100 TCO2-30 [**2123-2-11**] 06:15PM HGB-6.6* calcHCT-20 [**2123-2-11**] 05:30PM GLUCOSE-84 UREA N-22* CREAT-6.4*# SODIUM-140 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-30 ANION GAP-10 [**2123-2-11**] 05:30PM ALT(SGPT)-8 AST(SGOT)-22 LD(LDH)-243 CK(CPK)-25* ALK PHOS-195* TOT BILI-0.4 [**2123-2-11**] 05:30PM LIPASE-14 [**2123-2-11**] 05:30PM PHOSPHATE-3.2 MAGNESIUM-1.8 [**2123-2-11**] 05:30PM HAPTOGLOB-129 Brief Hospital Course: On admission the patient was thought to have a clotted HD line. She was evaluated in IR where the line was found to be kinked, not clotted. The line was unkinked. She was also admitted with a hematocrit of 19. She was given one unit of pRBC's and her repeat hematocrit was 29. This was thought to be an erroneous lab value. Her Coumadin had been initially held in this setting, and was restarted. Medications on Admission: 1. Pantoprazole 40mg qd 2. Vancomycin 125 mg po q6hr 3. Warfarin 2.5 mg qd 4. Clonazepam 0.5 mg tid 5. Diphenhydramine HCl 25mg q6 prn 6. Hydroxyzine HCl 25mg q6 prn 7. Metoprolol Tartrate 25mg [**Hospital1 **] 8. Benztropine 1mg tid 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule qd 10. Amlodipine 2.5 mg qd 11. Calcium Acetate 667 mg two tabs daily 12. Caspofungin Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Vancomycin 125 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H (every 6 hours). 3. Clonazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 4. Diphenhydramine HCl 25 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H (every 6 hours) as needed. 5. Hydroxyzine HCl 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 7. Benztropine 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 9. Amlodipine 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 10. Calcium Acetate 667 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 11. Caspofungin 70 mg Recon Soln [**Hospital1 **]: Fifty (50) mg Intravenous Q24H (every 24 hours) for 12 days. 12. PICC line care per protocol Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: - Complication of HD line - Candidemia - C. difficile colitis Secondary: - Systemic lupus erythematosis - Rheumatoid arthritis - CKD stage V on hemodialysis - Infected AV fistula - CVA, left facial drop and dysarthria - PF4 Antibody positive - likely false positive - TTP rx plasmaphersis x 10 ([**Hospital1 2177**]) - RUL Pulmonary embolism - Bilateral DVT - S/P IVC filter - Right IJ VRE septic thrombophlebitis - Idiopathic tardive dyskinesia - Hypetension - Anemia, CKD and chronic disease - Peripheral vascular disease - Bowel and bladder incontinence - GI bleed, work-up negative - Gout - ETOH abuse - Depression - Peptic ulcer disease - S/P Billroth II gastrectomy ([**2118**]) - S/P hysterectomy Discharge Condition: Stable Discharge Instructions: You were admitted with a kinked hemodialysis catheter. We had you evaluated by interventional radiology and they fixed this problem. . We made the following changes to your medications: 1. We have held your Coumadin for your current INR of 3.4. Please check your INR and restart Coumadin when it is in the therapeutic range (2.0-3.0). You may require a lower dose of Coumadin, as your INR of 3.4 occurred in the setting of a dose of 2.5mg PO daily. . Please follow up as indicated below. . Please return to the emergency department if you develop any concerning symptoms such as fevers or blood in your stool or emesis, as well as any shortness of breath, chest pain, abdominal pain, or other concerning symptoms. Followup Instructions: 1. Your next hemodyalisis session is Wednesday [**2123-2-17**] . 2. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2123-3-26**] 1:30 . 3. Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 16624**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2123-3-22**] 1:00

[ "008.45", "710.0", "E879.9", "585.6", "285.21", "112.89", "333.85", "714.0", "401.9", "E947.9", "996.1", "403.91" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

5948, 6027

4007, 4411

303, 330

6785, 6794

3501, 3984

7558, 7922

2501, 2545

4829, 5925

6048, 6764

4437, 4806

6818, 6976

2560, 3482

7005, 7535

248, 265

358, 1134

1156, 1823

1839, 2485

13,413

117,631

4760

Discharge summary

report

Admission Date: [**2155-4-21**] Discharge Date: [**2155-4-24**] Date of Birth: [**2117-6-19**] Sex: M Service: PRINCIPAL DIAGNOSIS: Right renal mass. PRINCIPAL PROCEDURE: Hand assisted laparoscopic right nephrectomy. HISTORY OF PRESENT ILLNESS: This is a 37 year old man with insulin dependent diabetes mellitus for thirty-six years presenting with end stage renal disease. Evaluation with magnetic resonance scan showed an enhancing mass of the right upper pole of his right kidney. The patient is a candidate for right nephrectomy prior to renal transplant. He denies having any fever, chills, nausea or vomiting. PAST MEDICAL HISTORY: 1. Hepatitis B. 2. Insulin dependent diabetes mellitus. 3. Gastroparesis. 4. Peripheral vascular disease. PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. Right leg below the knee amputation. 3. Left toe amputation. MEDICATIONS ON ADMISSION: 1. Lopressor 125 milligrams p.o. b.i.d. 2. Vasotec 20 milligrams p.o. b.i.d. 3. Imdur 60 milligrams p.o. q.h.s. 4. Prilosec 30 milligrams p.o. q.h.s. 5. PhosLo 667 milligrams p.o. t.i.d. 6. Niferex 150 milligrams p.o. b.i.d. 7. Plavix 75 milligrams p.o. q.d. 8. Neurontin 200 milligrams p.o. q.i.d. 9. Reglan 10 milligrams p.o. t.i.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: No tobacco and no ethanol. PHYSICAL EXAMINATION: The patient was afebrile with a blood pressure of 90/60. He has a port-a-cath in his neck. Otherwise, the neck is supple. The heart was regular. The lungs were clear. The abdomen is soft, nontender, nondistended. Genitourinary examination showed a normal scrotum, epididymis, testicles and penis. He is circumcised. Neurologically, the patient was intact. HOSPITAL COURSE: The patient was taken to the operating room on [**2155-4-21**], and received a hand assisted laparoscopic right nephrectomy. He tolerated the procedure well. There were no apparent complications. Given the patient's underlying medical condition, he was observed overnight in the Intensive Care Unit. Postoperatively, he was hypertensive and required some intravenous Nitroglycerin. He was able to be weaned off this by the morning of postoperative day number one. His volume status remained euvolemic and his vital signs were stable. On postoperative day number one, he was dialyzed per the Renal Service. Over the next two days, the patient advanced his diet as his bowel function returned. His pain was initially controlled by PCA and then was transferred to p.o. pain medication. The patient remained afebrile with vital signs stable. He was mildly hypovolumic after his first dialysis run but after taking p.o. fluids, his blood pressure rose from a systolic of 85 to a systolic of 100. He received a second hemodialysis on postoperative day number two. After the second dialysis, he was transferred home in stable condition. Of note, his creatinine ranges between 5.0 and 7.0, and his potassium ranges between 4.0 and 5.0. His phosphorus was consistently 5.0. His hematocrit was stable in the 30s postoperatively. DISCHARGE INSTRUCTIONS: 1. Follow-up - The patient should follow-up with Doctor [**Doctor Last Name 4229**] in two weeks and call for an appointment. He is also to be seen by his primary care physician to regulate medications and to restart Plavix approximately two weeks after his surgery. 2. Activity as tolerated. 3. Diet is as tolerated. 4. Medications: a. Vicodin one to two p.o. q4hours p.r.n. b. Insulin 19 units NPH subcutaneous q.a.m., and 9 units subcutaneous q.p.m. c. Nephrocaps one p.o. t.i.d. d. PhosLo two p.o. t.i.d. e. Lopressor 150 milligrams p.o. b.i.d. f. Vasotec 20 milligrams p.o. b.i.d. g. Blood pressure medications are to be held for low blood pressure. h. Resume taking his Prilosec. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 8916**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2155-4-24**] 13:28 T: [**2155-4-24**] 18:52 JOB#: [**Job Number **]

[ "585", "250.61", "536.3", "401.9", "V02.61", "250.41", "189.0", "V49.75" ]

icd9cm

[ [ [] ] ]

[ "39.95", "55.51" ]

icd9pcs

[ [ [] ] ]

910, 1293

1742, 3078

3102, 4128

796, 884

1361, 1724

266, 640

662, 773

1310, 1338

4,495

199,539

54251

Discharge summary

report

Admission Date: [**2108-3-7**] Discharge Date: Service: Vascular Surgery ADMISSION DIAGNOSIS: Bilateral lower extremity ischemia HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 79-year-old gentleman who stopped working approximately seven years ago. He had a brick contracting business which is now operated by his son. In mid [**Month (only) 956**], he noted that the right lower leg and foot were somewhat cool. He was admitted to [**Hospital3 2576**] [**Hospital3 **] for a rather paroxysmal episode of pulmonary edema and during the work up it was noted that his peripheral vascular disease was profound and a bypass in these extremities was planned. However, the patient did not have an angioscopy and eventually signed out against medical advice from [**Hospital1 2025**]. Since then, his right foot improved slightly. He does have some discomfort in the right great toe and also the medial aspect of the heel where a small blister had developed while in the [**Hospital3 2576**] [**Hospital3 **]. He does not have true rest pain at night and does not have paresthesias in his foot. Prior to his admission to [**Hospital1 2025**], the patient stated that he was able to walk slowly about three blocks. PAST MEDICAL HISTORY: The patient has had a coronary artery bypass graft three or four years ago and he is also status post a cardiac catheterization while at [**Hospital1 2025**] a month ago. He also had prostatectomy approximately five years ago and he is status post a stroke with no residual deficit. However, he did have a right sided hemiparesis approximately 10 years ago from this stroke. CURRENT MEDICATIONS: 1. Carbamazepine 200 mg [**Hospital1 **]. 2. Digoxin 0.125 mg qd. 3. Zestril 20 mg qd. 4. Amiodarone 200 mg qd. 5. Lasix 40 mg qd. 6. Zocor 40 mg qd. 7. Aspirin 325 mg qd. 8. Lopressor [**1-22**] of a 60 mg tablet [**Hospital1 **]. PHYSICAL EXAM: The patient is noted to be an elderly gentleman with 4+ radial pulses bilaterally. His carotid pulses were normal with no bruits. There were no aortic bruits. The left femoral pulse was 4+ with absent pulses distal to that pulse on the right side. There were no femoral or distal pulses. He had elevation pallor, right greater than left, with mild coolness of the right with comfort to the left and rubor that extends to the lower third of the leg. Motor, power and sensation are intact. There is a small collapsed blister on the medial aspect of the right heel. He has no lesion of the distal toes. He had a small damp lesion on the left medial malleolus which is probably a traumatic ulcer. The saphenous vein has been harvested in the left leg and remains in the right. Impression was that Mr. [**Known lastname **] had a fairly advanced ischemic lower extremity. He underwent an angiogram which showed bilateral iliac artery diseases. HOSPITAL COURSE: The patient was then taken to the Operating Room on [**2108-3-7**] for an aortobifemoral bypass graft which he tolerated well. He was admitted to the hospital following the surgery. After the operation, the patient was transported to SICU prior to Surgical Intensive Care Unit where he remained intubated. Postoperatively, while in the Intensive Care Unit, the patient was noted to have a progressively cooler left foot as compared to the right foot. His vascular pulse exam at this point was a dopplerable left PT with a relatively faint DP and an equally strong DP and PT with palpable signals. However, the left foot was markedly cooler as compared to the right foot, although it did not look ............. On postoperative day #1, the patient was weaned off the ventilator and he was extubated. His distal pulse exam remained as previously mentioned, where the left remained cool, as compared to the right foot and the left DP, which by this point was intermittently detectable by Doppler, the left DP, the right DP and PT, however at this point remained consistent with detectable Doppler. The only other events that the patient had postoperatively while in the Intensive Care Unit were intermittent hypertension which responded well with fluid boluses. The cardiology service was involved in the patient's care to the capacity where they followed him until discharge given patient's strong cardiac history and poor ejection fraction and prior echocardiogram. As patient improved, he was transferred to the floor. On postoperative day #3, the patient was started on sips while waiting for the return of his bowel function. By this time, the left foot which had been cool in the immediate postoperative period had progressively became warmer and on the vascular pulse exam, the DP on the left was now consistently present by Doppler. The patient was followed by physical therapy and his level of activity was gradually increased. Initially, he was able to get out of bed to chair with aid of physical therapy. However, subsequently prior to discharge, he was able to ambulate approximately 80 to 100 feet with a rolling walker. The rest of Mr. [**Known lastname 111148**] hospital course is essentially unremarkable. There was gradual improvement in his level of functioning where his diet was gradually advanced and prior to discharge he was tolerating a regular diet and his level of activity was gradually advanced. However, prior to discharge, he would still benefit from physical therapy following discharge and it is anticipated that the patient will go home with VNA service, however the discussion of potential rehabilitation is ongoing and will be addressed immediately prior to his discharge. At this point, it is anticipated the Mr. [**Known lastname **] will be discharged home on [**3-13**] to follow up with Dr. [**Last Name (STitle) 1476**] on an outpatient basis. VNA services have been arranged for him to help with improving his physical strength. DISCHARGE CONDITION: Mr. [**Known lastname **] is being discharged home with VNA services. DISCHARGE STATUS: The patient is fairly stable. DISCHARGE DIAGNOSES: 1. Lower extremity ischemia. 2. Status post an aortobifemoral bypass. 3. Coronary artery disease, status post coronary artery bypass graft. 4. Status post prostatectomy. 5. Cardiomyopathy. 6. Multiple episodes of flash pulmonary edema. DISCHARGE MEDICATIONS: 1. Simvastatin 40 mg po qd. 2. Tegretol 200 mg po tid. 3. Digoxin 0.125 mg po qd. 4. Lopressor 37.5 mg po bid. 5. Aspirin 325 mg po qd. 6. Amiodarone 200 mg po qd. 7. Lisinopril 10 mg po qd. 8. Lasix 40 mg po qd. 9. Tylenol #3 1 to 2 tablets po q4h prn. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**] Dictated By:[**Name8 (MD) 94181**] MEDQUIST36 D: [**2108-3-13**] 08:38 T: [**2108-3-13**] 09:42 JOB#: [**Job Number 111149**]

[ "428.0", "425.4", "414.00", "707.14", "V45.02", "401.9", "435.3", "440.23" ]

icd9cm

[ [ [] ] ]

[ "39.25" ]

icd9pcs

[ [ [] ] ]

5903, 6024

6045, 6288

6311, 6842

2890, 5881

1920, 2872

106, 142

1663, 1904

171, 1241

1264, 1642

4,104

161,930

6837

Discharge summary

report

Admission Date: [**2159-11-16**] Discharge Date: [**2159-11-29**] Date of Birth: [**2111-11-29**] Sex: F Service: MEDICINE Allergies: Reglan / Benzodiazepines Attending:[**First Name3 (LF) 1055**] Chief Complaint: vomiting and SOB Major Surgical or Invasive Procedure: graft removal History of Present Illness: HPI (on transfer from MICU): 47 F with ESRD on HD, insulin-dependent DM, s/p LR renal [**First Name3 (LF) **] [**2149**], w/ recent MSSA bacteremia ([**2-5**] AV fistula thrombus infection) doing well until [**11-15**] when she states she began to feel short of breath, subjective fevers, productive cough. She felt nauseous and started vomiting, non-bloody, non-bilious emesis. Had missed HD (MWF scheduled) Febrile in ED to 101.7 with a blood pressure of 259/77. Right Fem line placed. Glucose 359 with AG of 21 on admission. K on arrival to ED 6.3. No aggressive fluid resucitation [**2-5**] tenuous Given Vanco, Ceftriaxone and Flagyl in ED. Past Medical History: PMHX: 1. DMI 2. Renal [**Month/Day (2) **], chronic rejection on steroids, listed for kidney/ pancreas [**Month/Day (2) **] 3. AV fistula L arm- s/p revision [**7-8**] for thrombus 4. bilateral brachicephalic and IJ stenosis s/p stenting in [**6-8**] and [**7-8**] 4. MSSA bacteremia [**7-8**] 5. anemia 6. HTN 7. ESRD - on HD m/w/f; s/p renal tx 94' 8. h/o DVT - known L subclavian and brachocephalic clot 9. Seizure disorder 10 Abnl LFT's scheduled for liver biopsy on [**11-20**] (postponed)- transaminits w/u by [**Doctor Last Name 497**] 11.nl PMIBI with EF of 61% Social History: Lives with husband and 2 adopted children, age 14 and 18. Works as school teacher. Family History: Family hx: no liver dx, dad with cad Physical Exam: PE: Temp: 97.4 T max:99.6 BP: 160/58 RR:16 98% on RA I/0:520/ 0 Gen: Thin female, walking, and AEO x 3, NAD HEENT: PERRLA, EOMI, Bilateral periorbital edema CV: RRR, nl s1, s2, 2/6 sem murmur Pulm: decreased bs sounds at blt bases, with inspiratory crackles at left base, no wheezes Abd: soft, NT, ND, NABS Neuro: CN II-XII intact, moving all four extremities Pertinent Results: CXR: patchy bibasilar opacities AXR: no free air ECG:NSR 80s peaked T waves Echo: Conclusions: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Mild aortic valve sclerosis. Preserved global and regional biventricular systolic function. No 2D echo evidence for endocarditis identified. Compared with the prior study (tape reviewed) of [**2159-9-3**], the findings are similar. [**2159-11-16**] 12:50PM PLT COUNT-111* [**2159-11-16**] 12:50PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL [**2159-11-16**] 12:50PM NEUTS-91.5* BANDS-0 LYMPHS-5.5* MONOS-2.2 EOS-0.6 BASOS-0.3 [**2159-11-16**] 12:50PM WBC-7.2# RBC-3.98* HGB-12.8 HCT-38.0 MCV-95 MCH-32.1* MCHC-33.7 RDW-15.1 [**2159-11-16**] 12:50PM ALBUMIN-4.1 [**2159-11-16**] 12:50PM CK-MB-1 cTropnT-0.04* [**2159-11-16**] 12:50PM LIPASE-28 [**2159-11-16**] 12:50PM ALT(SGPT)-71* AST(SGOT)-44* CK(CPK)-146* ALK PHOS-323* AMYLASE-34 TOT BILI-0.6 [**2159-11-16**] 12:50PM GLUCOSE-359* UREA N-85* CREAT-7.6* SODIUM-137 POTASSIUM-6.3* CHLORIDE-91* TOTAL CO2-25 ANION GAP-27* [**2159-11-16**] 12:55PM LACTATE-3.6* [**2159-11-16**] 01:12PM PT-13.0 PTT-40.8* INR(PT)-1.1 [**2159-11-16**] 03:59PM CARBAMZPN-2.0* [**2159-11-16**] 03:59PM CORTISOL-42.7* [**2159-11-16**] 03:59PM ACETONE-NEG [**2159-11-16**] 03:59PM CALCIUM-8.8 PHOSPHATE-3.0 MAGNESIUM-2.1 [**2159-11-16**] 03:59PM GLUCOSE-257* UREA N-87* CREAT-8.0* SODIUM-139 POTASSIUM-4.7 CHLORIDE-93* TOTAL CO2-27 ANION GAP-24* [**2159-11-16**] 04:08PM K+-4.7 [**2159-11-16**] 04:08PM COMMENTS-GREEN TOP [**2159-11-16**] 08:27PM URINE MUCOUS-OCC [**2159-11-16**] 08:27PM URINE RBC-0 WBC-0 BACTERIA-MOD YEAST-NONE EPI-[**11-24**] TRANS EPI-[**3-9**] RENAL EPI-[**3-9**] [**2159-11-16**] 08:27PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2159-11-16**] 08:28PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.0 [**2159-11-16**] 08:27PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2159-11-16**] 08:28PM GLUCOSE-159* UREA N-89* CREAT-8.5* SODIUM-137 POTASSIUM-6.5* CHLORIDE-93* TOTAL CO2-25 ANION GAP-26* [**2159-11-16**] 09:55PM CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-2.1 [**2159-11-16**] 09:55PM GLUCOSE-125* UREA N-94* CREAT-8.7* SODIUM-137 POTASSIUM-4.9 CHLORIDE-92* TOTAL CO2-30* ANION GAP-20 [**2159-11-16**] 11:49PM CALCIUM-9.2 PHOSPHATE-4.8* MAGNESIUM-2.1 [**2159-11-16**] 11:49PM CK-MB-2 cTropnT-0.09* [**2159-11-16**] 11:49PM CK(CPK)-100 [**2159-11-16**] 11:49PM GLUCOSE-91 UREA N-95* CREAT-8.9* SODIUM-136 POTASSIUM-5.1 CHLORIDE-91* TOTAL CO2-31* ANION GAP-19 RADIOLOGY Final Report ABDOMEN (SUPINE ONLY) [**2159-11-16**] 1:33 PM ABDOMEN (SUPINE ONLY) Reason: assess for obstruction [**Hospital 93**] MEDICAL CONDITION: 47 year old woman with vomiting REASON FOR THIS EXAMINATION: assess for obstruction CLINICAL HISTORY: 47 y/o female with vomiting. TECHNIQUE: Supine view of the abdomen. FINDINGS: Right femoral central venous catheter terminates in the IVC. No free air is identified in this supine film. There is a nonspecific but nonobstructed bowel gas pattern. Extensive vascular calcifications are noted in the region of the kidneys bilaterally. Osseous structures are unremarkable. IMPRESSION: No evidence of obstruction or free air. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 306**] [**Last Name (NamePattern1) 11152**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 25860**] Approved: SAT [**2159-11-17**] 5:16 PM RADIOLOGY Final Report **ABNORMAL! CT 100CC NON IONIC CONTRAST [**2159-11-16**] 1:29 PM CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Reason: r/o PE Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 47 year old woman with hypoxia and cough and vomiting. no clear source of hypoxia on cxr. h/o dvt. is off her anticoagulants REASON FOR THIS EXAMINATION: r/o PE CONTRAINDICATIONS for IV CONTRAST: None. CLINICAL HISTORY: A 47-year-old female with hypoxia and cough. TECHNIQUE: Contiguous axial images of the chest were obtained prior to and following the administration of 100 cc Obturay. Non-ionic contrast was used due to patient debility. Multiplanar reformatted images were created. COMPARISON: None available. CT OF CHEST: The opacified pulmonary arterial tree does not demonstrate any filling defects indicative of pulmonary embolus to the level of the subsegmental pulmonary arteries. A stent is noted in the left brachiocephalic vein. The heart and great vessels otherwise appear grossly normal. Evaluation of lung fields is limited due to patient respiratory motion. There are multifocal air space opacities with airbronchograms within the lingula and left lower lobe. An additional 1.0 x 0.7 cm rounded opacity in the right upper lobe is noted as well. Several smaller nodular opacities are present within the right lung. There are small bilateral pleural effusions, right greater than left, with associated atelectasis. Bibasilar ground glass opacities likely represent dependent edema. Limited evaluation of the upper abdomen is notable for renal atrophy and extensive vascular calcifications. IMPRESSION: 1. No pulmonary embolus. 2. Dependent pulmonary edema and small bilateral effusions, right greater than left. 3. Lingular and left lower lobe consolidation, concerning for pneumonia. Nonspecific ill-defined nodular opacities in the right lung. Follow-up after treatment is recommended to ensure resolution. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 306**] [**Last Name (NamePattern1) 11152**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 25860**] Approved: SAT [**2159-11-17**] 5:16 PM RADIOLOGY Final Report CHEST (PORTABLE AP) [**2159-11-16**] 12:50 PM CHEST (PORTABLE AP) Reason: lINE PLACEMENT [**Hospital 93**] MEDICAL CONDITION: 47 year old woman with SOB VOMITING CENTRAL LINE REASON FOR THIS EXAMINATION: lINE PLACEMENT CLINICAL HISTORY: 47 y/o female with shortness of breath and vomiting. Evaluate central line placement. TECHNIQUE: Portable AP chest. COMPARISON: [**2159-9-26**]. FINDINGS: Vascular stent projects over the mediastinum. The heart is at the upper limits of normal for size. Patchy bibasilar opacities are again noted and appear unchanged. There may be a layering right pleural effusion. Osseous structures are unremarkable. No central venous catheter is identified. IMPRESSION: 1. Patchy bibasilar opacities, unchanged since prior study. 2. No central venous catheter identified. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 306**] [**Last Name (NamePattern1) 11152**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 25860**] Approved: SAT [**2159-11-17**] 5:14 PM Reason: r/o abscess or ifiltrative process along fistula [**Hospital 93**] MEDICAL CONDITION: 47 year old woman with ESRD on HD p/w sepsis/bacteremia with most likely culprit the left arm AV fistula graft REASON FOR THIS EXAMINATION: r/o abscess or ifiltrative process along fistula INDICATION: 47 year old with end stage renal disease on dialysis with bacteremia and sepsis. Patient has a left AV fistula/graft. Assess for abscess. [**Doctor Last Name **] scale and color images of the left upper extremity in the region of the patient's AV graft were obtained. Wall to wall color flow is seen within the graft with no evidence of intraluminal filling defect. Immediately medial to the graft in the mid portion of the bicep there is 1.1 x 0.9 x 0.7 cm homogenous somewhat echogenic rounded mass. No flow is seen within this. The patient was not tender over this area during scanning. IMPRESSION: Homogenous small echogenic focus medial to the left upper extremity AV graft. This most likely represents a small hematoma. There is no evidence of a definite abscess. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 7853**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 2601**] Approved: MON [**2159-11-19**] 3:04 PM RADIOLOGY Final Report CHEST (PORTABLE AP) [**2159-11-18**] 1:22 AM CHEST (PORTABLE AP) Reason: evaluate interval change [**Hospital 93**] MEDICAL CONDITION: 47 year old woman with mulifocal opacities, some nodular in upper lobes, Pna, sepsis REASON FOR THIS EXAMINATION: evaluate interval change CLINICAL HISTORY: 47 year old woman with multiple focal opacities, evaluate for change. The cardiac size is the upper limits for normal. No failure is seen. The costophrenic angles are sharp. The lung bases are now clear, no infiltrates or densities seen. Elsewhere, the lung fields also show no evidence of infiltrate. IMPRESSION: Lung fields clear. DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**] Approved: MON [**2159-11-19**] 11:30 AM RADIOLOGY Final Report UNILAT UP EXT VEINS US LEFT [**2159-11-21**] 2:37 PM UNILAT UP EXT VEINS US LEFT Reason: please assess for vein thrombosis [**Hospital 93**] MEDICAL CONDITION: 47 year old woman with ESRD on HD p/w bacteremia with left upper arm fistula with increased swelling of entire left arm REASON FOR THIS EXAMINATION: please assess for vein thrombosis INDICATION: Increased swelling of the left arm. AV fistula in left upper extremity, currently being used for dialysis. Evaluate for DVT. FINDINGS: Left upper extremity venous ultrasound: Comparison was made to [**2159-11-18**]. Using the linear probe, [**Doctor Last Name 352**] scale, and color Doppler son[**Name (NI) 1417**] of the left internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins was performed. No intraluminal thrombus is seen. The vessels demonstrate normal flow, compressibility, and respiratory variability. Arterialization of venous flow is seen in the axillary and subclavian veins, consistent within the patient's known fistula. Note that the patient has an AV graft. This was not assessed. IMPRESSION: No evidence of DVT in the left upper extremity. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) 640**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) 24357**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 24358**] Approved: [**Doctor First Name **] [**2159-11-22**] 8:56 AM RADIOLOGY Final Report RENAL [**Year (4 digits) **] U.S. RIGHT [**2159-11-21**] 2:38 PM RENAL [**Month/Day/Year **] U.S. RIGHT Reason: please eval for site of infection [**Hospital 93**] MEDICAL CONDITION: 47 year old woman with MRSA bacteremia and hx of [**Hospital **]- please eval for site of local infection REASON FOR THIS EXAMINATION: please eval for site of infection INDICATION: MRSA bacteremia. FINDINGS: An ultrasound of the [**Hospital **] kidney and native kidneys was obtained. Comparison is made with the prior ultrasound of the [**Hospital **] kidney dated [**2155-9-25**]. The [**Year (4 digits) **] kidney within the right lower quadrant is normal in size, measuring 10.4 cm long, without hydronephrosis or perinephric fluid. However, there is no diastolic blood flow visualized within the intrarenal arterial branches. The renal vein is widely patent. The native kidneys are poorly visualized, but appear atrophic and echogenic. . IMPRESSION: 1. No evidence of perinephric fluid or hydronephrosis within the [**Year (4 digits) **] kidney. 2. No forward diastolic blood flow within the intrarenal arterial branches, though the renal veins are widely patent. The findings suggest [**Year (4 digits) **] dysfunction. Clinical correlation is advised. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 7833**] [**Name (STitle) **] DR. [**First Name11 (Name Pattern1) 24357**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 24358**] Approved: [**Doctor First Name **] [**2159-11-22**] 8:56 AM Cardiology Report ECHO Study Date of [**2159-11-22**] PATIENT/TEST INFORMATION: Indication: Endocarditis. Height: (in) 60 Weight (lb): 106 BSA (m2): 1.43 m2 BP (mm Hg): 154/45 HR (bpm): 73 Status: Inpatient Date/Time: [**2159-11-22**] at 12:57 Test: TEE (Complete) Doppler: Full doppler and color doppler Contrast: None Tape Number: 2004W454-1:26 Test Location: West Echo Lab Technical Quality: Good REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **] DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **] INTERPRETATION: Findings: This study was compared to the prior study of [**2159-6-20**]. LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Smple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or vegetations on aortic valve. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [**Name13 (STitle) **] mass or vegetation on mitral valve. Moderate mitral annular calcification. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or vegetation on tricuspid valve. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. No vegetation/mass on pulmonic valve. 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 lidocaine spray. No TEE related complications. 0.1 mg of IV glycopyrrolate was given as an antisialogogue prior to TEE probe insertion. Echocardiographic results were reviewed by telephone with the houseofficer caring for the patient. Conclusions: The left atrium is mildly 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. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. No vegetation/mass is seen on the tricuspid valve. Compared with the prior study (tape reviewed) of [**2159-6-20**], there is no significant change. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD on [**2159-11-22**] 14:34. [**Location (un) **] PHYSICIAN: From [**11-16**]- 4/4 bottles of blood cultured grew MRSA Time Taken Not Noted Log-In Date/Time: [**2159-11-16**] 8:45 pm SEROLOGY/BLOOD ADDED TO CHEM S# [**Serial Number 25861**]M. **FINAL REPORT [**2159-11-17**]** CRYPTOCOCCAL ANTIGEN (Final [**2159-11-17**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. Performed by latex agglutination. Reference Range: Negative. A negative serum does not rule out localized or disseminated cryptococcal infection. Appropriate specimens should be sent for culture. [**2159-11-16**] 8:27 pm URINE **FINAL REPORT [**2159-11-18**]** URINE CULTURE (Final [**2159-11-18**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. RADIOLOGY Final Report CT CHEST W/O CONTRAST [**2159-11-25**] 3:12 PM CT CHEST W/O CONTRAST Reason: please assess for resolution of consolidations and assess fo [**Hospital 93**] MEDICAL CONDITION: 47 year old woman with ESRD, MRSA bacteremia, with LLL consolidation on previous chest CT, txed for pna REASON FOR THIS EXAMINATION: please assess for resolution of consolidations and assess for any other pulmonary process CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Followup of pulmonary consolidations. TECHNIQUE: Contiguous axial images of the chest were obtained without administration of IV contrast. COMPARISON: [**2159-11-16**]. CT OF THE CHEST WITHOUT IV CONTRAST: There is a central line through the right subclavian vein, ending in the mid-SVC. Again is noted the stent in the left brachiocephalic vein. The heart is mildly enlarged. There is calcification of the coronary arteries, most prominent in the LAD. There is no evidence of pericardial effusion. The great vessels are unremarkable on this non-contrast study. There is a small pleural effusion on the left and a moderate pleural effusion on the right, with associated atelectasis, not significantly changed from the prior study. Again are noted pleural plaque calcifications in the right lower lung. There is almost complete resolution of the air-space opacities seen on the prior CT. There is no significant lymph adenopathy in the mediastinum, hilar or axillary regions. The upper part of the abdomen visualized on this study appears unremarkable except for atrophic kidneys with marked vascular calcification. Bone windows reveal no suspicious lytic or sclerotic bony lesions. IMPRESSION: 1. Almost complete resolution of air-space opacities in the interval. 2. Small to moderate amount of pleural effusion bilaterally, with dependent atelectatic changes, not significantly changed from the prior study. Blood cultures from the 16th showed no growth Blood cultured from the 17th showed coag positive staph (prior to removal of AV graft) Tissue from the AV graft grew out MRSA Blood cultures from 18th, 20th, and 21st showed no growth RADIOLOGY Preliminary Report CT ABDOMEN W/O CONTRAST [**2159-11-28**] 11:50 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: please assses for liver hematoma, abscess, or any other acut [**Hospital 93**] MEDICAL CONDITION: 47 year old woman with ESRD on HD s/p kideny [**Hospital **], here with MRSA bacteremia but now s/p liver biopsy and PD catheter placement and with intense abdominal pain REASON FOR THIS EXAMINATION: please assses for liver hematoma, abscess, or any other acute abdominal process (patient is immunosuppresed) CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: End-stage renal disease, peritoneal dialysis catheter placement, MRSA bacteremia, liver biopsy. Intense abdominal pain. TECHNIQUE: MDCT images of the abdomen and pelvis were acquired following administration of oral contrast only. No IV contrast was used secondary to patient's elevated creatinine. COMPARISON: Chest CT from [**2159-11-25**]. CT OF ABDOMEN WITHOUT IV CONTRAST: There is a small right pleural effusion, which has decreased in size since [**11-25**], with associated basilar atelectasis and peripheral pleural calcification, also unchanged in appearance. The previously seen left pleural effusion has resolved, and there is minor residual left lower lobe atelectasis. There is no fluid adjacent to the liver. There is no free intraabdominal air. Note is made of a peritioneal dialysis catheter entering the right lower abdominal wall with the tip coiled in the left pelvis. Evaluation of the solid abdominal organs is limited without IV contrast. Allowing for the limitations, the liver, spleen, pancreas, and adrenal glands are unremarkable. The gallbladder is not distended and is unremarkable. There is heavy abdominal vascular calcification in all visualized vessels. The native kidneys are extremely small and atrophic. There is a small amount of fluid. Bowel loop are normal in course and caliber. CT PELVIS WITHOUT IV CONTRAST: The trasplanted kidney is identified in the right lower quadrant. There is no perinephric fluid collection or hydronephrosis. There is a small amount of fluid in the pelvis consistent with patient's peritoneal dialysis. Sigmoid colon and rectum are unremarkable. There is no evidence of intraabdominal abscess. BONE WINDOWS: No suspicious osseous lesions are identified. Note is made of sclerotic change in the left femoral head, which could be due to subchondral cyst formation or possibly osteonecrosis. IMPRESSION: 1. No intraabdominal hematoma, abscess, or free intraabdominal air. Small amount of intraabdominal fluid consistent with patient's peritoneal dialysis. No evidence of bowel obstruction. 2. Interval decrease in size of bilateral pleural effusions with improved aeration of both lower lobes. Residual bibasilar atelectasis present, right greater than left. Stable areas of peripheral pleural calcification in the right lung base. DR. [**First Name11 (Name Pattern1) 640**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**] Brief Hospital Course: 1. Fevers: -patient was treated for MRSA bactermia with vancomycin, initially ?of source, the us of the fistula showed a small echogenic focus, most likely a hematoma and not an abscess, but the most likely the source was still the AV graft (the patients left arm became swollen and the skin around the graft became increasingly erythematous although the cultures from the fluid in the area has no growth), patient then had the graft removed and a PD catheter placed. AV graft tissue grew coag + staph. This was the most likely source of the MRSA. Cultures from the 17th (prior to graft removal) also show MRSA, but surveillance cultures have all been negative. continued to dose vanc by level and it became apparent that 500 mg every ither day would be best regimen to keep vanc levels therapeutic. patient had a TTE which showed no evidence of endocarditis, but a TEE was done to confirm this. Given patients immunosuppressed state she will likely need a longer course of abx. In addition patient was initially started in ceftriazone for ?pna but maintained on azithro to tx her pna - started Ceftriaxone (initially), azithro for pneumonia (dc'ed on the 21st) - repeat CT -resolution of air-space disease, also evidence of small bilateral pleural effusions (per attnd these had attempted to be tapped previously but were to small for tap) 2. Metabolic Acidosis: Related to renal failure, infection, hyperglycemia in setting of metabolic alkalosis from n/v, we continued to monitor her gap (on admission was 21). Gap closed as patient had a stable dialysis regimen and glucose was better controlled 3. Hyperglcemia: Patient has very severe diabetes and is very sensitive to insulin, therfore [**Last Name (un) **] was contact[**Name (NI) **] to help manage her diabetic regimen 4) CRF: patient was maintained on HD (MWF) on immunosuppressive agents 6) HTN: patients blood pressure was controlled with CCB and ACE, hydral prn (not using beta blocker as may mask signs of hypoglycemia) 7) Diastolic HF: dialysis dependent 9) Abnl LFTs- patient liver was biopsied when the AV graft was removed- pending results 10) Epilepsy: we continued to monitor tegretol levels 11) Anemia: hct 38 on admission to 23.6 on [**11-24**] (patient also had some blood loss with removal of AV graft). Attempted to transfuse her on [**11-23**]- patient spiked a temp to 101, hemolysis work up was negative - likely nonhemolytic febrile reaction. Patient was premedicated and then transfused. Iron studies were also sent, in [**Month (only) 462**] iron studies were consistent with chronic disease and recent studies show the same. Patient was dc'ed home on [**11-29**] for [**Holiday 1451**] - she will return [**11-30**] Medications on Admission: renajel tegretol aspirin toprol prednison plavix protonix zoloft enalipril tums Discharge Medications: 1. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 3. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Enalapril Maleate 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: MRSA bacteremia 1. DMI 2. Renal [**Month/Year (2) **], chronic rejection on steroids, listed for kidney/ pancreas [**Month/Year (2) **] 3. AV fistula L arm- s/p revision [**7-8**] for thrombus 4. bilateral brachicephalic and IJ stenosis s/p stenting in [**6-8**] and [**7-8**] 4. MSSA bacteremia [**7-8**] 5. anemia 6. HTN 7. ESRD - on HD m/w/f; s/p renal tx 94' 8. h/o DVT - known L subclavian and brachocephalic clot 9. Seizure disorder 10 Abnl LFT's Discharge Condition: stable, tolerating POs, not requiring oxygen, able to ambulate Discharge Instructions: Please call your doctor or return to ED if you develop cp, sob, vomiting, fevers, chills, intense abdominal pain Followup Instructions: Please return to the hospital tomorrow [**11-30**] Completed by:[**2159-11-29**]

[ "285.29", "588.89", "482.41", "250.11", "790.7", "V09.0", "428.32", "996.62", "996.81", "790.4", "403.91", "041.11", "345.90" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.95", "39.95", "88.72", "54.93", "39.43", "99.04", "50.11" ]

icd9pcs

[ [ [] ] ]

28334, 28340

24553, 27266

306, 321

28837, 28901

2142, 5632

29062, 29145

1708, 1746

27396, 28311

21655, 21826

28361, 28816

27292, 27373

28925, 29039

15214, 18428

1761, 2123

249, 268

21855, 24530

349, 997

18461, 19454

1019, 1592

1608, 1692

14,520

124,705

4183

Discharge summary

report

Admission Date: [**2177-10-30**] Discharge Date: [**2178-1-30**] Date of Birth: [**2135-1-27**] Sex: F Service: [**Location (un) 259**] HISTORY OF PRESENT ILLNESS: Please see OMR note dated [**2178-1-17**]. HOSPITAL COURSE CONTINUED: 1. Pulmonary: The patient was admitted to [**Location (un) **] firm with a tracheostomy in place and a _________ valve fitted. She was doing well on humidified room air, and aggressive suctioning through the tracheostomy was continued. In addition, nebulizer treatment was continued as needed, and the tracheostomy was downsized prior to discontinuation on [**2178-1-23**]. Over the remainder of the hospital stay, the patient maintained her oxygen saturations on room air. However, just prior to tentative discharge, the patient experienced an acute episode of increased shortness of breath associated with tachypnea and developed an oxygen requirement of 2 liters by nasal cannula. A chest x-ray obtained at that time demonstrated a right lobe consolidation consistent with aspiration pneumonia. The patient was started on ceftriaxone and Flagyl to treat aspiration pneumonia, and her oxygen was weaned to 1 liter by nasal cannula. The patient had no further respiratory issues over the remainder of the hospital stay, and is to be transferred on continued metered dose inhaler treatments as well as continued antibiotic therapy to treat aspiration pneumonia. 2. Gastrointestinal: The [**Hospital 228**] hospital course was complicated by pancreatitis with development of a pseudocyst, into which a drain was placed. Drainage from the pancreatic pseudocyst decreased steadily over the course of the hospital stay, and was kept patent with multiple flushes daily. In addition, the patient had a Dobbhoff tube in place for tube feedings. However, during the hospital stay, a swallow study was performed, which the patient passed without difficulty. She was therefore slowly initiated on fluids and solids by mouth, which she tolerated without difficulty. Therefore, the Dobbhoff tube was removed, and the patient began taking her nutrition and her medications by mouth. In addition, the patient had some complaints of constipation associated with some nausea. She was therefore started on a bowel regimen including Colace, Dulcolax, Lactulose and an appropriate bowel regimen was obtained. Her nausea was well controlled with periodic droperidol. At the time of discharge, the patient was tolerating oral intake without difficulty. The pigtail catheter was to remain in place, given that it was still draining some fluid. 3. Renal: The patient had a history of baseline chronic renal insufficiency at the time of admission. Her creatinine had stabilized during the hospital stay, and she maintained good urinary output. As the patient's acute tubular necrosis causing acute renal failure resolved, her creatinine slowly trended down until it stabilized at approximately 2.3, which was back to her baseline prior to time of admission. In addition, the patient demonstrated a bicarbonate deficit over the course of the hospital stay, and was treated with a half teaspoon of sodium bicarbonate by mouth once daily, which resulted in a stable bicarbonate of approximately 19 at the time of discharge. The patient had no further renal issues over the remainder of the hospital stay. 4. Infectious Disease: The patient had multiple infections during the hospital stay, which were adequately treated with appropriate antibiotic therapies. At the time of transfer to the floor, the patient was on no antibiotic therapy, and had been afebrile. On [**1-20**], the patient was noted to have an increasing white blood cell count, and the most likely source was felt to be a urinary tract infection. She was therefore started empirically on levofloxacin and at the same time her subclavian line was discontinued. Urinalysis demonstrated fungal growth, and therefore she was started on fluconazole and the levofloxacin was discontinued. A further spike in temperature resulted in blood cultures, which demonstrated one set positive for gram-positive cocci. Therefore the patient was started on vancomycin, and her stool was checked once again for C. difficile. The patient was treated with vancomycin for a total course of seven days status post line removal. She was treated with fluconazole for a course of seven days to treat a fungal urinary tract infection. The Foley catheter was discontinued at the time of diagnosis of this infection. Prior to the time of discharge, the patient was noted to have a vesicular rash, and Dermatology was consulted, who performed a skin biopsy. Preliminary results suggested possible zoster and DFA and cultures were pending at the time of discharge. The patient was therefore started empirically on acyclovir 800 mg by mouth five times a day for seven days for zoster treatment. At the time of discharge, the patient was afebrile, with a normal white blood cell count. 5. Cardiovascular: The patient was hypertensive at the time of transfer from the Intensive Care Unit to the floor. Her blood pressure medications were titrated up as needed in order to maintain appropriate blood pressures. The patient otherwise remained hemodynamically stable over the remainder of the hospital stay. Her blood pressure was finally brought under control with a regimen of labetalol 300 mg by mouth three times a day as well as Hydralazine 20 mg by mouth four times a day. The patient had no further cardiovascular issues over the course of the hospital stay. 6. Hematology: The patient was found to be antibody positive while in the Intensive Care Unit, and therefore heparin was avoided over the remainder of the hospital stay. Her hematocrit was followed closely, given her history of bleed in the Intensive Care Unit, however, this remained stable over the course of the hospital stay. Her retroperitoneal hematoma was felt to be stable, and it was determined not to attempt drainage, given the risk of re-bleeding and infection, but to allow the hematoma to be resorbed on its own. The patient had no further hematologic issues over the course of the hospital stay. 7. Neurology: The patient's Dilantin initiated in the Intensive Care Unit was continued on the floor. However, her Dilantin dose was changed to 100 every morning, 50 every afternoon, 50 every evening. The patient will be discharged on this dose of Dilantin. 8. Rheumatology: The patient was diagnosed with sarcoidosis. The extent was uncertain during the hospital stay. The patient was continued on steroids per Rheumatology, with a plan to slowly taper them over the next few weeks following discharge. ACE levels were still pending at the time of discharge. The patient had no further rheumatologic issues over the course of the hospital stay. 9. Endocrine: The patient was placed on a regular insulin sliding scale secondary to elevated sugars, likely due to the initiation of steroid treatment. The patient is to be continued on the regular insulin sliding scale following discharge, which will likely be needed as long as her steroid therapy continues. 10. Psychiatry: The patient was felt to likely be depressed during her hospital stay, and Celexa therapy was initiated. This was continued without a change in dosage over the remainder of the hospital stay. At the time of discharge, the patient denied any homicidal or suicidal ideation, and her Celexa is to be continued. 11. Fluids, electrolytes and nutrition: The patient tolerated tube feeds with the Dobbhoff tube without difficulty. A swallow study was performed, which the patient passed. Therefore, she was slowly advanced on her diet until she was able to tolerate solids. At this point, the Dobbhoff tube was removed. CONDITION ON DISCHARGE: The patient was discharged to rehabilitation in stable condition. She is to follow up with her primary physician. [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 4223**], [**Hospital1 18205**], pending discharge from her rehabilitation center. DISCHARGE DIAGNOSIS: 1. Sarcoidosis 2. Status post pulmonary embolus 3. Status post adult respiratory distress syndrome and tracheostomy placement 4. Status post pancreatitis with pseudocyst 5. Pancreatic pseudocyst drainage in place 6. Chronic renal insufficiency with a baseline of 2.3 7. History of methicillin resistant staphylococcus aureus 8. Hypertension 9. Seizure disorder 10. Depression 11. Aspiration pneumonia DISCHARGE MEDICATIONS: 1. Levofloxacin 250 mg by mouth once daily for 14 days 2. Flagyl 500 mg by mouth every eight hours for 14 days 3. Acyclovir 800 mg by mouth five times a day for seven days 4. Dilantin 100 mg by mouth every morning, 50 mg by mouth every afternoon, 50 mg by mouth daily at bedtime 5. Solu-Medrol 40 mg intravenously once daily for seven days, then decrease by 5 mg once daily every week 6. Labetalol 800 mg by mouth three times a day (hold for heart rate less than 60, systolic blood pressure less than 110) 7. Hydralazine 20 mg by mouth four times a day (hold for systolic blood pressure less than 110) 8. Serax 10 mg by mouth every six hours as needed for anxiety 9. Albuterol metered dose inhaler two puffs every four hours as needed 10. Dulcolax 10 mg by mouth once daily as needed for constipation 11. Lactulose 30 cc by mouth once daily as needed for constipation 12. Droperidol 0.625 mg intravenously/intramuscularly every three hours as needed for nausea 13. Tylenol 650 mg by mouth every four to six hours as needed 14. Reglan 10 mg by mouth twice a day 15. Prevacid 30 mg by mouth once daily 16. Senna two tablets by mouth twice a day (hold for loose stool) 17. Flovent 220 mcg two puffs by mouth twice a day 18. Serevent two puffs by mouth twice a day 19. Colace 100 mg by mouth twice a day 20. Celexa 20 mg by mouth once daily 21. Fentanyl patch 75 mcg/hour to be changed every three days 22. Regular insulin sliding scale 23. One-half teaspoon baking soda by mouth once daily 24. Ativan 0.5 mg by mouth once three times a day 25. Trazodone 50 mg by mouth daily at bedtime as needed for insomnia 26. Epogen 6000 units subcutaneously every Sunday [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Name8 (MD) 8860**] MEDQUIST36 D: [**2178-1-30**] 01:46 T: [**2178-1-30**] 02:00 JOB#: [**Job Number 18206**]

[ "135", "790.7", "323.9", "537.0", "584.5", "507.0", "998.11", "518.5", "577.2" ]

icd9cm

[ [ [] ] ]

[ "31.1", "96.6", "99.15", "38.95", "40.11", "39.95", "52.01", "41.31", "54.11" ]

icd9pcs

[ [ [] ] ]

