ChanBeDu/relevant_section_length · Datasets at Hugging Face

4,903

194,150

26279

Discharge summary

report

Admission Date: [**2126-12-28**] Discharge Date: [**2127-1-2**] Date of Birth: [**2067-11-5**] Sex: F Service: MEDICINE Allergies: Naproxen Sodium / Ciprofloxacin Attending:[**First Name3 (LF) 1145**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: 1. percutaneous coronary intervention w/cypher stent 2. upper endoscopy w/electrocautery 3. 3 units packed red blood cells History of Present Illness: 59 yof pmh HTN, PUD and left subclavian artery stenosis? transferred from OSH with sscp for 20-30 minutes assoc with nausea and vomitting x2. Pain described as nonradiating constant chest pressure [**9-4**]. Assoc +diaphoresis and dizziness but no SOB. Found to have ST elevation in II-III and depression lateral lead V2-4, slight elevation in V1. . Patient received IV NTG, ASA 324mg, Heparin IV bolus 3000U, metoprolol, SL nitroglycerin, integrillin, atorvastatin and plavix. Patient was transferred to [**Hospital1 18**] ED. . In ED, AF 124/72 74 100% NC 2L, chest pressure [**3-7**], sent straight to cath. LCx and RCA . Recent stress echo [**10-30**] normal per patient. Denies having this chest pain ever before or prior MI. Reports sleeping on 2 pillows at night and denies PND or presyncopal/syncopal events. Past Medical History: 1. Hypertension 2. Peptic ulcer disease 3. PVD/?Left subclavian artery stenosis Social History: Lives with husband, has 3 kids and works as a traffic supervisor. Currently smokes [**1-27**] ppd for 30 years, occas 1 wine/week and denies illicit drugs. Family History: Father - HTN Mother - died of MI @ 76 yo Physical Exam: VS T 96.8 BP 134/70 HR 89 RR 22 O2sat 95% 2L NC Gen: lying in bed, NAD HEENT: PERRL, MMM, OP clear, JVP ~9cm, no thyromegaly, neck supple CV: nl S1 S2 RRR no m/r/g PULM: clear to auscultation bilaterally [**Last Name (un) **]/lat ABD: soft nt +bs guaic neg GROIN: nontender, no hematoma EXT: nonedematous, 1+ DPP bilaterally Pertinent Results: [**2126-12-28**] 04:20PM BLOOD cTropnT-<0.01 [**2126-12-28**] 10:25PM BLOOD CK-MB-82* MB Indx-12.0* [**2126-12-29**] 04:48AM BLOOD CK-MB-85* MB Indx-10.3* cTropnT-2.48* [**2126-12-29**] 01:23PM BLOOD CK-MB-49* MB Indx-7.5* cTropnT-1.62* %HbA1c: 6.6 Na 140 Cl 109 BUN 19 Gluc 114 AGap=14 Calcium-7.9* Phos-3.6 Mg-2.4 K 4.2 HCO3 21 Cr 1.0 ALT: 14 AP: 70 Tbili: 0.3 Alb: 3.5 AST: 15 Dbili: 0.1 [**Doctor First Name **]: 61 VitB12-372 Albumin-3.5 Cholest-79 WBC 18.2 HBG 7.9 PLAT 259 HCT 25.0 N:86.0 Band:0 L:10.4 M:3.2 E:0.4 Bas:0.1 Cardiac Catherization [**12-28**] RA pressure 12 mmHg Right dominant LMCA: normal LAD: mild disease LCx: occluded RCA: occluded->appeared to be [**Doctor First Name **]-> stented with 3.0 stent taken to 3.25->0% residual Echo: [**2126-12-30**] 1. EF: 40-45% 2. The mitral valve leaflets are mildly thickened. Severe (4+) mitral regurgitation is seen 3. Overall left ventricular systolic function is mildly depressed. Resting regional wall motion abnormalities include basal and mid inferior and inferolateral akinesis. Intrinsic LV function may be more depressed given the severity of the regurgitation 4. The estimated pulmonary artery systolic pressure is normal SPECIMEN SUBMITTED: EGD Procedure date Tissue received Report Date Diagnosed by [**2126-12-31**] [**2126-12-31**] [**2127-1-2**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 18795**]/vf DIAGNOSIS: Antrum, mucosal biopsies: No diagnostic abnormalities recognized. Focal and minimal chronic inflammation. Clinical: GI bleeding. EGD: Gastric angioectasias; antral erythema. Brief Hospital Course: 59 yof pmh HTN, PUD and PVD presents with IMI with RCA and LCx occlusions -> s/p PTCA/RCA stent as this was determined to be major cause of IMI. Now with GI bleed. s/p EGD 2 AVM seen and cauterized, bx H pylori also performed. . ##CARDIAC #ischemia: LCX and prox RCA occlusions. s/p RCA cypher stent. Given improvement in ST elev in II-III and depression in lateral leads this am, likely will not recath patient this admission to tx LCx and have her follow-up in cardiology clinic. Peak CPK 825. Continued on ASA, Plavix, Integrillin (total 18 hrs). Increased from 40mg to lipitor 80mg and normal LFTs. Started metoprolol 25mg PO TID and lisinopril 5mg PO QD. #pump: Echo on [**12-30**] showed EF of 40-45% with 4+ MR as well as basal, mid inferior and inferiolateral hypokinesis. Patient denies history of murmur. Tolerated blood transfusions as needed. #rhythm: Started metoprolol. Continued telemetry and serial EKGs. #Anemia: Per patient, stopped taking iron supplement [**2-27**] gastric irritation. Hct 25 on admission. Patient received blood tranfusions to keep Hct >30 in the setting of acute MI. Hct 32 on discharge. . #PUD/GIB: patient reported ulcers on EGD [**8-30**]. Follow-up EGD scheduled this month. Pt had 3 episodes of maroon colored/melena. GI consulted and perforemd upper endoscopy [**12-31**] which showed 2 AVM's which were cauterized and bx taken for H pylori. Continued protonix [**Hospital1 **] and sulcrafate, held cimetidine. . #PVD/L subclavian artery stenosis: intermittent L hand claudication. stable. . #FEN: cardiac healthy low sodium diet, replete lytes. . #PPX: bowel regimen, PPI, SQ heparin, C. diff precautions . #Code: full . #Dispo: PT consult, nutrition consult, likely dc home. Medications on Admission: 1. sucralfate [**Hospital1 **] 2. lipitor 40mg QD 3. quinipril 20mg QD 4. cimetidine 400mg [**Hospital1 **] 5. protonix 40mg [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 90 days. Disp:*90 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 4. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0* 5. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual q5 minutes as needed for chest pain: Please take 1 tablet as needed for chest pain. [**Month (only) 116**] repeat dose every 5 minutes as needed up 3 doses in 15 minutes. Disp:*1 bottle* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. ST elevation myocardial infarction Secondary Diagnosis: 2. history of gastric ulcers 3. peripheral vascular disease 4. 15 pack year smoking history Discharge Condition: stable Discharge Instructions: Please take medications as prescribed. You will need to take aspirin and plavix for at least 3 months. Please follow-up with Dr. [**Last Name (STitle) **] (cardiology) for duration of these medications. Please keep follow-up appointments. Please follow-up your gastric biopsy for H. pylori results. Please call your primary care physician or come to the emergency room if you have any chest pain, shortness of breath, near fainting or loss of consciousness, frequent bloody or black tarry stools or any other worrying symptoms. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Date/Time: [**2127-1-9**] 3:30pm Location: [**Street Address(2) **] [**Apartment Address(1) **], [**Hospital1 **], MA Phone: [**Telephone/Fax (1) 4475**] Provider: [**First Name8 (NamePattern2) 1955**] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 52520**] Fax: [**0-0-**] Date/Time: [**2127-1-17**] 3:00pm Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Cardiology) Please call [**Telephone/Fax (1) 5003**] to schedule a follow-up appointment in 1 month. Completed by:[**2127-1-5**]

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icd9cm

[ [ [] ] ]

[ "36.07", "88.52", "00.40", "44.43", "99.04", "00.66", "37.23", "88.56", "99.20", "00.46" ]

icd9pcs

[ [ [] ] ]

6673, 6679

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303, 428

6894, 6903

1972, 3573

7483, 8089

1568, 1611

5514, 6650

6700, 6700

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1626, 1953

253, 265

456, 1274

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6719, 6758

1296, 1378

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12,387

113,028

51827+59384

Discharge summary

report+addendum

Admission Date: [**2172-10-3**] Discharge Date: [**2172-10-7**] Service: MEDICINE Allergies: Naproxen Attending:[**First Name3 (LF) 2159**] Chief Complaint: brbpr Major Surgical or Invasive Procedure: None History of Present Illness: HPI: [**Age over 90 **] yo Russian speaking F with CAD, AFib, DM, HTN, CHF, CRI (Baseline Cr=1.4), anemia, who presents from [**Hospital 100**] rehab with 2 episodes of blood in her stool this am. She was found to have a supratherapeutic INR (5.9) at [**Hospital 100**] Rehab. She received one dose of Vit K 5 mg po and was transferred to [**Hospital1 18**] for evaluation. Per report patient denied lightheadedness, dizziness, CP, SOB, N/V, belly pain. Initial vitals revealed SBP in the mid 90's which increased to 110's without intervention, HR remained in the 60's. NG lavage negative. Hct noted to be 28.0. As per Nursing Home staff pt has been off coumadin for 5 days secondary to elevated INR. She was started on coumadin after her recent hip surgery. Her INR has been difficult to control. She has not been on any other new medications recently. . In the [**Name (NI) **], pt received an additional 10 mg of SC Vitamin K and 2 units of FFP. She has two large bore IV's. She has not yet received a blood transfusion. . Past Medical History: PMH: 1. CAD 2. AF 3. CKD (Cr 1.5-1.7) 4. DM 5. h/o UTI 6. Osteoporosis 7. Glaucoma 8. Hyperlipidemia 9. HTN 10. Depression 11. Anemia Social History: Nursing Home resident, lives a [**Hospital 100**] Rehab. Contact is son [**Name (NI) 4186**] ([**Telephone/Fax (1) 107323**] and ([**Telephone/Fax (1) 107324**] (h) Family History: Non-contributory Physical Exam: Physical Exam: Tc 97.6 BP 107/66 HR 72 RR 16 Sat 97% RA Gen: well appearing elderly female, NAD HENNT: MMM, anicteric Neck: no LAD, JVD flat, no carotid bruits CV: RRR, nl S1S2, III/VI systolic murmur heard best at apex Lungs: soft bibasilar crackles Abd: soft, NT/ND, +BS, No HSM Ext: no edema, strong DP/PT pulses bilaterally, blood filled flacid blisters on bilateral heals w/o surrounding erythema Neuro: Moving all extremeties . Pertinent Results: [**2172-10-3**] 08:08PM ALT(SGPT)-20 AST(SGOT)-27 LD(LDH)-256* ALK PHOS-480* TOT BILI-0.7 [**2172-10-3**] 08:08PM HAPTOGLOB-121 [**2172-10-3**] 08:08PM HCT-19.6*# [**2172-10-3**] 06:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2172-10-3**] 06:00PM URINE RBC-[**1-25**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2172-10-3**] 02:22PM GLUCOSE-134* UREA N-33* CREAT-1.3* SODIUM-140 POTASSIUM-5.4* CHLORIDE-113* TOTAL CO2-16* ANION GAP-16 [**2172-10-3**] 02:22PM WBC-11.9* RBC-2.98* HGB-9.3* HCT-28.0* MCV-94 MCH-31.2 MCHC-33.2 RDW-15.9* [**2172-10-3**] 02:22PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL [**2172-10-3**] 02:22PM PT-32.3* PTT-47.7* INR(PT)-7.9 Studies: CXR [**2172-10-3**]: hlar fullness, retrocardiac opacity with blunting of left costophrenic angle. . ECG: NSR, rate 64, nl intervals, nl axis, old Q's III, V1-V3, no new ST-T changes. . ECHO [**2-25**]: 1. The left atrium is mildly dilated. The interatrial septum is aneurysmal. 2. The left ventricular cavity size is normal. There is moderate global left ventricular hypokinesis. Overall left ventricular systolic function is moderately depressed. 3. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5. There is mild pulmonary artery systolic hypertension. Brief Hospital Course: A/P: [**Age over 90 **] yo Russian speaking F with CAD, AFib on coumadin, DM, HTN, CHF, CRI (Baseline Cr=1.4), anemia (baseline hct ~30), who presents from [**Hospital 100**] rehab with episodes of blood in her stool. . # GI bleed: The pt was admitted to the [**Hospital Unit Name 153**]. On admission the patient had a negative NG lavage in setting of INR of 7.9. Tthe etiology was felt to be a LGIB in the setting of a supratherapeutic INR. The DDX included diverticulosis, AVM, malignancy, hemorrhoids. On admission the pt received 15 mg of Vit K. She was given 2 units of FFP in addition to those given in the ED for a total of 4 Units and transfused 2 units of PRBC's. Initially she received q 6 hour hct checks and an IV PPI [**Hospital1 **]. Her [**Hospital1 **] and Coumdain were held. In the [**Hospital Unit Name 153**], the pt's hct stabilized. GI was consulted but did not want to do any intervention because they believed bleed was caused by supratherapeutic INR. The pt was transfered to the floor as she was hemodynamically stable, her hct is stable, and her INR dropped from 7.9 on admit to 0.9. While on the floor the pt initially reported feeling weak, but on the day of discharge reported feeling well after 2 days of po. . # Coagulopathy. The pt presented with an INR of 7.9. The pt had been off coumadin x5 days, but had been supratherapeutic and difficult to control on past admission. She had no new medications. Her coagulopathy was likely related to malnutrition and poor control on coumadin. She was given FFP and Vitamin K as above. Her coumadin was held. Her INR returned as above to 0.9. Per ortho, she was placed on lovenox 30 mg qd X 4 weeks for better-controlled anti-coagulation. . # CV: h/o CAD: The pt was placed on a BB and ACE-I, once her preussure could tolerate them. She wa splaced back on her home statin and [**Hospital Unit Name **], once her hct was stable. pump: Pt has a known CHF (EF 30-35%). An ACE-I was added for afterload reduction. rhythm: h/o PAFIB. The remained in sinus with well controlled HR. She wa splaced on anti-coag as above. . # Recent Hip Fracture s/p reduction and fixation: The patient was kept non wt bearing throughout her admission with PT follow-up. She was placed on standing tylenol with prn oxycodone for pain control. Eventually she was weaned off the tylenol with the prns adequately controlling her pain. Ortho recommended lovenox out-pt as above. . # HTN. Her BP remained well-currently during admission. She was continued on her out-pt lopressor 25 mg po bid. Her out-pt amlodipine was d/c'd and lisinopril was added given her known poor pump fxn and DM. # DM. Not treated at [**Hospital 100**] Rehab. Her Blood sugars remained well controlled on this admission without treatment. . # FEN. The pt was initially made NPO. On discharge she was tolerating a regular heart healthy/DM diet. . # PPX. anti-coag discussed above, PPI [**Hospital1 **] (switched to po once on the floor), bowel regimen . # Code: DNR/DNI as per NH records . # Communication: Son - [**Name (NI) 4186**] ([**Telephone/Fax (1) 107323**] /([**Telephone/Fax (1) 107324**] (h) . . Medications on Admission: Home Meds: 1. Amlodipine 10 mg PO DAILY 2. Aspirin EC 81 mg PO DAILY 3. Isosorbide Mononitrate 30 mg Sustained Release PO DAILY 4. trazadone 25 mg qhs prn insomnia 5. Mirtazapine 15 mg PO HS 6. Metoprolol Tartrate 100 mg PO BID 7. Lisinopril 5 mg PO DAILY 8. Oxycodone 5 mg PO Q4-6H as needed for pain. 9. Tylenol 975 mg q 6hrs 10. Senna 2 tabs qhs 11. simvastatin 20 mg qhs 12. coumadin d/c'ed 5 days ago . All: Naproxen Discharge Medications: 1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:*15 Tablet(s)* Refills:*0* 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily) for 4 weeks. Disp:*qs qs* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Primary Diagnoses: 1. GI Bleed 2. Supratherapeutic INR 3. Congestive Heart Failure Secondary Diagnoses: 1. CAD 2. PAfib 3. CKD 4. Diet controlled DM 5. s/p R hip ORIF 6. Hypertension 7. Osteoporosis 8. Hyperlipidemia Discharge Condition: stable, no further episodes of GI bleeding Discharge Instructions: Please contact your primary care doctor or 911 should you develop any abdominal pain, blood in your stools, abdominal pain, difficulty breathing, chest pain, or any other complaints. For DVT prophylaxis after her hip surgery, she should begin taking Lovenox, 30 mg sq qd x 4 weeks. She does not need coumadin. Mrs [**Known lastname 107322**] should have daily weights checked. If her weight increases more then 2 lbs, she should begin her outpatient Lasix dose. We have changed Ms. [**Known lastname 107327**] cardiac regimen as follows: 1. We have stopped her Isosorbide and Amlodipine. 2. We have increased her Lisinopril to 10 mg qd. 3. Her Metoprolol has been decreased to 50 mg [**Hospital1 **]. 4. We strongly recommend titrating her Lisinopril and Metoprolol as tolerated for her congestive heart failure. If she is still hypertensive on max dose Lisinopril (ie, 40 mg), we would recommend adding back the amlodipine. 5. She is a diabetic and has CAD, therefore her Aspirin dose has been increased to full strength (ie, 325 mg). Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 2637**] Name: [**Known lastname 17535**],[**Known firstname 17536**] Unit No: [**Numeric Identifier 17537**] Admission Date: [**2172-10-3**] Discharge Date: [**2172-10-7**] Date of Birth: [**2082-7-10**] Sex: F Service: MEDICINE Allergies: Naproxen Attending:[**First Name3 (LF) 4143**] Addendum: Wound care: The pt was noted to have a right heel ulcer. The ulcer was cleaned and dressed by the wound care service. She should continue to have daily cleanings and dressing changes on an out-pt basis. Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - LTC [**Name6 (MD) **] [**Name8 (MD) 4144**] MD [**MD Number(2) 4145**] Completed by:[**2172-10-7**]

[ "414.00", "707.14", "428.0", "578.9", "280.0", "427.31", "585.9", "288.8", "401.9", "250.00", "733.00", "272.4" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

10642, 10832

3694, 6841

222, 229

8870, 8915

2150, 3671

10010, 10415

1642, 1660

7315, 8509

8618, 8705

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1690, 2131

8726, 8849

177, 184

10427, 10619

257, 1286

1308, 1443

1459, 1626

83,351

192,751

1329

Discharge summary

report

Admission Date: [**2185-2-15**] Discharge Date: [**2185-2-20**] Date of Birth: [**2129-8-21**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: chest pressure x3-4 days, cough Major Surgical or Invasive Procedure: [**2185-2-18**] coronary artery bypass grafting times four (LIMA to LAD, SVG to DIAG, SVG to OM, SVG to PDA) History of Present Illness: Patient is a 55M IDDM, HTN who presents with left sided chest pain for past 3 days. Pain is a pressure on left chest without radiation. Brought on with exertion, intermittent, lasts approx 1 hr. Worse with deep inspiration, worse laying down. Pt had cold recently and has productive cough. Took advil with no relief. Denies N/V, diaphoresis, abdominal pain. His legs feel weak and he is more fatigued. In the ED, initial vitals were 97.7 103 136/87 24 98%. Labs and imaging significant for CXR LLL opacity: pleural fat, bilat patchy opacities in lung bases, small b/l pleural effusions. EKG showed <1 mm STE inferiorly. Troponin was 1.33. Patient given aspirin 325 mg and levaquin. He was gauic neg and was started on a heparin drip. Vitals on transfer were T: 100, Pulse: 92, RR: 20, BP: 149/80, O2Sat: 99 RA. On arrival to the floor, patient was comfortable. He states his chest pain is minimal and rated as a [**4-23**] whereas it was previously [**9-23**]. He is comfortable. REVIEW OF SYSTEMS On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. 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: # Type II DM: last hemoglobin A1c 9.1 in [**2-20**]. Trending upwards. Has associated neuropathy/Right charcot foot. Followed at [**Last Name (un) **]. # Hypercholesterolemia # Elevated LFTS from nonalcoholic fatty liver disease and chronic hepatitis B infection. Never been biopsied. # Hypertension. # Clostridium difficile colitis 5/[**2176**]. # Obesity. # Right rotator cuff tear treated conservatively. # Left foot infection due to a foreign body, complicated by infection and drainage back in [**2176**]. # Allergic rhinitis. # s/p Mumps in [**4-20**] # s/p vitrectomy [**6-20**] for retina detachment Social History: Pt was born in [**Country 532**] and moved to the US 16 years ago. He worked as a barber previously. He lives with his wife, has one daughter and 2 grandchildren. He denies ETOH or drug use. He is a former smoker, 2ppd x 30 years but quit [**2174**]. Family History: Brother had MI with 2 PCIs at age 48. Multiple family members with diabetes, hypertension, and depression. Physical Exam: ADMISSION EXAM: VS: T= 98.8 BP=151/91 HR=98 RR= 18 O2 sat= 95% on RA GENERAL: obese male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, obese, unable to assess JVD CARDIAC: distant heart sounds, RRR, no m/r/g LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: obese, Soft, NTND. No HSM or tenderness. EXTREMITIES: 1+ pedal edema PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 8152**] [**Hospital1 18**] [**Numeric Identifier 8153**]TTE (Complete) Done [**2185-2-17**] at 9:10:01 AM FINAL Referring Physician [**Name9 (PRE) **] Information FISH, [**Doctor First Name **] E. [**Hospital1 18**] - Cardiac Services [**Location (un) 830**], [**Hospital Ward Name 23**] 7 [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2129-8-21**] Age (years): 55 M Hgt (in): 68 BP (mm Hg): 135/77 Wgt (lb): 319 HR (bpm): 88 BSA (m2): 2.49 m2 Indication: Coronary artery disease. Hypertension. Preoperative assessment. ICD-9 Codes: 402.90, 786.05, 414.8, 424.0, 424.2 Test Information Date/Time: [**2185-2-17**] at 09:10 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**Name2 (NI) 8154**] Bzymek, RDCS Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: Optison Tech Quality: Suboptimal Tape #: 2012W004-0:00 Machine: Sequoia Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.6 cm <= 4.0 cm Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 30% to 35% >= 55% Left Ventricle - Stroke Volume: 91 ml/beat Left Ventricle - Cardiac Output: 8.04 L/min Left Ventricle - Cardiac Index: 3.23 >= 2.0 L/min/M2 Aorta - Sinus Level: *3.7 cm <= 3.6 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 22 Aortic Valve - LVOT diam: 2.3 cm Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.83 Mitral Valve - E Wave deceleration time: *133 ms 140-250 ms Findings This study was compared to the prior study of [**2181-7-25**]. Intravenous administration of echo contrast was used due to poor native endocardial border definition. LEFT ATRIUM: Dilated LA. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate-severe regional left ventricular systolic dysfunction. No LV mass/thrombus. No resting or Valsalva inducible LVOT gradient. RIGHT VENTRICLE: RV not well seen. Normal RV systolic function. AORTA: Mildy dilated aortic root. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR. Indeterminate PA systolic pressure. GENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of agitated normal saline at rest. Suboptimal image quality - body habitus. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate to severe regional left ventricular systolic dysfunction with inferior akinesis, inferolateral, septal and apical hypokinesis. No masses or thrombi are seen in the left ventricle. There is no left ventricular outflow obstruction at rest or with Valsalva. with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. IMPRESSION: Regional LV systolic dysfunction suggestive of multi-vessel CAD. No significant valvular abnormality. Compared with the prior study (images reviewed) of [**2181-7-25**], echo contrast was used on the current study. The above named wall motion abnormalities were not seen on the prior echo. However, echo contrast was not used on the prior. The inferior akinesis may well have been present on the prior. The septal and apical hypokinesis are new. Brief Hospital Course: Mr. [**Known lastname 3356**], a 55 year old gentleman with a history of hypertension, hyperlipidemia, and insulin dependent diabetes, presented with three days of chest pain. He was found to have EKG changes and a troponin elevation consistent with an ST elevation myocardial infarction. He was started on a heparin infusion and had a cardiac catheterization the next day which showed diffuse three vessel disease. Cardiac surgery was consulted. His hemoglobin A1C was 10.7 and he was poorly controlled in-house, [**First Name8 (NamePattern2) **] [**Last Name (un) **] was consulted. On [**2185-2-18**] Mr. [**Known lastname 3356**] [**Last Name (Titles) 1834**] a coronary artery bypass grafting times four performed by Dr. [**Last Name (STitle) **]. Please see the operative note for details. He tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. He extubated and was weaned from pressors by the following day. Hypertension was managed with beta blockade and amlodipine. He was diuresed with lasix. He weaned from his high dose insulin infusion with lantus and an aggresive sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. That evening he complained of muscular chest pain and was placed on a dilaudid PCA pump. In the morning he was placed on oral pain medication and weaned from the pump. With assistance he ambulated to the chair in the morning. Around 1050 he complained of shortness of breath and he was placed in the bed. He became obtunded and stopped breathing. He was found to be in pulseless electrical activity arrest and CPR/ACLS protocal was begun. A code was called. He was intubated by anesthesia using a glidescope. Dr. [**Last Name (STitle) **] came to the bedside and the chest was opened, Dr. [**Last Name (STitle) **] soon joined him. Internal cardiac massage was performed along with multiple rounds of internal defibrillation and emergency medical therapy. Resuscitation efforts continued for around forty minutes to no effect. He was pronounced expired at 1151 by Dr. [**Last Name (STitle) **]. Medications on Admission: TAKING: Insulin Humulin R-500 concentrated 20 units SQ at 7 am, 2 pm, 10 pm In addition, was prescribed: Amlodipine 10 mg po daily Bupropion 150 mg ER po BID Citalopram 20 mg po qAM HCTZ 25 mg po daily Lisinopril 40 mg po daily Metformin 1000 mg po daily Pregabalin 50 mg po TID Simvastatin 40 mg po daily Aspirin 81 mg po daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: ST elevation myocardial infarction Secondary Diagnoses: Hyperlipidemia, Hypertension, Insulin dependent diabetes mellitus, obstructive coronary artery disease and obesity Discharge Condition: expired Discharge Instructions: none Followup Instructions: none Completed by:[**2185-2-20**]

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icd9cm

[ [ [] ] ]

[ "39.61", "37.91", "36.13", "99.62", "99.60", "37.22", "36.15", "34.03", "88.56", "96.04" ]

icd9pcs

[ [ [] ] ]

10266, 10275

7711, 9857

342, 453

10509, 10518

3404, 6315

10571, 10606

2742, 2850

10237, 10243

10296, 10296

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2865, 3385

10371, 10488

271, 304

481, 1827

10315, 10350

1849, 2458

2474, 2726

23,979

161,156

25387

Discharge summary

report

Admission Date: [**2166-7-3**] Discharge Date: [**2166-7-7**] Date of Birth: [**2091-5-6**] Sex: F Service: MEDICINE Allergies: Codeine / Phenergan Attending:[**First Name3 (LF) 1436**] Chief Complaint: headache; "feeling jittery" Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname 63469**] is a 75 yo WF with HTN, Type II DM, paroxysmal afib, who presents with elevated blood pressure. She was recently discharged from a hospital stay for headaches and hypertensive urgency with BP in the 260's systolic. Of note, she has a history of wide differential between the systolic blood pressure in her left vs her right arm. During her hospitalization, her blood pressure was controlled with her home blood pressure meds as well as hydralazine. She was discharged on [**7-2**]. She now returns on the following day describing symptoms of feeling jittery and a headache at home. She denies any CP, SOB, palpitations, or nausea/vomiting. Past Medical History: 1) PAF never cardioverted. 2) DM2 3) CRI baseline Cr=1.2 4) HTN 5) hyperlipidemia 6) three cesarean sections 7) hysterectomy 8) cholecystectomy 9) appendectomy 10) left lung cancer, resected in [**2161**] Social History: Quit smoking in [**2153**]. Family History: Father with CAD/MI, deceased at age 47. Sister with CHF. Physical Exam: Gen: awake, alert, sitting in bed, NAD Neck: no JVD CV: reg rate, SEM LUSB Chest: CTA Abd: soft, nt/nd Ext: distal pulses intact Pertinent Results: [**2166-7-5**] 06:25AM BLOOD TSH-1.5 [**2166-7-5**] 06:25AM BLOOD Cortsol-21.0* [**2166-7-5**] 06:25AM BLOOD Metanephrines (Plasma)-PND . ECHO [**2166-7-2**]: Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). There is minimal resting LVOT gradient which increased with the Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. There is a trivial/physiologic pericardial effusion. . CAROTID SERIES [**2166-7-4**] IMPRESSION: On the right, there is no evidence of cervical internal carotid artery stenosis. However, based on the waveforms and velocities, there is likely to be a proximal arch stenosis that is severe. On the left, there is a 40-59% carotid stenosis. . MRI/MRA BRAIN [**2166-7-6**]: Chronic white matter ischemic disease. No acute infarcts. . MRA RENAL ARTERIES [**2166-7-6**]: IMPRESSION: 1) High-grade right-sided renal artery stenosis just beyond the ostium, and mild narrowing of the left renal artery at the ostium. 2) Mild bilateral renal cortical thinning. 3) Atherosclerotic changes of the aorta, including borderline aneurysmal change of the infrarenal aorta. . MR [**Name13 (STitle) 430**] [**2166-6-30**]: 1. No evidence of acute infarction. Chronic small vessel ischemic changes. 2. MR [**First Name (Titles) 20827**] [**Last Name (Titles) 4059**] marked decrease in signal intensity within the right internal carotid artery suggestive of proximal extracranial stenosis. 3. Flow-limiting stenosis in the proximal M1 segment of the right middle cerebral artery with apparent distal filling from leptomeningeal collateral vessels. 4. Normal MR venogram. . CT ABDOMEN WITH IV CONTRAST [**2166-7-3**]: The liver, gallbladder, spleen, adrenal glands, kidneys, stomach, and abdominal loops of small and large bowel are unremarkable. There is a 3.6 x 2.9 cm abdominal aortic aneurysm. There is severe atherosclerotic disease of the abdominal aorta with several focal ulcerations seen. At the level of the celiac axis on Series 4, Image 53 a linear irregularity within the aorta likely is secondary to focal ulceration, but a small dissection at this level cannot be excluded. No pathologically enlarged mesenteric or retroperitoneal lymph nodes. The common bile duct is mildly dilated measuring 12 mm. Brief Hospital Course: A/P: Ms. [**Known lastname 63469**] is a 75 yo WF with HTN, Type II DM, paroxysmal atrial fibrillation, who presents with hypertensive urgency. . 1. Hypertensive urgency: On admission, Ms. [**Known lastname 63469**] was found to have systolic blood pressure elevations in the 200's with, of note, large bp differential in her right and left arms. This large differential is attributable to stenosis of her right brachiocephalic artery. In the ED, her blood pressure was controlled on a nipride drip. On arrival to the CCU, she was transitioned to oral medications. In the 24 hours following her admission to the CCU team, she continued to have labile BP readings ranging from systolic pressures in the 90's-170's, but was also noted to have good response to antihypertensive medications. As an inpatient, she underwent a work-up for secondary causes of hypertension which included the following studies: TSH, 24 hour urine metanephrins, random cortisol, MRA of her renal arteries. On MRA of her renal arteries, she was found to have high-grade right-sided renal artery stenosis just beyond the ostium, and mild narrowing of the left renal artery at the ostium. She was scheduled for follow-up renal angiogram with Dr. [**First Name (STitle) 487**] as an outpatient. She was discharged on a regimen of HCTZ, Lisinopril, and Metoprolol. She was discharged with thrice weekly VNA services to help her coordinate her medication regimen and home blood pressure monitoring. She will also follow-up with Dr. [**Last Name (STitle) **], her Cardiologist, as an outpatient to assess her log of post-discharge blood pressure recordings. . 2. Cardiovascular: (a) Coronary arteries: no active signs of ischemia. Continue risk management with ASA and Lipitor. (b) Rhythm: paroxysmal A-fib now in NSR throughout hospital course with RBBB pattern. (c) Valves: no evidence of valvular disease on recent TTE. (d) Pump: LVEF > 55%. . 3. Vascular disease: patient is known to have 3.6x2.9 cm AAA, incidentally diagnosed on previous admission, with dissection at celiac artery. Pt was evaluated by Vascular Surgery in ED who assessed as no urgent need for catheterization. She was also found to have new brachiocephalic stenosis during the course of her hospitalization just a few days earlier. She was scheduled for out-patient follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] in the Dept of Vascular Surgery. She was advised that Dr. [**Last Name (STitle) 1391**] may recommend MRA of the neck as an outpatient to further examine the unilateral carotid stenosis. . 4. Chronic renal insufficiency: Likely secondary to her Type II DM vs. low perfusion state of the kidneys secondary to RAS. Her CR remained near baseline (1.2) throughout the hospitalization. . 5. Type II DM: At time of discharge, blood glucose levels were well-controlled (120's - 130's) on Glipizide alone. Metformin was discontinued in the setting of CRI. . 6. Anemia: patient has remained hemondynamically stable. Her anemia is likely chronic with a known baseline hct of 33.7. Medications on Admission: Medications from discharge summary on [**7-2**]: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet DAILY 2. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID 3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY 5. Hydralazine 10 mg Tablet Sig: 2.5 Tablets PO Q6H 6. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY 7. Pantoprazole 40 mg Tablet (1) Tablet PO Q24H 8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 5. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: 1. Hypertensive urgency. 2. Type II DM 3. AAA 3.6 x 2.9 cm, with dissection at level of celiac artery. Discharge Condition: Good. Discharge Instructions: 1. Be sure to take all of your medications exactly as prescribed. . 2. You have been started on a regimen on three medicines for your blood pressure. With your visiting nurse, you should learn how to monitor your own blood pressure at home. It will be helpful if you keep a daily log of your blood pressures and bring this log with you to your appointment with Dr. [**Last Name (STitle) **] so that he can adjust your medicines as needed. . Followup Instructions: 1) You have been scheduled for a follow-up appointment with your Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Tuesday, [**7-15**] at 1 p.m. His office is located on the [**Hospital1 18**] [**Hospital Ward Name 516**] in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. To reschedule, please call [**Telephone/Fax (1) 5003**]. . 2) You have an appointment with Vascular Surgeon Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] on [**7-23**] at 10 A.M. Dr. [**Last Name (STitle) 1391**] is located on the [**Hospital1 18**] [**Hospital Ward Name 517**] in the [**Hospital Unit Name **], Floor 5C. Please call ([**Telephone/Fax (1) 4852**] if you need to reschedule. This is to follow-up regarding your abdominal aortic aneurysm. You should also discuss with Dr. [**Last Name (STitle) 1391**] whether he wants to have a MRA of your neck to look at your carotid arteries. . 3) You are scheduled for a renal angiogram to be performed by Dr. [**First Name (STitle) 487**]. The scheduling nurses will be contacting you at the end of this week to tell you the exact time/date of your appointment. They will give you instructions for this procedure when they call. . 4) Please call to schedule a follow-up appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8682**] at [**Telephone/Fax (1) 133**].

[ "443.9", "281.9", "250.80", "403.01", "441.4", "443.29", "427.31" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8607, 8664

4357, 7446

305, 313

8811, 8819

1530, 4334

9310, 10720

1307, 1366

7980, 8584

8685, 8790

7472, 7957

8843, 9287

1381, 1511

238, 267

341, 1014

1036, 1245

1261, 1291

26,125

110,664

4448

Discharge summary

report

Admission Date: [**2148-10-25**] Discharge Date: [**2148-11-1**] Date of Birth: [**2097-5-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 477**] Chief Complaint: fever, chills, tacchypnea Major Surgical or Invasive Procedure: Percutaneous biliary tube exchange with internal drainage [**2148-10-30**] History of Present Illness: Pt is a 51 yo man with metastatic renal cell carcinoma who presented to the ED today with fever. Patient was discharged from the hospital on [**10-22**] and since been having low grade temps around 99. This am temp was 100.8 and patient was noted to be tacchycardic and tacchypneic by the VNA. Patient is not neutropenic. He was noted to be tachypneic with sats as low as 90s on nasal cannula and was placed on nrb with good response in the ED. He was also tacchy to the 130s and PE was considered given his recent PE earlier this month for which he did not receive coumadin given high bleeding risk with RCC and mets to his pancreas. CTA done in ED was negative. CT did however show a RLL consolidation. He was given vanco and ceftazidime in the ED. He was also given dilaudid and tylenol as well as 2 liters of IV NS. Surgery was consulted in ED and ext bag was placed for further drainage of perc biliary tubes. In the [**Hospital Unit Name 153**], initial VS were: T 100.7, P 120-130s, BP 94/59, R 24. Patient was sleepy but able to answer questions appropriately. He reported some sob, no dizziness, chest pain, abd pain, nausea, vomiting, dysuria, URI symptoms, muscle or joint pain. Had bm yesterday and ate breakfast this am without problem. [**Name (NI) **] wife, biliary tube was flusing fine but she noticed more output this am. . Of note, patient has had two previous admissions this past months. the first admission was [**2148-9-19**]. He was admitted with RCC with new pancreatic head mass. Underwent exploratoy lap and gastroenterostomy and open cholecystectomy and ileocolic bypass and appendectomy. During that admission he had a PE and as heparanized but not given coumadin for risk of bleed. He was admitted again on [**2148-10-15**] for worsening abdominal pain and ERCP was done which showed large fungating mass in the duodenum. Next day went for cholangiogram and showed complete obstruction of CBD, intrahepatic ducts-->int/ext biliary drainage catheter and ext bag drainage. Celiac plexus block was done on [**10-21**] for chronic pain. Patient was discharged on [**2148-10-22**]. Patient was intubated for procedures but then extubated. He did have foley while in the hospital. Past Medical History: Onc Hx: diagnosed with rcc in [**5-/2147**] when he presented with hematuria and abdominal pain. The CT showed a large right renal mass and he underwent nephrectomy on [**2147-6-6**]. Nephrectomy showed an 11 cm tumor with invasion into the perinephric tissues and major veins, with clear cell histology, Furhman nuclear grade 2. His preoperative workup had revealed pulmonary emboli requiring anticoagulation. CT scans following nephrectomy showed recurrence in the nephrectomy bed site as well as increased mediastinal lymphadenopathy. He received HD IL-2 treatment in [**2147-9-1**] without response. He was enrolled in the phase I avastin/sorafenib trial initiating treatment in [**11-5**]. Metastatic cancer to the pancreas. Last chemo was sutent stopped early [**Month (only) 462**] before whipple. . PAST SURGICAL HISTORY: 1. Exploratory lap, cholecystectomy, appendectomy and an antecolic retrogastric isoperistaltic gastroenterostomy and an ileocolic bypass [**2148-9-19**] 2. Status post partial colectomy after perforated bowel secondary to a motorcycle accident. 3. Status post right knee surgery. 4. Status post left knee arthroscopy. 5. History of pulmonary emboli on anticoagulation. Social History: He worked in the telecommunication industry and often drives for hours at a time. Remote ETOH hx.Tob: 1 ppd x 30 years Married and lives with wife and 7 yr old child. Family History: Father and uncle with lung CA [**Name (NI) **] with [**Name2 (NI) 499**] CA Sister with lung problems [**Name (NI) **] family hx of kidney cancer Physical Exam: VS T 100.8 P 120-130s BP 94/59 R 28 O2sat 100 % on NRB Gen- lethargic but awake and responsive to questions HEENT- NCAT, anicteric, no injections, MM dry, OP clear Neck- neck veins flat Cor- RR, tacchy, no MGR Pulm- crackles at right base Abd- +bs, soft, slightly distended, non-tender, well-healing midline scar Extrem- no cce, pedal pulses 2+ b/l Skin- no rashes or jaundice Pertinent Results: Labs: Lactate:1.6 . 134 98 13 AGap=11 -----------< 145 4.0 29 1.1 . estGFR: 71 / >75 (click for details) Ca: 8.4 Mg: 1.7 P: 2.5 . ALT: 35 AP: 572 (stable) Tbili: 0.9 Alb: AST: 42 LDH: Dbili: TProt: [**Doctor First Name **]: 72 Lip: 128 (stable) . wbc 11.0 hgb 7.0 crit 22.9 plt 472 (baseline crit is 20-25 in last month) N:85.3 L:7.3 M:6.2 E:1.2 Bas:0.1 . PT: 13.6 PTT: 23.9 INR: 1.2 . ekg: . Imaging: CTA [**10-25**]: . Interval increase in size of the right lower lobe consolidative process now encompassing the previously noted ground-glass opacity. Also interval development of air bronchograms. These findings raise the suspicion for right lower lobe pneumonia. 2. Interval development of loculated right-sided pleural effusion. 3. Right middle lobe and left lower lobe atelectasis. 4. No definite evidence of residual PE. 5. Differential enhancement of the right and left lobe of the liver which is only partially visualized. The vessels cannot be evaluated on this study. This is of uncertain etiology and significance. 6. Biliary drain with expected pneumobilia. . CXR [**10-25**]: Stable chest radiograph. . Biliary cath check: Persistently dilated common bile duct and mildly dilated intrahepatic ducts due to known metastatic mass of the duodenum. Internal- external drainage catheter in place, without evidence of leakage. The tube was connected to the bag. Brief Hospital Course: ASSESSMENT/PLAN: 51 yo man with met RCC to pancreas s/p biliary stent who presented w/ fever, tacchycardia, tacchypnea and possible RLL consolidation on chest CT. . # CAP: presented with sepsis requiring stay in intensive care unit, with fluid resusitation, supplemental O2 and IV antibiotic therapy. Pt with consolidation on CT chest consistent with pneumonia. Transferred to OMED after stabilization. Pt remained afebrile with improving leukocytosis - continued on vanc & zosyn for 72h, then vanc discontinued. Pt to complete 2 week course of antibiotic with augmentin at home. . # Respiratory Failure/pneumonia: Pt with hypoxia, tachypnea and increasing O2 requirement as above. Pt with consolidation on CT scan, CTA negative for PE. Provided nebulizers as needed, gentle diuresis with furosemide as pt fluid overloaded. He was weaned off O2 to room air without difficulty. He is to complete 2 week course of augmentin for community acquired pna. . # Pancreatic mets s/p biliary stent with perc.drainage: Cholangiogram done on admission, with external drainage bag placed per surgery. Leakage noted around insertion site during OMED stay, required IR to change perc. biliary drainage tube. Now with internal drainage. Family was taught drain care by the nurses. There was no evidence of abdominal infection during stay. . # Metastatic RCC: s/p Whipple due to mets to head of pancreas. Last chemotherapy, Sutent, stopped [**8-/2148**] prior to whipple procedure. Palliative care involved. Possibility of further treatment to be addressed by Dr.[**Last Name (STitle) **]. . # Pain: Chronic pain r/t malignancy. Well controlled during hospitalization. Palliative care with pain recommendations for patient. Regimen included Methadone and Dilaudid. . # Anemia: Chronic since early [**Month (only) 462**] coinciding with Whipple procedure. Nml folate & B-12, however with iron deficiency as well as anemia of chronic disease. Initiated Ferrous sulfate for iron replacement. . # Hypothyroid: Continued levothyroxine on home regimen . Pt reached maximal hospital benefit and was discharged home with services. Pt is to follow up with primary oncologist at 1-2 weeks after discharge Medications on Admission: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for anxiety. Disp:*45 Tablet(s)* Refills:*0* 7. Methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*2* 9. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as needed for pain. Disp:*200 Tablet(s)* Refills:*0* 10. Reglan 10 mg QID 11. Pt was also taking amoxicillin which he was on prior to surgery Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for anxiety. 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) for 1 months. Disp:*30 Capsule(s)* Refills:*0* 8. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times a day: Before meals & at bedtime. 11. Methadone 10 mg Tablet Sig: One (1) Tablet PO three times a day: Take 20mg qam, 10mg at midday & 30mg qpm. 12. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. Disp:*21 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: RLL pneumonia Anemia: iron deficiency & chronic disease Metastatic renal cell CA Discharge Condition: Stable Discharge Instructions: You were admitted with fevers and hypotension, found to have pneumonia. You have been treated for this. You have anemia which is in part due to the cancer but also due to iron deficiency. . Please complete your antibiotic therapy by taking Augmentin for 7 additional days. We have made some changes to your pain regimen. Methadone 30mg qam, 10mg at midday & 20mg qpm. We have started you on iron pills daily. . Please come to the emergency room or call your PCP if you develop fevers, worsening abdominal pain or any other worrisome symptoms. Followup Instructions: Please call Dr.[**Last Name (STitle) **] within 2 weeks of discharge for followup. [**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]