8583, 10499

8149, 8560

187, 7805

7831, 8128

18,982

137,674

3139+3140+3141+3142

Discharge summary

report+report+report+report

Admission Date: [**2133-11-27**] Discharge Date: [**2133-12-4**] Date of Birth: [**2069-8-5**] Sex: F Service: [**Hospital 14843**] Medical HISTORY OF PRESENT ILLNESS: This is a 64 year old female with a history of severe chronic obstructive pulmonary disease, congestive heart failure, with diastolic dysfunction who presented to the Emergency Department after being found unresponsive by her daughter on the morning of admission. Per the patient's daughter the patient had a three day history of lethargy and malaise prior to admission as well as increasing shortness of breath. The patient's daughter found her short of breath, helped her to bed and called 911. Paramedics found the patient to be sating 56% on room air with a blood pressure of 150/70, heartrate in 120s and respiratory rate of 28. The patient was transferred to the Emergency Department where she was found to be sating in the mid 80s on 100% nonrebreather and tachypneic to the 50s with a heartrate of 118, blood pressure 154/92. The patient was emergently intubated. We tried twice to intubate her, the first attempt was unsuccessful. In the Emergency Room the patient was also found to have a chest x-ray with bilateral effusions, suggestive of congestive heart failure and electrocardiogram with ST depressions in the lateral leads, suggestive of ischemia. The patient received 80 mg of Lasix intravenously, sublingual Nitroglycerin, Aspirin and intravenous Lopressor and was started on Solu-Medrol. The patient was also given Ceftriaxone prior to admission to the Medicine Intensive Care Unit. PAST MEDICAL HISTORY: Remarkable for chronic obstructive pulmonary disease. The patient is chronically steroid-dependent, on home oxygen and has an FEV1 of .55 which is 32% of predicted as of [**2133-8-10**]. The patient has a history of obstructive sleep apnea for which she uses CPAP. The patient has a history of coronary artery disease with catheterization in [**2129-11-10**] showing mild diffuse disease. The patient has a history of congestive heart failure, likely diastolic. She had an echocardiogram in [**2133-11-10**] which showed an left ventricular ejection fraction of 50 to 65%. The patient has a history of hypertension. The patient has a history of Type 2 diabetes for which she is on Insulin. The patient has a history of gastroesophageal reflux disease, a history of depression, a history of cerebrovascular accident from which she has no residual defects and a history of seizure disorder. The patient also has a history of chronic low back for which she is on OxyContin. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Prevacid, Lipitor, Lasix, Hydrochlorothiazide, Fluoxetine, Prednisone, Aspirin, Depakote, Neurontin, Verapamil, OxyContin, Flovent, Serevent, Combivent, Albuterol, and insulin 70/30. SOCIAL HISTORY: Socially the patient is a former smoker, greater than 80 pack years, still occasionally smokes. She has no history of alcohol use. She lives with her daughter and her son-in-law. PHYSICAL EXAMINATION: On admission to the Medicine Intensive Care Unit Team, the patient had a temperature of 104.8, heartrate 92, blood pressure 101/56. She was sedated and ventilated. Her ventilator was assist-control with title volume of 700, respiratory rate of 12, positive end-expiratory pressure of 5, FIO2 of 100%. Her gas on this was 7.37, 72, and 457. Generally, she was sedated but moving all of her extremities spontaneously. Head, eyes, ears, nose and throat showed pupils were equal, round and reactive to light. There was no icterus. Neck was supple. Pulmonary examination revealed diffuse wheezing bilaterally but the patient was moving air in all lung fields. Cardiovascular examination was remarkable for tachycardia, otherwise normal S1 and S2, no murmurs were appreciated. Abdomen was benign. Extremities, the patient had no lower extremity edema and palpable dorsalis pedis pulses bilaterally. LABORATORY DATA: Laboratory data on admission showed a white count of 10.8, with a differential of 71 polys, no bands, 21 lymphocytes. The patient had a hematocrit of 32.9, platelets 375, electrolytes with sodium 146, potassium 4.2, chloride 94, bicarbonate 37, BUN and creatinine 49 and 1.9 respectively. The patient's first set of cardiac enzymes, CPK was 329, MB 5. Urinalysis was unremarkable. Chest x-ray and electrocardiogram were as discussed in the history of present illness. HOSPITAL COURSE: In short, this is a 64 year old female with a history of severe chronic obstructive pulmonary disease and diastolic congestive heart failure, also a history of coronary artery disease who presented with acute shortness of breath with electrocardiogram changes and respiratory collapse. 1. Respiratory/pulmonary - The patient was intubated from [**11-27**] to [**11-30**] at which time she was successfully extubated. The patient was treated with intravenous steroids, started on Solu-Medrol in the Emergency Department and continued on Solu-Medrol until [**12-2**] at which point she was changed to a Prednisone taper. The patient was treated with albuterol and Atrovent nebulizers which as the patient became able to treat herself were changed to albuterol and Atrovent metered dose inhalers. The patient slowly improved over the next several days after admission and at the time of discharge was sating in the mid to high 90s on 4 liters of nasal cannula with much improved lung examination. 2. Cardiovascular - The patient was initially hypotensive after intubation. Her hypotension was responsive to fluids. The ischemia on her electrocardiogram was thought to be due to demand and the patient ruled out for myocardial infarction by enzymes. The patient's electrocardiogram changes reverted to normal as her heartrate came down. The patient was diuresed aggressively while in the Intensive Care Unit and was switched back to her baseline dose of 50 mg of Lasix p.o. once a day on the floor. The patient continued to be negative while she was hospitalized. 3. Infectious disease - The patient was febrile on admission, was initially covered with Ceftriaxone. The blood and urine cultures drawn on admission remained negative throughout the course of her admission. The patient had multiple sputum cultures which were all contaminated by epithelial cells but which eventually grew Hemophilus and Moraxella. The patient was thought to have an aspiration pneumonitis on chest x-ray on [**2133-11-28**] and was switched to Levofloxacin and Flagyl. As the patient gradually improved over the next couple of days, the patient was switched to Levofloxacin alone for which he will complete a ten day course. The patient had a repeat chest x-ray on [**2133-12-3**] which showed no evidence of infiltrates or effusion. 4. Renal - The patient has chronic renal insufficiency with a baseline creatinine of 1.4 to 1.7. The patient's creatinine on admission was slightly elevated at 1.9. The patient was aggressively hydrated in the Medicine Intensive Care Unit and had good urine output and creatinine returned back to baseline. The patient had no further renal issues throughout the course of her hospitalization. 5. Endocrine - The patient has a history of diabetes requiring insulin. The patient was maintained on an insulin drip while in the Medicine Intensive Care Unit. When she was transferred to the floor she was maintained on NPH and regular insulin sliding scale. The patient's insulin doses were adjusted to account for her steroid doses which made her sugars quite high in the 200s to 350 range and good control was still being achieved when the patient was discharged. 6. Neurological - The patient had no signs of seizure activity during the course of her hospitalization and was continued on her normal seizure medications of Depakote and Neurontin. The patient was stable and ready for discharge to rehabilitation on [**2133-12-3**] and will be transferred to [**Hospital1 **] on [**2133-12-4**] for continued rehabilitation and aggressive pulmonary rehabilitation. DISCHARGE DIAGNOSIS: 1. Chronic obstructive pulmonary disease 2. Obstructive sleep apnea 3. Coronary artery disease 4. Congestive heart failure with diastolic dysfunction 5. Chronic renal insufficiency with baseline creatinine 1.4 to 1.7 6. Previous cerebrovascular accident 7. Seizure disorder 8. Hypertension 9. Gastroesophageal reflux disease 10. Depression DISCHARGE MEDICATIONS: 1. Insulin NPH 45 units in the morning and 25 units at dinnertime. 2. Regular insulin sliding scale 3. Captopril 18.75 mg p.o. t.i.d. 4. Verapamil sustained release, 240 mg p.o. b.i.d. 5. Hydrochlorothiazide 25 mg p.o. q. day 6. Lasix 60 mg p.o. once a day 7. Metoprolol 50 mg p.o. b.i.d. 8. Atorvastatin 20 mg p.o. q. day 9. Gabapentin 300 mg p.o. t.i.d. 10. Divalproex Sodium 250 mg p.o. t.i.d. 11. Fluoxetine 20 mg p.o. q. day 12. Prednisone 60 mg p.o. b.i.d. which should be tapered to 60 mg p.o. q. day starting the day of discharge 13. Protonix 40 mg p.o. q. day 14. Albuterol 1 to 2 puffs q. 4 hours metered dose inhaler, using a spacer 15. Ipratropium Bromide 2 puffs q. 6 hours 16. OxyContin 20 mg p.o. q. 12 hours 17. Vicodin 1 to 2 tablets p.o. q. 4 hours prn pain 18. Levofloxacin 250 mg p.o. q. 24 hours for three more days, to complete a ten day course 19. Aspirin 325 mg p.o. q. day 20. Heparin 5000 units subcutaneously q. 12 hours 21. Tylenol 325 to 650 mg p.o. q. 4-6 hours prn pain CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To [**Hospital **] [**Hospital **] Hospital. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 8330**] MEDQUIST36 D: [**2133-12-3**] 17:41 T: [**2133-12-3**] 16:14 JOB#: [**Job Number 14844**] Admission Date: [**2133-11-27**] Discharge Date: [**2133-12-4**] Date of Birth: [**2069-8-5**] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 64 year old female with severe chronic obstructive pulmonary disease and known FEV1 of 0.55, on home oxygen, with multiple intubations in the past, also with a history of congestive heart failure, who presented with a history of three days of lethargy and one to two days of increased shortness of breath. On the morning of admission, the patient's daughter found her on the toilet short of breath, helped her to bed, and called 911. The patient was discovered by emergency medical technicians to have an oxygen saturation of 56%, which improved to 98% on a 100% nonrebreather. The patient was also found to have a temperature of 100.2, blood pressure of 160/70 and respiratory rate of 28. The patient was transferred to the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] Emergency Room, where she was saturating 87% in room air and again in the high 90s on a 100% nonrebreather briefly before desaturating to the mid-80s. The patient was intubated after one unsuccessful attempt, on the second try she was intubated, for impending respiratory collapse. A chest x-ray on admission showed bilateral effusion, and question of volume overload from congestive heart failure. Her electrocardiogram had lateral ST depressions. The patient received 80 mg of intravenous Lasix, sublingual nitroglycerin as well as aspirin and intravenous Lopressor. The patient was started on intravenous Solu-Medrol as well as being given ceftriaxone in the Emergency Room. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease, chronically steroid dependent, on home oxygen, FEV1 in [**2133-8-10**] was 0.55 which is 32% of predicted. 2. Type 2 diabetes mellitus, on insulin. 3. History of a cerebrovascular accident in the early 90s with no residual defects. 4. History of congestive heart failure, questionably diastolic; transthoracic echocardiogram in the beginning of [**Month (only) 359**] showed a left ventricular ejection fraction of 60% to 75%. 5. History of obstructive sleep apnea, on C-PAP. 6. History of hypertension. 7. History of gastroesophageal reflux disease. 8. History of depression. 9. History of coronary artery disease; cardiac catheterization in [**2129-11-10**] showed mild diffuse disease. 10. Seizure disorder. 11. History of total abdominal hysterectomy, bilateral salpingo-oophorectomy. 12. History of chronic low back pain, treated with narcotics. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient is a former smoker, two packs per day for more than 40 years, now only occasionally, and does not use any alcohol. She lives with her daughter and son-in-law. MEDICATIONS ON ADMISSION: Flovent and albuterol meter dose inhaler, Serevent meter dose inhaler, home oxygen, Prednisone 20 mg p.o.q.d., Lasix 50 mg p.o.q.d., Lipitor 20 mg p.o.q.d., Prevacid, aspirin 325 mg p.o.q.d., hydrochlorothiazide 50 mg p.o.q.d., Depakote 250 mg p.o.t.i.d., Vioxx 25 mg p.o.q.d., Neurontin 300 mg p.o.t.i.d., verapamil 240 mg p.o.q.d., Oxycontin 20 mg p.o.b.i.d., Percocet p.r.n. and 70/30 insulin 25 mg s.c.q.a.m. PHYSICAL EXAMINATION: On physical examination on admission, the patient had a temperature of 104.8, heart rate 92 and blood pressure 101/56. She was mechanically ventilated on assist control at a tidal volume of 700, breathing 12 times per minute with a PEEP of 5. Arterial blood gases on those settings were 7.37, 72, 457. General: Patient sedated but moving all four extremities spontaneously. Head, eyes, ears, nose and throat: Pupils equal, round, and reactive, anicteric sclerae. Neck: Supple. Pulmonary: Diffuse wheezes bilaterally. Cardiovascular: Tachycardia, normal S1 and S2, no murmurs appreciated. Abdomen: Soft, normal active bowel sounds. Extremities: Unremarkable, no cyanosis, clubbing or edema appreciated, palpable dorsalis pedis pulses bilaterally. Rectal exam in Emergency Room: Normal tone, heme negative. LABORATORY DATA: Chest x-ray and electrocardiogram are as discussed in history of present illness. White blood cell count was 10.8 with a differential of 71 neutrophils, 21 lymphocytes, 4 monocytes and no bands, hematocrit 32.9, platelet count 375,000, sodium 146, potassium 4.2, bicarbonate 37, chloride 94, BUN 49 and creatinine 1.9, baseline 1.4 to 1.7. First CK was 329, CK/MB 5. Urinalysis was unremarkable. HOSPITAL COURSE: The patient is a 64 year old female with severe chronic obstructive pulmonary disease presenting respiratory distress, requiring emergent intubation with signs of volume overload as well as diffuse wheezing, suggestive of a chronic obstructive pulmonary disease exacerbation. The patient has electrocardiographic changes suggestive of ischemia. 1. Respiratory: The patient was mechanically ventilated from [**2133-11-27**] until being successfully extubated on [**2133-11-30**]. The patient was treated with Atrovent and albuterol nebulizers and started on Solu-Medrol 80 mg three times a day, which she continued on until [**2133-12-2**], when she was begun on a Prednisone taper, noting that the patient is chronically Prednisone dependent. The patient continued to be treated with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 8330**] MEDQUIST36 D: [**2133-12-3**] 17:22 T: [**2133-12-3**] 17:27 JOB#: [**Job Number 4732**] Admission Date: [**2133-11-27**] Discharge Date: [**2133-12-9**] Date of Birth: [**2069-8-5**] Sex: F Service: ADDENDUM HOSPITAL COURSE: Endocrine: The patient was initially stable for discharge when it was noted that her creatinine was increasing. Her creatinine increased to a high of 2.6. This was thought to be secondary to the ACE inhibitor which had been started in the Medical Intensive Care Unit, as well as overdiuresis. Her ACE inhibitor was stopped, and her diuretics were held. The patient's creatinine gradually trended back down towards baseline. On the morning of discharge today, [**2133-12-9**], the patient's creatinine is 1.4. We recommend not starting an ACE inhibitor at any point in the future. Infectious disease: The patient had been on a ten-day course of Levofloxacin for aspiration pneumonia. The patient was also on steroids for her chronic obstructive pulmonary disease flare. Despite the fact that her steroids were being tapered prior to the previously planned day of discharge, her white count continued to increase reaching a high of 30 with a normal differential. The patient was pancultured. All of her cultures remained negative with the exception of C-difficile which was diffusely positive. The patient was started on Flagyl on the morning of [**2133-12-7**], and she should complete a 14-day course of Flagyl. Mental status: The patient was found to be lethargic with an oxygen saturation of 88% on baseline 4 L on the morning of [**2133-12-6**]. The patient underwent a large work-up for both hypoxia and her mental status changes. There was concern for seizure; however, the patient's Valproate level was therapeutic, and the patient received an EEG which was unremarkable and did not show any seizure activity. The patient's mental status improved markedly as her infection was treated and as her oxygenation was corrected. Pulmonary: As mentioned in the mental status section, the patient was found to be lethargic with decreased oxygen saturations on the morning of [**2133-12-6**]. The patient's blood gas at that time revealed the patient to be alkalotic and hypoxic with a pO2 in the 50s; however, this is not far off the patient's baseline where she is normally with a pCO2 in the 50s and pO2 in the 50s as well. Nevertheless, there was concern that some sort of acute pulmonary process had occurred. The patient had a chest x-ray done which was unremarkable. There were no infiltrates, no effusions, no signs of congestive heart failure. The patient also received PE protocol and CT scan which was suboptimal, however, appeared to be negative for pulmonary embolus. It was noted that the patient had been off of her CPAP machine for the two evenings prior to the 27th, and it was felt that perhaps this was contributing somewhat to her hypoxia. The patient was placed back on her CPAP machine, and over the next couple of days, her respiratory status improved markedly, and at discharge, she had an adequate oxygen saturation in the mid 90s on 2 L nasal cannula which is her baseline at home. GI: The patient had initially been constipated and given laxatives on the day of the 26th; however, on the evening of the 27th, she developed perfuse diarrhea which was sent for C-difficile, which as mentioned in the infectious disease section, was positive. The patient was started on Flagyl and will complete a 14-day course of Flagyl; however, at the time of discharge, she is still having diarrhea secondary to the C-difficile. The patient will be discharged to [**Hospital **] Rehabilitation on the [**2133-12-9**], in good condition. DISCHARGE DIAGNOSIS: 1. Chronic obstructive pulmonary disease. 2. Coronary artery disease. 3. Congestive heart failure with diastolic dysfunction. 4. Obstructive sleep apnea. 5. Diabetes. 6. Hypertension. 7. Depression. 8. History of seizures. 9. Increased cholesterol. 10. Clostridium difficile infection. DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. q.d., Lipitor 20 mg p.o. q.d., Lopressor 50 mg p.o. b.i.d., Hydrochlorothiazide 25 mg p.o. q.d., Verapamil sustained release 250 mg p.o. once a day, Fluoxetine 20 mg p.o. q.d., Neurontin 300 mg p.o. t.i.d., Valproic Sodium 250 mg p.o. t.i.d., Insulin NPH 40 U in the morning, 10 U with dinner, regular Insulin sliding scale, Protonix 40 mg p.o. q.d., Atrovent 2 puffs q.6 hours with spacer, Albuterol 1-2 puffs q.4 hours with spacer, OxyContin 20 mg p.o. q.12 hours, Vicodin [**2-11**] tab q.4-6 hours p.r.n. pain, Lasix 50 mg p.o. q.o.d. starting [**12-10**], Tylenol 325-650 mg p.o. q.4-6 hours p.r.n. pain, Heparin 5000 U subcue q.12 hours, Colace 100 mg p.o. b.i.d. p.r.n. constipation, Flagyl 500 mg p.o. t.i.d. for 11 more days, Prednisone taper, the patient should get 50 mg Prednisone for 3 more days from [**12-10**] to [**12-12**], then 40 mg x 4 days, from [**12-13**] to [**12-17**], then 30 mg x 4 days, from [**12-18**] to [**12-21**], and then 20 mg indefinitely. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 8330**] MEDQUIST36 D: [**2133-12-9**] 11:13 T: [**2133-12-9**] 09:56 JOB#: [**Job Number 14845**] Admission Date: [**2133-11-27**] Discharge Date: Date of Birth: [**2069-8-5**] Sex: F Service: Dictated By:[**Name8 (MD) 8330**] MEDQUIST36 D: [**2133-12-9**] 11:02 T: [**2133-12-9**] 09:54 JOB#:[**Job Number 14846**]

[ "593.9", "428.30", "780.39", "518.81", "276.6", "414.01", "507.0", "491.21", "276.4" ]

icd9cm

[ [ [] ] ]

[ "93.90", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

9553, 10001

19540, 21055

19220, 19516

12791, 13205

15722, 16948

13228, 14469

10030, 11580

16964, 19199

11603, 12574

12591, 12764

9522, 9529

67,281

167,316

43536

Discharge summary

report

Admission Date: [**2129-2-24**] Discharge Date: [**2129-3-11**] Date of Birth: [**2072-11-5**] Sex: F Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 7591**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Central Venous Line Placement and Removal History of Present Illness: 56 y/o woman w/CLL on her fourth cycle of chemotherapy who is admitted to the [**Hospital Ward Name **] ICU after presenting to the emergency departement with fever, tachycardia, neutropenia, and hypotension. . She began chemotherapy with her first cycle in [**2128-10-20**] and this was complicated by febrile neutropenia and pansensative ecoli sepsis. She was seen in clinic today for routine follow up for a coutn check as she was day +11 from [**Hospital1 **]. She was feeling fatigued and had a HR of 150. She was given 1LNS and cultures were sent. She continued to feel poorly, with fatigue and malaise. She was checking her temperature and when it hit 104.5 she contact[**Name (NI) **] the oncologist on call and came to the emergency department. She took a dose of levofloxacin orally at home prior to comming to the ED. . In the ED, she was febrile to 106.6, had a WBC of 0.2, platelets of 11, Hct 29 and a HR to 170 that appeared sinus tach. She was given a total of 6L NS, Vancomycin, Cefepime and Caspofungin. She had 2 bags of platelets infused and a right IJ was placed. Past Medical History: PAST ONCOLOGIC HISTORY: Dx [**6-/2126**] of stage IV CLL with cytogenetics notable for p53 mutation - c/b autoimmune hemolytic anemia on presentation - 2 cycles of CVP starting in [**7-/2126**] - Rituxan added in [**8-/2126**] - [**11/2126**] started 13 wks Campath - [**9-/2127**] in setting of rising WBC, additional 2 cycles of CVP - [**10/2127**] d/t poor response to CVP, received fludarabine, Cytoxan, and Rituxan (had 3 cycles of this) - [**1-/2128**] had mini-MUD allo SCT - [**11/2128**] persistent disease by her bone marrow, marked lymphadenopathy and an elevated LDH: Bone marrow biopsy showed approximately 80% of the marrow involved with her CLL/SLL. Cytogenetics: no abnl. FISH showed continued expression of p53 - Cycle 1 [**Hospital1 **] c/b E. coli bacteremia . PAST MEDICAL & SURGICAL HISTORY: CLL s/p allo transplant as above Autoimmune Hemolytic Anemia Depression GERD Menopause at age 50 Avascular necrosis of the right femoral head (f/u with Dr. [**First Name (STitle) 4223**] Social History: Social History: Widowed. Lost her mother in law who lived with her last year. Adult daughter lives with patient. Has three children with older son in [**Name2 (NI) **] and younger son in [**Name (NI) 620**]. Used to drink [**1-21**] mixed drinks daily for last 2-3 years, but has now stopped. 30 pack year history but quit 2 years ago. Family History: Family History: Mother with [**Name2 (NI) 499**] cancer at 69, alive. Father had non-Hodgkin's lymphoma. Brother in good health. Husband died from COPD and alpha-1-antitrpsin deficiency complications. Physical Exam: 99.7 135 80/40 95%RA GEN: alert, oriented actually in no acute distress at all HEENT: mosit mucus membranes CV: RRR s1, s2, no M/G/R RESP: CTA anteriorly and laterally ABD: soft, NT/ND, no masses EXT: no edema. petechia noted Pertinent Results: [**2129-2-24**] 08:34PM LACTATE-2.1* [**2129-2-24**] 08:33PM GLUCOSE-102 UREA N-24* CREAT-1.0 SODIUM-136 POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-27 ANION GAP-16 [**2129-2-24**] 08:33PM NEUTS-0* BANDS-0 LYMPHS-73* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-27* [**2129-2-24**] 08:33PM WBC-0.2* RBC-3.13* HGB-10.9* HCT-29.1* MCV-93 MCH-35.0* MCHC-37.6* RDW-19.2* [**2129-2-24**] 11:15AM GLUCOSE-154* UREA N-24* CREAT-0.9 SODIUM-133 POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-24 ANION GAP-16 [**2129-2-24**] 11:15AM ALT(SGPT)-46* AST(SGOT)-26 LD(LDH)-167 ALK PHOS-124* TOT BILI-1.1 [**2129-2-24**] 11:15AM ALBUMIN-3.9 CALCIUM-8.9 PHOSPHATE-3.1 MAGNESIUM-1.5* [**2129-2-24**] 11:15AM NEUTS-0* BANDS-0 LYMPHS-90* MONOS-5 EOS-0 BASOS-0 ATYPS-5* METAS-0 MYELOS-0 [**2129-2-23**] 10:35AM GRAN CT-20* [**2129-2-23**] 10:35AM PLT SMR-VERY LOW PLT COUNT-33* [**2129-2-23**] 10:35AM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL TEARDROP-1+ [**2129-2-23**] 10:35AM NEUTS-10* BANDS-0 LYMPHS-87* MONOS-2 EOS-2 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 Portable TTE (Complete) Done [**2129-2-25**] at 2:03:27 PM: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is borderline dilated. There is severe global left ventricular hypokinesis. Quantitative (biplane) LVEF = 21%. The estimated cardiac index is depressed (1.7 L/min/m2). Right ventricular chamber size is normal. with mild global free wall hypokinesis. 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. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No vegetations or clinically-significant regurgitant valvular disease seen (good-quality study). Severe global left ventricular systolic dysfunction. Mild right ventricular systolic dysfunction. Compared with the prior study (images reviewed) of [**2129-2-11**], left ventricular cavity is larger. Biventricular systolic function (especially LV function) has significantly deteriorated. Blood Culture, Routine (Final [**2129-2-27**]): KLEBSIELLA PNEUMONIAE. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 93676**] [**2129-2-24**]. Aerobic Bottle Gram Stain (Final [**2129-2-26**]): GRAM NEGATIVE ROD(S). Anaerobic Bottle Gram Stain (Final [**2129-2-26**]): GRAM NEGATIVE ROD(S). Brief Hospital Course: 56 y/o woman with CLL s/p 4 cycles of [**Hospital1 **] treatment on Neupogen s/p febrile neutropenia and septic shock requiring [**Hospital Unit Name 153**] stay, [**Hospital Unit Name 153**] course described below per day: In the ED T 102.9, P170, BP 113/65, 100% on RA. While there her BP dropped to 74/33, T to 106.6. She received 8L NS, cefepime 2gm, vancomycin 1gm, caspo 70, platelets 2u, and decadron 10mg. She was admitted to the [**Hospital Ward Name 332**] ICU, central access obtained, received an additional 10L of fluid, required 3 pressors to maintain MAP > 60. She also received zosyn x 1 and gentamicin x 1. The primary team thought they saw parasites on a peripheral smear and ID was consulted. Was weaned off pressors on [**2-25**] with MAP > 65. Her blood cultures grew Klebsiella on [**2129-2-24**]. C. difficile toxin negative x 2, O&P negative x 3, UCx w/NGTD on [**2-24**] and [**2-25**]. In addition, a new echo was done which demonstrated LVEF of 21% with severe global left ventricular systolic dysfunction, a deterioration from echo on [**2129-2-11**]. Pt. also had episodes of hematochezia and dropped to 24.3 on [**2-26**], GI consulted and concluded that bleeding is likely from polyp documented on previous colonoscopy, deferred colonoscopy to outpatient setting unless bleeding increases. In addition had asymptomatic episodes of brady to 40, sinus w/ no evidence of 1st degree/2nd degree heart block. Had received 2 units PRBC's and 1 unit of platelets during [**Hospital Unit Name 153**] stay. [**Hospital Unit Name 13533**] ====================== [**2129-2-25**] -Initially was on three pressors but weaned off over the course of the day with preservation of MAP's >65 -Blood cultures with GNR's, caspofungin discontinued (OK w/ hematology and oncology) -Echo showed new LV dysfunction with LVEF 20% per echo (new since [**2129-2-11**]) -Had hematochezia and AM Hct 24 and Plt 9. Ordered for one unit of blood and one unit platelets. ________________________________ [**2129-2-26**] -remains off pressors with stable BP -had multiple episodes bloody diarrhea (marroon, liquidy but not quantified) during the day. per BMT, consider Plt goal >30, Hct goal >25 -Changed PPI to IV pantoprazole [**Hospital1 **] -Stool culture and C diff sent- considering Shigella or other entero-invasive bacteria causing both bloody diarrhea and bacteremia. -GNR from admission blood cx ([**2129-2-24**]) are pan sensitive but not yet speciated. On cefepime, gent, vanco -Low UOP to 40cc/ 3 hrs in evening but CVP 14. Pt getting a lot of blood products and abx during the day although having diarrhea. Deferred giving more fluids for now -Got 2 units plt with plt 9-32 but with 1 u PRBCS Hct only from 24.4- 24.7. Getting 2nd unit prbcs in evening and will rechk Hct, Plt and coags. Premedicating before products with tylenol and benadryl so may be missing a fever today with these meds. -PM gent trough 2.7. Pharmacy states her trough goal is <2. Adjusted dose to 100 q8. Ordered level for tomorrow as well as vanco level for am. -Consider calling GI in am re: possible scope if bloody diarrhea persists. [**2129-2-27**] -GI: bleeding is likely from polyp documented on previous colonoscopy. Defer colonoscopy to outpatient setting unless bleeding increases. -Heme onc: Continue GCSF, give IVIG for sepsis in setting of CLL and hypogammaglobulinemia, aggressive platelet goals given hematochezia w/ plts>50K -Transfused 1 bag platelets -ID: stool studies for salmonella, shigella, e.coli 0157, yersinia; abdominal CT to r/o abscess in setting of GNR sepsis (we didn't order this because of the patient's questionable renal fxn in setting of decreased urine output and b/c our suspicion was low); hold gent until level comes back. Gent level was 3.9 so gent d/c'd for now before 3rd dose, abdominal CT -d/c'd vancomycin, foley and a. line -Hematochezia decreased in volume and rate -episodes of brady to 40, sinus w/ no evidence of 1st degree/2nd degree heart block, she says she has a history of this, remains asymptomatic (no syncope in past) ================================================= # CLL s/p SCT: Pt. continued to be on neupogen as per heme/onc recommendations in the [**Hospital Unit Name 153**]. Also started on prednisone. Counts increased steadily to over 1000, in the 1200's on discharge. Patient was having low grade temperatures on two days during her stay on BMT floor and so neupogen was discontinued as possible etiology. Pt. has outpatient follow up in Dr.[**Name (NI) 3588**] office the week after discharge. Pt. was also continued on prednisone and triamcinolone cream for her skin GVHD which was not an issue during her stay in the hospital. Also continued on Acyclovir during her stay. # Pan-Sensitive Klebsiella Bacteremia: Pt. afebrile, currently on cefepime, discontinued vancomycin, gentamicin as per ID. Was switched to ceftriaxone 2g IV Q24H as klebsiella was pan sensitive and as instructed by ID. Pt. was discharged with 4 days left on a 14 day course and will follow up each day at the oncology outpatient clinic to receive her daily ceftriaxone injection until [**2129-3-16**] (final day of 14 day course started when patient was no longer neutropenic on [**2129-3-2**]). # Colonic Polyp: Pt. with hematochezia and melena requiring transfusions. Hct relatively stable throughout course, never symptomatic clinically. After much discussion, it was decided that GI would scope patient as an outpatient when counts come up, which may be in a few weeks. The patient was amenable to this plan and was instructed to come into the hospital immediately if she experienced any lightheadedness, or passed an increased amount of blood in her stools. # New Onset Heart Failure: Pt. with decreased EF on most recent echo. Has not been started on any afterload reduction presumably due to hypotension and sepsis. [**Month (only) 116**] consider starting afterload reduction and possible diuresis once patient is hemodynamically stable, and outpatient echo. Medications on Admission: acyclovir 400mg po TID Fluconazole 200mg po Qday Folic Acid 1gm po qday Lorazepam 0.5mg po QHS prn insomnia Omeprazole 20mg po Qday Pentamidine 200mg inahled solution q4-6weeks Prednisone - dose unclear [**Name (NI) **] 5ng po Qhs Acetaminophen Calcium Carbonate Vitamin D3 Multivitamin Discharge Medications: 1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 9. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 10. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical TID (3 times a day). Disp:*1 Tube* Refills:*2* 11. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 4 days. Disp:*8 grams* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Septic Shock Chronic Lymphocytic Leukemia status post stem cell transplant Klebsiella Pneumoniae Bacteremia Secondary: Depression Discharge Condition: Stable, ambulating, eating, drinking, and voiding without complaints. Discharge Instructions: You were admitted for low blood pressure and high fevers. Upon arrival, you were transferred to the ICU where they did several blood tests and gave you several units of blood, platelets, and fluid. You were also found to have a bacteria growing in your blood and were treated with antibiotics. Upon arrival to the BMT floor, your counts were relatively stable, and it was decided that you might have a colonoscopy with polyp removal when your counts come up. You have some appointments scheduled below, please attend them all. We have started you on one new medication: START Ceftriaxone 2g IV Every 24 hours for a total course of 14 days (4 days remaining) If you experience any sudden lightheadedness, dizziness, an increase of blood in your stools, loss of consciousness, severe fevers, nausea, vomiting, diarrhea, constipation, or pain on urination, please contact your primary care provider or your primary oncologist immediately. Followup Instructions: 1.) You will be coming into the [**Hospital 3242**] clinic each of the next 4 days to have your antibiotics administered. 2.) Oncology: See Below -Provider: [**Name Initial (NameIs) 455**] 2-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2129-3-12**] 12:00 -Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2129-3-17**] 10:30 -Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**] Date/Time:[**2129-3-17**] 10:30 Completed by:[**2129-3-12**]

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icd9cm

[ [ [] ] ]

[ "99.14", "38.93" ]

icd9pcs

[ [ [] ] ]

13527, 13533

6104, 12116

275, 319

13717, 13789

3300, 6081

14779, 15390

2848, 3038

12454, 13504

13554, 13696

12142, 12431

13813, 14756

3053, 3281

230, 237

347, 1434

1456, 2458

2490, 2816

5,310

141,848

5957

Discharge summary

report

Admission Date: [**2196-10-5**] Discharge Date: [**2196-10-10**] Date of Birth: [**2123-11-13**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 73 year old male who presented for a stress test with a history of hypertension and unstable angina. He tested positive on stress test and was taken to the cath lab where catheterization showed multiple stenoses. MEDICATIONS ON ADMISSION: Atenolol 50 mg p.o. b.i.d., aspirin 81 mg q.d., multivitamin. PHYSICAL EXAMINATION: He was afebrile. Vital signs were stable. He had no JVD. Lungs were clear to auscultation bilaterally. Heart was regular rate and rhythm with no murmurs, gallops or rubs. Abdomen was soft, nondistended, nontender. Extremities were warm and well perfused, no cyanosis, clubbing or edema. On peripheral vascular exam he had 2+ pulses bilaterally. HOSPITAL COURSE: He was taken to the operating room where coronary artery bypass grafting was done times three with anastomosis of LIMA to LAD, saphenous vein graft to OM and diag. Patient was transferred to the intensive care unit postoperatively where he did well. On postoperative day one his chest tube was discontinued. His Foley was then removed. He was extubated and he continued to do well. Physical therapy was consulted for evaluation of his mobility. He did quite well. On postoperative day three he was cleared by physical therapy and was tolerating a regular diet. His wires were removed. His chest tube had been pulled. He was doing well. He was discharged home in stable condition. He was instructed to follow up with his primary care doctor in one to two weeks and follow up with cardiology in two to four weeks. He was also instructed to continue his physical activity at home. He was discharged in stable condition, given prescriptions for Lasix, Lopressor and Percocet as well as aspirin. Patient was discharged home in stable condition. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Known firstname 23403**] MEDQUIST36 D: [**2196-10-10**] 12:10 T: [**2196-10-15**] 17:21 JOB#: [**Job Number 23488**]

[ "V17.3", "414.01", "998.11", "794.31", "305.1", "599.7", "401.9", "411.1" ]

icd9cm

[ [ [] ] ]

[ "88.56", "88.48", "39.61", "36.12", "88.72", "88.53", "37.22", "36.15" ]

icd9pcs

[ [ [] ] ]

410, 473

867, 2199

496, 849

158, 383

16,797

139,788

6511

Discharge summary

report

Admission Date: [**2181-4-27**] Discharge Date: [**2181-5-21**] Date of Birth: [**2113-10-11**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: bronchoscopy pericardial window T12 biopsy History of Present Illness: 67 y/o female with a h/o right breast cancer in [**2172**] (s/p surgery, chemo, xrt) who presented to [**Hospital1 34**] ED with progressive shortness of breath over a few days. Echo reportedly revealed cardiac tamponade. Also had CT at OSH which revealed a moderate pericardial effusion, mult. pulm nodules c/w metastatic disease, right hilar adenopathy, 1cm area left aspect of T6 vert. body (?mets), T11-12 ?mets, and possible right lobe liver mets. She was then transferred to [**Hospital1 18**] for treatment. Past Medical History: Breast Cancer s/p right beast lumpectomy [**2172**] with chemo and xrt for 5 years Hypertension Hypercholesterolemia Gastroesophageal Reflux Disease Cataract Osteoporosis s/p Hysterectomy Social History: Remote tobacco use. Denies ETOH use. Family History: Mother had diabetes and breast cancer. Father had Alzheimer's disease. No family history of premature CAD. Physical Exam: Neuro: A&O x 3, MAE, non-focal HEENT: EOMI, PERRL, NC/AT, Anicteric sclera, OP benign Neck: Supple, FROM -JVD, -lymphadenopathy, -carotid bruit Lungs: CTAB -w/r/r Cor: RRR -c/r/m/g Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -c/c/e Pertinent Results: Admission Labs: [**2181-4-27**] 07:05PM BLOOD WBC-9.5# RBC-3.18* Hgb-9.9* Hct-27.6*# MCV-87 MCH-31.1 MCHC-35.8* RDW-13.9 Plt Ct-436# [**2181-4-27**] 07:05PM BLOOD Neuts-80.2* Lymphs-13.1* Monos-6.2 Eos-0.3 Baso-0.1 [**2181-4-27**] 07:05PM BLOOD PT-14.0* PTT-25.3 INR(PT)-1.2* [**2181-4-27**] 07:05PM BLOOD Plt Ct-436# [**2181-4-28**] 03:02AM BLOOD Fibrino-419* [**2181-4-29**] 04:00AM BLOOD Fibrino-375 [**2181-5-14**] 07:24AM BLOOD Ret Aut-3.4* [**2181-4-27**] 07:05PM BLOOD Glucose-102 UreaN-18 Creat-0.9 Na-135 K-4.2 Cl-100 HCO3-23 AnGap-16 [**2181-4-27**] 07:05PM BLOOD CK(CPK)-39 [**2181-5-1**] 07:00AM BLOOD CK(CPK)-70 [**2181-5-2**] 07:10AM BLOOD ALT-20 AST-20 CK(CPK)-71 AlkPhos-69 TotBili-0.7 [**2181-4-27**] 07:05PM BLOOD cTropnT-<0.01 [**2181-5-1**] 07:00AM BLOOD CK-MB-3 cTropnT-0.02* [**2181-5-1**] 07:42PM BLOOD CK-MB-2 cTropnT-<0.01 [**2181-5-2**] 07:10AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2181-5-13**] 04:55AM BLOOD proBNP-[**Numeric Identifier 16856**]* [**2181-5-17**] 12:36AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2181-4-27**] 07:05PM BLOOD Calcium-9.2 Phos-3.4 Mg-2.5 [**2181-4-28**] 03:02AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.2 [**2181-5-2**] 07:10AM BLOOD %HbA1c-6.1* [**2181-5-2**] 07:10AM BLOOD Triglyc-126 HDL-32 CHOL/HD-3.7 LDLcalc-62 LDLmeas-67 [**2181-5-10**] 07:00AM BLOOD TSH-1.9 [**2181-5-1**] 07:00AM BLOOD CEA-13* CA27.29-43* [**2181-5-10**] 07:00AM BLOOD Vanco-25.1* [**2181-4-27**] 09:27PM BLOOD Type-ART pO2-130* pCO2-55* pH-7.29* calTCO2-28 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [**2181-4-27**] 07:20PM BLOOD Lactate-1.1 [**2181-4-27**] 09:27PM BLOOD Hgb-8.5* calcHCT-26 Reports: [**2181-4-27**] Echo: Large pericardial effusion with invagination of right atrial wall and no doppler signs of suggestive of tamponade effects. These ar early signs of pericardial tamponade. Post pericardial window, small effusion with normal biventricular systolic function. . [**2181-4-29**]: No pneumothorax. Previously noted possible pneumothorax was likely artifact. Worsening atelectasis of retrocardiac left lower lobe and a small left pleural effusion. Right lung clear. . [**2181-5-2**] Liver: 1) No discrete hepatic lesion identified. Biopsy therefore not performed. 2) Right pleural effusion. . Bronchial Washing: Pleural Fluid: ATYPICAL. Rare atypical epithelioid cells - cannot exclude carcinoma; numerous pulmonary macrophages, bronchial epithelial cells, and squamous cells. Bronchial Brushing: Bronchial brush: NEGATIVE FOR MALIGNANT CELLS. Numerous bronchial epithelial cells, squamous cells, and some pulmonary macrophages. . [**2181-5-3**] MRI,MRA head/neck: 1. Evolving subacute infarction in the left posterior cerebral artery territory. Small regions of hemorrhagic transformation. 2. No aneurysm, significant stenosis, or occlusion of the major vessels of the head and neck. . [**2181-5-3**] MR thoracic spine:1. Likely metastatic lesion in the right side of the T12 vertebral body extending into the pedicle and lamina, as well as extending into the epidural space. No evidence of signal abnormality in the thoracic cord. 2. Areas of signal abnormality in the T3, T7, and T10 vertebral bodies are most consistent with hemangiomas when correlated with the bone scan and CT findings. 3. Bilateral kidney cysts. Please correlate with abdominal imaging. 4. Incompletely visualized left-sided lung masses, and reference should also be made to the CT of the torso for further evaluation of these. . [**2181-5-8**] CT Chest: CT CHEST WITHOUT IV CONTRAST: Non-dependent loculated left pleural effusion has evolved in the interval. Another area of loculated effusion is seen anteriorly in the left lung as well. In the left lower lobe, there are multiple peripheral masses. These are unchanged from the prior study. One of these has a small calcification (3, 32). These measure up to 1.8 x 1.7 cm (3, 34). In the left upper lobe, there are two nodules measuring 1.4 x 1.6 cm, and a larger mass measuring 2.1 x 2.6 cm (3, 16). New areas of ground-glass rounded opacities are seen in the right upper lobe (3, 24) measuring up to 11 mm in size. Multiple smaller nodules are seen bilaterally measuring 2-3 mm in size. Nodule in the right lower lobe measures 9 mm (3, 45). Large pericardial effusion is unchanged. Evaluation for mediastinal and hilar adenopathy is limited on this non- contrast study. No enlarged hilar nodes are seen. There is no pneumothorax. CT ABDOMEN: Evaluation of intra-abdominal organs is limited due to the lack of intravenous contrast. Given this limitation, there is no renal stone seen on either side. The spleen, gallbladder, pancreas, and loops of bowel are grossly normal. No enlarged retroperitoneal or mesenteric lymph nodes are present. Small areas of low density in the liver are incompletely characterized but present in the left [**Last Name (un) **] (6 mm [**2-/2125**]) and in the right lobe ([**2-/2128**] two small lesions and a small lesion on [**2-/2130**]). Small low density lesions in the interpolar region of the right kidney are simple cysts. CT PELVIS: The bladder is not distended. There is no free fluid in the pelvis. Sigmoid colon is collapsed. BONE WINDOWS: Destruction of the vertebral body at T12 is again noted, as seen on a recent thoracic MR study of [**2181-5-3**]. REFORMATTED IMAGES: Multiplanar reformatted images in the coronal and sagittal planes confirm the above findings. IMPRESSION: Multiple pulmonary masses and nodules in this patient with prior history of breast cancer and destructive lesion of right T12 vertebral body extending into the foramen and spinal canal at this level. . [**2181-5-8**] Echo: Conclusions: Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. There is a small to moderate sized circumferential pericardial effusion without evidence of hemodynamic compromise. . [**2181-5-9**] CT Head: FINDINGS: There is no evidence of acute intracranial hemorrhage. Evolving left posterior cerebral territory infarct, in the subacute stage, is noted with gyriform enhancement. No abnormal foci of enhancement are noted in the brain parenchyma elsewhere, to suggest metastatic disease. The visualized portions of the paranasal sinuses are clear. No osseous lytic or sclerotic lesions are noted. IMPRESSION: 1. No acute intracranial hemorrhage. 2. Evolving left PCA territory subacute infarct. . [**2181-5-10**] T12 biopsy: FNA, T12 Vertebral Body: POSITIVE FOR MALIGNANT CELLS, consistent with metastatic poorly-differentiated adenocarcinoma. . [**2181-5-17**] CXR: The right internal jugular line was inserted with its tip terminating about 1 cm below the cavoatrial junction. The heart size is enlarged due to known pericardial effusion, unchanged compared to the recent previous study. The left lower lobe atelectasis and known left upper lung masses and nodules are unchanged. The chronic left fourth rib fracture is again noted. Brief Hospital Course: Discharge Summary: # Pericardial Effusion: As mentioned in the HPI, Ms. [**Known lastname **] was transferred from OSH with a pericardial effusion. Upon admission she had an Echocardiogram which showed a large pericardial effusion with early tamponade physiology. She was then emergently taken to the operating room where she underwent a pericardial window. Please see operative report for surgical details. Following surgery she was transferred to the CSRU for invasive monitoring in stable condition. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. On post-operative day one she required transfusion of pRBC d/t low HCT. She was started on beta blockers in the setting of new onset Atrial Flutter and gentle diuresis was initiated. Oncology was also consulted for possible metastatic disease vs primary lung cancer. On post-op day three her chest tube was removed and she was transferred to the telemetry floor for further care. On post-operative day four she was transferred to the medical service for continued care. Pericardial window tissue culture- no growth, cytology: No malignancy identified. However, on CT Torso done on [**5-8**], pericardial effusion was noted and reported as unchanged. A stat bedside echo was done which showed a small to moderate sized circumferential pericardial effusion without evidence of hemodynamic compromise. Pulsus remained between [**7-20**] and she was monitored closely. Repeat echocardiogram on [**5-14**] showed stable pericardial effusion. No signs/symptoms of tamponade on exam. . # Metastases: On the medical floor, pt had an extensive work up of her metastatic disease without a known primary. The CT scans at the OSH show multiple metastic lesions in lungs, spine(T6/11/12), and small lesion in liver. The heme/onc service was consulted and recommended bone scan, tumor markers, and a biopsy of tissue for diagnosis. Pt had tumor markers checked - CA 27.29: 43, CEA: 13. Pt had Bone scan [**2181-5-2**] which showed lesions in L1 vertebral body and right posterior 5th rib concerning for metastatic disease. She had an MR thoracic spine shows T 12 met which does not break into cord, no conus or cord involvement seen. The interventional pulmonology service was consulted and attempted a biopsy of her lung mass. However the pathology results were indeterminate. Bronchial washings did show Rare atypical epithelioid cells - carcinoma could not be excluded. Interventional radiology was consulted for CT guided transthoracic biopsy, however, when the patient went down for the procedure she was noted to be tachycardic and had INR of 1.5. Due to risk of PTX in unstable patient, the procedure was deferred. Imaging of the T spine was reviewed with Neuroradiology who felt that tissue could be obtained from the T12 lesion. On [**5-10**], neuroradiology performed biopsy of T12 lesion. Tissue was sent for receptor staining. Receptor staining did not reveal the primary. Oncology was involved throughout and based on the patient's other illnesses there were no available treatment options. A family meeting was held on [**2181-5-17**] to discuss goals of care. The patient was made DNR/DNI and expressed that she would like to be moved to a nursing home facility/hospice for further care. Palliative care has also been involved while in house. . # s/p CVA: On the medical floor, pt was noted to have visual field defects. Pt had a CT of her head with a subacute infarct in the region of PCA- 4x6cm left occipital lobe. No metastasis were noted on CT. The neurology service was consulted and recommended MRI/MRA of her head which showed vessels in the neck without stenoses, subacute infarct again visualized in region of PCA. Pt had had recent TEE without signs of endocarditis and a repeat TTE which did not show clots. Pt had a lipid panel which showed LDL <70 without medications, ASA 325mg was continued. The issue of anticoagulation came up with regard to atrial fibrillation as well as discovery of segmental PEs. A repeat CT head showed no acute intracranial hemorrhage and an evolving left PCA territory subacute infarct. Per neurology recommendations, heparin gtt was started with low goal and close monitoring of mental status. Neuro exam remained unchanged. # Optic neuropathy: Ophthalmology service was also consulted, possible retinal metastasis was visualized and it was determined that pt needed further retinal evaluation. She was seen in house by Ophthomology. An MRI orbit was done. Report attached. . # C. diff: With regard to her C.difficile colitis- pt was initially continued on Flagyl, however, her white count continued to trend up. PO Vancomycin was added to her antibiotic regimen and her white count remained stable. Diarrhea improved on abx. Antibiotics were continued for C. diff as she remained on abx for pneumonia. . # Atrial fibrillation: With regard to her paroxysmal atrial fibrillation she had episodes of RVR in the 140's. She was initally rate controlled with Metoprolol but continued to have episodes. PO diltiazem was added to her regimen. On [**5-8**], she was started on a diltiazem drip with minimal improvement in rate. Cardiology was consulted on [**5-9**] and recommended starting amiodarone drip. She converted to normal sinus rhythm on [**5-9**]. Medications were changed to PO. She remained on PO amiodarone (weaned from 400 [**Hospital1 **] to 200 [**Hospital1 **]) and beta blockers (weaned to 25mg TID [**1-12**] low BP) with heart rates in the 100s-110s. She was asymptomatic with rapid heart rates. . # Pleural effusion: With regard to her Left pleural effusion- lasix IV prn was used for diuresis. She underwent thoracentesis in an effort to help tachypnea - but removing fluid did not improve RR or O2 sat. She continued to require 4-5L O2. # PNA: Due to some fevers and elevated white count, there was concern for PNA. Ground glass opacities were seen in RUL representing possible infection so she was started on Zosyn/Vancomycin, switched to Unasyn from Zosyn on [**5-10**]. Medications on Admission: Atenolol 50mg qd, Protonix 40mg qd, HCTZ 25mg qd, Zocor 20mg qd Discharge Medications: 1. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-12**] Sprays Nasal PRN (as needed). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q 2 HR PRN (). 4. Morphine 10 mg/5 mL Solution Sig: 2.5-10 mg PO Q 2 HR PRN (). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 12. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at Silver [**Doctor Last Name **] Commons Discharge Diagnosis: Metastatic carcinoma of unknown primary Atrial fibrillation with RVR Pericardial effusion with tamponade physiology C. Diff colitis Hospital acquired pneumonia Pulmonary embolus Oliguria Subacute CVA Pleural effusions Dyslipidemia Discharge Condition: Tachypneic. HR 110s-120s. O2sat 96-98% on 5L. Discharge Instructions: You were admitted to the hospital with pericardial tamponade which was relieved with surgery. Metastatic lesions were found on CT scan and an extensive work up was done to determine where the primary site was, however no primary malignancy was found. You will be discharged to hospice care. You completed a 10 day course of IV antibiotics for possible pneumonia. Please take all medications as prescribed and given to you by the nursing facility. Followup Instructions: As determined by skilled nursing facility

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Discharge summary

report

Admission Date: [**2112-9-4**] Discharge Date: [**2112-9-11**] Date of Birth: [**2048-10-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization Intra aortic ballon bump Mechanical Ventilation Arterial Line Central Line History of Present Illness: 63 yo female with history of depression and suicide attempt plus NSTEMI s/p Cath (30% LAD, 60% RCA) in [**2108**] presenting with chest pain, found to have anterolateral STEMI s/p cath with BMS in LAD and IABP placed. . Patient describes feeling chest pressure starting two days ago as well as some difficulty breathing. She came to the ED and was found to have an anterolateral STEMI. She was taken to the cath lab and had BMS in LAD, also found to have 60% stenosis of RCA. She developed hyoptension in the cath lab and an IABP was placed and dopamine drip started. . On review of systems, she denies cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: (per OSH records): 1.) Depression 2.) Migraine HA 3.) Chronic pain 4.) 100 lb weight loss over past year - pt has undergone extensive w/u including colonoscopy, GYN exam, HIV test, cardiac w/u, stool studies, celiac studies negative. Also had abd CT negative, Chest CT demonstrated LUL nodule which was monitered. Had recent scan that demonstrated increase in size of LUL nodule from 3mm->7mm, PET scan in [**12-11**] negative - scheduled to have repeat Chest CT this month. Social History: Patient is married, lives w/ husband and 14 [**Name2 (NI) **] grandson. + family stress due to death of her son from heroin overdose about 2 years ago. Also has daughter w/ current substance abuse problems. Remote tobacco history. Family History: mother-CHF, passed from alzheimers at age 80 father-passed from lung cancer Physical Exam: Physical Exam on Admission: GENERAL: NAD. Oriented x3. Mood, affect appropriate. [**Name2 (NI) 4459**]: Sclera anicteric. EOMI. no oral lesions NECK: Supple CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. exam limited, IABP LUNGS: Resp unlabored on face mask, no accessory muscle use. CTAB anteriorly, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. femoral line in place, mildly tender SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. . Physical Exam on Discharge: PHYSICAL EXAMINATION: VS: T 98.2 BP 101/61 (70-105/38-79) HR 83 (68-85) RR 18 O2Sat 94-96% RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. [**Name2 (NI) 4459**]: Sclera anicteric. EOMI. no oral lesions NECK: Supple,no carotid bruits appreciated CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. exam limited, IABP LUNGS: Resp unlabored, no accessory muscle use. CTAB anteriorly, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [**2112-9-11**] 07:00AM BLOOD WBC-9.7 RBC-3.73* Hgb-12.4 Hct-36.4 MCV-97 MCH-33.2* MCHC-34.1 RDW-15.1 Plt Ct-328 [**2112-9-10**] 06:37AM BLOOD WBC-7.5 RBC-3.75* Hgb-11.8* Hct-37.3 MCV-99* MCH-31.6 MCHC-31.8 RDW-14.9 Plt Ct-317 [**2112-9-9**] 06:14AM BLOOD WBC-7.8 RBC-3.76* Hgb-12.1 Hct-37.1 MCV-99* MCH-32.3* MCHC-32.7 RDW-14.9 Plt Ct-295 [**2112-9-8**] 04:45AM BLOOD WBC-7.5 RBC-3.88* Hgb-12.8 Hct-37.4 MCV-96 MCH-32.9* MCHC-34.2 RDW-14.9 Plt Ct-259 [**2112-9-7**] 05:32AM BLOOD WBC-8.6 RBC-3.92* Hgb-12.6 Hct-38.9 MCV-99* MCH-32.0 MCHC-32.3 RDW-14.7 Plt Ct-261 [**2112-9-6**] 04:20AM BLOOD WBC-9.5 RBC-4.01* Hgb-13.1 Hct-38.7 MCV-97 MCH-32.6* MCHC-33.8 RDW-14.9 Plt Ct-236 [**2112-9-5**] 05:47AM BLOOD WBC-10.7 RBC-4.31 Hgb-13.9 Hct-42.2 MCV-98 MCH-32.3* MCHC-33.0 RDW-14.8 Plt Ct-298 [**2112-9-4**] 10:25AM BLOOD WBC-9.3 RBC-4.22# Hgb-13.7# Hct-41.9# MCV-99* MCH-32.5* MCHC-32.7 RDW-15.0 Plt Ct-321 [**2112-9-11**] 07:00AM BLOOD Plt Ct-328 [**2112-9-10**] 06:37AM BLOOD Plt Ct-317 [**2112-9-10**] 06:37AM BLOOD PT-11.7 PTT-28.1 INR(PT)-1.0 [**2112-9-9**] 06:14AM BLOOD Plt Ct-295 [**2112-9-9**] 06:14AM BLOOD PT-11.9 PTT-46.6* INR(PT)-1.0 [**2112-9-8**] 04:45AM BLOOD Plt Ct-259 [**2112-9-8**] 04:45AM BLOOD PT-11.6 PTT-57.1* INR(PT)-1.0 [**2112-9-7**] 08:34PM BLOOD PT-11.2 PTT-50.5* INR(PT)-0.9 [**2112-9-7**] 12:40PM BLOOD PTT-45.0* [**2112-9-7**] 05:32AM BLOOD Plt Ct-261 [**2112-9-7**] 05:32AM BLOOD PT-11.5 PTT-51.9* INR(PT)-1.0 [**2112-9-6**] 04:20AM BLOOD Plt Ct-236 [**2112-9-6**] 04:20AM BLOOD PT-11.4 PTT-65.7* INR(PT)-0.9 [**2112-9-5**] 01:56PM BLOOD PTT-63.6* [**2112-9-5**] 05:47AM BLOOD Plt Ct-298 [**2112-9-5**] 05:47AM BLOOD PT-11.5 PTT-49.1* INR(PT)-1.0 [**2112-9-4**] 04:15PM BLOOD Plt Ct-264 [**2112-9-4**] 04:15PM BLOOD PTT-59.6* [**2112-9-4**] 10:25AM BLOOD Plt Ct-321 [**2112-9-11**] 07:00AM BLOOD Glucose-96 UreaN-9 Creat-0.4 Na-139 K-3.9 Cl-106 HCO3-21* AnGap-16 [**2112-9-10**] 06:37AM BLOOD Glucose-85 UreaN-10 Creat-0.5 Na-139 K-4.1 Cl-109* HCO3-20* AnGap-14 [**2112-9-9**] 06:14AM BLOOD Glucose-95 UreaN-9 Creat-0.6 Na-142 K-3.8 Cl-110* HCO3-21* AnGap-15 [**2112-9-8**] 04:45AM BLOOD Glucose-93 UreaN-10 Creat-0.6 Na-138 K-3.8 Cl-109* HCO3-22 AnGap-11 [**2112-9-7**] 05:32AM BLOOD Glucose-105* UreaN-9 Creat-0.5 Na-138 K-4.2 Cl-109* HCO3-23 AnGap-10 [**2112-9-6**] 04:20AM BLOOD Glucose-111* UreaN-9 Creat-0.4 Na-140 K-3.8 Cl-111* HCO3-20* AnGap-13 [**2112-9-5**] 05:47AM BLOOD Glucose-126* UreaN-9 Creat-0.5 Na-136 K-4.0 Cl-105 HCO3-22 AnGap-13 [**2112-9-4**] 09:48PM BLOOD Na-136 K-3.8 Cl-106 [**2112-9-4**] 04:15PM BLOOD Na-138 K-3.2* Cl-104 [**2112-9-4**] 10:25AM BLOOD Glucose-146* UreaN-18 Creat-0.5 Na-141 K-3.7 Cl-108 HCO3-25 AnGap-12 [**2112-9-8**] 04:45AM BLOOD CK(CPK)-104 [**2112-9-7**] 12:40PM BLOOD CK(CPK)-109 [**2112-9-7**] 05:32AM BLOOD CK(CPK)-122 [**2112-9-4**] 09:48PM BLOOD CK(CPK)-1740* [**2112-9-4**] 04:15PM BLOOD CK(CPK)-2549* [**2112-9-8**] 04:45AM BLOOD CK-MB-5 [**2112-9-7**] 12:40PM BLOOD CK-MB-6 cTropnT-2.35* [**2112-9-7**] 05:32AM BLOOD CK-MB-8 cTropnT-2.52* [**2112-9-5**] 05:47AM BLOOD CK-MB-80* cTropnT-5.06* [**2112-9-4**] 09:48PM BLOOD CK-MB-150* MB Indx-8.6* cTropnT-8.22* [**2112-9-4**] 04:15PM BLOOD CK-MB-230* MB Indx-9.0* cTropnT-10.10* [**2112-9-4**] 10:25AM BLOOD CK-MB-218* cTropnT-4.99* [**2112-9-11**] 07:00AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0 [**2112-9-10**] 06:37AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2 [**2112-9-9**] 06:14AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.4 [**2112-9-8**] 04:45AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.2 [**2112-9-7**] 05:32AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.0 [**2112-9-5**] 05:47AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.2 [**2112-9-4**] 09:48PM BLOOD Mg-2.0 [**2112-9-4**] 10:25AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.2 [**2112-9-5**] 02:01PM BLOOD Type-ART Temp-36.8 pO2-113* pCO2-39 pH-7.38 calTCO2-24 Base XS--1 Intubat-NOT INTUBA [**2112-9-5**] 02:01PM BLOOD O2 Sat-96 . EKG [**2112-9-4**] Normal sinus rhythm with atrial premature beats. Marked low voltage in the standard leads. Q wave in leads V1-V4. Possible left atrial abnormality. Anteroseptal myocardial infarction, possibly acute. Compared to the previous tracing of [**2108-3-24**] the low voltage in the standard leads was also present at that time. The Q waves and ST segment elevation in the right precordial leads V1-V4 is new, consistent with an acute anteroseptal myocardial infarction. Intervals Axes Rate PR QRS QT/QTc P QRS T 80 174 86 412/447 67 -7 59 . ECG Study Date of [**2112-9-4**] Normal sinus rhythm. Striking low voltage in the limb leads. Possible left atrial abnormality. Q waves in leads V1-V3. The previously described ST segment elevation in leads V1-V4 is somewhat less prominent at this time. The tracing remains consistent with an anteroseptal myocardial infarction of indeterminate age. Intervals Axes Rate PR QRS QT/QTc P QRS T 72 172 84 [**Telephone/Fax (2) 65766**]2 . Portable TTE (Complete) Done [**2112-9-5**] Conclusions The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is severe regional left ventricular systolic dysfunction with akinesis of the entire septum, distal [**3-10**] of the anterior wall, and distal inferior wall. The apex is aneurysmal and akinetic.No masses or thrombi are seen in the left ventricle. The remaining segments contract normally (LVEF = 20-25 %). Regional and global left ventricular systolic function are similar on/off the IABP. The estimated cardiac index is depressed (<2.0L/min/m2). Right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. The aortic root is mildly dilated at the sinus level. The descending thoracic aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size and extensive regional systolic dysfunction c/w CAD (LM or LM equivalent distribution). Moderate pulmonary hypertension. Regional right ventricular systolic dysfunction c/w CAD. Compared with the prior study (images reviewed) of [**2108-3-20**], the basal septum is now akintic (apical right ventricular systolic dysfunction was suggested on review of the prior study). CLINICAL IMPLICATIONS: The left ventricular ejection fraction is <40%, a threshold for which the patient may benefit from a beta blocker and an ACE inhibitor or [**Last Name (un) **]. Based on [**2109**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. . ECG Study Date of [**2112-9-5**] Some baseline artifact. There is now T wave inversion in leads I, aVL and V2-V6 with increased ST segment elevation in leads V2-V4 compared to tracing #2. This is consistent with an acute anteroseptal myocardial infarction. Intervals Axes Rate PR QRS QT/QTc P QRS T 77 156 78 436/[**Medical Record Number 65767**] 12 . ECG Study Date of [**2112-9-7**] Sinus rhythm. Anterior wall myocardial infarction with ST-T wave configuration consistent with acute/recent/in evolution process. Left axis deviation may be due to left anterior fascicular block. Low QRS voltage is non-specific. Since the previous tracing of [**2112-9-5**] further ST-T wave changes are present. Intervals Axes Rate PR QRS QT/QTc P QRS T 74 168 74 440/464 50 -48 97 . ECG Study Date of [**2112-9-8**] Normal sinus rhythm, rate 84. Low voltage in the standard leads. Q waves in leads V1-V3 with ST segment elevation in leads V2-V5. Compared to the previous tracing of [**2112-9-7**] changes are similar to those at that time, although possibly somewhat less prominent, consisent with evolution of an acute anterior wall myocardial infarction. Intervals Axes Rate PR QRS QT/QTc P QRS T 84 160 78 404/446 72 -41 90 Brief Hospital Course: Ms. [**Known lastname 53899**] is a 63 yo female with history of depression and suicide attempt plus NSTEMI s/p Cath (30% LAD, 60% RCA) in [**2108**] presenting with chest pain, found to have anterolateral STEMI s/p cath with BMS in LAD and placement of intra-aortic balloon pump. . # s/p Anterolateral STEMI: Patient was admitted for anterolateral STEMI s/p cath with BMS in LAD. She was also shown to have 60% stenosis of her RCA. She has a prior history of NSTEMI with cath in [**2108**]. An intra-aortic balloon pump was placed in the cath lab in addition to dopamine drip to maintain hemodynamic stability; dopamine drip was weaned and IABP was removed after a two-three days with no complications. Cardiac enzymes peaked post-procedure on [**9-4**] at CK 2549, MB 230, Trop T 10.10, then trended downwards appropriately. . Patient was noted to have ST elevations in leads V3-V4 on post-procedure. She did have some waxing and [**Doctor Last Name 688**] chest pain post-procedure. 2mm ST elevations persisted on daily EKGs; consider possible formation of LV aneurysm. Repeat ECHO was planned in roughly 2-4weeks to reassess cardiac function and possible formation of aneurysm. . Patient continued on aspirin, clopidogrel, and statin. Beta blocker was held in the setting of hypotension but should be restarted at small dose when tolerated by blood pressure as an outpatient for long term benefit. She was started on very low dose captopril for afterload reduction, despite low blood pressures; blood pressures are frequently in 80s systolic, and patient is asymptomatic. Patient was diuresed gently during hospitalization in the setting of low blood pressures. . Heparin drip was stopped a couple of days after removal of intra-aortic balloon pump. The patient may be at risk for LV thrombus formation, but warfarin was not started due to question of patient's psychiatric status and medication compliance. Patient would benefit from repeat echocardiogram in [**2-11**] weeks to look for regain of LV function and to make sure there is no LV thrombus. . Echocardiogram showed while an inpatient showed the following: LVEF of 20-25%. Normal left ventricular cavity size and extensive regional systolic dysfunction c/w CAD (LM or LM equivalent distribution). Moderate pulmonary hypertension. Regional right ventricular systolic dysfunction c/w CAD. Compared with the prior study (images reviewed) of [**2108-3-20**], the basal septum is now akintic (apical right ventricular systolic dysfunction was suggested on review of the prior study). . Patient did have an Echo in [**2108**] which showed LV systolic dysfxn with EF 20-30% [**2-9**] extensive apical akinesis, also 3+ MR; thought to be due to stress-induced cardiomyopathy. Of note, Echo report [**2108-4-20**] from outpatient cardiologist Dr. [**Last Name (STitle) **], showed LVH, normal LV function with EF 60%, mildly thickened mitral and aortic valves, trace AI and 1+ MR. . Pt was started on an ACEI. Attempts were made to also start a b-blocker while and inpatient; however, pt continued to have low blood pressures (although she remained asymptomatic) resulting in the need to hold either the ACEI or b-blocker. Decision was made to discharge the pt on a low dose of lisinopril 2.5mg with the plan to start a b-blocker as an outpatient as blood pressures improved and allowed. Pt was also discharged home on clopidigrel, high dose aspirin and high dose statin and was switched from omeprazole to ranitidine. . # Depression: Patient has history of depression with suicide attempt in [**2108**]. She was continued on home medications of prozac 60 daily, buproprion sustained release 100 mg [**Hospital1 **]. Per daughter, patient has history of abusing medications. She has overdosed on her grandson's ADHD medications in recent past. Her son had an accidental overdose 8 years ago that lead to his death, which likely contributes to patient's own depression. Also her husband is very dependent. Patient was evaluated by psychiatry team who felt her to be stable. . # Migraines: Patient has history of migraines and appears to be on high dose topiramate 150mg [**Hospital1 **] at home. She was weaned off of the topiramate because it has potential side effect of hypotension and patient was intially very hypotensive, though asymptomatic. Patient did not complain of migraines during this hospitalization. Pt can restart medication as outpt. . # Arthritis: Patient notes that she takes oxycodone or percocet at home but unsure of dose. She was given tylenol for pain control, then later started on small doses of PRN oxycodone for arthritic lower back pain which she took regularly. A new prescription was not written for the pt as it was believed (per pharmacy records) that the pt had enough remaining medicatin to provide pain management until she say her prescribing physician [**Name Initial (PRE) 1796**]. Of note, prescribing physician was not her PCP but the physician she sees for her arthritis. . # Smoking: Patient continues to smoke 1.5 packs per day. Encouraged smoking cessation and maintained her on nicotine patch during hospitalization. Pt decline prescription for nicotine patches at discharge but was encouraged to speak w/her doctors regarding options to aid in smoking cessation. . Patient confirmed Full Code during this hospitalization. Medications on Admission: -prozac 60 -bupropion 100 mg [**Hospital1 **] -topomax 150 mg [**Hospital1 **] -lasix 20 q day -HCTZ --> unsure of dose -oxycodone --> unclear dose -believes may be taking other medications but does not recall at this time . Pharmacy at which pt gets prescriptions was consulted and the following prescriptions were current for the pt: furosemide 20mg daily simvistatin 20mg daily provigil 100mg [**Hospital1 **] HCTZ 25mg daily oxcodone/acetaminophen 5/325 [**1-9**] tab TID PRN : prescriber Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], last filled [**2112-8-29**] 42 tabs gabapentin 400mg [**Hospital1 **] seroquel 25mg 1-2 tabs qHS omeprazole 20mg daily flexeril 10mg TID PRN topiramate 100mg [**Hospital1 **] fluoxetine 20mg 3 tabs daily well butrin SR 100mg [**Hospital1 **] Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for CAD: s/p LAD STEMI. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for CAD: s/p LAD BMS. Disp:*30 Tablet(s)* Refills:*0* 5. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Capsule(s) 6. Bupropion HCl 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 7. Topiramate 100 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Flexeril 10 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 9. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain. 10. Seroquel 25 mg Tablet Sig: 1-2 Tablets PO at bedtime. 11. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Provigil 100 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis STEMI (heart attack) Secondary Diagnosis Tobacco Abuse Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with chest pain. You were found to have a heart attack. You underwent a cardiac catherization procedure to look at the blood vessels in your heart. Your blood pressure was low during the procedure so you had an special assistive pump placed temporarily to help your heart pump blood and were treated with medications to help your heart and blood pressure. . Please make the following changes to your medications: -Please start taking Lisinopril 2.5mg daily -Please start taking Atorvastatin 80mg daily instead of simvastatin -Please start taking Plavix (clopidogrel) 75mg daily -Please start taking Aspirin EC 325mg daily -Please start taking Ranitidine 150mg daily instead of omeprazole -Please stop taking Lasix (Furosemide); you will need to speak with your primary care doctor and cardiologist about the need for this medication and if it should be restarted. -Please stop taking hydrochlorathiazide; you will need to speak with your primary care doctor and cardiologist about the need for this medication and if it should be restarted. -For pain management, you may continue to use your regular prescription of percocet (oxcodone/acetaminophen 5/325) 1-2 tabs three times a day which you already have at home; however, we recommend using as little pain medication as possible to prevent any adverse effects(such as drops in blood pressure) as you continue your recover. -Please discuss with your PCP the need to start a beta blocker such as metoprolol once your are more fully recovered; this was not started while you were in the hospital because we did not want your blood pressure to be too low. -Please continue to take all of your other home medications as prescribed. . You should not smoke given your recent heart attack and the negative impact smoking has on the cardiovascular and pulmonary systems. Smoking will have significant adverse effects on your recovery. We offered you nicotine patches but at the time of discharge you declined. You can talk to your doctor about a variety of options to assist you in quiting smoking including the nicotine patch, gum and other alternatives. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. . It was a pleasure taking care of you and we wish you a speed recovery. Followup Instructions: Please follow up with your PCP and with cardiology. . Please be sure to call your Primary Care Physician on Tuesday (after the Labor Day Holiday) to schedule a follow-up appointment for within the next week if you do not already have an appointment arranged. Physician: [**Name10 (NameIs) 1877**],[**Name11 (NameIs) 539**] [**Name Initial (NameIs) **]. Location: [**Hospital3 **] INTERNAL MEDICINE Address: [**Street Address(2) 4472**] [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 4475**] . Please call Dr.[**Name (NI) 8664**] office on Tuesday (after the Labor Day Holiday) to schedule a follow-up appointment for management of your heart issues. The office phone number is ([**Telephone/Fax (1) 2037**]. Please be sure to schedule an appointment within the next 1-2weeks. You will also need to discuss when you should have an echocardiogram to assess your current heart function after your heart attack as well as whether or not you should begin taking a beta blocker (such as metoprolol). Completed by:[**2112-9-11**]

[ "458.29", "785.51", "428.20", "311", "414.01", "305.1", "416.8", "E879.0", "428.0", "410.01", "272.4" ]

icd9cm

[ [ [] ] ]

[ "00.40", "37.22", "99.20", "88.56", "00.45", "37.61", "00.66", "36.06" ]

icd9pcs

[ [ [] ] ]

18915, 18921

11452, 16798

324, 425

19054, 19054

3400, 9783

21513, 22599

2137, 2214

17654, 18892

18942, 19033

16824, 17631

19205, 19610

2229, 2243

9806, 11429

2819, 3381

2797, 2797

19639, 21490

274, 286

453, 1369

2257, 2769

19069, 19181

1391, 1869

1885, 2121

76,267

185,888

51996

Discharge summary

report

Admission Date: [**2174-6-27**] Discharge Date: [**2174-7-1**] Date of Birth: [**2121-12-9**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3016**] Chief Complaint: R-sided flank pain Major Surgical or Invasive Procedure: Exchange of the right and left nephrostomy tubes History of Present Illness: In brief, the patient is a 52 F h/o metastatic colon ca recently place on hospice care and s/p bilateral nephrostomy tube placement. She presented to the ED on [**6-26**] with acute onset of R sided flank pain, associated with nausea and nonbloody vomiting on the evening of [**6-25**]. No fever, CP, SOB. On arrival to the ED, T 98, HR 100, 160/117, 16, 95%RA. Exam revealed diffusely tender abdomen without any peritoneal sign. WBC 20, Cr 1.9 (baseline 0.8), lactate 4.3. Non-contrast abdominal CT revealed R-sided hydronephrosis with fat stranding. She received ceftriaxone, vancomycin, and pip-tazo. After 3L of NS, her lactate went down to 3.7, and her HR down to 80s. IR replaced nephrostomy tubes on both sides. She was admitted to the MICU. She received IVF but never received vasopressors. Her lactate trended down. Her urine output improved. She had both nephrostomy tubes placed with good effect. Her creatinine peaked at 1.9, is now 1.4. She is now transferred to the floor. Ms. [**Known lastname 805**] feels much better. She has chronic constipation and abdominal discomfort, but takes no narcotics. Her R flank is still slightly painful, but improved. She is still somewhat nauseated. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea, constipation. No recent change in bowel or bladder habits. Denied arthralgias or myalgias. Past Medical History: Oncologic History: She initially presented on [**2173-12-18**] to the Emergency Department with abdominal pain and pelvic pain. She said at that time the pain was predominantly in her lower pelvic area. On a CT scan on [**2173-12-18**], she had a large pelvic mass measuring 14 x 8 x 8 cm. She underwent a TAHBSO and ileocolectomy on [**2173-12-20**]. On frozen section, it was found that the tumor was most consistent with a colonic primary. On final pathology, it was found to be a 7-cm colon cancer, which was a pT3 N2 M1 with metastases to the ovary. She was discharged from that admission on [**12-28**]. She had a Port placed on [**2174-2-14**]. She started on capecitabine, oxaliplatin on [**2174-2-14**]. Of note, she is K-RAS mutation positive for the Gly-12 [**Male First Name (un) **]. Ms. [**Known lastname 805**] was admitted on [**2174-4-5**] due to abdominal pain and was found to be in acute renal failure. Based on this, she had bilateral nephrostomy tube placement performed at that time. Of note, on her CT on [**2174-4-5**], she had evidence of disease progression. She completed three cycles of Capecitabine and oxaliplatin. She had evidence of CT progression on a scan performed on [**2174-4-5**]. Based upon that, we changed her to irinotecan alone, which she received for one cycle. She ended up having another CT performed on [**2174-5-18**] to evaluate hydronephrosis which showed further disease progression. As her disease continued to progress despite chemotherapy, she started receiving hospice care in [**6-18**]. PMH: stage IV colon ca h/o hydronephrosis s/p nephrostomy tube placement asthma Social History: The patient is currently on home hospice. She currently lives in [**Location 686**] with her longterm boyfriend. The patient has 3 children. She previously was employed as a case manager at [**Company 107640**] house working with patients with addictions. Tobacco: smokes a "few cigarettes" intermittently, 20-30 pack years. ETOH: None. Illicits: None Family History: Mother: [**Name (NI) **] [**Name (NI) 3730**] Physical Exam: Vitals: T: 98.4 BP: 130/86 P: 94 R: 18 O2: 98% on RA General: Thin, 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: mildly diffusely tender, firm R-sided mass, bowel sounds present, no rebound tenderness or guarding Flank: bilateral nephrostomy tubes in placed. L draining clear urine, R draining pink urine. R-sided flank pain to percussion, L non-tender Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2174-6-27**] 10:40AM GLUCOSE-146* UREA N-19 CREAT-1.9*# SODIUM-142 POTASSIUM-3.1* CHLORIDE-92* TOTAL CO2-26 ANION GAP-27* [**2174-6-27**] 10:40AM WBC-20.0*# RBC-4.85 HGB-14.0 HCT-42.1 MCV-87 MCH-28.9 MCHC-33.3 RDW-16.6* [**2174-6-27**] 10:40AM NEUTS-85.8* LYMPHS-8.5* MONOS-4.8 EOS-0.5 BASOS-0.3 [**2174-6-27**] 10:40AM PLT COUNT-751* [**2174-6-27**] 12:12PM LACTATE-4.3* [**2174-6-27**] 01:40PM LACTATE-3.7* [**2174-6-28**] 03:21PM LACTATE 2.4* [**2174-6-28**] 05:08AM LACTATE 2.4* Discharge labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2174-7-1**] 05:50AM 9.3 3.69* 11.0* 32.7* 89 29.9 33.7 17.2* 562* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [**2174-7-1**] 05:50AM 109* 5* 0.7 139 3.6 103 26 Micro: BCx x2: NGTD UCx: yeast Images: Abd CT abd/pelvis ([**6-27**]): 1. No evidence of free air. No evidence of bowel obstruction. Free fluid in the abdomen. Please note that evaluation is limited due to lack of IV and oral contrast. 2. Evidence of significant hydronephrosis and hydroureter on the right, with significant fat stranding and areas of fluid attenuation which could suggest urinoma. Findings are concerning for nonfunctioning right nephrostomy tube. 3. Innumerable hepatic and splenic lesions, with similar appearance compared to prior study consistent with metastatic disease. Peritoneal carcinomatosis with multiple mesenteric and peritoneal soft tissue implants. 4. Cholelithiasis with possible gallbladder adenomyomatosis. CXR ([**6-27**]): Vague lucency in the right upper abdomen may represent interposed bowel or gas related to nephrostomy tubes, but free air or gas in a collection cannot be excluded. CT may be helpful for further evaluation depending on level of clinical concern. Bilateral nephrostomy tube change ([**6-27**]): IMPRESSION: 1. Successful exchange of bilateral indwelling nephrostomy catheters with new 8 French Flexima nephrostomy catheter. 2. Moderate-to-severe right-sided hydronephrosis. ANTEGRADE UROGRAPHY([**6-30**]): IMPRESSION: 1. Right-sided percutaneous nephrostomy tube patent and in correct position within the renal pelvis. 2. Possible obstruction within the tube/bag which was exchanged. The patient was also educated regarding nephrostomy tube flushes b.i.d. KUB ([**6-30**]): IMPRESSION: Nonspecific bowel gas pattern with air seen throughout the large and small bowel. Brief Hospital Course: 52 yo female with metastatic colon ca s/p b/l nephrostomy tube placement admittd with right-sided flank pain, N/V, found to have severe R-sided hydronephrosis, s/p b/l nephrostomy replacement. # Hydronephrosis: The patient's ARF resolved with nephrostomy tube change. Her left nephrostomy tube consistently put out good urine output, however her right nephrostomy tube had low output intermittently. IR evaluated it several times and brought her back for a urogram, however the tube appeared to be in the correct position. They recommended twice daily flushing of the tube to maintain patency. Urine culture only grew out yeast which is likely due to colonization. She was initally treated with 4 days of ceftriaxone due for high suscipicion of hydronephrosis. This was changed to cefpodoxime and she was discharged to complete a 10 day course as an outpatient. # N/V/Constipation: The patient had over a week of constipation on admission. She was treated with colace, senna, lactulose, and a dulcolax suppository and eventually had several bowel movements. She continued to experience nausea and vomiting, but reported that it was her baseline and felt she could keep up with oral intake adequately at home. Her nausea was treated with zofran, compazine, and ativan prn. # Lactic acidosis: Her lactic acidosis (4.3 on admission) was likely secondary to dehydration and trended down with IVF. # Metastatic colon ca: Patient was supposed to have started hospice prior to admission to the hospital, however before discharge she decided she did not want enroll in hospice at this time. Her pain was controlled with percocet prn. She will follow up with Dr. [**Last Name (STitle) **] on [**7-6**]. # Asthma: Asymptomatic during this admission. She was continued on her albuterol prn. # Code: DNR/DNI Medications on Admission: albuterol inh fluticasone inh ondansetron prn oxycodone-acetaminophen prn polyethylene glycol prn KCl 40 mEq qday prochlorperazine prn docusate senna Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-11**] puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. Fluticasone 220 mcg/Actuation Aerosol Sig: Two (2) puff Inhalation twice a day. 3. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for constipation. 6. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet Sig: One (1) packet PO once a day. 7. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:*30 Tablet(s)* Refills:*2* 8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. Disp:*1 bottle* Refills:*2* 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day. 11. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal once a day as needed for constipation. Disp:*25 suppositories* Refills:*2* 12. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary - Obstruction of the right nephrostomy tube resulting in hydronephrosis Probable pylenephritis Constipation Secondary - Metastatic colon carcinoma Asthma Discharge Condition: Stable, consistent output from both the right and left nephrostomy tubes. Continues to have what she reports is her baseline occasional nausea and vomiting. Discharge Instructions: You were admitted to the hospital due to back pain, nausea and vomiting. You were found to have a blockage of your right nephrostomy tube which was causing your back pain. You were treated with antibiotics for possible infection. Interventional radiology changed your nephrostomy tubes with some resolution of your symptoms. Your right nephrostomy tube continues to intermittently become clogged, however with regular flushing of the tube it is now draining consistently. - You should flush your nephrostomy tubes at least twice a day as instructed. Medication changes: 1. You will need to complete 10 more days of antibiotics: cefpodoxime 200 mg twice daily. 2. If you become constipated you can take 30 mL of lactulose as needed or a dulcolax suppository as needed. You should continue to take colace, miralax, and senna regularly. 3. For pain you can take 1-2 tablets of percocet every 4 hours as needed. 4. For nausea you can continue to take your home regimen of compazine 10 mg every 6 hours as needed in addition to 8 mg of zofran every 8 hours as needed. Continue your outpatient medications as prescribed. You were set up for hospice at home but have declined this for now. You have the numbers to call to set this up when you are ready. Call your doctor if you experience fevers, chills, shortness of breath, chest pain, recurrent flank pain, decreased output from your nephrostomy tubes, or other worrisome symptoms. Followup Instructions: Please keep your previously scheduled appointments: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2174-7-6**] 3:00 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3150**] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2174-7-6**] 3:00 Provider: [**Name10 (NameIs) 454**],ONE [**Name10 (NameIs) 454**] Date/Time:[**2174-8-2**] 7:30 [**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**] Completed by:[**2174-7-2**]

[ "197.6", "198.6", "276.2", "590.80", "584.9", "593.4", "564.09", "591", "493.90", "153.8" ]

icd9cm

[ [ [] ] ]

[ "55.93" ]

icd9pcs

[ [ [] ] ]

10616, 10622

7183, 8995

333, 384

10829, 10989

4735, 5238

12478, 13041

4023, 4070

9195, 10593

10643, 10808

9021, 9172

11013, 11568

5256, 7160

4085, 4716

11588, 12455

275, 295

1643, 1974

412, 1625

1996, 3638

3654, 4007

57,159

107,505

46072

Discharge summary

report

Admission Date: [**2135-9-19**] Discharge Date: [**2135-10-3**] Date of Birth: [**2053-2-19**] Sex: M Service: MEDICINE Allergies: Procainamide / Morphine Attending:[**First Name3 (LF) 3556**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: [**9-19**]: Emergent Left Frani for SDH evacuation History of Present Illness: 82M on coumadin and asa for St [**Month/Year (2) 923**]'s valve who fell approx 2 am. This am c/o headache, came to ED. Reportedly following all commands with some R arm weakness. Was intubated due to respiratory decline. Past Medical History: 1. Atrial Fibrillation ?????? on coumadin and amiodarone --s/p pacemaker placement ?????? Dr. [**Last Name (STitle) **] - pacemaker originally placed [**2118**] d/t AV block --s/p generator change in [**2128**] --s/p lead revision [**4-9**] 2. Bicuspid aortic valve disease, s/p [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] replacement - [**2118**] 3. CHF - TTE [**3-12**]: LVEF>55%, dilated LA, dilated LV, Tr AR. Mod MR. Mod to severe TR. Significant pulmonic regurg. severe PA HTN. 4. Hypothyroidism ?????? secondary to amiodarone 5. Pancytopenia - anogenic myeloid metaplasia -- s/p bone marrow bx 6. BPH ?????? Dr. [**Last Name (STitle) 986**] 7. Hiatal hernia w/o GERD 8. s/p cholecystectomy [**2117**] 9. HTN 10. hypercholesterolemia 11. VSD 12. s/p coronary cath [**2126**] - showed clean coronaries 13. Aberrant L subclavian artery, 50% tracheal compression. 14. Traumatic L upper thigh bleed 15. Lumbar scoliosis 16. Sciatica with posterior disc protrusion 17. CRF - baseline Cr 2.3-3.0 18. Gout 19. Vasculitis 20. ex-lap/LOA [**2130**] Social History: Retired, was a property manager previously Family: lives with wife in [**Name (NI) **], married 60years Travel/Exp/Pets: no recent travel or exposures. No pets. Alc/Tob: No EtOH in past 14 years, before that, social EtOH. no tobacco. Family History: Father died at 84 from oral cancer Brother with skin cancer Mother died at 25 for ?pneumonia not significant for DM, HTN, or other CA history Physical Exam: On Admission: Gen: WD/WN,intubated, sedated in ED HEENT: Pupils: 2 min reactive Neck:in hard collar Extrem: Warm and well-perfused. Neuro: Mental status: intubated, sedated. no eye opening. when meds lightened, did move all 4 extrem antigravity to stim. Pertinent Results: Labs on Admission: [**2135-9-19**] 06:39AM BLOOD WBC-6.7 RBC-3.13* Hgb-10.5* Hct-31.3* MCV-100* MCH-33.4* MCHC-33.4 RDW-15.6* Plt Ct-172 [**2135-9-19**] 06:39AM BLOOD Neuts-73.1* Lymphs-20.5 Monos-4.9 Eos-1.4 Baso-0.1 [**2135-9-19**] 06:39AM BLOOD PT-39.7* PTT-38.1* INR(PT)-4.3* [**2135-9-19**] 06:39AM BLOOD Glucose-113* UreaN-48* Creat-2.7* Na-142 K-3.4 Cl-104 HCO3-28 AnGap-13 [**2135-9-19**] 06:39AM BLOOD cTropnT-0.02* [**2135-9-19**] 06:39AM BLOOD Calcium-10.0 Phos-3.3 Mg-2.9* Labs on Discharge: XXXXXXXXXX Imaging XXXXXXXXXX Head CT([**9-19**])-Pre-op: IMPRESSION: Large left subdural hematoma, likely hyperacute on acute, with associated rightward subfalcine herniation and uncal herniation. CT C-Spine ([**9-19**]): IMPRESSION: 1. No acute fracture or malalignment identified. 2. Multiple degenerative changes. Head CT([**9-19**]): Post-op There is a new approximately 3 x 3 cm left parieto-occipital intraparenchymal hemorrhage. Expected post-surgical changes from left craniotomy with evacuation of subdural hematoma. The degree of midline shift and mass effect is markedly reduced. Subfalcine and uncal herniation has resolved. gall bladder us: IMPRESSION: Prominent hepatic venous vasculature suggestive of passive hepatic congestion. Brief Hospital Course: Patient is an 82 y/o M with history of atrial fibrillation and [**Month/Year (2) 1291**] on coumadin, amiodarone, s/p Pacemaker, diastolic CHF, admitted s/p fall with SDH. He was originally admitted to the neurosurgery service and had an evacuation of Subdural hemorrhage with a left sided craniotomy for bleed with hernation. His post operative course was complicated by diastolic CHG exacerbation and strep pneumonia VAP. He remained unresponsive after the second intubation and was made CMO. he was extubated [**10-3**] and passed away 2 hours later. . Respiratory Failure: intially intunated for neurosurgery evacuation [**9-19**], extubated [**9-20**]. ReIntubated [**9-24**] after 1 day on bipap for increased work of breathing and airway protection in setting of pulmonary edema and pneumonia. Etiology of resp failure is infections and cardiogenic. Patient was alkalotic, is overbreathing the [**Last Name (LF) **], [**First Name3 (LF) **] decrease tidal volume. He was treated with ceftriaxone for the strep pneumonia and despite better volume status and treatment of PNA, he remained unresponsive on no sedation. He failed several pressure support trials secondary to hyperventilation and low tidal volumes, he likely had neurogenic respiratory failure. Subdural hemorrhage: s/p Craniotomy and evacuation [**9-19**], done emergently. had unequal pupils [**2-24**] and had stat Head CT showing no interval change. Pupils became equal again after several days. He was started and continued on dilantin prophylaxis. The dose was decreased given low albumin and corrected level higher than measured. Despite Improving Dilantin level and correcting hyponatremia, patient continued to have poor mental status. Anemia: unclear etiology. Patient was hypercoaguable around the time of fall. Not bleeding in brain, may have spontaneous RP bleed. Hct went from 23 -> 20 hospital day 6, and responded to 2 units pRBCs. Patient also has underlying myeloid metaplasia. His Hct did not drop after that. [**Month/Year (2) 1291**]/Coagulpathy: patient with [**Month/Year (2) 1291**] with [**Hospital3 **] valve that needs to be anticoagulated with INR goal [**2-6**]. Warfarin has been held since admission and Pt recieved 3 units FFP on admission. on [**9-25**] patient had INR 3.8 and recieved a total of 4 units FFP. For several days, the INR remained >2 despite any anticoagulation. When it fell below 2, coumadin 1mg was started. Cardiology had been consulted by neurosurgery service, and the decision was made to start coumadin without bolus when IRN <2 given the SDH on admisision. Possible etiologies of persistent coagulopathy were vitamin K deficiency vs liver damage vs most likely supratherapeutic phenytoin. When phenytoin values normalized, INR also normalized. Altered mental status: Patient unresponsive off sedation. Etiology is likely multifactorial: subdural, hypernatremia, uremia, and infection. Hypernatremia, uremia, infection were all treated and he remained unresponsive. Diastolic heart failure: EF >60% ([**3-12**]). Patient was on lasix drip for a day, on intermittent lasix until euvolemic. Transaminitis: unlikely from propofol as trigylcerides are normal. Shock liver unlikely, has not been hypotensive. [**Month (only) 116**] be septic. eventually trended down. CKD: baseline creatinine is 2.3-2.8. trended down and normalized. - renally dose meds Hypertension: His blood pressure was eventually controlled on the following regimen. - Hydralazine titrated up to 37.5mg TID, Isosorbide mononitrate increased from 10 to 20 PO BID, metoprolol 25mg [**Hospital1 **]. Atrial fibrillation: continue Amiodarone 200 [**Hospital1 **] Hypothyroidism: home dose of 75mcg PO levothyroxine HYperlipidemia: continue statin Hypernatremia: has been trending up, likely contributing to mental status - free water boluses from 200q6 to 300q4. BPH: held tamsulosin and finastride, not crushable via PEG ** Numerous family meeting were held, and given the lack of improvement in his mental status in the setting of the large subdural hematomas, the decision was made to transition the patients care to comform measures. Family was brought in from out of town, and the patient was extubated [**2135-10-3**]. He passed away a few hours after extubation. Medications on Admission: allopurinol,amiodarone,aspirin,calcium,fish oil, flomax, folic acid, hydralizine,imdur,levoxyl,lipitor,MVI, proscar,toprol xl, toresemide,coumadin Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: Acute Lt SDH diastolic heart failure respiratory failure Coagulpathy Hypertension Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**] Completed by:[**2135-10-11**]

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icd9cm

[ [ [] ] ]

[ "96.72", "93.90", "99.04", "01.31", "99.07", "96.6" ]

icd9pcs

[ [ [] ] ]

8182, 8191

3677, 6458

293, 346

8317, 8327

2395, 2400

8384, 8553

1961, 2105

8149, 8159

8212, 8296

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245, 255

2901, 3654

374, 600

2414, 2881

6473, 7951

622, 1691

1707, 1945

63,896

161,257

53324

Discharge summary

report

Admission Date: [**2162-7-8**] Discharge Date: [**2162-9-7**] Date of Birth: [**2093-10-8**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Iodine / Iodine; Iodine Containing / Darvon / Lexapro / Ceclor / Ampicillin / Novocain / Xylocaine / Percodan / Effexor / Trazodone / Lamictal / Epinephrine / Zosyn Attending:[**First Name3 (LF) 3233**] Chief Complaint: Chest pain, SOB Major Surgical or Invasive Procedure: 1. Posterior spinal instrumentation T1-L3. 2. Posterior spinal fusion T1-L3. 3. Application of interbody biomechanical device T6-T9. 4. Interbody fusion T6-T9. 5. Thoracentesis 6. Central line placement History of Present Illness: 68 yo F with RA, fibromyalgia, OA with 2 ED visits in last 2 days (this is third) for L sided chest pain with SOB. Was seen here in ED, CE negative, Ddimer elevated at 5000, VQ scan negative, no other lab abnormalities and she was d/c'ed home. When she arrived home, the security guard there noted pt to be struggling getting into apt and call EMS for transport back to ED. He checked her O2 say and she was reportedly hypoxic to 84% though there is no documentation. Patient reports she has midl pain at rest but extreme 10/10pain with any movement. Denies any rashes over area of pain, she has received zoster vaccine. States she has had this pain for the last 2 1/2 months which has worsened recently - no inciting factor. . In the ED, initial VS were 98.1, 68, 121/69, 16, 98%2LNC. no additonal labs were drawn, she received no pain meds. XR showed new small L sided effusion compared to CXR done yesterday. Pain is reproduicble. FAST exam negative. Is admitted for pain control. . Upon evaluation in the ED patient reports her pain feels better without movement. She denies any current SOB. Room air sat checked and is 90% which normalized to 100% with 2L nc. Past Medical History: Fibromyalgia, osteoarthritis, RA, DJD s/p laminectomy Social History: lives at home in [**Hospital 5087**] [**Hospital3 **] center with her husband. [**Name (NI) **] tobacco. Social EtOH only. Active, able to drive. Daughter very involved in their lives although she lives in [**State 622**]. Husband has bipolar disorder. Family History: non-contributory Physical Exam: Physical exam on discharge: VS: Tmax:98.8 Tc: 97.3 147/81 84 18 97%3LNC Gen: NAD, well appearing obese F, pleasant, talkative HEENT: MMM, no oral lesions noted, no sinus tenderness, yellow eye shadow Neck: supple, no LAD CV: RRR S1 S2 no R/G/M, Back: significant tenderness over L anterolateral chest and L upper/mid back, no vesicles or erythema present, nontender skin Pulm: minor discomfort with deep breaths, trace crackles at L base that do not clear with cough, no wheezing or rhonchi Abd: soft, nontender, nondistended, normoactive bowel sounds Ext: 2+ edema up to the knee, pulses 2+ bilaterally Neuro: CNII-XII intact, moving all extremities, L sided weakness noted . Pertinent Results: 1. Labs on admission: [**2162-7-8**] 05:45AM WBC-8.5 RBC-3.72* HGB-11.8* HCT-34.9* MCV-94 MCH-31.8 MCHC-33.9 RDW-14.4 [**2162-7-8**] 05:45AM PLT COUNT-310 [**2162-7-8**] 05:45AM CALCIUM-9.3 PHOSPHATE-6.0*# MAGNESIUM-1.9 [**2162-7-8**] 05:45AM cTropnT-<0.01 [**2162-7-8**] 05:45AM CK(CPK)-92 [**2162-7-8**] 05:45AM GLUCOSE-92 UREA N-24* CREAT-1.0 SODIUM-134 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-24 ANION GAP-10 [**2162-7-8**] 03:10PM cTropnT-<0.01 [**2162-7-8**] 03:10PM CK(CPK)-85 . 2. Labs on discharge: [**2162-9-7**]: WBC-7.5 RBC-2.54* HGB-8.0* HCT-25.0* MCV-99* MCH-31.6 MCHC-32.0 RDW-19.1* PLT COUNT-390 [**2162-9-7**]: GLUCOSE-144 UREA N-8 CREAT-0.5 SODIUM-142 POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-26 GAP-10 [**2162-9-7**]: ANC - 6800 . 3. Microbiology: - C. diff neg x 9 - Blood cultures neg x 10 - Spinal fluid culture neg - RESPIRATORY CULTURE (Final [**2162-7-26**]): SPARSE GROWTH Commensal Respiratory Flora. PLEASE SPECIIATE COMMENSAL RESPIRATORY FLORA PER DR. [**Last Name (STitle) **]. [**Last Name (un) **] (3-4893). STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. YEAST. SPARSE GROWTH. VIRIDANS STREPTOCOCCI. SPARSE GROWTH. STAPH AUREUS COAG +. SPARSE GROWTH. Sensitivity testing performed by Sensititre. SENSITIVE TO CLINDAMYCIN 0.12 MCG/ML. SENSITIVE TO OXACILLIN 0.25 MCG/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- S ERYTHROMYCIN---------- 0.5 S GENTAMICIN------------ 2 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- S TRIMETHOPRIM/SULFA---- 2 S . - Urine culture: yeast . 4. Imaging/diagnostics: - CT chest wo contrast [**7-12**]: Linear opacity in the b/l lungs likely represents atelectasis, but underlying infection cannot be excluded. Multiple lytic bone lesions involving multiple vertebral bodies/posterior elements, ribs, sternum could represent metastatic disease or multiple myeloma (new since CXR of [**2161-8-18**]). Lytic lesions most severe at T3, T7 and T12 where there is destruction of the osseus vertebral body cortex and extension of soft tissue density into the spinal canal and collapse of T7 vertebral body. Cannot exclude cord involvement. MRI could be obtained for further evaluation if concern for cord involvement or compression. Debris within proximal esophagus raises concern for aspiration risk. d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 402**] [**Last Name (NamePattern1) **] at 9:30 pm. . MRI spine [**7-13**]: Diffuse bone marrow replacement throughout the cervical, thoracic, and lumbar spine consistent with widespread osseous malignancy, most likely metastatic disease. Multilevel epidural soft tissue components with evidence of cord compression at the T3 vertebral body level without intrinsic cord signal abnormalities. Loss of height of the T7 vertebral body with diffuse bone marrow infiltration, concerning for pathologic compression fracture. Ventral epidural component narrowing the thecal sac and abutting the ventral spinal cord without evidence of cord compression. Multilevel degenerative disc disease throughout the cervical and lumbar spine. . Skeletal survey [**7-13**]: SKELETAL SURVEY: There are multiple punched-out lytic lesions without a sclerotic rim in calvarium, the largest measuring at least 1.5 cm. Multiple similar lytic lesions are seen in the right and left humeri and bilateral clavicles. In the left humerus, there is a large lytic lesion in the mid diaphysis with endosteal scalloping with this lesion at risk for pathologic fracture. There are no significant abnormalities of the visualized lung. The ribs bilaterally have a mottled appearance suggestive of lytic lesions. No discrete lesion is identified on the AP projection of the chest. On the lateral projection of the thoracic spine, there is loss of vertebral body height and disc space narrowing seen at multiple levels of the mid thoracic spine which correlates with the lytic lesions and compression fracture deformities seen on prior CT and MRI. No focal lytic lesions are seen in the pelvis or sacrum or proximal femurs. . ECHO TTE [**7-14**]: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. 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 no pericardial effusion. . CT lumbar spine wo contrast [**7-14**]: Multiple new lytic lesions within the lumbar spine and bony pelvis may represent metastatic disease versus multiple myeloma. The largest lesion is in the T12 vertebral body, with disruption of the cortex and epidural extension of soft tissue density , with distortion of the left lateral and anterior portions of the thecal sac. . Pathology ([**7-19**]): T3 tumor, corpectomy (A-B): Plasma cell myeloma (see note). T12 tumor, corpectomy (C-D): Plasma cell myeloma (see note). . ECHO ([**7-21**]): The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. . MRI C, T, L spine ([**7-24**]): CERVICAL SPINE: FINDINGS: Compared to the prior study of [**2162-7-13**], no significant change is seen in the cervical spine. Mild spinal stenosis at C4-5 level. No cord compression or abnormal signal seen within the cord, although evaluation on the inversion recovery images is limited due to artifacts. IMPRESSION: Degenerative changes in the cervical region without neoplastic cord compression. Mild spinal stenosis at C4-5. . THORACIC SPINE: The thoracic spine evaluation is significantly limited due to metallic artifacts. Since the previous study, the patient has undergone corpectomy of T7 with a fibular graft and multiple pedicle screws and rods in the posterior aspect of the spine. The artifacts limit the evaluation of the spinal canal, but at T3 level, there appears to be mild indentation on the posterolateral aspect of the spinal canal and indentation on the cord with mild narrowing at this level. At T6 to T8 level, there is no fluid seen in the paraspinal region which could be related to surgery, but CT could help for better assessment given the metallic artifacts limit the evaluation. There are bilateral pleural effusions identified. Evaluation of the spinal cord signal is limited due to artifacts. . LUMBAR SPINE: No evidence of high-grade spinal stenosis in the lumbar region. Mild degenerative changes as before. . CT Chest/Abd/Pelvis ([**7-26**]): Large bilateral pleural effusions, right greater than left with bilateral consolidations. An infectious etiology cannot be ruled out. Soft tissue thickening and induration posterior to the spinal rod placement. This soft tissue is consistent with postoperative changes but a superimposed infection cannot be ruled out. . Liver/Gallbladder U/S ([**7-28**]):Borderline echogenic liver, which might be seen with fatty change. No focal hepatic lesions. Gallbladder sludge, without son[**Name (NI) 493**] evidence of cholecystitis. Right pleural effusion, as seen on same-day chest radiograph. . CTA chest w/ and w/o contrast ([**8-13**]): The study is limited due to suboptimal opacification of the pulmonary arteries. Within this limitation, no pulmonary embolism is seen within the main and lobar pulmonary arteries and the proximal segmentaal artereries in the lower lobes; upper lobe segmental pulmonary arteries cannot be assessed with the poor contrast opacification, nor can any subsegmental arteries. Small-to-moderate bilateral pleural effusions and bibasilar consolidations, likely represent atelectasis and have not significantly changed since the prior study. Superimposed infection/aspiration cannot be completely excluded. Innumerable osseous metastases involving the thoracic vertebrae with intraspinal extension, have not significantly changed since the prior study. . MR THORACIC SPINE W/O CONTRASTR ([**2162-8-22**]): Very limited (non-enhanced) examination, with no gross evidence of large thoracic spinal epidural phlegmon or abscess. There are persistent moderate-sized pleural effusions with known extensive osseous metastatic disease, with a more fluidic appearance at the T6 through the T8-T9 level of the fibular strut graft. While this may simply represent the known extensive osseous metastatic disease at this site, given its fluidic characteristics (by both MR [**First Name (Titles) **] [**Last Name (Titles) **]), an infectious component cannot be excluded. . Brief Hospital Course: 68 yo F PMH of asthma, RA (unsubstantiated), fibromyalgia, OA, and DJD s/p laminectomy admitted with c/o 2.5 months of chest pain, now worsened over the last week. . # Chest pain: Work up for ACS negative. CTA negative for PE. Treated empirically with antibiotcs for CAP witout improvement. Chest CT showed lytic bone lesions in ribs, sternum, spine. Diagnosis for multiple myeloma was made. . #Multiple Myeloma: Lucency on hip xray prompted tests for total calcium = 10.2, with positive SPEP and UPEP. CT chest showed diffuse bony lesions. HemeOnc was consulted, and made the diagnosis of multiple myeloma after bone marrow biopsy. IgG =6261 (monoclonal IgG lambda) Beta-2 microglobulin = 3.0 Serum Viscosity = 1.9 MRI spine showed compression at level of T3 and involvement of T7 vertebral body. Patient transferred to the BMT service where she was started on Velcade/dexamethasone. Spinal surgery was done on [**2162-7-19**], with T7-T8 transpedicular corpectomy, T1-L3 posterior instrumented fusion. Radiation oncology consulted and started radiation therapy after stabilization with surgery. Complicated post-operative course, with SICU, MICU, and [**Hospital Unit Name 153**] stays for hypotension requiring intermittent pressors, volume overload, and aspiration pneumonia/pneumonitis. She responded to Velcade with decreasing IgG level and improving SPEP. Plan is for her to continue with radiation treatment and Velcade at rehabilitation center. She is to remain in TLSO when OOB and HOB >45 degrees. Her staples were removed and her incision appeared to be healing well with steristrips. Physical therapy was consulted and she was moved to chair daily for 2-3 hours, increasingly tolerated. She will follow up with Dr. [**Last Name (STitle) **] in the [**Hospital 3242**] clinic. . #Hypoxia: LLL opacity on CXR and new onset hypoxia to 87% on RA on admission. VQ low probability for PE. On the floor, pt's oxygen remained in 94% stable on 3-4L of oxygen. Post spine surgery, patient required several days of mechanical ventilation post-op, and developed an enlarging R-sided pleural effusion that expanded after extubation. She was started on antibiotics empirically for VAT. Pulmonary was consulted and performed thoracentesis x 2. Transudative on both occasions. Cytology showed plasma cells. Completed 14-day course of aztreonam, ciprofloxacin, flagyl, and vancomycin. After termination of antibiotics remained afebrile. Continued diuresis with goal of -1.5 L per day with good results. There were some blood pressure lability and tachycardia which eventually resovled. At the time of discharge, patient oxygen saturation 98% on 3L NC. . #Dysphagia: Finding on CT chest [**7-12**] suggest food bolus stuck in esophagus. She denies symptoms of dysphagia or choking. Pt reported history of mild GERD. She was able to tolerate PO intake w/o complication. Repeat CT chest showed mild esophageal dilation. She was cleared by swallow prior to taking PO on BMT floor. . #Rash: New pinpoint pruritic erythematous rash. No thrombocytopenia. No new medication. Rash excoriated. Symptomatically managed w hydrocortisone cream prn, likely secondary to sedentary status and decreased hygiene [**1-19**] pain w movement. Rash resolved during the hospitalization. . # RA/Fibromyalgia: continue home meds, Pt's rheumatologist emailed that he has not established a diagnosis in this pt incl RA. She believes she has RA and h/o sarcoidosis (unsubstantiated by her md's). After diagnosis of multiple myeloma was made, the pt was discontinued on her salsalate and other NSAIDs. She received Dexamethasone as part of chemotherapy but other home meds were held on BMT floor. . # HTN: BPs labile after surgery, on BMT floor. At time of discharge, blood pressure had been in the 130-140/60-70 range for one week. . # Psych: Extensive psychiatric history including hospitalization for suicide attempt in [**2154**]. Psychiatry consulted and she was started on olanzapine, continued on mirtazapine, and restarted on paroxetine with good effect. Medications on Admission: Clonazepam 0.25 mg qhs Neurontin 200 mg [**Hospital1 **] Hydrocortisone 2.5 % Cream apply rectally twice a day Combivent 1 puff prn Metoprolol Succinate 12.5 mg qd Mirtazapine 7.5 mg Tablet qhs Omeprazole 20 mg qd Paroxetine 10 mg qd Pramipexole 0.125 mg qhs Salsalate 750 mg [**Hospital1 **] prn Simvastatin 40 mg qd Vitmain C * OTCs * Aspirin 81 mg qd Calcium Carbonate-Vitamin D3 500 mg-200 qd Multivitamin-Minerals-Lutein qd Ocuvite Discharge Medications: 1. Clonazepam 0.5 mg Tablet Sig: [**12-19**] Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. 2. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qhs (). 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ascorbic Acid 250 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 14. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every four (4) hours as needed. 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 19. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 21. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 22. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 23. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 24. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 25. Vitamin A-Vitamin C-Vit E-Min Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: PRIMARY: Multiple Myeloma 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 complaints of chest and back pain, and difficulty breathing. You required oxygen administration to help you breathe well. . Your chest xray suggested a left lower lobe pneumonia and compression of your lung space due to restricted breathing. The compression of your lungs is likely due to shallow breathing from your chest pain. You also had fluid in your lungs, which were removed by the pulmonary doctors. . You did not have a pulmonary blood clot which was confirmed with dopplers which showed no blood clots in your legs and a lung scan that was negative as well. . Your chest pain was attributed to the bone lesions from the multiple myeloma. We treated you with pain medications. You were started on chemotherapy and radiation therapy to treat the multiple myeloma. You responded well to the treatment. . You had a spine stabilization surgery. You continue to wear a back brace after the surgery. Physical therapy worked with you to gain your strength back. . The following changes were made to your medications: STOPPED: - Hydrocortisone 2.5 % cream applied rectally twice a day - aspirin 81 mg by mouth every day - Salsalate 750 mg by mouth twice a day . CHANGED: - Gabapentin 200 mg by mouth twice a day --> 300 mg by mouth three times a day - Metoprolol S.R. 12.5 mg by mouth once a day --> 12.5 mg by mouth twice a day - Paroxetine Hcl 10 mg by mouth per day --> 5 mg by mouth at bedtime . STARTED: - acyclovir 400 mg by mouth every 8 hours - dapsone 100 mg by mouth every day - docusate 100 mg by mouth twice a day - folic acid 2 mg by mouth every day - hydrocerin 1 application topical twice a day (to radiation site) - miconazole powder 2% 1 application to skin folds twice a day - olanzapine 2.5 mg by mouth at night Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3238**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2162-9-14**] 3:00 Provider: [**First Name8 (NamePattern2) 3239**] [**Last Name (NamePattern1) 3240**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2162-9-14**] 3:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2162-11-2**] 11:20 Completed by:[**2162-9-7**]