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icd9cm

[ [ [] ] ]

[ "97.05", "38.93", "87.54", "99.04" ]

icd9pcs

[ [ [] ] ]

10524, 10581

6068, 8247

341, 418

10706, 10715

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11307, 11488

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183,667

10217

Discharge summary

report

Admission Date: [**2140-1-4**] Discharge Date: [**2140-1-5**] Date of Birth: [**2071-12-12**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**Doctor First Name 1402**] Chief Complaint: s/p elective PVI, hypotension Major Surgical or Invasive Procedure: [**1-4**] PVI ablation History of Present Illness: Mr. [**Known lastname 34071**] is a 68 year old man with h/o mitral valve prolapse, s/p MV repair [**2131**] and atrial fibrillation s/p PVI in [**2135**], on Coumadin, with recurrence of atrial fibrillation in summer [**2139**]. He had a cardioversion in [**10-23**] which converted him to sinus rhythm; however, he was back in Atrial fibrillation one week later. He underwent an elective PVI and cardioversion earlier today with conversion back into sinus rhythm. He was given lasix 30mg IV during the case with approximately 2.2L out. His case was complicated by mild hematoma in the right groin with a pressure dressing placed. He was given fluid boluses totaling 3L in the PACU, but was persistently hypotensive and started on a dopamine gtt. Echo was performed and was negative for effusion. He is asympomatic with the hypotension. He is being transferred to the CCU for further monitoring and management of his hypotension. On the floor he reports feeling much better in a normal heart rhythm. He had been feeling fatigued, mildly SOB with some DOE prior to the case because of his atrial fibrillation. He can generally feel palpitations when he is in atrial fibrillation. He denies any lightheadedness, chest pain, orthopnea, PND, LE edema, syncope. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: No Diabetes, No Dyslipidemia, No Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: [**2131**] normal coronaries -PACING/ICD: none - mitral valve prolapse with severe MR, s/p MV repair [**2131**] - atrial fibrillation, s/p ablation [**2135**] 3. OTHER PAST MEDICAL HISTORY: - arthritis - gout - Left THR - Right femur pinning [**2115**] - Left leg skin graft d/t burn [**2133**] Social History: Lives with wife. [**Name (NI) **] 3 grown children. Occupation: retired. -Tobacco history: none -ETOH: 1-2 drinks/day -Illicit drugs: none Family History: Brother died of MI at age 50. Physical Exam: GENERAL: WDWN 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 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB anteriorly, 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. pressure dressing on right. dressing bilat C-D-I. Skin soft. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ right fem with pressure dressing. DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS [**2140-1-4**]: [**2140-1-4**] 07:00AM WBC-5.4 Hgb-14.8 Hct-43.2 Plt Ct-301 [**2140-1-4**] 07:00AM PT-20.2* PTT-26.9 INR(PT)-1.9* [**2140-1-4**] 07:00AM UreaN-23* Creat-1.2 Na-142 K-4.5 Cl-106 HCO3-27 AnGap-14 STUDIES: [**1-4**] ECHO: The left atrium is mildly dilated. Left ventricular wall thickness and cavity size are normal. Global systolic function is low normal (LVEF 50-55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. A mitral valve annuloplasty ring is present. The mitral annular ring appears well seated with high normal gradient. There is moderate thickening of the mitral valve chordae. There is a minimally increased gradient consistent with trivial mitral stenosis. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. No pericardial effusion. Mild aortic regurgitation. Mild mitral regurgitation. Well seated annuloplasty ring with minimal mitral stenosis. On discharge: WBC-7.8 RBC-3.63* Hgb-11.2* Hct-32.1* Plt Ct-240 PT-21.3* PTT-46.0* INR(PT)-2.0* Glucose-127* UreaN-17 Creat-1.0 Na-129* K-3.2* Cl-99 HCO3-24 AnGap-9 Calcium-6.3* Phos-2.9 Mg-1.9 Brief Hospital Course: Mr. [**Known lastname 34071**] is a 68 yo male with h/o Mitral valve prolapse s/p repair and atrial fibrillation s/p second PVI (all veins re-isolated) and cardioversion. 1. Hypotension: Likely secondary to combination of bleeding into hematoma with substantial Hct drop, medication effect of antihypertensives and sedation, and excessive diuresis. No evidence of pericardial effusion or tamponade on echo. No evidence of infection. Pt was intially started on dopamine to maintain BP, bolused several liters and dopamine was weaned off overnight. Post cath check with no hematoma or vascular dissection at groin site or peripheral vasculature. Repeat Hct stable at 33.4. Remained hemodynamically stable through duration of hospital stay 2. Atrial fibrillation: s/p PVI and cardioversion on day of admission. Remained in sinus rhythm through duration of hospital staywith [**2-17**] brief episodes 3-20 seconds of asymptomatic SVT. Metoprolol was resumed when blood pressure could tolerate. Coumadin was resumed, INR on discharge was 2.0. Medications on Admission: Metoprolol Tartrate 50mg PO BID Warfarin 5 mg PO daily (for past 2 days was 7.5 mg daily) Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Discharge Disposition: Home Discharge Diagnosis: atrial fibrillation mitral valve disease Discharge Condition: Ambulatory Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Ambulatory Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: It was a pleasure taking care of you during your hospitalization. You had a procedure to ablate atrial tachycardia and atrial fibrillation. You were monitored after the procedure in the Intensive Care Unit because of low blood pressure. Your blood pressure improved and remained stable without any complications. Please continue all current medicines. -- You should continue your coumadin 7.5mg daily and have an INR checked in one week. -- You should continue your metoprolol 50mg twice a day Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 3321**] in [**2-17**] weeks

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icd9cm

[ [ [] ] ]

[ "37.27", "37.34" ]

icd9pcs

[ [ [] ] ]

6449, 6455

5082, 6133

299, 324

6540, 6551

3558, 4865

7349, 7429

2603, 2634

6273, 6426

6476, 6519

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4879, 5059

230, 261

352, 1972

6696, 6803

2325, 2431

1994, 2065

2447, 2587

56,636

117,470

37015

Discharge summary

report

Admission Date: [**2129-5-24**] Discharge Date: [**2129-5-27**] Date of Birth: [**2062-11-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Thoracentesis [**2129-5-25**] (~1L drained) History of Present Illness: The patient is a 66 yo man with h/o amyloidosis who presented with hypotension. Per the patient, he was in his normal state of health until last [**Month (only) 547**], when he began to experience DOE. He presented to his PCP who performed [**Name Initial (PRE) **] CXR and diagnosed the patient with PNA. He was given a 2-week course of Avalox, which did not improve his symptoms. In [**Month (only) 116**], the patient had a Myoview which was positive for inducible ischemia and demonstrated an EF of 48%. The next day, the patient developed substernal chest pain and presented to [**Hospital 1474**] Hospital where he was found to have negative cardiac enzymes and a clean cardiac catheterization. The patient continued to have DOE, PND, and orthopnea, and he was seen by cardiology at the beginning of [**Month (only) **]. At this time, he had a TTE, which showed significant concentric left ventricular hypertrophy. He then had a cardiac MRI, which demonstrated findings c/w amyloidosis. The patient was thus started on Lisinopril last night for this condition, with the intent on transferring his care to [**Hospital1 2177**] for further workup. . Over the past two months, the patient has developed recurrent pulmonary effusions and has had five thoracenteses. He has been followed closely by pulmonary and was scheduled to have an elective right-sided thoracentesis this morning. On arrival to the IP suite, the patient felt dizzy, nauseated, fatigued, and complained of a headache. His BP was found to be 88/40. He was given a 500 cc bolus of NS and his BP decreased to 75/35. On further questioning, the patient stated that he was instructed to take Lisinopril 2.5 mg last night as well as this morning. Given the patient's underlying amyloid, he was admitted to the CCU for further workup and monitoring. . On arrival to the CCU, the patient states that he feels "100% better" and is no longer dizzy. He had a brief episode of upper sternal chest pain, which lasted 2 minutes and was relieved with rest and worsened with deep breaths. ECG at this time was negative for acute ST/T wave abnormalities. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. He does endorse a 20 lb weight loss over the past two months, and he admits to hemorrhoids which last bled when he was on "blood thinners." 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: None. . 2. CARDIAC HISTORY: - Cardiac Cath: [**2129-3-25**] reportedly normal at [**Hospital 1474**] Hospital. . 3. OTHER PAST MEDICAL HISTORY: 1. Right-sided nephrectomy [**2111**] for cancer (details unknown). 2. Pneumonia [**2129-2-23**]. 3. Status post cataract surgery. 4. Status post TURP for BPH. 5. Hemorrhoids. 6. Question of carpal tunnel syndrome. Social History: He is a widower and remarried to his current wife. [**Name (NI) **] retired in [**Month (only) 404**] of this year. He previously worked in auto body work for 25 years but never as a mechanic and did not do brake repair. He does not know of any exposures to asbestos. He built fire trucks for many years. He smoked cigarettes only as a teenager but had a significant secondhand smoke exposure through his first wife who smoked 2 packs per day. He denies any drug use and drinks rare alcohol. He denies any TB exposure. He was in the service in the [**Company **] but was never in the shipyards. They have 2 cats at home. Family History: The patient's father passed away at 62 yo from an MI. His mother is [**Age over 90 **] [**Name2 (NI) **] and has CHF. Physical Exam: On admission: VS: T 97.5 BP 74/51 HR 89 RR 19 O2 99% on RA GENERAL: Elderly man, pleasant, anxious, in NAD. Oriented x3. Mood, affect appropriate. HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. Submandibular LAD on left CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR with multiple PVCs. Normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Dullness to percussion on right to mid-lung field and at left base. Decreased BS on right to mid-lung. No w/c/r ABDOMEN: Soft, NTND. No HSM or tenderness. Scar in RUQ from previous nephrectomy. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Pertinent Results: ADMISSION LABS: . [**2129-5-24**] 03:10PM BLOOD WBC-6.3 RBC-3.98* Hgb-11.3* Hct-33.1* MCV-83 MCH-28.5 MCHC-34.3 RDW-13.6 Plt Ct-321 [**2129-5-24**] 03:10PM BLOOD Neuts-71.6* Lymphs-20.9 Monos-4.8 Eos-2.3 Baso-0.4 [**2129-5-24**] 03:10PM BLOOD PT-13.2 PTT-25.7 INR(PT)-1.1 [**2129-5-24**] 03:10PM BLOOD Glucose-107* UreaN-35* Creat-1.9* Na-139 K-4.0 Cl-103 HCO3-24 AnGap-16 [**2129-5-24**] 03:10PM BLOOD Calcium-9.0 Phos-3.2 Mg-2.2 . . PERTINENT LABS/STUDIES: . Cr: 1.9 (baseline 1.2) -> 2.2 -> 2.1 -> 1.9 -> 1.8 ([**5-27**]) Troponin: 0.39 ALT: 19, AST 20, LDH 208, Alk Phos 76, Total bili 0.3 SPEP: TRACE ABNORMAL BAND BETWEEN BETA-1 AND BETA-2 REGIONS IDENTIFIED PREVIOUSLY, BY IFE, AS MONOCLONAL FREE (BENCE-[**Doctor Last Name **]) LAMBDA CANNOT QUANTIFY BY DENSITOMETRY SUGGEST FOLLOWING BENCE-[**Doctor Last Name **] PROTEIN IN URINE ONLY HYPOGAMMAGLOBULINEMIA Factor X: 65 . CXR ([**5-24**]): In comparison with study of [**5-7**], the pigtail has been removed. There is still a tiny apical pneumothorax. The bilateral pleural effusions are again seen and essentially unchanged. Some downward tilt of the minor fissure indicates volume loss involving the right lower lobe and possibly the right middle lobe as well. Interval CXR ([**5-26**]): Slight increase in bilateral pleural effusions. Unchanged retrocardiac and right basal atelectasis. ?mild overhydration . EKG: NSR with rate of 83. Diffusely low voltage in all leads. [**Street Address(2) 4793**] elevation in V1 and V2 with no T wave inversions. . 2D-ECHOCARDIOGRAM ([**5-5**]): The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy with a hyaline acoustic texture that raises the suspicion of an infiltrative cardiomyopathy. The left ventricular cavity is small. Overall left ventricular ejection fraction is normal (LVEF 60%). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is a rivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. . CARDIAC MRI ([**5-18**]): 1. Normal left ventricular cavity size with normal regional left ventricular systolic function. The LVEF was mildly depressed at 43%. The effective forward LVEF is moderately depressed at 30%. Delayed hyperenhancement imaging findings are consistent with cardiac amyloidosis. 2. Normal right ventricular cavity size and systolic function. The RVEF was normal at 49%. 3. Mild aortic and pulmonic regurgitation. Moderate mitral and tricuspid regurgitation. 4. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. 5. Moderate left atrial enlargement. 6. A cavitary or cystic lesion in the right lower lobe of the lung as well as dilated pancreatic duct with multiple pancreatic cysts were observed. Correlation with CT imaging is advised. . Fat Pad Aspirate Pathology ([**2129-5-25**]): FNA, Abdominal fat pad: NON-DIAGNOSTIC. Acellular specimen. . Abdominal U/S ([**5-25**]): The liver is homogeneous in echotexture. Note is made of moderate right pleural effusion and trace perihepatic ascites. The spleen is notable for cystic structures, unchanged from the recent CT. The right lobe of the liver contains a 9 x 10 x 9 mm hemangioma and there is no other focal hepatic mass. There is no intra- or extra-hepatic biliary ductal dilatation. The common bile duct is 4 mm. The gallbladder is obscured by cholelithiasis and there is no pericholecystic fluid or gallbladder mural edema. There is a negative son[**Name (NI) 493**] [**Name (NI) **] sign. The main portal vein is patent with normal hepatopetal flow. The patient is status post right nephrectomy. The spleen is homogeneous in echotexture, measuring 10.3 cm. The left kidney is 12 cm and there is no evidence of hydronephrosis. Prominence of the renal medullary pyramids is indicative of increased echogenicity in the renal cortices, possibly indicative of medical renal disease. Note is made of a small left renal cyst measuring 9 x 8 x 7 mm. IMPRESSION: Overall, minimal change since [**5-6**] with pleural effusion, hepatic hemangioma, splenic cysts and left renal cyst. Slightly echogenic left renal cortex may indicate medical renal disease. . Skeletal Survey ([**2129-5-25**]): LATERAL SKULL: No focal lytic or blastic lesions are seen. There are some degenerative changes of the mid cervical spine with some joint space narrowing. THORACIC SPINE: There are multiple anterior mild wedge compression deformities of the mid thoracic spine. Age of these are indeterminate. LUMBAR SPINE: There is some mild scoliosis with convexity to the right side centered at L3. There is loss of intervertebral disc height at multiple levels, worse at L2-L3 where there is also some mild retrolisthesis. No compression deformities are seen. BILATERAL HUMERI: No focal lytic or blastic lesions are present. AP PELVIS AND BILATERAL FEMORA: Joint spaces of both hips are preserved. Sacroiliac joints are unremarkable. No focal lytic or blastic lesions are seen in either femurs. IMPRESSION: 1. Degenerative changes of the lumbar spine and some wedge deformities of several mid thoracic vertebral bodies. 2. No focal lytic or blastic lesions identified. . PENDING LABS/STUDIES: - B2 microglobulin - UPEP - Fat Pad aspirate pathology - Bone Marrow biopsy - Bone Marrow Cytogenetics Brief Hospital Course: ASSESSMENT AND PLAN: The patient is a 66 yo man with h/o amyloidosis who presents with hypotension in the setting of Lisinopril 2.5 mg HS/AM. . #. Hypotension: The patient's BP on admission was 74/51, and he was experiencing dizziness, nausea, and HA. This was in the setting of starting Lisinopril on [**5-23**] and taking two doses over the past 24 hours prior to admission. His BP did not improve with NS on [**5-24**], but the patient was no longer symptomatic from his hypotension. Per the patient, his SBP normally runs in the 80s-90s. Symptomatic hypotension was most likely [**12-27**] Lisinopril in the setting of amyloidosis. Normal saline boluses were given to maintain a MAP>60 and lisinopril and lasix were held. The patient was ambulating without symptoms on discharge. He was discharged on Lasix 20 mg daily, which is decreased from his previous dose of 40 mg [**Hospital1 **]. . #. Amyloidosis: The patient was recently diagnosed with amyloidosis on findings from TTE and Cardiac MRI. The patient's PCP and pulmonologist were interested in referral to the Amyloid treatment program at [**Hospital6 **]. [**Hospital1 2177**] was contact[**Name (NI) **] and recommended inital work-up here and outpatient referral. Heme/Onc was consulted, who recommended fat pad biopsy and UPEP, in addition to the cardiac MRI, echocardiogram and SPEP which had already been done. Fat pad biopsy and fat pad aspirate were done. Preliminary results of both were inconclusive, though final staining results are pending. As a result, bone marrow biopsy was done on [**5-26**] per Heme/Onc recs, to ensure good sampling. Social work was also consulted to assist the patient with coping with his new diagnosis of cardiac amyloidosis. . #. Pleural Effusions: The patient has large bilateral pleural effusions that reaccumulates regularly; he had been scheduled for elective thoracentesis on the day of admission. Spoke with pulm on [**5-24**] and they took the patient for [**Female First Name (un) 576**] on [**5-25**] when his pressures improved. Since [**Female First Name (un) 576**], pleural effusions have been reaccumulating gradually. He was discharged on Lasix 20 mg daily. . #. Acute Renal Failure: The patient's Cr on presentation was 1.9, which was increased from his baseline of 1.2 in [**4-2**]. This was most likely pre-renal in the setting of poor forward flow. Urine electrolytes were sent, showing a fractional excretion of urea of 16%, suggesting a prerenal etiology. The patient was given 250cc NS fluid boluses PRN, and his creatinine decreased to 1.8 on discharge. . #. Abdominal Pain: The afternoon of [**5-26**] after bone marrow biopsy and discussion of amyloid diagnosis, patient began having crampy, intermittent lower quadrant abdominal pain following three loose stools. Abdomen was soft, non-distended and tender to deep palpation. Pain improved initially with low doses of Morphine, then resolved. A KUB showed no dilated bowel loops and no air-fluid levels. He was given simethicone and the patient's pain resolved. Medications on Admission: Lisinopril 2.5 mg daily Lasix 40 mg [**Hospital1 **] KCon 20 mg daily Discharge Medications: 1. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days: Discuss this medication with Dr. [**Last Name (STitle) **] at your next appointment. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Cardiac amyloidosis, pleural effusions, worsened kidney function (acute renal failure) Secondary: Status-post nephrectomy Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: You were admitted for low blood pressure after taking your new blood pressure medicine, Lisinopril. You were given IV fluids and your blood pressure returned to your prior low level of systolic blood pressure 80-90. You were also seen by hematology/oncology for evaluation and further work-up of amyloidosis. This disease causes deposition of abnormal proteins in organs including your heart. This results in impaired relaxation and filling of the heart, and can cause low blood pressures and decreased blood flow to your organs. You also underwent thoracentesis to remove extra fluid from the space around your lungs. You will continue to see Dr. [**Last Name (STitle) 4507**] for future treatment of this problem. The following changes to your medications were made: - STOP taking Lisinopril - DECREASE your Lasix to 20 mg daily Please seek medical attention if you develop fever, chills, difficulty breathing, chest pain, redness around your biopsy site or if you feel dizzy, lightheaded, faint or any other symptoms that are concerning to you. Followup Instructions: You have been referred to a specialist for your disease. Thus, you have an appointment at [**Hospital6 **] Amyloid Program. Your appointment is Monday, [**2129-5-30**] at 7:45AM. This is at the Moakley Building on the [**Location (un) **]. If you need to contact the clinic, call [**Telephone/Fax (1) 83462**]. Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 6330**] [**Last Name (NamePattern1) **]. Phone: [**Telephone/Fax (1) 18509**] Date: Friday, [**2129-6-3**] at 11:45 AM You have follow-up scheduled with Dr. [**Last Name (STitle) 4507**], your Pulmonologist: PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date:[**2129-6-8**] at 3:10 PM DR. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 612**] Date/Time: [**2129-6-8**] at 3:30 PM You will need to have the stitches take out of the skin on your abdomen in 2 weeks. This can be done by Dr. [**Last Name (STitle) 4507**] at your appointment. Completed by:[**2129-5-27**]

[ "511.9", "V45.89", "584.9", "455.6", "277.39", "V10.52", "458.29" ]

icd9cm

[ [ [] ] ]

[ "34.91", "77.49", "83.95", "86.11" ]

icd9pcs

[ [ [] ] ]

14516, 14522

11119, 14185

328, 373

14698, 14737

5289, 5289

15837, 16901

4252, 4373

14305, 14493

14543, 14677

14211, 14282

14761, 15814

4388, 4388

3249, 3335

277, 290

401, 3174

5305, 11096

4402, 5270

3366, 3589

3196, 3229

3605, 4236

25,917

121,031

46075

Discharge summary

report

Admission Date: [**2149-1-19**] Discharge Date: [**2149-1-28**] Date of Birth: [**2089-2-18**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male with a history of smoking, hypertension, hyperlipidemia, presenting with acute onset of substernal chest pain with exertion. The patient had baseline intermittent chest pain with exertion. His chest began eight years ago, and is induced by exercise and exposure to cold. One week ago, the patient began to take atenolol, which alleviated his pain. Cardiac risk factors include history of hypertension, hyperlipidemia, and heavy smoking history. No history of prior myocardial infarction. The patient was in his usual state of health until the day before admission, when he began exercising. He began to feel pain after three minutes. He characterized it as burning and substernal, which radiated to his shoulders bilaterally. The pain lasted less than ten minutes, but he went to [**Hospital1 69**]. Evaluation shows lateral wall motion defects and anteroapical reversible defects with an ejection fraction of 43%. Catheterization showed left circumflex 80% occlusion, 100% after the first branch, right coronary artery had mild disease, left main had 80% distal disease. PAST MEDICAL HISTORY: Significant for benign aldosteronoma diagnosed in [**2146**], hypertension, hyperlipidemia, gastroesophageal reflux disease, asthma questionable. ALLERGIES: Sulfa drugs. MEDICATIONS AT HOME: Atenolol 25 mg by mouth once daily, gemfibrozil 600 mg twice a day, aspirin 325 mg once daily. SOCIAL HISTORY: Significant for two to three packs of smoking a week, and two cigars a week for 20 years. He denies alcohol abuse and intravenous drug use. He works as a patent lawyer, and lives with his wife. FAMILY HISTORY: Significant for a grandmother with diabetes. His father died of a stroke, and his mother died of some complication of vascular disease. REVIEW OF SYSTEMS: Revealed recent weight loss, but negative for dyspnea, orthopnea, nocturia, palpitations, urinary frequency or burning. LABORATORY DATA: CBC of 7.7 white count, 42.7 hematocrit. PT 12, PTT 28, INR 1.0. Chemistry of 143/4.7/107/24/45/2.4, glucose 95. CKs were negative for acute infarct. HOSPITAL COURSE: The patient was taken to the operating room by the Cardiothoracic Surgery service under Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] for coronary artery bypass graft, off-pump, x 2. Postoperatively, the patient was transferred to the Intensive Care Unit, where he was on pressor support. The patient was intubated and remained intubated in the Intensive Care Unit. On [**2149-1-24**], the patient was doing well. He had been extubated in the interim, and transferred to the floor after discontinuation of his chest tube. The patient, on [**2149-1-25**], was doing well. His wires were discontinued without event. The patient was doing well, and Physical Therapy was involved. Physical Therapy felt that the patient was safe for discharge. A chest x-ray was done for a minor desaturation on [**2149-1-26**], which showed no acute pathology. On [**2149-1-27**], the patient was comfortable, was a Level V, with oxygen saturation of 94% on room air. The patient expressed a strong desire to go home, and rehabilitation services cleared him for discharge home on [**2149-1-28**]. The patient is being discharged on the following medications: Aspirin 325 mg by mouth once daily, Lopressor 25 mg by mouth twice a day, lasix 20 mg by mouth for another five days once a day, potassium 20 mEq by mouth for another five days only, Colace 100 mg by mouth twice a day, Plavix 75 mg by mouth once daily for three months total, Imdur 30 mg a day, Protonix 40 mg by mouth once daily, gemfibrozil 600 mg by mouth four times a day. The patient had a bad reaction to percocet, and he will not be going home on narcotics. The patient, upon discharge, is in good condition, with no acute pathology. His physical examination shows that his sternal wound is in good condition, with no discharge and no erythema. His leg wound is well approximated and healing. His pain is well controlled. He is to follow up with Dr. [**Last Name (STitle) 1537**]. He is to follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 1312**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1313**]. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2149-1-27**] 21:51 T: [**2149-1-28**] 00:05 JOB#: [**Job Number 98058**]

[ "272.4", "794.31", "401.9", "593.9", "272.1", "305.1", "780.2", "414.01", "411.1" ]

icd9cm

[ [ [] ] ]

[ "88.56", "88.53", "89.68", "36.31", "36.15", "37.22", "36.11" ]

icd9pcs

[ [ [] ] ]

1825, 1963

2296, 4730

1496, 1592

1984, 2277

160, 1276

1300, 1474

1610, 1807

4,392

142,798

54297

Discharge summary

report

Admission Date: [**2110-9-1**] Discharge Date: [**2110-9-3**] Date of Birth: [**2064-10-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2932**] Chief Complaint: weakness Major Surgical or Invasive Procedure: I & D of pilonidal cyst - lower back History of Present Illness: 45 yo male with ESRD on T/Th/Sat HD with triopathy, morbid obesity presented to ED with new complaint of weakness this AM. The patient was weak bilaterally in his arms/legs and he noticed this when he had difficulty arising from seated position. He has never had this type of symptom before. He states that his FS was 186 this AM and that his sugars were not low overnight. He also states that he was SOB at this time and was also SOB on walking to his car. He did not have any pleuritic pain. Denied any fevers, chills or night sweats or any cough. Denied any chest pain or palpitations. In the ED, the patient was noted to have: K of 7.1 -> treated with kayexalate, 10U insulin, 1 amp D50, kayexalate 15gm x1, 1 amp Na HCO3 and 1 amp Calcium gluconate. After this treatment, his K dropped to 6.7. The patient notes that he felt improvement in both his energy level/strength and had improvement in his respiration. He notes that he was able to transfer without significant weakness. On EKG, he was noted to have flattened P waves and a junctional rhythm with some deepening of S -> P waves which returned after treatment and the depth of his S in II was reduced. Additionally, a pilonidal cyst over the coccyx was lanced and drained. Patient has been on HD x 4 years and was being dialyzed through a tunneled L subclavian catheter. Patient notes that over the past week, the flow rate in his dialysis catheter has been reduced from 450mL/min to ~300mL/min. The dialysis RN notes that she had to remove a clot from one of his dialysis ports and needed to run the dialysis in reverse. Over the past 3 days, the patient has been dining on plantains. In the MICU, received emergent dialysis. K had decreased to 5.1 at the time of transfer. Past Medical History: DM - since age 10. He had an attempted fistula on the R wrist which did not mature. He then had a graft which lasted for a few years which clotted off. A trial of a repeat graft was unsuccessful. His current tunneled dialysis line has been in since [**12-30**]. ESRD - [**First Name8 (NamePattern2) 3122**] [**Doctor Last Name 1860**] is his Nephrologist Neuropathy HTN Obesity: Currently being evaluated at [**Hospital1 2025**] for gastric bypass prior to Renal transplant Social History: No EtOH, No cigarettes or illicity drug use. Currently unemployed Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: T: 98.0 BP: 135/37 P: 70 RR:16 O2 sats: 99% 1.5L Gen: Obese male in NAD HEENT: OP clear No lesions noted Neck: Large. Supple. CV: +s1+s2 RRR No mumurs appreciated Resp: CTA B/L. Mild expiratory wheezing. Abd: Obese. Non tender, non distended Ext: No edema. 2 toe amputation on L foot. S/P graft on L foot. Neuro: AAO x 3 CN: [**1-5**] intact Sensation: symmetric and intact on LEs Pertinent Results: [**2110-9-1**] 08:55PM COMMENTS-GREEN TOP [**2110-9-1**] 08:55PM GLUCOSE-77 K+-6.7* [**2110-9-1**] 08:45PM GLUCOSE-80 UREA N-105* CREAT-15.0* SODIUM-136 POTASSIUM-6.6* CHLORIDE-98 TOTAL CO2-21* ANION GAP-24* [**2110-9-1**] 08:45PM CALCIUM-8.8 PHOSPHATE-5.9* MAGNESIUM-3.3* [**2110-9-1**] 05:45PM GLUCOSE-145* UREA N-105* CREAT-14.5*# SODIUM-134 POTASSIUM-7.1* CHLORIDE-96 TOTAL CO2-21* ANION GAP-24* [**2110-9-1**] 05:45PM CK(CPK)-442* [**2110-9-1**] 05:45PM cTropnT-0.16* [**2110-9-1**] 05:45PM CK-MB-7 [**2110-9-1**] 05:45PM CALCIUM-9.1 PHOSPHATE-5.7*# MAGNESIUM-3.3* [**2110-9-1**] 05:45PM WBC-7.6 RBC-3.64* HGB-11.2* HCT-32.4* MCV-89 MCH-30.7 MCHC-34.5 RDW-16.5* [**2110-9-1**] 05:45PM NEUTS-66.4 LYMPHS-23.2 MONOS-5.9 EOS-4.1* BASOS-0.3 [**2110-9-1**] 05:45PM ANISOCYT-1+ [**2110-9-1**] 05:45PM PLT COUNT-302 [**2110-9-1**] 05:45PM PT-11.5 PTT-23.8 INR(PT)-1.0 [**9-1**] CXR: Limited study. No definite focal consolidation nor specific evidence of volume overload. Brief Hospital Course: Mr. [**Known lastname 111235**] weakness was likely a sequela of hyperkalemia secondary to dietary indiscretion. He demonstrated no signs of infection or cardiac etiology. Although trop is elevated, it is in the setting of ESRD and MB fraction not elevated. # Hyperkalemia: Seems to stem from dietary indiscretion. In the ED, he was aggressively treated with calcium gluconate, insulin, sodium bicaronate, and kayexelate. He was then urgently dialyzed. Following dialysis, his potassium remained stable. He was re-instructed regarding a low potassium diet. # ESRD: The hyperkalemia besides dietary indiscretion may also have been precipitated by decreased flow in his dialysis catheter. RN also found clot which was removed. The patient was dialyzed successfully and will continue dialysis as an outpatient as previously scheduled. He was continued on renagel, Phoslo, and Nephrocaps. # Abnormal EKG: In the ED, the patient was noted to have a loss of P waves (either a junctional rhythm or hyperkalemia-related). With treatment of his hyperkalemia, his EKG returned to baseline. # DM: The patient was continued on his home regimen of NPH and regular insulin. # Pilonidal cyst: This was lanced in the emergency room. VNA will assist in daily dressing changes upon return home. Given absence of cellulitis, no antibiotics were prescribed. If this does not adequately heal, surgical consultation may be considered as an outpatient. # Code: Full Medications on Admission: Protonix 40 mg QD Renagel 800mg 4 TID Phoslo 1 TID Renalcaps 1 QD ASA 325mg QD Cartia XT 180 mg QD Insulin N 28u Q AM, 16 u QPM Insulin R 14u Q AM, 15u Q afternoon Motrin 800mg 2 po BID x 1 week Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day) as needed for meals. 7. Insulin resume your outpatient NPH and regular insulin regimen upon discharge. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Hyperkalemia Pilonidal cyst Discharge Condition: Stable. Afebrile and ambulating without assistance. Discharge Instructions: Please return to the Emergency Room or call your doctor if you experience any of the following: fever > 101.5, intractable nausea/vomiting, severe pain, increasing weakness, chest pain, shortness of breath or any other concerning symptoms. . Please take all medications as prescribed. . Please follow-up with all appointments as scheduled. Followup Instructions: Please make an appointment with Dr. [**Last Name (STitle) **] in the next 1 to 2 weeks. You can make an appointment by calling [**Telephone/Fax (3) **]. . The following appointment has already been scheduled for you: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2110-10-20**] 2:50 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**] Completed by:[**2110-12-17**]

[ "583.81", "250.60", "250.50", "250.40", "V58.67", "585.6", "357.2", "282.5", "685.1", "276.7", "362.01", "276.2" ]

icd9cm

[ [ [] ] ]

[ "39.95", "86.03" ]

icd9pcs

[ [ [] ] ]

6529, 6586

4210, 5660

322, 361

6658, 6712

3186, 4187

7100, 7648

2727, 2744

5905, 6506

6607, 6637

5686, 5882

6736, 7077

2784, 3167

274, 284

389, 2130

2152, 2628

2644, 2711

52,307

173,342

46516

Discharge summary

report

Admission Date: [**2174-5-26**] Discharge Date: [**2174-6-1**] Date of Birth: [**2100-4-30**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1881**] Chief Complaint: Dyspnea, Sepsis Major Surgical or Invasive Procedure: None History of Present Illness: 74 yo F h/o Wegeners disease with pulmonary and renal involvement, most recently course complicated by tracheobronchial disease in particular bilateral bronchial stenosis status post balloon dilation with intralesional steroid therapy by interventional pulmonology with recent increase in prednisone and addition of azathioprine [**5-11**] by Dr. [**Last Name (STitle) 2168**] for maintenance. . Patient was doing well until one day prior to transfer when she developed shortness of breath and some lethargy. The day prior to admission, her daughter spoke to her on the telephone and noted dyspnea with speaking. On the evening of [**5-25**] she became acutely dyspnic with difficulty speaking. In additiona she had fever, chills, diffuse myalgias, fatigue and overall weakness. She called EMS and was taken to the [**Hospital6 28728**] Center ED. . Patient was taken to [**Hospital 1121**] Hospital. In the OSH, initial vs were: T 98.6 P 136 BP 138/73 R 20 O2 100% on CPAP. Patient was admitted to the ICU for acute hypoxic respiroty failure. She was weaned from CPAP to a open face high flow of 70%. Her blood gas was 7.29, pCO2 58, pO2 192. Patient also was hypotensive on admission and required phenylephrine gtt, which was weaned off overnight. Patient underwnet CTA, which was negative for PE, but showed bilateral pleural effusions and diffuse bilateral pneumonia. A 3-D view of her trachea to evaluate for tracheal stenosis was obtained, but was not read prior transfer. Labs were notable to WBC of 24.5 with 50% bands. No sputum culture was obtained. OSH team was concerned for PCP [**Name Initial (PRE) 1064**] (although patient is on PCP prophylaxis at home) and gave patient full-dose Bactrim. Patient was checked for Influenza A and B, which were negative, but was started on tamiflu. . Also, at OSH, patient had an elevated troponin-I at 3.46, which trended down to 2.72. EKG showed no ST elevations. Cardiology consulted and recommended an ECHO, which showed no obvious wall motion abnormalities per report. . Upon arrival to the MICU, patient reports her dyspnea is improved from yesterday. No chest pain, shortness or breath, diaphroesis. No fevers, rigors. . Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Wegener's granulomatosis: Followed by Dr. [**Last Name (STitle) **]; recent history detailed in progress note by Dr. [**First Name (STitle) **] [**2174-3-24**], recently complicated by tracheobronchial disease in particular bilateral bronchial stenosis status post balloon dilation with intralesional steroid therapy by interventional pulmonology - Hypothyroidism - Osteoporosis - History of breast cancer: in [**2151**], s/p surgery and chemo Social History: Lives with her son [**Name (NI) 122**]. Quit smoking ~50 years ago. Former social drinker, no alcohol in 2 years. Family History: -Brother with [**Name (NI) 98796**] Disease -Mother passed from sudden cardiac arrest s/p "hand procedure" at age 75 -Father passed at 89 from "old age" with Parkinson's Disease -Hypertension in several family members -[**Name (NI) **] history of cancer, autoimmune diseases Physical Exam: On Admission: Vitals: T: 97.1 BP: 95/57 P: 97 97 R: 27 O2: 100% on 70% face mask General: Alert and oriented, answers most questions appropriately HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diffuse rhonchi, inspiratory and expiratory wheezing Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachy, S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, no clubbing/cyanosis/edema Pertinent Results: Admission labs: [**2174-5-26**] 09:20PM BLOOD WBC-18.1*# RBC-3.54* Hgb-12.7 Hct-38.8 MCV-110* MCH-35.8* MCHC-32.6 RDW-14.0 Plt Ct-178# [**2174-5-26**] 09:20PM BLOOD PT-13.2 PTT-30.1 INR(PT)-1.1 [**2174-5-26**] 09:20PM BLOOD Glucose-97 UreaN-23* Creat-0.7 Na-141 K-3.8 Cl-104 HCO3-30 AnGap-11 [**2174-5-26**] 09:20PM BLOOD ALT-54* AST-42* CK(CPK)-65 AlkPhos-103 TotBili-0.4 [**2174-5-26**] 09:20PM BLOOD Albumin-2.8* Calcium-7.7* Phos-3.5 Mg-1.9 Cholest-176 Trop/CK/MB: [**2174-5-26**] 09:20PM BLOOD CK-MB-11* MB Indx-16.9* cTropnT-0.29* [**2174-5-27**] 04:41AM BLOOD CK-MB-8 cTropnT-0.21* [**2174-5-27**] 03:20PM BLOOD CK-MB-6 cTropnT-0.13* Chest X-Ray: Right internal jugular line tip is at the level of mid SVC. Right lower lobe and left lower lobe consolidations are present. There are also focal opacities in the right upper lobe and to a lesser extent to left upper lobe, findings consistent with severe multifocal infection. Heart size and the mediastinal silhouettes are unremarkable. Healed fractures with callus formation are noted on the right. There is no pleural effusion or pneumothorax, small amount of pleural effusion cannot be excluded. MICROBIOLOGY: 5/5 Blood Culture: ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. GRAM NEGATIVE ROD(S). SECOND MORPOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2174-5-29**]): NEGATIVE for Pneumocystis jirovecii (carinii CHEST PORT. LINE PLACEMENT Study Date of [**2174-5-30**] 8:46 AM FINDINGS: As compared to the previous radiograph, the patient has received a new left-sided PICC line. The course of the line is unremarkable. The tip of the line projects over the mid to low SVC. There is no evidence of complications, notably no pneumothorax. Borderline size of the cardiac silhouette. Unchanged signs of overinflation, the pre-existing areas of parenchymal opacities have decreased in extent and severity. VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2174-5-30**] 1:50 PM IMPRESSION: Aspiration of thin barium, which did not fully resolve with chin tuck. ECG Study Date of [**2174-5-26**] 5:21:30 PM Normal sinus rhythm with left atrial abnormality. Q waves in III and aVF consistent with prior inferior myocardial infarction. Peaked P waves in the inferior leads also suggest right atrial enlargement. Compared to the previous tracing of [**2174-3-31**] no diagnostic interval change. Brief Hospital Course: Ms. [**Known lastname 98795**] is a 74 y/o F with a h/o Wegener's who presented in respiratory distress, found to have multifocal HCAP and E.coli bacteremia and complicated by NSTEMI/demand ischemia, now improving. # Pneumonia/bacteremia: The patient has a complicated history of Wegner's with pulmonary involvement, most recently complicated by bilateral bronchial stenosis status post balloon dilation with intralesional steroid therapy by IP. She was also recently started on high-dose prednisone. She presented with fever, respiratory distress, and hypotension and was found to have bandemia, diffuse bilateral infiltrates on a CT scan at an outside hospital. There was primarily concern for hospital acquired pneumonia but also PCP given her long standing steroid use, though she was on PCP [**Name Initial (PRE) 1102**]. She initially needed pressors (phenylephrine) prior to transfer to [**Hospital1 18**]. Upon arrival, her BP stabliized and she was treated empirically with vancomycin and zosyn and transitioned to vancomycin/cefepime to also cover his bacteremia. She was also initially treated with bactrim for PCP empirically but this was stopped after negative studies. She will complete an 8 day course of vancomycin on [**6-3**] and a 14 day course of cefepime on [**2174-6-9**]. # NSTEMI/demand ischemia: She was found to have elevated troponin on presentation and ruled in for NSTEMI with elevated CK, CK-MB, and MBI. She was chest pain free and has no known coronary artery disease but EKG demonstrated <[**Street Address(2) 4793**] elevation in V3 and evidence of prior inferior MI (inferior q-waves also seen on old EKG). She was initially treated with a heparin gtt, aspirin, and atorvastatin and transitioned to full dose aspirin and simvastatin alone. An ECHO was performed at the outside hospital and demonstrated 65% EF, mild inferoseptal hypokinesis, no vegetations. # Wegener's granulomatosis: Patient with history of recent wegner's flare and bronchial stenosis status post balloon dilation with intralesional steroid therapy by IP. Recently started on azathioprine 50 mg [**Hospital1 **]. Her respiratory status stabilized with treatment of her pneumonia. She was continued on prednisone 20 mg [**Hospital1 **] and azathioprine was held because of her acute infection. This will need to be restarted as an outpatient. # Hypothyroidism: Continued home dose of levothyroxine 150 mcg daily. # Osteoporosis: Continued calcium and vitamin D. Weekly alendronate. # Communication: Patient, HCP/friend [**Name (NI) **] [**Name (NI) 31385**] ([**Telephone/Fax (1) 98797**] # Code: DNR, okay to intubate (discussed with HCP and patient's daughter) Transitions of care: - restart azathioprine in the outpatient setting after patient follows-up with rheumatology - pulmonology follow-up (cannnot currently schedule because patient's former pulmonologist, Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] no longer be at [**Hospital1 18**]) - cardiology follow-up Medications on Admission: Home Medications: Albuterol sulfate 90 mcg HFA 2 puffs [**Hospital1 **] Alendronate 70 mg weekly Atovaquone 1500 mg PO daily Azathioprine 50 mg [**Hospital1 **] Diazepam 5 mg q12 PRN Fluticasone 250 mcg 2 puffs [**Hospital1 **] Levothyroxine 150 mcg daily Nystatin 10 mL TID Omeprazole 20 mg qHS Prednisone 20 mg [**Hospital1 **] Vitamin B Complex Calcium carbonate Cholecalciferol Fish Oil Vitamin C/E complex . Transfer Medications: Combivent nebs Heparin 5000 units SQ q12 Hydrocortisone 60 mg IV q6h Insulin sliding scale Synthyroid 75 mcq QAM Omeprazole 20 mg daily Tamiflu 75 mg [**Hospital1 **] Zosyn 3.375 g IV q6 Bactrim 300 mg IV q8 Vancomycin 1 gIV [**Hospital1 **] Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 3. levothyroxine 75 mcg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 4. ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) solution Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable [**Hospital1 **]: Two (2) Tablet, Chewable PO BID (2 times a day). 7. cholecalciferol (vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 8. B complex vitamins Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 9. diazepam 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12 hours) as needed for anxiety. 10. atovaquone 750 mg/5 mL Suspension [**Hospital1 **]: Ten (10) ml PO DAILY (Daily). 11. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) ml Injection TID (3 times a day). 12. prednisone 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 13. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) neb Inhalation Q4H (every 4 hours) as needed for SOB, wheezing. 15. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 16. simvastatin 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 17. aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 18. therapeutic multivitamin Liquid [**Last Name (STitle) **]: Five (5) ML PO DAILY (Daily). 19. vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: 1.5 Recon Solns Intravenous Q 12H (Every 12 Hours) for 2 days: last day [**6-3**]. 20. cefepime 2 gram Recon Soln [**Month/Year (2) **]: One (1) Recon Soln Injection Q8H (every 8 hours) for 7 days: last day [**6-9**]. 21. alendronate 70 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a week. Discharge Disposition: Extended Care Facility: [**Hospital1 **] rehab Discharge Diagnosis: Primary: Pneumonia Bacteremia NSTEMI Secondary: Wegner's granulomatosis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for pneumonia and bacteremia, an infection in your bloodstream. We treated you with antibiotics and your breathing and infection improving. During your acute illness, you also had a heart attack, but your heart function was checked and is normal. Please take all of your medications as prescribed. Please keep all of your follow-up appointments. Followup Instructions: Department: RHEUMATOLOGY When: TUESDAY [**2174-6-14**] at 4:30 PM With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital Ward Name 706**] When: TUESDAY [**2174-11-8**] at 10:50 AM With: [**Year (4 digits) 706**] [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**] Completed by:[**2174-6-1**]

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

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104,653

45518

Discharge summary

report

Admission Date: [**2188-10-21**] Discharge Date: [**2188-11-3**] Date of Birth: [**2112-12-21**] Sex: F Service: MEDICINE Allergies: Fish Product Derivatives Attending:[**First Name3 (LF) 759**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Colonoscopy EGD History of Present Illness: History of Present Illness: 75 year old woman on Coumadin and Plavix, s/p mechanical MVR, h/o GI bleed (ten years ago), now presenting with black tarry stools overnight, with 2 additional episodes of melena this morning. Pt was seen in urgent care at PCP's office today and was guaiac positive. In PCP office she noted three black tarry stools. During this time, she has no nausea, vomiting, no epigastric pain, no lightheadedness, and no chest pain. She has not taken any over-the-counter medications. She usually takes MiraLax has a bowel movement every few days, and she has had three bowel movements in less than 24 hours. The patient has a history of peptic ulcer disease diagnosed in the mid 90s. She has been maintained on ranitidine 150 mg b.i.d. for many years. . In the ED, initial vs were: T99, P 81, 127/66, RR 16, 100%RA. Patient was given protonix 40 IV x1, and was seen by GI. GI recommended NG lavage, which showed brown effluent, no coffee grounds. Following NGT placement the pt developed brisk epistaxis, now has packing in place. Repeat hct stable at 40. Major source of bleeding is now iatrogenic nosebleed. Vitals on transfer were: 96.4 HR 97 127/63 19 100%RA. Past Medical History: CAD: s/p 1 vessel CABG [**2177**] Valvular dz: s/p mechanical MV replacement [**2177**] H/o supraventricular tachycardia TIA's (on plavix) hypertension hypercholesterolemia osteoporosis migraine headaches with aura carotid disease cataracts s/p hysterectomy [**6-20**] constipation History of a significant gastrointestinal bleed secondary to gastric ulcerations. Social History: She does not currently smoke cigarettes, does have a <3 pack year history, quit in [**2154**]. She is [**Name Initial (MD) **] retired RN, widowed. She does have a significant other who is being very supportive with her at this time. She rarely drinks alcohol. Family History: Positive for strokes in grandmother and mother. Physical Exam: Admission vitals: T:98.2 P:91 R: BP:112/87 SaO2:100 @ RA Pt [**Name (NI) **]3 HEENT: PREEL, oral moist Neck: no JVD, supple, no LN Chest: B/L Bs clear, no wheezing CVS: S1/S2 regular, thre was click in her apical area, no murmur Abd: soft, no tender, Bs present Ext: no pitting edema Rectum: there is no skin tag, there is black stool in her rectum, Guaiac test positive . Discharge vitals: T: P: RR: BP: O2Sat: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, no nasal bleeding, no conunctival pallor Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, + mechanical murmur at apex Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rashes Neuro: CN2-12 intact, strength intact [**6-17**] U&LE, sensation intact, DTRs 2+ patellar, gait deferred Pertinent Results: EGD [**2188-10-22**]: Impression: Normal mucosa in the esophagus Mild erosion in the antrum compatible with gastritis Erythema in the stomach body compatible with NG tube-induced trauma Normal mucosa in the duodenum During this procedure, we did not find activate bleeding. Small hiatal hernia Otherwise normal EGD to third part of the duodenum Recommendations: Because we did not identify the etiology of her G.I. bleeding during this procedure, she might need colonoscopy to rule out right colonic bleeding. We will discuss with Dr. [**Last Name (STitle) 2987**] this afternoon to recommend either regular colonoscopy or virtual colonoscopy. Colonoscopy [**2188-10-23**]: Angioectasia in the cecum (thermal therapy) Diverticulosis of the sigmoid colon Otherwise normal colonoscopy to cecum Recommendations: In patient care Capsule endoscopy. Serial hematocrits Brief Hospital Course: Assessment and Plan: 75 year old woman on Coumadin and Plavix, s/p mechanical MVR, h/o GI bleed (ten years ago), now presenting with GI bleeding in the setting of a supratherapeutic INR, c/b nasal bleeding following NGT placement. . # GI Bleed: The pt had three melenotic stools over 24 hrs, but has stable hct on labs and is otherwise asymptomatic (without fatigue, shortness of breath with exertion, chest pain, or orthostasis). NG lavage was negative for any coffee ground material or bloody contents. EGD did not reveal any source of bleed. The patient also underwent colonoscopy, revealing a bleeding AVM, which was coagulated using thermal therapy. She will need a capsule endoscopy as an out-patient in order to assess for additional, non-visualized AVM in the small bowel. She was monitored with serial hematocrits, which trended downward precipitating transfusion with 1 unit of blood. Her anti-coagulation with Plavix and Coumadin was held for her procedures. After, she was re-started on coumadin with a heparin bridge to therapeutic INR, and her plavix was restarted after being held for 7 days. Her hematocrit was stable at discharge. She was discharged once INR was therapeutic. . # Nasal trauma: Following NGT placement, pt developed bleeding from nose that was quite profuse. Packing was placed by ENT which was dislodged overnight. We suspect that a minor lac/contusion from NG tube in the setting of elevated INR precipitated this event. She experienced no further epistaxis during this admission. . # Mechanical MV replacement: Goal INR is 2.5-3.5. The patient is on a higher dose of Coumadin (5.5mg) to maintain this INR. Per discussion with cardiology, her anti-coagulation was not reversed. All anticoagulation was held pending her EGD, and she was started on a heparin drip afterwards. After her colonoscopy, she was restarted on Coumadin and a heparin drip was used to bridge the patient until her INR was therapeutic. At discharge, her INR was 2.6. . # CAD s/p 1 vessel CABG [**2177**]: The patient's beta blocker was initially held so as not to mask hypovolemia. It was re-started after the patient's procedures with normal heart rate and excellent blood pressure control. . # TIA's (on plavix): Plavix was restarted after being held for a total of 7 days after her colonoscopy. Medications on Admission: Lipitor 80 Plavix 75 Maxalt ML T 10 prn migraine Amoxicillin prn dental Atenolol 12.5 Alendronate 70 EpiPen prn fish Ambien 10 qhs Coumadin 5.5 everyday except Sat, on Sat pt takes 4mg Skelaxin 800 qhs Zantac 150mg [**Hospital1 **] meds at hospital: Maxalt-MLT *NF* 10 mg Oral daily prn migraine Oxymetazoline 1 SPRY NU [**Hospital1 **] Lorazepam 0.25 mg IV ONCE MR1 Pantoprazole 8 mg/hr IV INFUSION Discharge Medications: 1. Rizatriptan 10 mg Tablet Sig: One (1) Tablet PO daily prn () as needed for migraine. 2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Warfarin 5 mg Tablet Sig: 5.5 mg every day but Saturday, 4mg on Saturday. Tablets PO Once Daily at 4 PM: 5.5mg every day but Saturday. On saturday take 4mg. . 5. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 6. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 8. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) Intramuscular once a day as needed for anaphylaxis. 9. Skelaxin 800 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: 1) Gastrointestinal bleeding 2) Arteriovenous malformation of cecum Secondary diagnosis: 1. Coronary Artery Disease status post 1 vessel Coronary Artery Bypass Graft [**2177**] 2. Valvular disease: status post mechanical Mechanical valve replacement [**2177**] (on coumadin) 3. History of supraventricular tachycardia 4. Transient ischemic attacks (on plavix) 5. hypertension Discharge Condition: Stable, BP --, HR --, no recurrence of GI bleeding after colonoscopy with thermal therapy, HCT stable at --. Discharge Instructions: You were admitted to the hospital for GI bleeding. You had an EGD, which showed gastritis in your stomach. You also had a colonoscopy, which showed an AVM (arteriovenous malformation) in the cecum which was coagulated with thermal therapy to stop the bleeding. It also showed diverticulosis of the sigmoid colon. You will need to get a capsule endoscopy as an outpatient. This will be coordinated by gastroenterology. * We restarted your Coumadin before discharge. Your INR was between 2.5 and 3.5 at discharge. You will need to have a follow up INR check with your regular doctor next week. You should take your Coumadin as per your prior regimen (5.5mg every day but Saturday, on Saturday take 4mg). Please call your doctor or return to the ED if you experience any: Recurrence of bleeding Fainting or lightheadedness Abdominal or Pelvic Pain Pain with urination Fever or Chills Chest pain or shortness of breath, especially with exertion Followup Instructions: You need to follow up with gastroenterology for a capsule endoscopy as an outpatient and you also need to have an INR check next week. You need to schedule the following appointments: Appointment #1 MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] Specialty: Internal Medicine Location: [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg. [**Location (un) 895**] Phone number: [**Telephone/Fax (1) 250**] Appointment #2 MD: Dr. [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 3100**] Specialty: Gastroenterology Location: [**Last Name (NamePattern1) 439**]. [**Hospital Ward Name **] Bldg. [**Location (un) 858**] Phone number: [**Telephone/Fax (1) 463**] Please make appointments to follow up in the above two clinics upon discharge from the hospital. You also need to have your INR checked on wednesday, and follow up with the [**Company 191**] anticoagulation service as you have in the past. . Future appts you have scheduled: 1. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2188-11-27**] 9:40 2. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. Date/Time:[**2188-12-31**] 10:10

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icd9cm

[ [ [] ] ]

[ "45.43", "45.13" ]

icd9pcs

[ [ [] ] ]

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42104

Discharge summary

report

Admission Date: [**2189-5-26**] Discharge Date: [**2189-5-27**] Date of Birth: [**2124-9-28**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / moxifloxacin / metronidazole / cefazolin / Iodine / morphine / piperacillin / trimethoprim / Avelox Attending:[**First Name3 (LF) 3556**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Bronchoscopy with tracheal stent removal History of Present Illness: History of Present Illness: 64F with a hx of COPD, fibromyalgia, Factor V leiden c/b DVT and CVA, and tracheobronchomalacia s/p tracheal y-stent on [**2188-3-27**], stent removal [**2188-10-27**] for chronic infections and mesh tracheoplasty [**11/2188**] who presented with 1 day of dyspnea and hypoxia and admitted to the MICU for airway monitoring and bipap prior to bronchoscopy. . She states that the woke up and thereafter noticed SOB and checked her O2 sat using her husband's pulse ox and was at 85% at rest on RA. She then used some of her husband's O2 by nasal cannula (unclear dose) which brought her O2 to 99%. She ate breakfast and showered and began coughing junky grey and brown material. She then called her pulmonologist, who told her to come to the ED. She otherwise denies fevers, chills, nausea, vomiting, change in appetite, rashes, swelling, or any other symptoms. . Of note, patient recently underwent outpatient evaluation for dyspnea by IP who has been following including CT trachea which demonstrated malacic changes in the upper 3-4cm's of her trachea, PFT's which demonstrated low lung volumes (TLC 76% predicted, FEV1/FVC 104% predicted), and bronchoscopy ([**5-21**]) with dynamic maneuvers demonstrated severe cervical tracheomalacia, moderate bronchomalacia at the bronchus intermedius, but otherwise no malacia elsewhere. A 15-12-12 Y stent cut to a length of 4.5cm was deployed and pt was started on Mucinex, Albuterol, and Mucomyst nebs. Two days later she contact[**Name (NI) **] the IP office with complaint of dyspnea but denied symptoms of plugging and described using the mucinex and nebs as prescribed but poor compliance of spiriva leading IP to believe her symptoms were more related to her COPD. She called the IP office again on the day of admission and felt her symptoms were related to plugging of her stent so she was advised to proceed to the ED for further evaluation. . ED Course: In the ED, initial VS were T 99.4, HR 110, BP 135/88, RR 16, 99% on RA. She was evaluated by the IP team in the ED, who expressed concern for possible mucous plugging and recommended taking to the patient to the OR for bronchoscopy. CXR wnl's. She received nebs with albuterol and racemic epinephrine as well as 80 mg IV solumedrol and zofran 4 mg IV for nausea. ICU admission was recommended as patient may require BIPAP as well as close monitoring post-bronchoscopy. Transfer vitals were T 98.4 ??????F, HR 89, RR 20, BP 121/67, O2 Sat 98% on RA. . On arrival to the MICU, patient's VS: 99.6, 101, 146/83, 14, 100%3LNC. She confirms the above history and denies significant symptoms other than some discomfort with breathing and a moderate headache which she often has. Past Medical History: - Tracheomalacia s/p tracheal y-stent on [**2188-3-27**], stent removal [**2188-10-27**] for chronic infections - s/p PFO closure [**2183**], [**Hospital1 3278**] - Factor V Leiden deficiency with h/o DVT and CVA - Migraine - Fibromyalgia - Asthma - COPD, bronchiectasis - Glaucoma - C. difficile ([**2178**]) Social History: Social History: Retired social worker. Married and lives with her husband. [**Name (NI) **] a history of alcoholism but quit drinking almost 30 yaers ago. Former smoker, quit [**2175**]. No recreational drugs. Family History: Father (d) depression, COPD. Mother alcoholism. Physical Exam: Vitals: 99.6, 101, 146/83, 14, 100%3LNC General: Alert, oriented, no acute distress, not using accessory muscles HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD, soft submandibular fullness that seems to be adipose rather than edema CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Pertinent Results: [**2189-5-26**] 02:50PM BLOOD WBC-7.8# RBC-5.08# Hgb-13.4# Hct-44.9# MCV-89 MCH-26.3*# MCHC-29.8* RDW-16.9* Plt Ct-316 [**2189-5-26**] 07:53PM BLOOD WBC-6.7 RBC-4.63 Hgb-12.1 Hct-40.5 MCV-88 MCH-26.1* MCHC-29.8* RDW-16.9* Plt Ct-239 [**2189-5-26**] 02:50PM BLOOD Neuts-75.7* Lymphs-18.0 Monos-3.2 Eos-2.6 Baso-0.4 [**2189-5-26**] 02:50PM BLOOD Plt Ct-316 [**2189-5-26**] 07:53PM BLOOD PT-11.1 PTT-31.0 INR(PT)-1.0 [**2189-5-26**] 07:53PM BLOOD Plt Ct-239 [**2189-5-26**] 07:53PM BLOOD Glucose-287* UreaN-21* Creat-0.6 Na-143 K-4.2 Cl-108 HCO3-23 AnGap-16 [**2189-5-26**] 07:53PM BLOOD Calcium-9.1 Phos-2.3*# Mg-1.8 [**2189-5-26**] 02:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2189-5-26**] 02:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM [**2189-5-26**] 02:50PM URINE RBC-1 WBC-8* Bacteri-NONE Yeast-NONE Epi-0 [**2189-5-26**] 02:50PM URINE Mucous-RARE Time Taken Not Noted Log-In Date/Time: [**2189-5-26**] 6:09 pm MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Pending): CHEST (PORTABLE AP) Study Date of [**2189-5-26**] 2:14 PM IMPRESSION: No acute cardiopulmonary abnormality, and no significant interval change from prior. EKG: NSR @ 97, LAD which is old, NI, poor r-wave progression, otherwise similar to prior from [**2188-12-9**] Brief Hospital Course: Assessment and Plan: 64F with a hx of COPD, fibromyalgia, Factor V leiden c/b DVT and CVA, and tracheobronchomalacia s/p s/p mesh tracheoplasty [**11/2188**] and y-stent [**5-21**] who presented with 1 day of dyspnea and hypoxia and admitted to the MICU for airway monitoring and bipap prior to bronchoscopy. . # Hypoxia/Concern for Stent Plugging/Possible COPD Exacerbation: Pt with extensive tracheomalacia history on top of mild-moderate COPD without home O2 requirement presenting with repeated episodes of dyspnea following tracheal stent placement [**5-21**] concerning for mucous plugging. On exam, she is without significant stridor or upper airway sounds and without wheezes. While she does not currently have frank fevers, CXR infiltrates, or lung exam findings c/w pneumonia she does report history of productive cough that is different from her baselime sputum, temperatures are elevated, and she is somewhat diaphoretic raising possibility of COPD exacerbation. Unfortunately she has multiple antibiotic allergies which would make therapy selection more difficult. Interventional Pulmonology took the patient to the OR for bronchoscopy and removed the stent. They noted granulation tissue around the stent with mucous which was the likely cause of her dyspnea. They also removed some fo the granulation tissue. She was observed in the ICU for 4 hours after the procedure with O2 sat of 98 while ambulating on RA. Patient received methyl prednisolone while in the ICU and was discharged on 4 days of 40mg prednisone per IP recommendations. She will follow up with both IP and Thoracic surgery for eventual surgical repair of her tracheomalacia. . # COPD: Patient on no home O2, without wheezes on exams, only home med is spiriva. Patient's O2 saturation was monitored continously while in the ICU and was placed on PRN nebulized albuterol and ipratropium without issue. . # GERD: Stable. Perhaps a causative factor in her tracheomalacia. Patient was continued on ranitidine and omeprazole and tums. . # Fibromyalgia/Migraines: Stable. Patient was continued on her home gabapentin, citalopram, cyclobenzaprine. Medications on Admission: Medications: Confirmed with Rite-Aid pharmacy (237 [**Location (un) **], [**Location (un) 2498**], MA; Phone: [**Telephone/Fax (1) 77218**]) - Sodium chloride 3% 3ml via nebulizer Q8H 20 minutes after albuterol nebs (this was in lieu of acetylcysteine nebs, which could not be obtained by pharmacy; script filled [**2189-5-22**]) - xBenzonatate 100 mg 2 capsule Q8H x 10 days PRN cough (script filled [**2189-5-22**]) - xClonazepam 1 mg PO TID PRN vertigo (script filled [**2189-5-18**]) - xLidoderm patch 5% 12 hours on/12 hours off (script filled [**2189-5-16**]) - Promethazine with codeine syrup, 240 ml, 1 tsp Q4H PRN cough (script filled [**2189-5-16**]) - xCyclobenzaprine 10 mg PO QHS x 30 days (script filled [**2189-5-14**]) - xVicodin 10-325 mg [**2-9**] tab PO TID PRN pain #50 (script filled [**2189-5-14**]) - xTramadol 50 mg [**2-9**] tab PO TID PRN pain #50 (script filled [**2189-5-11**]) - xRanitidine 300 mg PO QHS (script filled [**2189-4-22**]) - xPromethazine 25 mg PO QID PRN #50 (script filled [**2189-4-7**]) - Acetylcysteine nebs 20% 5ml Q8H to be used 20 minutes after albuterol nebs (prescribed [**2189-5-22**] but not filled as unavailable at pharmacy; saline nebs substituted) . Old scripts not filled in months: - Fiorcet 50 mg-325 mg-40 mg [**2-9**] Tablet(s) by mouth every six (6) hours as needed for headache (script last filled [**10/2188**]) - Gabapentin 200 mg PO BID (script last filled [**1-/2189**]) - Hydromorphone 2 mg [**3-13**] tab Q3H PRN pain #60 (script filled [**1-/2189**]) - Lorazepam 0.5 mg Q6H PRN (script last filled [**12/2188**]) - Nifedipine 10 mg PO Q8H (script last filled [**1-/2189**]) - Metformin 500 mg PO QHS (script last filled [**8-/2188**]) - Spiriva 18 mcg 1 cap inhaled daily (script last filled [**2185**]) - Citalopram 20 mg PO daily (script last filled [**2183**]) . Meds per OMR record, but no record at pharmacy: - Dozolamide-timolol eye drops, dose unknown - no record at Rite-Aid - Simvastatin 20 mg PO daily - no record at Rite-Aid - Omeprazole 40 mg PO, frequency unknown - no record at Rite-Aid (? OTC) - Colace 100 mg PO, frequency unknown - no record at Rite-Aid (? OTC) - Mucinex ER Multiphase 1,200 mg by mouth twice a day #60 (prescribed [**2189-5-21**], no record at Rite-Aid, ? OTC) . Discharge Medications: 1. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for 4 days. Disp:*8 Tablet(s)* Refills:*0* 2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for vertigo. 3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 4. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for spasm. 5. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO ONCE (Once) for 1 doses. 6. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. benzonatate 100 mg Capsule Sig: Two (2) Capsule PO every eight (8) hours as needed for cough for 5 days. 8. tramadol 50 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain for 7 days. 9. promethazine 25 mg Tablet Sig: One (1) Tablet PO four times a day for 10 days. 10. acetylcysteine Sig: 20% 5mL nebs Inhalation every eight (8) hours as needed for shortness of breath or wheezing for 7 days: use 20min after albuterol nebs. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebs Inhalation Q6H (every 6 hours) as needed for SOB/Wheezes. Discharge Disposition: Home Discharge Diagnosis: tracheomalacia mucous plugging tracheal stent with granulation tissue causing airway narrowing Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname 91270**], You were admitted to [**Hospital1 69**] for shortness of breath. Our interventional pulmonologists removed your tracheal stent. You had formed some scar tissue around the stent and had mucous plugging which likely lead to your shortness of breath. We gave you steroids in the ICU to help with inflammation. Please take 4 more days of prednisone, a steroid, as prescribed. Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 3020**]) and Dr. [**Last Name (STitle) 11482**] [**Name (STitle) **] ([**Telephone/Fax (1) 3020**]) offices are making appointments for you. If they do not contact you by [**Name (NI) 2974**] [**2189-5-29**], please call their offices. The following appointments have already been scheduled: Provider: [**Name10 (NameIs) 15040**] [**Last Name (NamePattern4) 15041**], MD Phone:[**Telephone/Fax (1) 41**] Date/Time:[**2189-5-28**] 3:30 Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2189-6-3**] 9:00 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 590**] Date/Time:[**2189-8-25**] 8:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**] Completed by:[**2189-5-27**]

[ "E912", "996.59", "530.81", "493.20", "725", "V15.82", "934.0", "729.1", "494.0", "729.89", "438.89", "346.90", "519.19", "289.81", "701.5", "E879.8", "250.00" ]

icd9cm

[ [ [] ] ]

[ "32.01", "31.42", "98.15" ]

icd9pcs

[ [ [] ] ]

11575, 11581

5943, 8067

416, 459

11720, 11720

4569, 5920

12307, 13235

3772, 3822

10389, 11552

11602, 11699

8093, 10366

11871, 12284

3837, 4550

369, 378

515, 3194

11735, 11847

3216, 3528

3560, 3756

51,795

147,916

32768

Discharge summary

report

Admission Date: [**2118-12-4**] Discharge Date: [**2118-12-19**] Date of Birth: [**2085-12-11**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2836**] Chief Complaint: abdominal pain, nausea Major Surgical or Invasive Procedure: [**2118-12-14**] CT guided aspiration of peripancreatic fluid collection History of Present Illness: 32M relatively healthy reports sudden onset diffuse abdominal pain and severe nausea at 11:30 AM one day prior to presentation followed by diarrhea starting in the evening. After several episodes of emesis and diarrhea, reports lightheadedness and near syncopal episode. He called EMS and taken to local hospital where SBP, per report, in the 60s, HR in 130s. Per OSH, CT scan was consistent with pancreatitis and concerning for liver infarction. Denies recent binge alcohol intake, denies trauma or steroid usage. Reports much milder but similar abdominal pain, diffuse, which self-resolved approximately 2 weeks ago and was not limited to right upper quadrant or associated with nausea. Past Medical History: PMH: depression, anxiety, chronic neck pain since MVA in [**1-/2118**] PSH: none Social History: teacher, married, no children, no smoking, approximately 7 drinks per week Family History: no history of pancreatitis, liver disease Physical Exam: Admission Physical Exam: Vitals: 98.9 116 129/91 20 100%2LNC Gen: NAD, AAOx3 CV: tachycardic, regular rythym Pulm: clear to auscultation, slightly decreased at bases Abd: abdomen firm, tender to palpation diffusely but greatest in right upper quadrant, mildly distended, no ecchymosis periumbilical or in flanks DRE: no gross blood, guiaic +ve Ext: no edema Discharge Physical Exam: Vitals: 98.3 87 100/76 18 97%RA Gen: NAD, AAOx3 CV: RRR Pulm: clear to auscultation, easy work of breathing Abd: soft, non-tender to palpation, non-distended, no palpable masses, no ecchymosis Ext: no edema/clubbing/cyanosis Pertinent Results: [**2118-12-4**] CT a/p: The lung bases are clear. There are small bilateral simple pleural effusions. The heart is normal in size, without pericardial effusion. A moderate sliding hiatal hernia is present. ABDOMEN: The pancreas is diffusely enlarged and edematous with marked surrounding fat stranding, compatible with acute inflammation. Fat stranding and free fluid are seen dissecting throughout the peritoneum and retroperitoneum, with preferential involvement of the anterior perirenal and pararenal spaces. Fluid tracks inferiorly through the bilateral paracolic gutters into the pelvis. There are no loculated collections suspicious for pseudocyst formation. There is diffuse hypodensity throughout the entire left and medial right lobes of the liver, with more focal involvement of the medial left lobe. Density is -25 [**Doctor Last Name **], and the morphology is nonencapsulated with multiple internal coursing vessels. The gallbladder is non-distended, without wall edema or calcified stones. Spleen is normal in size. Adrenals are normal. The kidneys are symmetric, without stones or hydronephrosis. The stomach and small bowel are normal. PELVIS: There is mild colonic wall thickening, most significant at the splenic flexure, likely due to third spacing. Bladder and distal ureters are normal. Prostate and seminal vesicles are unremarkable. Small bilateral fat-containing inguinal hernias are present, left greater than right. Retroperitoneal and mesenteric lymph nodes are not pathologically enlarged. No suspicious lytic or sclerotic osseous lesions are present. IMPRESSION: 1. Acute pancreatitis with diffuse abdominal fat stranding, moderate ascites, and small bilateral pleural effusions. 2. Fatty infiltration of the liver, most significant in the medial left lobe. Brief Hospital Course: Mr. [**Known lastname 5239**] was admitted for one day of sudden diffuse abdominal pain and severe nausea, followed by diarrhea, emesis and near syncope. Taken to OSH where SBP, per report, in the 60s, HR in 130s. Per OSH, CT scan was consistent with pancreatitis. He was transferred to [**Hospital1 18**], at which time lipase was 3200 and u/a grossly positive. A RUQ u/s demonstrated no evidence of cholelithiasis or cholecystits, and a CT scan demonstrated acute pancreatitis. He was initially admitted to the ICU for acute care. He was started on zosyn for UTI and fluid resuscitated. He did well and was transferred to the floor on HD1 for further care. He recieved conservative management of his pancreatitis. Neuro: Hospital course was complicated by episode of acute agitation with fever on HD2, at which point he was transferred back to the ICU. He required four-point restraints and haldol. A psychiatry consult was obtained and valium started with concern for DT's. Head CT at this point was negative. He remained combative, not following commands, tachypneic and mildly hypoxic. A precedex drip was started for presumed DT's. He slowly improved and the drip was weaned [**12-13**]. At that point he was transferred to the floor and remained lucid. Psychiatry and SW continued to follow. CV: Originally tachycardic, he responded to fluid resuscitation and remained hemodynamically stable throughout the hospital stay. Pulm: During acute DT's he was tachypneic with ABG demonstrating hypoxia; however this resolved with resolution of acute agitation and he had no further issues. FEN/GI: He was made NPO at admission with IVF. On [**12-7**] a Dobhoff was placed for TF's; he self-dc'd this the same day. It was replaced [**12-9**] however he again self d/c'd. The following day a PICC was placed and TPN started. He was started on clears on [**12-15**], diet was slowly advanced and TPN d/c'd once tolerating regular diet. ID: Pt was persistently febrile during the first week of his hospital stay; he was cultured and started empirically on vanc/[**Last Name (un) 2830**] as well as the zosyn that had been started at admission. No cultures showed any growth, and he defervesced on [**12-12**]. After that point he remained afebrile throughout the hospital course. It was thought that the UTI was sufficiently treated, and as he had no other infectious source antibiotics were discontinued. He also had CT-guided aspiration of his pancreatic pseudocyst which also had no growth. Prophylaxis/Health Maintenance: He was maintained on subcutaneous heparin with venodynes in place for prevention of DVT. While inpatient, he was seen by psychiatry, nutrition, social work, and case management. Mr. [**Known lastname 5239**] is discharged to home on [**2118-12-19**], he is tolerating a regular diet, he has no pain currently, he is alert and oriented, ambulating without assistance. He will follow up with his regular primary care physician and outpatient psychiatrist. He will also follow up with Dr. [**First Name (STitle) **] in 3 weeks. Medications on Admission: celexa 10'', ativan 1', tylenol with codeine PRN for neck pain Discharge Medications: 1. Celexa 10 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Ativan 1 mg Tablet Sig: One (1) Tablet PO once a day. 3. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain. 4. Aspirin Low Dose 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Discharge Instructions: Please begin to take a baby aspirin daily. 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 driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2119-1-4**] 11:30 Completed by:[**2118-12-19**]

[ "291.81", "300.4", "303.90", "276.0", "577.0", "348.30" ]

icd9cm

[ [ [] ] ]

[ "99.15", "38.93", "54.91" ]

icd9pcs

[ [ [] ] ]

7385, 7391

3857, 6913

328, 403

7448, 7448

2033, 3834

8126, 8310

1341, 1385

7027, 7362

7412, 7427

6939, 7004

7599, 7599

1425, 1763

7631, 8103

266, 290

431, 1126

7463, 7575

1148, 1232

1248, 1325

1788, 2014

15,674

126,152

3633

Discharge summary

report

Admission Date: [**2186-8-19**] Discharge Date: [**2186-9-17**] Date of Birth: [**2136-4-8**] Sex: F Service: O-MED HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old female with recurrent ovarian cancer (end-stage) presenting with increasing temperature, diarrhea and rectal vaginal bleeding. The patient was initially transferred to the Medical Intensive Care Unit because of hypotension. Patient felt right-sided weakness. CT scan and MRI showed either diffuse brain metastases versus septic emboli. Patient was eventually made comfort care only and placed on a morphine drip. SUMMARY OF HOSPITAL COURSE: The patient was comfort measures only, "Do Not Resuscitate," "Do Not Intubate." Patient was made comfortable on morphine drip. Morphine, dexamethasone and atropine nebulizers were given to decrease oral secretions and make breathing much more comfortable. Patient was maintained on 100% nonrebreather. Eventually the morphine drip was changed to Dilaudid. Patient was started on Haldol, Ativan, was given around-the-clock. On the night of [**2186-9-17**], M.D. was called for patient being unresponsive. M.D. evaluated patient and time of death was called at 7:10 p.m. [**2186-9-17**] Sunday. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 16520**] Dictated By:[**Last Name (NamePattern1) 1183**] MEDQUIST36 D: [**2186-9-22**] 16:36 T: [**2186-9-22**] 16:36 JOB#: [**Job Number 16521**]

[ "038.19", "197.5", "578.1", "V10.43", "619.1", "198.3", "518.82", "038.3", "V44.3" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

638, 1484

162, 609

23,483

158,887

50017

Discharge summary

report

Admission Date: [**2166-9-5**] Discharge Date: [**2166-9-18**] Date of Birth: [**2106-9-14**] Sex: F Service: MEDICINE Allergies: Biaxin / Erythromycin Base Attending:[**First Name3 (LF) 2074**] Chief Complaint: mechanical fall v-fib arrest Major Surgical or Invasive Procedure: Pacemaker generator change [**2166-9-8**] History of Present Illness: 59 yo F with h/o severe NICM EF 15-20%, severe MR, c CAD s/p iatrogenic MI '[**39**] from LAD dissection, CABG '[**41**] SVG to LAD, mild 2v-d in '[**63**], biV/ICD in [**6-/2162**], paroxysmal A-fib. Multiple previous admissions for CHF. Recently, admitted for SOB [**Date range (1) 14629**], for heart failure, recieved lasix, dobutamine, dig, once more stable with improved volume status and hemodynamics, the pt was transferred to [**Hospital **] rehab still on dobutamine. She was able to return home 10 days ago. At home, the pt requires a lot of help with adls. She has significant lower extremitity deconditioning. On [**9-4**], the pt presented to OSH after mechanical fall at home. The pt describes that shw was walking with her walker and tried to walk backwards, which led her to lose her balance and trip and fall and hit her head. No LOC. The pt notes some increased LE weakness over the past 2 days. The pt was taken to OSH and Dig level was found to be 6. She got 4 vials of digibind at OSH. CPR was required. In the ED at [**Hospital1 18**], the pt noted ICD firing. The cardiology note [**2166-8-7**] mentions episodes of firing. The pt denies that she has felt any shocks at home over the past 10 days since she left the rehab facility. Past Medical History: 1. Advanced CHF with a LVEF of 15 to 20% secondary to ischemic cardiomyopathy, on home dobutamine. Uncertain if she wants cardiac transplantation. 2. Severe 4+ MR [**First Name (Titles) **] [**Last Name (Titles) 113**] on [**2166-2-17**] 3. Mild to moderate [**12-29**]+ TR by [**Month/Day (2) 113**] on [**2166-2-17**] 4. [**Hospital1 **]-V/ICD in [**6-/2164**], generator change [**2166-9-8**], [**Company 1543**] [**First Name9 (NamePattern2) 104431**] [**Last Name (un) 24119**] 5. CAD s/p MI in [**2139**] and CABG in [**2141**] 6. PFTs from [**2166-4-15**] with a mild restrictive ventilatory defect 7. Hypothyroidism secondary to amiodarone toxicity 8. History of paroxysmal atrial fibrillation- Pt is anticoagulated on coumadin and her INR from [**4-28**] was 3.8. 9. S/P cholecystectomy [**70**]. S/P TIA x3 with slurred speech- This was transient and is currently resolved. . Social History: 18 pack year history but quit in [**2139**], currently, not smoking. No alcohol use. The patient lives alone and has VNA. She is retired dental assistant,is divorced and has one son. She is the youngest of 3 childern. Family History: Mother - non-alcoholic liver cirrhosis, CAD, lung CA, alzheimer's disease Father - DM. deceased MI at age 50. Sister with SLE. Physical Exam: Physical exam: T afeb HR 80 BP 110/70 R 18 sat 98% gen: NAD, slightly drowsy CV: RRR, loud holosystolic murmur apex. +heave. Lungs: clear abd: s/nt/nd +BS ext: no edema Neuro: MAEW Pertinent Results: CT pelvis [**2166-9-6**] IMPRESSION: No fracture or dislocation. . CT T-spine [**2166-9-6**] IMPRESSION: 1. Compression fracture T5. See above. 2. Prominent supraclavicular lymph nodes. 3. Moderate-sized right-sided pleural effusion. 4. Patchy lung opacities in the visualized lung fields. . CT L-spine [**2166-9-6**] IMPRESSION: No evidence of fracture. Deganerative disease with disc abnormalities at L3-S1 as described. Brief Hospital Course: 59 yo F with h/o severe NICM EF 15-20%, severe MR, CAD s/p MI, mild 2v-d in '[**63**], biV/ICD in 7/[**2161**]. Pt now presents with dig toxicity and ICD shocks. . 1. rhythym: The pt was admitted to the Cardiac Intensive care unit, given the history of v-fib arrest with loss of pulse and unresponsiveness in the ambulance to the hospital. The electrophysiology team was called to evaluate the pacemaker/ICD and found that the device was functioning according to its programmed parameters, sensing fast Vfib/Vtach. However, the ICD was unable to detect slow VT, which the pt was experiencing in the setting of digoxin toxicity. The device was reprogrammed to sense lower rates of VT. On [**9-8**], the pt was taken to the EP lab for generator change since the battery was low. This operation proceeded without complications. The unstable rhythm occured in the setting of digoxin toxicity in acute renal failure. Digoxin was stopped, with the plan to not restart given the history of prior episodes of dig toxicity. The pt was noted to have a hematoma around the device, on the day prior to discharge. This was evaluated by the EP team, found to be stable. Should be followed up at rehab. . 2. CHF: Primarily secondary to valvular dz with 4+ MR, CAD s/p MI and CABG (SVG--> LAD), Pt was euvolemic most of the hospital stay. After the EP lab operation, the pt was found to be volume overloaded and diuresed with lasix over the following several days, returned to [**Location 52753**]. Pt did not appear to tolerate ACE or [**Last Name (un) **] well with creatinine [**Last Name (LF) 34001**], [**First Name3 (LF) **] plan is to continue Imdur/hydral. Pt will be continued on aldactone, Imdur/Hydral, lasix 120 PO Bid. . 3. CAD: No active ischemia during the hospitalization. Pt has chronic CP symtoms, likely not anginal. Pt had LAD dissection 20 y ago, CABG SVG to LAD, last cath [**2163**] shows occ SVG, but otherwise mild 2V disease. Pt will be continued on ASA, statin . 3. Chronic back pain: The pt's PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 2031**] recommended high doses of pain medicines, given the patient's poor overal prognosis with severe CHF. The plan was to help provide as much comfort for the patient as possible. The patient agreed with this plan. Pt was started on a regimen of fentanyl patch, morphine IR, and valium. . 4. Weakness/deconditioning: Pt will get further conditioning at rehab. . 5. ARF: Resolved. cr bumped to 1.6 from baseline cr. 0.7 secondary to pre-renal state. . 5. Paroxysm a-fib: Pt was in paced rhythm during hospitalization. The a-fib was not an acute issue. Continue amio, was loaded with 200 [**Hospital1 **] for 2 weeks, then started 200 daily. Continue coumadin 3 mg HS, being discharged on lovenox bridge. . 6. hypothyroid: on levoxyl . 7. diarrhea: resolved Medications on Admission: Amio 200 mg [**Hospital1 **] ASPIRIN E.C. 81 MG--One tablet by mouth every day ALDACTONE 25mg po qd DIGOXIN 125 mcg po qod LASIX 100 mg [**Hospital1 **] NITROGLYCERIN 0.4MG/dose spray PRN WARFARIN 2 MG--Take 2 mg every day except sunday tues and thurs 3 mg LEVOTHYROXINE SODIUM 137MCG--Take one tablet by mouth every day ATIVAN 1MG--Take one tablet by mouth three times a day PEPCID 40MG--Take one tablet by mouth every day PERCOCET 5-325MG--Take 1-2 tabs by mouth every 4-6 hours as needed Zoloft 100 mg Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine Sodium 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 8. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 12. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 13. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 14. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for back pain. 15. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 16. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 17. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 18. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 19. Enoxaparin 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 20. Lasix 80 mg Tablet Sig: 1.5 Tablets PO twice a day. Discharge Disposition: Extended Care Facility: Bear [**Doctor Last Name **] Nursing Center - [**Location (un) 2199**] Discharge Diagnosis: CHF V-fib arrest Digoxin toxicity 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: Followup Instructions: Please follow up in heart failure clinic. [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 3670**]: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2166-10-1**] 9:00

[ "428.43", "E942.1", "412", "426.6", "V53.32", "724.5", "424.0", "276.1", "244.9", "998.12", "V45.81", "584.9", "427.31", "787.91", "425.4" ]

icd9cm

[ [ [] ] ]

[ "99.04", "37.98" ]

icd9pcs

[ [ [] ] ]