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icd9cm

[ [ [] ] ]

[ "03.4", "03.31", "81.63", "38.93", "41.31", "80.99", "34.91", "84.51", "99.28", "92.29", "81.05", "03.53" ]

icd9pcs

[ [ [] ] ]

19108, 19179

12492, 16526

459, 663

19249, 19249

2956, 2964

21217, 21699

2222, 2240

17014, 19085

19200, 19228

16552, 16991

19400, 21194

2255, 2255

2283, 2937

404, 421

3477, 12469

691, 1858

2978, 3458

19264, 19376

1880, 1935

1952, 2206

3,268

103,745

6522

Discharge summary

report

Admission Date: [**2161-11-3**] Discharge Date: [**2161-11-16**] Service: VASCULAR SURGERY CHIEF COMPLAINT: 5.6 cm infrarenal abdominal aortic aneurysm. HISTORY OF PRESENT ILLNESS: [**Known firstname 4115**] [**Known lastname 17147**] is a 77 year-old white female with a past medical history significant for colon carcinoma status post sigmoidectomy in [**2158-3-5**] who presents with a 5.6 cm infrarenal abdominal aortic aneurysm found on workup for her colon cancer. Her initial CAT scan in [**2158**] revealed her aneurysm to be approximately 4 cm in diameter with subsequent CT scanning this year revealing a significant enlargement to 5.6 cm. She had a full course of chemotherapy and radiation therapy and her last colonoscopy revealed no recurrent cancerous lesions. Her hepatic workup was negative for any liver involvement. She is a fairly active individual and was referred for the repair of the abdominal aortic aneurysm. She has a history of known coronary artery disease, which has been managed conservatively. She has a 60% right CA and 90% mid circumflex lesion. She does admit to shortness of breath, but no angina and denied any history of coronary artery disease. She was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for evaluation of her preoperative coronary artery disease. He decided that she had no previous angiographic evidence of progression of her coronary artery disease and in view of her mild stable symptoms and it was reasonable to proceed with her aneurysm surgery with the usual perioperative precautions without any intervention at that time. She was noted to have a 58% ejection fraction on cardiac catheterization. She was evaluated for a endoluminal stent graft, however, was not a candidate possibly due to her femoral and iliac disease. PAST MEDICAL HISTORY: Significant for sigmoid and colon cancer managed with surgery, chemotherapy and x-ray therapy. Hypertension, coronary artery disease, nicotine abuse in the past that had ceased since [**2158**], as well as hyperlipidemia. PAST SURGICAL HISTORY: Colon resection, appendectomy, left salpingo-oophorectomy and splenectomy. PREOPERATIVE LABORATORIES: CAT scan with a 5.5 cm abdominal aortic aneurysm starting just below the renal arteries and ending at the iliac bifurcation. Her iliac arteries appeared to be heavily calcified. Cardiac catheterization revealed 58% ejection fraction, normal left main coronary artery, mild narrowing of approximately 50% stenosis at the ostium of the left anterior descending coronary artery, left circumflex artery with a 60% stenosis before the origin of the first major marginal. The right coronary artery had an osteal lesion at approximately 68% and a sequential 80% lesion in the mid vessel at the site where the vessel is calcified and tortuous. There was slight prolapse of the posterior mitral valve leaflet without evidence of regurgitation. Chest x-ray revealed slight ventricular enlargement without evidence of heart failure. Electrocardiogram revealed nonspecific lateral ST segment changes, but otherwise normal sinus rhythm. Her white blood cell count was 10.1 with a hemoglobin of 13.2, hematocrit 42.1, platelet count 341. Potassium blood sugar was 85. BUN 18, creatinine 0.6, potassium 4.6. Other electrolytes were within normal limits. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] where she underwent open repair of her abdominal aortic aneurysm with an aortobifemoral bypass. Details of this procedure are dictated in a separate operative note. The patient was subsequently transferred up to Far Nine in the Vascular Intensive Care Unit where she was monitored for any hemodynamic changes, drop in urine output, and cardiac events. She did well until postoperative day number three when it was noted that she had an elevated white blood cell count to be approximately 20.2. Her hemoglobin and hematocrit had also dropped from 33 to 29.6 and a rectal examination was performed due to her history of colon CA, which was guaiac negative. She was essentially asymptomatic and denied any history of fevers or chills, nausea, vomiting or abdominal pain. She did have a low grade fever of approximately 100.7. A stool was sent for C-difficile. On postoperative day number four her white count did drop to 15.5 and she continued to do well. She was afebrile at that time and no active issues were going on. She was evaluated by physical therapy and got out of bed and the Swan-Ganz catheter was discontinued. On postoperative day number four at approximately 1:00 in the morning she went into a rapid atrial fibrillation and dropped her blood pressure. She was somewhat nauseated at the time and feeling lightheaded. She responded rather well with beta blockade and with Cardizem 25 mg intravenous bolus. She then dropped her rate severely down into the 40s and was prepared for pacing. She did respond spontaneously though without need for pacing. She was seen by cardiology who started her on a Cardizem drip at 5 cc per ml to be titrated slowly. They were advised not to give any bolus of Cardizem after that. She ruled out for a myocardial infarction as per enzyme criteria. Her blood pressure did remain somewhat low being less then 100 and one unit of packed red blood cells was transfused. She responded very well to this. She did remain in atrial fibrillation for the next several days going in and out of normal sinus rhythm. She was started on a heparin drip with PTT being monitored anywhere between 50 and 60. It was noted though after three days of anticoagulation that she begin to have epistaxis and hematuria. The heparin was subsequently discontinued after an echocardiogram. The echocardiogram failed to reveal any kind of mural thrombus present and it was decided by cardiology that she could be maintained on oral aspirin rather then chronic anticoagulation. She continued to do well and remained in normal sinus rhythm. She was transferred out to the floor and off monitor. She was evaluated by physical therapy and due to the events was thought to need rehabilitation. On postoperative day number nine, the patient again had a fever of 100.1 and an elevated blood cell count to 15.6. It was noted by the nurse that the urine was quite cloudy and slightly foul smelling. A urinalysis and urine culture were obtained, which grew out E-Coli. This was susceptible to Bactrim and she was subsequently started on this twice a daily. It should also be noted she was discontinued off her cardizem drip and advised by cardiology to remain on her Atenolol. She was then evaluated by Dr. [**Last Name (STitle) **] who was concerned about an intra-abdominal process due to her history of the colon cancer as well as her new aortic graft. A repeat CBC was obtained that morning and revealed the white blood cell count to have risen to 20.5. A CAT scan with contrast was then performed who ruled out an intra-abdominal abscess. This was negative for any kind of abscess or perforation and only revealed gallstones without evidence of gallbladder wall thickening as well as a left flank hematoma beneath her kidney, which was expected secondary to her aortic surgery and the retroperitoneal incision. Her Bactrim was discontinued and she was started on Levaquin and Flagyl to cover for any kind of occult infection or C-diff. She continued to do well over the weekend and her white count dame down and she is currently afebrile. At this time the patient is doing quite well and is feeling much better. She has had three bowel movements over the weekend, which she feels has resolved some of her discomfort and she is able to ambulate without difficulty at this time. She has been cleared by physical therapy to go home. She no longer has any urinary symptoms and her urine has come back clean. She has been discontinued from her antibiotics and will go home with visiting nurse this evening. DISCHARGE MEDICATIONS: Ambien 5 mg po q.h.s., Colace 100 mg po q.d., Dulcolax 10 mg per rectum prn, Senokot two tabs po q.d., Atenolol 50 mg po b.i.d., Zantac 150 mg po b.i.d., Norvasc 2.5 mg po q.d., Ecotrin 325 mg po q.d., potassium chloride 40 milliequivalents po prn and she will be sent home on Percocet one to two tabs q 4 to 6 hours prn pain. CONDITION ON DISCHARGE: Stable and progressing well. DISCHARGE DIAGNOSES: 1. Abdominal aortic aneurysm with need for repair. 2. Proximal atrial fibrillation currently resolved and in sinus rhythm. 3. Elevated temperature and white blood cell count secondary to urinary tract infection. 4. Hypertension. 5. Colon cancer. 6. Anemia with the need for blood transfusion currently resolved. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**] Dictated By:[**Doctor First Name 22875**] MEDQUIST36 D: [**2161-11-16**] 09:50 T: [**2161-11-16**] 10:17 JOB#: [**Job Number 25012**]

[ "276.5", "599.0", "041.4", "V10.05", "441.4", "997.1", "458.2", "427.31", "426.13" ]

icd9cm

[ [ [] ] ]

[ "39.25", "38.44" ]

icd9pcs

[ [ [] ] ]

8407, 9007

8003, 8331

3378, 7979

2107, 3360

121, 167

196, 1837

1860, 2083

8356, 8386

2,406

161,120

50107

Discharge summary

report

Admission Date: [**2161-5-30**] Discharge Date: [**2161-6-5**] Date of Birth: [**2118-12-12**] Sex: F Service: [**Location (un) 259**] CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: This is a 42-year-old female with history of end-stage renal disease status post [**2160-6-21**] renal transplant (this is her second transplant with her first one being in [**2159-11-22**]), and hypertension who is normally followed at [**Hospital1 20954**] Hospital, now presents with abdominal pain. Yesterday around noon, the patient noted some acute onset of crampy diffuse abdominal pain which was board like and radiated to the back. She also had some nausea and vomiting. She admits to about five episodes of clear bilious emesis. Her abdominal pain increased throughout the day. She denies any fever, chills, bright red blood per rectum, or melena. She denies any history of gallstones. She did admit to using Lasix about a month ago for about a two week period. She was on Imuran up until about a week ago. The Imuran was stopped secondary to lightheadedness. She also admitted to some viral upper respiratory symptoms for the past week, which has improved for the past two days. She says that she does have alcohol which ranges about 3-5 drinks a week. PAST MEDICAL HISTORY: 1. Hypertension. 2. End-stage renal disease status post two renal transplants with the last one being in [**2159-11-22**]. MEDICATIONS AT HOME: 1. Prednisone 10 mg po q day. 2. Metoprolol 400 mg po bid. 3. Nifedipine 90 mg po q day. 4. Prograf 6 mg po bid. 5. Protonix 40 mg po bid. ALLERGIES: Iron. SOCIAL HISTORY: The patient lives in [**Location 669**]. She denies any tobacco use. She admits to some social alcohol use. PHYSICAL EXAMINATION UPON ADMISSION: Temperature is 98.6, pulse of 98, blood pressure of 160/100 range, and 160-190 and 100-130, respiratory rate 14. Generally, this is a middle age female in moderate distress. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is clear. Mucous membranes dry. Chest was clear to auscultation anteriorly. Cardiovascular: Regular, rate, and rhythm, normal S1, S2, 3/6 systolic ejection murmur best heard at the right upper sternal border that can also be heard throughout the precordium. Abdomen has normoactive bowel sounds. There is some moderate tenderness to palpation in the epigastric and right upper quadrant area. There is some rebounding, but no guarding. Extremities: There is trace edema. Neurologic examination is nonfocal. LABORATORIES UPON ADMISSION: White count is 8.2, hematocrit 35.3, hemoglobin 12.2, and MCV of 95, platelets of 220, sodium of 138, potassium 5.3 which is hemolyzed, chloride 99, bicarb 19, BUN 15, creatinine 0.8, glucose 85, and hemolyzed blood. ALT 79, AST 127, alkaline phosphatase 69, total bilirubin 1.4, LDH 7705, lipase 2817. Right upper quadrant ultrasound shows no evidence of cholelithiasis or cholecystitis. CT scan of the abdomen and chest x-ray are pending. ELECTROCARDIOGRAM: Normal sinus rhythm at 82 beats per minute. There is left ventricular hypertrophy. HOSPITAL COURSE: 1. Acute pancreatitis: Given the patient's symptoms and laboratories, it is most likely acute pancreatitis. This was also found on CT scan of the abdomen which showed some stranding around the pancreas consistent with acute pancreatitis. Patient was given nothing by mouth and hydrated aggressive with IV fluids. Her pain was controlled with IV Morphine. Initially, the patient refused a nasogastric tube. A calcium and triglyceride level were checked, and found to be within normal level. It was likely that acute pancreatitis is secondary to alcohol use plus or minus Lasix use. On the second day of hospitalization, the patient's urine output started dropping off. Thus she was aggressive hydrated with IV fluids at a rate of 200 cc/hour, her urine output fell to less than 300 cc in an 18 hour period. At which point, she was then transferred to the Surgical Intensive Care Unit for aggressive hydration. While in the Intensive Care Unit, a nasogastric tube was placed to give the patient additional bowel rest. She was aggressively hydrated so that by the end of her two day stay in the Intensive Care Unit, she received a total of 9 liters of fluid. She was also temporarily covered with imipenem until a second CT scan of the abdomen revealed no evidence of necrotizing pancreatitis at which point the antibiotic was discontinued. With the acute pancreatitis, the patient was losing electrolytes and her potassium, magnesium, and phosphate were aggressively replenished. After the aggressive IV hydration at the Intensive Care Unit, the patient started to make good urine output. Before coming back to the Medical Floor from the Intensive Care Unit, the nasogastric tube was removed. The patient was then started on a clear liquid diet, and her diet was advanced as tolerated. The patient did tolerate the food without any additional abdominal pain. She was able to hydrate herself with more than a liter and a half of fluid per day. She was advised strongly to abstain from drinking alcohol, because it became more clear that it has led to her acute pancreatitis. 2. Respiratory alkalosis secondary to hyperventilation: Also on the second day of hospitalization, the patient was starting to be tachypneic with a respiratory rate in the 40s. An arterial blood count was done and she was found to have a pH of 7.44, pCO2 of 28, and pO2 of 48. This gas reflected the fact that she is hyperventilating secondary to pain and possibly alcohol withdrawal. Repeat gas in the Intensive Care Unit shows similar numbers. It was also shown that she was developing a metabolic acidosis to compensate her respiratory alkalosis with a bicarb going down to 16. The Renal Transplant team, which was following throughout, felt the bicarb should not be replenished at the present time. After the pain diminished and the acute withdrawal stage started to pass, patient's respiratory rate did come back down to the low 20s. That is at the point in which she was called out to the medical floor. 3. Hypertension: Patient's blood pressure ran up to the 220s systolically. She could not take anything by mouth, so she was initially put on Lopressor 5 mg IV q6 and hydralazine 10 mg IV q6. This regimen caused her systolic blood pressure to run down to the low 120s. The hydralazine was then discontinued given fear of dropping her systolic blood pressure too low and thus might causing any ischemic events. In talking to the [**Hospital1 20954**] Hospital, it was discovered that her blood pressure normally runs around 140s/90s. In the Surgical Intensive Care Unit, she was placed on clonidine, hydralazine, and metoprolol po to medically manage her hypertension. Again, she remained quite hypertensive up in the 150s-180s systolic ranges. When she returned to the Medical floor, it was verified that with the [**Hospital1 20954**] Hospital, that she takes nifedipine 90 mg po bid and metoprolol 200 mg po bid. She was then restarted on this regimen and her blood pressure came back down to her normal ranges. 4. Renal: End-stage renal disease, status post renal transplant. The patient did take her Prograf by mouth during the whole hospital course, but her prednisone was give in the form of Solu-Medrol. When she started to be able to take po, she then took the Prograf 6 mg po bid and prednisone 10 mg po q day by mouth. The Renal Transplant felt that given her chronic steroid use, she should be put on Bactrim one tablet po q day. It was difficult to get a Prograf trough level on her. Her Prograf was held given that her level did go up to 28.2 at one point. Finally, her Prograf was decreased down to 5 mg po bid, and she left with a trough level of 9.2. She is to followup with her nephrologist for further dosing of this Prograf. 5. Psychiatry: Transitory delirium. When the patient returned to the medical floor from the Intensive Care Unit, she was put on a CIWA scale and given volume as needed. Two days prior to discharge, the patient attempted to sign against medical advice, and even threatened to harm one of the nurses at which point a Code Purple was called, and Psychiatry wrote a note to have restraints and sedatives as needed. The patient did remain on restraints overnight, and remain with a sitter for 24 hours. She could not recall the events of trying to leave. Urinalysis was checked, but no source of infection was found. She did receive some Haldol to calm her down. She then quickly became quite clear, so all restraints, sitter, and sedatives were discontinued. DISCHARGE MEDICATIONS: 1. Prednisone 10 mg po q day. 2. Metoprolol 200 mg po bid. 3. Nifedipine extended release 90 mg po bid. 4. Prograf 6 mg po bid. 5. Protonix 40 mg po q day. 6. Bactrim single strength one tablet po q day. DISCHARGE DIAGNOSES: 1. Acute pancreatitis. 2. Hypertension. 3. End-stage renal disease status post renal transplant. 4. Respiratory alkalosis secondary to hyperventilation. 5. Delirium. 6. Alcohol use. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Home. FOLLOWUP: Patient is to followup with her primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 111**] on [**2161-6-12**], and she is to followup with the Renal [**Hospital 1326**] Clinic over the at the [**Hospital1 20955**] Hospital on [**2161-6-8**]. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) 4270**] MEDQUIST36 D: [**2161-6-6**] 23:01 T: [**2161-6-11**] 10:01 JOB#: [**Job Number 104611**]

[ "276.2", "305.00", "291.81", "577.0", "401.9", "276.3", "V42.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9182, 9770

8977, 9160

8751, 8956

3194, 8728

1459, 1618

170, 187

216, 1292

2627, 3177

1314, 1438

1635, 1769

59,348

145,296

38788

Discharge summary

report

Admission Date: [**2171-3-27**] Discharge Date: [**2171-3-28**] Date of Birth: [**2087-5-24**] Sex: F Service: NEUROLOGY Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2569**] Chief Complaint: Decreased responsiveness Major Surgical or Invasive Procedure: extubation History of Present Illness: Patient is a 83 yo woman (born L handed but trained to use R hand in school) with paroxysmal atrial fibrillation on Coumadin, CAD, hx of TIA, HTN and hyperlipidemia here from [**Hospital **] Hospital after presenting with unresponsiveness. Per husband, she awoke around 5:30 and went to the bathroom. She then called out for her husband who found her sitting in the bathroom leaning against a wall (bathroom too small for her to be laying down flat). She was able to speak to him and answer his questions but she seemed to fade hence 911 was called. She was still answering EMT's questions per husband. At the OSH, head CT revealed large L IPH (per report measures 7X5cm with midline shift). Hence patient paralyzed then intubated. Patient also received FFP for INR of 2.06 and loaded with fosphenytoin 1g. Additionally, 2mg of IV Ativan given prior to transfer but no report of any seizure activity. Given the large hemorrhage, NSURG initially consulted but felt that intervention would be futile. Head CT repeated here showing again large L IPH measuring about 8x5cm seen in 13 slices with midline shift and sub falcine herniation. INR was 1.7 upon arrival and patient received 10mg of Vitamin K in our ED. No further sedatives given. Past Medical History: 1. Paroxysmal AF - on Coumadin 2. CAD s/p MI in [**2147**] and PCI in [**2169**] 3. HTN 4. Hyperlipidemia 5. Stroke in [**5-1**] - presented with speech difficulty, continued to have some word-finding difficulty. 6. Osteoporosis 7. R CEA in [**2168**] 8. s/p Tonsillectomy 9. ?L cataract repair Social History: Lives with husband - DNR/[**Name2 (NI) 835**] per husband and son who is also the HCP, [**Name (NI) **] [**Name (NI) 59454**] [**Name (NI) **] [**Telephone/Fax (1) 86112**]). Remote (> 40 yrs ago) smoking hx and no EtOH. Walks without assistance at baseline - independent in all ADLs. Family History: NC Physical Exam: T 97 BP 120 - irregular HR 119/87 RR 16 O2Sat 100% intubated Gen: Intubated - received paralytics and sedation prior to transfer around 3 hrs previous to exam. HEENT: Hard cervical collar. CV: Irregularly irregular and rapid. Lung: Clear anteriorly. Abd: +BS, soft, nontender Ext: No edema Neurologic examination: Mental status: Intubated and s/p sedation about 3 hrs prior. No response to verbal or noxious stimuli but some spontaneous movements including L hand and both feet but not anti-gravity. Cranial Nerves: L pupil appears post-surgical - both pupils about same size (2.5mm). R pupil reactive but sluggish. No blinking to visual threat and no Doll's eyes. No corneal's but some body movements to nasal tickle. +gag. Face appears symmetric. Motor: Possibly increased tone in both LEs but no lateralization with the tone. Some spontaneous movements on L hand and both feet but not anti-gravity. Does not appear to be myoclonic jerks. Withdraws L arm to noxious stim and triple flexion to noxious stim on both legs. No response on RUE. Sensation: Intact to noxious stim - L arm appears to localize when nail bed pressure applied on R fingers. Reflexes: 2s for biceps, [**Last Name (un) **] and patellar. Toes are upgoing bilaterally. Pertinent Results: [**2171-3-27**] 08:45AM BLOOD WBC-15.7* RBC-4.26 Hgb-12.7 Hct-38.4 MCV-90 MCH-29.8 MCHC-33.1 RDW-13.0 Plt Ct-199 [**2171-3-27**] 08:45AM BLOOD Neuts-81.2* Lymphs-13.6* Monos-4.4 Eos-0.5 Baso-0.3 [**2171-3-27**] 08:45AM BLOOD UreaN-25* Creat-0.8 [**2171-3-27**] 08:45AM BLOOD PT-18.8* PTT-27.6 INR(PT)-1.7* [**2171-3-27**] 08:45AM BLOOD cTropnT-0.08* [**2171-3-27**] 08:45AM BLOOD Phenyto-22.9* CT head: IMPRESSION: Large left frontoparietal intraparenchymal hemorrhage with surrounding edema with sulcal effacement and rightward midline shift, as above. Areas of bifrontal subarachnoid hemorrhage. Findings may relate to patient's anticoagulation, although consider MRI once/if patient is stable to evaluate for underlying mass or vascular malformation. Brief Hospital Course: In summary, patient is a 83 yo born left-handed but trained right handed woman with PAF, HTN, hyperlipidemia and prior stroke on Coumadin and ASA (INR 2.06 on presentation) who fell this morning in the bathroom and found to have large L IPH measuring 8X5cm with midline shift and sub falcine herniation. Unclear if spontaneous or traumatic but likely exacerbated by anticoagulation. No indication or record of elevated BP. On initial exam, patient was intubated and she did receive paralytics and sedation about 3 hrs prior to the exam. R pupil is reactive but sluggish. She has gag and some spontaneous movements in L hand and both feet. She withdraws to nox stim on LUE and triple flexion in both LEs. Nothing on RUE but she appears to localize with the RUE when noxious stim applied to RUE. Reflexes present and both toes going upward. Given the hx and imaging, most likely either spontaneous or traumatic hemorrhage exacerbated by anticoagulation. Discussed with the family of the grim prognosis given ICH score of 4 - expected 30 day mortality nears 90%. At this time family chose to focus on comfort care. Patient was extubated and admitted to TSICU for CMO care. She passed away on [**3-28**] due to herniation. Medications on Admission: 1. Coumadin (2.5 on MF and 5mg other days) 2. ASA 81mg daily 3. Lipitor 80mg daily 4. Sotalol 40mg [**Hospital1 **] 5. Lasix 20 daily 6. KCl 10mEq 7. Lisinopril 2.5mg daily 8. Fosamax 70 weekly Discharge Medications: na Discharge Disposition: Expired Discharge Diagnosis: na Discharge Condition: na Discharge Instructions: na Followup Instructions: na [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2171-3-28**]

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icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

5836, 5845

4330, 5564

322, 334

5891, 5895

3549, 3944

5946, 6090

2254, 2259

5809, 5813

5866, 5870

5590, 5786

5919, 5923

2274, 2565

258, 284

362, 1614

2793, 3530

3954, 4307

2604, 2777

2589, 2589

1636, 1932

1948, 2238

80,805

177,671

36188

Discharge summary

report

Admission Date: [**2189-1-20**] Discharge Date: [**2189-2-16**] Date of Birth: [**2121-4-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Pneumonia Major Surgical or Invasive Procedure: Hemodialysis initiation Paracentesis Thoracentesis History of Present Illness: HPI: Mr. [**Known lastname **] is a 67 y.o. male with cryptogenic cirrhosis and hepatorenal syndrome presented to outside hospital with incrasing abdominal girth. He has also experienced increasing shortness of breath and right flank pain similar to his prior symptoms due to increased ascities. He was [**Hospital 82065**] [**Hospital3 8834**] and had his ascities tapped today, approx 5000 ml (turbid serosanguineous) taken out. His CXR was suspicious for Multifocal PNA. His lab tests there were HCT 30.3, plt 193, wbc 12.1, PT 17, INR 1.7, glu 136, BUN 61, CR 3.8, Na 134, K 5.7, Cl 102, bicarb 17, Ca 9.3, prot 6.1, alb 3.6, bili 1.8, alk phos 353, alt 20, ast 60, amylase 58, lipase 112. His creatine trended upto 4.7 today per discharge summary. He was treated with zosyn 2.25 grams IV q8h, cipro 250 mg daily, midodrine 5 mg tid, prilosec 20 mg daily, carafate 1 gram qid, sodium bicarb 650 mg [**Hospital1 **], lactulose 10 grams [**Hospital1 **], dilaudid 1 mg q3h, vitamin K 5 mg oral. He was afebrile at OSH with stable vital signs per verbal report. On arrival to MICU his vitals were HR 106 BP 112/50 RR 22 96% on 4LNC. Temp was not measured. Patient states that his symptoms improved after the paracentesis. Past Medical History: - cryptogenic cirrhosis; heterozygous for HFE gene mutation and liver biopsy with marked iron deposition; grade I varices s/p banding [**10/2188**]; listed for transplant (currently inactive given his pneumonia) - recent hepatorenal syndrome with rising creatinine - left carotid endarterectomy on [**2189-1-13**] with Dr. [**Last Name (STitle) **] - known left-sided chylothorax per thoracentesis [**12/2188**] - nephrolithiasis s/p surgical stone extraction Social History: Patient denies current alcohol, tobacco or illicit drug use. He reports prior, social alcohol use and infrequent tobacco use. He has no tattoos or piercings and also denies a history of blood transfusions. He is self-employed, working in sales. Family History: Nephew with hemachromatosis, otherwise no family history of liver disease. Father died from prostate CA and mother died from CAD. Two sisters died from CAD. Two brothers alive with cardiac problems. 3 daughters alive and well. Physical Exam: Admission Exam Vitals: HR 106 BP 112/50 RR 22 96% on 4LNC General: pleasant gentleman in no acute distress, following commands HEENT: MMM, EOM-I, sclerae anicteric Neck: supple, JVP 8-9 cm Cor: S1S2, regular tachycardic Lungs: Left base > right base crackles, no wheezing Abd: distended but soft, nontender, hypoactive bowel sounds Ext: 3+ pitting edema bilaterally, feet warm, cellulitis in left lower extremity, right elbow abrasion. Neuro: AOx3, strength 5/5, sensation is intact. No asterixis Skin: no jaundice, multiple skin tears Discharge Exam: Patient deceased Pertinent Results: [**2189-1-20**] 09:35PM PT-28.5* PTT-46.0* INR(PT)-2.9* [**2189-1-20**] 09:35PM PLT COUNT-228 [**2189-1-20**] 09:35PM NEUTS-82* BANDS-3 LYMPHS-7* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2189-1-20**] 09:35PM WBC-17.5* RBC-2.86* HGB-10.2* HCT-31.5* MCV-110* MCH-35.5* MCHC-32.2 RDW-18.8* [**2189-1-20**] 09:35PM ALBUMIN-3.6 CALCIUM-10.2 PHOSPHATE-6.0*# MAGNESIUM-2.3 [**2189-1-20**] 09:35PM ALT(SGPT)-221* AST(SGOT)-1452* LD(LDH)-1412* ALK PHOS-337* TOT BILI-2.5* [**2189-1-20**] 09:35PM estGFR-Using this [**2189-1-20**] 09:35PM GLUCOSE-57* UREA N-72* CREAT-5.2*# SODIUM-138 POTASSIUM-6.9* CHLORIDE-102 TOTAL CO2-19* ANION GAP-24* [**2189-1-22**] 02:07AM BLOOD WBC-14.0* RBC-2.50* Hgb-8.9* Hct-26.8* MCV-107* MCH-35.7* MCHC-33.3 RDW-19.0* Plt Ct-139* [**2189-1-22**] 02:07AM BLOOD PT-33.6* PTT-56.8* INR(PT)-3.5* [**2189-1-22**] 02:07AM BLOOD Plt Smr-LOW Plt Ct-139* [**2189-1-22**] 02:07AM BLOOD Glucose-128* UreaN-82* Creat-5.8* Na-141 K-4.2 Cl-103 HCO3-21* AnGap-21* [**2189-1-20**] 09:35PM BLOOD ALT-221* AST-1452* LD(LDH)-1412* AlkPhos-337* TotBili-2.5* [**2189-1-21**] 06:58AM BLOOD ALT-177* AST-1137* LD(LDH)-827* AlkPhos-230* TotBili-1.9* [**2189-1-22**] 02:07AM BLOOD ALT-107* AST-358* LD(LDH)-270* CK(CPK)-38 AlkPhos-222* TotBili-1.7* [**2189-1-22**] 02:07AM BLOOD Albumin-3.8 Calcium-9.7 Phos-5.6* Mg-2.2 . [**2189-1-21**] 3:41 pm PERITONEAL FLUID GRAM STAIN (Final [**2189-1-21**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): . [**2189-1-21**] 4:29 pm URINE Source: CVS. **FINAL REPORT [**2189-1-22**]** URINE CULTURE (Final [**2189-1-22**]): YEAST. >100,000 ORGANISMS/ML.. . [**2189-1-21**] 4:29 pm URINE Source: CVS. **FINAL REPORT [**2189-1-22**]** Legionella Urinary Antigen (Final [**2189-1-22**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. . [**1-20**] CXR: PORTABLE AP CHEST RADIOGRAPH: New right mid lung perihilar consolidation. Oblique sharp margin seen in the left lower chest is frequently assigned to collapse of left lower lobe. However, no heart border can be identified, the appearance is similar in prior studies, and there is no displacement of the heart. Therefore, we would like to think that this sharp margin probably does not represent lung collapse. . [**1-21**] Liver US FINDINGS: As before, the liver is diffusely nodular and heterogeneous in architecture, in keeping with cirrhosis. There is a large amount of ascites. Incidental note is also made of a left pleural effusion. The spleen measures 10.6 cm in length. There is no intra- or extrahepatic biliary dilatation. The common bile duct measures 4 mm, unchanged. Main portal vein, left portal vein, and right portal vein are all patent, and demonstrate normal waveform and flow direction. Left, middle, and right hepatic veins are patent and demonstrate normal flow direction. IVC is unremarkable. Hepatic arteries are patent and demonstrate normal waveforms. Splenic vein is patent. IMPRESSION: 1. Patent and normal-appearing hepatic vessels. 2. Cirrhosis with large amount of ascites. 3. Left pleural effusion . [**1-21**] Renal US: FINDINGS: Comparison made to [**2189-1-8**]. Right kidney measures 11.3 cm, left kidney measures 10.5 cm. Cyst in the upper pole of the left kidney measuring 2.1 x 1.5 x 1.4 cm is not significantly changed. There is no solid mass, stone, or hydronephrosis in either kidney. There is a large amount of ascites throughout the abdomen. Color Doppler evaluation of both kidneys shows normal color flow and arterial waveforms. IMPRESSION: 1. No hydronephrosis. No evidence of renal artery stenosis. 2. Large volume ascites. . [**1-22**] CXR: In comparison with study of [**1-20**], the moderate left pleural effusion persists. Right upper lobe consolidation is similar in appearance to the previous study. Left basilar atelectasis is unchanged. . [**1-26**] CT Abd, Chest: 1. Multiple tiny hepatic non-enhancing hypodensities are consistent with cirrhosis although small hepatic abscesses can not be excluded (in the absence of prior studies to suggest stability). 2. Right upper lobe opacification with consolidation worse posteriorly suggests pneumonitis from aspiration or infection. 3. Persistent multifocal ground-glass opacification in the right lower lobe; the etiology can be infectious or inflammatory. 4. Large left pleural effusion with associated relaxation atelectasis. 5. Persistent significant ascites, cirrhosis. 6. Engorgement of mesenteric vessels. . [**1-30**] CXR: Overall unchanged compared to prior study, with moderate-sized left pleural effusion associated with left basilar atelectasis. Brief Hospital Course: 67 y.o. male with cryptogenic cirrhosis, likely due to alpha-1-antitrypsin deficiency (per biopsy) and hemochromatosis, complicated by hepatorenal syndrome was admitted to OSH with PNA and transfered here for further evaluation. # Fungemia (ICU Course): The patient was transferred to the ICU for sepsis and hemodynamic instability. He was intubated and ventilated with Central access obtained. He was found to be fungemic. Treatment was initated, however the family was consulted and directed our team to withdraw care. # Pneumonia: Transfered from OSH for CXR with multifocal PNA. HAP given recent admission. Hemodynamically stable on arrival, sating in mid 90s on 4 L NC. CXR with R upper/middle lobe infiltrate. By day of transfer patient had O2 sat 99% on 2L, significantly better than on admission. He has CP with coughing localized to R ribs, Had significant fall at OSH when getting Out of bed and landed on right side. It is possible that the CXR finding reflect a contusion from fall and not pneumonia. Sputum culture with yeast. urine legionella negative. Treated with vanc, zosyn, and fluconazole for two weeks. The pt's symptoms resolved, as did the consolidation on CXR. However, Mr. [**Known lastname **] had a persistant, left-sided pleural effusion. Due to persistent episodes of SOB, pt. underwent thoracentesis w/ 1.8L removal. Fluid showed chylous transudative materarial, consistent w/ hepatic hydrothorax. # L. Effusion. Pt. w/o overt signs of infection, but continued to have episodes or respiratory distress including dyspnea, felt to be [**3-9**] hepatic hydrothorax. As pt. continued to experience respiratory distress episodes of tachypnea, and SOB, he underwent a therpaeutic and diagnostic thoracentesis on [**2189-2-8**]. Fluid was transudative, w/ 58 WBCs, 7 Polys, 23 Meso, 43 Macro and > 14K RBCs, chylous, cytology was pending at time of discharge. Pt. developed small L PNTx, persistent on CXR on post thoracentesis day 1, on discharge this had resolved. Patient will require a repeat CT of chest in 4wks to assess for resolution of RUL PNA and L effusion. # Tachycardia. Pt had persistently elevated HR in 100-110 during floor stay. He was ruled out for PE w/ CTA, which showed slightly worsened RUL opacification (see below). There was no chest pain, no changes in ECG. He completed ABx course as above and there were no signs of infection, w/ [**Female First Name (un) 576**]/para results negative for infection after initial PNA was treated. Pain was adequately controlled. Despite tachycardia, patient was he denied palpitations. # Respiratory distress episodes. Pt. w/ dyspnea, tachypnea, wheezing and tachycardia on occasions and during HD. These episodes ceased temporarily after thoracentesis on [**2189-2-8**], however recurred by [**2189-2-10**]. They were felt to be related to the RUL lesion, L effusion and massive ascites. Pt. had emphysematous changes on CXRs. Due to continued SOB, patient underwent another therapeutic paracentesis on [**2189-2-11**] with improvement in symptoms. Mr. [**Known lastname **] was started on ipratropium nebulizers while treated for PNA and Xopenex was added on [**2189-2-7**]. Echo w/ bubble study was performed to assess for intrapulmonary shunting and reassessment of pulmonary hypertension as possible causes of dyspnea episodes. # Hepatorenal syndrome: Patient currently on both the liver and kidney transplant lists. Serum Creatinine on recent discharge from [**Hospital1 18**] was 3.8 with BUN of 60. He was treated with midodrine as outpatient. On admission Cr was over 5, it was unclear if this was purely HRS or if this represented intrinsic kidney insult. UOP steadily declined during admission and Cr peaked at 6.7. Renal US [**1-21**] was normal. Pt did not respond to fluid challenge and HRS was diagnosed. Pt was treated for HRS with midodrine 10mg tid, octreotide (200mg Q8h), and albumin until dialysis. A R tunneled line was placed on [**1-23**] followed by HD as transition to transplant. BPs improved, thus midodrine and ocreotide were discontinued. Mr. [**Known lastname **] had two episodes of hypotension to SBP in 70s during dialysis and was thus restarted on Midodrine in AM prior to dialisis. The first, on [**1-26**], was associated with dyspnea and diaphoresis. His infectious work-up was negative. He received a diagnostic and therapeutic paracenteses that afternoon, while led to complete relief of his symptoms and increase in his BP. On [**1-31**], the pt had hypotension to SBP 70s while attempting to take fluid off - he was given albumin and his BP recovered. Pt. continued to receive midodrine and albumin prior to each dialysis session. His MELD ranged 27-30 through most of his hospitalization. SBPs were in 90-110 range. Pt. was arranged for HD on T/T/Saturday as OP (please see discharge plan). For hyperphosphatemia patient was started on Ca Acetate. In addition he was started on nephrocaps. Pt. is on SBP prophylaxis. # Abdominal Pain/Cirrhosis: Secondary to cryptogenic/alpha-1-antitrypsin/hemochromatosis cirrhosis. Pt was accepted to liver and kidney transplant lists. Paracentesis [**1-27**] showed no SBP; 7.5L taken off. Para [**2-4**] no SBP; 5.5L taken off, while paracentesis on [**2-11**] was performed w/ 5L removal. These procedure also led to resolution of the pt's abdominal pain, indicating that the distension was his trigger. Pt's cirrhosis confirmed on CT and continued to have elevated LFTs throughout his stay. His Tbili ranged from 1.5 to 3.0; his INR ranged from 1.9 to 3.7. PPD was negative and HBsAg, HBcAb were also negative. HBsAb intermediate. HCV neg. His MELD ranged 27-30 through most of his hospitalization. Pt. is to follow up with Liver clinic within 1wk of discharge from [**Hospital1 18**]. # Anemia. Macrocytic. On admission, Hct decreased from 31.5 -> 23.6. Likely a dilutional effect in addition to rectal bleeding. The pt has confirmed internal hemorrhoids, small AV malformations [**10-13**] on c-scope, and had several episodes of BRBPR prior to admission and early in the admission. His Hct stayed in the 25-30% throughout his admission. He did not require transfusions. The stool guaiacs during the second half of his stay were negative for blood. Folate, B12 were nl. TSH was mildly high, 6.6 and free T4 was marginally low 0.91 (lower limit of nl 0.93). This decrease was felt not significant enough to account for anemia. # Nurtition. Patient w/ poor nutritional status and irregular intake of caloric requirement. Albumin was 3.1 on admission. Due to this, he required placement of post pyloric tube placed on [**2189-2-9**] with required tube feeds, Nutren Renal Full strength at 40 ml/hr, w/ 50 ml water flushes q4h. # Peripheral arterial disease: s/p recent left carotid endarterectomy [**2189-1-13**]; no active issues; outpatient follow-up. Medications on Admission: Medications on Transfer: Zosyn 2.25 grams IV q8h Ciprofloxacin 250 mg daily Midodrine 5 mg tid Prilosec 20 mg daily Carafate 1 gram qid Sodium bicarb 650 mg [**Hospital1 **] Lactulose 10 grams [**Hospital1 **] Dilaudid 1 mg q3h Vitamin K 5 mg oral. . Allergies/Adverse Reactions: NKDA 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. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO 7AM ON DAYS OF DIALYSIS (). Disp:*30 Tablet(s)* Refills:*2* 3. Lactulose 10 gram/15 mL Syrup Sig: 15-45 MLs PO TID (3 times a day): Titrate to [**4-8**] bowel movements daily. Disp:*5 bottles* Refills:*10* 4. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO QFriday. Disp:*12 Tablet(s)* Refills:*2* 5. 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. 6. Albumin, Human 25 % 25 % Parenteral Solution Sig: 12.5 mg Intravenous Q Dialisis. 7. Epogen 4,000 unit/mL Solution Sig: One (1) ml Injection Q Dialisis. 8. Outpatient Lab Work CBC with differential, Chem 10, AST, ALT, Total Bilirubin, Albumin, PT/PTT/INR, to be drawn at EOD or at discretion of rehabilitation physician. 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for itchyness. 12. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: - Cirrhosis, likely from alpha-1-antitrypsin deficiency and hemochromatosis - Hepatorenal syndrome - L-sided pleural effusion - Hospital-acquired pneumonia . Secondary diagnoses: - peripheral vascular disease Discharge Condition: Deceased [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

[ [ [] ] ]

[ "34.91", "99.04", "54.91", "38.93", "96.71", "39.95", "96.04", "38.95", "96.6" ]

icd9pcs

[ [ [] ] ]

17011, 17020

8365, 15239

332, 385

17291, 17438

3250, 4774

2412, 2641

15574, 16988

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3213, 3231

283, 294

413, 1650

4854, 8342

15290, 15551

1672, 2133

2149, 2396

4806, 4821

51,657

195,624

49392

Discharge summary

report

Admission Date: [**2115-3-3**] Discharge Date: [**2115-3-14**] Date of Birth: [**2050-6-21**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2115-3-4**] - left heart catheterization [**2115-3-6**] - Placement of intra-aortic balloon pump [**2115-3-7**] Coronary artery bypass grafting x3,(LIMA-LAD,SVG-OM,SVG-PDA),Left atrial appendage resection, Mitral valve repair(26mm [**Doctor Last Name **] annuloplasty ring) History of Present Illness: This 64 year old male who has not seen a physician for over 5 years presented with chest pain that started 2 days prior ( [**7-2**]) , lasted for "several hours" and resolved spontaneously. This was associated with mild dyspnea. He denies fevers, chills, nausea, vomiting, diaphoresis, PND, orthopnea, palpitations, syncope, presyncope, weight change, lower extremity swelling. His symptoms seemed to be worsened with exertion and relieved by rest. ECG in the ED was consistent with recent an inferolateral STEMI with q waves and prominent R waves in V1-3 and was admitted. A cardiac cath found 3 vessel disease (90% LAD, LCx was 100% occluded at its origin, RCA with long 70% mid-vessel stenosis). He was also found to have moderate-to-severe MR noted on echo and confirmed with his RHC tracings and ventriculogram. A cardiac surgery consult was requested for evaluation for CABG and possibly MV repair. Past Medical History: Paroxysmal atrial fibrillation Left atrium thrombus s/p tonsillectomy Social History: [**Hospital 8735**] medical assistant. Lives alone. No children. Not married. - Tobacco history: 50 pack year history, stopped 2 weeks ago. - ETOH: Sparing social consumption. - Illicit drugs: Denies. Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Mother: Denies. - Father: Denies. - Brother who passed from a ruptured AAA in his 60s Physical Exam: VS: 98.5, 101/68, 78, 14, 99%RA. GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, 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. Faint bibasilar crackles (L>R). No egophony appreciated. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 1+ bilateral pitting edema SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: AAOx3, CNII-XII intact, 5/5 strength in all extremities. 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: . - ECHO ([**2115-3-4**]) Conclusions The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The left ventricle is not well seen. The left ventricular cavity size is normal.There is mild regional left ventricular systolic dysfunction with mid to distal inferior and inferolateral hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION; Regional left ventricular systolic dysfunction consistent with inferior infarction/ischemia. Moderate to severe mitral regurgitation which is likely due to leaflet tethering. Severe pulmonary artery systolic hypertension. - Chest radiograph ([**2115-3-3**]) COMPARISON: None. CLINICAL HISTORY: Chest pain and shortness of breath, assess for pneumonia. FINDINGS: Portable AP upright chest radiograph was obtained. Consolidation is noted at the left lung base with associated effusion concerning for pneumonia. Right lung is clear. Cardiomediastinal silhouette is normal. Bony structures intact. IMPRESSION: Left lower lung pneumonia with associated effusion. - Carotid Series ([**2115-3-5**]) Study: Carotid Series Complete Reason: 64 year old man pre/op CABG. Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right there is no plaque seen in the ICA . On the left there is mild heterogeneous plaque seen in the ICA. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 72/25, 68/28, 63/27, cm/sec. CCA peak systolic velocity is 71 cm/sec. ECA peak systolic velocity is 81 cm/sec. The ICA/CCA ratio is 1.0. These findings are consistent with <40% stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 79/26, 61/20, 69/34, cm/sec. CCA peak systolic velocity is 84 cm/sec. ECA peak systolic velocity is 95 cm/sec. The ICA/CCA ratio is .94 . These findings are consistent with no stenosis. There is antegrade right vertebral artery flow. There is antegrade left vertebral artery flow. Impression: Right ICA no stenosis. Left ICA <40% stenosis. . [**2115-3-12**] 04:45AM BLOOD WBC-7.6 RBC-3.26* Hgb-10.2* Hct-30.8* MCV-95 MCH-31.4 MCHC-33.2 RDW-14.4 Plt Ct-139* [**2115-3-11**] 03:27AM BLOOD WBC-9.7 RBC-3.67* Hgb-11.3* Hct-33.8*# MCV-92 MCH-30.9 MCHC-33.5 RDW-14.4 Plt Ct-166 [**2115-3-13**] 05:15AM BLOOD PT-16.5* INR(PT)-1.6* [**2115-3-12**] 04:45AM BLOOD PT-14.3* PTT-27.2 INR(PT)-1.3* [**2115-3-11**] 03:27AM BLOOD PT-13.0* PTT-21.9* INR(PT)-1.2* [**2115-3-10**] 04:35AM BLOOD PT-13.7* PTT-23.9* INR(PT)-1.3* [**2115-3-9**] 02:02AM BLOOD PT-16.7* INR(PT)-1.6* [**2115-3-8**] 12:11PM BLOOD PT-17.8* INR(PT)-1.7* [**2115-3-8**] 01:56AM BLOOD PT-20.8* PTT-31.6 INR(PT)-2.0* [**2115-3-7**] 03:08PM BLOOD PT-20.4* PTT-43.9* INR(PT)-1.9* [**2115-3-12**] 04:45AM BLOOD Glucose-145* UreaN-14 Creat-0.9 Na-135 K-3.9 Cl-97 HCO3-31 AnGap-11 [**2115-3-11**] 03:27AM BLOOD Glucose-120* UreaN-14 Creat-0.8 Na-135 K-3.8 Cl-97 HCO3-31 AnGap-11 [**2115-3-10**] 04:35AM BLOOD Glucose-113* UreaN-17 Creat-0.8 Na-134 K-3.8 Cl-96 HCO3-31 AnGap-11 [**2115-3-3**] 06:44PM BLOOD WBC-10.4 RBC-3.36* Hgb-10.9* Hct-30.7* MCV-91 MCH-32.5* MCHC-35.6* RDW-12.8 Plt Ct-257 [**2115-3-14**] 06:25AM BLOOD PT-21.4* INR(PT)-2.0* [**2115-3-13**] 05:15AM BLOOD PT-16.5* INR(PT)-1.6* [**2115-3-12**] 04:45AM BLOOD PT-14.3* PTT-27.2 INR(PT)-1.3* [**2115-3-11**] 03:27AM BLOOD PT-13.0* PTT-21.9* INR(PT)-1.2* [**2115-3-14**] 06:25AM BLOOD Na-136 K-4.6 Cl-100 [**2115-3-7**] 03:08PM BLOOD UreaN-16 Creat-0.8 Na-137 K-4.2 Cl-105 HCO3-25 AnGap-11 Brief Hospital Course: Mr. [**Known lastname 55334**] was admitted to the [**Hospital1 18**] on [**2115-3-3**] for management of his chest pain and myocardial infarction. Heparin and Plavix were started. An echocardiogram showed an EF of 45-50% with moderate to severe mitral regurgitation, severe pulmonary artery systolic hypertension and inferior and inferiorlateral hypokinesis. A cardiac catheterization was performed which showed severe three vessel disease. Given the severity of his disease, the cardiac surgical service was consulted. Mr. [**Known lastname 55334**] was worked-up in the usual preoperative manner. A dental consult was obtained for oral clearance for surgery. Plavix was allowed to washout. After obtaining a panorex film, multiple extractions were recommended prior to surgery. On [**2115-3-6**], Mr. [**Known lastname 55334**] developed chest pain. He was returned to the cardiac catheterization lab where an intara-aortic balloon pump was placed. His pain resolved. On [**2115-3-7**] he was taken to the Operating Room where he underwent coronary artery bypass grafting to three vessels, a mitral valve repair and resection of his left atrial appendage. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. On postoperative day one, he awoke neurologically intact and was extubated. His balloon pump was weaned and removed. Pressors and inotropes were slowly weaned off. Beta blocker was initiated and the patient was gently diuresed toward his preoperative weight. The patient was transferred to the telemetry floor for further recovery. He had a brief episode of post-op atrial fibrillation. He converted to sinus rhythm with titration of beta blocker. Anti-coagulation was started with Coumadin for left atrial thrombus noted on echo. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the Physical Therapy service for assistance with strength and mobility. By the time of discharge on POD 6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital **] rehab in [**Location (un) 583**] on [**3-14**] in good condition with appropriate follow up instructions. Medications on Admission: None. No OTC medications. Discharge Medications: 1. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-24**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed for rhinitis. 2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 10 days. 13. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day: INR goal [**1-25**]. Discharge Disposition: Extended Care Facility: [**Hospital3 8221**] - [**Location (un) 583**] Discharge Diagnosis: Coronary artery disease Mitral valve regurgitaion Paroxysmal atrial fibrillation Left atrium thrombus s/p tonsillectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments [**Hospital **] Clinic in [**Last Name (un) 6752**] 2A ([**Telephone/Fax (1) 170**]) on [**2115-3-19**] at 10:45am Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2115-4-4**] at 2:15pm Cardiologist: Dr. [**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 437**] ([**Telephone/Fax (1) 62**]) on [**2115-4-3**] at 9:00 Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16642**] ([**Telephone/Fax (1) 34194**]) in [**3-28**] 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** Labs: PT/INR for Coumadin ?????? indication - atrial thrombus( for three months) Goal INR [**1-25**] First draw [**2115-3-14**] **please arrange for coumadin follow-up prior to discharge from rehab** Completed by:[**2115-3-14**]

[ "410.21", "276.1", "416.8", "428.0", "424.0", "429.79", "414.01", "427.31", "V58.61", "997.1", "523.40", "423.1", "458.29", "305.1", "278.00", "428.43", "486" ]

icd9cm

[ [ [] ] ]

[ "37.23", "36.12", "88.56", "36.15", "39.61", "88.53", "35.12", "37.12", "37.36", "37.61" ]

icd9pcs

[ [ [] ] ]