8626, 8723

3608, 6437

315, 358

8801, 8810

3160, 3585

8977, 9224

2812, 2941

6992, 8603

8744, 8780

6463, 6969

8834, 8954

2971, 3141

247, 277

386, 1650

1672, 2560

2576, 2796

7,223

187,070

19799+19800+19801

Discharge summary

report+report+report

Admission Date: [**2152-11-3**] Discharge Date: [**2152-12-30**] Date of Birth: [**2109-7-17**] Sex: F Service: Cardiothoracic Surgery CHIEF COMPLAINT: Searing chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old gentleman with a noncontributory previous medical history who developed severe nonradiating pain in his epigastrium on [**2152-11-3**]. The patient states that he developed leg numbness associated with this pain. The patient was taken to [**Hospital **] Hospital prior to his transfer to the [**Hospital1 69**]. At [**Hospital **] Hospital it was determined had suffered from an emergent type A dissection. The patient was transferred to [**Hospital1 188**] on Nipride and esmolol for a systolic blood pressure of greater than 200. It was presumed that this dissection was due to a positive history of cocaine. The patient underwent an aortic arch repair on [**11-4**] and a femoral-to-femoral bypass by the vascular surgeons at the same time. The aortic arch repair was performed by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**]. The femoral-to-femoral bypass was performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. For full details of this operation please see the dictated Operative Notes for [**2152-11-3**]. During the operation, it was noted that the patient had lower extremity ischemia. The patient underwent an emergent exploratory laparotomy which revealed extensive bowel ischemia. There small bowel was pale in color as was the liver. Further examination demonstrated what appeared to be a hemorrhagic infarction of the entire right colon to the mid transverse colon. The abdominal aorta revealed a hematoma involving the entire left half of the aorta. The hematoma extended down to the entire left side of the aorta and was compromising flow into the left common iliac artery. After the patient's aortic arch was repaired with a graft, the patient's bowel ischemia markedly improved and a strong palpable pulse was located in the superior mesenteric artery. When this had been revascularized, a femoral-to-femoral had been performed to revascularize the lower extremities. Following the procedure, no attempt was made to close either the chest of the abdomen, and the entire wound was closed with a rubber [**Doctor Last Name **] with nylon sutures, and chest tubes were left in place. The patient was transfused with 22 units of packed red blood cells during the entire procedure. The patient was placed on the Cardiothoracic Intensive Care Unit for 48 hours before the patient returned to the operating room for an exploratory laparotomy. During the second look laparotomy it was determined that the patient's remaining small bowel and colon were viable and well perfused. The appearance of the liver was somewhat congested but with normal perfusion. All sponges that had been previously placed in the prior operation were removed at this time. Following a brief stay in the Postanesthesia Care Unit, the patient was transferred to the Cardiothoracic Surgery Recovery Unit for continued postoperative care. PAST MEDICAL HISTORY: None noted. SOCIAL HISTORY: Cocaine abuse. MEDICATIONS ON ADMISSION: 1. Propofol drip. 2. Nitroprusside drip. 3. Neo-Synephrine drip. 4. Vancomycin 1000 mg intravenously twice per day. 5. Flagyl 500 mg intravenously three times per day. 6. Epinephrine drip. 7. Norepinephrine drip. 8. Dopamine drip. 9. Vasopressin drip. 10. Milrinone drip. 11. Sodium bicarbonate 150 mg. 12. Insulin drip. ALLERGIES: PHYSICAL EXAMINATION ON PRESENTATION: Temperature maximum was 99.7, his heart rate was 110 (in sinus tachycardia), pulmonary artery pressure was 95/22, central venous pressure was 22. Cardiac index was 2.67. Arterial blood gas revealed 7.44/31/73 on a PCV of 20 X 600, 100% oxygen. Generally, the patient was intubated and sedated. Cardiovascular examination was tachycardic though a regular rhythm. Lung examination indicated coarse breath sounds throughout. Abdominal examination revealed the patient's abdomen was open. Extremities showed trace edema. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 6, his hematocrit was 32, and his platelets were 135. Sodium was 141, potassium was 5.1, chloride was 104, bicarbonate was 23, blood urea nitrogen was 23, and his creatinine was 2.2. Alanine-aminotransferase was 1109, aspartate aminotransferase was 3807, lactate dehydrogenase was 2550, total bilirubin was 1.1, and his alkaline phosphatase was 46. Partial thromboplastin time was 39. INR was 1.3. PERTINENT RADIOLOGY/IMAGING: A computed tomography angiogram showed a dissection from the aortic valve to the iliac vessels with questionable carotid involvement. There was dissection into the right renal artery. The right kidney was partially perfused, delayed filling with contrast. The left kidney with normal perfusion. A chest x-ray indicated superior mediastinal widening and a right-sided effusion. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was seen and evaluated by a variety of specialty services including Infectious Disease who recommended continuation of vancomycin and Flagyl in addition to ceftazidime for greater gram-negative coverage. Postoperatively, the patient remained in the Cardiothoracic Surgery Recovery Unit on maximum pressor regimen, intubated, and sedated. The patient's was maintained on broad spectrum antibiotics with fungal coverage. Following the femoral-to-femoral bypass, the patient had bilateral lower extremities well perfused. From a cardiovascular standpoint, the patient had difficulty maintaining a stable blood pressure. The patient was extremely labile and unable to tolerate any sort of position changes. On postoperative day two, the patient was attempted to be weaned off the milrinone. The patient went into cardiac arrest at this time. The patient was initially in TEA. The patient was treated with epinephrine. A cardiac massage was performed by Dr. [**Last Name (STitle) 53522**]. The patient went into ventricular fibrillation, and a defibrillation was performed with internal paddles times three at 20 joules each time. The patient continued to be resuscitated by bicarbonate, Valium, packed red blood cells, fresh frozen plasma, and lactated Ringer's. The patient was noted to have generalized oozing from all incision, and it was questionable having disseminated intravascular coagulation. Following the resuscitation, the patient was continued on maximum pressors and placed continuous venovenous hemofiltration at 100 cc per hour. The patient continued to have a difficult postoperative recovery, requiring many units of blood products and developing a respiratory acidosis. The patient received a total of 7 units of fresh frozen plasma and 4 units of packed red blood cells on postoperative day three. Fortunately, the patient's blood pressure became more stable and they were able to wean down to Levophed to 0.4 mcg. On postoperative day three, the patient became hypotensive, and the chest had to be reopened. Massive blood clots were removed. His blood pressure dropped even further, and the patient arrested once again. The patient had an open heart massage. He was resuscitated with epinephrine, calcium, and 1 ampule of sodium bicarbonate. The patient received 3 units of packed red blood cells, 2 units of fresh frozen plasma, and 1.1 liters of lactated Ringer's. Over the next couple of days, the patient continued to be intubated, sedated, and on a variety of pressors. The patient's pupils were equal and round but nonreactive. The patient had his nitroglycerin weaned to off and was able to maintain his systolic blood pressure between 95 and 110. The patient's pressors continued to be weaned down without any adverse effects. On [**2152-11-10**] had his chest and abdomen closed. The patient was able to tolerate this procedure well, and there were no complications during this. The patient was seen by Nutrition in consultation at this time, and it was determined that the patient needed to be started on total parenteral nutrition for nutritional support. A orogastric tube was placed, and the patient was started up on Criticare and total parenteral nutrition. On [**11-10**], the patient underwent a liver needle biopsy. The results of this biopsy indicated a marked hemorrhagic necrosis which extended to periportal region. The results of the pathology were consistent with ischemic disease. The patient remained in the Intensive Care Unit. He was continued on ceftazidime, levofloxacin, vancomycin, Flagyl, and fluconazole. The patient also remained on several pressors at this time. From a vascular standpoint, the patient had palpable pulses in the bilateral lower extremities and was doing well. From a renal standpoint, the patient was on continuous venovenous hemofiltration running at 100 cc per hour. The patient continued to be weaned slowly off all his pressors, Fentanyl, and propofol. By [**11-12**], the patient was able to respond to verbal stimuli by opening his eyes. He was not able to follow commands, but his pupils were equal and reactive. The patient continued to do well from a cardiac standpoint, running in the 90s to 100 beats per minute with an occasional run of ventricular tachycardia. The patient was still continued on epinephrine at this time, but he maintained a cardiac index of greater than 2.5. His abdomen was softly distended, and ileostomy was putting out slight amounts of liquid stool at this time. On [**2152-11-13**] the patient's blood pressure was labile and he required intravenous nitroglycerin for better control. The patient underwent a burst of rapid atrial fibrillation converting over to supraventricular tachycardia. The patient had to be electrically cardioverted at 200 joules for rapid atrial fibrillation of 150 to 160 beats per minute. The patient converted after one jolt and was started on an amiodarone bolus and drip. Due to concerns about the patient's mental status following all the procedures, the patient was evaluated by the Neurology staff. The patient underwent a head computed tomography on [**11-15**] which showed multiple infarctions. Following the findings of the infarctions, the patient had an electroencephalogram performed on [**11-16**] which showed minimal brain activity. The patient was not arousable at this time, but his pupils were equal and reactive. The patient continued to be sedated with Versed, Fentanyl, and cisatracurium. The patient continued on his postoperative course, all the while undergoing acute renal failure; for which he was treated with hemodialysis. Additionally, the patient was septic several times and had to be treated with broad-spectrum antibiotics and fungal coverage. On [**11-18**], the patient was transferred out of the Cardiothoracic Surgery Recovery Unit to the Surgical Intensive Care Unit. The patient continued to be weaned off his pressors and taken off sedation to assess whether or not the patient would be able to spontaneously wake up. The patient was able to open his eyes but was unresponsive to verbal stimuli. The patient continued to be followed by Neurology. On [**11-20**], the patient once again had another episode of atrial fibrillation for which he was cardioverted. The patient was placed on continuous positive airway pressure and off the synchronized intermittent mandatory ventilation, and he was able to tolerate this without any difficulty. The patient continued to be weaned off his nitroglycerin. On [**11-25**], after a protracted course on ventilation, it was determined that the patient would be unable to be weaned off the ventilator without great difficulty. At this time, the patient underwent a tracheostomy performed by Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **]. There were no complications during this procedure, and the patient tolerated this procedure without any difficulty. For full details, please see the Operative Report dated [**2152-11-24**]. A #8 cortex tracheostomy tube was inserted. There was minimal blood loss during this procedure. Following the tracheostomy, the patient continued to have a protracted course of recovery in the Intensive Care Unit. The patient remained sedated and on continuous positive airway pressure. The patient continued to be weaned off his pressors and nitroglycerin. The patient remained sedated on propofol, nonresponsive, and with no spontaneous movement of the extremities. The patient's urine output increased from being anuric to having a urine output of 10 cc to 15 cc per hour with [**Year (4 digits) **] hematuria and clots. The patient continued to be dialyzed. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 846**] MEDQUIST36 D: [**2152-12-30**] 12:47 T: [**2152-12-30**] 04:50 JOB#: [**Job Number 53523**] Admission Date: [**2152-11-3**] Discharge Date: [**2152-12-30**] Date of Birth: [**2109-7-17**] Sex: F Service: Cardiothoracic Surgery Service ADDENDUM: This is a continuation of the previous Discharge Summary. BRIEF SUMMARY OF HOSPITAL COURSE (CONTINUED): The patient continued to do well throughout the early part of [**Month (only) 404**] with an increase in the weaning of his ventilator. He was able to get down to a positive end-expiratory pressure of 10 by [**12-9**]. The patient continued to have thick sputum exhibited from his tracheostomy. The patient was stable and able to maintain his oxygen saturations at greater than 97%. From a cardiac standpoint, the patient was weaned off almost all of his intravenous Lopressor and had to be started on a diltiazem drip and titrated up to a maximum dose to decrease his heart rate. The patient responded poorly to these medications and had to be given several units of packed red blood cells at this time. Unfortunately, on [**12-9**], the patient had a systolic blood pressure in the 70s and an increased heart rate. The patient's heart rates ranged in the 120s, and the patient spiked a fever of 101.4 degrees Fahrenheit. The patient had all of his lines changed out, was pan-cultured, as well as sputum and urine being sent. The patient was started on Flagyl, vancomycin, and levofloxacin for a suspected sepsis. Following this episode of sepsis, the patient was once again seen by the Infectious Disease Service who recommended tapping his effusions and ascites to rule out peritonitis. The patient was also changed from vancomycin to linezolid. The only culture that came back positive for the patient at this time was methicillin-resistant Staphylococcus aureus which was growing out of his sputum. The patient continued to present in a septic picture with an increased heart rate, rigors, febrile, and tachycardic. Fortunately, no further cultures were positive at this time, and the patient was maintained on his broad spectrum antibiotics. In addition, on [**12-13**], the patient was seen by the Neurology Service to assess his clinical situation. The patient had been very poorly responsive since the discontinuation of his sedatives and paralytics. After multiple images, it was determined that the patient had bilateral watershed strokes. An electroencephalogram was done at this time which indicated that the patient had a very depressed responsiveness and poor brain activity. Over the next several days the patient continued along his difficult course of recovery. Despite the clinical picture of sepsis, the patient did not grow any further positive blood cultures other than the methicillin-resistant Staphylococcus aureus in his sputum. The patient was continued on his hemodialysis for acute renal failure. The patient was seen and evaluated by the Neurology Stroke Team. The formal read of the electroencephalogram done on [**12-15**] demonstrated diffuse delta slowing; indicative of an encephalopathic appearance. There was no clear cut evidence for seizures at this time. The patient's head computed tomography did reveal bilateral watershed infarctions but did not affect the hypothalamus. It was determined that an acute stroke was not the cause of the patient's poor responsiveness at this time. On [**12-18**], by this time the patient had been on tracheostomy mask trials; although had been placed back on the ventilator overnight to rest him. The patient did very well on tracheostomy mask and was able to maintain his oxygen saturations at greater than 97%. With a positive trial, the patient was able to remain off the ventilator for the remainder of his course in the Intensive Care Unit. Also, the patient did remain on continuous positive airway pressure during the evening for rest. On [**12-20**], the patient was evaluated for a Passy-Muir valve. The patient was able to tolerate his cuff deflation and placement of the Passy-Muir valve without difficulty, but he was unable to produce any comprehensible language at this time. By [**2152-12-20**] the patient was slowly down to his tracheostomy mask and off of ventilator support completely. The patient was able to maintain stable oxygen saturations with 35% oxygen. From a cardiovascular standpoint, the patient continued to be tachycardic in the range of 100 to 100s and slightly hypertensive with a systolic blood pressure of up to 190 mmHg. The patient was maintained on Lopressor to help control his blood pressure. On [**12-21**], the patient was seen and evaluated for a bedside swallow. The patient did not have any overt aspiration, but it was determined that the patient had presented at significantly high risk to advance him to oral intake without a video swallow first. The patient underwent the video swallow on the subsequent day, which indicated that the patient had moderate pharyngeal dysphagia. This unfortunately allowed aspiration of all consistencies that were assessed by the Speech and Swallow Team. The recommendations of the team was to have the patient undergo a percutaneous endoscopic gastrostomy tube or gastrojejunostomy tube with follow up at a rehabilitation facility. By [**12-25**], the patient was off all pressors but remained on broad-spectrum antibiotics. The patient was alert and oriented to himself and to place. He was able to follow commands, and mouth words, and answer "yes" or "no" appropriately to questions. The patient had a normal affect, good gag, and good reflexes. From a respiratory standpoint, the patient had coarse breath sounds in his upper lobes and diminished at the bases. The patient was maintained on 40% oxygen on a tracheostomy mask. The patient still had a significant amount of heavy secretions coming from his tracheostomy, requiring constant suctioning. The patient's ileostomy produced red/golden drainage and positive flatus. The patient's systolic blood pressures were maintained in the 140 to 180 range; depending on his level of activity. He remained in a normal sinus rhythm and without any ectopy. In light of the continuation of the recovery, the patient was screened for continued care in a rehabilitation facility. DISCHARGE DISPOSITION: On [**12-30**], the patient was discharged to the [**Hospital3 **] facility. The patient was instructed to follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] when he left the rehabilitation facility or earlier if any surgical questions arose. DISCHARGE SERVICES: (The patient was to be discharged with the following services) 1. Occupational Therapy. 2. Physical Therapy. 3. Respiratory Therapy. 4. Speech Therapy. MAJOR SURGICAL/INVASIVE PROCEDURES PERFORMED: 1. Aortic grafting. 2. Femoral-to-femoral bypass. 3. Right colectomy. 4. Exploratory laparotomy. 5. Continuous venovenous hemofiltration dialysis with multiple catheter placements. 6. Multiple bronchoscopies. 7. Tracheostomy. 8. Thoracotomy for intrathoracic bleed; left open temporarily. DISCHARGE DIAGNOSES: 1. Type A aortic dissection. 2. Ischemic bowel. 3. Acute renal failure. 4. Sepsis. 5. Respiratory failure. 6. Cardiopulmonary arrest multiple times. 7. Methicillin-resistant Staphylococcus aureus pneumonia. 8. Vancomycin-resistant enterococcus wound infection and bacteremia. 9. Coccyx decubitus ulceration. 10. Occipital decubitus ulceration. 11. Right antecubital phlebitis. 12. Hemoptysis secondary to tracheostomy. 13. Greater than 75% liver necrosis. 14. Multiple cerebral watershed infarctions. 15. Pericardial effusions. 16. Periaortic effusions MEDICATIONS ON DISCHARGE: 1. Artificial Tear ointment. 2. Polyvinyl alcohol 1.4% drops 1 to 2 drops both eyes as needed. 3. Albuterol 90-mcg inhaler 1 to 2 puffs inhaled q.6h. 4. Albuterol sulfate 0.083% solution 1 nebulizer inhaled q.4h. 5. Fluticasone 110-mcg inhaler 2 puffs inhaled twice per day. 6. Ibuprofen 400-mg tablets one tablet by mouth q.8h. as needed. 7. Nystatin 100,000/mL suspension 5 mL by mouth four times per day as needed. 8. Insulin one dose injected as directed. 9. Aspirin 325-mg tablets one tablet by mouth once per day. 10. Zinc sulfate 220-mg tablets one tablet by mouth once per day. 11. Ascorbic acid 500 mg by mouth once per day. 12. Multivitamin one tablet by mouth once per day. 13. Lansoprazole 30 mg by mouth once per day. 14. Heparin 5000 units q.8h. 15. Calcium acetate 667-mg tablets two tablets by mouth three times per day (with meals). 16. Metoclopramide 10-mg tablets one tablet by mouth four times per day (with meals). 17. Metoprolol 150 mg by mouth three times per day. 18. Amlodipine 10 mg by mouth once per day. 19. Dilaudid 0.5 mg to 1 mg q.2-3h. as needed (for pain). 20. Metronidazole 500 mg by mouth q.12h. 21. Zosyn 2.25 mg intravenously q.8h. 22. Diphenhydramine 25 mg by mouth q.6h. as needed (for insomnia). 23. Metoprolol 10 mg intravenously q.4h. as needed for a heart rate greater than 110 or a systolic blood pressure of greater than 160. 23. Hydralazine 20 mg q.6h. 24. Linezolid 600 mg intravenously twice per day. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 846**] MEDQUIST36 D: [**2152-12-30**] 01:14 T: [**2152-12-30**] 05:37 JOB#: [**Job Number 53524**] Admission Date: Discharge Date: [**2153-1-2**] Date of Birth: Sex: Service: ADDENDUM Please see prior discharge summary for full details. The patient is being discharged on [**2153-1-2**], after a planned discharge on [**2152-12-30**]. It was found on [**2152-12-30**], that the patient's white count had elevated up to 21, and there was a concern of whether or not the patient had a recurrence in infection. Therefore, it was decided that the patient would have a full set of cultures sent which was done. A follow-up white count had dropped down to 19 the next day. It was decided that all of his lines would be changed. Therefore, his central line was removed, and a PICC line was placed, and his left IJ central line was removed, and his PICC line was replaced On [**2153-1-2**], the patient was noted to have some mild chills while having dialysis. It was decided that his tunneled catheter would be changed in Interventional Radiology. They changed this tunnel catheter on [**2153-1-2**], and it was planned that the patient would have cultures sent at that time. The patient was discharged on [**2153-1-2**], after getting a new central line, as well as a new dialysis catheter to [**Hospital3 4419**]. The patient was discharged in stable condition. There were no changes to his medications from his prior discharge summary. Of note, it was decided by Renal that a 24-hour urine creatinine clearance would be done. This was planned to be done at the rehabilitation facility to evaluate his creatinine clearance and plan for future dialysis. CONDITION ON DISCHARGE: The patient is discharged in stable condition to a rehabilitation facility. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2153-1-2**] 13:06 T: [**2153-1-2**] 13:19 JOB#: [**Job Number 53525**]

[ "441.03", "557.0", "998.11", "570", "518.5", "584.5", "707.0", "997.02", "427.5" ]

icd9cm

[ [ [] ] ]

[ "39.29", "46.21", "99.15", "31.1", "37.91", "34.03", "38.45", "00.14", "39.95", "50.11", "39.61", "45.73", "99.62", "38.95" ]

icd9pcs

[ [ [] ] ]

19360, 20150

20172, 20750

20777, 24144

3316, 5127

5156, 19336

174, 195

224, 3220

3243, 3256

3273, 3289

24169, 24504

12,222

170,987

27659

Discharge summary

report

Admission Date: [**2134-6-30**] Discharge Date: [**2134-7-3**] Date of Birth: [**2056-2-7**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing / Levofloxacin / Tetracycline / Clindamycin Attending:[**First Name3 (LF) 297**] Chief Complaint: Lower GI bleed Acute blood loss anemia Major Surgical or Invasive Procedure: Tagged RBC scan History of Present Illness: 78 yo man with h/o diverticulosis, ischemic small bowel with associated GI bleed s/p resection, hemmorhagic CVA, distant etoh abuse, who presented to OSH with BRBPR, found to have diverticular GI bleed, and was transferred to [**Hospital1 18**] for further management. The patient states that he awoke on [**2134-6-28**] and passed a large amount of blood in the toilet with his AM bowel movement. He told his RN at the NH, who arranged for transfer to [**Hospital6 19155**]. There, he was noted to have an initial Hct 43, INR 2.9. His Hct dropped from 43->37->34 over his first night in the hospital. He went for a cspy that showed the area of most intense bleeding to be in the sigmoid and descending colon, with only backwash blood in the transverse colon. No polyps or AVMs were noted. He then had a tagged RBC scan which was positive at the splenic flexture. He continued to put out melanotic stool and his Hct dropped from 34->28 over next 24h. He was then transferred to OSH ICU, given Vit K 10mg, 1 unit PRBC, 2 units FFP. . After discussion with Surgery, the ICU team decided to transfer the patient for angiography and embolization of the bleeding artery in his L colon. Past Medical History: PMH: -HTN -CVA, hemorrhagic; [**2132**]; initially had L paresis which resolved, but continues to have residual memory deficit and ataxia -Etoh, in the past -GERD -Psoriasis -BPH, with subsequent urinary retention and prior UTIs -Colonic diverticuli, with several episodes of diverticulitis -Ischemic small bowel assoc with GI bleed, s/p resection in [**2133**] -Rheumatic heart disease, with cardiac murmur -First degree AV block -Vitamin B12 deficiency . PSH: -Partial small bowel resection for ischemia/bleed, done in [**2133**] Social History: Lives at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57850**] House (NH), where he moved in [**2132**] after his stroke left him ataxic. He was married but is now a widower. He has 3 sons and 3 daughters, and his daughter/HCP [**Name (NI) 553**] [**Name (NI) 7931**] is a RN at [**Name (NI) 191**]. Tob: [**2-26**] ppd x 40-50y (~120 pack-years). Etoh: drank "a lot" of whisky when younger, then stopped when he had his stroke in [**2132**]. Denies other drug use. . Comm: primary contact is [**Name (NI) 553**] [**Name (NI) 7931**] (daughter, HCP) [**Telephone/Fax (1) 67552**] (h), [**Telephone/Fax (1) 67553**] (c), [**Telephone/Fax (1) 67554**] (w); secondary contacts are dtr [**Name (NI) **] [**Name (NI) 67555**] [**Telephone/Fax (1) 67556**] (h), [**Telephone/Fax (1) 67557**] (w) or dtr [**Name (NI) **] [**Name (NI) 67558**] [**Telephone/Fax (1) 67559**] (c) . Code: DNR/DNI; confirmed with pt, HCP, [**Name (NI) **] Family History: Noncontributory Physical Exam: Vitals: HR 77, BP 153/71, RR 18, sat 99% on RA Gen: elderly well-nourished appearing man, lying flat in bed in NAD, pleasant and conversant HEENT: EOMI, conjunctivae not pale, OP clear with MMM, no subungal jaundice Neck: JVP 8-9cm, brisk 2+ carotids with no bruits CV: RRR, distant HS, ?s4 Lungs: decreased BS throughout, prolonged expiratory phase, no wheeze, scant rales at L base Abd: old well-healed periumbilical scar with no hernia, increased BS, nontender, nondistended, no HSM, no r/g Ext: 2+ DP bilaterally, no peripheral edema, FROM x 4 Skin: warm and dry Neuro: A+Ox2 ("[**2106**]"), approp affect Pertinent Results: [**2134-6-30**] 07:15PM BLOOD WBC-11.8* RBC-3.64* Hgb-11.1* Hct-32.8* MCV-90 MCH-30.5 MCHC-33.9 RDW-16.3* Plt Ct-157 [**2134-6-30**] 11:25PM BLOOD Hct-25.6* [**2134-7-2**] 03:45AM BLOOD WBC-9.2 RBC-4.65# Hgb-14.1# Hct-40.5 MCV-87 MCH-30.3 MCHC-34.8 RDW-16.4* Plt Ct-158 [**2134-7-3**] 04:54AM BLOOD WBC-10.0 RBC-4.37* Hgb-13.2* Hct-37.8* MCV-87 MCH-30.1 MCHC-34.8 RDW-16.4* Plt Ct-168 [**2134-6-30**] 07:15PM BLOOD Neuts-70.3* Lymphs-22.7 Monos-4.2 Eos-2.5 Baso-0.4 [**2134-6-30**] 07:15PM BLOOD PT-18.2* PTT-33.7 INR(PT)-1.7* [**2134-7-2**] 05:09AM BLOOD PT-12.0 INR(PT)-1.0 [**2134-6-30**] 07:15PM BLOOD Ret Aut-1.5 [**2134-6-30**] 07:15PM BLOOD Glucose-103 UreaN-13 Creat-1.1 Na-143 K-4.1 Cl-108 HCO3-24 AnGap-15 [**2134-7-3**] 04:54AM BLOOD Glucose-108* UreaN-24* Creat-1.2 Na-140 K-4.2 Cl-106 HCO3-25 AnGap-13 [**2134-7-2**] 05:25PM BLOOD CK(CPK)-44 [**2134-7-2**] 05:25PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2134-6-30**] 07:15PM BLOOD Calcium-9.0 Phos-2.0* Mg-1.9 [**2134-7-3**] 04:54AM BLOOD Calcium-8.6 Phos-2.2* Mg-2.1 [**2134-6-30**] 07:15PM BLOOD VitB12-926* [**2134-7-1**] 04:02AM BLOOD freeCa-1.16 [**2134-7-2**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) **],[**First Name3 (LF) **] J. APPROVED UPRIGHT AP VIEW OF THE CHEST: The heart is top normal in size. The mediastinal and hilar contours are normal. The pulmonary vascularity is normal and the lungs are clear. There are no effusions or pneumothorax. Multilevel degenerative changes with osteophyte formation are seen within the thoracic spine. IMPRESSION: No congestive heart failure. [**2134-7-1**] Radiology GI BLEEDING STUDY INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the abdomen for minutes were obtained. A left lateral view of the pelvis was also obtained. Blood flow images are unremarkable. Dynamic blood pool images do not demonstrate definite tracer uptake within bowel, thus not identifying a bleed source. The study was performed for 90 minutes. Static activity within the left abdomen does not demonstrate progression and is non-specific. IMPRESSION: The bleeding source not identified. Brief Hospital Course: 78 yo man with diverticular GI bleed while therapeutic on coumadin, which required multiple transfusions of FFP and PRBCs, now resolved with stable Hct and no further melanotic stools or BRBPR. . Lower GI bleed: Patient had already received 2u FFP and 1u PRBC at OSH, and received 2u more PRBC and 1u more FFP at [**Hospital1 18**]. First, d/w GI service, who recommended transfusing FFP to get INR<1.5, and to touch base with IR and Gen [**Doctor First Name **] given that bleeding source was already localized at OSH. Then, d/w IR service, who said that pt is contraindicated for IR procedure given his anaphylactic reaction to iodine-containing dye previously. This was on later review felt not to be an anaphylactic reaction, though apparently the pt did receive epinephrine so it is unclear how bad it was. Next, d/w Gen [**Doctor First Name **] to make them aware of the patient should he decompensate or open up, which he did not. Maintained two large bore IVs at all times. Initially held BB to allow for compensatory tachycardia if pt opens up, and held ACEI in case his BP dropped. These were both restarted once he was stable. He did not have any further BMs after arrival. . h/o ischemic small bowel: unclear etiology, though was on coumadin for this reason and not because of CVA per daughter who is a RN (she states that the CVA was hemorrhagic not ischemic/embolic). Held anticoagulants including coumadin and heparin, held ASA given acute bleed. Discussed with patient and his daughter about the risks and benefits of coumadin, for now will continue to hold but will need to readdress with PCP after discharge. [**Month (only) 116**] be able to restart ASA soon if bowel movements clear of melanosis. . CV a)CAD: unknown if has CAD, though had mildly positive p-MIBI with reversible defect in [**2133**] and has RFs of tobacco, age, gender, HTN; held ASA and BB initially, restarted BB in house, will defer restarting ASA until outpt and stools are clear. b)Rhythm: NSR c)Pump: no evid of CHF; has h/o rheum heart disease and murmur, though could not appreciate the murmur on our exam; held antihypertensives initially in case he opened up, then restarted once he stabilized. . GERD: cont PPI . BPH: cont Proscar, Flomax . Etoh history: cont thiamine, folate . B12 def: not on B12 currently per med list; checked level, found to be high normal; unclear if he has been getting this as outpt once per month and it was just not listed on his med list. Will need to clarify with PCP and restart if indicated. . Act: bedrest initially, then once he was stable was walked with a walker and remained stable on his feet . FEN: NPO initially, then advanced to regular cardiac diet which he tolerated well . PPx: PPI, pneumoboots, restarted bowel regimen as no BMs x several days, fall precautions given ataxia . Access: two large PIVs . Comm: primary contact is [**Name (NI) 553**] [**Name (NI) 7931**] (daughter, HCP) [**Telephone/Fax (1) 67552**] (h), [**Telephone/Fax (1) 67553**] (c), [**Telephone/Fax (1) 67554**] (w); secondary contacts are dtr [**Name (NI) **] [**Name (NI) 67555**] [**Telephone/Fax (1) 67556**] (h), [**Telephone/Fax (1) 67557**] (w) or dtr [**Name (NI) **] [**Name (NI) 67558**] [**Telephone/Fax (1) 67559**] (c) . Code: DNR/DNI; confirmed with pt, HCP, [**Name (NI) **] Medications on Admission: Meds at home: -ASA 81mg qd -Coumadin 7.5mg qd -Protonix 40mg qd -Flexeril 5mg qhs -Flomax 0.4mg qhs -Proscar 5mg qd -Lisinopril 10mg qd -Folic acid 1mg qd -Thiamine 100mg qd -Metoprolol 25mg [**Hospital1 **] -Tylenol Extra Strength [**Hospital1 **] . Meds on transfer: -Proscar 5mg qd -Lisinopril 10mg qd -Folic acid 1mg qd -Thiamine 100mg qd -Metoprolol 25mg [**Hospital1 **] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57850**] Healthcare Center - [**Location (un) **] Discharge Diagnosis: 1. Lower GI bleed, likely diverticular 2. Acute blood loss anemia, requiring transfusions 3. Coagulopathy, medication (coumadin) related Discharge Condition: Hemodynamically stable, with stable hematocrit for 36 hours and no further evidence of bleeding rectally. No lightheadedness or dizziness, no shortness of breath or chest pain. Standing and able to walk with a walker as per his baseline. Discharge Instructions: Please continue to take all medications as prescribed and to cooperate with your healthcare team. Tell your healthcare provider or unit supervisor if you develop rectal bleeding, shortness of breath, dizziness or lightheadness, abdominal pain or distention, chest pain, palpitations, or any other concerning symptoms. Followup Instructions: Please arrange to have follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19154**] [**Telephone/Fax (1) 67560**], within the next week. You should discuss with her and with your family about the risks and benefits of coumadin given your recent GI bleed. You may not want to restart this medication if you feel that the risk outweighs the benefit, but this is a decision you should make together. You should also discuss the possibility of restarting low dose aspirin, which was held in the setting of your GI bleed but which you may want to restart. Lastly, you have a history of Vitamin B12 deficiency, but are not on B12 replacement and your B12 level is currently high normal. You should discuss with your PCP whether you need monthly injections of this medication.

[ "557.9", "V58.61", "790.92", "530.81", "600.01", "562.12", "285.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.07", "99.04" ]

icd9pcs

[ [ [] ] ]

10427, 10565

6003, 9308

366, 384

10746, 10986

3793, 5980

11352, 12211

3130, 3147

9735, 10404

10586, 10725

9334, 9585

11010, 11329

3162, 3774

288, 328

412, 1594

1616, 2151

2167, 3114

9603, 9712

43,460

104,114

34827

Discharge summary

report

Admission Date: [**2116-12-13**] Discharge Date: [**2116-12-18**] Date of Birth: [**2042-4-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1253**] Chief Complaint: Lower extremity weakness Major Surgical or Invasive Procedure: Dobhoff placement and removal History of Present Illness: Mrs. [**Known lastname **] is a 74 year old woman with history of metastatic pancreatic cancer and distant history of [**First Name9 (NamePattern2) 7816**] [**Location (un) **] Syndrome who is now transferred from an outside hospital with lower extremity weakness. Patient is unable to provide any history at present. Chart review from the OSH and discussion with patient's husband provided history contained here. Per husband, the patient had her last chemotherapy about 10 days ago and was feeling well one day following. Was able to go shopping with a few friends for an hour or two. The following day the patient complained of generalized malaise, fatigue, then rigoring at home. EMS took her to [**Hospital **] Hospital [**2116-12-8**] where she was noted to be febrile and she was treated with Ceftriaxone and Azithromicin for ? RLL pneumonia and UTI. The patient improved the following day and was ambulatory in the hospital, however the following day (Sat. [**12-12**]) the patient was very lethargic and slept most of the day. This continued to Sunday [**12-13**] and pt was noted to be unable to get out of bed on her own. She could sit at the edge of the bed but her "legs were like a rag doll's," and she was unable to stand. Her arms also seemed weak. The patient and her husband had a negative experience with a neurologist at [**Hospital1 **], and they love their GI surgeon here at [**Hospital1 18**] and requested transfer for further evaluation. The patient underwent MRI of her T and L spine without note of cord compression at the OSH prior to transfer. Vitals at OSH T 98--Tm 99, BP 98-120/56-82, she was on 2L NC sat 91-93%, Prior to transfer NIF -30, Vital capacity 1 Liter. MRI T and L spine with no reported compression, ? bone metastsis in T 5, T6, T10. Pt was more drowsy than earlier due to ____ she got (for MRI sedation?). Also given 1g solumedrol earlier in the day. She was treated with ceftriaxone and azithromycine for RLL pneumonia and also treated for E. Coli UTI. In arrival to the Trauma ICU the patient was hypoxic at 89% and started on 40% facemask. Patient is unable to offer a full ROS. She denies any pain or discomfort at present. Past Medical History: 1) Metastatic Pancreatic Cancer- diagnosed with obstructive jaundice d/t pancreatic head mass, mets to liver and ? lung, tumor is inoperable. She is s/p biliary stent placement. Pt was undergoing chemotherapy, last dose ~10 days ago, her oncologist is Dr. [**First Name4 (NamePattern1) 19948**] [**Last Name (NamePattern1) **] in [**Hospital1 **], MA. 2) [**First Name9 (NamePattern2) 79755**] [**Location (un) **] Syndrome- "GBS approximately 5 years ago a few weeks after receiving a flu shot. She describes being at work (at [**Hospital1 3597**] Witchcraft Elementary School) when a young boy asked her to help tie his shoe, when she reached to tie the shoe her hands completely passed their mark and she was concerned. She rapidly worsened with total body weakness prompting hospitalization at [**Hospital **] Hospital where she was plasmapheresed x 5 days. She did have a few days of dyspnea but did not require ventilatory support. Residual pins and needles sensation in the hands and feet and residual BLE weakness. She thought she might have had a recurrence a few years ago (felt weak for 2 days), but these symptoms resolved on their own." 3) Hypertension 4) Hypothyroidism 5) Hyperlipidemia 6) Esopageal spasm 7) S/p CCK. Social History: Married with 2 children. Worked at [**Hospital1 3597**] Elemetary in kitchen; retired after GBS. Quit smoking 5 years ago, no recent ETOH. No illicits. Family History: Father died of MI Mother died of stroke No history of other neurologic disease or malignancy Physical Exam: Vitals: T 96.7, HR 105, BP 106/70, R 24, 94% on 40% FM Gen- ill appearing, drowsy but arouses briefly to voice, appears comfortable. HEENT- NCAT, pale, anicteric sclera, MMM, OP clear Neck- no carotid bruits. CV- tachycardic, no MRG Pulm- scattered crackles throughout. Abd- soft, nt, nd, BS+ Extrem- no CCE. Neurologic Exam: MS- place=[**Hospital **] hospital, month=[**Month (only) **], year=?. She is inattentive. able to name days of week forwards, but when asked to say them backwards she is unable to switch tasks. Her naming of "watch" is intact, but with other objects the patient is too inattentive to comply with further testing. She follows simple commands, but is perseverative "open your eyes" but difficulty with "show me two fingers on your left hand" CN- smell not tested, pupils 4mm-->3mm and sluggish to light bilaterally, EOM's are full, no nystagmus. blinks to threat bilaterally. Funduscopic exam could not be performed due pt uncooperativeness with exam (pulled eyes shut forcibly). face is symmetric with symmetric sensation to LT. no ptosis. hearing intact to FR bilat, unable to view palate with face mask for O2, tongue protrudes at midline. Motor- no adventitious movements, tone appears low throughout. She displays motor impersistence. Holds both arms antigravity for 2-3 seconds and they fall to her chest. She spontaneously holds her legs antigravity briefly. When asked to move her legs to command she is unable to do so. She briskly withdraws her legs to noxious stim. Sensory- intact to light touch in all extrem, intact to noxious in all extrem. unable to perform detailed sensory testing due to mental status. Reflexes: unable to elicit any DTR's in [**Hospital1 **], tri, [**Last Name (un) **], patell, ankles. Plantar response down on right, up on left. Gait- unable to test. Pertinent Results: CHEST RADIOGRAPH AP ([**2116-12-13**]): Mild cardiomegaly. No vascular engorgement. No lung consolidation or mass. No pleural effusion. Metallic stent projects over the right upper quadrant. CT HEAD WITHOUT CONTRAST ([**2116-12-14**]): 1. No evidence of infarction, hemorrhage, of mass effect. 2. MR [**First Name (Titles) 151**] [**Last Name (Titles) **] is most sensitive for evaluation of intracranial metastatic disease. BILATERAL LOWER EXTREMITY DOPPLERS ([**2116-12-15**]): No DVT in the bilateral lower extremities. CHEST PA/LAT ([**2116-12-16**]): In comparison with the study of [**12-14**], the patient has taken a somewhat better inspiration and the atelectatic changes at the bases have decreased. Some costophrenic angle filling posteriorly suggests small pleural effusions. Dobbhoff tube remains in place. Specifically, no evidence of acute pneumonia. [**2116-12-18**] 06:30AM BLOOD WBC-7.9 RBC-2.87* Hgb-9.6* Hct-28.3* MCV-99* MCH-33.4* MCHC-33.9 RDW-17.4* Plt Ct-342 [**2116-12-16**] 07:55AM BLOOD Neuts-71.7* Lymphs-18.2 Monos-6.8 Eos-2.6 Baso-0.7 [**2116-12-16**] 07:55AM BLOOD PT-14.0* PTT-27.2 INR(PT)-1.2* [**2116-12-18**] 06:30AM BLOOD Glucose-108* UreaN-6 Creat-0.6 Na-143 K-4.3 Cl-105 HCO3-33* AnGap-9 [**2116-12-16**] 07:55AM BLOOD ALT-52* AST-88* LD(LDH)-358* AlkPhos-120* TotBili-0.2 [**2116-12-16**] 07:55AM BLOOD calTIBC-157* VitB12-767 Folate-17.4 Ferritn-334* TRF-121* [**2116-12-13**] 10:05PM BLOOD TSH-0.069* [**2116-12-15**] 01:17AM BLOOD Free T4-0.89* [**2116-12-14**] 12:13AM BLOOD Type-ART pO2-84* pCO2-37 pH-7.46* calTCO2-27 [**2116-12-14**] 12:13AM BLOOD Lactate-1.5 Brief Hospital Course: 74 year-old female with pancreatic cancer metastatic to her liver and possibly lung, GBS 5 years ago after a flu shot, hypertension, and hyperlipidemia who intially presented to an OSH with a fever after chemotherapy and was found to have pneumonia and E. coli UTI, and then was transferred to [**Hospital1 18**] for neurological evaluation for lower extremity weakness. Hospital course was as follows. NeuroICU course: Her neurologic examination on admission was notable for marked inattention, which further limited detailed motor and sensory testing; however, she was able to hold her legs antigravity. Neurologic exam the morning after her admission showed [**3-2**] strength in the IPs, [**4-3**] in the deltoids and quads, and 5-/5- in all other muscle groups. She was areflexic, but this was documented in previous neurology notes from [**2116-8-31**]. Her inattention was thought to be due to toxic metabolic encephalopathy, likely due to her underlying pneumonia and UTI. It was determined that GBS was not the cause of her symptoms, and her encephalopathy improved by the second day (oriented to person, place, and date). Head CT showed no evidence of infarction, hemorrhage, of mass effect. Ammonia 10, ALT 13/AST 31, LDH 489, AP 166, T bili 0.3, alb 2.5, INR 1.6, amylase 14/lipase 8, TSH 0.069, T4 6.0; free T4 0.89. She was continued on ASA 325 mg daily, Amlodipine 5 mg daily, and Levothyroxine 75 mcg daily. Her PNA and UTI were treated with CTX and azithromycin. The medicine team was consulted for her PNA and UTI, and the patient was called out to the medicine floor with neurology following. Medicine course: On arrival to medicine floor, patient appeared well. Her breathing felt improved over her baseline and she felt stronger than when she arrived initially. Her active issues included resolving mental status changes, ?RUL PNA (sat's 98% on 60%FM, apparently baseline O2 sat in low 90's), UTI, and climbing WBC (12) on antibiotics. As above, the patient's weakness was thought to be secondary toxic metabolic encephalopathy; she continued to improve on antibiotics for treatment of UTI and community acquired pneumonia. Patient completed a 5 day course of azithromycin and 7 day course of ceftriaxone. Blood cultures remained no growth to date of discharge, and patient was unable to provide sputum specimen. Leukcytosis resolved. Concurrently the patient's hypoxia also improved. Of note, patient has history of COPD with baseline sats in the low 90's. She was initially kept on standing albuterol and ipratropium nebulizer treatments. Patient worked with physical therapy as well. On day of discharge, patient was satting at baseline at rest but requiring oxygen (1 to 2 liters) with ambulation. Remained of care was as follows. - Hypertension: Continued antihypertensives per home regimen. - Hypothyroidism: TSH, FT4 low. Given acute illness, no changes to medication regimen were made. Patient will require recheck of TFTs as outpatient. - Anemia: Hematocrit slightly lower than baseline on admission. B12 and folate normal. Labs consistent with anemia of chronic disease. Continued folate, iron per home regimen. - GERD: Continued omeprazole per home regimen. - Hyperglycemia: Patient was started on metformin for persistently elevated blood glucose. Blood glucose should be checked at rehab facility and hypoglycemics titrated as needed. - Nutrition: Patient required Dobhoff for short duration in neuroICU. On medicine floor, she was evaluated by speech therapy and was found to be able to take regular food and thin liquids without problem. **Code status: DNR/DNI **Communication: [**Name (NI) **] [**Name (NI) **] (husband), ([**Telephone/Fax (1) 79756**] Medications on Admission: Medications on Transfer: Amlodipine 5mg daily ASA 325mg daily Azithromycin 500mg daily (day 1 is ??) Ceftriaxone 1gram IV daily (day 1 is ??) Carbamazepine 200mg [**Hospital1 **] Folate 1mg daily Gabapentin 600mg TID Heparin 5000units SC TID Synthroid 0.075mg daily MVI Nortriptyline 50mg QHS Prilosec 20mg daily Potassium Chloride 20mg PO daily Albuterol 1puff INH Q6h Zofran 4mg IV q6h Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium 500 With D 500 (1,250)-400 mg-unit Tablet Sig: One (1) Tablet PO once a day. 4. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 9. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 month supply* Refills:*2* 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 15. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 16. Home oxygen 1-2L oxygen by nasal cannula, continuous. Goal is to maintain O2 sat greater than 90%. 17. Tegretol 200 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Primary: - Toxic metabolic encephalopathy secondary to urinary tract infection, community acquired pneumonia] - Hyperglycemia Secondary: - History of [**Last Name (un) 4584**] [**Location (un) **] - Pancreatic cancer - Hypothyroidism Discharge Condition: Hemodynamically stable. Ambulatory. Discharge Instructions: You were transferred to [**Hospital1 **] Hospital on [**2116-12-13**] for further care of your weakness. You were initially admitted by the neurology team, who felt that your weakness was due to an infection in your bladder or lungs. You were treated with antibiotics for both of these infections and your weakness improved. You also required a feeding tube placed temporarily. You worked with physical therapy and your strength and coordination improved, and you will be going to a rehabilitation facility for more physical therapy. On discharge, you are eating and drinking well. Your medication regimen has changed. We added a new medication, Metformin, for better control of your blood glucose. Other than this change, you may resume your home medications just as you were doing prior to this hospitalization. Please be sure to follow-up with your appointments as listed below. Please call your physician or return to the emergency department for any worsening weakness, shortness of breath, fevers, or for any other concerns. Followup Instructions: Someone from Dr.[**Name (NI) 60764**] office (neurology) will call you with an appointment time. If you do not hear from them by Monday, please give them a call at ([**Telephone/Fax (1) 79757**] on Tuesday. Someone from your primary care physician's office will call you early next week with an appointment date with Dr. [**First Name (STitle) **]. If you do not hear from them on Monday, please call the office at ([**Telephone/Fax (1) 79758**]. Completed by:[**2116-12-18**]

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icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

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7,884

196,535

12868

Discharge summary

report

Admission Date: [**2160-3-28**] Discharge Date: [**2160-4-4**] Date of Birth: [**2100-10-31**] Sex: M Service: MEDICINE Allergies: Metoprolol / Ibuprofen / Aspirin Attending:[**First Name3 (LF) 477**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: 59 y/o male with Stage IIIA NSCLC on chemo&XRT, CAD s/p CABG [**2150**], COPD, p/w SOB and tachypnea x 1 day. Although reports from the ED describe the pt as receiving XRT today and was noted to have increasing wheezing and dyspnea, he told us that he was in his USOH other than a slight cough productive of brown sputum x 1 week, when he developed sudden onset shortness of breath last night. He denies any CP, N/V, F/C/NS, LH, Palp, DOE, Orthopnea, PND. He notes that he had some LE edema a while ago, but that it resolved with lasix. He is a fairly poor historian, and says that he's too tired to give more history tonight, but that he's feeling better after what he received in the ED. . In the ED on presentation, he was tachycardic to 110, RR 24, with O2 sat 96% (?NRB), BP 105/66. He was given combivent nebs, prednisone 60mg, ceftaz 1g, transfused 1u PRBCs, ativan 2mg. Per report, he felt better afterwards. Onc fellow saw pt in ED, recommend 1 U PRBCs given Hct 25, hold chemo, and given cefepime for neutropenia and ?RML infiltrate. . On transfer to floor, pt is feeling well and states his breathing is comfortable although he is audibly wheezing. Productive cough of yellow-green sputum w/ occasional blood. He reports pain with swallowing, but can take pills. No bm in over 2 days. Radiation burn on back otherwise no rash. Denies cp, palp, sob, abd pain, n/v. Past Medical History: . # Arterial embolic disease status post right SFA stent in [**Month (only) **] [**2159**] # CAD: Silent MI in [**2150**], inferior and posterior walls of LV, s/p 2 vessel CABG at [**Hospital1 112**] in [**Month (only) 205**] 97 (L radial artery, and L [**Female First Name (un) 899**]); no beta blocker due to bronchoconstriction. On statin, ACE. Pt reports allergy to ASA, BB. # HTN: Poorly controlled; difficult to manage due to fixation on side effects of anti-HTN meds. On Mavik. Reports compliance only with Mavik # COPD: On Advair, Albuterol, Atrovent. [**9-30**] PFTs with moderate obstructive ventilatory defect. FEV1 1.68 # CHF: EF 35-40%. Multiple WMA with AK and HK. Likely ischemic cardiomyopathy. RV function depressed on ACE #Hypercholesterolemia # primary polydipsia ([**2157**]) Hyponatremia with low urine osmolarity that improved with reducing water intake on 2 seperate occassions # Tobacco use: [**1-29**] ppd x 30 yrs, has tried gum and patch; did not tolerate wellbutrin either; attempted to quit again using nicotine gum but without much success. # BPH s/p TURP ([**2157-7-15**]) on Flomax # Schizophrenia, Paranoia ([**2113**]) # Nephrotic Syndrome - recently Bx and found to have membranous GN. . Social History: Married, 2 sons; His family owns a real estate company for which he used to work approximately 20 years ago. He smoked one to two packs a day for 30 years but quit about four months ago. He does not drink. No drug abuse. Lives with wife. Family History: Non-contributory Physical Exam: Vitals: T 95.6 BP 114/77 HR 84 R 20 Sat 99% 2 liters * PE: G: Pleasant male, hoarse voice, audible wheeze, appears breathing is comfortable HEENT: Some mucosal inflammation, mild mucositis, dry MM Neck: Supple, No LAD, No JVD Lungs: BS BL, Course rhonchi BL at bases, with end-expiratory wheezes throughout Cardiac: RR, NL rate. Distant S1S2. No murmurs appreciated--limited by wheezing Abd: Soft, NT, softly distended, NL BS. No HSM. Ext: No edema. 2+ DP pulses BL. Neuro: A&Ox3. Appropriate. Grossly normal. skin- xrt burn on back Pertinent Results: Initial labs: [**2160-3-28**] 11:00AM PT-10.8 PTT-21.7* INR(PT)-0.9 [**2160-3-28**] 11:00AM PLT SMR-LOW PLT COUNT-97* [**2160-3-28**] 11:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2160-3-28**] 11:00AM NEUTS-62 BANDS-22* LYMPHS-7* MONOS-5 EOS-1 BASOS-0 ATYPS-3* METAS-0 MYELOS-0 NUC RBCS-1* [**2160-3-28**] 11:00AM WBC-1.0*# RBC-2.97* HGB-8.8* HCT-25.6* MCV-86 MCH-29.7 MCHC-34.3 RDW-19.9* [**2160-3-28**] 11:00AM CALCIUM-8.0* PHOSPHATE-3.4 MAGNESIUM-2.2 [**2160-3-28**] 11:00AM CK-MB-8 cTropnT-0.12* proBNP-3429* [**2160-3-28**] 11:00AM LIPASE-18 [**2160-3-28**] 11:00AM ALT(SGPT)-21 AST(SGOT)-40 CK(CPK)-1203* ALK PHOS-58 AMYLASE-49 TOT BILI-0.6 [**2160-3-28**] 11:00AM GLUCOSE-171* UREA N-102* CREAT-2.5* SODIUM-132* POTASSIUM-3.9 CHLORIDE-91* TOTAL CO2-27 ANION GAP-18 [**2160-3-28**] 11:07AM GLUCOSE-166* LACTATE-1.5 K+-3.8 [**2160-3-28**] 05:05PM CK-MB-8 cTropnT-0.07* [**2160-3-28**] 05:05PM CK(CPK)-1289* [**2160-3-28**] 05:35PM LACTATE-1.2 Discharge labs: 1.Dramatic improvement in the size of the right hilar mass, and mediastinal and hilar lymphadenopathy. The right upper lobe bronchus is now patent. 2.Resolved ground-glass opacities and bronchiolar nodules. 3.Severe emphysema. [**2160-4-4**] 12:00AM BLOOD WBC-1.5* RBC-2.99* Hgb-9.0* Hct-26.9* MCV-90 MCH-30.0 MCHC-33.3 RDW-18.5* Plt Ct-98* [**2160-4-4**] 12:00AM BLOOD Plt Ct-98* [**2160-4-4**] 12:00AM BLOOD Glucose-117* UreaN-58* Creat-1.6* Na-133 K-4.4 Cl-100 HCO3-27 AnGap-10 [**2160-4-4**] 12:00AM BLOOD ALT-12 AST-17 LD(LDH)-245 AlkPhos-51 TotBili-0.1 [**2160-4-4**] 12:00AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.4 CXR negative Low prob Lung scan Brief Hospital Course: A/P: 59M PMH NSCLC--Stage IIIA currently undergoing chemo and XRT, COPD, CAD s/p CABG, p/w acute onset SOB. . DYSPNEA: Likely COPD exacerbation as pt has known lung disease. Peak flow is 325 and expected is approx 525. Pt does not have sob and o2 sats are 97% on RA with ambulation. Wheezing is improving and chest CT only showed emphysema and known right hilar mass which is unchanged. ENT did laryngoscopy and did not see upper airway obstruction. Lung scan low prob for PE. Patient was treated with prednisone 60 mg-->40 mg, around the clock atrovent/albuterol nebs, advair and levaquin as this was thought to be a COPD exacerbation. Patient improved on this regimen, normal o2 sats but still very wheezy. * RENAL FAILURE: Baseline ill-defined, but appears to be around 1.5-2.0. Creatinine trended down to baseline. * Schizophrenia- cont fluphenazine, olanzapine and ativan prn . Dysphagia- oral ulcers in posterior oropharynx c/w fungal infection and then patient had tongue ulcers that looked herpetic. Preliminary viral culture of the lesions was negative for herpes. Speech and swallow evaluation was normal and laryngoscopy showed normal vocal cord movement. Patient treated with roxicet for pain control and discharged on oxycodone as his dysphagia improved. He was also treated with fluconazole and acyclovir for two weeks empirically as he was neutropenic. * Hypothyroid- levothyroxine * NEUTROPENIA: Likely [**2-29**] chemotherapy * LUNG CA: As above, defered treatment to primary oncology team. * CAD: Cont Plavix. ASA allergy. On HCTZ and valsartan for HTN control. Medications on Admission: Lisinopril 5 mg qd Fluphenzine 15 mg qAM, 10 mg qhs Olanzapine 30 mg qhs HCTZ 25 mg qd Levothyroxine 25 mch qd Plavix 75 mg qd Lasix 160 mg qAM, 80 mg qhs Ativan 2 mg qAM, 1 mg qnoon, 2 mg qhs Valsartan 240 mg qd Combivent nebs qid Tiotropium qd Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Olanzapine 10 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Disp:*90 Tablet(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Fluphenazine HCl 10 mg Tablet Sig: as directed Tablet PO twice a day: Take one tablet in am and 1.5 tablets at night. Disp:*45 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Valsartan 160 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*2* 9. Ativan 1 mg Tablet Sig: as directed Tablet PO three times a day: take 2 tablets in am and night and 1 tablet at noon. Disp:*60 Tablet(s)* Refills:*2* 10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 12. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) for 2 weeks. Disp:*84 Capsule(s)* Refills:*0* 13. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day) for 2 weeks. Disp:*qs qs* Refills:*0* 14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day): rinse mouth after use. Disp:*1 disk* Refills:*2* 15. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: One (1) neb Inhalation every four (4) hours. Disp:*qs qs* Refills:*2* 16. Levaquin 750 mg Tablet Sig: One (1) Tablet PO every other day for 10 doses. Disp:*10 Tablet(s)* Refills:*0* 17. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 18. Nebulizer Device Sig: One (1) device Miscellaneous every four (4) hours. Disp:*1 device* Refills:*2* 19. Nebulizer Kit Sig: One (1) kit Miscellaneous every four (4) hours. Disp:*1 kit* Refills:*2* 20. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day for 15 days: Take 3 tablets in am x 5days, then take 2 tabs in am x 5 days, then take 1 tab in am x 5 days. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: COPD Flare Lung Cancer Pneumonia Esophagitis Discharge Condition: HD stable and afebrile. O2 sats 98% RA. Discharge Instructions: You were admitted with shortness of breath and were found to have a COPD flare and possible pneumonia. You were treated with nebulizers, inhalers and antibiotics. Please take all medications as directed. Please follow-up with outpatient appointments. Please call your oncologist or return to the ED if you experience any fever > 100.4, shortness of breath, worsening cough, difficulty swallowing, chest pain, vomiting or any other concerning symptoms. Followup Instructions: You have the following appointments: Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2160-4-7**] 11:10 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2160-4-7**] 11:30 Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2160-4-7**] 11:30 Please follow-up with Dr. [**Last Name (STitle) **] on thursday [**4-10**] at 10 am on [**Hospital Ward Name **] 9. [**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]

[ "585.9", "412", "486", "530.19", "E879.2", "285.29", "491.21", "276.1", "414.01", "288.03", "112.0", "581.9", "244.9", "403.90", "E933.1", "112.84", "295.90", "162.9", "440.20", "584.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9847, 9904

5548, 7130

296, 303

9993, 10035

3816, 4854

10538, 11227

3229, 3247

7427, 9824

9925, 9972

7156, 7404

10059, 10515

4870, 5525

3262, 3797

253, 258

331, 1708

1730, 2955

2971, 3213

29,262

121,558

44342

Discharge summary

report

Admission Date: [**2126-10-9**] Discharge Date: [**2126-10-15**] Date of Birth: [**2049-8-19**] Sex: F Service: CARDIOTHORACIC Allergies: Lisinopril Attending:[**First Name3 (LF) 1505**] Chief Complaint: angina/DOE Major Surgical or Invasive Procedure: AVR [**2126-10-9**] (21mm St. [**Male First Name (un) 923**] Epic porcine) History of Present Illness: 77 yo female with known AS/CAD presneted in [**8-13**] with angina and DOE. Cath showed mild CAD with patent CX/RCA stents. Referred for surgery. Past Medical History: AS s/p AVR MR left central retinal occlusion elev. lipids osteoporosis CAD s/p stents CX/RCA [**3-13**] vertigo depression HTN right hand carpal tunnel PSH: appy rem. blood clot left leg [**2109**] Social History: retired economist lives alone quit 17 years ago; 2.5 pack-year hx no ETOH used Family History: NC Physical Exam: Admission 5'0" 150# NAD skin /HEENT unremarkable neck supple, full ROM CTAB RRR brady at 56, 3/6 SEM left SB to apex, and radiates to bil. carotids soft, NT, ND, + BS warm, well-perfused, trace edema, no varicosities noted neuro grossly intact 2+ carotids 2+ fems/radials 1+ bil DP/PTs Discahrge VS 98.6 136/69 81SR 18 O2sat 95%RA Gen NAD Neuro A&O, nonfocal exam CV RRR, sternum stable incision CDI Pulm diminished bases otherwise CTA bilat Abdm soft, NT +BS Ext warm trace edema, palpable pulses Pertinent Results: [**Known lastname **],[**Known firstname 95080**] [**Medical Record Number 95081**] F 77 [**2049-8-19**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2126-10-14**] 8:05 AM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2126-10-14**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 95082**] Reason: f/u atx [**Hospital 93**] MEDICAL CONDITION: 77 year old woman with s/p avr, septal myomectomy REASON FOR THIS EXAMINATION: f/u atx Provisional Findings Impression: IPf MON [**2126-10-14**] 1:29 PM Left lower lobe opacification with blunting of the left costophrenic angle, raising the possibility for a small pleural effusion on the left with associated consolidation in the lower lobe. Please evaluate and correlate clinically. This opacification might be also due to positioning of the patient and attenuation from the soft tissue of the breasts. Final Report HISTORY: 77-year-old woman with status post aortic valve replacement, septal myomectomy. Follow up for pneumothorax. FINDINGS: On the left, there is increased opacification in the lower lobes, which might be related to soft tissue positioning of the breasts, but consolidation cannot be excluded. There is blunting of the left costophrenic angle, which likely represents small pleural effusion. The post-surgical changes are noted again. The right IJ has been removed. The cardiac silhouette is unchanged compared to the previous scan. The visualized osseous and soft tissue markings are unchanged compared to the previous scan. IMPRESSION: Opacification in the left lower lobe, which might represent small pleural effusion with associated consolidation. The opacification might be also due to adjacent soft tissue attenuation from the breast tissue. Clinical correlation is needed. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: TUE [**2126-10-15**] 9:04 AM Echo Prebypass 1.The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. with normal free wall contractility. 4.There are simple atheroma in the descending thoracic aorta. 5.The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. 6.The mitral valve leaflets are moderately thickened. Mild to moderate ([**2-6**]+) mitral regurgitation is seen. 7.There is no pericardial effusion. 8. Septal hypertrophy seen. Very narrow LVOT( 1.1 cm in diamter) 8. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2126-10-9**] at 1030am. Post Bypass 1. Patient is being AV paced and receiving an infusion of phenylephrine. 2. Biventricular systolic function is preserved. 3. Bioprosthetic valve seen in the aortic position. Leaflets move well and the valve apears well seated. Peak gradient is 12 mmHg. 4. Mild moderate mitral regurgitation present. 5. Aorta intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2126-10-9**] 15:25 ?????? [**2121**] CareGroup IS. All rights reserved. [**2126-10-9**] 02:01PM UREA N-10 CREAT-0.5 CHLORIDE-113* TOTAL CO2-23 [**2126-10-9**] 02:01PM WBC-12.2* RBC-2.96*# HGB-9.1*# HCT-26.0*# MCV-88 MCH-30.7 MCHC-34.9 RDW-14.1 [**2126-10-9**] 02:01PM PLT COUNT-151 [**2126-10-9**] 02:01PM PT-16.5* PTT-52.3* INR(PT)-1.5* [**2126-10-15**] 05:30AM BLOOD WBC-11.2* RBC-3.48* Hgb-10.9* Hct-31.5* MCV-91 MCH-31.2 MCHC-34.5 RDW-13.8 Plt Ct-271 [**2126-10-15**] 05:30AM BLOOD Plt Ct-271 [**2126-10-9**] 02:01PM BLOOD PT-16.5* PTT-52.3* INR(PT)-1.5* [**2126-10-15**] 05:30AM BLOOD Glucose-78 UreaN-10 Creat-0.5 Na-141 K-3.7 Cl-101 HCO3-30 AnGap-14 Brief Hospital Course: Admitted [**10-9**] and underwent surgery with Dr. [**Last Name (STitle) **]. Transferred to the CVICU in stable condition on insulin, phenylephrine, and propofol drips. Extubated the morning of POD #1. She remained hemodynamically stable and was transferred to the stepdown floors on POD1. Once on the fllor the patients post-op course was uneventful. Her cardiac medications were tapered to hemodynamics, her activity was advanced with the assistance of physical therapy however her progress was slow and on POD6 it was decided she would require a short stay at rehabilitation. She was transfereed to [**Hospital 100**] Rehab on POD6. Medications on Admission: ASA 325 mg daily atenolol 50 mg/chlorthalidone 12.5 mg daily plavix 75 mg daily denavir 1% cream to lips lexapro 10 mg daily nifedipine ER 90 mg daily SL NTG 0.4 mg prn vytorin 10/80 mg daily ambien 2.5 mg daily MVI daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous once a day. 5. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection QAC&HS. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) cc Inhalation Q6H (every 6 hours) as needed. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO DAILY (Daily). 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: AS s/p AVR MR left central retinal occlusion elev. lipids osteoporosis CAD s/p stents CX/RCA [**3-13**] vertigo depression HTN right hand carpal tunnel PSH: appy rem. blood clot left leg [**2109**] Discharge Condition: good Discharge Instructions: shower daily and pat incisins dry no lotions, creams or powders on any incision no lifting greater than 10 pounds for 10 weeks no driving for one month and untill off all narcotics call for fever greater than 100, redness, or drainage Followup Instructions: see Dr. [**Last Name (STitle) **] in [**2-6**] weeks see Dr. [**Last Name (STitle) **] in [**3-10**] weeks see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Completed by:[**2126-10-15**]

[ "V45.82", "311", "429.3", "V12.51", "272.4", "401.9", "733.00", "424.1" ]

icd9cm

[ [ [] ] ]

[ "35.21", "88.72", "37.33", "39.61" ]

icd9pcs

[ [ [] ] ]

8112, 8197

5912, 6551

289, 367

8441, 8448

1421, 1774

8731, 8945

877, 881

6823, 8089

1814, 1864

8218, 8420

6577, 6800

8472, 8708

896, 1402

239, 251

1896, 5889

395, 542

564, 765

781, 861

83,057

129,799

1456

Discharge summary

report

Admission Date: [**2135-5-17**] Discharge Date: [**2135-5-26**] Date of Birth: [**2072-3-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2279**] Chief Complaint: decreased mobility, falls. Major Surgical or Invasive Procedure: 1. [**2135-5-20**] Anterior Cervical Discectomy and Fusion with Interbody Biomechanical Device C3-C4 White 2. [**2135-5-21**] POSTERIOR C2-C4 DECOMPRESSION, DEEP BIOPSIES, OPEN TREATMENT OF FRACTURE DISLOCATION, INSTRUMENTED FUSION C2-C5 WITH AUTOGRAFT AND ALLOGRAFT History of Present Illness: The patient is a 62-year-old female with Parkinsons and dementia over the past year who for the past 4-5 days has been having worsening gait instability and decreased mobility. She has also had some falls over the past few days which is new for her. Normally the patient is able to complete her ADLS with some assistance (although she does not cook). In retrospect the family noticed some weakness in left arm and left leg. Her movement seems to be worse acutely, although she does have some chronic problems as well. Her movement apparently deteriorated to the point where she could not walk on Monday. On talking to the PCP the family brought the patient to the ED at [**Hospital1 **]-[**Location (un) 620**]. She was initially admitted to the hospital for possible stroke/infection work up. An echo reportedly showed a normal EF and neuro recommended a head and neck CT. The neck CT returned with a left sided C3-C4 subluxation. The patient was unable to go for the MRI at [**Location (un) 620**] given agitation and IV inflitration. When she was evaluated later in the day it was thought that her left sided weakness had progressed and so she was sent transferred to [**Hospital1 **] for further care. Past Medical History: Parkinson's for 15 years. Dementia worse for the last 1 year. Obesity. No history of CVA, cancer, MI or other chronic illnesses. Usually blood pressure is low. She has a history of multiple falls. Social History: Lives at home with husband. Usually walks and plays piano but sometimes dependent on cane also. She is a retired school teacher. No smoking, alcohol or drugs. Family History: Parkinsons - Dad, brother Physical Exam: Admission Physical: VS: Temp: 96.8, BP: 147/61 HR: 71, RR: 18, O2sat: 89%RA/ GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions RESP: CTA b/l ant. CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: Some bruising on LE b/l. NEURO: Alert, answers some questions appropriately at times, speech difficult to understand. Cn III-XII intact. Diffuse weakness, patient follows commands but poor effort on exam. However when agitation was moving LUE less than right UE. Does have movement of all 4 extremities however. Positive Babinski on left, negative on right. No sensory deficits to light touch appreciated. Pertinent Results: I. Labs A. Admission [**2135-5-17**] 11:39PM BLOOD WBC-6.6 RBC-4.35 Hgb-12.0 Hct-36.3 MCV-83 MCH-27.7 MCHC-33.2 RDW-13.9 Plt Ct-261 [**2135-5-17**] 11:39PM BLOOD PT-13.9* PTT-32.8 INR(PT)-1.2* [**2135-5-17**] 11:39PM BLOOD Glucose-93 UreaN-15 Creat-0.7 Na-138 K-4.2 Cl-105 HCO3-24 AnGap-13 [**2135-5-17**] 11:39PM BLOOD ALT-2 AST-10 LD(LDH)-168 AlkPhos-90 TotBili-0.4 [**2135-5-17**] 11:39PM BLOOD Albumin-3.7 Calcium-9.1 Phos-2.6* Mg-1.9 B. Discharge [**2135-5-25**] 06:10AM BLOOD WBC-6.4 RBC-4.28 Hgb-11.4* Hct-35.4* MCV-83 MCH-26.6* MCHC-32.2 RDW-14.1 Plt Ct-290 [**2135-5-25**] 06:10AM BLOOD Plt Ct-290 [**2135-5-25**] 06:10AM BLOOD Glucose-98 UreaN-17 Creat-0.7 Na-142 K-4.0 Cl-104 HCO3-26 AnGap-16 [**2135-5-25**] 06:10AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.1 C. UA [**2135-5-22**] 02:34AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012 [**2135-5-22**] 02:34AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG II. Microbiology A. Pending [**2135-5-25**] Clostridium Difficile toxin A&B test - pending [**2135-5-22**] Blood culture x 3 [**2135-5-21**] Anaerobic culture from Epidural Tissue C-spine - pending B. Final [**2135-5-22**] and [**2135-5-18**] Urine culture - no growth x 2 [**2135-5-21**] TISSUE EPIDURAL TISSUE C-SPINE. GRAM STAIN (Final [**2135-5-21**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2135-5-24**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. C. Radiology [**2135-5-24**]: Unilateral UP EXT Veins US IMPRESSION: Limited ultrasound due to presence of C-spine [**Month/Day/Year 8658**]. Thrombus within the left cephalic vein was identified. Internal jugular veins were not accessible or evaluated. [**2135-5-24**]: C-Spine Non-Trauma [**12-22**] Views IMPRESSION: Status post laminectomy and posterior fusion at C2 through C5. Anterior fusion at C3/4. Minimal anterolisthesis C2/3. [**2135-5-22**]: CXR CHEST (PORTABLE AP) Reason: 63 year old woman POD day # 1 and #2 from spinal operations FINDINGS: No previous images. The heart is normal in size and configuration. There is increased opacification at the left base silhouetting the hemidiaphragm. This is consistent with pleural effusion and compressive atelectasis. However, in view of the clinical history, the possibility of supervening pneumonia can certainly not be excluded. If clinically possible, lateral view would be helpful. No vascular congestion. The remainder of the lungs is clear. [**2135-5-19**]: MRI C/T-Spine IMPRESSION: 1. Multilevel degenerative changes in the cervical spine with severe compression of the cord at C3-C4. 2. Multilevel cervical neural foraminal narrowing. [**2135-5-19**]: MRI Head w/o contrast INDINGS: There is no evidence of hemorrhage, edema, mass, mass effect or infarction. The ventricles and sulci are normal in caliber and configuration. There are no diffusion abnormalities. There is mild T2/FLAIR hyperintensities in the periventricular and subcortical white matter compatible with chronic small vessel ischemic disease. The paranasal sinuses are clear. IMPRESSION: No acute intracranial abnormality. D. Pathology Pending - epidural mass Final - C3-C4 Disc Cartilage and bone fragments with degenerative changes. Brief Hospital Course: # C3-C4 subluxation with spinal cord compression Patient is a 63-year-old female with a history of Parkinson's disease and dementia who had an increasing number of falls recently in the setting of progressively worse gait instability. She was initially seen at the [**Hospital1 **] [**Location (un) 620**] emergency room on [**2135-5-17**] and transferred to [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] spine evaluation in the setting of family noticing left-sided weakness and difficulty standing. A [**Location (un) 2848**] J [**Location (un) 8658**] was placed in the emergency room and was kept on the entire hospitalization. An MRI revealed severe spinal cord compression, confirming that the hyper-reflexia found on her neurological exam was secondary to an upper motor neuron insult. She had uncomplicated operations. On [**5-20**] and [**5-21**], the patient was taken to the OR for Anterior Cervical Discectomy and Fusion with Interbody Biomechanical Device C3-C4 and Posterior C2-C4 Decompression, Deep Biopsies, Open Treatment of Fracture Dislocation, Instrumented Fusion C2-C5 with Autograft and Allograft, respectively. Post-operatively, the patient remained in the PACU with initial difficulty with extubation with subsequent oxygen requirement for day until transitioned to room air with incentive spirometry. She is to wear the [**Location (un) 2848**] J [**Location (un) 8658**] for 6 weeks after her operation. Pathology is pending at time of writing to exclude neoplastic or infectious etiologies of the subluxation. On discharge, her neurological exam is improved with increased strength, notably on her left side. She will benefit from rehab. Advise both rehab and outpatient assessment of fall risk and implementation of fall risk reduction strategy. # Post-operative fever The patient's highest temperature in the post-operative period was 101.3 degrees F. Given that she had been in a hospital environment for near a week, the possibility of a hospital-acquired infection was entertained. A chest x-ray, blood cultures, C. Difficile test and urinalysis given her foley were all unremarkable except the chest x-ray discussed below excluding some tests that are still pending. She had leukocytosis with maximal WBCs at 17.3, which subsequently trended to 6.4 upon discharge likely secondary to adrenergic demargination from the stress of her two operations. She was treated with APAP, and her fevers trended down to normal range. In addition to infection, a rare consideration of her fever may also be the variable intake of her Parkinson's medications, which can cause NMS. Post-operatively, her medications were given on a consistent basis. Overall, this course represents normal post-operative fever. # Abnormal chest x-ray On [**5-22**] during her post-op fever work-up, a chest x-ray revealed increased opacification at the left base silhouetting the hemidiaphragm, which was consistent with a pleural effusion and compressive atelectasis. There was concern by radiology for the possibility of supervening pneumonia. The likely explanation is that she had been placed on an increased amount of IV fluids during the peri-operative period. There were no clinical signs or symptoms of pneumonia. Incentive spirometry was encouraged, and the patient had copious urine output consistent with diuresis of excessive IVF fluid. A repeat chest x-ray on an outpatient basis would be advised to assess resolution. A lateral x-ray could not be performed for further characterization secondary to the patient's immobility and inability to cooperate. # Superficial phlebitis On [**2135-5-24**], nursing staff noticed asymmetry between Mrs. [**Known lastname 8659**] right and left arm with left being greater than right with respect to circumference. An upper extremity US was performed that showed thrombus within the left cephalic vein (superficial vein). The study was limited by the [**Last Name (LF) 8658**], [**First Name3 (LF) **] the internal jugular veins were not evaluated. Her arm circumference has remained constant since evaluation. She is being treated with arm elevation and warm compresses until resolution. If her left arm has additional swelling, another US would be indicated to assess for DVT on an outpatient basis. # Parkinson's Disease: Neurology in addition to her outpatient neurology followed her during her hospital stay. Her home medications were continued but were given inconsistently in the pre- and peri-operative period due to various interventions needed to prepare her for the operations. Lodosyn was not available on the [**Hospital1 18**] formulary, so she allowed to take her home medication of Lodosyn during her stay. Per neurology recommendations, we avoided anti-psychotics such as Haldol and anti-emetics during hospitalization, both of which can aggravate Parkinson's disease. She is to follow-up on an outpatient basis with Dr. [**Last Name (un) 8660**] at [**Hospital1 2177**] # Dysphagia It was suspected that spinal surgery had caused irritation of pharyngeal structures given the proximity to the spine. A speech and swallow evaluation was performed in the setting of difficulty in the post-operative period of eating. The recommendations were continuing her current PO diet of thin liquids and puree with medications crushed with puree. In addition, she is to have 1:1 supervision for all PO to assist with feeding along with q6 hr oral care. Diet can be advanced as tolerated. # Dementia/Delirium: Her baseline mental status is a fluctuating level of consciousness, speech difficulties, and hallucinations. There was a concern for delirium in the pre-operative period with the patient refusing medications and continuously talking overnight on [**5-19**] on transfer. We oriented her to the day-night cycle with a window room and to date, time, and place with a calendar and expo board in addition to utilizing consistent wear of her glasses. Family members visited daily and assisted with orientation. Four bed rail restraints were used in the post-operative period briefly for non-aggressive behavior. She was continued on her home medications of Donepezil and Namenda in addition to Quetiapine presumed for sundowning. # Normocytic, Hyperchromic Anemia During her hospitalization, her highest Hgb was 13.6 and on discharge was 11.4. Her anemia is likely multi-factorial with phlebotomy, surgical blood loss, and possible underlying nutritional deficits. Her anemia should be characterized further on an outpatient basis. # Wound care: The patient has 3 areas of stage 2 pressure ulcers/skin excoriation on buttocks that are being cleansed and covered with mepilex dressings, which are changed every 3 days and as needed. On discharge to rehab, please utilize pressure-reduction strategies to avoid evolution of ulcers. # Pending results: [**2135-5-25**] Clostridium Difficile toxin A&B test - pending [**2135-5-22**] Blood culture x 3 [**2135-5-21**] Anaerobic culture from Epidural Tissue C-spine - pending Pathology: epidural mass tissue analysis Please note that this report summarizes only results from [**Hospital1 1535**] in [**Location (un) 86**], [**State 350**] unless otherwise stated. Please consult any notes from [**Hospital1 **] if needed. Medications on Admission: 1. Colace 100 mg p.o. t.i.d. 2. Sinemet 25/100, 1.5 pills q.2 h while awake. 3. Carbidopa 25 mg 1 dose with each dose of Sinemet. 4. Paxil 40 mg p.o. daily. 5. Seroquel 200 mg p.o. q.h.s. 6. Naproxen 500 mg p.o. q.12 h. 7. Mirapex 0.25 mg [**11-20**] tablet with each dose of Sinemet except for the last dose (8 times a day). This is also while awake. 8. Ativan 2 mg t.i.d. 9. Aricept 10 mg p.o. q.p.m. 10. Vitamin D 50,000 international units 1 capsule weekly for 12 weeks. 11. Zonegran 25 mg p.o. q.h.s. 12. Namenda 5 mg p.o. b.i.d. Discharge Medications: 1. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Zonisamide 25 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). 3. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO eight times daily (): Give with each dose of sinemet except with the last dose while awake. 4. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO EVERY 2 HOURS (): Hold during evening hours while patient sleeping. Resume at 8 AM . 5. Lodosyn 25 mg Tablet Sig: One (1) Tablet PO ASDIR (AS DIRECTED): Take with each dose of sinemet. 6. Paxil 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day: with dinner. 8. Namenda 5 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Naproxen 500 mg Tablet Sig: One (1) Tablet PO twice a day: with food. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a day: Hold for loose stools. 11. Ativan 2 mg Tablet Sig: One (1) Tablet PO three times a day. 12. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week for 12 weeks. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: 1. Spinal cord compression at C3-C4 secondary to subluxation from fall Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: 1. Take all medications as prescribed. 2. Attend all follow-up appointments listed below 3. Call your doctor or return to the hospital if you develop the below danger signs. 4. Do not take off the [**Location (un) 2848**] J [**Location (un) 8658**] under any circumstances. It is important that the [**Location (un) 8658**] stay on for 6 weeks. Followup Instructions: Follow-up with your primary care doctor whenever you get out of rehab. 1. [**Location (un) 1957**] Spine Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] Location: [**Hospital1 69**] [**Location (un) **], [**Location (un) 8661**] Building, [**Location (un) **] Date: [**2135-7-13**] @ 1:30 PM Phone: ([**Telephone/Fax (1) 2007**] 2. Neurology Dr. [**Last Name (un) 8660**] at [**Hospital6 **] Location: [**Hospital6 **], Deparment of Neurology [**Apartment Address(1) 8662**] Date: [**2135-8-12**] @ 1:30 PM Phone: ([**Telephone/Fax (1) 8663**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]

[ "707.05", "806.05", "722.71", "285.9", "E888.9", "780.62", "294.10", "331.82", "344.00", "707.22", "451.82" ]

icd9cm

[ [ [] ] ]

[ "81.02", "81.62", "03.53", "77.49", "84.51", "80.51", "81.03", "81.63" ]

icd9pcs

[ [ [] ] ]

15348, 15438

6399, 12933

342, 612

15553, 15553

3031, 4539

16105, 16802

2269, 2296

14265, 15325

15459, 15532

13694, 14242

15731, 16082

2311, 3012

276, 304

12945, 13668

640, 1856

4575, 6376

15568, 15707

1878, 2077

2093, 2253

51,297

148,544

44975

Discharge summary

report

Admission Date: [**2155-4-7**] Discharge Date: [**2155-4-9**] Date of Birth: [**2070-8-28**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Flank pain Major Surgical or Invasive Procedure: Stenting of left renal artery with covered stent (7 Fr sheath) [**2155-4-7**] Placement of R IJ hemodialysis catheter [**2155-4-8**] History of Present Illness: Mr [**Known lastname **] is a pleasant 84 yo gentleman with history of afib on coumadin, RCC who presented to the ED today with flank pain in the settting of recent renal biopsy. Pt states that he was in his usual state of health when he went for a biopsy of a left peritoneal lymph node last tuesday. He tolerated the procedure well and was feeling well until Sunday when he noted significant L flank pain. Over the course of the day his sxs worsened and pain migrated to his left abdomen as well. At that time he was advised to go to the ED by his daughter, an ICU nurse. In the ED, initial vs were: 97 73 139/100 20 99% sat. Labs were notable for elevated WBC to 18.9 with 92% neutrophils. Crit dropped from 38.1 to 32.6, however this was with 1.5 L fluid. INR was elevated to 1.8. Urine notable for elevated WBC, RBCs and nitrate. Patient was given Morphine, hydromorphone, ondansetron and phytonadione as well as 2 U FFP to reverse INR. CT abd showed retroperitoneal bleed, slightly enlarged from prior. IR was contact[**Name (NI) **] and did not feel that the bleeding was excessive, however was concerned for possible pseudoanuerysm based on CT findings and therefore recommended angiogram in AM for further characterization. Surgery was also consulted and did not recommend surgical intervention at this time. He was admitted to the ICU for monitoring given unstable vitals and crit drop. 20 gauge IV in L and 2 IVs in R. After 2 Ls NS in the ED, vitals were 100/59, HR 66. . On the floor, pt is doing well without new complaints. History is obtained primarily through his daughter at pts request. His pain persists however he states that he had some improvement with the pain meds given in the ED. Past Medical History: CAD s/p MI [**2124**], PTCA LCx [**2136**], RCA occlusion Afib s/p cardioversion x 2 and on amiodarone Aortic stenosis HTN HLD CVA [**2124**] Abdominal aortic aneurysm s/p right carotid endarterectomy COPD Renal cell Ca s/p radioablation [**2152**] with suspected recurrence Laryngeal CA s/p radioablation Hematuria GERD Social History: -Tobacco history: 3ppd x 30 years, quit 23 yrs ago -ETOH: occasional -Illicit drugs: none -Lives with wife -[**Name (NI) **] very supportive daughter who is a SICU nurse here at [**Hospital1 18**] Family History: non-contributory Physical Exam: Admission Physical Exam: Vitals: T:98 BP:126/73 P:86 R:18 O2:98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, R pupil slightly larger than left, both PERRLA Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, faint crackles in bases CV: Regular rate and rhythm, normal S1 + S2, 1/6 systolic murmur loudest at the RUSB Abdomen: soft, exquisitely TTP, most notably on L side extending to L flank, distended, no discoloration, bowel sounds present Neuro: aao x3, CNs [**3-8**] intact, motor function grossly normal Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2155-4-7**] 07:30PM GLUCOSE-201* UREA N-33* CREAT-1.4* SODIUM-135 POTASSIUM-6.7* CHLORIDE-101 TOTAL CO2-26 ANION GAP-15 [**2155-4-7**] 07:30PM CALCIUM-8.1* PHOSPHATE-5.6*# MAGNESIUM-2.0 [**2155-4-7**] 07:30PM WBC-14.5* RBC-3.18* HGB-9.4* HCT-28.4* MCV-89 MCH-29.6 MCHC-33.1 RDW-17.8* [**2155-4-7**] 07:30PM PLT COUNT-167 [**2155-4-7**] 07:30PM PT-19.7* PTT-37.9* INR(PT)-1.8* [**2155-4-7**] 09:15AM URINE COLOR-Red APPEAR-Hazy SP [**Last Name (un) 155**]-1.017 [**2155-4-7**] 09:15AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-SM [**2155-4-7**] 09:15AM URINE RBC-210* WBC-48* BACTERIA-NONE YEAST-NONE EPI-0 [**2155-4-7**] 09:15AM URINE HYALINE-8* [**2155-4-7**] 09:15AM URINE MUCOUS-FEW [**2155-4-7**] 08:30AM PT-19.5* INR(PT)-1.8* ADDITIONAL LABS: [**4-9**] WBC 18.7, Hgb 10.0, Hct 28.6, Plt 104 [**4-9**] Na 141, K 5.8, Cl 101, HCO3 26, BUN 56, Cr 3.2, Glu 86 [**4-9**] Ca 7.0, Mag 2.1, Phos 7.9 [**4-9**] PT 18.6, PT 41.9, INR 1.7 [**4-9**] Fibrinogen 369 [**4-9**] Lactate 6.4, K 5.7 [**4-9**] CK MB 6, 11 [**4-9**] Trop 0.03, 0.05 [**4-9**] free Ca 0.96 MICRO: [**4-7**] Blood cx: pending [**4-7**] Urine cx: negative [**4-8**] Blood cx: pending [**4-8**] Urine cx: negative IMAGING: [**4-7**] CXR: No evidence of pneumothorax or acute cardiopulmonary process. In comparison to [**2155-2-11**] exam, there is marked improvement of the left lower lobe opacity. [**4-7**] CTA AB/PEL: . The known left perirenal left retroperitoneal hemorrhage is slightly larger and has higher attenuation, compared to the prior study done 5 hours earlier. The superior hematoma now measures, 7.5 x 5.5 cm, previously 6.4 x 4.9 cm. The inferiorly seen hematoma now measures 9.7 x 8.0 cm. The findings were discussed with Dr.[**First Name (STitle) **] at 7:20 p.m on [**2155-4-7**]. The hematoma extends into the left inguinal hernia. Dense contrast pooling in the upper pole of the left kidney, likely contained urinoma. 2. S/P RF ablation of a left renal mass. Soft tissue nodule in this RF ablation site, left adrenal lesion, and left para-aortic lymphadenopathy are all unchanged. 3. Infrarenal AAA maximally [**Last Name (un) **] 4.1 cm. 4. Bilateral multiple pulmonary nodules. [**4-8**] CXR: AP single view of the chest has been obtained with patient in sitting semi-upright position. Comparison is made with the next preceding PA and lateral chest examination of [**2155-4-8**]. Heart size unchanged. Densities on the left lung base obliterating partially the diaphragmatic contours remain. Inspirational effort is lower than on the preceding study, which accounts for the more crowded appearance of the pulmonary vasculature which also may represent some increased fluid load. No new pulmonary abnormalities can be identified on this portable chest examination. No pneumothorax has developed. Review is also performed of a torso CT of [**2-12**], [**2155**], which demonstrated among other findings an inflammatory process in the left lower lobe. This finding has decreased, but was not completely eliminated on the next preceding PA and lateral chest examination of [**2155-4-7**]. The remaining left basal densities may well be the cause of the increased white blood count. If diagnostic difficulties persist, consider a PA and lateral chest examination or renewed CT to evaluate in more detail the previously identified pulmonary processes as seen on CT in [**Month (only) 404**]. [**4-8**] Ultrasound: 1. Suboptimal exam. Left retroperitoneal hematoma is poorly visualized and obscures evaluation of the left kidney. 2. Simple right renal cysts. Otherwise, unremarkable ultrasound of the right kidney. [**4-9**] CXR: In comparison with the study of [**4-8**], there has been placement of a right IJ catheter that extends to the mid-to-lower portion of the SVC. The endotracheal tube and nasogastric tube remain in place. Overall appearance of the heart and lungs is essentially unchanged. [**4-9**] CT ABD/PELVIS: 1. Small right effusion and associated bibasilar atelectasis. 2. Increase in size of left-sided retroperitoneal hematoma. 3. Development of anasarca, likely due to resuscitation. 4. Persistent predominantly cortical enhancement involving both kidneys, indicating an element of ATN. Brief Hospital Course: 84yo gentleman with RCC, s/p recent aortic lymph node biopsy who presents with flank pain, dropping HCT and evidence of RP bleed on CT. . # Retroperitoneal bleed with subsequent hemorrhagic shock: Patient admitted with flank pain, 6 point drop in HCT, and intermittently unstable blood pressures, likely due to bleeding s/p recent procedure and elevated INR while on anticoagulation for afib. CT abd/pelvis revealed a left sided retroperitoneal hematoma with saccular hyperenhancing lesion anterior to the left renal artery, likely representing a pseudoaneurysm. General surgery and IR consulted, and initial plan was for close monitoring if patient remained hemodynamically stable with angiogram the following morning to better characterize the pseudoaneurysm. However, HCT further dropped by 10 points, and given concern for ongoing bleed in setting of further decrease in HCT and worsening pain, patient went to angio for immediate procedure early the following morning. Was found to have pseudoaneurysm of left renal artery, which was stented via 7 Fr sheath. Patient received additional 2 units FFP just prior to procedure. Received total of 6 units of pRBCs, both prior to and following the procedure. Following the transfusion and stenting, HCT stabilized. However, the patient developed increasing respiratory distress and hypotension, requiring initiation of pressors and intubation. Was again noted to have falling HCT, and had repeat CT abd/pelvis which revealed increased size of left RP hematoma, indicating ongoing bleeding. Prior to any additional procedures, family meeting held and decision was made to not continue aggressive measures. Pressors stopped, and patient was terminally extubated on afternoon of [**2155-4-9**]. . # [**Last Name (un) **]: Patient's Cr elevated from baseline of 1.2 to 1.4 on presentation, with [**Last Name (un) **] felt to be secondary to volume depletion in setting of bleed. Was also concern for infection given recent intervention and cloudy urine, as well as ATN given recent dye load and possible hypotension. Urine culture obtained, but was negative. Cr continued to rise over hospital course as patient developed hypotension requiring pressors. Cr peaked at 3.2 on morning patient expired. [**Last Name (un) **] was most likely secondary to ATN in setting of hemorrhagic shock. Patient had R IJ HD catheter placed [**4-8**] in anticipation of possible HD, though he was not dialyzed after family meeting held [**4-9**] and decision was to focus on comfort measures only. . # Elevated Potassium: Was likely due in part to worsening renal function. Patient's EKGs monitored for changes, and he received several doses of kayexalate. When EKG demonstrated peaked T waves and K 6.7, he received CaGluc, Insulin+Glucose, and additional kayexalate with subsequent decrease in K. Plan had been for HD, though initiation of HD deferred as above given goals of care to focus on comfort. . #Afib: Patient was rate controlled at time of admission, and per daughter, had been well rate-controlled despite recent discontinuation of amiodarone. His beta blocker and diltiazem were held in setting of hemodynamic instability, and anticoagulation held given bleed. . # Elevated WBC: WBC elevated in setting of recent intitation of steroid therapy. No focal source of infection or fever. Patient had blood and urine cultures sent; urine cultures negative and blood cultures negative to date at time patient expired. CXR did not show any acute cardiopulmonary process, and showed marked improvement of the left lower lobe opacity seen on prior studies. . # COPD: Continued outpatient regimen of advair. . # GERD: Stable. Continued outpatient regimen of Omeprazole 20 daily on admission. . # Elevated glucose: [**Month (only) 116**] have been secondary to prednisone use; no known history of DM. Had QID fingersticks and ISS. Medications on Admission: ATENOLOL - 25 mg Tablet - one half Tablet(s) by mouth b.i.d. DILTIAZEM HCL - 240 mg Capsule, Ext Release 24 hr - one Capsule(s) by mouth once a day (no substitution) FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 puff(s) inhalation by mouth twice a day METHIMAZOLE - 30 mg daily PREDNISONE - 20 mg Tablet - two Tablet(s) by mouth daily in AM ROSUVASTATIN [CRESTOR] - 20 mg Tablet - 1 Tablet(s) by mouth once daily WARFARIN - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]) - 2.5 mg Tablet - 1 or 2 Tablet(s) by mouth daily as directed by Dr. [**Last Name (STitle) **] LOVENOX bridge DIFLUCAN-started last week by ENT OMEPRAZOLE [PRILOSEC] - (OTC) - 20 mg Capsule, Delayed Release(E.C.) - one Capsule(s) by mouth daily Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Hemorrhagic shock, retroperitoneal bleed, acute kidney injury Discharge Condition: Expired Discharge Instructions: No discharge instructions; patient expired. Followup Instructions: No follow-up instructions; ;patient expired. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "242.80", "518.81", "424.1", "276.7", "427.31", "E878.8", "E942.0", "998.0", "189.0", "998.12", "584.5", "401.9", "414.01", "530.81", "V58.61", "V10.21", "442.1", "412", "496" ]

icd9cm

[ [ [] ] ]