10738, 10811

7028, 9298

320, 598

10975, 11197

3018, 7005

12086, 13107

1863, 2069

9376, 10715

10832, 10954

9324, 9351

11221, 12063

2084, 2998

270, 282

626, 1534

1556, 1628

1644, 1847

18,839

136,227

43925

Discharge summary

report

Admission Date: [**2193-2-7**] Discharge Date: [**2193-2-18**] Service: MEDICINE Allergies: Quinine Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is an 85 yo M w/PMHx sx for diastolic CHF, s/p MVR, CAD, HTN, DM2 who presents with one month of gradually worsening fatigue and dyspnea, with weight gain of approximately 10 lbs at home. Per daughter, patient has been gradually becoming more fatigued. He has developed increased lower extremity swelling. He has stable 2 pillow orthopnea. He has been compliant with his medications, including his torsemide, and has not been eating salty foods, and has in fact been taking very little po in the past several days. His oxygen requirement has increased from 2L NC at night only to 80% of the time requiring supplemental oxygen. He has had a labile INR as well, yesterday measured at 6.3, and had epistaxis, ecchymoses and occasional hematuria. His daughter denies [**Name2 (NI) **], coffee grounds emesis, or BRBPR. He has never had a colonoscopy/endoscopy. She denies chest pain, fevers, chills, nausea, vomiting, head trauma, falls, increased confusion, cough, dysuria. Patient has been living at home with his wife, who helps with his medications. . In the ED patient received 5 mg vitamin K and 2u FFP to reverse his coagulopathy. He was noted to be guaiac positive as well. He was started on a lasix gtt for volume overload. Past Medical History: Congestive heart failure, systolic and diastolic with EF 50% S/p MVR on coumadin Atrial fibrillation DMII CRI 3.0 Anemia Aortic stenosis s/p pacemaker CVA BPH Insomnia Social History: Retired [**Name2 (NI) 595**] literature professor. Lives with wife in [**Name (NI) 583**], quit tobacco 50 years ago. 20 pack year. No ETOH, IVDA. Family History: n/c Physical Exam: VS: Temp 96.6 BP 98/43 HR 57 RR 22 O2sat 99% 2L Gen: chronically ill appearing HEENT: JVD to tragus. No carotid bruits. MMM. No oral ulcers. Conjunctiva pale. Hrt: [**2-6**] holosystolic murmur at apex. S1 click. No rubs or gallops. Lungs: Rales 1/3 up both lung fields. Minimal expiratory wheezing. Abd: Soft, nontender, nondistended. No organomegaly. Guaiac positive brown stool per ED. Ext: Cool. 1+ pulses at radial, DP. 3+ pitting edema to sacrum. Neuro: Extremely hard of hearing. PERRL. Moves all extremities. Responds to daughter's voice. Pertinent Results: Trop-T: 0.24 116 81 131 / 141 ------------- 4.0 22 3.1 \ . CK: 182 --> 159 --> 150 --> 137 MB: 17 --> 14 --> 13 --> 11 Trop-T: 0.24 --> 0.25 --> 0.27 --> 0.26 . Ca: 8.6 Mg: 2.3 P: 5.4 86 4.9 \ 9.1 D / 150 -------- 25.8 D N:85.8 Band:0 L:10.7 M:2.5 E:1.0 Bas:0.1 . Creatinine : 3.1 --> 3.9 . BUN: 131 --> 169 . Sodium: 116 --> 136 . CXR: 1. Stable massive cardiomegaly. 2. Mild improvement in the pulmonary vascular congestion although not totally resolved. 3. Loculated chronic right-sided pleural effusion. . ECHO: The left atrium is markedly dilated. The right atrium is markedly dilated. The right atrial pressure is indeterminate. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is moderately depressed (LVEF= 35-40 %) with inferior/infero-septal, and inferoapical hypokinesis/akinesis. The remaining segments appear hypokinetic. There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild to moderate ([**1-2**]+) aortic regurgitation is seen. A bileaflet mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Torn mitral chordae are present. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2192-4-3**], the overall LVEF is slightly lower (overerstimated on the prior study). The degreee of pulmonary hypertension detected has increased. Brief Hospital Course: A/P: Mr. [**Known lastname **] is an 85 yo M w/PMHx sx for severe diastolic CHF, CAD, DM2, CVA who presents with a GIB with associated SOB and fatigue, also with evidence of NSTEMI with elevation in cardiac enzymes likely in setting of demand. . #. Acute on chronic systolic and diastolic CHF: The patient was started on a Lasix drip in the emergency department for both evidence of volume overload on exam (crackles and sacral/peripheral edema) and pulmonary edema on CXR. He also had a Ck and troponin elevation consistent with either NSTEMI or more likely demand ischemia secondary to volume overload and heart failure. An echocardiogram showed multiple wall motion abnormalities and overall depressed EF at 35-40% with moderate pulmonary artery hypertension. He was transferred out of the ICU and transferred to the cardiology service. His Lasix drip was continued and uptitrated to 20mg/hour in order to attain approx 1L negative daily. He did have improvement of edema and oxygen saturation, and appeared more comfortable with diuresis, though it was difficult to ascertain improvement in dyspnea as pt was often sleepy or confused. His diuresis was limited by rising creatinine and uremia and his Lasix drip was discontinued. His carvedilol dose was decreased to 12.5mg po bid to allow more room in blood pressure for diuresis. He was continued on aspirin, atorvastatin, isosrbide mononitrate and ezetimibe. Due to continued elevated creatinine/BUN, his home torsemide dose was not restarted on discharge, to be restarted based on labs [**2-20**] and clinical status, may be restarted. Pt was also provided with a prescription for concentrated morphine in the event of shortness of breath not relieved with Lasix. . #. Acute blood loss anemia: Upon admission patient had self-limited [**Month/Year (2) **] thought secondary to a supratherapeutic INR. NG lavage was not done secondary to concern for elevated INR for which he received FFP. The patient had no further episodes of GI bleeding and hematocrit remained stable throughout his hospital course. He was started on a heparin drip once hematocrit stablized with bridge to Coumadin for mechanical mitral valve. His INR was held for several days after supratherapeutic value of 7 and given 1.25mg po vitamin K and 2 units of FFP with decline to 2.4. His coumadin was then resumed at a lower dose of 2.5mg po daily, to be checked on [**2-20**]. . #. Hyponatremia. Upon admission, patient's sodium was 116 and did partially correct with above medical managment and diuresis to 136 without the need for other intervention. . #. Acute on Chronic Renal Failure: The patient was continued on calcitriol and started on sevelemer for increased phosporus. His BUN remained elevated throughout admission, likely high enough to be causing symptoms of confusion from uremia, but after discussion with the family it was decided to direct care more towards comfort, and in particular, relief of dyspnea so diuresis was pursued in spite of this. Creatinine increased to 3.9 and Lasix drip was discontinued. His home dose of torsemide should be restarted as above. . #. Goals of care: As previously mentioned, the patient's family and health care proxy had already decided against dialysis and DNR/DNI order. They also asked to speak with the palliative care team regarding hospice options but ultimately it was decided not to pursue comfort care at this time, though this might occur on the next hospitalization if he does not respond to diuresis. Medications on Admission: Potassium 20 mEq every day Lipitor 40 mg daily Prozac 10 mg daily Warfarin as directed Aspirin 325 mg daily Imdur 60 mg daily Torsemide 100 or 150 mg depending on weight Flomax daily Calcitriol 0.25 mcg daily Coreg 25 mg twice daily Clonidine 0.3 mg twice a day Epogen per H and H levels Zetia 10 mg daily Ferrous sulfate twice a day, Amaryl 0.5 mg daily Hydralazine 75 mg four times a day. Discharge Medications: 1. Please dispense 1 (one) hospital bed 2. Calcitriol 0.25 mcg Capsule [**Month/Year (2) **]: One (1) Capsule PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID (2 times a day). 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr [**Month/Year (2) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Atorvastatin 80 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 7. Fluoxetine 10 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO DAILY (Daily). 8. Ezetimibe 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 9. Amaryl 1 mg Tablet [**Month/Year (2) **]: 0.5 mg PO once a day. 10. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable PO DAILY (Daily). 11. Lactulose 10 gram/15 mL Syrup [**Month/Year (2) **]: Thirty (30) ML PO TID (3 times a day). 12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Month/Year (2) **]: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime): hold for sbp <100. 13. Carvedilol 12.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Year (2) **]: [**1-2**] Drops Ophthalmic PRN (as needed). Disp:*qs * Refills:*2* 15. Torsemide 100 mg Tablet [**Month/Day (2) **]: 1-1.5 Tablets PO once a day: To be started when instructed by Dr. [**First Name (STitle) 437**]. Disp:*30 Tablet(s)* Refills:*2* 16. Morphine Concentrate 20 mg/mL Solution [**First Name (STitle) **]: 0.5-1 mg PO every four (4) hours as needed for shortness of breath or wheezing. Disp:*10 mL* Refills:*0* 17. Please provide one wound mattress 18. Home o2 Home o2 at 2L per minute 19. Warfarin 2.5 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO once a day: take as directed by your [**Hospital 197**] clinic. 20. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day: for acid reflux. Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 21. Calcium Acetate 667 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a day: Take crushed with meals. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: Primary: 1.) Acute on chronic systolic and diastolic congestive heart failure (EF 35-40%) 2.) Acute on chronic renal failure Secondary: 3.) Acute blood loss anemia 4.) Diabetes mellitus Discharge Condition: afebrile, displaying normal vital signs. Discharge Instructions: You were admitted to the hospital for fatigue and shortness of breath. You were found to have excess fluid in your lungs as a result of your heart failure. You were treated with a Lasix drip to help relieve your symptoms. . You should take all medications as prescribed or as instructed by your physician. . If you develop worsening shortness of breath, chest pain, abdominal pain, lightheadedness or if your feel worse in any way call your doctor. Followup Instructions: You have a follow-up appointment with Dr. [**First Name (STitle) 437**] on [**4-1**]. Call his office to set up an earlier appointment. . Follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as needed. . You have the following previously scheduled follow-up appointments: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2193-4-1**] 1:30 Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2193-4-1**] 2:00

[ "276.1", "V12.54", "403.90", "E934.2", "285.1", "600.00", "427.31", "428.43", "585.9", "790.92", "410.71", "428.0", "V45.01", "V43.3", "578.9", "V58.61", "584.9", "250.00" ]

icd9cm

[ [ [] ] ]

[ "99.07" ]

icd9pcs

[ [ [] ] ]

10846, 10921

4544, 8038

230, 237

11151, 11194

2480, 4521

11691, 12288

1893, 1898

8479, 10823

10942, 11130

8064, 8456

11218, 11668

1913, 2461

183, 192

265, 1521

1543, 1712

1728, 1877

61,667

125,899

27116

Discharge summary

report

Admission Date: [**2158-8-30**] Discharge Date: [**2158-9-17**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 2080**] Chief Complaint: Altered mental status and melena Major Surgical or Invasive Procedure: esophageogastroduodenoscopy [**2158-9-1**], esophageogastroduodenoscopy [**2158-9-5**], colonoscopy [**2158-9-11**] History of Present Illness: 88 year old male with recent gastrointestinal bleeds attributed to gastric ulcer, status post mechanical aortic valve replacement on Coumadin, chronic kidney disease, history of NSTEMI in [**7-11**], with altered mental status and a hematocrit drop from his baseline of 30 to 20 after being transferred to a new long term care facility. He was found to be dizzy, confused, and weak to the point where he could not stand up. He is not demented at baseline per the family, but today he was exhibiting extensive mental slowing. His blood pressure was 100/60 with a heart rate of 60 and his Hgb=6.7, HCT=20.9. Prior Hgb [**8-8**] was 10.7. He used to get his care at [**Hospital3 **] and presented [**7-11**] with altered mental status and anemia in the setting of a GI bleed. He was also seen [**6-10**] for anemia in setting of supratherapeutic INR. In the ED, initial VS: 97.5, 93, 123/67, 99% 3L. EKG shows right bundle branch block and left ventricular hypertrophy which was unchanged. His stools were guaiac positive and he has a sacral decubitus ulcer. His Coumadin was not reversed and he was ordered 1 unit of blood, but could not receive it because he has antibodies that need to be screened for. He received PO Protonix. On the floor, the patient had active melena(about 7 pm) which given his anticoagulation status and difficulty with blood products was felt to require intensive care monitoring. He was transferred to the MICU. Past Medical History: # Listeria Endocarditis s/p AVR, suppressive amoxicillin stopped due to hemolytic anemia, previously on prednisone [**11-9**] # hx recent GI bleeds: colonoscopy [**9-9**]: noted normal colon, hemorrhoids # Aortic mechanical valve, last INR 2.0 # GERD: EGD [**7-11**] with non-bleeding ulcers in esophagus and stomach # Anemia from GI bleed of gastric ulcer vs. hemolytic anemia from AVR # CKD 1.6-2.0 # CAD s/p NSTEMI # h/o likely diastolic CHF on diuretics # Hyperlipidemia # Hypertension # Depression since death of his brother # Prostate ca- s/p radiation # Bladder/bowel incontinence # Right lateral malleolus stage 1 pressure ulcer Social History: He was born in NY and has been a book binder all of his life. he moved to [**Location (un) 86**] to be closer to his son. [**Name (NI) **] does not smoke or drink currently. He was just transferred to [**Hospital 100**] rehab, but also lived at the [**Hospital3 **]. His brother recently died. He requires a significant degree of assistance in all his ADLs and IADLs. Family History: Non contributory. Physical Exam: EXAM ON ADMISSION: Vitals - T: 98.1 BP: 150/68 HR: 76 RR: 20 02 sat: 97% on 3L GENERAL: Pleasant, pale, elderly male, confused at times HEENT: MMM, conjunctival pallor, NCAT, PERRLA/EOMI, neck supple CARDIAC: RRR, mechanical click noted, systolic murmur at LUSB LUNG: L crackles ABDOMEN: soft, NT/ND, BS+ EXT: No c/c/e NEURO: He is oriented to person, place, and time, but does not know why he is in the hospital and clearly has mental slowing DERM: Grade [**2-3**] sacral decubitus and heel ulcers Pertinent Results: Admission labs: WBC-3.7* RBC-2.16*# Hgb-7.1*# Hct-22.3*# MCV-104*# MCH-33.0*# MCHC-31.8 RDW-18.2* Plt Ct-223 Neuts-60.6 Lymphs-26.5 Monos-8.6 Eos-3.4 Baso-0.9 PT-21.8* PTT-34.3 INR(PT)-2.0* Glucose-92 UreaN-30* Creat-1.5* Na-144 K-3.5 Cl-108 HCO3-27 AnGap-13 ALT-5 AST-14 LD(LDH)-227 CK(CPK)-21* AlkPhos-55 TotBili-0.8 Calcium-8.7 Phos-4.0 Mg-1.8 Hapto-<20* . Cardiac enzymes with Trop increasing to 0.51. CK-MB stable. . H. pylori -positive . MRSA - positive . Blood smear without large amount of hemolysis . EKG: sinus with atrial ectopic foci, vs. ectopic atrial rhythm, RBBB, 1st (present on EKG at [**Hospital 100**] Rehab), 1st degree AV block, no signs acute ischemia . EGD [**2158-9-1**]: Small hiatal hernia ,Normal stomach. No fresh or old blood seen. A single 8mm non-bleeding polyp was found in the second part of the duodenum. Otherwise normal EGD to third part of the duodenum CXR [**2158-9-2**]: no acute infiltrate, possible [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**] and mild vascular congestion, costophrenic angles clears . ECHO [**2158-9-4**]: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with overall low normal left ventricular systolic function. LVEF 50-55%. Mechanical AVR with normal gradients. Moderate mitral regurgitation. Moderate tricuspid regurgitation. (Note: LVEF 55% in [**6-/2158**] per report) . EGD [**2158-9-5**]: Small hiatal hernia; Normal stomach. No fresh or old blood seen. A single 8mm non-bleeding polyp was found in the second part of the duodenum. Otherwise normal EGD to third part of the duodenum . Colonscopy [**2158-9-11**]: Stool was found in the cecum, ascending colon, transverse colon, splenic flexure and descending colon. Extensive washing was done, but due to the semi-solid nature of the stool the scope clogged multiple times. There was limited visualization of the colon- especially the right colon. Small polyps and flat lesions could have easily been missed. No large lesion noted Brief Hospital Course: 88 year old male with mechanical aortic valve on warfarin and hx of gastric ulcer who presented with melena and altered mental status. . # GI bleed: Patient was admitted to the floor on [**2158-8-30**] but transferred to the MICU due to melena and low blood pressure. Patient received 2 units of packed red blood cells and 2 units of fresh frozen plasma. Hematocrit bumped from 22 to 28. Patient was started on proton pump inhibitor drip and transferred to floor after stabilization of hematocrit and vital signs. EGD on [**2158-9-1**] was negative for source of bleeding. Patient was started on heparin drip and developed recurrent bouts of hematemesis. Patient was transferred to the [**Hospital Unit Name 153**] on [**2158-9-2**] and received 1 unit of packed red blood cells on [**2158-9-3**] for a hematocrit down to 28.3 from 34. Patient developed atrial fibrillation with rapid ventricular response. He was started on metoprolol 5mg IV every six hours with resolution of atrial fibrillation. Hematocrit was stabilized in the mid 30s. On [**2158-9-5**] patient underwent a second EGD which was again negative for active upper gastrointestinal bleed. Patient was restarted on intravenous proton pump inhibitor. On [**2158-9-7**] pt was transferred back to the floor. Heparin drip was started on [**9-9**] and discontinued on [**9-10**] hours prior to placement of nasogastric tube for bowel prep. Colonoscopy on [**2158-9-11**] was limited by poor prep. However, no source of bleeding was identified. Patient was bridged to coumadin with heparin drip after colonscopy. By discharge, his hematocrit was stable in the high 20s with no sign of active bleeding. He is to follow up with GI as outpatient when a capsule endoscopic study will be considered. . # Aortic valve replacement with mechanical valve [**2151**]: Given acute gastrointestinal bleeds with anticoagulation, warfarin was held until colonoscopy was conducted. Warfarin 3.5mg daily was started on [**2158-9-12**] with heparin bridge. INR at discharge was 2.5. Heparin drip was discontinued. . # Atrial fibrillation: with one episode of rapid ventricular response that resolved with metoprolol IV and amiodarone drip. At discharge patient's heart rate was stable. . # Chronic diastolic heart failure: Echo on [**2158-9-4**] showsed ejection fraction of 50%. On furosemide (20mg daily)at home, which was held given gastrointestinal bleed. Patient was significantly edematous. Patient was diuresed with 20mg IV furosemide from [**9-13**] to [**9-15**] with significant improvement in edema. Creatinine level rose but plateaued at 1.4. Home dose of furosemide was held at discharge and could be restarted once creatinine stabilizes. . # GERD: Pt was started on intravenous proton pump inhibitor on admission. He was transitioned to oral pantoprazole after colonoscopy. . # H/o CAD s/p NSTEMI: Aspirin and beta blocker were held given gastrointestinal bleed. Metoprolol 25mg PO BID was restarted on [**2158-9-12**]. Given recent GI bleed and patient's being on warfarin, aspirin was held on discharge with decision to restart deferred to outpatient cardiologist. . # Chronic kidney disease: Creatinine remained stable. It elevated to 1.4 with diuresis. At discharge, creatinine was stable at 1.4. All medications were renally dosed. . # Hyperlipidemia: Patient was kept on home dose of statin . # Urethral stricture: Foley placed by urology because patient bled with insertion. Patient noted to have urethral stricture. Per urology, patient is to follow up with Dr. [**Last Name (STitle) 770**] either on Wednesday [**2158-9-20**] or [**2158-9-27**] for a voiding trial. Patient is to call ([**Telephone/Fax (1) 18197**] to set up an appointment. Foley should not be removed at rehab since it was difficult to place. . # CONTACT: son [**Name (NI) **] [**Name (NI) 66590**] (w)[**Telephone/Fax (1) 66591**] (h)[**Telephone/Fax (1) 66592**] (c)[**Telephone/Fax (1) 66591**] Medications on Admission: Coumadin 3.5mg daily ECASA 325mg daily Acetaminophen 650mg Q4h PRN Vitamin D 1000 units daily Calcium carbonate 650mg [**Hospital1 **] Milk of Magnesia 30ml daily Ferrous Sulfate 325mg [**Hospital1 **] Lasix 20mg daily Metoprolol 25mg [**Hospital1 **] Omeprazole 20mg daily Simvastatin 80mg QPM Miralax daily Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 5. Calcium Carbonate 650 mg (1,625 mg) Tablet Sig: One (1) Tablet PO twice a day. 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Warfarin 1 mg Tablet Sig: 3.5 Tablets PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Gastrointestinal bleed Discharge Condition: Stable Discharge Instructions: You were admitted with changes in your mental status and blood in your stool. You were transferred to the ICU twice because you had acute bleeding and your vital signs were not stable. You received blood transfusions because your blood level was low. We held your coumadin because of the bleeding. You underwent two endoscopies and a colonscopy and no source of bleeding was identified in your GI tract. Your blood level is now stable and we have restarted you on your coumadin. Please continue taking your coumadin. Your INR will be monitored at the rehab facility. Followup Instructions: 1. GI follow up in 2 months . 2.Please call [**Telephone/Fax (1) 164**] to schedule a urology follow-up appointment with Dr. [**Last Name (STitle) 770**] on wednesday [**9-20**] or 26 for a voiding trial. Foley catheter should remain in place until then as it was very difficult to place.

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icd9cm

[ [ [] ] ]

[ "45.13", "45.23" ]

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Discharge summary

report

Admission Date: [**2190-12-11**] Discharge Date: [**2190-12-20**] Date of Birth: [**2156-4-7**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: [**2190-12-11**] Chest Tube Placement History of Present Illness: 34 male s/p single vehicle accident. Per report the patient was intoxicated and hit a stationary object and his head went through the windshield. He did not recall the exact circumstances surrounding the event. Past Medical History: -Hypertension -Bradycardia -Obstructive sleep apnea b/l adrenalectomy Social History: SOCIAL HISTORY: Lives with mother and brother, occasional cigar, no drugs, + ETOH Family History: noncontributory Physical Exam: Constitutional: Moderate respiratory distress, anxious HEENT: Small abrasion to anterior frontal region C. collar in place Chest: Tachypneic with coarse breath sounds Cardiovascular: Regular Rate and Rhythm Abdominal: Soft GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: No rash Neuro: Speech fluent Pertinent Results: [**2190-12-11**] 08:57PM GLUCOSE-130* UREA N-16 CREAT-1.2 SODIUM-139 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14 [**2190-12-11**] 08:57PM CALCIUM-8.7 PHOSPHATE-4.4# MAGNESIUM-2.4 [**2190-12-11**] 12:26PM GLUCOSE-67* UREA N-9 CREAT-0.5 SODIUM-138 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-14* ANION GAP-23* [**2190-12-11**] 12:26PM CK(CPK)-328* [**2190-12-11**] 12:26PM CK-MB-3 cTropnT-<0.01 [**2190-12-11**] 12:26PM CALCIUM-6.9* PHOSPHATE-1.8* MAGNESIUM-0.9* [**2190-12-11**] 09:39AM TYPE-ART TIDAL VOL-600 PEEP-12 O2-100 PO2-298* PCO2-42 PH-7.36 TOTAL CO2-25 BASE XS--1 AADO2-381 REQ O2-67 INTUBATED-INTUBATED VENT-CONTROLLED [**2190-12-11**] 09:39AM HGB-15.0 calcHCT-45 [**2190-12-11**] 07:29AM LACTATE-1.4 [**2190-12-11**] 07:29AM LACTATE-1.4 [**2190-12-11**] 07:13AM URINE HOURS-RANDOM [**2190-12-11**] 07:13AM URINE HOURS-RANDOM [**2190-12-11**] 07:13AM URINE UHOLD-HOLD [**2190-12-11**] 07:13AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2190-12-11**] 07:13AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.030 [**2190-12-11**] 07:13AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2190-12-11**] 07:13AM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 [**2190-12-11**] 04:55AM GLUCOSE-120* UREA N-15 CREAT-1.3* SODIUM-142 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15 [**2190-12-11**] 04:55AM estGFR-Using this [**2190-12-11**] 04:55AM CK(CPK)-480* [**2190-12-11**] 04:55AM LIPASE-17 [**2190-12-11**] 04:55AM cTropnT-<0.01 [**2190-12-11**] 04:55AM ASA-NEG ETHANOL-249* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2190-12-11**] 04:55AM WBC-6.0 RBC-5.34 HGB-15.7 HCT-46.4 MCV-87 MCH-29.3 MCHC-33.7 RDW-13.1 [**2190-12-11**] 04:55AM PLT COUNT-227 [**2190-12-11**] 04:55AM PT-13.9* PTT-24.4 INR(PT)-1.2* [**2190-12-11**] 04:55AM FIBRINOGE-281 Brief Hospital Course: The patient was evaluated in the emergency room. Due to concern for possible worsening respiratory capacity as well as somnolence, the patient was intubated in the emergency room for airway protection. After his intubation it was appreciated that he had developed a pneumothorax, hence a right sided chest tube was placed. He was admitted to the intensive care unit. He was transferred to the floor on [**2190-12-12**] The chest tube was maintained to suction and then brought to water seal. Serial chest x-rays demonstrated gradual partial resolution of the pneumothorax. A CTscan was performed on [**2190-12-16**] which demonstrated that the tube was within the minor fissure and that there was some inflammatory change in the lateral aspect of the lung at the site of placement of the chest tube. The chest tube was felt to be in suboptimal position within the minor fissure, hence it was pulled on [**2190-12-16**]. The patient was maintained on oxygent to promote reabsorption of the pneumothorax. Due to continued shortness of breath, he underwent a CT-angiogram with pulmonary embolism protocol on [**2190-12-17**] which demonstrated no pulmonary embolism. He had purulent discharge from the chest tube placement site hence he was started on broad spectrum antibiotics and wound cultures were sent. Infectious diseases was consutled. Wound cultures came back with mixed bacterial flora, and eventually demonstrated MSSA, hence he was started on PO augmentin per ID recommendations for MSSA coverage as well as broad coverage for other bacterial contaminants of his wound. He was discharged on [**2190-12-20**] in good condition. Medications on Admission: Included atenolol and prazosin Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 2. prazosin 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*2* 4. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 10 days. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Pneumothorax Wound infection Discharge Condition: At the time of discharge, the patient was afebrile with vital signs within normal limits. He was ambulating and voiding without difficulty. He was tolerating a regular diet and his pain was well controlled. Discharge Instructions: You were treated for a pneumothorax, which is air that collects in the space between the lung and the chest wall and interferes with breathing. You were treated for this condition with the placement of a chest tube, which enables the air trapped between the lung and the chest wall to be removed so that the lung can function normally. After your chest tube was removed, you developed an infection at the site of placement of your chest tube, for which you are receiving antibiotics. Please refrain from heavy exertion until cleared by a physician. [**Name10 (NameIs) **] you smoke, it is important that you stop for your general health, but particularly while recovering from this illness. It is also important that you refrain from alcohol until cleared by a physician. [**Name10 (NameIs) 357**] do not drive while taking pain medications. You will need to do dressing changes daily on your chest wound. a visiting nurse will come initially to help with this. Followup Instructions: Please call the Acute Care Surgery clinic to make an appointment to be seen in follow up in 2 weeks. The phone number for the [**Hospital 2536**] clinic is ([**Telephone/Fax (1) 2537**]. Please get a chest x-ray before coming to thsi appointment. You can do the chest x-ray on the day of your appointment prior to meeting with the doctor. Please call the number above to schedule the chest x- ray as well. Completed by:[**2190-12-20**]

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icd9cm

[ [ [] ] ]

[ "96.71", "34.04", "96.04" ]

icd9pcs

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311, 351

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Discharge summary

report

Admission Date: [**2147-1-23**] Discharge Date: [**2147-1-31**] Date of Birth: [**2074-3-2**] Sex: F Service: MEDICINE Allergies: Levaquin / Latex / Keflex / Aspirin Attending:[**First Name3 (LF) 1711**] Chief Complaint: dCHF exacerbation/PNA Major Surgical or Invasive Procedure: none History of Present Illness: 72 yo female with history of CAD s/p CABG [**56**] years ago recent cath with BMS to SVG to OM, CHF (EF 20-25% with LVH and mod MR) who presents to the ED with chest pain after transfer from [**Hospital **]. . She reports the chest pain has been present for the past [**4-7**] days. She was in her usual state of health until several days ago when she had a nose bleed, as well as what was described as a possible panick attack, with increased shortness of breath and chest discomfort. She was taken to the [**Hospital1 1474**] ([**Hospital3 **]) ED. She was thought to be dry there, home lasix held since Friday and she was given IV fluids (amout unknown). From there she was sent back to rehab. At which point, on the day of admission she again had an episode of shortness of breath and was brougth to [**Hospital3 **], where she was told she had a heart attack (as per family members). At [**Hospital3 **], here troponins-I were elevated at 1.9, up to 2.2. Her labs there showed Crn 2.5 She was given lasix 80mg IV. Of note, Since her discharge in [**Month (only) 359**], she has been at rehab. She subsequently developed chest pain. . In the ED, initial VS were 98.3 115 143/73 20 98% on 4LNC (on 2L home O2). CXR was significant for bilateral infiltrates. EKG showed LBBB. Labs were significant for elevated trop to 0.9, WBC 14.8. She received insulin for FSBG in 400s, lasix 80mg IV ? , nitro and heparin drip, and azithro/ceftriaxone for CAP coverage. VS on transfer RR 24, 97% On 4L, 118, 154/75. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains. She denies recent fevers. She denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: CAD, s/p MI x 2, chronic atrial fibrillation, not anticoagulated, chronic diastolic CHF, last echo [**2145-3-5**] LVEF 61% w/mod LV hypertrophy and L atrial dilation -CABG: 20 yrs ago -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: Asthma COPD on 2L home O2 L great toe non-healing ulcer followed by vasc surgery Mild chronic kidney disease [**3-8**] DM/HTN DJD MRSA Ulcerative colitis Incisional hernia hx cerebral aneursym, s/p clipping 30 yrs ago w/residual R pupil defect and strabismus hx of AAA s/p repair at [**Hospital1 112**] in the 90s Social History: -Lives with husband; 4 children. Has been in rehabilitation since last hospitalization. -Tobacco history: quit in [**2124**] -ETOH: denies -Illicit drugs: denies Family History: Mother w/DM died from CVA; father w/DM died from complications w/gangrene, 1 brother w/DM and died from PNA. Physical Exam: On admission: VS: T=97 BP=135/54 HR 126 O2Sat 99% on 4L GENERAL: Obese woman in NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: JVP could not be appreciated due to body habitus, port catheter seen in the neck. CARDIAC: irregularly irregular, tachycardic, distant S1 and S2. No m/r/g could be heard. LUNGS:Bilateral crackles 1/2 up the lungs. ABDOMEN: Soft, NT, obese. +BS. GU: Foley in place. EXTREMITIES: No c/c/e. No femoral bruits. Large scar (cabg graft). SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. On Discharge:.............. Physical Exam: Gen: alert, oriented x3, NAD, eating breakfast HEENT: supple, unable to assess JVD CV: RRR, 1/6 systolic murmur, LLSB RESP: No wheezes, bibasilar crackles. ABD: soft, mild tenderness with palpation EXTR: obese, 1+ bilat to knees NEURO: A/O, no focal defects Extremeties: Groin Pulses: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Skin: bilat callus on plantar aspect of great toes bilat. No open areas . Access: port a cath right SVC, no redness or swelling Pertinent Results: Labs on admission: . [**2147-1-23**] 02:30PM PT-13.6* PTT-75.9* INR(PT)-1.2* [**2147-1-23**] 02:30PM PLT COUNT-222 [**2147-1-23**] 02:30PM NEUTS-93.4* LYMPHS-4.3* MONOS-1.8* EOS-0.2 BASOS-0.3 [**2147-1-23**] 02:30PM WBC-14.5*# RBC-3.07* HGB-9.1* HCT-28.0* MCV-91 MCH-29.6 MCHC-32.4 RDW-15.7* [**2147-1-23**] 02:30PM CK-MB-10 MB INDX-6.6* cTropnT-0.19* proBNP-[**Numeric Identifier **]* [**2147-1-23**] 02:30PM CK(CPK)-151 [**2147-1-23**] 02:30PM estGFR-Using this [**2147-1-23**] 02:30PM GLUCOSE-441* UREA N-68* CREAT-0.8 SODIUM-133 POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-26 ANION GAP-17 [**2147-1-23**] 02:38PM GLUCOSE-417* LACTATE-2.4* NA+-142 K+-4.9 CL--98* TCO2-28 [**2147-1-23**] 02:38PM COMMENTS-GREEN TOP [**2147-1-23**] 08:39PM CALCIUM-10.1 PHOSPHATE-3.0 MAGNESIUM-2.5 [**2147-1-23**] 08:39PM CK-MB-8 cTropnT-0.22* [**2147-1-23**] 08:39PM CK(CPK)-154 [**2147-1-23**] 08:39PM GLUCOSE-286* UREA N-71* CREAT-2.7*# SODIUM-144 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-28 ANION GAP-19 . Labs on discharge: . [**2147-1-31**] 12:40PM BLOOD WBC-11.5* RBC-3.15* Hgb-9.1* Hct-28.2* MCV-90 MCH-29.0 MCHC-32.4 RDW-15.9* Plt Ct-230 [**2147-1-30**] 06:40AM BLOOD PT-12.6 PTT-28.7 INR(PT)-1.1 [**2147-1-31**] 12:40PM BLOOD Glucose-226* UreaN-54* Creat-2.2* Na-139 K-4.1 Cl-98 HCO3-32 AnGap-13 [**2147-1-30**] 06:40AM BLOOD ALT-15 AST-22 AlkPhos-72 TotBili-0.5 [**2147-1-30**] 06:40AM BLOOD Calcium-10.0 Phos-4.7* Mg-2.5 [**2147-1-30**] 06:40AM BLOOD PTH-138* [**2147-1-30**] 06:40AM BLOOD VITAMIN D [**2-28**] DIHYDROXY-PND . Microbiology: . Blood cx - negative Urine cx - negative Legionella urine antigen - negative Resp cx - negative C. diff toxin - negative . Imaging: . ECHO [**1-24**]: The left atrium is moderately dilated. The right atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). The right ventricular cavity is dilated with depressed free wall contractility. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2146-11-17**], the findings are similar. . Renal Ultrasound: [**1-30**] IMPRESSION: Progressive bilateral renal atrophy, reflecting chronic kidney disease. . CXR [**1-29**]: FINDINGS: As compared to the previous radiograph, the pre-existing bilateral pleural effusions have markedly decreased. On the right, the effusion is barely visible. On the left, large parts of the effusion have resolved. As a consequence, the basal lung areas show substantially improved ventilation. Unchanged is the overall increased size of the cardiac silhouette. The diameter of the pulmonary vessels suggests ongoing slightly increased intravascular fluid. No focal parenchymal opacities suggesting pneumonia . Specialty recs: . Speech and Swallow Eval: RECOMMENDATIONS: 1. Suggest a PO diet of nectar thick liquids and regular consistency solids. 2. Meds crushed with puree per pt request 3. ENT consult to evaluate vocal cord mobility / adduction 4. TID oral care 5. We will f/u to try to advance her diet with strategies if her respiratory status improves further. . ENT [**1-24**]: A/P: 72 F with complicated cardiac and pulmonary history notable for CAD s/p CABG, asthma COPD on 2L at home, with dysphonia. Exam notable for mild-moderate supraglottic edema suggestive of laryngopharyngeal reflux changes and presbylarynx (ie, age related changes to glottis). No evidence of focal traumatic injury to laryngeal apparatus. Also noted to have history of frequent epistaxis, self resolving, which are likely related to dry air and irritation from nasal cannula. Recommendations: - start omeprazole 40 mg PO QAM 30 minutes before breakfast and ranitidine 150 mg QPM - humidification via facemask to soothe airway -Diet per Speech and Swallow. -Given recent episode of epistaxis, would avoid nasal cannula; as she needs supplemental O2, would recommend use of face mask. - Epistaxis precautions (No nose-blowing, no straining, no heavy lifting) -Start saline nasal spray tomorrow (3 sprays each side three times daily until follow up) -Bactroban / Vaseline ointment to both nostrils [**Hospital1 **] -If bleeding develops, try several sprays of afrin and squeeze tip of nose to hold pressure for 15 minutes. Brief Hospital Course: 72 yo female with history of CAD s/p CABG [**56**] years ago recent cath with BMS to SVG to OM, CHF (EF 20-25% with LVH and mod MR) who presents to the ED with chest pain after transfer from [**Hospital **] with what appears to be CHF exacerbation, compounded with new WBC count and hyperglycemia, and elevated cardiac enzymes. . # CHF: patient is likely in heart failure exacerbation, given amount of fluids she was given at outside facilities, and lack of diuretics. Her chest pain is not currently reproducible and she points more to her stomach bilaterally, not endorsing any chest pain currently. EKG shows RBBB. Cardiac enzymes not dramatically elevated. BNP very high. We felt that this was unlikely to be due to ACS, her heparin and nitro drips were weaned off. She complained of no chest pain since admission to the CCU. We proceeded with duiresis, given fluid in lungs on CXR. She was initially bolused with 80mg IV lasix, but had a poor response, put on Lasix drip 20mg/hr but we had to augment this with metolazone 5mg, with her urine output improving. Diuretics were then held secondary to overdiuresis and worsening renal failure. As she began to slowly reaccumulate, it was decided to keep on furosemide as an outpatient at 40mg by mouth every day. She will continue to hold diovan until her renal function returns to baseline. Weight at discharge was 85.5 kg. . #Rhythm: Patient was initially tachycardic, in AF with LBBB. We uptitrated her metoprolol to her home dose for rhythm control and she tolerated this well. . # Acute renal failure: Creatinine progressively increased, in setting of furosemide drip. She appeared to be overdiuresed and the drip was stopped, resulting in an improvement of creatinine. Renal ultrasound only showed progressive chronic kidney disease. Renal service was consulted and advised to diurese based on symptoms of shortness of breath or if CXR showed pulmonary edema. FeNa 2% on day of discharge (2.65%, FeUrea 14.4%, on [**12-28**]). Per Renal recs, the following labs were sent: PTH 138, vit D (25-hydroxy) pending on discharge. She will follow-up these results with Renal as an outpatient. # Leukocytosis: Patient has bilateral pleural effusions and could not exclude a retro-cardiac pneumonia on CXR. She was also given solumedrol two doses at rehab. Speech and swallow saw her while she was in the CCU and noted extensive aspiration. She received a 5-day course of pip-tazo and azithromycin to cover for aspiration pneumonia with improvement of leukocytosis. Due to increased diarrhea, C. diff toxin was sent and negative. . # DM: Sugars in 400s on admission, as well as at OSH. This was felt to be due to previous steroid administration. Her blood glucose improved when she was given her home doses and covered with sliding scale. Her insulin 70/30 was changed to 30 units [**Hospital1 **] due to low AM blood sugars, decreased from 38 units. . # COPD: She has 2L baseline O2 requirement, but came in on 4L nasal cannula. We monitored her O2 sat and kept her above 90%. She was given Ipratropium and xopenex nebs PRN q6H as well as Spiriva and diuresed. Her respiratory status improved to her baseline. . # Dysphagia: Due to hoarseness, ENT evaluated and laryngoscopy showed bilateral vocal cord nodules and edema. Recommended omeprazole 40 mg PO QAM 30 minutes before breakfast and ranitidine 150 mg QPM. Speech and swallow also evaluated and recommended nectar thick liquids for diet. She will follow-up with ENT s/p discharge. Medications on Admission: 1. aspirin 80 2. tiotropium bromide 18 mcg Capsule Cap Inhalation DAILY 3. atorvastatin 80 mg DAILY 4. pantoprazole 40 mg TabletPO Q12 5. nitroglycerin 0.3 mg Tablet, Sublingual PRN. 6. cholecalciferol (vitamin D3) 400U Daily 7. clopidogrel 75 mg Daily for 1-3 months: *3 months recommended. 8. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen 38 QAM, 38 QPM. 10. Diovan 80 mg Tablet Sig: One (1) Tablet PO once a day - was held due to renal failure (as per daughter) 11. metoprolol succinate SR 300MG. . MEDS as confirmed with Rehab: 1. Plavix 75 2. Robitussin q6 3. ASA 81 4. Atorvastatin 80 5. Lisinopril 10 6. KCL 30 Q12 7. Zosyn - Started for 1 night 8. Albuterol/Atrovent 9. Lasix 80IV (and smaller doses). Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. 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. 4. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection TID (3 times a day). 8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for pain. 10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 13. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: Thirty (30) units Subcutaneous twice a day. 14. ipratropium bromide 0.02 % Solution Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for wheezing or shortness of breath. 15. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: Three (3) ML Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 16. furosemide 40 mg Tablet Sig: One (1) Tablet PO every other day. Discharge Disposition: Extended Care Facility: [**Hospital1 **] [**Location (un) 701**] Discharge Diagnosis: Acute on chronic systolic congestive heart failure Acute on chronic kidney injury Leukocytosis Community acquired pneumonia Vocal Cord Dysphagia Coronary Artery disease Atrial fibrillation 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 had chest pain and trouble breathing and was brought to [**Hospital 6451**] Hospital and transferred to [**Hospital1 **]. You required a course of antibiotics for pneumonia and developed acute congestive heart failure and kidney failure. You received diuretics to help your heart and your kidneys are slowly improving now. We have held your lisinopril until your kidney function improves. You will need to see Dr. [**Last Name (STitle) 3321**] in about a month and you will come back to [**Hospital1 18**] to see a nephrologist or kidney doctor. It is very important that you eat a low sodium diet. Weigh yourself every morning, call Dr. [**Last Name (STitle) 3321**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . Medication changes: 1. Start Heparin injections to prevent a blood clot 2. Start Pantoprazole and ranitidine to help your swallowing 3. Start Vitamin D because your kidneys are unable to make this vitamin well now. 4. STart tylenol as needed for pain 5. Start Ipratroprium and Xopenex to help with wheezing 6. Decrease your insulin to 30 units in the morning and at night 7. Start furosemide at 40 mg every other day Followup Instructions: Department: OTOLARYNGOLOGY (ENT) When: WEDNESDAY [**2147-2-15**] at 10:45 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**] Building: LM [**Hospital Unit Name **] [**Location (un) 895**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE . Primary Care: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 84368**]. Pls make an appt for follow up when ready to go home. . Name: [**Last Name (LF) 3321**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Cardiology Address: [**Last Name (un) **], [**Location (un) **],[**Numeric Identifier **] Phone: [**Telephone/Fax (1) 5315**] Appt: [**2-15**] at 1:40pm Department: Nephrology at [**Hospital1 18**] Phone: [**Telephone/Fax (1) 721**] Appt: We are working on an appt for you within the next [**3-10**] weeks. The office will call you at home with an appt. If you dont hear from them by Wednesday, please call them directly at number above.

[ "707.15", "555.9", "V58.67", "403.90", "250.40", "428.43", "585.9", "584.9", "478.6", "486", "V46.2", "V45.82", "V12.04", "493.20", "428.0", "427.31", "V15.82", "715.90", "426.3", "787.20", "478.5", "V45.81", "288.60", "272.4", "787.91" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15059, 15126

8989, 12492

317, 323

15359, 15359

4298, 4303

16716, 17782

3039, 3149

13266, 15036

15147, 15338

12518, 13243

15535, 16275

3827, 4279

2262, 2497

3797, 3812

16295, 16693

256, 279

5328, 8966

351, 2158

4317, 5309

15374, 15511

2528, 2843

2180, 2242

2859, 3023

28,336

146,716

9659

Discharge summary

report

Admission Date: [**2114-8-2**] Discharge Date: [**2114-10-19**] Date of Birth: [**2059-3-13**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: pancreatic pseudocyst Major Surgical or Invasive Procedure: [**2114-8-13**] CT-guided pigtail catheter placement into R flank fluid collection [**2114-8-17**] upsizing of R flank catheter & CT-guided placement of peripancreatic drainage catheter [**2114-8-29**] CT-guided exchange of L drainage catheter [**2114-9-4**] CT-guided exchange of R drainage catheter, upsizing of L drainage catheter [**2114-9-18**] tracheostomy [**2114-9-20**] CT-guided flushing/aspiration of both drainage catheters [**2114-10-11**] Dobhoff feeding tube placement History of Present Illness: This is a 55 year old female admitted for fever/leukocytosis, abd pain. Tx to ICU at [**Hospital1 **] for hypotension, acidosis. Complications during that admission include: sepsis, coagulopathy with INR-7.85 and ?DIC (received FFP and vit. K), ARF [**1-5**] ATN from hypotension/sepsis. CT scan: ?multiloculated pseudocysts. Past Medical History: PMH: hemorrhagic pancreatitis and pancreatic pseudocyst, HTN, CAD w/ ischemic cardiomyopathy (EF=15-20%) s/p STEMI, NSTEMI [**5-10**], CHF, IDDM, SLE, CRI [**1-5**] SLE ?lupus nephritis vs. DM, baseline Cr=1.5, hypothyroid, ? embolic CVAs in [**6-9**], obesity, dyslipidemia, adrenal insufficiency [**1-5**] chronic steroid use PSH: s/p AICD placement [**Hospital1 **]-v pacer [**2112**] (for A-fib), cardiac cath [**2106**], h/o trach/PEG, c-section Social History: 20ppy tobacco history - stopped in [**2106**] Resides in nursing care facility Physical Exam: On admission: VS: 97.6, 64, 156/84, 20, 96% RA Gen: NAD, resting comfortably Chest: bibasilar rales, otherwise clear CV: RRR Abd: Obese, soft, non-distended, mild tenderness to deep palpation in LUQ and epigastrim Ext: +2 edema, ecchymosis anterior aspect of bilat LE. Pertinent Results: [**2114-8-2**] 09:45PM BLOOD WBC-16.7* RBC-3.78* Hgb-11.4* Hct-35.9* MCV-95# MCH-30.1 MCHC-31.7 RDW-17.8* Plt Ct-435 [**2114-8-2**] 09:45PM PT-15.4* PTT-20.0* INR(PT)-1.4* [**2114-8-2**] 09:45PM GLUCOSE-174* UREA N-43* CREAT-2.7*# SODIUM-143 POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-16* ANION GAP-20 [**2114-8-2**] 09:45PM CALCIUM-7.9* PHOSPHATE-3.7 MAGNESIUM-1.8 [**2114-8-2**] 09:45PM ALT(SGPT)-20 AST(SGOT)-56* LD(LDH)-583* ALK PHOS-158* AMYLASE-11 TOT BILI-0.7 [**2114-8-2**] 09:45PM LIPASE-11 . CT ABDOMEN W/O CONTRAST [**2114-8-3**] 1:18 PM IMPRESSION: 1. Evaluation of pancreas is limited without contrast, though a large fluid collection within the lesser sac likely represents a large pseudocyst. Separate right sided large retroperitoneal collection may represent a resolving hematoma. 2. Cholelithiasis. . CT ABD W&W/O C [**2114-8-5**] 4:30 PM IMPRESSION: 1. Pseudocyst anterior to body of pancreas measuring 13 cm in transverse x 7.6 cm in AP diameter with fluid extending superiorly to join inflammatory phlegmon posterior to the spleen and inferiorly to collection in right flank which is unchanged and measures 13 cm in transverse x 10 cm in AP diameter. 2. No significant remaining enhancing pancreas noted, pancreas appears replaced by the pseudocyst. 3. Renal cysts and renal calculi. 4. Small bilateral pleural effusions and atelectasis. 5. Cholelithiasis. . Cardiology Report ECHO Study Date of [**2114-8-7**] IMPRESSION: Severe dilated cardiomyopathy with regional left ventricular dysfunction consistent with multivessel coronary artery disease. Mild aortic and mitral regurgitation. Mild pulmonary hypertension. . UNILAT UP EXT VEINS US RIGHT [**2114-8-9**] 8:58 PM IMPRESSION: No evidence of DVT . CT ABD PELVIS W/O CONTRAST Study Date of [**2114-8-17**] 9:16 AM IMPRESSION: 1. Decrease in size of right flank collection with pigtail catheter in place. 2. Stable lesser sac collection with extension into the perisplenic region. 3. Nonobstructing left renal calculus. CT ABDOMEN W/O CONTRAST Study Date of [**2114-8-22**] 3:49 PM IMPRESSION: 1. Slight interval decrease in size of a pancreatic pseudocyst and inferior component of a right flank fluid collection with pigtail catheters in appropriate position. 2. Stable size of a perisplenic fluid collection. 3. No evidence of new fluid collection within the abdomen or pelvis. 4. Mild sigmoid wall thickening, compatible with segmental colitis. CT FISTULOGRAM S&I Study Date of [**2114-8-29**] 2:21 PM IMPRESSION: Multiple intra-abdominal fluid collections most of which appear to be slightly smaller when compared with the prior study. CT ABDOMEN W/CONTRAST Study Date of [**2114-9-2**] 10:39 AM IMPRESSION: 1. Mild decrease in some of the multiple pancreatitis related intra- abdominal fluid collections as described with pigtail catheters in place. No new collections seen. 2. Small bilateral pleural effusions slightly increased compared to recent prior. LIVER OR GALLBLADDER US Study Date of [**2114-9-9**] 1:18 PM IMPRESSION: 1. Echogenic liver, likely representing diffuse fatty infiltration. Other forms of liver disease and more advanced liver disease, including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 2. No evidence of cholecystitis. UNILAT UP EXT VEINS US Study Date of [**2114-10-1**] 8:39 AM IMPRESSION: No son[**Name (NI) 5326**] evident thrombus right upper extremity. [**2114-10-19**] 02:36AM BLOOD WBC-15.8* RBC-2.89* Hgb-8.9* Hct-29.4* MCV-102# MCH-30.8 MCHC-30.2 RDW-19.6* Plt Ct-293 [**2114-10-19**] 02:36AM PT-18.1* PTT-41.4* INR(PT)-1.7* [**2114-10-19**] 02:36AM GLUCOSE-69* UREA N-52* CREAT-1.7*# SODIUM-143 POTASSIUM-5.5 CHLORIDE-111* TOTAL CO2-25* ANION GAP-13 [**2114-10-19**] 02:36AM CALCIUM-8.5* PHOSPHATE-4.9 MAGNESIUM-2.2 [**2114-10-19**] 02:36AM ALT(SGPT)-13 AST(SGOT)-49* ALK PHOS-568* AMYLASE-10 TOT BILI-0.9 [**2114-10-19**] 02:36AM LIPASE-8 Brief Hospital Course: This is a 55 year old female who was transferred here from [**Hospital1 **] with a large (13 x 7.6 cm) pseudocyst anterior to body of pancreas with fluid extending superiorly to join an inflammatory phlegmon posterior to the spleen and inferiorly to a 13 x 10 cm collection in the right flank. She was made NPO and started on TPN. Imipenem and Bactrim were started. [**Last Name (un) **] was consulted and managed her insulin for the entirety of her hospital stay. On [**8-5**], she was switched to meropenem, vanco, and Flagyl. Bactrim was d/c'd on [**8-6**]. She was transferred to the ICU on [**8-6**] for respiratory distress, thought to be secondary CHF/overly aggressive hydration. Cardiology was consulted, given her extensive cardiac history. She was gently diuresed (1L/day). On [**8-8**], she was transferred back to the floor. Her diet was advanced on [**8-10**]; she was tolerating a regular diet by [**8-12**]. TPN was later d/c'd. On [**8-13**], CT-guided pigtail catheter placement into the right flank fluid collection. The culture grew VRE & Pseudomonas (resistant to carbepenems). On [**8-15**], [**Last Name (un) 2830**] was d/c'd and ceftaz was started. On [**8-16**], vanco was d/c'd and linezolid was started. On [**8-17**], ID was consulted and recommended d/c ceftaz/Flagyl, continue linezolid for VRE, start Zosyn for Pseudomonas. On [**8-17**], she underwent CT guided upsizing of this drain and placement of a 2nd peripancreatic drain. Cultures grew VRE, Pseudomonas, and Strep viridans. On [**8-20**], her stool was positive for C.diff. Flagyl was restarted. On [**8-21**], linezolid was switched to daptomycin secondary to leukopenia. A repeat CT on [**8-22**] showed slight interval decrease in size of the pancreatic pseudocyst and inferior component of a right flank fluid collection with pigtail catheters in appropriate position, as well as stable size of tne perisplenic fluid collection. On [**8-23**], aztreonam and PO vanc were started. On [**8-29**], the L drainage catheter was exchanged with CT guidance. On [**9-4**], the R catheter was exchanged and the L catheter was upsized under CT guidance. On [**9-5**], she was transferred back to the ICU for anuria (<15 cc/h despite IVF and albumin boluses), ARF (Cr 1.9 from nadir 1.2), hypotension requiring pressors, pulmonary edema, and respiratory & metabolic acidoses. Nephrology was consulted and advised against Lasix. On [**9-6**], she went into respiratory distress while being repositioned in bed and was intubated. Her UOP improved slightly following intubation. An echo demonstrated severe global LV systolic dysfunction and an EF of 15-20%. Her troponin was 0.06. Cardiology recommended Lasix. She was started on a Lasix gtt and Diuril with good response. An NGT was placed for tube feeds. On [**9-7**], she went into V-tach with hypotension. She was cardioverted x1 and bolused with amio. Dopamine was changed to dobutamine and neo. Vasopressin was then started to wean the neo. Amiodarone was d/c'd on [**9-8**]. Trophic tube feeds were started. On [**9-11**], she had several runs of NSVT with hypotension. An amio bolus was given followed by an amio gtt. Cardiology & EP were consulted and agreed with current management. TF were advanced. On [**9-18**], a tracheostomy was placed. On [**9-20**], her drains were flushed under CT guidance. She was weaned off dobutamine gtt on [**9-20**], but required it again by [**9-22**]. On [**9-24**], CVVHD was started. Neo was weaned off on [**9-25**]. On [**9-27**], her R flank drain was d/c'd by IR. Her pressure dropped in the setting of aggressive ultrafiltration and neo was restarted. CVVHD was stopped overnight for continued hypotension despite being run even. On [**9-28**], her antibiotics were d/c'd. CVVHD was restarted on [**9-29**] with gentle removal of fluid. Psychiatry was consulted on [**10-3**] for depression; continuation of her Celexa was recommended. On [**10-4**], dobutamine was weaned off. On [**10-6**], Cipro and ceftaz were started for a Pseudomonas & Klebsiella UTI. Cipro was changed to Zosyn on [**10-9**]. ID was consulted and recommended d/c ceftaz/Zosyn, starting meropenem and empiric fluc/PO vanc. She stopped requiring CVVHD on [**10-9**]. Neo was restarted on [**10-10**] for hypotension. She vomited several times on [**10-10**], so on [**10-11**], a Dobhoff tube was placed into the duodenum under fluoroscopic guidance. Aztreonam was started on [**10-11**] for sputum Pseudomonas resistant to meropenem. On [**10-15**], she desat'd while being turned and was placed back on a ventilator. Vanc and fluc were d/c'd. She failed a speech & swallow evaluation on [**10-16**]; she was continued NPO with TF. On [**10-17**], she was weaned off of neo. She completed a 7 day course of [**Last Name (un) 2830**]. On [**10-19**], she was discharged to vent rehab in stable condition. Discharge Medications: simvastatin 20 mg', levothyroxine 200 mcg', ASA 81 mg', Tylenol 325-650 mg q6 prn, Benadryl 12.5 mg q6 prn, Sarna lotion, Celexa 20 mg', Zofran 4 mg q8 prn, albuterol 6 puffs q4 prn, chlorhexidine gluconate 0.12% 15 ml [**Hospital1 **] if on mechanical vent, simethicone 40-80 mg QID prn, famotidine 20 mg', heparin 5000U TID, KPhos sliding scale, MgSO4 sliding scale, trazodone 50 mg qhs prn, KCl sliding scale, MVI 1 tab', folic acid 1 mg', loperamide 4 mg TID prn, Dilaudid 2 mg q4h prn, Lasix 20 mg", Ativan 0.5-1 mg q3h prn, metoprolol 25 mg", insulin sliding scale, prednisone 7.5 mg' Discharge Disposition: Extended Care Facility: [**Location (un) 32674**] - [**Location (un) **] Discharge Diagnosis: necrotizing pancreatitis, bacteremia, urinary tract infection, respiratory distress Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, 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. * Continue to amubulate several times per day. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 468**] in 4 weeks. Call ([**Telephone/Fax (1) 27734**] to schedule an appointment. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2114-9-28**] 10:30 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2114-10-19**] 9:00 Completed by:[**2114-10-19**]