[ "39.90", "00.45", "88.45", "39.50", "88.42", "00.40", "96.04", "38.95", "96.71" ]

icd9pcs

[ [ [] ] ]

12590, 12599

7798, 11682

320, 454

12704, 12713

3478, 3478

12805, 12988

2766, 2784

12561, 12567

12620, 12683

11708, 12538

12737, 12782

2824, 3459

270, 282

482, 2191

3494, 7775

2213, 2535

2551, 2750

81,122

148,020

25525

Discharge summary

report

Admission Date: [**2155-10-8**] Discharge Date: [**2155-10-10**] Date of Birth: [**2111-7-13**] Sex: M Service: MEDICINE Allergies: Tegaderm Attending:[**First Name3 (LF) 1943**] Chief Complaint: Hypotension, Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 8952**] is a 44-year-old man with melanoma and known mets to lung, liver, and brain who presented for a scheduled clinic with his oncologist, was found to have left lower quadrant pain and hypotension, referred to the ED for further evaluation, and was admitted to the [**Hospital Unit Name 153**] for ongoing management of hypotension and likely sepsis. He presented to clinic for his last session of whole brain xrt and was seen by his oncologists, Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **]. He was noted to be more lethargic and nauseated by his family members, with poor po intake for a few days, rigors, and his radiation oncologist had recommended increasing dexamethasone from 4mg to 6mg. He was also complaining of lightheadedness and LLQ abdominal pain for three days. His vitals were notable for hypotension to the 70s and tachycardia to 120, and he was referred to the ED for further evaluation. His recent oncologic history is notable for completing a course of IL-2 ([**2155-7-18**]), and his melanoma has been complicated by liver hemorrhage from metastatic nodules requiring embolization, brain mets found on MRI in [**10-10**] in the setting of headaches and gait abnormalities, and numerous liver, lung, mesenteric, and retroperitoneal mets. In the ED, initial VS: 98.0 90 85/63 18 96% on room air. He was given 4L saline with improvement in his SBPs to the 110s, and an abdominal CT was obtained that demonstrated a necrotic LLQ mass. Surgery was consulted for evaluation and felt excision was likely not indicated, and he was started empirically on vanco and zosyn, with the necrotic mass as the presumed source of infection. Decadron 10 mg iv x 1 was also given. On arrival to the [**Hospital Unit Name 153**], he was comfortable and has no complaints. Review of systems: As above. no change in bowel habits with one bowel movement per day. Positive for rigors this morning. no cough or dyspnea. Past Medical History: - Stage IV melanoma with involvement of the lungs and liver - Depression Past Surgical History: - Cervical mediastinoscopy - L VATS LUL wedge resection [**2155-3-13**] - Wide-excision of malignant melanoma left suboccipital scalp with SLN bx left neck/deep jug nodes [**1-8**] - L axillary LND [**2154-1-17**] - Left arm wide local excision & SLN Lt axillary bx [**2153-12-20**] - Wisdom tooth extraction Social History: Originally from [**Location (un) 311**], moved to the US 8 yrs ago. He is married and has an 18 mo old daughter. History of smoking (quit 4 years ago). Has 10 beers a week. He was a purchasing [**Doctor Last Name 360**] for a company in [**Location (un) 86**] but is no longer working. Family History: Mother and father are living. Father has diabetes type 2. Mother is well; pt has two younger brothers Physical Exam: ON ADMISSION Vitals: 99.1 87 108/74 24 96%2L General: Alert, oriented, no acute distress Neck: supple, JVP not elevated, no LAD Lungs: coarse breath sounds at left base, decreased breath sounds on right CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, distended, hypoactive BS, moderately tender in LLQ to palpation, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2155-10-8**] 03:44PM BLOOD WBC-24.5* RBC-4.71 Hgb-12.5* Hct-37.8* MCV-80* MCH-26.4* MCHC-33.0 RDW-17.4* Plt Ct-335 [**2155-10-8**] 03:44PM BLOOD Neuts-86* Bands-7* Lymphs-4* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2155-10-8**] 03:44PM BLOOD UreaN-29* Creat-1.8*# Na-131* K-5.0 Cl-94* HCO3-23 AnGap-19 [**2155-10-8**] 05:42PM BLOOD Lactate-3.2* [**2155-10-8**] 03:44PM BLOOD ALT-493* AST-454* LD(LDH)-6140* AlkPhos-682* TotBili-2.6* BLOOD CULTURE [**2155-10-8**]: NO GROWTH TO DATE URINE CULTURE [**2155-10-9**]: NEGATIVE MRSA SCREEN [**2155-10-9**]: NEGATIVE CATHERTER TIP CULTURE [**2155-10-9**]: NEGATIVE [**10-8**] CT abdomen/pelvis: 1. Marked interval progression of widespread metastatic disease, including pulmonary, hepatic, gallbladder, mesenteric, retroperitoneal, and subcutaneous lesions. 2. Large metastatic mass in the left anterior mid abdomen, with adjacent inflammatory stranding, may reflect infarction possibly related to the rapid growth. Please note, this mass corresponds to site of patient's focal pain as determined by physical exam. [**10-8**] CXR: AP upright portable chest radiograph is obtained. A right IJ central line is seen extending into the expected location of the superior vena cava. There is marked elevation of the right hemidiaphragm. There is consolidation and effusion at the right lung base as seen on CT. Known lung metastasis is poorly assessed. Heart size appears grossly within normal limits. No pneumothorax is seen. DISCHARGE LABS [**2155-10-10**] 07:20AM BLOOD WBC-14.2* RBC-4.03* Hgb-10.1* Hct-32.7* MCV-81* MCH-25.2* MCHC-31.0 RDW-18.1* Plt Ct-275 [**2155-10-10**] 07:20AM BLOOD Neuts-88.8* Lymphs-7.0* Monos-3.8 Eos-0.2 Baso-0.3 [**2155-10-10**] 07:20AM BLOOD Glucose-76 UreaN-17 Creat-0.5 Na-140 K-4.3 Cl-106 HCO3-24 AnGap-14 [**2155-10-10**] 07:20AM BLOOD ALT-346* AST-172* LD(LDH)-8680* AlkPhos-543* TotBili-1.2 Brief Hospital Course: 44 year-old man with melanoma and known mets to lung, liver, and brain who presented for a scheduled clinic with his oncologist, was found to have left lower quadrant pain and hypotension, referred to the ED for further evaluation, an was admitted to the [**Hospital Unit Name 153**] for management of hypotension and likely sepsis. BP was very responsive to IVF resuscitation and was normal after 4 liters. Vanco and Zosyn were started to empirically cover for infection. He was only in the ICU about 8 hrs before being transferred to the medicine floor. Due to his marked improvement and unclear localization of an infection, antibiotics were discontinued an the patient was watched overnight. He remained afebrile overnight and throughout the next day. He was discharged in stable condition late on [**2155-10-10**]. While it may have been prudent to have Mr. [**Known lastname 8952**] observed another night while off of antibiotics, he had his parents visiting from [**Location (un) **] only for about 1.5 more days before returning to [**Location (un) **]. With the patient's poor prognosis from his cancer, he expressed strong wishes to be with his parents at home for one more day in what he stated would be very likely the last time they would be able to see him alive. The patient was given very strict return precautions if he were to develop fever, low blood pressure, or any other sign of worsening condition. PROBLEM LIST: 1. Hypotension/Sepsis: On admission he met the SIRS criteria with tachycardia and tachypnea. Aside from the necrotic mass in his left anterior abdomen, the patient had no other localizing source of infection. Surgery eval stated no urgent surgical interventions were indicated. The patient's hypotension responded very well to IVF which suggests that he may have been severely volume depleted from decreased PO intake and recent very warm weather. Leukocytosis can occur in volume depletion. Bandemia could possibly be [**3-4**] dexamethasone effect. In any case, if fever were to develop or any other signs of infection, the patient was instructed to return immediately to the hospital for reevaluation and likely reinitiation of antibiotics. Reconsideration of tissue biopsy of the necrotic mass could be considered to r/o infection. 2. Metastatic melanoma: Given the numerous metastatic masses previously identified, the newly identified mass likely represents a new metastatic lesion. The patient had recently been made DNR/DNI at a [**2155-10-8**] clinic visit. No actions were taken regarding additional treatment of his cancer although on transfer to the floor it was recommended that there be follow up with the patients oncologist regarding whether he would potentially be a candidate for anti-BRAF agents ([**2155-8-31**] NEJM article). 3. Acute kidney injury: He was admitted with an elevated creatinine to 1.8 from his baseline of 0.6. It was believed this was secondary to hypovolemia, and was treated as described above. His creatinine improved with IVFs to 1.0. 4. Nausea: The patient was admitted with increasing nausea, believed to be secondary to brain mets, liver involvement, and general abdominal involvement of cancer. He was given symptomatic management with anti-emetics. 5. Depression: Citalopram 6. Code status: DNR/DNI Medications on Admission: CITALOPRAM - 40 mg Tablet - one and one half Tablet(s) by mouthonce a day DEXAMETHASONE - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27785**]) - 2 mg Tablet - 1 Tablet(s) by mouth 2 mg three time a day On [**10-11**] take 2mg twice a day. On [**10-14**], take 2 mg in the am. On [**10-18**], no Decadron, [**10-19**] 2mg am, [**10-20**] no Decadron, [**10-21**] 2mg am, [**10-22**] no Decadron, [**10-23**] 2mg am. Stop Decadron on [**10-24**]. FAMOTIDINE [PEPCID] - Dosage uncertain OLANZAPINE [ZYPREXA] - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day as needed for anxiety/agitation ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth every 8 hours as needed for nausea/vomiting OXYCODONE - 5 mg Tablet - [**2-1**] Tablet(s) by mouth every 4-6 hours as needed for prn pain OXYCODONE - 20 mg Tablet Sustained Release 12 hr - 1 Tablet(s) by mouth twice a day POLYETHYLENE GLYCOL 3350 - 17 gram/dose Powder - 1 pkt by mouth daily as needed for constipation PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth every 6 hours as needed for nausea CLOTRIMAZOLE - (Prescribed by Other Provider; OTC) - 1 % Cream -apply to lesions, and one one inch beyond border twice a day DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a day SENNA - 8.6 mg Capsule - 2 (Two) Capsule(s) by mouth twice a day Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 4. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for nausea. 5. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 8. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for n/v. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Capsule Sig: Two (2) Capsule PO twice a day. 11. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO as directed below: 1 Tablet(s) by mouth 2 mg three time a day On [**10-11**] take 2mg twice a day. On [**10-14**], take 2 mg in the am. On [**10-18**], no Decadron, [**10-19**] 2mg am, [**10-20**] no Decadron, [**10-21**] 2mg am, [**10-22**] no Decadron, [**10-23**] 2mg am. Stop Decadron on [**10-24**]. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: - Hypotension from dehydration - Acute kidney injury Secondary Diagnoses: - Metastatic melenoma - Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 69**] ([**Hospital1 18**]) because of pain in your lower abdomen as well as nausea and decreased ability to eat. As a result of this pain, you saw your oncologist who found that you had low blood pressure and fast heart rate and sent you to [**Hospital1 18**]. You had a CT of your abdomen which showed a necrotic mass in the left lower quadrant and you were started on fluids and transferred to the ICU. There was a concern for an infection so you were started on antibiotics. You improved and were transferred to the floor. As there was no clear source of infection, antibiotics were discontinued. This decision was discussed with Dr. [**Last Name (STitle) **] as well as the general surgeons. You continued to do well off antibiotics without evidence of infection. It was thought that your low blood pressure was from dehydration. You were discharged on [**2155-10-10**] in stable condition. NEW MEDICATIONS ON DISCHARGE: None Please be sure to go to all of your follow up appointments. You should also come back to the ED right away if you have any signs of infection. This may be in the form of fever, chills, cough, burning on urination, abdominal pain, nausea, diarrhea, or confusion. Followup Instructions: Please go to the following appointments Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2155-10-15**] at 3:00 PM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6575**] MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) 1413**],[**First Name3 (LF) 1412**] W. Location: [**Hospital1 18**] DIVISION OF INFECTIOUS DISEASE Address: [**Doctor First Name **], STE GB, [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 457**] Appt: The office is working on getting an appt with Dr [**Last Name (STitle) **] for next week. They will call you at home with an appt.

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icd9cm

[ [ [] ] ]

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icd9pcs

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231, 260

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7023, 8889

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165,580

33818

Discharge summary

report

Admission Date: [**2125-4-26**] Discharge Date: [**2125-5-7**] Date of Birth: [**2055-3-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3276**] Chief Complaint: Pneumonia Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 70 yom with lung cancer metastatic to femur, s/p chemotherapy 2 weeks ago (cycle 2 of [**Doctor Last Name **]/Taxol) presented to oncology appt today with cough, fever for one night. + chills. no fever at home. +chronic cough with blood streaks worse after the last round of chemo. . While patient was at his appointment he "Passed out" and son [**Name (NI) 78187**] him. Regained conciousness very quickly. Vitals at the time BP 90/60. O2 sat 96%. He was given IV fluid and Oxygen and sent to the Emergency room. . In the ER, vitals T 102.7 HR 78 BP 90/67 RR 21 O2 95%2L, CXR with Lingular and LLL PNA. given 4 L IVF, Cefepime. His SBP continued to be low SBP 78 so CVL placed and transferred to the ICU. . At time of presentation to the [**Hospital Unit Name **], patient able to give a good detailed history without difficulty. . ROS: Denies any chest pain, shortness of breath, fevers, chills, nausea, vomiting, diarrhea. Denies any urinary frequency or dysuria. . Recently had Lasix increased to 80mg [**Hospital1 **] and 40mg in the evening. SOB with 1 flight of stairs at baseline. Past Medical History: SVT (paroxysmal atrial fibrillation) chronic renal insufficiency COPD CHF/diastolic GERD status post pilonidal cystectomy, status post lipoma removal Social History: 1.5 pack a day for 50 years, discontinued [**1-2**]. He is a retired. denies etoh/illicits Family History: no known cancer history. He has 3 children and 3 grandchildren that are all healthy Physical Exam: Tmax: 36.7 ??????C (98.1 ??????F) Tcurrent: 36.7 ??????C (98.1 ??????F) HR: 72 (60 - 72) bpm BP: 83/44(54) {74/35(45) - 103/59(78)} mmHg RR: 17 (10 - 17) insp/min SpO2: 97% Heart rhythm: SR (Sinus Rhythm) Height: 67 Inch General Appearance: Well nourished, No acute distress, Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : b/l L>R) Abdominal: Soft, Non-tender, Bowel sounds present, Distended Extremities: Right: Absent, Left: Absent Skin: Not assessed, No(t) Rash: Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed, CNII-XII grossly intact Pertinent Results: [**2125-4-26**] 06:47PM WBC-4.8# RBC-3.89* HGB-10.9* HCT-32.0* MCV-82 MCH-28.0 MCHC-34.0 RDW-16.6* [**2125-4-26**] 06:47PM NEUTS-12* BANDS-5 LYMPHS-31 MONOS-47* EOS-2 BASOS-2 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-1* [**2125-4-26**] 06:47PM PLT SMR-NORMAL PLT COUNT-243 [**2125-4-26**] 06:47PM PT-14.4* PTT-26.2 INR(PT)-1.2* [**2125-4-26**] 06:47PM GLUCOSE-149* UREA N-26* CREAT-1.6* SODIUM-134 POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-23 ANION GAP-18 [**2125-4-26**] 06:47PM LACTATE-1.7 . IMAGING: * Chest CT [**2125-4-28**]: A 1.3 x 1.6 cm left upper lobe nodule is re-demonstrated, abutting a left rib without causing cortical breakthrough. Throughout the lungs are multiple cysts, mostly peripherally based in the lateral lobes and apparent honeycombing adjacent pattern although this may also represent pneumonia in emphysematous lung. In the right lower lobe, there is a spiculated focus of increased opacification. There are small bilateral pleural effusions. There are prominent prevascular nodes measuring to 9 mm in short axis dimension. Subcarinal nodes are enlarged at 1.5 cm maximal short axis diameter. A paratracheal node measures to 1.7 cm, and bilateral hilar nodes are also noted, most on the left. Heart and great vessels are essentially unremarkable excepting for vascular calcifications and some atherosclerosis. There is a central line with its tip terminating in the mid-to-lower SVC. The visualized abdomen, the spleen, liver, and adrenals appears are normal. The pancreas is atrophic. There is a 5.2 cm low-attenuation cystic lesion in the right kidney. Again seen is a moderate hiatal hernia. . * CXR: The patient has known emphysema and interstitial lung disease. As best can be determined, without comparison x-ray at this institution, there is a superimposed process. Given the underlying emphysema, edema may assume atypical configuration and the overall appearance may be due to failure. However, the more confluent areas particularly in the lingula in left lower lobe raise the concern for possible pneumonia as well. . * PET scan [**4-24**]: 1. 13 mm nodule in the left upper lobe with SUV of 5.5 representing known lung cancer, with multiple mediastinal nodes with FDG avidity as described above. 2. A focal uptake in the left nasopharynx with SUV of 11.2 of unknown significance, for which clinical correlation and possible direct visualization is recommended. 3. A focal area of FDG uptake with the SUV of 5.4 in the vertebral body of T8 without CT correlate, suspicious for metastasis. 4. Bilateral peripheral parenchymal opacities with cystic changes and bronchiolectasis with the SUV ranging from 3.7-5.5, likely due to interstitial lung disease such as drug related lung disease with inflammatory activity. Superimposed infection cannot be totally excluded and clinical correlation is recommended. 5. Uptake in the left proximal femur is noted with the SUV of 2.8, representing known metastasis, proven on biopsy. . Cytology lefet femur [**2125-3-8**] - POSITIVE FOR MALIGNANT CELLS (consistent with metastatic adenocarcinoma). . Pathology L fever - [**3-8**] - Metastatic, poorly-differentiated carcinoma with focal necrosis (This immunophenotype is compatible with a lung origin and raises the possibility of a poorly differentiated squamous carcinoma or large cell neuroendocrine carcinoma.) . TTE [**2125-4-26**]: The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild biventricular cavity dilation with grossly preserved biventricular systolic function. Moderate pulmonary hypertension. Brief Hospital Course: Mr. [**Known lastname 14887**] was a 70-year-old man with likely non-small-cell lung cancer with metastasis in left femur, status cycle 2 of carboplatin and paclitaxel on [**2125-4-12**], who was admitted after fainting in his oncologist's office with hypotension. . # Pneumonia with septic shock: The patient had SBP in the 70s on admission and was admitted to the ICU. Chest imaging studies revealed bilateral honeycombing pattern, concerning for pneumonia in the setting of emphysematous lungs versus pulmonary fibrosis. His BP quickly stabilized after IVF, initiation of antibiotics, and discontinuation of furosemide. His sputum culture was negative. Urine Legionella antigen was negative. He was started on cefepime and azithromycin but spiked a fever, and vancomycin was added. He quickly defervesced. Pulmonary was consulted and thought that a bronchoscopy was not indicated at this time. There was a concern for a chronic underlying lung disease such as IPF, but the diagnosis would not change management at this point. He was to follow up with Pulmonary in 4 weeks. He was originally on 4L NC but was weaned down to 1L NC without any respiratory difficulty. He was to finish his 10th and last dose of cefepime on [**2125-5-8**] to to finish his 14-day course of vancomycin on [**2125-5-14**]. . # Lung mass: metastatic to femur. Cytology from femur showed adenocarcinoma, but path raised concern for poorly differentiated squamous verus large cell neuroendocrine tumor. He was to follow up with his oncologists, Dr. [**Last Name (STitle) 3274**] and Dr. [**Last Name (STitle) **] on [**2125-5-17**]. He needs to call to make this appointment. . # PAF: well controlled. He was put on sotalol at a lower dose of 40 mg [**Hospital1 **] and was continued on his aspirin 325 mg qday. . # Diastolic heart failure: EF > 55% on echo on [**2125-4-27**]. He displayed no sign of failure and his furosemide was held. . # Syncope at oncologist's office: likely due to hypotension from sepsis. Might also be due to atrial fibrillation with SVT. Sinus rhythm here. . # Anemia and leukopenia: likely from recent chemotherapy. His counts quickly recovered, and his hematocrit was stable at discharge. . # FULL CODE Medications on Admission: Furosemide [Lasix] 80 mg Tablet and 40 mg in the evening. Hydrocodone-Acetaminophen [Vicodin] 5 mg-500 mg Tablet q6 prn Omeprazole [Prilosec] 20 mg Capsule, Delayed Release(E.C.) Sotalol 80 mg Tablet AM and 40 mg PM. Aspirin 325 mg Tablet PO daily Ibuprofen 400 mg q4-6hrs Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). 6. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for SOB. 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 7 days. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57850**] Healthcare Center - [**Location (un) **] Discharge Diagnosis: Pneumonia Lung cancer Atrial Fibrillation Discharge Condition: Stable Discharge Instructions: Please take all your medications and follow up with all your appointments. Please report to your physician if you have any worsening shortness of breath, chest pain or any other concerns. Followup Instructions: * Oncology (cancer): Please call Dr. [**Last Name (STitle) 3274**] and Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 3280**] to make an appointment for [**2125-5-17**]. * Pulmonary (lungs): Please call Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 514**] to make an appointment within 4 weeks. * Primary care: Please call Dr. [**First Name (STitle) 17859**] at [**Telephone/Fax (1) 40171**] to make an appointment within 2-3 weeks. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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242

192,980

12062

Discharge summary

report

Admission Date: [**2122-1-15**] Discharge Date: [**2122-1-20**] Date of Birth: [**2045-1-21**] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old female with a history of chronic obstructive pulmonary disease, peripheral vascular disease, and a history of a left lung nodule admitted from an outside hospital Intensive Care Unit ([**Hospital3 **]) with hypotension, fever, and recurrent pneumonia. In brief, the patient has a long history of recurrent bronchitis and periodic episodes of pneumonia. She was admitted to an outside hospital approximately a few week prior to the current presentation with pneumonia and was treated with an unknown antibiotic. Unfortunately, she returned to the outside hospital's Emergency Department on [**1-13**] with fever, rigors, dizziness, and weakness. When her blood pressure could not be obtained in her upper extremities, she was started on dopamine and transferred to the Intensive Care Unit and underwent a CT of the abdomen to rule out abdominal aortic aneurysm, which was negative. Chest x-ray revealed right lower lobe pneumonia, and the patient was placed on vancomycin, gentamicin, and Zosyn. Additionally, chest x-ray showed left lung nodule (old) and right hilar mass. She was then transferred to the [**Hospital1 1444**] medical intensive care unit on [**1-15**] on dopamine. On arrival to the [**Hospital1 69**] her blood pressure (via the right thigh cuff) was 127/60, whereas arm pressures were considerably lower at 60/20 in right arm and 40/20 in the left arm. Arm pressures were though secondary to subclavian disease, and dopamine was successfully weaned based on thigh blood pressures. Antibiotics were changed from vancomycin, gentamicin, and Zosyn to levofloxacin and Flagyl. The patient has been saturating well on nasal cannula oxygen while in the Medical Intensive Care Unit. Chest CT scheduled to further evaluate left lung nodule and right hilar mass. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease, chronic smoker with recurrent bronchitis and pneumonia times five in the last 10 years. 2. Peripheral vascular disease, bilateral subclavian stenosis, bilateral carotid disease (50% on the right and 80% on the left), arm claudication. Negative cardiac catheterization in [**2118**]. 3. Left lung nodule (about 4 cm). 4. Cluster headaches times 18 years. 5. Hyperlipidemia. 6. Glaucoma. 7. Status post partial hysterectomy. ALLERGIES: IODINE (anaphylaxis). MEDICATIONS ON DISCHARGE: Medications in the [**Hospital Unit Name 153**] included enteric-coated aspirin 325 mg p.o. q.d., prednisone 40 mg p.o. q.d., albuterol meter-dosed inhaler, Atrovent meter-dosed inhaler, selective serotonin reuptake inhibitor, levofloxacin, and Flagyl. SOCIAL HISTORY: Lives with son. Smoking history times 55 years; one and a half to two packs per day, quit in [**2121-12-2**]. PHYSICAL EXAMINATION ON PRESENTATION: On admission vital signs were afebrile, blood pressure 151/83, pulse of 106, respiratory rate of 22, oxygen saturation of 92% to 96% on 3 liters nasal cannula. General appearance revealed alert, in no acute distress. Head, eyes, ears, nose, and throat revealed pupils were equal, round, and reactive to light. Oropharynx was clear. Extraocular movements were intact. Neck was supple, no bruits. Lungs revealed decreased breath sounds at the right base. Heart was mildly tachycardic, a regular rhythm. The abdomen was soft, nontender, and nondistended, normal active bowel sounds. Extremities revealed no edema. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data included white blood cell count of 11.3, hematocrit of 41.2, platelets of 449. Chem-7 was normal. INR of 1. Legionella urine antigen negative. RADIOLOGY/IMAGING: Chest CT revealed two suspicious lung nodules identified in the left lung; one at the left apex measuring 2.7 cm in greatest dimension with features characteristic of adenocarcinoma with bronchoalveolar features. The second lesion is in the left lower lobe measuring about 1 cm in diameter and located at the bifurcation of the posterior and lateral segment bronchi. This could reflect either a second primary lung cancer; or, given its location at the bifurcation of the bronchi, a carcinoid tumor. In addition, the CT revealed ill-defined peribronchial nodules in the right lower lobe with associated small airway disease, likely due to resolving pneumonia. Additionally, there were small nodules in the right upper lobe which could also be an inflammatory/infectious, but tiny fossae of metastatic disease were not excluded. A direct comparison to outside CT will be most helpful. This CT also revealed thickening of the posterior wall of the right upper lobe bronchus, possibly related to reactive lymph nodes given other findings in the right lung but comparison to outside study would be helpful. HOSPITAL COURSE: The patient is a 76-year-old female with a history of chronic obstructive pulmonary disease, peripheral vascular disease, left lung nodule, and a long history of tobacco use presenting with pneumonia and hypotension, likely secondary to subclavian vascular disease and was stable for transfer to the medical floor from the [**Hospital Unit Name 153**]. The patient was treated with levofloxacin and Flagyl for her pneumonia for a total course of 10 days. Her chronic obstructive pulmonary disease was treated with albuterol, and Atrovent, and prednisone taper. Pulmonary was consulted and recommended a CT-guided biopsy of the left lung nodule which was concerning for bronchogenic carcinoma. The patient agreed to CT-guided biopsy but was currently on aspirin. The patient was then scheduled for outpatient biopsy of lung nodule for the following week. The patient was to stay off aspirin until biopsy date and will be n.p.o. after midnight the day prior to biopsy. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: Pneumonia. MEDICATIONS ON DISCHARGE: 1. Prednisone taper. 2. Levofloxacin 500 mg p.o. q.d. (total 10-day course). 3. Flagyl 500 mg p.o. t.i.d. (total 10-day course). [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 34724**] Dictated By:[**Last Name (NamePattern1) 1183**] MEDQUIST36 D: [**2122-1-21**] 16:24 T: [**2122-1-23**] 07:23 JOB#: [**Job Number 37835**]

[ "518.89", "365.9", "458.9", "443.9", "272.4", "V64.1", "486", "496" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6015, 6027

6053, 6427

4929, 5913

5928, 5993

166, 1976

1998, 2507

2805, 4911

20,411

130,603

19650+19651+19652

Discharge summary

report+report+report

Admission Date: [**2126-1-4**] Discharge Date: [**2126-1-6**] Date of Birth: Sex: Service: ADDENDUM COVERING HOSPITAL COUSRE FROM [**2126-1-4**] TO [**2126-1-6**]: 1. Gastrointestinal: The patient was noted to have an increasingly distended abdomen over the period covered through this discharge addendum. On Sunday a KUB and upright film was obtained and demonstrated significant distention of the colon particularly of the transverse colon that measured 16 mm in diameter, but also of the colon generally. There was no significant obstructing mass or fecal material noted on the KUB, and the ileus was felt most likely to be functional, perhaps secondary to his opiate pain regimen. A rectal tube was inserted on [**2126-1-6**] for decompression, with mild relief of his symptoms. After his symptoms did not significantly further improve after an hour the initial rectal tube was removed and a larger 36 French rectal tube was placed. The patient will next undergo a gastrografin enema in the morning of [**2126-1-7**] to rule out colonic obstruction and if negative may require neostigmine for further decompression. The patient's opiate pain medications were discontinued and the patient was begun on Ketoralac with a 30 mg loading dose and then standing 15 mg intravenous q 6 thereafter for up to the next five days. The patient continued to have intermittent loose bowel movements, though two C-diff tox and ASAs are negative thus far. 2. Infectious disease: The patient was continued on a ten day course of Levofloxacin. His white count remained stable at 16.1 on the first of [**Month (only) 956**]. The patient remains afebrile. 3. Staple removal: The patient's eight staples placed on the right side of his scalp were removed on the first of [**Month (only) 956**]. There appears to have been proper skin closure over the ten days the staples were in with nice approximation of the skin around the linear laceration on his forehead. 4. PE: The patient was maintained on intravenous heparin as he continued to be loaded with Coumadin. The patient received 5 mg of Coumadin on the 30th and the [**1-5**] and then an additional 7.5 mg on the first of [**Month (only) 956**]. His INR remains subtherapeutic. 5. Diabetes: The patient was maintained on his NPH 45/20 regimen with Metformin 500 b.i.d. as well as a sliding scale insulin as needed. The patient's sugars remained well controlled on this regimen, though he had one episode of hypoglycemia on the [**1-5**] with a blood sugar of 64. 6. Intravenous access: An attempt was made to place a peripheral IV in the patient. However, it was difficult to find adequate intravenous access and both the floor team as well as the IV nurse attempted without success to place a peripheral IV. Thus the patient was continued on his central IV line through the first of [**Month (only) 956**]. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By:[**Last Name (NamePattern1) 11363**] MEDQUIST36 D: [**2126-1-7**] 12:20 T: [**2126-1-7**] 07:41 JOB#: [**Job Number 53223**] Admission Date: [**2125-12-30**] Discharge Date: Date of Birth: [**2060-10-16**] Sex: M Service: [**Hospital1 139**] HISTORY OF PRESENT ILLNESS: The patient is a 65 year old male with a past medical history of laryngeal carcinoma, hypertension, hypercholesterolemia who presented to [**Hospital6 40383**] on [**2125-12-27**], after falling off of his roof while cleaning his chimney, landing approximately 20 feet below on the ground. It is not known whether the patient's loss of consciousness prior to or after the fall, but the patient was able to get up on his own and walk back into his house, where his wife later found him confused and disoriented, sitting in a chair. He was then brought to the Emergency Department of [**Hospital6 5016**] where he complained of pain his right head, posterior neck, right shoulder, right chest tenderness, right thigh and elbow discomfort. In the Emergency Department at [**Hospital6 10443**], his forehead was noted to have a laceration that was stapled. His admission laboratory data were notable for a white blood cell count of 23. Imaging in the Emergency Department at [**Hospital3 **] was notable for a C2 hangman's type fracture, as well as fracture of his right olecranon and fracture of his right posterior ribs 2 through 7. Computerized tomography scan of his head was negative for acute intracranial hemorrhage or mass effect. The patient was placed in a halo for immobilization of his cervical spine, given his C2 fracture (halo was placed on [**2125-12-29**]), and the patient was found to be neurologically intact. The patient underwent open reduction and internal fixation of his comminuted, right olecranon fracture on [**12-28**]. On [**12-30**], the patient was noted to be agitated, disoriented, tachypneic and was noted to have copious secretions from his endotracheal tube. Otorhinolaryngology was called to perform a tracheotomy for ventilatory support. On fiberoptic endoscopy, the patient was noted to have mucopurulent secretions, largely in the left main stem bronchus. The patient was started on Levofloxacin. The repeat computerized tomography scan of the head did not demonstrate any bleed. However, a computerized tomographic angiogram of the chest was obtained given his shortness of breath that showed atelectasis infiltrate in the right lower lobe as well as right pleural thickening and filling defect in the left pulmonary artery extending to the lower lobe, consistent with pulmonary emboli, as well as filling defects in the right lower lobe pulmonary artery. The patient was begun on intravenous heparin for treatment of his pulmonary emboli. On [**12-30**], the patient was transferred to [**Hospital6 1760**] for further management per the patient's family request. PAST MEDICAL HISTORY: 1. Laryngeal carcinoma 12 years prior to admission. The patient was treated with radiation as well as tracheostomy. 2. Hypertension. 3. Hypercholesterolemia. 4. Hypothyroid. MEDICATIONS ON ADMISSION: Pepcid 20 mg intravenously q. 12; Reglan 10 mg intravenously q. 8; Clindamycin 600 mg intravenously q. 8; Solu-Medrol 60 mg intravenously q.i.d., Lopressor 50 mg b.i.d.; Levaquin 500 mg p.o. q. day; Morphine 4 to 6 mg subcutaneous q. 3 to 4 prn; Zofran 4 mg intravenously q. 8 prn; Ativan 1 to 2 mg q. 4 prn; Haldol 1 to 2 mg q. 4 hours intravenously prn; Heparin drip at 800 units/hour. Medications at home prior to his fall included Lopressor 50 mg b.i.d., Lovastatin 40 q. day and Levothyroxine 200 mcg q. day. ALLERGIES: Penicillin causes hives. Possibly to codeine which reportedly causes hives. SOCIAL HISTORY: The patient is married and lives with wife and several children. Smoked tobacco for 30 years. PHYSICAL EXAMINATION: On admission temperature was 98.8, blood pressure 164/86, heart rate 112, the patient was ventilated on assist control, 800/12/5/0.7. In general, this is an obese, elderly male lying flat with a halo placed in no acute distress. Head, eyes, ears, nose and throat, pupils equal, round and reactive to light. Trach in place. Cardiovascular: Regular rate and rhythm, no murmurs, rubs or gallops. Lungs: Equal breath sounds bilaterally anterolaterally. Abdomen, soft, distended. Decreased bowel sounds. Extremities, no edema. Neurological examination, limited by sedation, though the patient moving all four extremities spontaneously. LABORATORY DATA: Laboratory data on admission revealed white count 23, hematocrit 47, platelets 262, 78 neutrophils, 6 bands. Sodium 138, potassium 3.7, chloride 100, bicarbonate 20, BUN 23, creatinine 1.2, glucose 170. INR 1.2. PTT 68.4. Creatinine kinase 1279, troponin T less than .01. TSH 0.81. Arterial blood gases 7.42/40/120/27 with lactate of 2.1. Portable chest film demonstrated an endotracheal tube, left subclavian line that were properly placed as well as slight left ventricular enlargement of the heart. Electrocardiogram demonstrated normal sinus rhythm at 77 beats/minute with left anterior descending, Q wave in 3 and AVF. No ischemic ST or T segment changes. HOSPITAL COURSE: 1. Pulmonary - The patient arrived intubated in respiratory distress. It is felt that respiratory failure on admission was likely due to a combination of pulmonary embolus as well as infection. The patient was initially maintained on a ventilator though was given a trial of transition to trach collar on [**12-31**] and did well with that. However, the patient was noted to have extensive wheezing and was begun on frequent Albuterol and Atrovent nebulizers. In addition he was given a trial of Lasix diuresis. Given his significant wheezing on examination and initial respiratory distress, a bronchoscopy was performed on [**1-1**]. The bronchoscopy demonstrated significant dynamic airway collapse that was noted mostly in the trachea as well as the left airways, the right airways were not evaluated due to the patient's shortness of breath. The patient underwent repeat bronchoscopy on [**1-3**] by the Interventional Pulmonology Service. The flexible bronchoscopy demonstrated mild malacia with 80% patency of the airways on forced expiration and coughing. No endobronchial lesions were seen. On forced expiration and coughing a mild malacia was noted in the trachea. The patient tolerated the procedure well. The patient successfully transitioned to trach collar and for the several days prior to admission was breathing well through the stoma with significantly decreased respiratory distress. The patient was continued on anticoagulation for his pulmonary embolus which was demonstrated at the outside hospital. A lower extremity noninvasive study was carried out and did not demonstrate any deep vein thrombosis. The patient was maintained on intravenous heparin and was begun on Coumadin on [**1-4**]. The patient was continued on his course of Levofloxacin for his presumed pneumonia. Sputum sample was obtained on [**12-31**] which demonstrated greater than 25 polymorphonuclear cells and 4+ gram positive rods, although respiratory culture revealed moderate growth of oropharyngeal Flora. Repeat sputum stain and culture on [**1-3**] demonstrated less than 10 polymorphonuclears and oropharyngeal Flora. The patient's white cell count decreased from a maximum of 22.9 on [**12-27**] to 16.4 on [**1-4**]. The patient defervesced and remained afebrile for several days prior to hospital discharge. 2. Status post fall with fractures - The trauma team was consulted for management of the patient's multiple fractures. The patient was maintained on proper halo pin care, b.i.d. 50% water/50% hydrogen peroxide cleaning of the pin and scalp in the area of the pins, as well as proper cleaning of the vest area. The patient was maintained in a halo throughout his hospital course. 3. Cardiovascular - It is not clear why the patient fell from the roof. A syncope workup was carried out which included an echocardiogram on [**1-1**]. Cardiac echocardiogram demonstrated left ventricular cavity size that was normal with left ventricular wall motion that was also normal, so a focal wall motion abnormality could not be fully excluded due to suboptimal technical quality. The left ventricular ejection fraction was greater than 55%. There was trace aortic regurgitation as well as trivial mitral regurgitation and trivial tricuspid regurgitation. There was no pericardial effusion seen. The patient was also ruled out for myocardial infarction by serial negative cardiac enzymes. The patient was maintained on beta blockade for management of his hypertension as well as on Atorvastatin. There was no evidence of cardiac arrhythmias or ischemia while the patient was hospitalized. 4. Endocrinological - The patient's Medicine Intensive Care Unit course was complicated by significant hypoglycemia that at one point required insulin drip for proper control of his hyperglycemia. It appears that the patient has newly diagnosed diabetes mellitus Type 2. Of note, his hemoglobin A1c was found to be 6.7. It is not known why the patient had the significantly elevated blood glucose while in the Medicine Intensive Care Unit. The insulin drip was successfully weaned off on [**1-2**] and the patient was transitioned to a subcutaneous regimen of NPH Insulin 40 q. AM, and 20 q. PM as well as regular insulin sliding scale for additional coverage q.i.d. The patient was also started on Metformin 500 mg b.i.d. in hopes of eventually transitioning him to an oral regimen for his newly diagnosed Type 2 mellitus. In addition the patient was maintained on Levothyroxine replacement for his hypothyroidism. His TSH was checked at the time of admission and was found to be 0.81. 5. Renal - The patient's creatinine was slightly elevated on admission with a value of 1.1. His creatinine trended downwards during the course of his hospitalization and was 0.9 on [**1-4**]. The patient may have been slightly prerenal on admission as his BUN as 36 and trended down to 28 on [**1-4**]. The patient was noted to have an elevated creatinine kinase on admission of 1279 that was thought to be secondary to muscle damage. The patient was given hydration initially to prophylaxis and rhabdomyolysis. The patient's creatinine kinase trended downward and was 849 on [**12-31**]. 6. Gastrointestinal - The patient was noted to have a distended abdomen on admission and had a presumed functional ileus. The patient was given an aggressive bowel regimen and his distention improved. The patient was continued on Metoclopramide. The patient subsequently developed diarrhea, though was negative for DIF. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By:[**Last Name (NamePattern1) 11363**] MEDQUIST36 D: [**2126-1-4**] 19:28 T: [**2126-1-4**] 20:08 JOB#: [**Job Number 53224**] Admission Date: [**2125-12-30**] Discharge Date: [**2126-1-16**] Date of Birth: [**2060-10-16**] Sex: M Service: ADDENDUM: This is an Addendum to the previous Discharge Summary. As per previous Discharge Summary dictation (which was dictated by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2126-1-4**]), the plan at that time was for the patient to be discharged to rehabilitation. However, on the evening of [**2126-1-6**] the patient developed increasing abdominal distention with concern obstruction versus ileus. Hospital course since that time has been as follows. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED): 1. PULMONARY ISSUES: The patient continued to do well with tracheostomy. Occasional suctioning of secretions was required. Nebulizer treatments were increased to as needed which the patient tolerated well. 2. STATUS POST FALL/FRACTURE ISSUES: The patient was maintained on halo throughout his hospital course. On [**2126-1-14**] I contact[**Name (NI) **] Dr. [**Last Name (STitle) **] at [**Hospital6 5016**] regarding care of the patient's halo. Per this neurosurgeon, the halo does not have to be tightened for approximately two more weeks. The patient will follow up with Dr. [**Last Name (STitle) **] as an outpatient. In addition, I contact[**Name (NI) **] the orthopaedic surgeon at [**Hospital6 5016**] who had set the patient's right olecranon fracture. The patient will follow up with this physician in one to two weeks. 2. CARDIOVASCULAR ISSUES: The patient continued to be stable cardiovascularly throughout the remainder of the hospitalization. He was mildly hypertensive, so an ACE inhibitor was added to his medication regimen as the patient is also diabetic. The patient has tolerated this well with good control of his blood pressure. 3. ENDOCRINE ISSUES: Following development of the ileus, the patient's thyroid-stimulating hormone was rechecked. It was found to be high at 9.3, despite being normal at 0.81 on [**2125-12-30**]. At that time, his levothyroxine was increased to 212.5 mcg by mouth once per day. This will be rechecked in five to six weeks. 4. RENAL ISSUES: The patient had no further issues. 5. GASTROINTESTINAL ISSUES: As previously mentioned, the patient developed increasing abdominal distention on the evening of [**2126-1-4**]. A Surgery consultation was obtained at that time. A KUB was suggestive of obstruction versus ileus. On [**2126-1-7**] a gastrograph enema was obtained which was negative for an obstruction. The ileus was most likely due to prolonged narcotic use for the patient's pain status post fracture. Hypothyroidism may also have played a roll. The patient was made nothing by mouth and started on total parenteral nutrition for nutrition. The Surgery Service and Gastroenterology Service followed on a regular basis. Consideration was given to giving the patient neostigmine for the ileus. However, it resolved on its own over the course of the next week with decreased abdominal distention, increased stool output, and no nausea or vomiting. Over the last three to four days, the patient's diet has slowly been advanced, and he has tolerated this well. 6. DIABETES MELLITUS ISSUES: The patient's blood sugars were well controlled on metformin and a regular insulin sliding-scale. 7. PULMONARY EMBOLISM ISSUES: The patient is anticoagulated at this time on Coumadin. He will need to continue to have coagulations checked as an outpatient at rehabilitation. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: The patient was to be discharged to [**Hospital3 12564**] in [**Hospital1 3597**], [**State 350**]. DISCHARGE DIAGNOSES: 1. Status post fall with CT fracture. 2. Pulmonary embolism. 3. Pneumonia. 4. Hypothyroidism. 5. Rib fractures. 6. Diabetes mellitus. 7. Hypertension. 8. Functional ileus. MEDICATIONS ON DISCHARGE: 1. Levothyroxine 212.5 mcg by mouth every day. 2. Tylenol 325-mg tablets one to two tablets by mouth q.4-6h. as needed. 3. Atorvastatin 40 mg by mouth once per day. 4. Metoclopramide 10 mg by mouth four times per day. 5. Warfarin 4 mg by mouth once per day. 6. Metformin 500 mg by mouth once per day. 7. Albuterol nebulizers as needed. 8. Metoprolol 75 mg by mouth twice per day. 9. Pantoprazole 40 mg by mouth once per day. 10. Senna one tablet by mouth twice per day as needed. 11. Bisacodyl 10 mg by mouth once per day as needed. 12. Colace 100 mg by mouth once per day. 13. Atrovent inhaler. 14. Regular insulin sliding-scale. 15. Trazodone 25 mg by mouth at hour of sleep as needed. 16. Lisinopril 20 mg by mouth once per day. 17. Ativan 0.5 mg to 1 mg intravenously q.4-6h. as needed. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [**Last Name (STitle) **] for adjustment of his halo. 2. The patient was instructed to follow up with Dr. [**Last Name (STitle) 1391**] regarding orthopaedic issues status post his fall. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Name8 (MD) 315**] MEDQUIST36 D: [**2126-1-15**] 19:02 T: [**2126-1-15**] 19:04 JOB#: [**Job Number 53225**]

[ "486", "415.19", "518.81", "805.02", "728.88", "V44.0", "560.1", "807.05", "250.00" ]

icd9cm

[ [ [] ] ]

[ "96.71", "99.15", "33.21" ]

icd9pcs

[ [ [] ] ]

17861, 18042

18069, 18886

6203, 6809

8291, 17669

18919, 19390

6945, 8273

17684, 17840

3355, 5972

5995, 6176

6826, 6922

52,730

175,578

55031

Discharge summary

report

Admission Date: [**2155-4-28**] Discharge Date: [**2155-5-1**] Date of Birth: [**2087-11-9**] Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[**First Name3 (LF) 613**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Past Medical History: Emphysema Asthma History of Present Illness: 67 yo Haitian-Creole speaking male with COPD on 2L oxygen at home, recently discharged from [**Hospital1 2177**] for COPD exacerbation and treated for pneumonia presenting with shortness of breath. Pt reports that he was recently hospitalized at [**Hospital3 9947**] from [**2155-4-25**] to [**2155-4-27**] for COPD exacerbation and was also treated with antibiotics for pneumonia. He was discharged home yesterday and was planning to fill his prescriptions today until he became short of breath. He presented to the ED where he was noted to be tachypneic (RR38) with oxygen saturation of low 80s. He was placed on NRB and then bipap. He was given 125mg iv solumedrol, 2g iv ceftriaxone, and 500mg iv azithromycin. He was weaned to 4L oxygen by nasal cannula by time of transfer to ICU. Vitals prior to transfer: 123/62 108 98%4L. Labs were remarkable for lactate 2.8, trop <0.01, BNP 163. Past Medical History: Emphysema Asthma Social History: Came to the US in [**2136**]. Lives alone. Does not work; on disability. Reports that he quit smoking many years ago. Denies alcohol or illicit drug use Family History: Denies family hx of cardiopulmonary disease or cancer Physical Exam: Admission physical exam General: Alert, oriented x 3, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVD not appreciated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: faint wheezes diffusely, mildly tachypneic Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact Discharge physical exam General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased breath sounds bilaterally, no wheezes, no crackles, rales or rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, distended at baseline, bowel sounds present, no rebound tenderness or guarding, no organomegaly, Ext: Bilateral LE are Warm, well perfused, 2+ DP pulses Pertinent Results: Admission labs [**2155-4-28**] 05:12PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP [**2155-4-28**] 05:12PM LACTATE-2.7* [**2155-4-28**] 04:47PM CK(CPK)-614* [**2155-4-28**] 04:47PM CK-MB-21* MB INDX-3.4 cTropnT-<0.01 [**2155-4-28**] 02:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2155-4-28**] 02:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2155-4-28**] 11:54AM TYPE-[**Last Name (un) **] PO2-82* PCO2-102* PH-7.23* TOTAL CO2-45* BASE XS-10 [**2155-4-28**] 11:20AM GLUCOSE-156* UREA N-18 CREAT-1.0 SODIUM-145 POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-36* ANION GAP-15 [**2155-4-28**] 11:20AM estGFR-Using this [**2155-4-28**] 11:20AM WBC-10.3 RBC-4.48* HGB-12.2* HCT-40.3 MCV-90 MCH-27.2 MCHC-30.2* RDW-12.9 [**2155-4-28**] 11:20AM NEUTS-64.4 LYMPHS-24.9 MONOS-7.9 EOS-2.3 BASOS-0.5 Imaging: IMPRESSION: Vague opacities obscuring the right and left heart border which could represent pneumonia, although the possibility of epicardial fat pad is also raised. Recommend followup to resolution. Consider dedicated PA and lateral views for a more complete assessment. Micro: [**2155-4-28**] 4:48 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2155-5-1**]** MRSA SCREEN (Final [**2155-5-1**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS [**2155-4-28**] 2:00 pm URINE **FINAL REPORT [**2155-4-29**]** URINE CULTURE (Final [**2155-4-29**]): NO GROWTH Discharge labs [**2155-4-29**] 12:39AM BLOOD WBC-6.7 RBC-4.37* Hgb-11.8* Hct-38.6* MCV-88 MCH-27.0 MCHC-30.6* RDW-12.9 Plt Ct-144* [**2155-4-30**] 06:05AM BLOOD Glucose-105* UreaN-18 Creat-1.0 Na-142 K-4.6 Cl-96 HCO3-40* AnGap-11 [**2155-4-29**] 12:39AM BLOOD LD(LDH)-268* CK(CPK)-576* [**2155-4-29**] 12:39AM BLOOD CK-MB-16* MB Indx-2.8 cTropnT-<0.01 [**2155-4-29**] 12:39AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.9* [**2155-4-29**] 12:50AM BLOOD Lactate-2.0 Brief Hospital Course: 67 year old Hatian-Creole speaking male with a history of COPD who presented with shortness of breath likely a COPD exacerbation. # COPD Exacerbation: Patient presented with hypoxia and shorntess of breath which required BiPap and an ICU admission. He improved with BiPap and standing nebulizers and was transferred to the floors on 2L of oxygen. He was placed on standing albuterol and ipratroium nebulizers q6h with a q2h PRN which he improved on. He was also placed on prednisone 60mg daily. His symptoms improved however his oxygen requirement fluctuated during his time on the general medical floors. On the day of discharge he was comfortable on 2L but continued to have a persistent cough which waxed and waned. Plan would be for a prednisone taper of 60mg for 1 day (End [**5-2**]), 40mg for 3 days ([**Date range (1) **]), 20mg for 3 days ([**Date range (1) 61537**]) and 10mg for 3 days ([**Date range (1) 61876**]). He should conintue with albuterol nebs PRN and spiriva daily. He was also placed on Levofloxacin as he was having dyspnea and increased sputum production. He will continue until [**5-2**] for a total of 5 days. # Hyperglycemia: He has a history of glucose intolerance and while on prednisone, his sugars did go up. He was started on an inuslin sliding scale and his sugars improved. His insulin sliding scale will need to be titrated based on his sugars and prednisone taper. # Cognitive impairment: Patient was noted to have poor insight on his current condition. Upon further evaluation, it was found out that he was living in squalor. Concern regarding patients cognition was brought up during his hospitalization therefore neurocognitive assessement is recommended. # BPH: Patient had no symtoms during his admission therefore he was continued on terazosin. # GERD: He was stable in his home regimen therefore was continued on omeprazole. TRANISTIONAL ISSUES: - Taper prednisone 60mg for 1 day (End [**5-2**]), 40mg for 3 days ([**Date range (1) **]), 20mg for 3 days ([**Date range (1) 61537**]) and 10mg for 3 days ([**Date range (1) 61876**]). - Will need to titrate insulin based on blood glucose and prednisone taper Medications on Admission: 1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] 2. Tiotropium Bromide 1 CAP IH DAILY 3. Albuterol Inhaler 2 PUFF IH Q4H 4. Omeprazole 20 mg PO DAILY 5. Terazosin 5 mg PO HS 6. Acetaminophen 500 mg PO Q6H:PRN PRN 7. Azithromycin 500mcg for 3 days 8. Prednisone 20mg tabs (3tabs for one day, 2tabs for 3 days, 1tab for 3 days and half tab for 3 days) Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN PRN 2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] 3. Omeprazole 20 mg PO DAILY 4. Terazosin 5 mg PO HS 5. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB or wheeze 6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H 7. Guaifenesin [**5-1**] mL PO Q6H:PRN PRN 8. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 9. Ipratropium Bromide Neb 1 NEB IH Q6H 10. Levofloxacin 750 mg PO Q24H Start: In am End [**5-2**] 11. PredniSONE 60 mg PO DAILY Start: In am prednisone 60mg for 1 day (End [**5-2**]), 40mg for 3 days ([**Date range (1) **]), 20mg for 3 days ([**Date range (1) 61537**]) and 10mg for 3 days ([**Date range (1) 61876**]) Tapered dose - DOWN Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**] Discharge Diagnosis: Primary: COPD exacerbation Secondary: Glucose intolerance probable cognitive impairment 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 because you had a COPD exacerbation. You have improved with antibiotics and albuterol, ipratropium and systemic steroids. You are currently on 2Liters of oxygen and at your baseline. If you experience further shortness of breath or difficulty breathing, please see your doctor. Medications stopped Azithromycin Medications started Prednisonse 60mg for 1 day (End [**5-2**]), 40mg for 3 days ([**Date range (1) **]), 20mg for 3 days ([**Date range (1) 61537**]) and 10mg for 3 days ([**Date range (1) 61876**]) Tapered dose - DOWN Levofloxacin 750mg daily until [**5-2**] Insulin Sliding Scale (see sheet) Guaifenesin [**5-1**] mL every 6 hours as needed for cough Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Hospital 112345**] [**Hospital1 **] [**Location (un) 686**], [**Numeric Identifier 12201**] [**Telephone/Fax (1) 12016**] Friday [**5-9**] at 11AM [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "V58.65", "V60.1", "491.21", "249.00", "V15.81", "V58.83", "518.81", "319", "486", "E932.0", "530.81", "V58.67", "276.2", "794.31", "799.02", "600.00", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

7872, 7971

4530, 6690

304, 304

8104, 8104

2571, 4507

8981, 9293

1506, 1562

7111, 7849

7992, 8083

6716, 7088

8255, 8958

1577, 2552

245, 266

373, 1275

8119, 8231

1297, 1316

1332, 1490

14,703

130,576

8602

Discharge summary

report

Admission Date: [**2177-7-23**] Discharge Date: [**2177-7-29**] Date of Birth: [**2118-2-7**] Sex: F Service: MEDICINE Allergies: Morphine / Latex / Vancomycin Hcl/D5w / Pepto-Bismol Attending:[**First Name3 (LF) 348**] Chief Complaint: Transfer from [**Hospital 1562**] Hospital for melena. Major Surgical or Invasive Procedure: EGD . Blood transfusion, platelet transfusion History of Present Illness: 59 yo F with a h/o hep C cirrhosis, breast CA, pancytopenia thought to be [**12-19**] to hypersplenism p/w melena X 4 days. Pt with large, black, tarry stools for the past four days. Presented to [**Hospital 1562**] hospital last night. Found to have hct 19, plt of 9, ANC 400, inr 1.3. O/n received 5 units prbcs and a six pack of plts. Also placed on protonix and octreotide drips. After fourth unit of prbcs and plts: hct 24, plt count 15. Also given vitamin K 10 mg X2 at osh, no repeat inr. . Pt transferred to [**Hospital1 18**] for further management. . On ROS: pt denies n/v. Mild diffuse abdominal pain for months. c/o b/l upper abd/lower chest pain occuring with exertion X 2 days. Pain non-radiating, associated with mild sob, lasts a few minutes. Past Medical History: # HCV secondary to blood transfusion diagnosed in [**2164**]. # Cirrhosis since [**2165**], still followed by Dr. [**Last Name (STitle) 497**]. # Status post portocaval shunt in [**2167**]. # Variceal bleed in [**2165**]. # Last admit [**12-21**] with confusion and UTI. # Multiple admissions with encephalopathy and anasarca. # History of vaginal bleeding. status post D&C and ablation. # Obesity. # Lower extremity cellulitis. # MRSA. # Pancytopenia thought secondary to increased spleen. # Scoliosis as a teenager, status post surgery. # Breast Cancer Social History: Lives with her daughter who is a [**Name (NI) **] and granddaughter. [**Name (NI) 4906**] died 9 years ago. No alcohol. Quit tobacco 25 years ago (smoked 2ppd for 1 yr). No IV drug use. Family History: No history of liver disease. Physical Exam: Temp 98 n BP 109/44 Pulse 72 Resp 17 O2 sat 98 RA Gen - Alert, no acute distress HEENT - extraocular motions intact, anicteric, mucous membranes mildly dry Neck - no JVD, no cervical lymphadenopathy Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, 5/6 SEM throughout precordium radiating to carotids Abd - Soft, nondistended, diffusely tender, palpable liver edge at 8cm below costal border, normoactive bowel sounds Extr - 1+ pitting edemato ankles b/l. venous stasis changes. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, cranial nerves [**12-29**] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact Pertinent Results: [**2177-7-23**] 11:47PM CK(CPK)-45 [**2177-7-23**] 11:47PM CK-MB-NotDone cTropnT-<0.01 [**2177-7-23**] 11:47PM HCT-24.1* [**2177-7-23**] 11:47PM PLT COUNT-32*# [**2177-7-23**] 07:26PM PT-15.8* PTT-43.2* INR(PT)-1.4* [**2177-7-23**] 05:34PM GLUCOSE-154* UREA N-17 CREAT-0.6 SODIUM-137 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-15* ANION GAP-25* [**2177-7-23**] 05:34PM CK(CPK)-50 [**2177-7-23**] 05:34PM CK-MB-NotDone cTropnT-<0.01 [**2177-7-23**] 05:34PM CALCIUM-8.2* PHOSPHATE-3.4 MAGNESIUM-2.3 [**2177-7-23**] 05:34PM WBC-0.6*# RBC-2.73* HGB-8.6* HCT-23.3* MCV-85# MCH-31.7 MCHC-37.2* RDW-15.9* [**2177-7-23**] 05:34PM PLT COUNT-21*# [**2177-7-23**] 05:34PM GRAN CT-300* . [**2177-7-24**] EGD Impression: Normal no varices Normal fundus no portal gastropathy or varices In antrum fresh blood seen oozing from very mildly erythematous mucosa. Erythema and congestion in the antrum and pre-pyloric region compatible with gastritis (thermal therapy) The area of gastritis was of mild severity and did not look classic for GAVE. Normal bulb D2 and D3 with no blood and bile seen . CT Chest/Abd/Pelvis on [**2177-7-26**] IMPRESSION: 1. Interval development of a new liver lesion in segment 7 of the liver, measuring [**Date Range 13835**] 1.7 cm. This is concerning for metastatic disease. 2. Asymmetric breast tissue within the right breast likely represents patient's known cancer, correlate with mammography or clinical history. 3. Cirrhosis, splenomegaly and collateral formation compatible with portal hypertension. . RUQ Ultrasound: [**2177-7-25**] Premilinary read: portocaval shunt patent . Bone scan: [**2177-7-28**] Brief Hospital Course: Impression/Plan: 59 yo F with h/o hep C cirrhosis, breast CA, pancytopenia, p/w with melena, s/p GIB, stabilized in the [**Hospital 30166**] transferred to the floor with . MICU course: The patient was stabilized from a hemodynamic standpoint with 5 units of pRBC and 6 units of platelets; she was started on an octreotide/protonix drip. She did not require any further transfusions during her admission. Her melena resolved. EGD showed gastritis, no active site of bleeding and no cauterization was required. At that point, the octreotide/protonix was discontinued, and she was started on protonix [**Hospital1 **] as well as nadolol for esophageal prophylaxis. She was transferred to the floor after 24 hours of stable hematocrit and after she had tolerated a diet. . 1. Melena: Pt presented with melena [**12-19**] gastritis on EGD. No varices on EGD. Hct was stable during hospitalization after transfusions, and on discharge, her hematocrit was 28.2 on discharge. BPs stable throughout, and she did not experience any further episodes of melena. She should continue on nadolol and protonix [**Hospital1 **] on discharge for variceal prophylaxis, and this should be followed up with GI. . 2. Shortness of breath: Patient with crackles on exam, and new oxygen requirement. This is likely due to third spacing given her end stage liver disease, and although she diuresed appropriately in response to lasix, she does have moderate pleural effusions. She will be sent home on oxygen as her ambulatory saturation was 87%. Her lasix was increased to 100BID on discharge which was to be continued for one week. This should help to appropriately diurese her, then she should resume her home dose of 80 [**Hospital1 **]. . 3. Atypical Chest pain: now resolved. [**Month (only) 116**] have been due to demand ischemia from anemia. Her enzymes were negative times 3 and she didnt have any ecg changes. . 4. Cirrhosis/Hep C: portocaval shunt in place which is patent by ultrasound. Pt recently on tx list, but taken off due to breast CA. CT torso significant for new 1.7 cm liver lesion, concerning for either metastatic disease from breast CA or HCC. AFP has not been elevated, however, can still have HCC - AFP. Will have patient follow up with Dr. [**Last Name (STitle) 10656**] for further characterization of the lestion. CEA was sent as well as CA [**97**]/29 and CA 125. Heme/Onc recommends to consider colonoscopy to look for lesion. She should continue on lactulose and her home dose of lasix. . 5. Pancytopenia: [**Month (only) 116**] be secondary to hypersplenism which is evidenced on her CT. Heme/Onc following through hospital course and determined that she did not need a bone marrow biopsy as an inpatient. Hemolysis labs showed a mild hemolytic anemia with decreased haptoglobin and increased LDH. Her vitamin B12 an folate levels were normal. Her retic count was very inappropriate suggesting that she may have a component of myelodysplastic syndrome, but will need to be further evaluated. She will see Dr. [**Last Name (STitle) 2539**] for this as an outpatient. Pt does not need additional transfusions based off of am labs and transfusion requirements. . 6. Coagulopathy: INR of 1.7 currently with no bleeding. s/p 3 doses of vitamin k, and is likely due to her liver disease. . 7. Breast CA: s/p R lumpectomy with local recurrence. Per OMR notes, pt's breast surgeon feels that mastectomy would be ideal. However, pt's hepatologist, Dr. [**Last Name (STitle) 497**], feels that given pt's liver dx, general anesthesia is contra-indicated. Pt's co-morbidities also severely limit chemo options. Now also with new liver lesion on CT torso yesterday, concerning for metastatic disease vs. HCC. Bone scan for staging did not show any other lesions. CEA, CA [**97**]/29 and CA 125 were sent out. . 8. DM: Patient with good glucose control during hospitalization. Was originally on a slidine scale, then when we restarted her glyburide she had several episodes of hypoglycemia. She informed us that she only takes glyburide at home when her blood sugars reach > 200. She was continued on this home regimen and only received sliding scale coverage for BS > 200 given her hypoglycemia. . 9. Back pain: likely [**12-19**] cancer, cont tylenol 3 for pain control. . 10. FEN: Diabetic diet . 11. Code: FULL CODE, this was reconfirmed with the patient prior to discharge. . 12. Comm: Daughter [**Name (NI) **] (cell) [**Telephone/Fax (1) 30167**] Medications on Admission: glyburide calcium carbonate/vit D 600 mg [**Hospital1 **] Nadolol 10 mg daily folate 1 mg daily spironolactone 200 mg daily ursodiol 300 mg [**Hospital1 **] lactulose 30 cc qid magnesium oxide 400 mg daily pantoprazole 40 mg daily fluticasone Lasix 80 mg [**Hospital1 **] potassium cholride Discharge Medications: 1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO BID (2 times a day): Dispense one month supply. Disp:*qs mL* Refills:*2* 3. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for back pain. Disp:*120 Tablet(s)* Refills:*0* 4. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Lasix 40 mg Tablet Sig: 2.5 Tablets PO twice a day: Please take a total of 100mg of lasix twice a day for one week, then take 80mg twice a day after that. Disp:*150 Tablet(s)* Refills:*2* 8. Oxygen-Air Delivery Systems Device Sig: One (1) Miscell. Continuous: Please use oxygen continuously . Disp:*1 1* Refills:*2* 9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day: Please take if your blood sugar is greater than 200. Discharge Disposition: Home Discharge Diagnosis: Gastrointestinal bleeding from gastritis and low platelets. You will need to follow up with hematology/oncology regarding your low platelet count for a repeat bone marrow biopsy. . Breast Cancer: Please follow up with your breast surgeon regarding your recurring breast cancer and treatment for this. . Hepatitis C: You have hepatitis C and should be followed for this as an outpatient with Dr. [**Last Name (STitle) 497**]. . Pancytopenia: In general, you have low blood counts of your platelets and your white blood cell counts. You will need follow up for this in hematology clinic. Discharge Condition: Stable Discharge Instructions: Please call if you notice that you continue to experience shortness of breath, chest pain, pain uncontrolled by medications. If you continue to have black, tarry stools, feel any dizziness or increasing weaness. . Please use continuous oxygen by nasal cannula for decreased saturations. . Please take 100mg of lasix twice a day for one week, and then after that take 80 mg of lasix twice a day for fluid overload. This will be adjusted by your primary care doctor. Followup Instructions: Dr. [**First Name8 (NamePattern2) 18654**] [**Last Name (NamePattern1) 30168**] (primary care doctor): ([**Telephone/Fax (1) 30169**], [**8-1**] @ 2:15pm. Fax number: . Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10656**] (breast surgery): ([**Telephone/Fax (1) 17070**] , [**8-6**], @ 115 . Dr. [**Last Name (STitle) 2539**] (hematology):([**Telephone/Fax (1) 30170**], [**8-8**] @ 10:30am . Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] (gastroenterology): ([**Telephone/Fax (1) 3618**], [**8-13**] @ 930. .

[ "284.8", "571.5", "287.5", "070.70", "535.51", "V10.3", "250.00", "573.9" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

10397, 10403

4401, 8874

366, 414

11035, 11044

2731, 4378

11558, 12121

2002, 2032

9216, 10374

10424, 11014

8900, 9193

11068, 11535

2047, 2712

272, 328

442, 1203

1225, 1782

1798, 1986

70,491

165,089

42003

Discharge summary

report

Admission Date: [**2105-9-12**] Discharge Date: [**2105-9-28**] Date of Birth: [**2026-5-4**] Sex: F Service: MEDICINE Allergies: Ampicillin Attending:[**First Name3 (LF) 2145**] Chief Complaint: left neck mass Major Surgical or Invasive Procedure: US guided left neck mass FNA [**2105-9-14**] Left hilar Lymph node biopsy [**2105-9-24**] History of Present Illness: 79-year-old woman who has not seen a physician in over 20 years who is presenting today with a neck mass and recent weight loss. The patient reports that the mass on her left neck started to appear six months ago and orginated like a swollen lymph node. For the past three months, the mass has been intermittently draining a thick, clear fluid. The mass itself has not been painful or tender to the touch. However, as it has expanded, the patient has found to difficult to eat, drink, or even open her mouth. She has been losing weight recently because of the difficulty eating. The patient denies any difficulty in breathing. She denies any symptoms aside from the pain with mouth movement and weight loss. The patient has not had any sick contacts and has never traveled overseas. About thirty years ago, the patient worked in a rehabilitation facility that had once been a tuberculosis hospital. Upon questioning, the patient says that she never worked with tuberculosis patients. . In the Emergency Department, her initial vitals were TT 99 HR 104 BP 144/60 RR 18 100% RA. ENT was consulted and a CT neck was obtained. ENT did not feel as though airway compromise would be likely. The mass is not resectable due to encasement of vessels, but they will follow and recommend an FNA. ENT also recommends patient be NPO and have a Speech and Swallow consult. ID was contact[**Name (NI) **] and recommended TB precaution and rule out. The patient received blood cultures and a swab of the left neck mass. On transfer to Medicine, the patient's vitals were T 97.4 HR 104 BP 144/60 RR 18 96%. Past Medical History: None Social History: No tobacco history. The patient does not drink. The patient lives in a home alone with her dog, a mini-poodle. Ex husband does groceries for her. She moved out from her daughter's flat 4-5 years ago. Family History: The patient denies that any cancers, heart disease, or diabetes, runs in her family. Physical Exam: Admission physical exam: VS: T 96.0 BP 156/65 HR 91 RR 18 100% RA GENERAL: Cachectic woman in no acute distress. HEENT: PERRL, EOMI, sclerae anicteric and without injection NECK: approximately 10cm x 8cm firm left mass beneath mandible, fixed, warty protusions, including one area that appears necrotic; tracheal deviation; anterior lymph nodes palpable; patient can only open mouth 2-3 cm secondary to pain. HEART: S1, S2, [**3-8**] holosystolic murmur heard at base of heart. LUNGS: CTA bilaterally, respirations unlabored. ABDOMEN: Soft, non-tender, non-distended, bowel sounds quiet. EXTREMITIES: WWP, no c/c/e, 2+ radial/pedal pulses. NEURO: Awake, A&Ox3, CNs III-XII grossly intact, muscle strength [**5-7**] throughout, patellar reflexes 2+. . Discharge physical exam: VS: 98.4 159/79 95 18 98% RA GENERAL: no acute distress. HEENT: EOMI, sclerae anicteric, MM NECK: neck mass unchanged HEART: S1, S2, [**2-8**] holosystolic murmur heard at base of heart. LUNGS: CTA bilaterally, no wheezes, rales, or rhonchi. ABDOMEN: Soft, non-tender, non-distended, + bowel sounds. EXTREMITIES: WWP, no c/c/e. NEURO: Awake, knows self, year, confuses B&W with [**Hospital1 18**], doesn??????t know day or month, does have insight into medical situation and can repeat plan. , CNs III-XII grossly intact, muscle strength 5/5 throughout. Pertinent Results: CBC and coagulation profile: [**2105-9-12**] BLOOD WBC-12.6* RBC-4.01* Hgb-11.6* Hct-32.7* MCV-82 MCH-28.9 MCHC-35.5* RDW-12.7 Plt Ct-323 [**2105-9-23**] BLOOD WBC-10.9 RBC-2.98* Hgb-8.4* Hct-24.1* MCV-81* MCH-28.2 MCHC-34.8 RDW-13.1 Plt Ct-287 [**2105-9-12**] BLOOD PT-14.0* PTT-32.6 INR(PT)-1.2* . Blood Chemistry: [**2105-9-12**] BLOOD Glucose-86 UreaN-19 Creat-0.7 Na-139 K-3.9 Cl-102 HCO3-23 AnGap-18 [**2105-9-12**] BLOOD Lactate-1.1 [**2105-9-23**] BLOOD Glucose-113* UreaN-2* Creat-0.4 Na-131* K-3.5 Cl-97 HCO3-26 AnGap-12 [**2105-9-15**] BLOOD ALT-8 AST-14 LD(LDH)-202 AlkPhos-54 TotBili-0.2 [**2105-9-15**] BLOOD TotProt-4.5* Albumin-2.6* Globuln-1.9* UricAcd-3.1 . ESR, CRP and Iron profile: [**2105-9-23**] BLOOD Calcium-7.6* Phos-2.7 Mg-1.7 [**2105-9-21**] BLOOD calTIBC-125* Folate-10.3 Ferritn-316* TRF-96* [**2105-9-16**] BLOOD CRP-59.8* [**2105-9-16**] BLOOD ESR-42* . [**2105-9-16**] BLOOD PEP-HYPOGAMMAGLOBULINEMIA, IgG-473* IgA-139 IgM-27* IFE-NO MONOCLONAL GAMMOPATHY [**2105-9-15**] BLOOD b2micro-2.0 [**2105-9-16**] Serum Protein Electrophoresis: HYPOGAMMAGLOBULINEMIA BASED ON IFE (SEE SEPARATE REPORT), NO MONOCLONAL IMMUNOGLOBULIN SEEN . Left neck mass Fluid SWAB: [**2105-9-12**] 11:11 pm SWAB GRAM STAIN (Final [**2105-9-13**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2105-9-15**]): 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.. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. ACID FAST CULTURE (Preliminary): A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [**2105-9-14**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. . Blood cultures: NO GROWTH . IMAGING: CXR PA & LAT [**2105-9-12**] IMPRESSION: No acute cardiopulmonary abnormality. . CT NECK WITH CONTRAST [**2105-9-12**] IMPRESSION: 1. Heterogeneous ill-defined large left neck mass with internal necrosis compatible with a neoplasm. This mass encases and markedly attenuates the left internal carotid artery as well as occludes the distal branches of the left external carotid artery as well as the left internal jugular vein. Please note that superimposed infection of this necrotic mass cannot be excluded on this imaging study. 2. Multiple enhancing left submental and submandibular lymph nodes suspicious for malignancy. 3. Right thyroid nodule. Correlation with non-emergent ultrasound is recommended. 4. Biapical lung scarring. . US guided FNA of left neck mass [**2105-9-15**] POSITIVE FOR MALIGNANT CELLS. Consistent with poorly differentiated squamous cell carcinoma. . Thyroid US [**2105-9-21**] IMPRESSION: Solitary 1.2 x 1.8 cm posterior mass in lower pole of right lobe of thyroid gland as was shown on recent CT scan. This is not deemed safe for a percutaneous aspiration biopsy. . G tube placement . . Brief Hospital Course: 79-year-old woman without significant past medical history who presented with a left neck mass and weight loss, found to have poorly differentiated sqaumous cell carcinoma. G tube was placed in anticipationg of chemotherapy and radiation therapy, transferred to rehabilitation in stable condition. . # Left neck mass: Per aspiration Biopsy and PET-CT scan, poorly differentiated squamous cell carcinoma with multiple adjacent lymph nodes, involved hilar LN and pulmonary nodule. Family meeting held on [**9-18**] during which diagnosis, treatment plan and prognosis was discussed in the presence of both of her daughters. Thyroid nodule US was done and given its posterior location FNA was not done. [**Hospital **] medical oncology and radiation oncology were included in her care during her stay. NG tube was placed prior to G tube placement which was done on [**2105-9-23**]. G tube is placed prior to initiation of chemotherapy and radiation therapy in anticipation of significant mucositis which would aggrevate even more her poor oral intake. G tube was placed by the interventional radiology team under general anesthesia. It was not done endoscopically because her mouth orifice was small and she was unable to open further. She remained intubated after G tube placement and transferred to ICU for observation. The following day, she had biopsy of her left hilar lymph node through bronchoscopy. She was subsequently extubated and transfered back to the medical floor. She is discharged to ECF and will continue follow-up with oncology and radiation oncology for chemical and radaiation treatment. . # Anemia: Baseline unknown. Her anemia is normocytic. Hgb on admission was 11.6 down to 8.4 on discharge. No signs of active bleeding, vital signs were stable throughout her stay. Most likely dilutional effect given her almost daily IVF. On [**9-25**] patient was transfused one unit prior to transfer back to the floor. Her Hgb was subsequently stable around 8.4-8.6. Will continue monitoring and work up in ECF. . # Fall - on [**9-26**] she fell out of her hospital bed, she did not loose consiousness or have any evidence of trauma on clinical exam. Head CT was negative for bleed. . # Urinary retention: on [**9-28**] patient found to have urinary retention which resolved with foley with 400cc residual. Patient is discharged with foley, with recommendation for pulling foley for a voiding trial the day after discharge. . # elevated blood pressures: this was noted on [**9-27**] with SBP to max of 190. Patient does not have HTN at baseline and this was thought to be secondary to urinary retention. BP's trended down after resolution of urinary retention. . # Nutritional status: PEG placed on [**9-24**]. TF started. . # Right forarm swelling. No previous IV access in forearm. RUQ US ruled out DVT. . # mental and cognitive status: patient very soft spoken at baseline with impression of mild cognitive decline. During hospital course was occasionally mildly disorientated. A+O X [**2-5**] with mild fluctuations, knows self, year, confuses B&W with [**Hospital1 18**], doesn??????t know day or month, does have insight into medical situation and can repeat plan. . . Transitional issues: - continue tube feeds - repeat CBC on [**9-30**] - to monitor WBC and Hct - Monitor vital signs daily - MD follow up at ECF. - Pull foley on [**9-29**] for voiding trial - follow-up pathology results from biopsy on neck mass and pulmonary lesion - follow-up as below with oncology and radiation oncology - patient does not have a listed PCP, [**Name10 (NameIs) 5001**] discharge home from rehab may call ([**Telephone/Fax (1) 1300**] to establish care at [**Hospital **] if interested. . Medications on Admission: None Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: Poorly differentiated Squamous Cell Carcinoma (left neck) with possible metastasis . Secondary Diagnosis: Anemia - borderline microcytic Discharge Condition: Mental Status: mostly Clear and coherent, confused sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms [**Known lastname **], . You were admitted to [**Hospital1 69**] because of the mass on the left side of your neck that has been there for a few months. The sample taken through a needle have showed cancer cells known as "squamous cell carcinoma". You had an advanced imaging study that showed a mass next to your air-pipe concerning of a metastasis there. . You've been evaluated by the medical cancer doctors, radiation cancer doctors as [**Name5 (PTitle) **] as Ear Nose Throat doctors. It was necessary to place a feeding tube through your stomach because with chemotherapy and radiation therapy your throat is expected to have irritation that would prevent you further from having good oral intake. This tube was placed on [**2105-9-23**] under general anesthesia. You were kept intubated after the feeding tube placement to ensure the safety of your airways for the mass that was biopsied next to your air-pipe the following day ([**2105-9-24**]). The biopsy results are still pending. You stayed in the ICU where you received 1 unit of blood for low blood levels. You were transferred to the floor in a stable condition with no complications following the procedures. . You fell out of bed the night prior to your discharge. We were concerned about your fall and therefore you had an CT scan of your head which showed no bleed. . You are being transferred to a rehabilitation center to follow with your upcoming therapy and further care. . We did not add any medication. . Please follow with your appointments as stated below. Followup Instructions: Please call ([**Telephone/Fax (1) 14703**] on Monday morning for an appointment with Cancer specialist [**Last Name (LF) **], [**First Name3 (LF) **] M. MD within one week of your discharge. . Please call ([**Telephone/Fax (1) 8082**] on Monday morning for an appointment with Radiation Oncology Specialist [**Last Name (LF) 3929**], [**Name8 (MD) **] MD within one week of your discharge. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2105-9-30**]