[ "995.92", "008.45", "V45.82", "785.51", "041.7", "584.9", "567.22", "585.9", "286.9", "427.31", "250.00", "599.0", "041.3", "427.1", "038.9", "710.0", "518.81", "414.01", "577.2" ]

icd9cm

[ [ [] ] ]

[ "39.95", "31.1", "52.01", "96.04", "38.93", "38.91", "99.15", "96.6", "54.91", "96.72" ]

icd9pcs

[ [ [] ] ]

11566, 11641

5997, 10928

335, 820

11768, 11775

2051, 5974

12865, 13270

10951, 11543

11662, 11747

11799, 12842

1761, 1761

274, 297

848, 1175

1775, 2032

1197, 1650

1666, 1746

22,293

136,611

53525

Discharge summary

report

Admission Date: [**2182-4-2**] Discharge Date: [**2182-4-3**] Date of Birth: [**2133-9-14**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: Dizziness, Hypoxia Major Surgical or Invasive Procedure: Central Venous Line Placement History of Present Illness: HPI: 48 y/o F w/recent diagnosis of metastatic lung ca (R apical lung mass, trapezius muscle, liver, adrenals, left paraspinal muscle, C2 vertebrae, brain) who came here from XRT today after feeling dizzy. She was recently admitted from [**Date range (2) 110025**] where all of this was recently diagnosed. At that time she began palliative XRT to her thorax and had stents to her trachea, bronchus intermedius, and left mainstem. She was discharged to home on [**3-29**] with plans to continue XRT. However, per her husband, today she came to the [**Name (NI) **] c/o dizziness for the last 2 days. Chronic SOB but nothing acute, and denied all other complaints per ED notes. * In the ED, she was tachycardic in the 110s-130s, hypotensive in the 60s-70s/40s, and hypoxic to 82% on an unclear amt of oxygen. Pulsus 9. She was given 4 L IVF and levophed, and a central line was placed. She also received decadron, vanc/levo/flagyl, and ativan. CTA was negative for PE and showed a large mediastinal mass. They planned on intubating her, but at that point social work met with the patient and she decided to be CMO. She was transferred to the CCU on a morphine gtt. Past Medical History: 1. recently diagnosed metastatic lung cancer 2. s/p assault in [**2175**] Social History: Social Hx: engaged, lives on Cape. Works as an event planner. Has a 17 y/o daughter. +30 pk yr hx, social EtOH. Family History: Father died of MI in his 60s, mother w/ alzheimer's in her 80s, no cancer Physical Exam: PE: T: 95.8 (Tmax 99.2 rectally) P: 128 BP: 76/47 R: 22 O2 sat: 86% on NRB Gen: breathing heavily, asleep Neck: R IJ TLC in place Lungs: rhonchorous anteriorly CV: tachycardic, no murmur Abd: nondistended Pertinent Results: CXR: Lordotic positioning. A right IJ line is present, new compared with [**2182-3-28**]. The tip overlies the expected site of the SVC/RA junction. Rightward displacement of the line is thought to reflect the presence of the large mediastinal mass displacing the SVC. Again seen is dense opacification of the right upper and medial midzones, somewhat denser on the current examination. There is also increased retrocardiac density, essentially unchanged. Increased opacity above the aortic knob likely reflects the patient's mediastinal mass and is unchanged. Again noted are the lower tracheal and right bronchial stents. No left-sided effusion is identified. No CHF is detected. No pneumothorax is identified. * Chest CT: IMPRESSION: 1. Again seen is a large right mediastinal mass not significantly changed from prior study. There has been interval stenting of the trachea and main stem bronchi. The aorta, SVC, and IVC appear patent. 2. Interval increase in right upper lobe atelectasis/consolidation of fluid. Large right pleural effusion again seen. Multiple pulmonary metastases again identified. 3. Left upper back metastasis and adrenal masses again seen. * ECG: sinus tach at 120, nl axis, QT 465, S1Q3T3, Q's in V1-3 w/TWI V3-6 Brief Hospital Course: 48 y/o F presenting with metastatic end-stage cancer, who was in the ER after feeling dizzy on the [**Hospital Ward Name **]. In the [**Name (NI) **], pt. was hypoxic - likely secondary to her mass. Pt. had a CTA that showed a large mediastinal mass - metastatic lung cancer. Pt. had a discussion w/ her fiance and the ER attending. Pt. decided that she did not want to be intubated or resuscitated in any way. Pt. was brought to the ICU for a morphine gtt for comfort. Pt. was in the ICU for a few hours with comfort care and died from carediopulmonary arrest within hours. Medications on Admission: * Medications: clonazepam 0.5 [**Hospital1 **] percocet lidocaine patch colace dulcolax levofloxacin flagyl motrin guaifenesin * Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Pt. expired Discharge Condition: Pt. expired Discharge Instructions: Pt. expired Followup Instructions: Pt. expired

[ "197.7", "198.7", "198.89", "162.8", "198.3", "198.5", "197.0" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

4188, 4197

3394, 3976

333, 364

4252, 4265

2117, 3371

4325, 4339

1802, 1877

4156, 4165

4218, 4231

4002, 4133

4289, 4302

1892, 2098

274, 295

392, 1558

1580, 1656

1672, 1786

23,456

115,112

21287

Discharge summary

report

Admission Date: [**2140-3-22**] Discharge Date: [**2140-4-8**] Service: TRA ADMISSION DIAGNOSIS: Status post fall. DISCHARGE DIAGNOSES: 1. Subarachnoid hemorrhage. 2. Bilateral frontal lobe contusions. 3. Right cerebellar hemispheric bleed. 4. Subdural bleed. 5. Right occipital bone fracture, nondisplaced. 6. Left lung collapse requiring bronchoscopy with persistent left lower lobe collapse. 7. Question of ligamentous injury of the cervical spine of C3, C4. 8. Methicillin-resistant Staphylococcus aureus pneumonia. PROCEDURES DURING ADMISSION: Bronchoscopy for left lung collapse. HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old female, who suffered a mechanical fall from a standing position on [**2140-3-22**]. She was transferred from [**Hospital 1474**] Hospital for further trauma management. The patient was hemodynamically stable. She was never hypoxic. Her GCS was 7 on arrival. She underwent further imaging evaluation by the Trauma Team after she was seen and evaluated in the Trauma Bay. PAST MEDICAL HISTORY: 1. Gout. 2. Osteoarthritis. 3. Hypertension. 4. Cataracts. 5. Question of CHF. PAST SURGICAL HISTORY: Not available. OUTPATIENT MEDS: 1. Vioxx. 2. Lasix 40 4x a day. 3. Prevacid 30 once a day. 4. Atenolol 25 twice a day. 5. Allopurinol 100 once a day. 6. Iron. 7. Tylenol. 8. Eyedrops. PHYSICAL EXAMINATION: On exam the patient had a GCS of 7. The patient was intubated for airway control given her GCS of 7. Her pupils were equal and reactive bilaterally. Heart was regular. Chest was clear. Abdomen was soft, nontender, nondistended. Her lower extremities revealed no deformity. Her right upper extremity had a small laceration that was not bleeding. RADIOLOGY FILMS: 1. Chest x-ray was negative. 2. A-P pelvis was negative. 3. CT head revealed contusion to the frontal lobes with a hematoma on the right cerebellar hemisphere, a subdural hematoma, and subarachnoid blood, a nondisplaced single fracture of the right occipital bone as well as a probable chronic subdural fluid collection in the right frontoparietal area with some brain atrophy. 4. Her CT of the abdomen and pelvis was negative. 5. TLS negative. 6. Right humerus negative. HOSPITAL COURSE: The patient was seen and evaluated in the Trauma Bay by the Trauma Team, and was admitted to the Intensive Care Unit for q1h neurological checks and hemodynamic monitoring. The [**Hospital 228**] hospital course by systems is as follows: 1. Neurologic: The patient had the above mentioned findings on head CT and was seen and evaluated by the Neurosurgery team. She had several repeat head CT scans, which were stable, and her neurologic exam slowly improved over the hospital course to the point where she was following commands and was able to be extubated. The patient's C spine was attempted to be cleared when she was extubated, however, she did have some probable ligamentous instability at C3-C4, therefore she was kept in a C collar. 1. Cardiovascular: The patient did have some episodes of tachycardia during her hospital stay. It was thought to be sinus tachycardia with PAC's given her EKG findings. Her Lopressor dose was increased and her heart rate reduced into the low 100s. 1. Respiratory: The patient was extubated initially midway throughout her hospital course, and given the fact that she was having difficulty breathing after extubation, and was tachypneic and tachycardic, she was reintubated. Upon reintubation, she had copious increase in thick secretions and was started on Levaquin empirically for a pneumonia. Her secretions did improve to the point that she was able to be extubated with aggressive pulmonary toilet. She did have a total collapse of her left lung and underwent an x- ray on [**2140-4-2**]. She underwent a bronchoscopy and awake bronchoscopy, and the patient's left lung, did improve, but she did have some persistent left lower lobe collapse. Her sputum did grow out on [**2140-4-1**] MRSA and the patient was started on vancomycin for this. Her respiratory status improved greatly with pulmonary toilet. 1. GI: The patient was started on tube feeds initially during her stay. These were continued and most recently she was started on a diet as her speech and swallow evaluation revealed that she was able to tolerate nectar- thickened liquids and a soft puree diet. As her nutrition is not optimized yet, she is continuing on her tube feeds until she is at goal nutrition. 1. GU: The patient does have a Foley catheter. She has had no issues with urine output. Has received Lasix intermittently for diuresis. Of note, she was on Lasix at home, however, this was not restarted during her hospital stay. She appeared to be fairly euvolemic. She may require Lasix to be restarted during her rehab stay. 1. Heme: The patient did not have any significant drops in her hematocrit. She was started on subcutaneous Heparin 5000 b.i.d. when cleared by Neurosurgery, and should continue on this. 1. ID: The patient is now on vancomycin day nine. She is going to get five more days of vancomycin for a 14 day course for her MRSA pneumonia. She had no other positive blood cultures, and does have a persistent left lower lobe collapse with secretions. 1. Endocrine: The patient is on a sliding scale with her tube feeds and receiving insulin per the sliding scale with q.i.d. fingersticks. 1. Prophylaxis: The patient is on Prevacid with Venodyne boots and subcutaneous Heparin. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Tylenol 325 p.o. q.4-6h. prn. 2. Heparin 5000 units subQ b.i.d. 3. Dulcolax prn. 4. Regular insulin-sliding scale. 5. Acetylcysteine 20 percent q.2h. prn for thick secretions. 6. Albuterol nebulizers q.4h. 7. Ipratropium bromide two puffs q.i.d. 8. Lopressor 50 mg p.o. t.i.d. 9. Nystatin swish and spit p.o. q.i.d. prn. 10. Vancomycin 1000 mg q.24h. for five more days. DISCHARGE INSTRUCTIONS: Patient's discharge instructions are to followup with Dr. [**Last Name (STitle) 26803**] in one month at [**Telephone/Fax (1) 56306**] with a head CT and flex-x films of her C spine prior to followup. She is to followup in the Trauma Clinic in [**12-29**] weeks. She continued receiving Impact with fiber at 60 cc an hour, to get chest PT q.6h. with nasogastric suction q.6h. She needs a Xeroform dressing and dry dressing to her right upper arm q.d. She does need aggressive physical therapy and pulmonary toilet. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], MD 2211 Dictated By:[**Last Name (NamePattern1) 55418**] MEDQUIST36 D: [**2140-4-8**] 10:13:57 T: [**2140-4-8**] 10:59:38 Job#: [**Job Number **]

[ "804.20", "804.30", "427.89", "953.9", "518.0", "482.41", "E888.9", "804.10", "478.30" ]

icd9cm

[ [ [] ] ]

[ "99.04", "96.04", "33.23", "96.6", "96.72", "96.71" ]

icd9pcs

[ [ [] ] ]

5664, 5673

150, 610

5696, 6077

2258, 5642

6102, 6872

1172, 1360

1383, 2240

110, 129

639, 1045

1067, 1148

29,164

152,477

44939

Discharge summary

report

Admission Date: [**2148-8-17**] Discharge Date: [**2148-9-4**] Date of Birth: [**2072-1-21**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 301**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Open cholecystectomy. 3. Closure of peptic ulcer with [**Location (un) **] patch. 4. Anterior selective vagotomy. History of Present Illness: The patient is a 76-year-old woman with a history of aspirin use. She presents with 1 day of abdominal pain. CT consistent with finding of free air and perforated viscus. The patient with acute abdomen on presentation, resuscitated and brought to the operating room. Past Medical History: 1. HTN 2. CAD 3. COPD 4. Diabetes 5. Head injury age 11 when hit by horseshoe 6. Schizoaffective disorder 7. Hypercholesterolemia 8. GERD Social History: She denies alcohol and tobacco use. Family History: Non-contributory Physical Exam: On discharge Gen: no acute distress. HEENT: Pupils are equal, round and reactive to light. Sclerae are anicteric. Oropharynx is clear. Neck: Supple without lymphadenopathy. Trachea is midline. Pulm: Lungs are clear to auscultation bilaterally. CV: Regular rate and rhythm. Normal S1-S2. Abd: soft, obese, non-distended, well-healed incision. There is no organomegaly or masses. Ext: warm, well-perfused without clubbing, cyanosis, or edema. Neuro: no focal deficits. Pertinent Results: CT abdomen [**2148-8-17**]: IMPRESSION: 1. Pneumoperitoneum. Although no definite bowel perforation was seen, significant thickening and stranding surrounding the second portion of the duodenum suggests duodenal perforation. 2. Free fluid is surrounding the liver. 3. Significant thickening of the distal esophagus concerning for esophagitis. 4. Small bilateral pleural effusions, more prominent on the right side. 5. 2.8cm septated cystic mass of the pancreatic tail concerning for a mucinous tumor. Echo [**2148-8-21**] Conclusions: The left atrium is normal in size. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets 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. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Lower extremity ultrasound: IMPRESSION: 1. No DVT. 2. Bilateral small popliteal cysts. Video swallow study [**2148-8-26**] IMPRESSION: Limited study. Mild to moderate oral dysphagia with functional pharyngeal swallow. No evidence of aspiration. CT chest/abdomen/pelvis [**2148-8-29**] IMPRESSION: 1. Extraluminal gas identified as noted above in the region of the patient's recent surgery. Also, more focal area containing gas and fluid noted adjacent to the surgical site. 2. Stable cystic pancreatic tail lesion. Chest x-ray [**2148-9-1**] IMPRESSION: 1. No active disease. 2. Interval resolution of right pleural effusion and right basilar opacity. [**2148-8-17**] 07:50AM BLOOD WBC-14.9*# RBC-4.54 Hgb-14.0 Hct-41.8 MCV-92 MCH-30.9 MCHC-33.6 RDW-15.0 Plt Ct-282 [**2148-8-19**] 02:31AM BLOOD WBC-12.1*# RBC-2.97* Hgb-9.1* Hct-27.6* MCV-93 MCH-30.6 MCHC-32.9 RDW-14.8 Plt Ct-179 [**2148-8-28**] 06:50AM BLOOD WBC-6.7 RBC-2.48* Hgb-7.7* Hct-22.5* MCV-91 MCH-30.9 MCHC-34.1 RDW-15.2 Plt Ct-297 [**2148-8-31**] 12:05PM BLOOD WBC-6.1 RBC-3.34* Hgb-10.2* Hct-30.1* MCV-90 MCH-30.7 MCHC-34.0 RDW-15.5 Plt Ct-395 [**2148-8-17**] 07:50AM BLOOD Glucose-213* UreaN-34* Creat-1.6* Na-138 K-3.3 Cl-89* HCO3-36* AnGap-16 [**2148-8-17**] 03:54PM BLOOD Glucose-177* UreaN-23* Creat-0.9 Na-142 K-3.7 Cl-102 HCO3-29 AnGap-15 [**2148-8-28**] 06:50AM BLOOD Glucose-51* UreaN-28* Creat-1.1 Na-139 K-4.0 Cl-103 HCO3-29 AnGap-11 [**2148-8-28**] 06:31PM BLOOD Glucose-79 UreaN-28* Creat-1.2* Na-137 K-4.1 Cl-100 HCO3-25 AnGap-16 [**2148-8-29**] 06:40AM BLOOD Glucose-99 UreaN-24* Creat-1.2* Na-136 K-3.6 Cl-98 HCO3-26 AnGap-16 [**2148-8-30**] 06:20AM BLOOD Glucose-155* UreaN-19 Creat-1.2* Na-139 K-3.7 Cl-100 HCO3-29 AnGap-14 [**2148-8-31**] 12:05PM BLOOD Glucose-143* UreaN-12 Creat-1.0 Na-138 K-3.7 Cl-102 HCO3-27 AnGap-13 [**2148-9-1**] 07:18AM BLOOD Glucose-133* UreaN-11 Creat-0.9 Na-139 K-4.6 Cl-103 HCO3-28 AnGap-13 [**2148-8-19**] 06:29PM BLOOD CK-MB-6 cTropnT-0.09* [**2148-8-20**] 01:44AM BLOOD CK-MB-6 cTropnT-0.07* [**2148-8-30**] 06:20AM BLOOD calTIBC-153* VitB12-1631* Folate-GREATER TH Ferritn-402* TRF-118* [**2148-8-30**] 06:20AM BLOOD Free T4-1.2 [**2148-8-30**] 06:20AM BLOOD TSH-1.6 [**2148-8-17**] 08:03AM BLOOD Lactate-2.1* [**2148-8-17**] 12:20PM BLOOD Glucose-187* Lactate-2.0 Na-137 K-2.9* Cl-99* calHCO3-33* [**2148-8-17**] 01:40PM BLOOD Glucose-142* Lactate-3.5* Na-139 K-3.1* Cl-102 [**2148-8-17**] 04:19PM BLOOD Glucose-166* Lactate-1.5 K-3.5 [**2148-8-23**] 04:59AM BLOOD Lactate-0.8 Brief Hospital Course: Ms. [**Known lastname **] is a 76F who presented to the emergency department with abdominal pain of 1 day duration. CT scan revealed free air consistent with a perforated viscus. She was fluid resuscitated and taken to the operating room where it was discovered that she had a perforated duodenal ulcer. An open cholecystectomy, anterior parietal cell vagotomy, and [**Location (un) **] patch closure of the perforated duodenal ulcer were performed. She was taken to the intensive care unit and remained intubated post-operatively. Neurologic: The patient suffers from schizoaffective disorder. In the initial post-operative period sedation was required. As her pulmonary status improved on the ventilator sedation was weaned and she was extubated. Her PCP has been following her status with us and states that she is back to her baseline mental status. Cardiovascular: Her post-operative course was complicated by atrial fibrillation with rapid ventricular response. A cardiology consult was obtained and while in the ICU she required diltiazem, amiodarone, and metoprolol IV to obtain adequate rate control. She has been transitioned to oral diltiazem, amiodarone, and metoprolol and has since converted to a normal sinus rhythmn as evidenced by an EKG obtained on [**2148-8-31**] as well as on date of discharge. Cardiology has recommended that she be discharged on her current regimen, not to change the dosing, and follow up in the cardiology clinic. An appointment was scheduled for her for [**2148-9-9**]. Pulmonary: She remained intubated post-operatively. Her ventilatory status improved and she was able to be extubated in the ICU. She has had problems with clearing upper airway secretions. She was given an incentive spirometer and extensive chest physical therapy and this has helped clear the secretions. A sputum culture was sent and revealed only the growth of normal oropharyngeal flora. With her history of COPD she received scheduled albuterol/ipratropium nebulizers. Her oxygen saturations are in the high 90s on room air. Gastrointestinal: The patient remained NPO in the immediate post-operative period. After extubation there was concern for aspiration with swallowing. A swallow study was obtained and revealed a functional pharyngeal swallow with no evidence for aspiration. She was started on a pureed and nectar thickened liquid diet. Her swallow study was repeated with the same results and she was advanced to a regular diet with nutritional shakes with every meal. Her bowel function has returned and she is having normal bowel movements. GU: She was transferred to the floor with a foley catheter in place. On POD 13 her foley catheter was removed. She did complain of suprapubic so a straight cath was performed to obtain a sterile urine specimen. When the straight cath was inserted, 900cc of urine was obtained so the foley [**Last Name (un) **] was left in place. A second voiding trial was obtained and this time the patient was able ambulate to the bathroom with assistance and void. Renal: On presentation her creatinine was 1.6. After surgery and aggressive fluid resuscitation her creatinine normalized to 0.7. While on the surgical floor her creatinine did elevate to 1.2. Urine lytes and a smear for eosinophils were normal. She was gently rehydrated with intravenous fuids and her creatinine has normalized back to 0.9. Endo: The patient was receiving blood sugar checks 4 times a day with sliding scale insulin as needed. She did have blood sugars as low as 60 and 78. Due to these low blood sugars her oral diabetic medications were initially held, then restarted as blood sugars improved. Heme: The patient's hematocrit upon presentation was 41.8, but this was falsely elevated due to hemoconcentration. Post-operatively her hematocrit trended downward from 32.4 to 22.5. This was thought to be due to anemia of chronic disease as her vital signs remained stable and her urine output was adequate. She was transfused with 2 units of packed RBCs. Her post-transfusion hematocrit was 30.4 and it has remained stable at 30. ID: She was empirically treated for H.pylori. While in the ICU and on the floor she did have low grade temperature spikes. The source of the spikes was unclear so she was empirically started on Zosyn and a CT scan of her chest, abdomen, and pelvis was obtained which revealed normal post-operative changes in her abdomen and no organizing consolidations in her lungs. The zosyn was discontinued after 3 days and she has remained afebrile. She was placed on Lansoprazole for empiric HPylori treatment. Medications on Admission: 1. Lisinopril 20mg daily 2. Atenolol 3. Glipizide 1.25mg daily 4. Aspirin 81mg daily 5. Spiriva 6. MVI 7. Nexium 40mg daily 8. Seroquel 200mg [**Last Name (un) **] 9. Trazadone 75mg [**Last Name (un) **] 10. Duoneb 2.5/.5 q4H 11. MoM [**Name (NI) **] 12. [**Name2 (NI) **] 100mg [**Hospital1 **] 13. Nitroquick 0.4mg prn 14. Lipitor 10mg [**Hospital1 **] 15. Albuterol qid 16. Nicoderm c-q 7' Discharge Medications: 1. Glipizide 5 mg Tablet [**Hospital1 **]: 0.25 Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*0* 3. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Diltiazem HCl 30 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 8. Quetiapine 25 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). 9. NitroQuick 0.4 mg Tablet, Sublingual [**Hospital1 **]: One (1) tab Sublingual repeat q5min. up to 3 doses in 15min as needed for chest pain. 10. Nicoderm CQ 7 mg/24 hr Patch 24 hr [**Hospital1 **]: One (1) patch Transdermal once a day. 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*0* 12. DuoNeb 2.5-0.5 mg/3 mL Solution [**Last Name (STitle) **]: One (1) neb Inhalation every four (4) hours. 13. Aspirin 81 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 14. Lipitor 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime. 15. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 16. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO at bedtime. 17. Milk of Magnesia 7.75 % Suspension [**Last Name (STitle) **]: Thirty (30) ml PO at bedtime. 18. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device [**Last Name (STitle) **]: One (1) IH Inhalation once a day. 19. Vitamin E 400 unit Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a day. 20. Aerobid 250 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) puffs Inhalation twice a day. 21. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 22. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO every four (4) hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Perforated peptic ulcer Discharge Condition: Stable. Patient will be discharged to rehabilitation facility until able to return to home, duration of stay anticipated to be less than 30 days. Discharge Instructions: If fever >101.5, worsening abdominal pain, redness or drainage from incision, shortness of breath, or inability to tolerate food or medications, please call Dr. [**Last Name (STitle) 15645**] office or go to emergency room. Followup Instructions: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2148-10-1**] 9:30 Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 2723**]. Please call and schedule appointment in [**2-17**] weeks. An appointment has been scheduled for you with Cardiology for [**9-9**] at 9am with Dr. [**Last Name (STitle) **] [**Name (STitle) 23**] 7. Please call for confirmation or rescheduling [**Telephone/Fax (1) 62**].

[ "401.9", "574.10", "285.29", "496", "V15.82", "780.6", "998.89", "250.00", "427.31", "532.50", "272.0", "997.1", "530.81", "295.70" ]

icd9cm

[ [ [] ] ]

[ "99.04", "44.42", "51.22", "99.15", "44.02" ]

icd9pcs

[ [ [] ] ]

12774, 12844

5326, 9949

327, 477

12912, 13060

1529, 5303

13332, 13862

1004, 1022

10392, 12751

12865, 12891

9975, 10369

13084, 13309

1037, 1510

273, 289

505, 774

796, 935

951, 988

40,934

105,418

42276

Discharge summary

report

Admission Date: [**2114-10-3**] Discharge Date: [**2114-10-9**] Date of Birth: [**2055-7-5**] Sex: F Service: UROLOGY Allergies: Latex Attending:[**First Name3 (LF) 11304**] Chief Complaint: large right renal mass tumoral thrombus extending into the right renal vein, hepatic vein, and inferior vena cava Major Surgical or Invasive Procedure: Dr.[**Name (NI) 11306**] PROCEDURES: 1. Right open radical nephrectomy. 2. Retroperitoneal lymph node dissection 3. Inferior vena cava removal (dictated by and performed by Dr. [**First Name (STitle) **]. Dr.[**Name (NI) 670**] PROCEDURE PERFORMED: Mobilization the liver and takedown of the caudate lobe off the inferior vena cava, resection of the infrahepatic inferior vena cava down to the bifurcation of the common iliac veins. History of Present Illness: 59F with recently diagnosed large right renal mass with tumoral replacement of the right kidney and tumoral thrombus extending into the right renal vein, hepatic vein, and inferior vena cava now s/p right radical nephrectomy with resection of IVC and RPLND. She intially presented to her PCP back in [**6-13**] with vague symptoms of fatigue and back pain. In the month following she reported some abd discomfort and bloating and peripheral edema. She was sent for CT abd/pelvis which then revealed the renal mass which was highly suspicious for renal cell carcinoma. In the setting of IVC involvement the decision was made to proceed with tumor debulking as opposed to tissue biopsy. Prior to surgery she was sent for staging with CT chest and bone scan which did not show evidence of metastasis. Past Medical History: PMHx: -HLD -osteopenia -basal cell carcinoma of forehead s/p excision [**2114**] -superficial melanoma s/p excision [**2093**] -cervical cancer -h/o PUD and h.pylori PSHx: -s/p hysterectomy and appendectomy [**2081**] Social History: SocHx: -30 py smoker - quit [**2102**] -occasional etoh -no IVDA Family History: FamHx: -sister - breast cancer Physical Exam: WdWn pleasant female, NAD, AVSS Abdomen soft, nt/nd appropriate tenderness along large incision line with staples/surgical skin clips. Localized erythema c/w with skin clips. No evidence hematoma, infection. extremities soft w/out pitting, calf pain. Bilateral lower extremities w/out pitting to palpation to proximal tibia areas. Pertinent Results: [**2114-10-8**] 08:15AM BLOOD WBC-7.1 RBC-2.90* Hgb-9.1* Hct-26.5* MCV-91 MCH-31.3 MCHC-34.3 RDW-14.2 Plt Ct-363# [**2114-10-7**] 10:10AM BLOOD WBC-7.0 RBC-2.63* Hgb-8.5* Hct-24.1* MCV-91 MCH-32.2* MCHC-35.2* RDW-13.9 Plt Ct-234 [**2114-10-7**] 08:53AM BLOOD WBC-6.7 RBC-2.90* Hgb-9.3* Hct-26.5* MCV-91 MCH-32.0 MCHC-35.0 RDW-14.0 Plt Ct-265 [**2114-10-7**] 10:10AM BLOOD Glucose-134* UreaN-12 Creat-1.0 Na-142 K-4.3 Cl-106 HCO3-27 AnGap-13 [**2114-10-7**] 08:53AM BLOOD Glucose-147* UreaN-11 Creat-1.0 Na-141 K-4.0 Cl-105 HCO3-30 AnGap-10 [**2114-10-6**] 04:10AM BLOOD Glucose-118* UreaN-13 Creat-0.9 Na-141 K-4.0 Cl-105 HCO3-29 AnGap-11 [**2114-10-4**] 12:40AM BLOOD Type-ART pO2-196* pCO2-40 pH-7.41 calTCO2-26 Base XS-1 [**2114-10-3**] 06:59PM BLOOD Type-ART pO2-344* pCO2-45 pH-7.37 calTCO2-27 Base XS-0 [**2114-10-3**] 04:38PM BLOOD Type-ART pO2-221* pCO2-39 pH-7.33* calTCO2-21 Base XS--4 [**2114-10-3**] 04:38PM BLOOD Glucose-212* Lactate-4.9* Na-136 K-4.9 Cl-113* Brief Hospital Course: Ms. [**Known lastname **] was admitted to the TSICU and then to the general urology service after undergoing the above listed procedures with Dr. [**Last Name (STitle) 3748**] and Dr. [**First Name (STitle) **]. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. Ms. [**Known lastname **] was recoved in the TSICU afte surgery and kept intubated until POD1 where she was successfully weened and extubated. She was transferred to the general surgical floor from the TSICU in stable condition on POD2. Pain was well controlled with an epidural managed by the Acute Pain service and she was hydrated for urine output >30cc/hour, provided with pneumoboots and incentive spirometry for prophylaxis, and kept on subcutaneous heparin. On POD2 she was out of bed to chair and by POD3 she was ambulating. On POD2 her nasogastric tube was clamped and on POD3 it was discontinued alltogether. With the gradual passage of flatus her diet was slowly advanced, epidural discontinued and she was transitioned to oral pain medications. Her labs were monitored daily and she did not require any blood transfusions. Urethral Foley catheter was removed without difficulty and the remainder of the hospital course was relatively unremarkable. The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up with Dr. [**Last Name (STitle) 3748**], Dr. [**First Name (STitle) **] and her PCP. Medications on Admission: Allergies: -latex Home medications: -cyclobenzaprine -diclofenac -vicodin 2.5mg / 500 -raloxifene -simvastatin Discharge Medications: 1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): Hold for SBP < 100, HR < 55 . Disp:*45 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: PREOPERATIVE DIAGNOSIS: Renal cell carcinoma with a caval thrombus and extension of tumor. POSTOPERATIVE DIAGNOSIS: Renal cell carcinoma with a caval thrombus and extension of tumor. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Please also refer to the provided written instructions on post-operative care, instructions and expectations made available from Dr. [**Last Name (STitle) 3748**]??????s office. -Resume your pre-admission/home medications except as noted. ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor -To help manage your Blood pressure (control hypertension) we have started you on a NEW medication called METOPROLOL listed here. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): Hold for SBP < 100, HR < 55 . A prescription "script" has been provided. -Please keep a blood pressure log and review this medication and log with your surgeons and PCP. Disp:*45 Tablet(s)* Refills:*2* -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -Resume all of your pre-admission/home medications except as noted. Do not take Aspirin or Non-steroidal anti-inflammatories (ibuprofen, etc.) unless advised to do so. -Call your Urologist's and Vascular Surgeon's office to schedule/confirm your follow-up appointment in 3 weeks AND if you have any questions. -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks or until otherwise advised -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthrough pain >4. Replace Tylenol with narcotic pain medication. -Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -If you have been prescribed IBUPROFEN (the ingredient of Advil, Motrin, etc.) , you may take this and Tylenol together (alternating) for additional pain control---please try TYLENOL FIRST and take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark tarry stools) -You may shower normally but do NOT immerse your incisions or bathe -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest emergency room.ks time. Followup Instructions: -Call Dr.[**Name (NI) 11306**] office at ([**Telephone/Fax (1) 8791**] for follow-up AND if you have any urological questions. Dr. [**Last Name (STitle) 3748**]??????s Nurse Practitioner [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22714**] may be reached at the same number. -You will follow-up in [**8-12**] days for post-operative evaluation and Surgical skin clip (staple) removal Please call and arrange follow up with Dr. [**First Name (STitle) **] Please call your PCP for an appointment as well: Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 91619**] Completed by:[**2114-10-9**]

[ "V10.82", "189.0", "458.29", "V10.41", "272.4", "453.2" ]

icd9cm

[ [ [] ] ]

[ "40.29", "38.07", "55.51", "38.93" ]

icd9pcs

[ [ [] ] ]

5914, 5920

3380, 5105

379, 816

6150, 6150

2383, 3357

8983, 9622

1984, 2017

5267, 5891

5941, 6129

5131, 5149

6301, 8960

2032, 2364

5167, 5244

226, 341

844, 1643

6165, 6277

1665, 1885

1901, 1968

19,819

151,971

7258

Discharge summary

report

Admission Date: [**2173-2-11**] Discharge Date: [**2173-2-19**] Date of Birth: [**2096-7-24**] Sex: F Service: MEDICINE Allergies: Aspirin / Doxil Attending:[**First Name3 (LF) 783**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: 76 yo female w/hx of ovarian CA dx in [**2150**] s/p TAH BSO, debulkining last in [**7-21**] resulting in colostomy and 9 rounds of chemo on gemcitibine prior to admission, HTN, CHF (EF now 35% but nl EF and clean c's in [**7-21**] cath), anxiety, PUD, ureteral obstruction s/p stents last on left in [**11-21**] who was admitted to the MICU after severe pulmonary edema after blood transfusion in Heme/[**Hospital **] clinic. Pt was on regimen of gemcitibine for ovarian CA after poor tolerance for doxorubacin and routine labs in clinic revealed Hct 24 so she was she was transfused 2 units PRBC's. She then developed respiratory distress requiring intubation in the ED. She was found to have a small troponin leak to .10 and cardiology was consulted, but attributed it to CHF and recommended no need for cath or heparin. TTE revealed apical and septal HK with an EF of 35% with most recent TTE Social History: Lives on her own. Is Greek speaking. Two sons live close by and are involved -- [**Doctor Last Name **] and [**Doctor Last Name **]. She does not use tob, etoh, or drugs. Family History: Sister has breast cancer Physical Exam: T 100.7 HR 94 BP 99/76 AC 550 x 14 PEEP 15 100% o2 GEN: sedated, intubated HEENT: PERRL, EOMI CV: RRR S1S2 no murmurs Chest: left port LUNG: clear anteriorly, crackles r base ABD:soft, nt, ostomy in place, slightly distended, midline scar, bs+ EXT: no edema Pertinent Results: ekg: nsr 99 bpm, nl axis, left bundle branc block, no st/t changes, no change from previous * cxr #1 b/l patchy infiltrates cxr #2 improved pulmonary edema, ett tube in place * Abdominal MRI [**2-15**]: 1) Extensive tumor mass within the lower pelvis, growing superiorly, resulting in bilateral distal ureteral obstruction. Progression vs. prior. 2) Large suprapubic enhancing tumor mass as described, corresponding to the calcified mass detected on recent CT. 3) Incidentally detected deep venous thrombosis within the left leg. * ECHO [**2-12**]: EF 35%, mild symmetric LVH, mild global HK and severe HK of septum and apex c/w CAD. * cath [**7-21**]: nl coronaries, diastolic dysfunction * renal u/s: IMPRESSION: Bilateral nephroureteral stents. Mild pelviectasis on the right,and more prominent pelvocaliectasis on the left, with additional multiple parapelvic cysts bilaterally. In comparison to the CT dated [**2172-12-24**], the most recent comparison examination available, the degree of bilateral pelvocaliectasis is probably stable to perhaps slightly decreased. * [**2172-12-23**] ct abd: delayed left nephrogram, no hydro * Brief Hospital Course: 1. SOB. The patient was treated with oxygen, lasix, nitro, morphine in the ED with little result. She intubated in the emergency department because of worsening respiratory status and transferred to the ICU. CXR at the time showed patchy bilateral infiltrates consistent with pulmonary edema. In the ICU, the patient was successfully diuresed and repeat CXR was greatly improved and she was successfully extubated on HOD#2. On arrival to the floor, the patient was breathing comfortably on 4 L supplemental O2 which was successfully weaned on the day prior to admission. 2. CHF. The patient was found to be in CHF at presentation. After initial diuresis, the patient was thought to be euvolemic and diuresis was stopped prior to transfer to the floor. The patient had a slight troponin elevation to 0.10 but ruled out for acute coronary syndrome by CK and MB fraction. Echocardiogram revealed an EF of 35% with global and focal hypokinesis suggesting an acute coronary event may have occurred sometime in the interim between her normal cath in [**2170**] and this hospitalization. Chemotherapy-induced cardiomyopathy is not thought to have been responsible for the CHF. The etiology of the patient's CHF is presumed to be volume overload from the transfusion. In house, the patient was treated with metoprolol, aspirin, nitrates/hydralzine. It was not felt that the patient would benefit from having a stress test or cath during this hospitalization. The patient will follow-up with cardiology in [**1-21**] weeks to repeat echo and determine outpatient plan. It is recommended that the patient begin an ACE inhibitor when renal function returns to baseline. 3. ARF/Ureteral obstruction. The patient was found to be in acute renal failure in the ICU with creatinine to 4.6 (BUN 76). Initially this was thought to be ischemia-induced ATN secondary to the flash pulmonary edema, but given the patient's history of ureteral obstruction, this was investigated by renal U/S. U/S was inconclusive and a follow-up abdominal MRI revealed bilateral distal ureteral obstruction on HOD #4. In the interim, creatinines had already begun to trend down, consistent with ATN. On HOD#5, the patient had bilateral ureteral stent replacement and the creatinine subsequently continued to normalize to a level of 1.5 on day of discharge. The patient will follow-up with urology for outpatient management and likely restenting in a few months. 4. Anticoagulation/Anemia. A left femoral vein DVT was found on MRI on HOD #4. At this time, the patient was begun on heparin for anticoagulation. Given the patient's history of GI bleed on coumadin, the decision was made not to initiate coumadin for outpatient anticoagulation. Instead, an IVC filter was placed with the assumption that the long-term complications of clot may not be as significant in this patient with a somewhat limited life expectancy. Medications on Admission: 1. Toprol 50qd 2. Prochlorperazine prn nausea 3. Phenazopyridine prn 4. Oxycodone prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 4. Hydralazine HCl 10 mg Tablet Sig: Four (4) Tablet PO Q6H (every 6 hours). Disp:*480 Tablet(s)* Refills:*2* 5. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. prescription One hospital bed. 7. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once a day. Disp:*30 packet * Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: * Ureteral obstruction from ovarian cancer * peptic ulcer disease with history of gastrointestinal bleed * hypertension * anxiety * deep venous thrombosis * acute renal failure * pulmonary edema * anemia Discharge Condition: stable Discharge Instructions: Please take all medications as prescribed. If you develop chest pain, shortness of breath, or have swelling, please call your PCP or come to the ED. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11139**] at [**Telephone/Fax (1) 26838**], for a follow up appointment in the next 1-2 weeks. Please have your blood counts and potassium level checked at this time. You will need to have a repeat echocardiogram in [**1-21**] weeks. Please talk with Dr. [**Last Name (STitle) 11139**] about scheduling this as well as following up with a cardiologist. If Dr. [**Last Name (STitle) 11139**] does not have another recommendation you may follow up with cardiologist Dr. [**First Name (STitle) **] [**Name (STitle) **] by calling [**Telephone/Fax (1) 26839**]. Please discuss the use of aspirin at this appointment. Please follow up with urology. You have already been contact[**Name (NI) **] and scheduled an appointment. The phone number for the urology clinic is ([**Telephone/Fax (1) 13609**]. Please follow up with oncology in the next several weeks as well. You can call to schedule an appointment with Dr. [**Last Name (STitle) **] at ([**2173**]. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "285.9", "183.0", "593.4", "599.0", "428.0", "518.81", "428.20", "584.9", "453.41", "591" ]

icd9cm

[ [ [] ] ]

[ "57.32", "87.74", "96.71", "38.7", "59.8" ]

icd9pcs

[ [ [] ] ]

6763, 6826

2913, 5798

296, 302

7074, 7082

1753, 2890

7279, 8441

1433, 1459

5935, 6740

6847, 7053

5824, 5912

7106, 7256

1474, 1734

236, 258

330, 1229

1245, 1417

14,810

186,299

12151

Discharge summary

report

Admission Date: [**2151-5-19**] Discharge Date: [**2151-5-27**] Date of Birth: [**2092-2-5**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2698**] Chief Complaint: Hypoxia s/p cardiac cath Major Surgical or Invasive Procedure: Cardiac catheterization Hemodialysis TUnnelled line placment History of Present Illness: 59 y.o. Female presented to [**Hospital1 **] ER on day of admission w/ SOB, no chest pain. RA sat noted to be 86%, RR 36. EKG shows borderline STE inferiorly, inferior Q waves, TWI in inferior and lateral leads. She was given ASA, lasix 120 mg IV and solumedrol and started on heparin and nitro gtt. Labs there notable for K 5.1, BUN 114, Crn 4.4, hct 28.8, CK 202, trop I 0.2, elev transaminases, nl t bil, nl ocags, nl alb. tx'd to [**Hospital1 18**] for cath. Of note pt fell recently and hurt L arm. Got cath with following findings 1. Selective coronary angiography revealed a right dominant system with three vessel coronary artery disease. The long LMCA had no hemodynamically significant flow limiting lesions. The attentuated LAD had diffuse moderate disease with high grade disease in the branch vessels. The small attenuated LCX had diffuse moderate disease. The RCA had an 80% proximal lesion with a 95% mid vessel stenosis with thrombus. The PDA and PL branches had high grade diffuse disease with left to right collaterals from the LAD. 2. Resting hemodynamics demonstrated severely elevated right sided (mean RA 14 mmHg), pulmonary (mean PA 46 mmHg), and left sided pressures (mean PCWP 33 mmHg). The cardiac index was normal (2.9 l/min/m2). 3. Left ventriculography was deferred for severe renal insufficiency. 4. The right femoral arteriotomy was closed successfully with angioseal. 5. ABG in cath lab 7.16/55/70. She was transferred to CCU post cath on 100% NRB, satting 95% on natrecor. ABG in cath lab 7.16/55/70. Given elevated wedge, hypoxia, and severe CHF, Renal was consulted. She was given 200 IV lasix and 500 IV diamox with little response. R femoral Quinton catheter was placed. She was dialyzed with 2.5 kg UF. She also was placed on Bipap for oxygenation. Repeat ABG on Bipap and during dialysis was 7.31/41/94. She was ordered to get blood transfusion, given her anemia, during dialysis but the blood was not ready in time. She was taken off bipap and her sats were 95% on 70%NRB and weaned to nasal cannula over the first night of admission. Labs: **creat 4.3, trop .2, ck 200's, bnp 2,320, h/h 9.5/28.8, elevated AST and ALT Past Medical History: Chronic Kidney Dissease, CAD, DM, silent MI's, EF 30%, CHF, dialysis in the setting of CHF, but otherwise does not regularly get HD. Social History: Married, with large family No ETOH, no drugs Physical Exam: AF, 73, 129/61, 22, 95% on 100% NRB GENL: Mild resp distress HEENT: no JVP visualized CV: RRR, no MRG LUNGS: course breath sounds diffusely ABd: soft, nt, nd, +bs, no HSM Ext: trace pedal edema Pertinent Results: ECHO [**5-20**]: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] size. EF 35%. No ASD. LV wall thickness/ cavity size nl. LV systolic function moderately depressed w/mild global HK and near AK of inferior and infero-lateral walls. [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] RV chamber size and free wall motion are normal. The aortic valve leaflets (3) mildly thickened, no AS/ AR. moderate (2+) MR. Mild pulmonary artery systolic hypertension. Small to moderate sized pericardial effusion mostly localized anterior to the RA. no tamponade. - Cardiac cath: 1. Selective coronary angiography revealed a right dominant system with three vessel coronary artery disease. The long LMCA had no hemodynamically significant flow limiting lesions. The attentuated LAD had diffuse moderate disease with high grade disease in the branch vessels. The small attenuated LCX had diffuse moderate disease. The RCA had an 80% proximal lesion with a 95% mid vessel stenosis with thrombus. The PDA and PL branches had high grade diffuse disease with left to right collaterals from the LAD. 2. Resting hemodynamics demonstrated severely elevated right sided (mean RA 14 mmHg), pulmonary (mean PA 46 mmHg), and left sided pressures (mean PCWP 33 mmHg). The cardiac index was normal (2.9 l/min/m2). 3. Left ventriculography was deferred for severe renal insufficiency. 4. The right femoral arteriotomy was closed successfully with angioseal. 5. ABG in cath lab 7.16/55/70. [**2151-5-19**] 04:12PM BLOOD WBC-8.2 RBC-3.18* Hgb-8.5* Hct-27.1* MCV-85 MCH-26.8* MCHC-31.4 RDW-15.3 Plt Ct-231 [**2151-5-22**] 08:00AM BLOOD Plt Ct-231 [**2151-5-19**] 04:12PM BLOOD PT-13.8* PTT-136.7* INR(PT)-1.3 [**2151-5-19**] 04:12PM BLOOD Plt Smr-NORMAL Plt Ct-231 [**2151-5-19**] 02:30PM BLOOD Glucose-257* UreaN-114* Creat-4.4* Na-142 K-5.1 Cl-106 HCO3-18* AnGap-23* [**2151-5-19**] 02:30PM BLOOD ALT-197* AST-202* LD(LDH)-394* CK(CPK)-180* AlkPhos-215* Amylase-59 TotBili-0.5 [**2151-5-19**] 04:12PM BLOOD CK(CPK)-187* [**2151-5-20**] 04:25AM BLOOD ALT-142* AST-71* CK(CPK)-163* AlkPhos-178* TotBili-0.8 [**2151-5-19**] 04:12PM BLOOD CK-MB-4 cTropnT-0.22* [**2151-5-20**] 04:25AM BLOOD CK-MB-5 cTropnT-0.33* [**2151-5-22**] 08:00AM BLOOD Albumin-3.8 Calcium-8.6 Phos-5.9* [**2151-5-19**] 09:36PM BLOOD calTIBC-228* Ferritn-516* TRF-175* [**2151-5-19**] 09:36PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE HAV Ab-POSITIVE [**2151-5-19**] 09:36PM BLOOD HCV Ab-NEGATIVE [**2151-5-19**] 03:04PM BLOOD pO2-70* pCO2-55* pH-7.16* calHCO3-21 Base XS--9 [**2151-5-20**] 04:45AM BLOOD Type-ART FiO2-70 pO2-131* pCO2-36 pH-7.38 calHCO3-22 Base XS--2 Brief Hospital Course: 59 yo female w/ hx DMII, chronic kidney disease, baseline creat 4.0, hx " silent MI" w/ EF 30%, admitted s/p cath for borderline STE in inferior leads, elevated PCWP 33, w/ distal occlusion of RCA s/p stent, metabolic acidosis, with decompensated CHF requiring dialysis. 1. CHF: Unclear exacerbating factor. Likely related to dietary indiscretion and ARF on CRF with sytolic and diasotolic dysfuncion. SHe responded well to hemodialysis with approximately 2.5 liters taken off over 3 sessions. Pt had HD again on [**5-24**] after tunneled line was placed at which time 1kg was taken off. Last HD(ultrafiltration) prior to d/c was on [**5-25**] at which time she had fluid removed (1.7 kg) [**1-20**] to O2 sats in low 90's. O2 sats improved after dialysis. During admission she was started on regimen of afterload reduction with isordil and hydralazine. She will be discharged on Imdur, 90mg QD and hydralazine, 25mg q6hr. We resumed her coreg at 12.5mg [**Hospital1 **]. After she is stable on regular outpt hemodialysis, she should be switched to an ACEI. Echo showed EF 35% during admission. . 2. Hypoxia: Likely secondary to CHF and pulmonary edema. She had no clear infiltrate on CXR. Her hypoxia improved after hemodialysis. She was sating 95-98% on room air at time of discharge. . 3. ACS: She may have had a small STEMI. Her CK's were flat, but troponin of 0.22-0.4. She is S/P RCA stent at cath. She was maintained on her coreg, ASA and plavix and lipitor were started during admission. She was started on hydralazine and imdur. She will benefit from and ACEI or [**Last Name (un) **] for afterload reduction and remodeling after HD is started on outpt basis, and then can discontinue hydralazine and imdur. . 4. Hypertension: Her BP was quite labile at times. She was treated with Carvedilol, isosorbide dinitrate. We held norvasc given more benefit from hydral/nitrate and afterload reduction. As above, she will be discharged on hydralalzine and imdur. . 5. ARF: SHe is requiring HD at this point. Per her outpt neprhologist she did require HD in past for CHF but recvoered her kidney function and creatinine went down to 3.5. It appears that she will need chronic dialysis to keep her euvolemic. Renal ultrasound was negative for obstruction, urine eos neg, u/a neg. Spoke to her nephrologist, Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 26271**] and plans underway for her to get out patient dialysis at [**Location (un) 47**] - west suburban kd [**Telephone/Fax (1) 38075**]. She had a tunneled line placed in R ant chest on [**5-24**] without complication. Last dialysis was on Wed, [**2151-5-26**]. Her first outpt dialysis appointment has been scheduled for Sat [**5-29**]. S/P placement of tunneled cath by interventional radiology. . 6. DM2: On NPH [**4-27**] QAM/PM at home. During admission, her doses of NPH were lowered [**1-20**] to episodes of hypoglycemia. Given multiple epsiodes of hypoglycemia her insulin regimen was ultimatey changed to long acting glargine (5 units) each morning. She was covered with regular insulin sliding scale; however, given hypoglycemia and brittle diabetes, she did not receive any insulin per scale until BG levels >150. Please see attached sliding scale. . 7. Elevated transaminases: Felt to be due to hepatic congestion from CHF. No h/o alcohol use. Hepatitis serologies postivie for Hepatitis A antibody and Hepatitis B surface antibody, likely form vaccination. . 8. L shoulder pain: possible trauma s/p fall. Shoulder and elbow xray negative from fracture. . 9. ANemia: unlcear baseline, likely secondary to CKD. S/p 3 units of blood. Started iron. [**Month (only) 116**] benefit from epogen at hemodialysis. . 10. Abdominal pain - KUB [**5-26**] without evidence of obstruction. She had some diarrhea on day of discharge. Cdiff negative X2. . 11. Leukocytosis: pt developed leukocytosis on [**5-26**]. Unclear etiology. Medications on Admission: Norvasc 10 mg QD Coreg 12.5 mg [**Hospital1 **] Insulin NPH 5 units QAM, 10 units QPM lasix 160 mg QD Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 9. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please hold for HR<55 or SBP<110. 10. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): hold for SBP<110. 11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed. 13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. 15. Insulin Glargine 100 unit/mL Cartridge Sig: Five (5) untis Subcutaneous once a day: please give 5 units of glargine to patient each morning; see sliding scale attached for TID sliding scale parameters. 16. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily): please hold for SBP<105. 17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal ONCE (once) as needed for constipation for 1 doses. Discharge Disposition: Extended Care Facility: [**Location (un) 38076**] House - [**Location (un) 47**] Discharge Diagnosis: Discharge Worksheet-Discharge Diagnosis-Finalized:[**Last Name (LF) **],[**Name8 (MD) **], MD on [**2151-5-27**] @ 1535 Priamry Diagnosis: 1. CHF 2. distal occluded RCA s/p stent placement 3. Acute on chronic renal insufficiency with initiation of long term dialysis Secondary Diagnosis: 1. Chronic Kidney Dissease 2. CAD 3. DM - silent MI's, EF 30%, 4. CHF 5. HTN Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L You were started on hemodialysis during your admission for your congestive heart failure and worsening renal status. A tunneled line was placed for you to continued hemodialysis as an outpatient. Please take all medications as prescribed. You are scheduled for dialysis on Tuesdays, THurdays, and Saturdays at Framinham Artificial Kidney Center Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 38077**], at [**Telephone/Fax (1) **] to schedule a follow up appointment within 2 weeks of discharge. Please call your nephrologist, Dr. [**Last Name (STitle) 38078**], at [**Telephone/Fax (1) 38079**], on discharge to schedule a follow up appointment after you are discharged from rehabilitation. Please continue outpatient hemodialysis as per your tuesday,thursday, saturday schedule.

[ "428.0", "425.4", "584.9", "272.4", "428.41", "403.91", "250.00", "423.9", "414.01", "416.8", "276.4", "599.0", "285.9", "041.01" ]

icd9cm

[ [ [] ] ]

[ "36.01", "93.90", "38.95", "37.23", "36.07", "88.56", "00.13", "99.04", "38.93", "39.95" ]

icd9pcs

[ [ [] ] ]

11686, 11769

5769, 9668

340, 402

12178, 12186

3052, 5746

12704, 13172

9821, 11663

11790, 12057

9694, 9798

12210, 12681

2838, 3033

275, 302

430, 2604

12078, 12157

2626, 2761

2777, 2823

79,751

193,760

38637

Discharge summary

report

Admission Date: [**2180-2-1**] Discharge Date: [**2180-2-5**] Date of Birth: [**2127-7-25**] Sex: M Service: CARDIOTHORACIC Allergies: Mucolytic / IV Dye, Iodine Containing Attending:[**First Name3 (LF) 1505**] Chief Complaint: Syncope; fatigue; decreased exercise tolerance Major Surgical or Invasive Procedure: [**2180-2-1**] Acending aorta replacement with 28mm gelweave graft History of Present Illness: 52 year old male with heart murmur for years and serial echos showing functional vs. anatomic bicuspid Aortic valve. Has had increasing symptoms in past 1-2 years. First CT scan done recently shows 4.9 cm ascending aorta. Referred for surgical second opinion. Today presents for surgical work-up. Of note patient went to [**Hospital1 1774**] last Monday after feeling ill with upper abdominal/lower chest pain that radiated to back. Work-up revealed was negative. During visit patient had cardiac cath, which was also negative for CAD. Past Medical History: Aortic aneurysm s/p ascending aorta replacement Past medical history: Hypertension Hyperlipidemia Syncope Anemia Bicuspid Aortic Valve Benign Prostatic Hypertrophy Chonic Renal Insufficiency (1.8) Ocular Migraines Anxiety Gastroesophageal reflux disease/Barrett's esophagus Hypothyroid Separated Left shoulder Skin Cancer Past Surgical History: Testicular torsion Repair Ligament repair Right wrist Left facial skin Cancer removal/Chest Bilateral eye [**Last Name (un) 8509**] Surgery Social History: Race: Caucasian Last Dental Exam: last month Lives with: wife and 2 kids and mother in law Occupation: Supervisor for TSA Tobacco: never ETOH: denies Rec drugs: denies Family History: Father died with CABG age 79 Physical Exam: Pulse: 57 O2 sat: 100% B/P Left: 126/77 Height: 5'8" Weight: 174 LBS General: No acute distress Skin: Dry [X] intact [X]WELL HEALED RIGHT ARM SCARS. small, pinpoint papules on hands (?rxn to medication received at cath) HEENT: PERRLA [X] EOMI [X]ANICTERIC SCLERA; OP UNREMARKABLE Neck: Supple [X] Full ROM [X]NO JVD Chest: Lungs clear bilaterally [X]HEALED SM.SCAR AT XIPHOID Heart: RRR [X] Irregular [] Murmur FAINT SEM Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] NO HSM/CVA TENDERNESS Extremities: Warm [X], well-perfused [X] Edema/Varicosities: None [X] Neuro: Grossly intact Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [**Name (NI) 167**]:NP Left:NP Radial Right:2+ Left:2+ Carotid Bruit Right:0 Left:0 Pertinent Results: [**2180-2-1**] Echo: PRE-BYPASS: 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. Left ventricular wall thicknesses and cavity size are normal. The right ventricular cavity is mildly dilated with borderline normal free wall function. The ascending aorta is moderately dilated. The aortic valve is bicuspid. Tthere is a median fibrous raphe in the anterior aortic cusp and causing limited leaflet excursion. here is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Aoritc valve area by planimetry (2D and 3D) was consistently obtained to be 3.4 cm2 POST CPB: 1. Preserved [**Hospital1 **]-ventricular systolci function 2. The aoritc valve leaflets are freely mobile 3. Aortic valve area by planimetry was consistentlyu obtained to be > 4 cm2 4. There is no aortic regurgitation 5. A tube graft is visualized in the ascending aortic position. [**2180-2-1**] 01:21PM BLOOD WBC-18.7*# RBC-3.15*# Hgb-8.2*# Hct-25.0*# MCV-80* MCH-26.0* MCHC-32.7 RDW-14.0 Plt Ct-288 [**2180-2-3**] 05:50AM BLOOD WBC-14.9* RBC-3.34* Hgb-9.2* Hct-27.1* MCV-81* MCH-27.6 MCHC-34.0 RDW-14.1 Plt Ct-214 [**2180-2-1**] 01:21PM BLOOD PT-15.3* PTT-31.2 INR(PT)-1.3* [**2180-2-1**] 02:56PM BLOOD UreaN-16 Creat-1.4* Cl-115* HCO3-23 [**2180-2-3**] 05:50AM BLOOD Glucose-109* UreaN-22* Creat-1.6* Na-140 K-4.2 Cl-104 HCO3-26 AnGap-14 Brief Hospital Course: Mr. [**Known lastname 31102**] was a same day admit after undergoing pre-operative work-up as an outpatient. On [**2180-2-1**] she was brought to the operating room where he underwent replacement of his ascending aorta. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one his chest tubes were removed and he was transferred to the telemetry floor for further care. pain control was a major issue requiring 4-6 mg dilaudid every 3hrs. Pain improved once his chest tubes were removed. The temporary pacing wires were removed on POD#3. He was evaluated by physical therapy for strength and conditioning and cleared for discharge to home on POD#4 by Dr. [**Last Name (STitle) **]. Medications on Admission: Nexium 40mg po BID Atenolol 12.5mg po daily Gemfibrozil 600mg po BID Lipitor 20mg po daily Flomax 0.4mg po daily Levoxyl 50 mcg po daily Sertraline 50mg po daily Aranesp 60mg q monthly Saw [**Location (un) **] daily Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*0* 2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 10 days. Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 9. Levoxyl 50 mcg Tablet Sig: One (1) Tablet PO once a day. 10. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 11. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Aortic aneurysm s/p ascending aorta replacement Past medical history: Hypertension Hyperlipidemia Syncope Anemia Bicuspid Aortic Valve Benign Prostatic Hypertrophy Chonic Renal Insufficiency (1.8) Ocular Migraines Anxiety Gastroesophageal reflux disease/Barrett's esophagus Hypothyroid Separated Left shoulder Skin Cancer Past Surgical History: Testicular torsion Repair Ligament repair Right wrist Left facial skin Cancer removal/Chest Bilateral eye [**Last Name (un) 8509**] Surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with dilaudid prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care Dr. [**First Name8 (NamePattern2) 1169**] [**Last Name (NamePattern1) **] in [**11-27**] weeks Cardiologist Dr. [**Last Name (STitle) **] in [**11-27**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2180-2-5**]

[ "585.9", "530.85", "300.00", "600.00", "441.2", "746.4", "244.9", "403.90", "285.9", "458.29", "272.4", "530.81" ]

icd9cm

[ [ [] ] ]

[ "38.45", "35.11", "39.61" ]

icd9pcs

[ [ [] ] ]

6540, 6615

4126, 5004

349, 417

7143, 7238

2560, 3348

7778, 8208

1691, 1721

5270, 6517

6636, 6684

5030, 5247

7262, 7755

6981, 7122

1736, 2541

263, 311

445, 982

6706, 6958

1506, 1675

3358, 4103

79,053

106,359

13102

Discharge summary

report

Admission Date: [**2167-10-28**] Discharge Date: [**2167-11-5**] Date of Birth: [**2096-5-11**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor / Tricor Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2167-10-30**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to LPDA), Right Carotid Endarterectomy [**2167-10-28**] Cardiac Cath History of Present Illness: Mr. [**Known lastname 1458**] is a 71 y/o male transferred from [**Hospital3 **] after +ETT (had chest pain with EKG changes). Underwent cardiac cath which revealed severe three vessel disease. Past Medical History: Carotid Stenosis s/p Left Carotid Endarterectomy, Hyperlipidemia, Hypertension, Peripheral Vascular Disease, Peptic Ulcer Disease with GI bleed 12 yrs ago, Borderline Diabetes Mellitus, s/p Left Carotid Endarterectomy, s/p Hemorrhoidectomy Social History: Quit smoking less than 1 yr ago. Smoked x 30-40 years. Denies ETOH use. Family History: Mother with MI at age 68. Physical Exam: At Discharge: VS:T98 BP150/80 P69 RR20 I&O925/700+ Wt88.5kg 96% 2LNC Gen:NAD Chest:lungs CTA bilaterally Heart:RRR, no M/C/R Abd: S, NT, ND Ext:1+ edema, well perfused Incision: C/D/I, sternum stable Pertinent Results: [**2167-10-30**] Echo: PRE CPB The left atrium is moderately dilated. The left atrium is elongated. 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. 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. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are mildly to moderately thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST CPB Normal biventricular systolic function. Thoracic aorta appears intact. No significant change from the pre bypass study. [**2167-10-29**] Carotid U/S: 70-79% stenosis of the bilateral internal carotid arteries. [**2167-11-5**] 05:55AM BLOOD WBC-12.0* RBC-3.30* Hgb-10.0* Hct-28.6* MCV-87 MCH-30.4 MCHC-35.0 RDW-13.8 Plt Ct-149* [**2167-11-5**] 05:55AM BLOOD Plt Ct-149* LPlt-3+ [**2167-11-5**] 05:55AM BLOOD Glucose-89 UreaN-26* Creat-1.1 Na-137 K-4.2 Cl-98 HCO3-30 AnGap-13 [**2167-11-5**] 05:55AM BLOOD WBC-12.0* RBC-3.30* Hgb-10.0* Hct-28.6* MCV-87 MCH-30.4 MCHC-35.0 RDW-13.8 Plt Ct-149* [**2167-10-28**] 04:30PM BLOOD WBC-8.1 RBC-3.94* Hgb-12.5* Hct-33.8* MCV-86 MCH-31.7 MCHC-37.0* RDW-12.8 Plt Ct-109* [**2167-11-5**] 05:55AM BLOOD PT-14.5* INR(PT)-1.3* [**2167-10-28**] 04:30PM BLOOD PT-13.7* PTT-29.4 INR(PT)-1.2* [**2167-11-5**] 05:55AM BLOOD Glucose-89 UreaN-26* Creat-1.1 Na-137 K-4.2 Cl-98 HCO3-30 AnGap-13 [**2167-10-28**] 04:30PM BLOOD Glucose-120* UreaN-18 Creat-0.9 Na-139 K-3.5 Cl-102 HCO3-29 AnGap-12 [**2167-11-3**] 04:35AM BLOOD Mg-2.4 [**2167-10-29**] 06:45AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.3 Cholest-129 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 1458**] was transferred from OSH after +ETT. Underwent Cardiac Cath on [**10-28**] which revealed severe three vessel coronary artery disease. Patient underwent pre-operative work-up which included echo and carotid u/s. On [**10-30**] he was brought to the operating room where he underwent a coronary artery bypass graft x 4 and left carotid endarterectomy. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Chest tubes were removed on post-op day one. Beta blockers and diuretics were initiated and he was gently diuresed towards his pre-op weight. On post-op day two he was transferred to the telemetry floor for further care. HIT panel was drawn as platelets trended down post-operatively and found to be negative. He was also anemic with a HCT at 23.2 on post-op day three, but patient refused transfusion. His HCT rose on its own. He was placed on amiodarone for atrial fibrillation and converted. He remained in normal sinus rhythm for greater than 24 hours so coumadin was discontinued. By post-operative day 6 he was ready for discharge. Medications on Admission: Home: Crestor 40mg qd, Gemfibrozil, Atenolol 50mg qd At Transfer: Aspirin 325mg qd, Lopressor 12.5mg [**Hospital1 **], Nitro gtt, Norvasc 5mg qd, Imdur 30mg qd, Omeprazole 20mg qd, Crestor 40mg qd 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 11. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Disp:*qs ML(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Lifecare Center of [**Location **] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Carotid Stenosis s/p Right Carotid Endarterectomy PMH: Hyperlipidemia, Hypertension, Peripheral Vascular Disease, Peptic Ulcer Disease with GI bleed 12 yrs ago, Borderline Diabetes Mellitus, s/p Left Carotid Endarterectomy, s/p Hemorrhoidectomy Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 11763**] Dr. [**Last Name (STitle) **] (vascular) in 4 weeks.([**Telephone/Fax (1) 8343**] Dr. [**Last Name (STitle) 10165**] [**Name (STitle) 31187**] in [**1-25**] weeks ([**Telephone/Fax (1) 40026**] Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] in [**12-24**] weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2167-11-5**]

[ "998.12", "433.30", "E878.2", "414.01", "287.4", "276.2", "533.90", "272.4", "250.00", "427.31", "443.9", "411.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "36.13", "88.53", "37.22", "39.61", "00.40", "38.12", "36.15", "88.56" ]

icd9pcs

[ [ [] ] ]

6521, 6583

3501, 4783

294, 456

6932, 6938

1309, 3478

7715, 8198

1047, 1074

5030, 6498

6604, 6911

4809, 5007

6962, 7692

1089, 1089

1103, 1290

244, 256

484, 679

701, 942

958, 1031

31,942

178,290

54109

Discharge summary

report

Admission Date: [**2126-5-7**] Discharge Date: [**2126-5-15**] Date of Birth: [**2073-1-25**] Sex: M Service: MEDICINE Allergies: Codeine / Compazine / Penicillins / Metformin / Heparin Agents / Ativan Attending:[**First Name3 (LF) 2485**] Chief Complaint: Respiratory distress. Major Surgical or Invasive Procedure: PICC line placement ([**5-8**]). History of Present Illness: This is a 53 yo man with history of severe COPD s/p tracheostomy on continuous home 02 who presents with 2-3 days of worsened dyspnea and thicker respiratory secretions. He has a complicated pulmonary history with tracheomalacia s/p tracheal stent placement and subsequent removal, history of MRSA and resistant pseudomonas pneumonia, chronically elevated right hemidiaphragm, chronic copious secretions and right and left base atelectasis. PMHx also notable for steroid induced DM and osteoporosis with subsequent vertebral fracture, kyphosis and chronic back pain. He had been doing well from a respiratory standpoint until recently. He had seen his pulmonologist Dr. [**Last Name (STitle) 4507**] in clinic on [**4-24**], was steadily improving and tapering his oxygen, requiring as little as 1L with rest at 3L with exertion. At that time his steroids were decreased from 20mg daily to 10mg alternating with 20mg. He does not endorse sick contacts, but states " I live in a nursing home, everybody's sick." Otherwise no change in medications. Symptoms of increased dyspnea associated with low 02 sats, he checked on his own, noted some levels to as low as the high 70s. He always has lots of secretions, but noted lately they were thicker and harder to cough up. Unsure if he has had fevers or chills, but has had night sweats for the past several weeks. He has been using his nebulizers more frequently. Also reports chest tightness with episodes of respiratory distress, resolves with nebulizers. Complaining of exacerbation of chronic low back pain, occasional abd pain, improving with eating, and increased lower extremity edema with R>L lower extremity erythema. . Reported VS at NH: VS 98.1 RR32 88/65 98% NRB with BS 177. Received some IVF prior to transfer. In ED was 99.2 120 118/80 28 97% NRB, improved to 92% on 4L HR 110 100/70 RR 26 at time of transfer to ICU. Labs were notable only for a left shifted WBC. CXR showed old LLL collapse with partial new RLL collapse. He received 1 dose of vancomycin in the ED, received 300 cc IVF with 850 cc UOP. ECG showed sinus tach. He had a trop of 0.02 with MBI 9.1, CK 219 MB 20. Cardiology was called and recommended trending enzymes, giving aspirin, no heparin. There was concern for a PE in the ED due to patient's tachycardia, but as he was unable to lay flat due to respiratory distress the decision regarding treatment and work up was left to the accepting team. . He was admitted to the [**Hospital Unit Name 153**] for further monitoring in the setting of respiratory distress with tachycardia and need for frequent suctioning. . In the [**Hospital Unit Name 153**] the patient complained mainly of [**8-19**] back pain as well as shortness of breath as described above. He denied HA, no change in appetite/PO intake. Endorses occasional heart burn and RUQ pain, improved with meals. Constipation. No melena or hematochezia. Otherwise ROS negative. Past Medical History: 1) Severe O2-dependent COPD, recently on [**1-12**] L continuous O2 at home 2) Tracheal stenosis s/p stent, stent removal, dilatation, and tracheostomy insertion [**Month (only) 205**]-[**2124-8-9**] 3) Diabetes mellitus. 4) Osteoporosis. 5) Hepatitis B. 6) Vertebral compression fractures (details unknown). 7) Left 3rd finger amputation for osteomyelitis 8) History of intravenous drug use. 9) multi-drug resistant pseudomonas infection, + MRSA sputum 10) PUD hx of ulcers 11) Chronic right hemidiaphragm elevation/paralysis Social History: Mr. [**Name13 (STitle) 14302**] lives in the [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing Home. He quit using heroin about eight years ago, but has an approximately 20 year history. He quit drinking more than seven years ago. He quit smoking approximately one to two ears ago and has a 60 pack year history. He smoked two packs per day for many years. He tested HIV negative in the past. He used to work as a dog groomer. He did work in construction in the past, but does not know of any asbestos exposure. He denies TB exposure. Family History: Non-contributory. Physical Exam: Physical Exam at discharge: Vitals: afebrile, normotensive, SaO2: 93% 40% Trach mask and 3L General: unkempt, diaphoretic, jocular, mild tachypnea. HEENT: No scleral icterus. Cushingoid facies. MMM. Neck: Trach collar in place. JVD to 7cm at 90 degrees. Supple. Pulmonary: Markedly kyphotic, persistant but overall inproved wheezes with mildly prolonged expiratory phase. No crackles, no appreciable egophany. Cardiac: Tachycardic, regular Abdomen: Protuberant. + BS. No rebound or guarding. Mild distention. Bowel sounds present. Extremities: R>L pitting edema to knee, RLE with pretibial erythema, not warm, non-blanching, improves with elevation. Skin: Cherry angiomata on chest. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. No abnormal movements noted. No deficits to light touch throughout. Pertinent Results: Labs at Admission: [**2126-5-7**] 01:00PM BLOOD WBC-6.4 RBC-4.83 Hgb-12.4* Hct-41.7# MCV-86# MCH-25.7* MCHC-29.8* RDW-15.7* Plt Ct-294 [**2126-5-7**] 01:00PM BLOOD Neuts-86.0* Lymphs-7.9* Monos-4.4 Eos-1.3 Baso-0.5 [**2126-5-8**] 03:02AM BLOOD PT-11.7 PTT-26.9 INR(PT)-1.0 [**2126-5-7**] 01:00PM BLOOD Glucose-104 UreaN-9 Creat-0.7 Na-142 K-4.0 Cl-101 HCO3-32 AnGap-13 [**2126-5-8**] 03:02AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1 [**2126-5-7**] 01:10PM BLOOD Lactate-1.8 Cardiac Enzymes: [**2126-5-7**] 01:00PM BLOOD CK-MB-20* MB Indx-9.1* proBNP-36 [**2126-5-7**] 01:00PM BLOOD cTropnT-0.02* [**2126-5-7**] 08:13PM BLOOD CK-MB-16* MB Indx-5.6 cTropnT-<0.01 [**2126-5-8**] 03:02AM BLOOD CK-MB-20* MB Indx-7.1* cTropnT-0.01 Imaging Studies: Chest x-ray PA and lateral ([**5-7**]): 1. Worsening right lung atelectasis with collapse of right middle and right lower lobes. 2. Improving atelectasis left lower lobe. Transthoracic Echocardiogram ([**5-8**]): The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. with normal free wall contractility. There is abnormal septal motion/position. 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 moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2124-6-9**], there is now moderate pulmonary hypertension detected. Pertinant labs from admission: [**2126-5-7**] 01:00PM BLOOD WBC-6.4 RBC-4.83 Hgb-12.4* Hct-41.7# MCV-86# MCH-25.7* MCHC-29.8* RDW-15.7* Plt Ct-294 [**2126-5-15**] 04:41AM BLOOD WBC-11.3* RBC-4.55* Hgb-11.6* Hct-38.3* MCV-84 MCH-25.4* MCHC-30.2* RDW-15.1 Plt Ct-329 [**2126-5-7**] 01:00PM BLOOD Glucose-104 UreaN-9 Creat-0.7 Na-142 K-4.0 Cl-101 HCO3-32 AnGap-13 [**2126-5-15**] 04:41AM BLOOD Glucose-146* UreaN-13 Creat-0.5 Na-142 K-4.6 Cl-94* HCO3-43* AnGap-10 [**2126-5-7**] 01:00PM BLOOD CK(CPK)-219* [**2126-5-7**] 08:13PM BLOOD CK(CPK)-287* [**2126-5-8**] 03:02AM BLOOD CK(CPK)-283* [**2126-5-7**] 01:00PM BLOOD cTropnT-0.02* [**2126-5-7**] 08:13PM BLOOD CK-MB-16* MB Indx-5.6 cTropnT-<0.01 [**2126-5-8**] 03:02AM BLOOD CK-MB-20* MB Indx-7.1* cTropnT-0.01 [**2126-5-8**] 03:02AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1 [**2126-5-15**] 04:41AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.1 [**2126-5-7**] 06:53PM BLOOD Type-ART pO2-76* pCO2-86* pH-7.26* calTCO2-40* Base XS-8 [**2126-5-13**] 02:02PM BLOOD Type-ART pO2-77* pCO2-74* pH-7.42 calTCO2-50* Base XS-18 [**2126-5-13**] 02:02PM BLOOD Lactate-1.8 CXR: The tracheostomy is at the midline with its tip approximately 5 cm above the carina. The left PICC line tip is at the level of cavoatrial junction/low SVC. There is no interval change in bilateral pleural effusions, moderate in bibasal atelectasis. The heart size is difficult to assess due to obscuration by bilateral pleural effusions. Brief Hospital Course: In summary a 53 yo man with complicated pulmonary history including COPD, tracheomalacia, diaphragmatic paralysis and chronic right lower lobe collapse now presenting with three days of worsening respiratory distress. # Respiratory distress The differential diagnosis for his respiratory distress included COPD flare, pneumonia, lung collapse, CHF, pulmonic effusion, PE, ACS. His respiratory symptoms were likely multifactorial. He has had worsening thickened secretions and a CXR with evidence of bilateral collapse and a possible LLL infiltrate. His BNP was normal arguing against CHF. His ECG was unchanged, and the slight increase in cardiac enzymes was likely due to demand in the setting of tachycardia rather than true ACS. In terms of PE, he had other more compelling diagnoses so this was not pursued aggressively at admission. ABG in the ICU showed acute on chronic respiratory acidosis. He was started on meropenem and vancomycin given his history of MRSA and MDR pseudomonas in sputum. Sputum and blood cultures taken during this admission were negative. He was also started on high dose corticosteroids with standing nebulizers with q1h suctioning. Overnight he was placed on pressure support. With these interventions, his respiratory status improved. He will complete an eight day course of Vancomycin and Merpenum on [**2126-5-15**]. A PICC-line has been placed for IV antibiotics. He was given high dose steroids for COPD flare. He was attempted to wean down to oral prednisone but the patient felt he was not ready and so he remained on solumedrol. He was discharged on solumedrol 20mg tid and will require a slow taper. His trach was replaced with a trach that had a cuff to mechanically ventilate him. This should be left in place until he is at his baseline. He was having a lot of mucous secretions and an insuflator/exeflator was utalized to mobalize secretions. # Lower extremity erythema and edema This appeared to be chronic, and per patient had worsened with the need to sit up to sleep with legs dangling. On exam the erythema was not warm, tender or blanching and thus a low suspicion for cellulitis. He was encouraged to elevate his legs at night. In addition, a TTE was done to work-up lower extremity swelling. The TTE showed preserved left ventricular ejection fraction with moderate pulmonary artery systolic hypertension. There were no valvular abnormalities. On the second hospital day, he was restarted on home Lasix. The lower extremity erythema and edema remained stable. # Chronic back pain He has chronic mid-back pain, likely associated with known mid-thoracic vertebral compression fractures from osteoporosis. His pain was managed with prn Percocet and morphine IR. Narcotic-related constipation was treated with docusate, senna, and lactulose. During his course his morphine was increased as he continually requested pain medication. He eventually started to retain CO2 and his Trach was replaced with a cuffed trach so he could be mechanically ventilated. He was somnolent for about a day and his morphine was held. He recovered well and was started on percocet 325/5 and oxycodone 5 to approximate his home regemin. # Elevated cardiac enzymes These were felt to be due to demand ischemia as mentioned above. Serial troponins were negative. He was continued on aspirin. # Diabetes mellitus He was kept on a regular diet with humalog insulin sliding scale. # Osteoporosis We continued his home calcium and vitamin D. We spoke to him about the importance of alendronate, which he adamently refused to take due to stomach upset. # Restless legs and insomnia We increased the dose of Mirapex. # FEN/electrolytes He was kept on a cardiac, diabetic diet. # Prophylaxis No heparin for reported allergy, pneumoboots. Home proton-pump inhibitor. # Code status His code status is full code as confirmed with patient. Medications on Admission: Albuterol sulfate nebs - 2.5 mg/3 mL (0.083 %) solution q4h prn Alendronate 70 mg qweek Citalopram 20 mg qday Advair HFA 230 mcg-21 mcg inh - 2 puffs [**Hospital1 **] Lasix 20 mg [**Hospital1 **] Dilaudid 2 mg q6h prn Insulin lispro sliding scale Ipratropium 0.2 mg/mL (0.02 %) solution - 1 neb q4h Lactulose 10 gram/15 mL - 30 mL [**Hospital1 **] Omeprazole 20 mg [**Hospital1 **] Percocet 7.5 mg-325 mg q6h Oxygen [**2-13**] lpm at rest, 4 lpm with sleep/exertion Prednisone 10 mg qday alternatin with 20 mg qday Bactrim DS 800 mg-160 mg qM-W-F Acetaminophen 650 mg q4h prn Bisacodyl 10 mg PR prn Calcium 500 mg tid Vitamin D3 800 U [**Hospital1 **] Docusate 100 mg [**Hospital1 **] Milk of magnesia Senna 8.6 mg 2 tablets qhs Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day) as needed. 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO twice a day. 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours). 10. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours). 11. Pramipexole 0.125 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for shortness of breath. 18. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 19. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed for pain. 20. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 21. MethylPREDNISolone Sodium Succ 20 mg IV Q8H Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnoses Tracheobronchitis COPD exacerbation Secondary Diagnoses Severe O2-dependent COPD Tracheal stenosis s/p tracheostomy Steroid-related diabetes mellitus Steroid-related osteoporosis Hepatitis B Chronic back pain, likely related to known vertebral compression fx History of intravenous drug use Narcotic dependence Discharge Condition: Vital signs stable Discharge Instructions: You were admitted to the hospital for respiratory distress. Your symptoms improved with antibiotics and high-dose steroids. We have increased the dose of the steroids, and started two new antibiotics to be taken for two-weeks total. In addition, we increased the dose of the Mirapex to help treat restless legs syndrome and insomnia. There have been no other changes to your medicines. Please call your doctor or return to the ED for: -worsening difficulty breathing, fevers -any other symptoms concerning to you Followup Instructions: Previously-scheduled appointments DR. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2126-9-24**] 8:30

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icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

15355, 15421

8681, 12558

353, 387

15795, 15816

5456, 5925

16378, 16554

4498, 4517

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15442, 15774

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5943, 6179

292, 315

415, 3345

3367, 3895

3911, 4482

6197, 8658

16,963

179,368

29647

Discharge summary

report

Admission Date: [**2100-12-29**] Discharge Date: [**2101-1-7**] Date of Birth: [**2019-7-20**] Sex: M Service: NEUROSURGERY Allergies: Morphine Attending:[**First Name3 (LF) 2724**] Chief Complaint: Subdural Hemorrhage, Intraparenchymal hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: 80 y/o white male with extenisve PMHX who was in his usual state of health today when he had a witnessed fall by VNA at home. Reported that pt was at coumadin clinic earlier today where INR was 8.0. He was reaching for his walker at home when he fell forward striking his head. He was sent to [**Hospital 1514**] Hospital where he received 2 units of FFP, Vit K 5mg IM, Dilatin and Mannitol 100mg. He deteriorated in their ER, was intubated and had a second CT. The times of the CT's are not known to this hospital although we do have the images. He was transferred here after CT head revealed large SDH / Interhemispheric with right left frontal contusion. Pt received proplex in this ER. Past Medical History: afib PPM< DM CABG BPH Aortic stenosis Social History: widowed Family History: unknown Physical Exam: Gen: WD/WN, barrel chest, intubated with cervical collar in place on propofol. HEENT: NCAT, Pupils:reactive 2.5 to 2.0 mm bilaterally, EOM unable to assess, no battles sign, no raccoon signs, hemotympanum not appreciated [**2-4**] cerumen impaction bilaterally. Neck: collar in place. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. loud murmur appreciated. ? type Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: sedated - sedation held for exam Orientation: unable to assess [**2-4**] intubation Cranial Nerves: Pt unable to participate with exam pupils as above, Positive corneals bialterally. no obvious facial droop. NO gag or cough, Motor: moves all extremeties/ localizes with LUE> RUE. W/D's x 4 to noxious Toes downgoing bilaterally Pertinent Results: CT HEAD W/O CONTRAST [**2100-12-29**] 1. Large left frontal intraparenchymal hemorrhage effacing mass effect described above. 2. Moderate right parafalcine subdural hematoma CT HEAD W/O CONTRAST [**2100-12-30**] 11:35 AM Stable appearance of left frontal and right parafalcine subdural hemorrhages Brief Hospital Course: Subdural/Intraparenchymal hemorrhage: Patient admitted on [**12-29**]. Patient's INR was reversed in the ED, he was loaded with dilantin and a CT Head was obtained. [**12-30**]: Repeat CT head was obtained which showed a stable appearance of his Subdural bleed. [**12-31**]: A follow-up CT head was obtained which was unchanged from prior studies. [**1-2**]: The patient developed a fever, pan cultures were sent which revealed E.Coli in the urine and Gram Negative rods in the sputum antibiotics were started. [**1-3**]: The patient continued to spike temps as high as 103. There was discussion about possible trach and peg to be performed by the trauma service, however, the family was contact[**Name (NI) **] and decided that this was not what what they wanted. He was made comfort measures and expired [**2101-1-7**]. Medications on Admission: coumadin pepcid provachol timoptic beconase nulev neurontin amoxicillin flexaril flomax vicodin Klonopin. Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: S/P CLOSED HEAD INJURY - BIFRONTAL CONTUSIONS Discharge Condition: . expired Discharge Instructions: none Followup Instructions: none Completed by:[**2101-1-7**]

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icd9cm

[ [ [] ] ]

[ "38.91", "96.72" ]

icd9pcs

[ [ [] ] ]

3303, 3312

2293, 3117

322, 328

3402, 3415

1967, 2270

3469, 3504

1154, 1164

3274, 3280

3333, 3381

3143, 3251

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234, 284

356, 1052

1716, 1948

1615, 1700

1074, 1113

1129, 1138

26,661

157,053

14551

Discharge summary

report

Admission Date: [**2161-8-5**] Discharge Date: [**2161-8-18**] Date of Birth: [**2094-11-23**] Sex: F Service: MEDICINE Allergies: allopurinol / Plavix Attending:[**First Name3 (LF) 4327**] Chief Complaint: Chest Pain and Shortness of Breath Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: Mrs. [**Known lastname 42950**] is a 66 y/o F with hx CAD (s/p CABG with LIMA-->LAD, SVG-->DM1 in [**2150**]; DES to mid-proximal RCA [**2154**]; and BMS to proximal LCx [**2156**]), dHF, DM, HPL, Stage III CKD who presented to OSH with CP, cough, and SOB. She reports that over the last two weeks she has had increasing SOB with minimal activity, weight gain, cough and fleeting CP relieved with SL Nitro. She was treated prior to presentation for a PNA with 7 days of clarithromycin. At baseline, she is minimally active requiring assistance with cleaning the house and grocery shopping. Per her daughter, she never full bounced back from the CABG in [**2150**]. Prior to admission on [**8-3**] she reports that she was shaking and felt feverish and shaky, she checked her temperature and it was 99.6. She also had increasing left-sided sharp CP that radiated down her left arm, she took SL Nitro x 3 but had continued CP and was taken to the OSH by her daughter. At the OSH, vitals were 98.6, 78, 136/62, 22, 96%RA. EKG showed NSR 72BPM LBBB unchanged from prior EKG. CXR showed cardiomegaly but was otherwise clear. She had a leukocytosis to 18.7-->10.8 which was attributed to acute gout. Glucose 243, BNP was 2443-->3229, Cr 1.5-->2.1 (baseline 1.3-1.5), TnT and CK were negative, no CK-MB reported. She was treated with ASA, Nitroglycerin paste and SL Nitro, continued on [**Month/Year (2) **] and Bumex. Patient reports she is down 9lbs since presenting to OSH. On the morning prior to transfer TNT <0.01 and CKMB 9, Index 4. Around 6pm [**8-4**] she had sudden onset [**9-2**] CP and diaphoresis. She was started on a Nitro gtt and transferred to [**Hospital1 18**] for further management. Vitals on transfer were T98.1 BP94/47 RR16 HR65 O297% On arrival to the floor, patient was comfortable, in NAD, speaking in full sentences and had no c/o. Past Medical History: HTN DM2 CAD CABG [**5-25**] LIMA to LAD, SVG to small diffusely diseased diagonal, EF 40% with 2+MR [**First Name (Titles) **] [**Last Name (Titles) **] '[**50**] dyslipidemia ?CRI obesity gout hypothyroid Social History: The patient is Armenian. She lives with her husband and son, independent of ADLs. No history of tobacco, alcohol or illicit drug use. Family History: Both parents died in 70s/80s from SCD. Physical Exam: ADMISSION EXAM: VS: T=98.1 BP=94/47 HR= 65 RR=18 O2 sat=97% 4L GENERAL: WDWN overweight woman 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 [**4-30**] cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Distant heart sounds, RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 1+ pre-tibial edema bilaterally. 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+ DISCHARGE EXAM: GA: well-appearing, speaking full sentences, A&Ox3 HEENT: PERRL, EOMI, MMM Neck: flat JVP CV: RRR, normal S1, S2, no m/r/g Pulm: CTAB, no wheezes, crackles, rhonchi Extremities: trace peripheral edema bilaterally Skin: no rash, warm, dry Neuro: CNII-XII grossly intact, alert and oriented as above, gait deferred Pertinent Results: ADMISSION LABS: [**2161-8-5**] 01:31AM WBC-11.9* RBC-4.11* HGB-11.0* HCT-33.9* MCV-82 MCH-26.8* MCHC-32.5 RDW-17.1* [**2161-8-5**] 01:31AM PLT COUNT-193 [**2161-8-5**] 01:31AM GLUCOSE-237* UREA N-45* CREAT-1.7* SODIUM-140 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-30 ANION GAP-14 [**2161-8-5**] 01:31AM CALCIUM-8.6 PHOSPHATE-3.9 MAGNESIUM-2.4 [**2161-8-5**] 01:31AM CK-MB-65* MB INDX-14.8* cTropnT-0.58* [**2161-8-5**] 01:31AM CK(CPK)-439* 2-D ECHOCARDIOGRAM [**2161-8-5**]: The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. Due to suboptimal technical quality, focal wall motion is difficult to assess but there appears to be apical akinesis, marked inferolateral hypokinesis, and moderate hypokinesis of the remaining walls. A left ventricular thrombus cannot be excluded. Overall left ventricular systolic function is severely depressed (LVEF= 25-30 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The aortic valve leaflets are mildly thickened (?#). There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. ([**8-5**]) [**Month/Year (2) **]: FINAL DIAGNOSIS: 1. Three vessel native coronary artery disease. 2. Known occluded SVG-D1 and patent LIMA-LAD. 3. Successful PTCA and stenting of the Cx with a DES. 4. Successful PTCA and stenting of OM1 with a DES. 5. Mild systolic heart failure. 6. Elevated pulmonary capillary wedge and right ventricular filling pressures. 7. Pulmonary hypertension. . ([**8-5**]) CXR: IMPRESSION: Severe cardiomegaly, in particular dilatation of the pulmonary arteries are longstanding. Pulmonary edema is mild. There is no appreciable pleural effusion. . ([**8-14**]) CXR: Again, the heart is grossly enlarged. The left pleural effusion likely is stable. Right lung appears grossly clear. Bilateral pulmonary opacities are consistent with pulmonary edema which is slightly improved since the prior study. The patient is status post median sternotomy. . DISCHARGE: [**2161-8-18**] 06:20AM BLOOD WBC-12.9* RBC-4.55 Hgb-12.2 Hct-37.1 MCV-82 MCH-26.8* MCHC-32.8 RDW-17.5* Plt Ct-266 [**2161-8-18**] 06:20AM BLOOD PT-20.2* PTT-75.0* INR(PT)-1.9* [**2161-8-18**] 06:20AM BLOOD Glucose-180* UreaN-51* Creat-1.9* Na-136 K-4.6 Cl-95* HCO3-32 AnGap-14 [**2161-8-18**] 06:20AM BLOOD Calcium-9.5 Phos-2.9 Mg-2.6 [**2161-8-10**] 05:20PM BLOOD %HbA1c-7.6* eAG-171* Brief Hospital Course: 66 y/o F with hx CAD (s/p CABG with LIMA-->LAD, SVG-->DM1 in [**2150**]; DES to mid-proximal RCA [**2154**]; and BMS to proximal LCx [**2156**]), DM, HPL, Stage III CKD who presented to OSH with CP, cough, and SOB, likely [**12-25**] unstable angina now with elevated TnT and CK-MB without EKG changes which is c/w NSTEMI. Likely that she was having UA prior to presentation to OSH and her event occurred around 10pm on [**8-4**] prior to transfer to [**Hospital1 18**]. . # NSTEMI: Initially at OSH patient did not have troponin or CK-MB leak, but in setting of acutely worsening CP prior to transfer requiring Nitro gtt and then found to have significantly elevated CM with no EKG changes, she has likely suffered a NSTEMI. She was taken for cardiac catheterization, which showed occluded LAD (old), 90% proximal instent restenosis of Lcx, 70% mid Lcx stenosis, 50% mid RCA in prior stent, and patent LIMA to LAD. Successful PTCA and stenting of the Cx with a DES and succssful PTCA and stenting of OM1 with a DES. After the cardiac catheterization, she continued to complain of less intense chest pain. She was medically optimized with the following medications: ASA 81, Prasugrel 10 mg , Atorva 80, Metop 12.5mg [**Hospital1 **]. Post [**Hospital1 **] chest pain would improve after starting ranolazine 500mg [**Hospital1 **]. In subsequent days, the patient's functional status and chest pain symptoms resolved and no longer would she complain of this pain. On day of discharge the patient was pain free. Post [**Hospital1 **] Echo showed LVEF 25-30% with probable apical akinesis and severe inferolateral hypokinesis. The remaining walls are moderately hypokinetic. Severe pulmonary artery systolic hypertension. Mild aortic stenosis. Mild-to-moderate mitral regurgitation. Likely elevated PCWP. The patient should be considered for ICD after 40 days post PCI. . # Acute on Chronic systolic and diastolic CHF: Hx of diastolic HF with preserved EF. However, post-[**Hospital1 **] Echo here showed LVEF 25-30%. Given her sxs, likely NYH Class III-IV. We aggressively diuresed the patient, first with Lasix drip at 25mg/hour and then with oral torsemide. The patient had an acute episode of hypotension after undergoing cardioversion, and at that time responded to 2L NS IVF. We suspect that the oral torsemide was started too soon after the lasix gtt. Patient home regimen was Bumex 4mg [**Hospital1 **]. Admission weight was 117kg. Discharge weight was 238lb (approx 20lb down). Please consider restarting losartan and starting spironolactone once kidney function improves. . # ATRIAL FIBRILLATION: On [**8-12**], patient developed new atrial fibrillation with RVR rate 120s-130s. First episode was accompanied by 10/10 chest pain, which resolved when she was treated with IV metoprolol and IV diltiazem, which controlled her rate (to 90s-110s). [**Month/Year (2) **] was increased from 12.5mg daily to 25mg daily. Regarding anticoagulation, CHADS2 score was 3. She was put on heparin gtt with a bridge to warfarin. Patient was cardioverted on [**8-13**]. Post cardioversion pt was hypotensive, in sinus rhythm, required transfer back to CCU for 24 hours where her blood pressures normalized. Etiology likely over diuresis. She remained in sinus rhythm for the remainder of her admission. She remained normotensive for the remainder of her admission. She was discharged home on warfarin after heparin gtt, pt was not candidate for Lovenox bridge [**12-25**] poor renal function. On discharge, INR was 1.9. . # HTN: At home, BP was controlled with [**Month/Day (2) 42949**], losartan, and bumetanide. [**Month/Day (2) **] was switched to Metoprolol 12.5mg [**Hospital1 **], Losartan was held given her low BPs, and Torsemide 40 daily was initiated instead of bometanide. Pt remained normotensive after a hypotensive episode as described above. . # AOCKD: Thought to be acute on chronic kidney disease in the setting NSTEMI with possible worsening EF. Cr 1.7 on admission, peaked at 2.7 and was 1.9 on discharge. . # DM: We continued home Lantus QHS, but the dose had to be adjusted frequently due to hyperglycemia at different points during her hospitalization. She was also put on insulin SC. Discharged on following regimen: Glargine 10 Units Bedtime Humalog 4 Units Lunch Humalog 8 Units Dinner Insulin SC Sliding Scale using HUM Insulin . . # HYPOTHYROIDISM: We continued home Synthroid 150mcg. Pt discharged with this. . # GOUT: Complained of pain in her right [**Hospital1 **] toe c/w prior episodes of gout. She was treated with colchicine and prednisone 200mg x 5 days. . TRANSITIONAL ISSUES: - evaluate for ICD >40 days out from ACS - consider outpatient sleep study - will discuss as outpt to restart Losartan - will consider spironolactone as outpatient to optimize CHF regimen) - home telemonitoring Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from OSH. 1. Aspirin 81 mg PO DAILY 2. [**Hospital1 **] 12.5 mg PO BID 3. Rosuvastatin Calcium 5 mg PO DAILY 4. Losartan Potassium 100 mg PO DAILY 5. NovoLOG *NF* (insulin aspart) 4 Units Subcutaneous DAILY with lunch 6. Levothyroxine Sodium 150 mcg PO DAILY 7. Vitamin D [**2148**] UNIT PO DAILY 8. Bumetanide 4 mg PO BID 9. Zolpidem Tartrate 10 mg PO HS 10. Prasugrel 10 mg PO DAILY 11. Nitroglycerin SL 0.3 mg SL PRN Chest Pain 12. Lantus *NF* (insulin glargine) 50 UNITS Subcutaneous QHS 13. NovoLOG *NF* (insulin aspart) 8 UNITS Subcutaneous DAILY with Dinner Discharge Medications: 1. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 2. Aspirin 81 mg PO DAILY 3. Levothyroxine Sodium 150 mcg PO DAILY 4. Prasugrel 10 mg PO DAILY 5. Zolpidem Tartrate 10 mg PO HS 6. Colchicine 0.3 mg PO DAILY RX *colchicine [Colcrys] 0.6 mg 0.5 (One half) tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 7. Glargine 10 Units Bedtime Humalog 4 Units Lunch Humalog 8 Units Dinner Insulin SC Sliding Scale using HUM Insulin 8. Metoprolol Succinate XL 25 mg PO DAILY Hold for sbp<90, HR,60 RX *metoprolol succinate 25 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 9. ranolazine *NF* 500 mg ORAL [**Hospital1 **] Reason for Ordering: Starting while inpatient RX *ranolazine [Ranexa] 500 mg one tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*2 10. Torsemide 40 mg PO DAILY Hold for BP <90 RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*2 11. Warfarin 7 mg PO DAILY16 RX *warfarin [Coumadin] 2 mg 3.5 tablet(s) by mouth daily Disp #*120 Tablet Refills:*2 12. Nitroglycerin SL 0.3 mg SL PRN Chest Pain 13. Vitamin D [**2148**] UNIT PO DAILY 14. Outpatient Lab Work Check Chem-7 and INR on Thursday [**8-20**] with results to Dr. [**Last Name (STitle) **] at Phone: [**Telephone/Fax (1) 11554**] Fax: [**Telephone/Fax (1) 11555**] ICD9 427.3 Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Non ST elevation myocardial infarction Acute on Chronic systolic CHF Exacerbation (EF 25%-30%) New onset Atrial Fibrillation and atrial flutter Hypertension Diabetes Mellitus Coronary artery Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted with a heart attack and an exacerbation of your congestive heart failure. You were taken to the cardiac cathterization lab and 2 drug leuting stents were placed in your heart arteries. You had some chest pain after the procedure and you were started on Ranexa which has eliminated the pain. Your weight was increased from excess fluid in your lungs and your belly. You were on a furosemide intravenous drip and are now on a new pill, torsemide, to help keep the fluid off. Weigh yourself every morning morning before breakfast, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. Your weight at discharge is 238 pounds. We are holding your losartan right now because your kidney function is improving, but not normal yet. You will need to have this restarted by Dr. [**Last Name (STitle) **]. You also developed atrial fibrillation and atrial flutter and needed a cardioversion to shock you out of this rhythm. You are in a normal sinus rhythm now and should monitor your pulse to make sure it remains regular. Having the atrial fibrillation puts you at increased risk for a stroke so you are now on warfarin to prevent blood clots and strokes. Dr.[**Name (NI) 32383**] office will let you know how much warfarin to take every day. Followup Instructions: Cardiology Appointment: Thursday, [**8-20**] at 3:15pm With:[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],MD Location:[**Location (un) **] Cardiology Associates, Inc. [**Street Address(2) 26336**].,[**Location (un) 1468**], [**Numeric Identifier 5689**] Phone: [**Telephone/Fax (1) 11554**] Department: CARDIAC SERVICES When: FRIDAY [**2161-9-25**] at 9:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "00.41", "36.07", "00.46", "88.56", "99.20", "99.62", "00.66", "37.23" ]

icd9pcs

[ [ [] ] ]

13702, 13760

6794, 11397

316, 341

14003, 14003

3998, 3998

15537, 16135

2640, 2681

12330, 13679

13781, 13982

11656, 12307

5539, 6771

14154, 15514

2696, 3648

3664, 3979

11418, 11630

242, 278

369, 2242

4015, 5522

14018, 14130

2264, 2472

2488, 2624

21,051

175,956

14453

Discharge summary

report

Admission Date: [**2130-9-11**] Discharge Date: [**2130-9-13**] Date of Birth: [**2090-7-3**] Sex: F Service: CCU HISTORY OF THE PRESENT ILLNESS: The patient is a 40-year-old female with a past medical history significant for chronic atrial flutter of idiopathic origin who presented to the [**Hospital3 **] Hospital on [**2130-9-11**] for a third attempt at DC cardioversion. She was also started on propafenone 150 mg t.i.d. and Lopressor 25 mg b.i.d. The patient has a history of chronic atrial fibrillation, formerly diagnosed in [**2124**] but most likely present since her teenage years. She was successfully cardioverted on [**2130-8-31**]. However, she did not take her propafenone as prescribed and then went back into atrial fibrillation after one week. On [**2130-9-8**], she underwent repeat DC cardioversion and remained in sinus rhythm for about 10-15 minutes but then experienced palpitations and returned to atrial fibrillation. She returned on [**2130-9-11**] for a third attempt at cardioversion. The patient initially was in atrial fibrillation with rates in the 120s to 180s. She was symptomatic with palpitations but denied any other symptoms. She took propafenone and Lopressor for 3 1/2 days prior to admission. On the day following admission, she developed a cardiac arrhythmia. She had an eight second pause and a change in her rhythm to a junctional rhythm with left bundle block. She was bradycardiac to the 30s with a systolic BP in the 70s. She was thought to have blocked sinus node conduction with a junctional escape rhythm and to have a [**Doctor Last Name **] A wave resulting in increased vagal tone, thus precipitating bradycardia and hypotension. The patient initially was given Atropine and Glucagon and started on a peripheral dopamine drip. The patient declined a central line placement. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Last Name (NamePattern1) 42749**] MEDQUIST36 D: [**2130-9-13**] 12:01 T: [**2130-9-14**] 19:55 JOB#: [**Job Number 42750**]

[ "E942.0", "427.89", "282.49", "276.5", "458.29", "426.3", "427.31" ]

icd9cm

[ [ [] ] ]

[ "37.78" ]

icd9pcs

[ [ [] ] ]

82,296

169,930

40064

Discharge summary

report

Admission Date: [**2187-12-19**] Discharge Date: [**2188-1-2**] Date of Birth: [**2125-9-16**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2291**] Chief Complaint: Abdominal pain, vomiting Major Surgical or Invasive Procedure: [**2187-12-19**] endotracheal intubation [**2187-12-19**] femoral central venous catheter placed History of Present Illness: 62 year old male with a chief complaint of abdominal pain with nausea and vomiting for about 2 days. +obstipation Patient lives at a group home due to hx of cerebral palsy and mental retardation. Staff at house noticed patient more lethargic and pale. Did not report any fevers. No known aspiration event. Sent to [**Hospital1 **] [**Location (un) 620**]. At OSH patient had NGT placed with feculant material output. CT abd was consistent WITH SMALL BOWEL OBSTRUCTION AT THE SITE OF A LARGE PARASTOMAL HERNIA. Patient became hypotensive and was intubated for airway protection. He received 2 L of crystalloid with appropriate increase in his blood preussure. A right femoral CVL was placed after failed attempt at Left IJ. He received IV ciprofloxacin and metronidazole. Surgery consult at [**Location (un) 620**] recommended transfer to [**Hospital1 18**] for further management of his SBO. At [**Hospital1 18**] ED the patient was hemodynamically stable. A surgery consult was placed and evaluated the patient. Believed that patient had illeus and did not have mechanical obstruction. Recommended medical management and will continue to follow the patient. In the ED, initial VS were: HR 110s, BP 94/72, RR 14 on FiO2 100%. . On arrival to the MICU, the patient was intubated and sedated. Hemodynamically stable not on pressors. . Review of systems: (+) Per HPI Past Medical History: Cerebral palsy, Mental retardation, Seziure disorder, hypothyroidism, chronic constipation, depression Social History: unknown, intubated upon arrival Family History: unknown, intubated upon arrival Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:97.5 BP:110/70 P:99 R:20 O2:100% FiO2 50% General: Intubated and sedated, mildly contracted HEENT: Sclera anicteric, PEARLA Neck: JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally Abdomen: Distended and tympanetic, colostomy present with parastomal hernia GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Sedated Pertinent Results: ADMISSION LABS: [**2187-12-19**] 07:00PM BLOOD WBC-16.6* RBC-4.54* Hgb-14.6 Hct-43.3 MCV-95 MCH-32.0 MCHC-33.6 RDW-13.0 Plt Ct-274 [**2187-12-19**] 07:00PM BLOOD Neuts-80.3* Lymphs-13.1* Monos-6.4 Eos-0 Baso-0.3 [**2187-12-19**] 07:00PM BLOOD PT-14.0* PTT-32.6 INR(PT)-1.3* [**2187-12-19**] 07:00PM BLOOD Glucose-138* UreaN-26* Creat-0.7 Na-147* K-4.6 Cl-117* HCO3-22 AnGap-13 [**2187-12-19**] 07:00PM BLOOD ALT-30 AST-38 AlkPhos-123 TotBili-0.8 [**2187-12-19**] 07:00PM BLOOD Lipase-10 [**2187-12-19**] 07:00PM BLOOD Calcium-7.9* Phos-4.0 Mg-1.9 [**2187-12-19**] 07:00PM BLOOD TSH-4.5* [**2187-12-19**] 07:41PM BLOOD Type-ART Rates-[**7-3**] Tidal V-400 FiO2-60 pO2-113* pCO2-46* pH-7.30* calTCO2-24 Base XS--3 -ASSIST/CON Intubat-INTUBATED [**2187-12-19**] 07:06PM BLOOD Lactate-1.6 [**2187-12-20**] 03:34AM BLOOD freeCa-1.10* . IMAGING: [**2187-12-19**] CT ABDOMEN AND PELVIS: CLINICAL HISTORY: Abdominal discomfort Multidetector CT of the abdomen and pelvis was performed with intravenous infusion of 150 cc Omnipaque 300. The study was somewhat limited because of the patient's inability to fully cooperate. Comparison is made with the previous examination done [**2184-6-6**]. An enterostomy has been placed in the left mid abdomen in the interval. The anatomy of the enterostomy is unclear but a narrowed segment of large bowel and fluid and air-filled small bowel enter a parastomal hernia. The small bowel appears constricted where it enters the hernia but dilated within it and there are multiple dilated air and fluid-filled loops of small bowel proximal to this site. Gas and fecal material are present in the colon, proximal and distal to the site. The large bowel is not dilated. Cholelithiasis is redemonstrated. There is no pericholecystic fluid or gallbladder wall thickening. The liver, pancreas, spleen, adrenal glands and kidneys are unremarkable in appearance, as before. The stomach is somewhat distended by fluid and air. Scattered atherosclerotic calcification is present as before. Visualized pelvic structures are unremarkable. There is persistent mild compression deformity of the L1 vertebral body and there are accompanying degenerative arthritic changes in the spine, which appear stable. IMPRESSION: FINDINGS CONSISTENT WITH SMALL BOWEL OBSTRUCTION AT THE SITE OF A LARGE PARASTOMAL HERNIA. THE SURGICAL ANATOMY IS UNCLEAR AND [**Name2 (NI) 88087**]N WITH THE PATIENT'S CLINICAL HISTORY IS RECOMMENDED. CHOLELITHIASIS. . [**2187-12-24**] TTE: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. No valvular pathology or pathologic flow identified. Dilated aortic sinus. CLINICAL IMPLICATIONS: Based on [**2183**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. CT abdomen [**2188-1-1**]: IMPRESSION: 1. Dilated loops of small bowel are seen proximal and distal to the parastomal hernia, suggesting an ileus, although partial obstruction cannot be fully excluded. This study is somewhat limited due to motion. If clinical suspicion continues to exist for mechanical obstruction, would recommend repeat CT. 2. Bilateral small pleural effusions. 3. Cholelithiasis without cholecystitis. Labs at time of death: [**2188-1-1**] 09:14PM BLOOD WBC-32.1*# RBC-3.88* Hgb-12.7* Hct-39.1* MCV-101* MCH-32.6* MCHC-32.4 RDW-14.2 Plt Ct-409# [**2188-1-1**] 09:14PM BLOOD Glucose-165* UreaN-22* Creat-1.2 Na-141 K-5.0 Cl-106 HCO3-24 AnGap-16 [**2188-1-1**] 09:28PM BLOOD Type-[**Last Name (un) **] pO2-79* pCO2-54* pH-7.27* calTCO2-26 Base XS--2 Comment-GREEN TOP Brief Hospital Course: Mr. [**Known lastname **] is a 62 year old male with a history of cerebral palsy and colostomy surgery who presented to [**Hospital1 **] [**Location (un) 620**] with constipation and was found to have herniation around his prior stoma. Transferred to [**Hospital1 18**] after intubation at [**Hospital1 **] [**Location (un) 620**] for airway protection given large volumes of feculent vomiting. . ACTIVE ISSUES BY PROBLEM: #Small bowel obstruction (SBO/Ileus): Patient presented with obstipation for 2 days. CT consistent with SBO with peristomal hernia. Surgery evaluated the patient and did not feel that this is a mechanical SBO as his hernia was reducable. There was no other significant pathology on the CT scan. Nasogastric tube was placed to continue to suction the feculent material in his stomach. He recieved fleets and mineral oil enemas through the stoma, miralax and GoLytely through the NGT and he was kept NPO. This resulted in small amounts of stomal output after a few days. Surgery recommended that we can slowly start tube feeds and monitor stool output. Patient was transferred to the floor on [**2187-12-27**]. See below for the MICU course prior to transfer to the floor: #Hypotension: Patient was hypotensive at [**Hospital1 **] [**Location (un) 620**] and on arrival in the ED. Patient's blood pressure improved after fluid resuscitation through the femoral central line. Also was treated with vancomycin, cefepime, and metronidazole for possible aspiration pneumonia as a cause of both hypotension and respiratory distress (see below). His only positive culture was a urine culture from [**Hospital1 **] [**Location (un) 620**] which grew E. coli. A PICC was placed for continued IV access for antibiotics, femoral line discontinued. . #Intubation: patient was intubated at [**Hospital1 **] [**Location (un) 620**] for hypotension and to protect the airway given large volume feculent material in stomach. He remained intubated for a few days while undergoing fluid resuscitation for possible sepsis as above. After his hypotension resolved, he required some diuresis prior to extubation. Extubation was also delayed because his lung volumes are very small due to baseline cerebral palsy. His TTE showed LVEF > 55% and no valvular pathology. He was extubated after diuresis and did very well. . # Hypoglycemia: His early am fasting blood glucose measurements were consistently in the 60s. He was given half-amps of D50 daily. He was never symptomatic. . #Seizure disorder: Continued home medications IV. . #Cerebral palsy (CP): He was continued on his home regimen. While intubated and sedated he required a foley, however, due to his CP there was extra muscle resistance. Urology was consulted to place a kuday which was successful. FLOOR COURSE: Given improvement in hemodynamics and some stoma output, clear liquid diet was initiated, however, patient developed worsening abdominal distension, nausea, emesis and respiratory distress along with leukocytosis. Given suspicion of recurrent SBO or GI sepsis, IV antibiotics were restarted and NGT decompression was performed. Within 48 hours, patient was more alert and awake with improved respiratory status. His RR remained in 30s and shallow, w/o hypoventilation and with minimal O2 requirement. Given recurrent symptoms per discussion with HCP, further evaluation was performed. Repeat surgical consultation again endorsed severe ileus vs. obstruction. Patient was restarted on clear liquids, with again, worsening of his abdominal distension. CT abdomen was consistent with ileus vs. partial obstruction. Unfortunately, Mr. [**Known lastname **] continued to detereiorate as during a prior episode. NGT decompression improved symptoms, but not respiratory distress. Within the next 24 hours, tachypnea worsened and with increasing abdominal distension, hypoventilation ensued. On prior discussion, the [**Hospital 228**] health care proxy, his sister, had made him DNR/DNI and also did not want surgery to be pursued as an option. This was re-addressed with his sister given his worsening respiratory status, and she once again confirmed that she did not wish to pursue aggressive treatment, including intubation, resucitation, and/or surgery. At that point, she wished to pursue symptom management and elected for initiation of comfort care measures only. Pt was placed on IV morphine and ativan and patient died within 24 hours from respiratory distress. He died peacefully on [**1-2**] with his sister at his bedside on [**1-2**]. Medications on Admission: Colace 100 mg Cap Paxil 20 mg Tab Multivitamin Tab Peridex Mouthwash Synthroid 100 mcg Tab, Synthroid 50 mcg Tab Zyprexa 15 mg Tab Milk of Magnesia Oral Susp Phenytoin 50 mg Chewable Tab Acetaminophen 650 mg Tab Ativan 2 mg Tab Lamisil 1 % Topical Cream Dextromethorphan-Guaifenesin 10 mg-100 mg/5 mL Syrup, Protonix 40 mg Tab AmLactin 12 % Topical Liquid, Ferrous Sulfate 325 mg (65 mg Iron) Tab Desenex Topical Powder Dilantin Cap Enulose Syrup Depakote Oral Depakote 500 mg Tab Keppra 500 mg Tab Miralax 17 gram Oral Powder Packet Singulair 10 mg Tab Discharge Disposition: Expired Discharge Diagnosis: PRIMARY DIAGNOSIS Small bowel obstruction due to herniation . Death resulting from small bowel obstruction leading to respiratory failure. Discharge Condition: patient died Discharge Instructions: patient died Followup Instructions: patient died Completed by:[**2188-2-17**]

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icd9cm

[ [ [] ] ]

[ "96.72", "99.15", "96.6" ]

icd9pcs

[ [ [] ] ]

12243, 12252

7085, 11639

330, 428

12434, 12448

2559, 2559

12509, 12552

2017, 2050

12273, 12413

11665, 12220

12472, 12486

2090, 2540

6034, 7062

1811, 1825

265, 292

456, 1792

2575, 6011

1847, 1952

1968, 2001

22,871

158,497

52295

Discharge summary

report

Admission Date: [**2189-11-11**] Discharge Date: [**2189-11-20**] Date of Birth: [**2112-3-15**] Sex: M Service: VASCULAR CHIEF COMPLAINT: Right iliac aneurysm and aortic pseudoaneurysm. HISTORY OF PRESENT ILLNESS: This is a 77 year old male, retired policeman, who underwent abdominal aortic aneurysm repair 12 years. The repair was accomplished with a straight tube graft placed from the infrarenal aorta to the aortic bifurcation. At the time of that surgery there was no evidence of iliac arterial aneurysm, although his iliac arteries were somewhat ectatic. Patient returns now on [**2189-10-18**] after undergoing an MR of his spine and subsequently confirmed by MRA done on [**2189-10-8**] that he has a 4 cm aneurysm on the left common iliac. There is slight protuberance of the lower abdominal aorta posterior to the distal end of the graft and the right common iliac is somewhat aneurysmal. He does admit to some left hip pain over the last few months and has been seeing a physical therapist with some improvement. He also notices discomfort in the left anterior groin region when he gets out of bed and is particularly troubled early in the morning. He is now admitted for elective surgery. MEDICATIONS: Celebrex, Prilosec, aspirin 81 mg, atenolol 25 mg q.d., Tylenol two q.a.m. and two q.p.m. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: History of MI times two, one two years ago and one four years ago. He is status post coronary angioplasty with stent placement which was done at [**Hospital6 11241**] and a second one done at [**Hospital3 2576**] [**Hospital3 **]. Patient also had a mini-stroke in the past with minimal residual. PHYSICAL EXAMINATION: This was a moderately overweight gentleman. There was no aneurysm palpable on abdominal exam. Femoral, popliteal, dorsalis pedis and posterior tibial pulses were 4+. Neurologically he was intact. HOSPITAL COURSE: The patient was admitted to the preoperative holding area and on [**2189-11-11**] he underwent aorto-[**Hospital1 **]-iliac bypass with Dacron and oversewing of the right iliac aneurysm. At the end of the procedure patient had monophasic DPs bilaterally, biphasic PT on the right and triphasic PT on the left. He required two units of packed red blood cells and one liter of Cell [**Doctor Last Name **] intraoperatively. Patient was transferred to the SICU secondary to high fluid volume requirements. Postoperative hematocrit was 36.5, BUN 31, creatinine 1.3. Blood gas was 7.32, 49, 77, 24, -3. EKG was without acute changes. Chest x-ray did not show any pneumothorax. Postoperatively he continued to require large amounts of fluid and neo support. He was transfused two units of packed red blood cells for hematocrit of 28, down from 35. He remained NPO. The patient was extubated. He remained in the SICU. There was some bleeding from the abdominal wound which diminished over the next 48 hours. Serial hematocrit was monitored. Patient's NG was removed and he was advanced to clears on postoperative day two. Patient had episodes of rapid atrial fibrillation requiring amiodarone and Lopressor for rate control. He was continually diuresed. Hematocrit was stable. The P-line and A-line were discontinued. A CVL was placed on postoperative day three. He remained in the SICU. Ambulation to a chair was begun on postoperative day five and physical therapy was requested to see patient for evaluation for discharge planning. The patient had a t-max of 101.4 on postoperative day seven. On exam lungs were clear. Abdomen was soft, nondistended, nontender. Extremities were warm with dopplerable DP and PT pulses. Incisions were clean, dry and intact. Urinalysis was sent and chest x-ray and blood cultures were obtained. Blood cultures grew staph coag positive preliminary sensitivities. Patient was pansensitive to clinda, erythro, gentamicin, levofloxacin, oxacillin and penicillin. The anaerobe cultures also were staph coag positive. These were two out of two sets. CVP tip culture was positive for the same organism. Wound cultures were obtained on [**11-18**] and were pending at the time of dictation. Stool culture for C.diff was sent on [**11-19**] and was pending at the time of dictation. The patient will require four to six weeks of antibiotics for positive blood cultures since he has a synthetic graft. A PICC line was placed on [**2189-11-20**]. Dr. [**Last Name (STitle) 1476**] spoke to the family and to the patient and they felt, given the circumstances, that he would benefit from rehab and continued nursing care. Patient was agreeable to family's recommendations and Dr.[**Name (NI) 27017**] recommendations. The remainder of [**Hospital 228**] hospital course was unremarkable. Wounds were clean, dry and intact at the time of discharge. DISCHARGE MEDICATIONS: 1. Flagyl 500 mg IV q.eight hours. 2. Levofloxacin 500 mg q.24 hours. 3. Vancomycin 1 gm IV q.12 hours. 4. Protonix 40 mg q.d. 5. Ambien 5 to 10 mg h.s. 6. Lopressor 25 mg b.i.d., hold for systolic blood pressure less than 100, heart rate less than 55. 7. Aspirin 81 mg q.d. 8. Heparin subcu 5000 units q.eight hours until patient is ambulating on a consistent basis. 9. Amiodarone 400 mg q.d. This was started on [**2189-11-15**] and will be continued for a total of seven days. This is for his atrial fibrillation. 10. Albuterol multidose inhaler q.six hours p.r.n. 11. Insulin sliding scale. 12. Acetaminophen 325 to 650 mg q.four to six hours p.r.n. DISCHARGE DIAGNOSES: 1. Bilateral iliac aneurysms, status post aorto-[**Hospital1 **]-iliac bypass graft. 2. Hypertension, controlled. 3. Staph coag positive blood cultures in CVL, treating with vancomycin, levo and Flagyl. 4. Coronary artery disease, stable. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2189-11-20**] 10:42 T: [**2189-11-20**] 10:43 JOB#: [**Job Number 108120**]

[ "038.19", "401.9", "998.11", "442.2", "427.31", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "39.25", "38.93", "39.57" ]

icd9pcs

[ [ [] ] ]

5550, 6078

4863, 5529

1940, 4840

1723, 1922

161, 210

239, 1377

1400, 1700

32,318

126,006

32372

Discharge summary

report

Admission Date: [**2170-1-9**] Discharge Date: [**2170-1-29**] Date of Birth: [**2119-1-11**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 281**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2170-1-10**] Open J Tube Placement [**2170-1-10**] Bronchoscopy Flexible and Rigid, Tumor Destruction with mechanical Debridement Y stent placement [**2170-1-17**] Bronchoscopy with aspiration of secretions Esophagogastroduodenoscopy with attempted percutaneous endoscopic gastrostomy. [**2170-1-22**] Direct Laryngoscopy and Esophagoscopy with biopsy History of Present Illness: Mrs. [**Known lastname 75607**] is a 51 year-old female with a history of paroxysmal atrial fibrialltion, COPD and increased shortness of breath. She was intubated on [**2170-1-1**] for respiratory distress. On bronchoscopy revealed a mass above the carina, extending onto the left mainstem bronchus. On [**2170-1-2**] Resection of endobronchial tumor (Yag laser) and endoscopy showing a ulcer at the GE junction. She was unable to be extubated and was transferrd from [**Hospital 11066**] Hospital for Y stent placment of distal trachea and proximal mainstem bronchus. Past Medical History: PMH: AFib, HTN, EtOH, COPD, CAD Social History: Lives at home alone,has never married.0.5-1 pack a day cigarettes for 30 years. Alcohol 6 pack beer per day. Family History: Mother had breast cancer and pancreatic cancer,father also died of cancer. Physical Exam: General: 51 year-old female who appears older than stated age and cachexic HEENT: normocephalic, mucus membranes dry, Neck: Nontender diffuse fullness of R neck, no discrete LAD palpable. No LAD on L. Trachea midline. Cardiac: Irregular, variable S1 and S2, no m/r/g, PMI lateral,precordium quiet Resp: decreased breath sounds bibasilar crackles GI: bowel sounds positive, abdomen soft non-tender/non-distended PEG in place, site clean, no erythema Extr: warm no edema Neuro: awake, alert & oriented Pertinent Results: [**2170-1-9**] WBC-6.4 RBC-2.75* Hgb-9.6* Hct-27.4 Plt Ct-161 [**2170-1-23**] WBC-10.1 RBC-3.21* Hgb-11.2* Hct-33.2 Plt Ct-383 [**2170-1-9**] Glucose-74 UreaN-13 Creat-0.4 Na-145 K-3.6 Cl-109* HCO3-31 [**2170-1-25**] Glucose-86 UreaN-10 Creat-0.3* Na-136 K-4.0 Cl-102 HCO3-30 Tracheal Tumor. Pathology [**2170-1-10**] Squamous cell carcinoma, invasive and moderately differentiated. Procedure date Tissue received Report Date Diagnosed by [**2170-1-22**] [**2170-1-22**] [**2170-1-26**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**],DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/tcc [**-8/4872**] Tracheal Tumor. SPECIMEN SUBMITTED: Biopsy right tonsillar fossa, additional right tonsil. DIAGNOSIS: I. Right tonsillar fossa, biopsy (A-B): Invasive squamous cell carcinoma, well to moderately differentiated, involving squamous mucosa; focal necrosis is identified. II. Right tonsil, additional tissue (C): Invasive squamous cell carcinoma, well to moderately differentiated, involving squamous mucosa and adjacent skeletal muscle. FDG TUMOR IMAGING (PET-CT) [**2170-1-17**] INTERPRETATION: There is focal abnormal uptake of FDG in a right pharyngeal mucusal soft tissue mass measuring 2.2 x 2.8 cm, with an SUV max of 11.8. There is no FDG-avid neck lymphadenopathy. There is another focus of marked FDG avidity (SUV max 8.9) within the mediastinum, in the subcarinal region, approximatey 3.3 x 3.9 cm (including the carina, which is stented and patent). There are several additional mediastinal lymph nodes that are not FDG-avid. There is no FDG avid parenchymal lesion within the lungs. There is a moderate right and small left effusion. There is no abnormal FDG avid lesion within the abdomen and pelvis. Note is made of dependent fluid layering in the presacral and perirectal space along with diffuse and dependent subcutaneous edema within the lower abdomen and pelvis. Physiologic uptake is seen in the heart, liver, spleen, GI and GU tract. IMPRESSION: 1. Abnormal markedly FDG-avid subcarinal mass consistent with pathological diagnosis of squamous cell carcinoma. 2. No additional FDG-avid mediastinal, hilar, or lung lesions. 3. Worrisome FDG avid right pharyngeal mass concerning for separate malignancy given patient's history and location. Recommend direct visualization of this lesion. 4. Dependent subcutaneous and perirectal/presacral edema. 5. Bilateral pleural effusions. MR HEAD W & W/O CONTRAST [**2170-1-19**] 10:24 AM FINDINGS: There is no evidence of mass, abnormal enhancement, hemorrhage, or abnormal signal intensity in the brain. The ventricles are within normal limits. The surrounding osseous and soft tissue structures are unremarkable with mild mucosal thickening in the ethmoid sinus and small amount of fluid in the mastoid air cells. There is no diffusion abnormality. The cystic lesion in the left mandible is partially included and shows low signal on T1 without ehhancement. IMPRESSION: Normal brain MRI. No evidence of metastasis. Mucosal thickening in ethmoid sinus and within the mastoid air cells. Left mandibular cystic lesion. CT NECK W/CONTRAST (EG:PAROTIDS) [**2170-1-19**] 9:51 AM NECK CT WITH CONTRAST: Comparison was made with a prior PET CT dated [**2170-1-17**]. There is asymmetric soft tissue measuring approximately 2.5 x 2.0 cm in the right hypopharynx at the tonsillar pillar, corresponding to the FDG- avid mass, suspicious for neoplasm likely a primary tumor rather than metastasis. There is no significant mass or asymmetry in the nasopharynx. There is no significant lymphadenopathy. There is a 2 x 1 cm fluid-containing cystic lesion in the subcutaneous tissue anterior to the mandible. In the left internal jugular vein, there is tubular filling defect measuring 4 mm in diameter, and -30 [**Doctor Last Name **]. In the visualized portion of the lung apices, there are bilateral pleural effusion and patchy opacities in the lungs. There are degenerative changes of a cervical spine. IMPRESSION: 1. Soft tissue mass and asymmetric in the right hypopharynx, corresponding to FDG-avid tumor, suspicious for primary neoplasm such as squamous cell carcinoma. Direct visualization and biopsy is recommended. 2. 2 x 1 cm fluid-containing cystic lesion anterior to the left mandible. Physical examination is recommended. 3. Hypodense tubular small filling defect in the left internal jugular vein. The Hounsfield unit is somewhat too low for thrombus or turbulent flow, however, if clinically indicated, please perform ultrasound for further evaluation. 4. Bilateral pleural effusion and patchy opacities in the apices. Mucous secretion in trachea. CT CHEST W/CONTRAST [**2170-1-21**] 3:56 PM FINDINGS: There is a conglomerate nodal mass centered at the level of the carina, extending superiorly to the level of the aortic arch and inferiorly to the azygoesophageal recess. This lesion encases the mainstem bronchi with extension peripherally to the hilar regions, with possible encasement of the upper and lower lobe bronchi. Although this mass encases the central airways, there is no evidence of significant airway narrowing or endobronchial lesion. Y-stent is seen in the trachea, with a small focus of extraluminal gas lateral to the trachea at approximately the level of the aortic arch. This may represent a localized perforation. No evidence of diffuse mediastinal gas. Moderate-sized bilateral pleural effusions are seen, with atelectasis of the adjacent lung parenchyma. This is more severe on the left compared to the right. Additionally, multifocal areas of peribronchiolar ground- glass opacities are also present, which may be infectious, inflammatory, or related to aspiration. Compared to PET/CT [**2170-1-17**], these ground- glass opacities are slightly improved. Mild paraseptal and centrilobular emphysema. A small pericardial effusion is seen. Otherwise, the heart and great vessels are unremarkable. IMPRESSION: 1. Large conglomerate nodal mass with its epicenter at the level of the carina, encasing the central airways. Given possible hypopharyngeal primary malignancy identified on PET/CT, this conglomerate nodal mass may represent a metastatic site. 2. Focal small extraluminal gas collection lateral to the trachea at site of stent. This may represent a small localized/contained perforation. 3. Moderate bilateral pleural effusions with atelectasis of adjacent lung parenchyma. 4. Multifocal areas of subtle peribronchiolar ground-glass opacities, may be infectious or inflammatory (e.g. aspiration). 5. Free intraperitoneal air, likely related to recent PEG tube placement. [**2170-1-9**] 10:18PM PT-12.9 PTT-23.3 INR(PT)-1.1 [**2170-1-9**] 10:18PM PLT COUNT-161 [**2170-1-9**] 10:18PM NEUTS-80.6* LYMPHS-16.5* MONOS-2.5 EOS-0.4 BASOS-0 [**2170-1-9**] 10:18PM NEUTS-80.6* LYMPHS-16.5* MONOS-2.5 EOS-0.4 BASOS-0 [**2170-1-9**] 10:18PM WBC-6.4 RBC-2.75* HGB-9.6* HCT-27.4* MCV-100* MCH-34.8* MCHC-34.9 RDW-14.0 [**2170-1-9**] 10:18PM CALCIUM-8.3* PHOSPHATE-3.8 MAGNESIUM-2.1 [**2170-1-9**] 10:18PM estGFR-Using this [**2170-1-9**] 10:18PM estGFR-Using this [**2170-1-9**] 10:18PM GLUCOSE-74 UREA N-13 CREAT-0.4 SODIUM-145 POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-31 ANION GAP-9 [**2170-1-9**] 10:18PM GLUCOSE-74 UREA N-13 CREAT-0.4 SODIUM-145 POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-31 ANION GAP-9 Brief Hospital Course: 50 yo F with past h/o paroxyoxysmal Afib & COPD admitted on [**12-22**] to [**Hospital **] hospital for SOB.During her admission Afib was complicated by what was thought to be a severe COPD exacerbation.[**12-23**] they did an xray chest which showed b/l LL infiltrates.The CT scan revelaed L endobronchial narrowing, mediastinal abnormalities, extensive compression of the left main stem bronchus and the esophagus.The patient continued to have worsening respiatory status and had to placed in BiPAP,her PH at this time was 7.33 but pco2 had gone upto 82. On [**2170-1-1**] she continued to have hypercapneic respiratory insufficiency and had to be intubated.A bronchoscopy followed demonstrating a mass above the carina,extending into the left mainstem bronchus.The right side was clear.Biopsies were taken from the area which showed non small cell lung cancer.On [**1-2**] she got a YAG laser resection of the endobronchial tumor with resultant opening of 40% of the L main stem bronchus.She also got an endoscopy which showed a benign appearing ulcer at the GE junction.No tumor was seen.A trial for extubation was made on [**1-7**] but she could not last too long of the breathing machine. She was then transferred to [**Hospital1 18**] for stent placement of distal trachea and proximal mainstem bronchus. She received this Y-stent without any adverse sequelae. Multiple trials with extubation were not successful, but the patient was eventually able to extubate, leave the ICU care setting, and transfer to the floor. As she remained on the hospital surgical [**Hospital1 **] floor, the patient's heart rate had been a chronic issue of management, but was kept under the control with the assistance of Cardiology consultants. The surgical team was concerned about her nutritional status; as such a J tube was placed surgically with good success. The patient was able to tolerate tube feeds at goal nutritional status (evaluated jointly between the primary team and [**Hospital1 18**] nutritionists) and manage the basic care of her J tube. At the time of discharge the patient's nutritional status is improving, and her heart rate is well-controlled on her current cardiac medical regimen. There are no lingering surgical issues at this time, and the patient's Y-stent has functioned appropriately at this time. Medications on Admission: Meds upon transfer: Diltiazem 5mg/hr IV propofol 20-50 mcg/kg/min potassium chloride 20mcg/1000ml fentanyl citrate 25-1000mcg/hr flucanazole 100mg iv once chlorhexidine 0.12% pantoprazole 40 mg q24h methylprednisone sodium succinate 10 mg iv q24h albuterol- ipratropium 8 puff q4h heparin 5000 unit sc TID fluticasone propionate 110 mcg. Discharge Medications: 1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for copd. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): via j-tube. 5. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for afib: via j-tube. 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): via j-tube. 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for afib: all meds via j-tube. 8. Pepcid 40 mg/5 mL Suspension Sig: Five (5) mls PO once a day. 9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): via j-tube. 10. Guaifenesin 100 mg/5 mL Liquid Sig: Twenty (20) mls PO Q4H (every 4 hours) as needed for stent maintenance: via j-tube MUST STAY ON FOR LIFE OF SILICONE STENT- NOT PRN. 11. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for loose BM: via j-tube. 12. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day. 13. tube feed Tubefeeding: Nutren Pulmonary Full strength; Goal rate:45 ml/hr Flush w/ 50 ml water q8h Discharge Disposition: Extended Care Facility: [**Hospital 75608**] Rehab and Nursing center Discharge Diagnosis: Lung Cancer Squamous Cell Pharyngeal Cancer Atrial Fibrillation Coronary Artery Disease s/ MI c/b VF age 32 & 42 Chronic Systolic Dysfunction Hyperlipidemia Hypertension COPD Breast Cancer s/p lumpectomy Discharge Condition: deconditioned- awaiting chemotherapy and radiation. Discharge Instructions: Call Dr.[**Name (NI) 5070**] office [**Telephone/Fax (1) 10084**] if you experience chest pain, shortness of breath, fever, chills, nausea, vomiting, diarrhea, or abd pain. strict NPO- wilent aspiration If your feeding tube sutures become loose or break, please tape tube securely and call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 170**]. If your feeding tube falls out, save the tube, call the office immediately [**Telephone/Fax (1) 170**]. The tube needs to be replaced in a timely manner because the tract will close within a few hours. Do not put any medication down the tube unless they are in liquid form. Flush your feeding tube with 50cc every 8 hours and before and after every feeding. Follow up with oncology and radiation oncology to begin treatment. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 71346**] PCP [**Telephone/Fax (1) 58547**] Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 75609**] Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Radiation Oncologist Follow-up with Dr. [**Last Name (STitle) 75610**] [**Telephone/Fax (1) 7732**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]

[ "146.8", "V10.3", "414.01", "V45.82", "261", "162.8", "707.05", "427.31", "425.4", "428.0", "519.19", "496", "197.0", "428.22" ]

icd9cm

[ [ [] ] ]

[ "29.12", "31.42", "42.23", "96.6", "45.13", "33.23", "38.91", "32.01", "96.05" ]

icd9pcs

[ [ [] ] ]

13534, 13606

9508, 11834

339, 696

13854, 13908

2109, 9485

14736, 15163

1494, 1571

12223, 13511

13627, 13833

11860, 12200

13932, 14713

1586, 2090

280, 301

724, 1296

1318, 1351

1367, 1478

19,668

149,482

5549

Discharge summary

report

Admission Date: [**2115-1-15**] Discharge Date: [**2115-1-27**] Date of Birth: [**2046-7-11**] Sex: M Service: MEDICINE Allergies: Methotrexate / Enbrel / Ceftazidime Attending:[**Last Name (NamePattern1) 293**] Chief Complaint: lower extremity weakness, aspiration pneumonia post-surgery Major Surgical or Invasive Procedure: laminectomy and discectomy History of Present Illness: This is a 68year old M with history of hypertension, coronary artery disease, diabetes mellitus, rheumatoid arthritis and spinal stenosis who presented with increased lower extremity weakness 3 days prior to admission. He underwent L3-5 laminectomy /fusion for spinal stenosis on [**2114-11-16**]. He has been lying flat in bed since surgery and on [**1-19**] 04 developed shortness of breath with sat in 91%RA and then 80%RA. He was put on NRB at87-95%. ABG 7.44/33/69 on NRB. CXR showed RLL superior segment pneumonia, likely from aspiration Past Medical History: 1. Hypertension 2. diabetes mellitus 3. COPD 4. spinal stenosis 5. pheumatic heart disease Social History: occasional ETOH, no other drug use. smoked >1ppd for >40 years, quit 8 years ago Family History: father and brother with kidney cancer Physical Exam: T99.1 P130 BP 129/73 R22 sat 98% NRB, I/O 2L/2.2L Gen-moderate respiratory distress HEENT_mmm, JVP 8cm CV-tachy, rrr, no r/m/g resp-b/l expiratory wheezes [**Last Name (un) 103**]-slight distension, +BS extremities-no edema, no tenderness, no Homans, 2+pulses Pertinent Results: [**2115-1-21**] 03:52AM BLOOD WBC-8.3 RBC-3.24* Hgb-9.8* Hct-29.8* MCV-92 MCH-30.3 MCHC-33.0 RDW-14.5 Plt Ct-252 [**2115-1-20**] 05:41AM BLOOD WBC-11.7* RBC-3.49* Hgb-10.8* Hct-32.6* MCV-93 MCH-30.9 MCHC-33.1 RDW-15.5 Plt Ct-269 [**2115-1-19**] 08:35PM BLOOD WBC-12.3*# RBC-4.15* Hgb-12.8*# Hct-39.0*# MCV-94 MCH-30.9 MCHC-32.9 RDW-15.0 Plt Ct-406 [**2115-1-20**] 05:41AM BLOOD Neuts-86* Bands-3 Lymphs-8* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2115-1-21**] 03:52AM BLOOD Plt Ct-252 [**2115-1-21**] 03:52AM BLOOD PT-13.2 PTT-34.6 INR(PT)-1.1 [**2115-1-21**] 03:52AM BLOOD Glucose-131* UreaN-36* Creat-1.1 Na-141 K-5.0 Cl-111* HCO3-21* AnGap-14 [**2115-1-20**] 05:41AM BLOOD Glucose-111* UreaN-26* Creat-1.0 Na-140 K-4.8 Cl-111* HCO3-20* AnGap-14 [**2115-1-19**] 08:35PM BLOOD Glucose-160* UreaN-24* Creat-0.9 Na-138 K-5.1 Cl-105 HCO3-22 AnGap-16 [**2115-1-20**] 05:41AM BLOOD CK(CPK)-35* [**2115-1-19**] 08:35PM BLOOD Lipase-21 [**2115-1-19**] 08:35PM BLOOD CK-MB-3 cTropnT-<0.01 [**2115-1-17**] 07:00AM BLOOD CK-MB-5 cTropnT-0.01 [**2115-1-21**] 03:52AM BLOOD Calcium-8.0* Phos-3.9 Mg-2.4 [**2115-1-19**] 11:18PM BLOOD Type-ART Temp-38.3 pO2-113* pCO2-42 pH-7.34* calHCO3-24 Base XS--2 Intubat-NOT INTUBA Comment-NON-REBREA [**2115-1-19**] 08:50PM BLOOD Type-ART Temp-36.1 Rates-/22 FiO2-100 pO2-69* pCO2-33* pH-7.44 calHCO3-23 Base XS-0 AADO2-630 REQ O2-100 Intubat-NOT INTUBA Vent-SPONTANEOU [**2115-1-19**] 11:18PM BLOOD Lactate-1.4 [**2115-1-19**] 08:50PM BLOOD Lactate-1.9 [**2115-1-16**] 06:25PM BLOOD Hgb-10.2* calcHCT-31 [**2115-1-19**] 08:50PM BLOOD freeCa-1.13 CTA [**2115-1-19**]:CTA CHEST WITH AND WITHOUT CONTRAST: Examination of the pulmonary arterial tree fails to reveal any intraluminal filling defect that would suggest pulmonary embolus. Coronary artery and aortic arthroscerlotic calcifications are present. Small mediastinal and hilar lymph nodes are present, but they do not meet the CT criteria for pathologic enlargement. There is no pericardial effusion. The central airways are patent. There is a background of centrilobular emphysema. Moderate patchy consolidated opacities are present in the dependent portions of the right upper and lower lobes. Given the diffuse thickening of the esophagus and fluid within the proximal esophagus, the consolidation may represent aspiration pneumonia. There is some mild pleural thickening posteriorly on the right. Minimal atelectasis is present in the dependent portions of the left lower lobe. Multiple old rib fractures are noted on the right. CT RECONSTRUCTIONS: Coronal and sagittal reformatting performed for additional assessment of the pulmonary arteries agrees with the above findings. IMPRESSION: 1. No pulmonary embolus detected. 2. Right upper and lower lobe consolidated opacities suggesting pneumonia. 3. Thickened esophagus suggesting esophagitis. Retention of fluid in the proximal esophagus raises suspicion for aspiration in the right lung. Brief Hospital Course: This is a 68yo male who underwent laminectomy and fusion on [**2115-1-16**] who developed respiratory distress from likely aspiration pneumonia.Post surgery, he had to be lying flat and most likely aspirated. He was also found to have possible dural leak and had to lie flat for more days in ICU. This impaired mucus clearance and further increased his chance of continued aspiration. He was put on high flow mask and antibiotics were started. He was initially on ceftazidime and levofloxacin. However, he developed allergic rash and the antibiotic was hence changed to Zosyn. Sputum culture initially showed gram negative rods and zosyn was continued while waiting for sensitivity. His respiratory status improved dramatically when he was able to be sitted up per neurosurgery. He was also found to be very sedated with just a tiny touch of morphine. His mental status improved drastically with discontinuation of morphine and just using tylenol for pain control. His sputum eventually grew Citrobacter which is sensitive to levofloxacin and he was hence changed to PO levofloxacin. Of note, his RA medication-Arava was initially held because of the immunosuppresive effect while he was acutely ill. It has been restarted prior to discharge from the hospital. Patient found to be guiaic positive on this admission. Stable hematocrit, recommend outpatient colonoscopy. He has been very cooperative with physical therapy and is discharged to rehab with outpatient follow up with neurosurgery. . Medications on Admission: lisinopril atenolol lipitor protonix metformin ASA flovent heparin sc TID SSI cefazolin colace lipitor prednisone Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: [**1-20**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for constipation. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. Methyl Salicylate-Menthol Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. 9. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Albuterol Sulfate 0.083 % Solution Sig: [**1-20**] Inhalation Q4-6H (every 4 to 6 hours) as needed. 12. Ipratropium Bromide 0.02 % Solution Sig: [**1-20**] Inhalation Q6H (every 6 hours) as needed. 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 14. Leflunomide 10 mg Tablet Sig: One (1) Tablet PO q3days (). 15. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Tablet(s) 18. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**] Discharge Diagnosis: 1. Aspiration pneumonia 2. post laminectomy 3. diabetes 4. hypertension Discharge Condition: stable, ambulating with assistance, no oxygen requirements Discharge Instructions: Please return to the hospital or call your doctor if you have difficulty in breathing, fever, sudden worsening of back pain, sudden worsening of weakness or if there are any concerns at all Followup Instructions: 1. Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1327**] from neurosurgery on Tuesday [**2115-1-29**] to have the clips from your surgery removed. Call to confirm appointment [**Telephone/Fax (1) 1669**] Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 1339**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3231**] Appointment should be in [**7-28**] days Call your pcp, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], this week to set up an appointment for after you get out of rehab. [**Telephone/Fax (1) 3183**].

[ "412", "997.09", "250.00", "792.1", "401.9", "496", "344.60", "724.02", "722.10", "V58.65", "507.0", "714.0", "997.3", "414.00", "E878.8", "736.79", "785.0" ]

icd9cm

[ [ [] ] ]

[ "03.09", "99.04", "80.51", "88.43" ]

icd9pcs

[ [ [] ] ]

7929, 8032

4496, 5994

363, 391

8148, 8208

1526, 4473

8446, 9021

1192, 1231

6158, 7906

8053, 8127

6020, 6135

8232, 8423

1246, 1507

264, 325

419, 964

986, 1078

1094, 1176

46,801

176,093

33495

Discharge summary

report

Admission Date: [**2122-6-27**] Discharge Date: [**2122-7-3**] Date of Birth: [**2044-9-13**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: Abdominal Pain and cough Major Surgical or Invasive Procedure: laparoscopic cholecystectomy History of Present Illness: PCP: [**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) 275**] A./[**First Name4 (NamePattern1) 401**] [**Last Name (NamePattern1) **] PA/ Location: [**Hospital **] MEDICAL ASSOCIATES, PC Address: 20 GRANITE STATE COURT, [**Location (un) **],[**Numeric Identifier 77660**] Phone: [**Telephone/Fax (1) 27649**] Fax: [**Telephone/Fax (1) 77661**] confirmed by paperwork sent with pt from doctor's visit on the day of presentation. Last saw urgent care PA on [**2122-6-26**]. Also confirmed pt's doctors with dtr. . Cardiologist Dr. [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) 77662**] Pulmonologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3501**] The patient is a poor historian in terms of dates and timing so much of the history is obtained from his dtr. His dtr confirms that he does have short term memory deficits. . HPI: 77 year old male sent from [**Hospital3 635**] hospital with known history of cholelithiasis with recurrent RUQ pain x 1 month which began one month ago, other complicated medical history including CABG, implanted defibrillator, bladder CA s/p urostomy, orthostatic hypotension sent to [**Hospital1 18**] for CT today showing 9 mm stone in CBD. Of note he was admitted to [**Hospital3 **] Hospital on [**2122-5-25**] for PNA s/p L thoracentesis. He was also having abdominal pain then. An US was performed which demonstrated cholelithiasis but there was no cholecystitis so there was no intervention. He then went to rehab from [**5-28**] to [**6-5**]. He improved somewhat but still walking with a wheelchair. He then started home VNA. Two days later he developed nausea with non bloody, bilious emesis. He did not take the last doses of the levaquin because his family was concerned that this might be contributing to his nausea and vomiting. He continued to report RUQ abdominal pain, burping, worse with palpation. Two days PTP his blood pressure was lower than baseline 77/33. The home VNA. His lasix and potassium was held. His BP continued to fluctuate. He remained ill with malaise and worsening abdominal pain. He then went to his PCP-> [**Hospital3 **] Hospital -> Hospital. He also reports ongoing cough of productive white sputum. Per his daughter there is no change in his baseline. Pain with deep inspiration. T = 100.9 the night prior to presentation. Tbe patient is unable to identify any ameliorating or triggerin factors. Pain not relived with IV morphine. He reports spasms of sharp pain which lasts seconds. He reports that he has had a cough for a while. He is on 2L of oxygen at home. Per his dtr the pain is worse with eating and there has been no change in his baseline cough. There may have been some improvement since he is on mucinex. . In ER: (Triage Vitals: 19:16 10 98.8 70 135/44 16 96 ) Meds Given: unasyn 3 g IV, morphine 2 mg IV, coreg 3.125 mg po, zocor 20 mg po, advair 250/50 2 puffs INH Fluids given: none at [**Hospital1 18**] but 500 cc at CCH po intake in ED UOP 300cc Radiology Studies:, consults called: surgery; admit to medicine for ERCP. ERCP aware Vitals 98.7, 71, 125/52, 16, 95% on 2L . PAIN SCALE: [**11-8**] location: RUQ _______________________________________________________________ REVIEW OF SYSTEMS: as per HPI Past Medical History: Coronary artery disease s/p CABG x [**2120-3-31**] - s/p defibrillator placed in [**2120-3-30**] because he developed V-tach s/p ablataion which was not effective - L ventricular anneurysm - H/o hyperlipidemia - H/o malignancy s/p bladder resection for bladder cancer - Orthostatic hypotension choledolithiasis s/p ERCP ?[**2120**] @ [**Hospital1 112**] - did not undergo surgery at this time given history of heart disease. Recurrent abd pain since that time. + alcoholic encephalopathy- recovering alcoholic + neuropathy - admitted to [**Hospital3 **] Hospital with Klebsiella PNA on [**5-25**] [**2122**] s/p L lung thoracentesis Thrombophlebitis of L arm at site of IV during recent rehab stay [**2122-5-30**] Social History: SOCIAL HISTORY/ FUNCTIONAL STATUS: DNR per conversation with daughter [**Name (NI) 2808**] - HCP who lives with him. Family contact information: [**Name (NI) 2808**] [**Name (NI) 77663**] [**Telephone/Fax (1) 77664**] cell [**Telephone/Fax (1) 77665**] [**Doctor First Name **] can also answer questions (daughter in law) Cigarettes: 50 pack years, quit [**6-/2117**], recovering alcoholic 2 drinks/day: Drugs: none Occupation: unemployed Marital Status: Divorced, lives with daughter . Independent of ADLs but dtr helps him put on his socks He walks pushing a wheelchair and he sits down when he is tired. Dtrs does accounting, dtr's partner cooks. [**Name2 (NI) **] does not drive. Dentures/hearing aides/eye glasses No recent falls PPD negative Family History: + for coronary artery disease and CVA. Mother died of colon CA Physical Exam: PAIN SCORE: [**11-8**] VS T = 97.2 P = 65 BP = 146/122-> 120/48 on re-check RR = 20 O2Sat = 91% on 2L GENERAL: Thin male laying in bed. Nourishment: At risk Grooming: OK Mentation: Alert, not delirious but a difficult historian since he cannot clearly tell me when his pain started, what makes it worse, etc. Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Respiratory: Decreased breath sounds at the bases b/l Cardiovascular: RRR, nl. S1S2, no M/R/G noted but heart sounds are distant Gastrointestinal: soft, tender in the RUQ with deep palpation. Genitourinary: Periumbilical urostomy bag draining clear yellow urine. No prostate tenderness Guiac negative brown stool Skin: no rashes or lesions noted. No pressure ulcer Extremities: No C/C/E bilaterally, 2+ radial, DP pulses b/l. L arm more swollen than right. Lymphatics/Heme/Immun: No cervical, lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to do DOWB -cranial nerves: II-XII grossly intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. + urostomy catheter draining clear yellow urine. Site C/D/I Psychiatric: appropriate full affect ACCESS: [X]PIV []CVL site ______ UROSTOMY CATHETER FOLEY: [X]present []none UROSTOMY: :[X]present []none [ ]site C/D/I Pertinent Results: [**2122-6-26**] 10:28PM COMMENTS-GREEN [**2122-6-26**] 10:28PM LACTATE-1.0 [**2122-6-26**] 08:00PM GLUCOSE-97 UREA N-11 CREAT-1.1 SODIUM-135 POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-28 ANION GAP-14 [**2122-6-26**] 08:00PM estGFR-Using this [**2122-6-26**] 08:00PM ALT(SGPT)-13 AST(SGOT)-29 ALK PHOS-80 TOT BILI-0.7 [**2122-6-26**] 08:00PM LIPASE-14 [**2122-6-26**] 08:00PM ALBUMIN-3.3* [**2122-6-26**] 08:00PM WBC-8.3 RBC-3.87* HGB-12.2* HCT-37.1* MCV-96 MCH-31.6 MCHC-33.0 RDW-15.0 [**2122-6-26**] 08:00PM NEUTS-84.4* LYMPHS-9.1* MONOS-5.3 EOS-1.0 BASOS-0.2 [**2122-6-26**] 08:00PM PLT COUNT-160 . ECG: SR at 69 bpm, Q in III and avF, RBBB. No acute changes. LABS: OSH LIpase/Amylase WNL D bili = 0.4 T bili = 1.1 WBC = 9.5 with 84 % PMNS. UA +ve . CXR: CCH Chronic atelectasis of the R lower lung field. Increasing L pleural effusion and LLL atelectasis. . CT SCAN: CCH Moderate amt of sludge filling [**2-1**] of the GB with a 9 mm stone at the neck. No pericholecystic fluid or GB wall thickening is seen. With addition of contrast there is chronic enhancement similar to previous exam. No son[**Name (NI) 493**] [**Name2 (NI) **] sign. CBD = 9 mm. Impression: Possible obstructing CBD stone. Acute cholecystitis cannot be ruled out. . ERCP [**4-/2120**] Normal major papilla Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique. Cholangiogram showed a mild dilation of CBD and CHD. The cystic duct was filled with contrast. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire to prevent future biliary obstruction. Balloon sweep was performed which did not show stone because of earlier passage of stone. Recommendations: Return to outside hospital under referring physician 's care NPO overnight , then advance diet as tolerated in AM. Consider cholecystectomy No ASA or NSAIDs for 10 days. Follow-up with Dr. [**Last Name (STitle) **] Additional notes: The procedure was performed by Dr. [**Last Name (STitle) **] and the GI fellow. The patient's reconciled home medication list is appended to this report. . Brief Hospital Course: ASSESSMENT: The patient is a 77 year old male with multiple medical problems including CAD s/p CABG x 2, L ventricular anneurysm, s/p defibrillator placement, COPD on home O2 2L, short term memory deficits, who presented with recurrent abdominal pain and was found to have cholangitis/choledolithiasis. . Cholangitis/choledolithiasis: Patient was started on IV Unasyn. He underwent an ERCP on [**2122-6-28**] with removal of a 12mm nonobstructing common bile duct stone. There was also noted to be a stone at the cystic duct. He tolerated the procedure well and returned to the floor postop. He continued to have intermittent RUQ pain. The patient also underwent a thorocentesis on [**2122-6-30**] for his recurrent bloody pleural effusion. Discussions were held with the patient, his family, the medical (primary) service, and the surgical service and the decision was made for laparoscopic cholecystectomy given continued pain and evidence of cholecystitis on imaging combined with his presentation of choledocholithiasis. His medical team felt that no further cardiac testing was required and that he would tolerate surgery. Discussions were held regarding his increased risk of needing to remain intubated postoperatively given his chronic pulmonary issues and the patient agreed to this and a perioperative suspension of his DNR/DNI order. He underwent a lap ccy on [**2122-7-1**] after evaluation by anesthesia for tolerance to general anesthesia. This was uncomplicated and he tolerated the procedure well. He was extubated postoperatively and his respiratory status was stable, however after IV fluids and pain medications, on POD1 he became SOB and hypoxic w/ O2 sats at 86% on 6L face mask. He was also found to be transiently hypotensive so he was transferred to the ICU for further management. In the ICU his Cxray showed worsening moderate interstitial pulmonary edema and moderate bilateral pleural effusions so he was started on lasix gtt. He was also kept on Unasyn for possible pneumonia. There he was maintained on nonrebreather, but eventually developed hypercarbia. Bipap was tried, but the patient could not tolerate it. He also developed worsening renal failure thought to be due to the hypotension as well as a pan sensative enterococus UTI. After a family meeting, it was decided to transition the patient to comfort measures and he expired soon after. Medications on Admission: Confirmed with dtr on admission protonix 40 mg po qd after breakfast amiodarone 200 mg after breakfast Zocor 20 mg po qd after dinner Coreg 3.125 mg T after dinner on M/W/F MagOx = 400 mg [**Hospital1 **] Niferex 150 mg qhs spiriva T qd Florinef 0.1 mg qd after breakfast aspirin 81 mg po qd mucinex 600 mg [**Hospital1 **] ibuprofen 600 mg tid prn lasix 20 mg po every other day after breakfast. His last dose was Friday [**6-26**] B12 q month advair 250/50 [**Hospital1 **] proair hFA 2 puff q4 prn O2 2L Potassium 10 MEQ QOD with lasix Vitamin C 500 mg [**Hospital1 **] MVT Discharge Medications: na Discharge Disposition: Expired Discharge Diagnosis: choledocholithiasis cholecystitis respiratory failure Discharge Condition: Expired Discharge Instructions: n/a Followup Instructions: n.a

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icd9cm

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[ "51.88", "96.04", "38.93", "34.91", "51.23", "96.72" ]

icd9pcs

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