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Discharge summary

report

Admission Date: [**2132-10-6**] Discharge Date: [**2132-10-29**] Date of Birth: [**2080-3-10**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: FEVER Major Surgical or Invasive Procedure: Lumbar Puncture IVC filter placement [**2132-10-15**] History of Present Illness: 52 y/o M w/ hx of Ph + ALL D 91 Double cord transplant who was on his way from an appt when he scraped his left leg on the step of the shuttle. He was treated with wound care, vancomycin IV and d/c home on [**10-3**]. He presented today to OSH with fever 100.4 concerning for neutropenic fever. Earlier in the morning he felt warm and measured his temp to 99.8, and later to 100.4. At the ED, his temp. was 100.6, other vitals stable. The patient was transferred to [**Hospital1 18**] for further evaluation and management. He feels well other than fevers. He denies headaches, dizziness, cough, shortness of breath, URI symptoms, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, joint pains, bony pains, urinary symptoms. He does have persisting pain over the left leg/shin wound, but without worsening redness, swelling, tenderness or warmth. He denies any other rashes. Review of Systems: [-] Fever [-] chills [-] night sweats [+] fatigue [-] nausea vomiting [-] diarrhea [-] weight loss [-] food intolerance [-] cough [+] DOE since discharge [-] SOB at rest [-] Chest pain [-] palpitation [-] skin rash-psoriasis remains improved [-] neuropathy Past Medical History: PAST ONCOLOGIC HISTORY (from [**Hospital1 **], confirmed with patient and wife): TREATMENT HISTORY: * [**2131-9-17**] - HyperCVAD, part A. Also started on Gleevec 300 mg twice per day. * IT Cytarabine on [**2131-9-23**] * [**2131-10-9**] - HyperCVAD, Part B with IT Methotrexate on [**2131-10-12**]. Difficult time with this LP with resulting headache. * [**2131-10-26**] - High dose Methotrexate * Bone marrow biopsy without evidence for ALL * [**2131-11-9**] - High dose Methotrexate * [**2131-11-19**] - HyperCVAD, part A. IT Methotrexate on [**2131-11-20**] under IR with resulting headache. D 8 IT Cytarabine held due to previous difficult LP. D 11 Vincristine held d/t previously elevated bilirubin. * Admitted on [**2131-11-30**] with fever, neutropenia and paronychia of left great toe. Treated with IV abx and discharged on Keflex * [**2131-12-12**] - HyperCVAD, part B. * [**2131-12-25**] - Admitted with fevers and neutropenia. Treated for pneumonia with persistent fevers and night sweats. Workup negative for infection and BM biopsy with no evidence for ALL. Discharged on [**2132-1-8**]. * [**2132-1-14**] - HyperCVAD, part A, IT methotrexate on [**2132-1-15**]. * [**2132-1-27**] - Admitted for headaches and lightheadedness. CT head negative. Improved with IVF's and transfusions. Discharged on [**2132-1-29**]. * [**2132-2-12**] - HyperCVAD, part B. Gleevec on hold with lower blood counts. * [**2132-2-20**] - Admitted with fever and neutropenia; no infectious etiology found * [**2132-3-16**] - Presented to EW with abdominal pain and increased creatinine to 1.8. Noted for kidney stones. Pain resolved; creatinine now normal. * [**2132-3-22**] - Started Sprycel 100 mg daily; held on [**2132-4-9**] due to increasing diarrhea. * [**2132-4-11**] - Started Gleevac and discontinued on [**2132-6-24**]. POST TRANSPLANT COURSE: D 0 [**2132-7-2**]. Long complicated post transplant course with prolonged admission. Developed acute mental status changes in setting of + HHV6 viremia and CSF involvement treated with Foscarnet induction with recovery of mental status. HHV6 viremia never decreased in the setting of treatment with Foscarnet. Also noted CMV viremia with peak CMV VL in the 700-800 range. Currently on Valganciclovir with most recent CMV viral load undetectable. Ready for discharge on [**2132-9-7**] but developed orthostatic hypotension felt related to autonomic insufficiency. Started on Florinef with improvement in symptoms and blood pressure. Discharged to local apartments on [**2132-9-16**]; returned home as of [**2132-9-27**]. PAST MEDICAL/SURGICAL HISTORY: 1. Non-insulin-dependent diabetes type 2, previously on metformin/glyburide, now on glyburide and insulin -[**2123**] 2. Hypertension - [**2123**] 3. Hyperlipidemia -[**2123**] 4. Hypothyroidism -[**2123**] 5. Cervical DJD/osteoarthritis -[**2119**] 6. CAD status post stenting x1 in [**2123**] 7. Status post cholecystectomy in [**2127**]. 8. Psoriasis, controlled with topicals in the past - dx'ed atage 29 Social History: Living situation: Has returned to own home Isolation: Continues with post transplant restricitons [**Known firstname **] is married and lives with his wife. They have 2 children ages 19 (daughter in nursing school) and son 14. He ran the park/rec dept in [**Location (un) 32775**], MA and worked part time at [**Company 7546**] but is currently not working. EtOH: none Tobacco: Never. Illicits: Denies, no h/o IVDU Diet/Exercise: No regular exercise, tries to follow cardiac/diabetic diet Pets: 1 cat Family History: From [**9-17**] Discharge Summary No known hematologic malignancies Daughter with [**Name2 (NI) 933**] disease Physical Exam: ADMISSION PHYSICAL EXAM GEN: Middle-aged male, fatigued-appearing, lying comfortably in bed, NAD Conjunctiva: not injected Oral mucosa: No oral lesions, moist Neck: Supple, no masses Lungs: CTAB, no wheezes, rhonchi, or rales Cor: normal rate, regular rhythm, nl S1S2 no MRG Abd: Obese, soft, non-tender, nondistended, with normal bowel sounds and without hepatosplenomegaly. scattered superficial ecchymoses. Line: Central venous line dressing clean and site non-tender Ext: 1+ edema, mostly non-pitting, with dark ruddy confluent areas with flaking skin. RLE wrapped in bandages, laceration with marked surrounding erythema unclear if changed from prior Skin: Dry skin on scalp. Mild erythema of psoriatic patches on back; minimal patches on abdomen and chest. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-12**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric DISCHARGE PHYSICAL EXAM: VITALS - Tm 99.7 Tc 98.3 BP 118-130/78-82 P 81-100 R 18 O2 96-99%RA GEN: Awake, alert, oriented, appropriate HEENT: MMM, no ulcers. Small white ulcer on right side of lower lip. Skin: Diffuse areas of hypopigmentation on back, hyperpigmented, hyperepithelialized lower extremities Lungs: decreased breath sounds in all lung fields, shallow breathing, no use of accessory muscles Cardiac: normal rate, regular rhythm, nl S1S2 no MRG Abd: NABS, nontender Ext: trace edema bilateral lower extremities. [**10-27**] exam: healing abrasions without surrounding warmth, erythema, or fluctuance. Area of moist granulation tissue, but no drainage or bleeding on lower shin. SKIN: Right lateral shin has 1cm black nodule with regular borders, non-tender, non pruritic NEURO - CNs II-XII grossly intact, moving all limbs spontaneously, mild tremor bilaterally, no asterixis. ACCESS: Hickman central line; dressing clean and site non-tender Pertinent Results: **********ADMISSION LABS********** [**2132-10-6**] 06:48PM WBC-3.3*# RBC-2.97* HGB-10.2* HCT-28.2* MCV-95 MCH-34.3* MCHC-36.2* RDW-17.0* [**2132-10-6**] 06:48PM NEUTS-87.1* LYMPHS-11.2* MONOS-1.4* EOS-0.1 BASOS-0.1 [**2132-10-6**] 06:48PM PLT COUNT-47* [**2132-10-6**] 06:48PM PT-10.8 PTT-28.6 INR(PT)-1.0 [**2132-10-6**] 06:48PM GLUCOSE-254* UREA N-19 CREAT-0.8 SODIUM-137 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13 [**2132-10-6**] 06:48PM CALCIUM-8.2* PHOSPHATE-3.1 MAGNESIUM-1.7 *********DISCHARGE LABS********* [**2132-10-29**] 12:00AM BLOOD WBC-2.9* RBC-2.82* Hgb-9.0* Hct-25.4* MCV-90 MCH-32.0 MCHC-35.5* RDW-16.1* Plt Ct-58* [**2132-10-29**] 12:00AM BLOOD Neuts-67 Bands-1 Lymphs-11* Monos-18* Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0 NRBC-1* [**2132-10-29**] 12:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2132-10-29**] 10:30AM BLOOD Plt Ct-94*# [**2132-10-29**] 12:00AM BLOOD Glucose-135* UreaN-12 Creat-1.0 Na-136 K-3.5 Cl-101 HCO3-25 AnGap-14 [**2132-10-29**] 12:00AM BLOOD ALT-22 AST-19 LD(LDH)-415* AlkPhos-62 TotBili-0.4 [**2132-10-29**] 12:00AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.6 **********MICROBIOLOGY********** EBV VIRAL LOAD < 200 on [**2132-9-22**], [**2132-9-29**], [**2132-10-13**], [**2132-10-23**] CMV VIRAL LOAD [**2132-8-25**] = 746 copies [**2132-8-26**] = 649 CMV Viral Load (Final [**2132-9-10**]): 796 copies/ml. CMV Viral Load (Final [**2132-9-16**]): 765 copies/ml. CMV viral load [**2132-9-29**], [**2132-10-13**], [**2132-10-21**] negative CMV Viral Load (Final [**2132-10-28**]): 989 copies/ml. HHV6 serology - [**9-22**] - HHV6 1,980,591 [**9-29**] - Herpes Virus 6 DNA, QN [**Numeric Identifier 90980**] [**10-7**] - Herpes Virus 6 DNA, QN PCR >[**Numeric Identifier 73096**] H [**10-23**] - Herpes Virus 6 DNA, QN [**Numeric Identifier 90981**] [**Date range (1) 90982**] multiple negative blood cultures, urine cultures, c. diff **********CSF STUDIES*********** Total Protein, CSF 76* 15 - 45 mg/dL Glucose, CSF 70 mg/dL Lactate Dehydrogenase, CSF 21 IU/L HHV6, EBV PCR, HSV - NOT DETECTED ************IMAGING****************** TIB-FIB X-RAY [**10-1**]: 1. No acute fracture. 2. Extensive vascular calcifications. #[**2132-10-6**] CXR: FINDINGS: As compared to the previous radiograph, there is no relevant change. Borderline size of the cardiac silhouette. No evidence of pneumonia. Known scar at the bases of the right upper lobe. No pleural effusions. No pneumothorax. Double-lumen right central venous catheter in unchanged position. #[**2132-10-7**] Head CT: There is no CT evidence for acute intracranial hemorrhage, large mass, mass effect, edema, or hydrocephalus. There is preservation of [**Doctor Last Name 352**]-white matter differentiation. The basal cisterns appear patent. The ventricles and sulci are normal in caliber and configuration for patient's age. The visualized portions of the paranasal sinuses and mastoid air cells appear well aerated. No acute bony abnormality is detected. #[**2132-10-12**] CT HEAD IMPRESSION: No CT evidence for acute intracranial abnormality. #[**2132-10-13**] TTE The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Compared with the prior study (images reviewed) of [**2132-1-1**], the findings are similar. # [**10-15**] CTA CHEST 1. Occlusive right main pulmonary artery embolus with extension into the lobar and segmental vessels in the right upper and lower lobes. No evidence of right ventricular dysfunction. 2. Small bilateral effusions with associated atelectasis. # [**10-15**] TRANSTHROACIC ECHOCARDIOGRAM Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is mildly dilated There is a very small pericardial effusion located along the infero-lateral left ventricular wall. There are no echocardiographic signs of tamponade. Compared with the prior complete study (images reviewed) of [**2132-10-14**], visualization of the right ventricle is suboptimal. With this limitation, the RV appears slightly more dilated. RV systolic function is probably similar. Left ventricular systolic function is more vigorous. The very small pericardial effusion was present on the prior study. # [**10-15**] LOWER EXTREMITY ULTRASOUND: Bilateral DVT, occlusive on the left, near-occlusive on the right. # [**10-20**] TTE No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>70%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a very small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Mildly dilated right ventricle with mild global wall hypokinesis. Mild symmetric left ventricular hypertrophy with normal global systolic function. Very small pericardial effusion without echocardiographic tamponade. ********* PATHOLOGY ************ [**2132-10-8**] BONE MARROW BIOPSY : HYPOCELLULAR ERYTHROID-DOMINANT MARROW WITH ERYTHROID AND MEGAKARYOCYTIC DYSPOIESIS. NO DIAGNOSTIC MORPHOLOGIC FEATURES OF INVOLVEMENT BY LEUKEMIA SEEN. Brief Hospital Course: 52 year old male with hx of Ph + ALL D +96 (on admission [**10-6**]) double cord transplant, with history of HHV6 encephalitis, diabetes, adrenal insufficiency & orthostatic hypotension (on fludocortisone), who presented as a transfer for fever to 100.6. On [**10-1**] days prior to this admission, he was admitted after he scraped his right shin on a shuttle bus. He got IVIG, and was discharged on [**10-3**]. On this admission, he presented fever and was empirically started on vancomycin and cefepime. He developed a headache on HD2, which was initially thought to be related to IVIG. On HD3, he was somnolent / confused, so an LP was done on [**10-9**]. CSF studies revealed elevated protein, concerning for viral / aseptic meningitis. He was started on foscarnet empirically on [**10-10**], but this was stopped when CSF studies came back negative for HHV6. His mental status improved and the etiology of headache and altered mental status remains unclear to date. He developed acute hypoxemia and was discovered to have an acute pulmonary embolus, provoked by prolonged immobilization and inability to anticoagulate because of thrombocytopenia. # Submassive pulmonary embolus - The patient developed acute hypoxemia on [**10-14**], was found to have a large pulmonary embolus involving the right main with extension into the upper, middle, and lower segmental arteries, and was started on a heparin drip. LENI showed bilateral deep venous thrombi, so he was brought emergently to the cath lab for IVC filter placement. He was brought to the CCU after his thrombectomy and did well. He he was maintained on heparin drip because of thrombocytopenia. Once he was able to maintain his platelet count with every other day platelet transfusions, he was started on subcutaneous lovenox. He developed bleeding complications and was found to be supratherapeutic with the 1mg/kg [**Hospital1 **] dosing of enoxaparin, so he was placed on 1mg/kg DAILY enoxaparin, and factor Xa levels were appropriate. - Anticoagulation should be continued for 6 months for provoked pulmonary embolus, and IVC filter should be removed at the same time (around [**2133-5-15**]) # Fever - Had one isolated fever 101.3 on [**10-12**]. He was started empirically on vancomycin, cefepime. No definitive source was identified. Possible localizing sources: CNS, line infection, cellulitis (however left lower extremity appeared to be healing well and did not appear to be infected or cellulitic), GI (had watery diarrhea on the day he spiked a fever). Most concerning was HHV6 encephalitis, so he was started empirically on foscarnet as described below. CSF studies were negative for HHV6, EBV, HSV. Also possible is foscarnet reaction (has previously had fever & diarrhea with foscarnet). Because he remained afebrile and his WBC counts recovered, antibiotics were stopped on [**10-14**], and he remained afebrile. # Ph + ALLO s/p double cord transplant: On Protocol #11-085, reduced intensity conditioning with fludarabine, melphalan, and low dose TBI followed by double umblical cord blood SCT (D 0 [**2132-7-2**]). Treatment has been complicated by [**Last Name (un) **], mucositis, neutropenic fever, HHV6 infection with CNS involvement, giardiasis, mild GVHD of the gut following engraftment, and CMV viremia. Maximun Grade II GVHD of the GI tract while hospitalized, biopsy-proven from EGD [**2132-7-30**], now resolved. No other evidence for GVHD. Discharged on [**2132-9-16**] after a prolonged hospitalization and is recovering slowly. Counts remain low and seem to fluctuate somewhat in the setting of his medications and infections. - We continued his anti-rejection regimen with methylprednisolone, sirolimus, and tacrolimus. Methylprednisolone was tapered. - Prophylaxis was continued with atovaquone, fluconazole. Valgancyclovir held while on foscarnet. He receives monthly IVIG, last received [**10-3**]. - Scheduled bone marrow biopsy from [**10-8**] revealed no evidence of leukemia but hypocellular marrow with erythroid & megakaryocytic dyspoiesis # Pancytopenia: Chronic pancytopenia likely due to hypoproliferation and recurrent infections. He got neupogen on [**10-9**] and [**10-10**] for downtrending WBCs with good response. # Altered mental status / headache / concern for viral encephalitis - Originally presented with headache which improved with IVF, thought most likely related to IVIG received [**10-3**]. CT head was negative for hemorrhage. The patient had altered mental status [**10-9**]. There was concern for HHV6 encephalitis because the patient has a personal history of HHV6 encephalitis and a persistently elevated HHV6 viral load. Lumbar puncture was performed. CSF studies were positive for elevated protein, consistent with possible aseptic meningitis, so he was started on foscarnet, but was discontinued when CSF HHV6 was confirmed negative. Headache and altered mental status improved. Etiology remains unclear. # CMV viremia - He is on valgancyclovir prophylaxis at home. Valgancyclovir was held in the setting of pancytopenia to allow counts to recover. He developed a positive CMV viral load. He was seen by infectious diseases and was discharged on a suppressive dose of valgancyclovir with infectious disease follow-up. # Orthostatic hypotension: The patient has a h/o orthostatic hypotension on fludrocortisone at home. Orthostatic hypotension was unresponsive to IV fluids which suggests he has a degree of adrenal insufficiency. Of note, methylprednisone has been tapered as he is now > 100 days out from transplant. # CAD/hypertension: Continued home nifedipine. # Diabetes: Patient developed hypoglycemia while tapering methylprednisone, so home glargine was decreased from 30U to 4U, and he was maintained on a sliding scale with humalog. TRANSITION OF CARE - Please keep platelets > 60,000 while on lovenox - CMV levels should be drawn on Friday, [**10-31**], and the dose of valgancyclovir may be changed accordingly - Continue lovenox for 6 months after provoked pulmonary embolus (until [**2133-5-15**]) - IVC filter should be removed in 6 months by interventional cardiology (around [**2133-5-15**]) MEDICATION CHANGES - DECREASE dose of tacrolimus to 0.5 mg twice daily - DECREASE dose of methylprednisone to 2mg daily - DECREASE dose of glargine insulin to 4U each night - START enoxaparin injections 90mg DAILY for 6 months (until [**2133-5-15**]) - START pantoprazole 40mg daily to protect your stomach from bleeding while you are on lovenox Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atovaquone Suspension 1500 mg PO DAILY 2. Calcipotriene 0.005% Cream 1 Appl TP DAILY Apply to affected area 3. Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **] Do not put on face. 4. Fluconazole 400 mg PO Q24H 5. Fludrocortisone Acetate 0.1 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Glargine 30 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 8. Levothyroxine Sodium 100 mcg PO 4X/WEEK (MO,TU,WE,TH) 9. Levothyroxine Sodium 200 mcg PO 3X/WEEK ([**Doctor First Name **],FR,SA) 10. Methylprednisolone 8 mg PO DAILY 11. NIFEdipine CR 30 mg PO DAILY hold for SBP <100 HR <60 12. Ondansetron 8 mg PO Q8H:PRN nausea 13. Sirolimus 1 mg PO DAILY Daily dose to be administered at 6am 14. Tacrolimus 1.5 mg PO Q12H 15. ValGANCIclovir 900 mg PO BID 16. Potassium Chloride 40 mEq PO TID Duration: 24 Hours Hold for K > 5.5 17. Magnesium Sulfate 4 gm IV 4X/WEEK ([**Doctor First Name **],TU,TH,SA) Hold for Mg>2.6 18. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain hold for sedation, rr<12 Discharge Medications: 1. Enoxaparin Sodium 90 mg SC DAILY pulmonary embolus Duration: 6 Months RX *enoxaparin 100 mg/mL Inject 90mL twice a day Disp #*60 Syringe Refills:*5 2. Calcipotriene 0.005% Cream 1 Appl TP DAILY Apply to affected area 3. Atovaquone Suspension 1500 mg PO DAILY 4. Fluconazole 400 mg PO Q24H 5. Fludrocortisone Acetate 0.1 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain hold for sedation, rr<12 8. Levothyroxine Sodium 100 mcg PO 4X/WEEK (MO,TU,WE,TH) 9. Levothyroxine Sodium 200 mcg PO 3X/WEEK ([**Doctor First Name **],FR,SA) 10. Magnesium Sulfate 4 gm IV 4X/WEEK ([**Doctor First Name **],TU,TH,SA) Hold for Mg>2.6 11. NIFEdipine CR 30 mg PO DAILY hold for SBP <100 HR <60 12. Potassium Chloride 40 mEq PO TID Duration: 24 Hours Hold for K > 5.5 13. Ondansetron 8 mg PO Q8H:PRN nausea 14. Methylprednisolone 2 mg PO DAILY RX *methylprednisolone 4 mg 0.5 (One half) tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0 15. Tacrolimus 0.5 mg PO Q12H RX *tacrolimus 0.5 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 16. ValGANCIclovir 900 mg PO Q12H RX *valganciclovir [Valcyte] 450 mg 2 tablet(s) by mouth twice a day Disp #*120 Tablet Refills:*0 17. Sirolimus 1 mg PO DAILY Daily dose to be administered at 6am 18. Glargine 4 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 19. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Primary: Acute lymphocytic leukemia Secondary: Pulmonary embolus, altered mental status, headaches, adrenal insufficiency, diabetes mellitus, hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure caring for you during your recent hospitalization. You came in with a fever and were neutropenic so we started you on antibiotics. We did not identify a clear source of your fevers but they resolved without antibiotics upon discharge. Early in your hospitalization, you complained of headaches and we were concerned that you seemed a bit confused, so you got a lumbar puncture because you have a history of HHV6 encephalitis. You were treated briefly with foscarnet but the spinal fluid did not grow HHV6, so we stopped the foscarnet. Your headaches improved upon discharge. One week into your hospitalization, your oxygen levels dropped and we discovered that you have a large clot in your lungs, which was most likely caused by your prolonged hospitalization which made it difficult for you to walk around. You developed blood clots in your legs, which can travel to your lungs. The treatment for pulmonary embolus is anticoagulation with heparin. You were placed on a heparin IV until your platelet counts were adequate, then we started you on enoxaparin (lovenox) shots. You were seen by dermatology for a skin rash on your right shin. They felt it was a simple hematoma (bruise). Nonetheless you should follow-up in dermatology clinic as an outpatient. It is very important that you keep the following appointments we have made for you. TRANSITION OF CARE - Please keep platelets > 60,000 while on lovenox - Continue lovenox for 6 months after provoked pulmonary embolus (until ~[**2133-5-15**]) - IVC filter should be removed in 6 months by interventional cardiology (~ [**2133-5-15**]) - CMV levels should be drawn on Friday, [**10-31**], and the dose of valgancyclovir may be changed accordingly MEDICATION CHANGES - DECREASE dose of tacrolimus to 0.5 mg twice daily - DECREASE dose of methylprednisone to 2mg daily - DECREASE dose of glargine insulin to 4U each night - START enoxaparin injections 90mg DAILY for 6 months - START pantoprazole 40mg daily to protect your stomach from bleeding while you are on lovenox Followup Instructions: Department: BMT CHAIRS & ROOMS When: FRIDAY [**2132-10-31**] at 9:30 AM Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2132-10-31**] at 9:30 AM With: [**First Name8 (NamePattern2) 8081**] [**Last Name (NamePattern1) 396**], BSN [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/BMT When: FRIDAY [**2132-10-31**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23455**], NP [**Telephone/Fax (1) 3237**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please make a follow-up appointment in the dermatology clinic 1-2 weeks after discharge or earlier if the rash on your right shin does not resolve. Please call [**Telephone/Fax (1) 1971**] to make an appointment. Test for consideration post-discharge: BNP, CMV VL (Friday [**10-31**]), MRI Completed by:[**2132-11-16**]

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Discharge summary

report

Admission Date: [**2181-8-28**] Discharge Date: [**2181-9-9**] Date of Birth: [**2121-2-4**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Cipro / vancomycin / shellfish / Haldol Attending:[**First Name3 (LF) 613**] Chief Complaint: Lethargy Major Surgical or Invasive Procedure: Tunneled hemodialysis catheter removal Hemodialysis catheter insertion left internal jugular central venous catheter hemodialysis History of Present Illness: Ms. [**Known lastname 91333**] is a 60yo female with pmhx of T2DM complicated by nephropathy (ESRD on HD), retinopathy, neuropathy and peripheral vascular disease, CAD, CHF, presented from her rehab with lethargy and hypoglycemia. The patient was scheduled for her HD today, and her vital signs in the AM were normal, although she was felt to be lethargic at her nursing home. In the ambulance on the way to HD, the patient's BG was 60, which improved to 110 after oral sugar. She was then brought to the [**Hospital1 18**] ED for evaluation rather than going to HD. Of note, the patient has chronic pruritis for which she is followed by a dermatologist, she has many excoriations. The patient's [**Hospital1 **] glucose was 60 on admission in the ED. This improved to 106 after a glass of OJ, which also improved her mental status. She was A&Ox1 at time of initial evaluation in the ED. FSGS 66 -> [x]oral OJ -> repeat 68 -> []oral OJ. In the ED, initial VS were: 103.5 101 113/50 16 100% at 1500. She then had a desaturation recorded at 87% at 1600, which improved to 100%. Her [**Hospital1 **] pressure was >100 systolic until around 1900, at which point she decrease to 90 systolic and was maintained around there until 2100. Her fever curve trended down so that she was afebrile at the time of leaving the ED at 22:28. O2 sat for the remainder of stay in the ED. 18g was placed at the wrist. [**Hospital1 **] BP per her nursing home is 90-100 systolic. The patient received 2L NS, Cefepime, Flagyl, Daptomycin and Tylenol. A CXR revealed pulmonary congestion. Her abdomen was distended so a bladder pressure was obtained, which was 18mmHg. A CT abdomen was obtained, which revealed no acute pathology. Nephrology was consulted in the ED, but no note was left. Lactate was 1.5. Per ED report, they evaluated the patient. She was admitted to the MICU for concern for urosepsis due to her [**Hospital1 **] pressures, which is [**Hospital1 5348**] per her nursing home, hypoglycemia. On arrival to the MICU, the patinet was alert and oriented x3, except not to the date but to the month and year. She reported that she had been having periods of "black outs" where she doesn't recall details over the past 3 months. She says that that happened this morning when she does not know what happened, but the next thing she knew, she was at [**Hospital1 18**]. Of note, the patient has recently had the following discontinued or changed: Lantus 24U qhs increased to 26U; gabapentin increased from 300mg after HD to 400mg QID; ativan 0.5mg q8h PRN anxiety was d/c'd; buproprion was d/c'd, venlafaxine d/c'd. Past Medical History: # CAD: STEMI in [**2174**] with occlusion of vein graft INTERVENTIONS: - CABG [**2172**] with LIMA -> LAD and vein graft to [**Last Name (LF) 11641**], [**First Name3 (LF) **] 25 % - [**2174**] stents in left anterior descending and [**Year (4 digits) 11641**] # Systolic CHF, ischemic cardiomyopathy (TTE [**4-2**] with EF 25 - 30%) # PACING/ICD: Right-sided AICD in place ([**2178**]) for primary prevention given EF # DM II, eye and renal manifestations, last HbA1c 9.3% ([**Month (only) 116**] [**2179**]) # asthma # PVD # s/p left BKA [**2176**] # s/p right 1st toe amputation [**2176**] # h/o left intraductal breast cancer - s/p left mastectomy in [**Month (only) 116**]/[**2173**], now question of right-sided breast cancer, which is being followed # s/p cholecytectomy Social History: Hospitalized at [**Hospital1 18**] and/or rehab since [**2180-11-23**]. Otherwise lives in [**Hospital3 **]. Wheelchair-bound. Son [**Name (NI) **] (nurse) is HCP, daughter [**Name (NI) **] also involved; a third son [**Name (NI) **] lives in [**Name (NI) 86**]. -Tobacco history: none -ETOH: rarely -Illicit drugs: denies, but used marijuana in the past Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Exam Vitals: T: 97.7 BP: 90/53 P: 73 R: 18 O2: 94% 3L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: large neck. JVP not appreciated. CV: Regular rate and rhythm, normal S1 + S2, No rubs. Systolic murmer appreciated. Lungs: No wheezes. Mild crackles and coarse breath sounds bilaterally. Good air movement throughout anterior lungs. Abdomen: soft, non-tender, distended, bowel sounds present. GU: no foley Ext: BKA on left. warm, 1+ pulses. Left UE fistula with very faint palpable thrill. Neuro: CNII-XII intact, moving bilateral UE spontaneously. Skin: excoriations throughout the dermis without signs of pus or erythema. Discharge Exam: VS 98 99/54 86 18 98%@4L General: Alert, oriented x3, conversive HEENT: Anicteric sclera, EOMI, NCAT, several healed facial excoriations Neck: No JVD CV: RRR. NS1&S2. [**1-29**] holosystolic murmur at apex Resp: CTAB. Good air flow GI: BS+4. Non-distended. Edematous abdominal wall worse in dependent areas Ext: RLE free from edema. BKA on left. LUE fistula with very faint palpable thrill. Pertinent Results: Admission Labs: [**2181-8-28**] 04:20PM [**Month/Day/Year 3143**] WBC-15.0*# RBC-3.51*# Hgb-10.0*# Hct-32.3*# MCV-92 MCH-28.4 MCHC-30.8* RDW-19.9* Plt Ct-239 [**2181-8-28**] 04:20PM [**Month/Day/Year 3143**] Neuts-90.0* Lymphs-6.5* Monos-3.3 Eos-0.1 Baso-0.2 [**2181-8-28**] 04:20PM [**Month/Day/Year 3143**] Glucose-57* UreaN-52* Creat-5.2* Na-127* K-5.7* Cl-93* HCO3-24 AnGap-16 [**2181-8-28**] 04:20PM [**Month/Day/Year 3143**] ALT-15 AST-27 CK(CPK)-50 AlkPhos-173* TotBili-1.3 [**2181-8-28**] 04:20PM [**Month/Day/Year 3143**] Lipase-23 [**2181-8-28**] 04:20PM [**Month/Day/Year 3143**] CK-MB-3 [**2181-8-28**] 04:20PM [**Month/Day/Year 3143**] Albumin-3.1* [**2181-8-28**] 08:40PM [**Month/Day/Year 3143**] Calcium-8.7 Phos-3.3# Mg-1.8 [**2181-8-28**] 04:35PM [**Month/Day/Year 3143**] Lactate-1.5 [**2181-8-28**] 04:55PM URINE Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.019 [**2181-8-28**] 04:55PM URINE [**Month/Day/Year **]-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [**2181-8-28**] 04:55PM URINE RBC-2 WBC-68* Bacteri-FEW Yeast-NONE Epi-1 [**2181-8-28**] 04:55PM URINE CastHy-8* . Discharge Labs: [**2181-9-8**] 07:00AM [**Month/Day/Year 3143**] WBC-11.7* RBC-2.98* Hgb-8.8* Hct-28.4* MCV-95 MCH-29.6 MCHC-31.1 RDW-21.4* Plt Ct-137* [**2181-9-7**] 08:00AM [**Month/Day/Year 3143**] PT-16.2* PTT-36.6* INR(PT)-1.5* [**2181-9-8**] 07:00AM [**Month/Day/Year 3143**] Glucose-180* UreaN-29* Creat-3.6* Na-133 K-3.5 Cl-96 HCO3-26 AnGap-15 [**2181-9-5**] 01:04AM [**Month/Day/Year 3143**] ALT-5 AST-30 LD(LDH)-203 CK(CPK)-45 AlkPhos-184* TotBili-1.4 [**2181-9-8**] 07:00AM [**Month/Day/Year 3143**] Albumin-3.0* Calcium-8.5 Phos-3.4 Mg-1.9 . Pertinent Labs: [**2181-8-28**] 04:20PM [**Month/Day/Year 3143**] CK-MB-3 [**2181-9-3**] 03:20AM [**Month/Day/Year 3143**] CK-MB-4 [**2181-9-4**] 02:29AM [**Month/Day/Year 3143**] CK-MB-4 cTropnT-0.25* [**2181-9-5**] 01:04AM [**Month/Day/Year 3143**] CK-MB-3 cTropnT-0.25* [**2181-8-30**] 01:45PM [**Month/Day/Year 3143**] TSH-1.7 [**2181-9-2**] 06:28AM [**Month/Day/Year 3143**] Cortsol-24.4* [**2181-9-5**] 01:04AM [**Month/Day/Year 3143**] Digoxin-0.4* [**2181-8-30**] 01:45PM [**Month/Day/Year 3143**] Digoxin-0.5* [**2181-8-29**] 03:14AM [**Month/Day/Year 3143**] Digoxin-0.6* [**2181-9-4**] 03:07AM [**Month/Day/Year 3143**] Type-ART Temp-38.1 pO2-131* pCO2-43 pH-7.37 calTCO2-26 Base XS-0 Comment-AXILLARY T [**2181-8-30**] 12:44PM [**Month/Day/Year 3143**] Type-ART pO2-75* pCO2-37 pH-7.45 calTCO2-27 Base XS-1 . Micro: [**2181-9-5**] [**Numeric Identifier 3143**] CULTURE [**Numeric Identifier **] Culture, Routine-PENDING INPATIENT [**2181-9-4**] [**Numeric Identifier 3143**] CULTURE [**Numeric Identifier **] Culture, Routine-PENDING INPATIENT [**2181-9-4**] [**Numeric Identifier 3143**] CULTURE [**Numeric Identifier **] Culture, Routine-PENDING INPATIENT [**2181-9-3**] [**Year (4 digits) **] Culture, Routine-PENDING [**2181-9-3**] [**Year (4 digits) **] Culture, Routine-PENDING [**2181-9-2**] URINE CULTURE-FINAL {YEAST} [**2181-9-1**] [**Year (4 digits) **] Culture, Routine-Neg [**2181-9-1**] STOOL C. difficile DNA amplification assay-Neg [**2181-9-1**] [**Year (4 digits) **] Culture, Routine-Neg [**2181-8-31**] URINE CULTURE-FINAL {YEAST} [**2181-8-30**] [**Year (4 digits) **] Culture, Routine-MSSA [**2181-8-30**] URINE CULTURE-FINAL {YEAST} [**2181-8-30**] [**Year (4 digits) **] Culture, Routine-MSSA [**2181-8-30**] [**Year (4 digits) **] Culture, Routine-MSSA [**2181-8-30**] [**Year (4 digits) **] Culture, Routine-Neg [**2181-8-30**] [**Year (4 digits) **] Culture, Routine-Neg [**2181-8-29**] CATHETER TIP-IV WOUND CULTURE-MSSA [**2181-8-29**] [**Year (4 digits) **] Culture, Routine-MSSA [**2181-8-29**] [**Year (4 digits) **] Culture, Routine-Neg [**2181-8-29**] URINE CULTURE-FINAL {YEAST} [**2181-8-29**] URINE CULTURE-FINAL {YEAST} [**2181-8-29**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS} [**2181-8-28**] [**Year (4 digits) **] Culture, Routine-MSSA [**2181-8-28**] [**Year (4 digits) **] Culture, Routine-MSSA [**2181-8-28**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL {STAPH AUREUS COAG +, STAPH AUREUS COAG +} EMERGENCY . Studies: EKG [**2181-8-28**] Normal sinus rhythm. First degree A-V block. Left axis deviation. Intraventricular conduction defect. Non-specific ST-T wave abnormalities. Compared to the previous tracing of [**2181-6-29**] intraventricular conduction defect is more marked and heart rate has increased. . CXR [**2181-8-28**] IMPRESSION: Moderate cardiomegaly and mild pulmonary edema. No evidence of pneumonia. . CT Abd Pelvis woth contrast [**2181-8-28**] Small-to-moderate amount of simple ascites and anasarca may be from fluid overload. Extensive atherosclerotic disease of the abdominal aorta and major visceral branches. Hepatic steatosis. Fibroid uterus. . CXR [**2181-8-29**] There is no significant change since prior exam. There is no new lung consolidation. Pulmonary edema is severe. . CXR [**2181-9-3**]: No new focal consolidation to suggest pneumonia. Stable pulmonary edema. . Cardiac Echo [**2181-8-30**] Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. [Due to acoustic shadowing from the defibrillator coil, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2181-6-11**], the findings are similar. IMPRESSION: no vegetations seen . CT Head [**2181-8-30**]: No acute intracranial process . CXR [**2181-9-3**]: No new focal consolidation to suggest pneumonia. Stable pulmonary edema. Brief Hospital Course: 60yo female with pmhx of CAD, CHF, ESRD on HD, T2DM, and history of chronic pruritic excoriations presented with lethargy, found to have MSSA sepsis secondary to infected [**Month/Day/Year 2286**] line vs. infected skin sores. Required intermittent pressure support. course also c/b delirium [**1-25**] toxic-metabolic encephalopathy. Delirium cleared and will be empirically treated as outpt with 6 week course of cefazolin (day 1:[**2181-9-8**]) . # MSSA Bacteremia: Presented with SIRS criteria for leukocytosis and transient hypotension (although may have been near [**Month/Day/Year 5348**]). Initial empiric coverage with daptomycin (vanco allergy), flagyl, and cefepime. Lactate normal. [**Month/Day/Year **] on [**2181-8-28**] grew MSSA in [**1-25**] bottles, wound cultures grew MSSA as well, and nasal swab grew MRSA. Surveilance cultures 9/6 grew MSSA. RIJ tip culture also grew MSSA. Urine cultures on [**8-29**] grew yeast. CXR [**2181-8-29**] concerning for pneumonia, so daptomycin was swithced to Linezolid, flagyl was DC'd. The patient remained afebrile and WBC trended down. She was transferred to the floor on [**8-30**]. She was transferred back to the MICU on [**9-1**] for worsening mental status and hypotension. Surveillance BCxs remained negative, but given worsening clinical picture, antibiotics were broadened to daptomycin and cefepime. Dapto and cefepime started on [**9-3**], and per ID, to be continued for 7 days, followed by 6 weeks of cefazolin for presumptive MSSA endocarditis (TTE showed no vegetations; TEE not pursued as not within patient's goals of care). Transferred back to the floor wher VS were stable oand treated for a total of 6 days with IV cefepime/dapto. Switched to cefazolin 2g Post HD (day 1:[**2181-9-8**]). [**Month/Day/Year **] cultures negative to date. . #Hypotension: possibly [**1-25**] sepsis, possibly related to HD. Pt. was occasionally on low-dose norepinephrine. This was discontinued on [**9-5**] and patient was started on midodrine 10mg TID. Pt. tolerated HD from hemodynamic standpoint on this regimen. Midodrine started in an attempt to wean off pressors. At rehab, [**Month/Year (2) **] pressure should be monitored ([**Month/Year (2) 5348**] pressures ~80's systolic) and midodrine weaned as tolerated. . # AMS: Likely multifactorial including sepsis, hypoglycemia, polypharmacy, and underlying psychiatric condition. The patient's mental status fluctuated from lethargy at presentation to evening lucidity and profound AM somnolence, as well as hyperactive delirium with paranoia and hallucinations. ABG was not conerning for hypercarbia, and was not hypoglycemic during admission and without signs active infection. Per psych recs, Zyprexa 5mg in [**Hospital1 **], plus 10mg QHS dose. Remained lucid while on the floor. Hydroxyzine was held in an attempt to limit sedating medications, however, may be slowly restarted at rehab facility. . # Hypoglycemia: Most likely due to infection. The patient is taking insulin with only a slight increase in her lantus from 24U to 26U prior to admission, otherwise is on a fairly moderate humalog sliding scale. She denies changes in diet. BG monitored 5x/day, the patient ate regular meals. Lantus was held and pt.'s [**Hospital1 **] glucose was adequately controlled with regular insulin sliding scale, however, became hyperglycemic near day of discharge. Low dose lanutus restarted at 10U qday, and will need to be uptitrated. . # CKD stage V on HD: Patient received make-up HD on hospital day two, then line removed. HD line was replaced on [**8-31**] and pt. resumed intermittent HD. . #Acute on chronic systolic CHF: Euvolemic on admission with O2 requirement but it is minimal. Digoxin was held, and a digoxin level was 0.6. She had a 1500cc fluid restriction and I/O's trended. Was volume overloaded after [**Hospital **] transfer to floor, however, after several UF HD sessions became euvolemic. EF on [**2181-8-30**] 35%. Thought that ESRD contributed to acute on chronic systolic heart failure. . # CAD: no CP or anginal symptoms at this time. Continued aspirin, simvastatin. Plavix has been discontinued per [**Date Range 2287**] records and [**Hospital3 2558**] [**Month (only) 16**]. . # DM II, uncontrolled with complications: multiple complications although control has improved with most recent HgA1c at goal. Likely significant contributor to multiple medical problems. [**Name (NI) **] sugars difficult to control, and will need to be monitored and insulin adjusted as necessary. . # Depresion: Seen by psychiatry after reporting SI and depressed mood. Restarted venlafxine at discharge with the plan to continue at 37.5mg through [**2181-9-9**]. Then increase to 75mg daily. Holding Wellbutrin, but may restart on [**2181-9-14**]. Also started on zyprexa 5mg TID and 10mg hs. Daily EKG to monitor QTc. . # Goals of care: Spoke with HCP (son [**Doctor Last Name **] and daughter [**Name (NI) 8982**] regarding goals of care given patient's multiple hospitalizations. Pt and family reaffirmed that she is DNR/DNI. Patient expressed that she is "tired of this" and would rather be home than in the hospital. Family and patient stated that they would like for her to be treated with IV antibiotics for the 6 week duration suggested by ID. Options of obtaining TEE to look for endocarditis and for consideration of pacemaker removal given her bacteremia were discussed. After discussion of risks and benefits, family decided not to pursue either. They stated that they would like to have hospice care consult initiated at rehab. If re-hospitalization is recommended during her rehab stay, the family should be [**Name (NI) 653**] for a discussion before patient is again admitted to the hospital. On day of discharge pt requested to go over goals of care again, citing "I want my family to know that moms OK". Unfortunately her son was not able to be [**Name (NI) 653**], and pt agreed to have discussion at LTAC. . Transitional Issue: #Started Midodrine on transfer out of MICU, [**Name (NI) **] pressures need to be monitored, midodrine weaned as appropriate. #Restarted effexor at 37.5mg. Will need to increase dose to 75mg qday on [**2181-9-10**]. [**Month (only) 116**] restart Wellbutrin on [**2181-9-14**] #Held scheduled lantus due to initial hypoglycemia, however restarted on day of discahrge [**1-25**] hyperglycemia. Will need to be closely monitored and titrated up as necessary. #Will need follow-up scheduled with PCP [**Last Name (NamePattern4) **] [**4-1**] days #Will need to treat for 6 weeks with cefazolin 2g post HD, and 3g post HD on long cycle (tues of T,TH,Sa schedule) #Will need weekly CBC w/ diff, ESR/CRP, to be drawn at HD Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from [**Hospital3 2558**]. 1. Gabapentin 400 mg PO QID Start: q48h give only on days after HD. In the evening. 2. Docusate Sodium 100 mg PO BID hold for loose stools 3. Digoxin 0.0625 mg PO EVERY OTHER DAY on non-HD days 4. Calcium Acetate 1334 mg PO TID W/MEALS 5. Aspirin 81 mg PO DAILY 6. Ascorbic Acid 500 mg PO DAILY 7. Nephrocaps 1 CAP PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD DAILY apply to back 9. Metoprolol Tartrate 12.5 mg PO BID on NON HD DAYS. Hold for SBP < 90, HR < 55 10. Pantoprazole 40 mg PO Q12H 11. Senna 2 TAB PO HS hold for loose stools 12. Simvastatin 40 mg PO DAILY 13. HydrOXYzine 25 mg PO Q8H:PRN pruritis 14. Guaifenesin [**5-3**] mL PO Q6H:PRN cough 15. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain hold for somnolence, RR<12 16. Glargine 26 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Preadmission medications listed are correct and complete. Information was obtained from [**Hospital3 2558**]. 1. Gabapentin 400 mg PO QID Start: q48h give only on days after HD. In the evening. 2. Docusate Sodium 100 mg PO BID hold for loose stools 3. Digoxin 0.0625 mg PO EVERY OTHER DAY on non-HD days 4. Calcium Acetate 1334 mg PO TID W/MEALS 5. Aspirin 81 mg PO DAILY 6. Ascorbic Acid 500 mg PO DAILY 7. Nephrocaps 1 CAP PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD DAILY apply to back 9. Metoprolol Tartrate 12.5 mg PO BID on NON HD DAYS. Hold for SBP < 90, HR < 55 10. Pantoprazole 40 mg PO Q12H 11. Senna 2 TAB PO HS hold for loose stools 12. Simvastatin 40 mg PO DAILY 13. HydrOXYzine 25 mg PO Q8H:PRN pruritis 14. Guaifenesin [**5-3**] mL PO Q6H:PRN cough 15. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain hold for somnolence, RR<12 16. Glargine 26 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Ascorbic Acid 500 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Digoxin 0.0625 mg PO EVERY OTHER DAY on non-HD days 4. Docusate Sodium 100 mg PO BID hold for loose stools 5. Lidocaine 5% Patch 1 PTCH TD DAILY apply to back 6. Metoprolol Tartrate 12.5 mg PO BID on NON HD DAYS. Hold for SBP < 90, HR < 55 7. Nephrocaps 1 CAP PO DAILY 8. Senna 1 TAB PO BID hold for loose stools 9. Heparin Flush (1000 units/mL) 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line flush [**Numeric Identifier **] Catheter (Tunneled 2-Lumen): [**Numeric Identifier **] NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. 10. Hydrocerin 1 Appl TP TID Apply to excoriations on arms 11. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR DAILY PRN rectal pain 12. Midodrine 10 mg PO TID 13. Mupirocin Cream 2% 1 Appl TP [**Hospital1 **] Apply to arm excoriations 14. OLANZapine 5 mg PO HS:PRN agitation please hold for sedation or RR<10 15. Venlafaxine XR 37.5 mg PO DAILY 16. HydrOXYzine 25 mg PO Q8H:PRN pruritis 17. Pantoprazole 40 mg PO Q12H 18. Calcium Acetate 1334 mg PO TID W/MEALS 19. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain hold for somnolence, RR<12 20. Simvastatin 40 mg PO DAILY 21. CefazoLIN 2 g IV POST HD Give 3g when >2 days between HD 22. Glargine 10 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 23. OLANZapine (Disintegrating Tablet) 5 mg PO TID agitation Hold for sedation or RR <10 Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: Primary diagnosis: Sepsis secondary to staph aureus bacteremia (MSSA) chronic kidney disease stage V on HD acute on chronic systolic congestive heart failure delirium secondary to toxic-metabolic encephalopathy insulin diabetes mellitus type II, uncontrolled with complications hypoglycemia Secondary diagnoses Pruritus w/ excoriations/ diabetic dermopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with a bacterial infection in your [**Hospital1 **], and your [**Hospital1 **] sugar was low. You were treated with antibiotics through your veins. We believe the infection was due to your hemodialysis catheter, so it was pulled during your time in the intensive care unit. A second hemodialysis catheter was placed after your [**Hospital1 **] cultures were no longer growing bacteria. At discharge you demonstrated no signs of bacterial [**Hospital1 **] stream infection. Because you did not want to get a transesophageal echocardiogram or have your AICD pulled we want you to take cefazolin for the next 6 weeks. This should adequately treat any infection of your heart or AICD, if there is one there. Your [**Hospital1 **] pressure was difficult to control and at times it became very low. We were concerned this may due to the infection in your [**Hospital1 **], and you were treated in the intensive care unit with medication to increase your pressure. You will be continued on one of these medications, midodrine, as an outpatient. At discharge your [**Hospital1 **] pressure was stable. You were intermittently confused and tired during your stay at [**Hospital1 18**]. We believe this is due to your underlying renal failure in addition to your [**Hospital1 **] stream infection. It also may have been due to your hydroxyzine. Your hydroxyzine was stopped for this reason. Your itching was not changed after stopping this, but if it worsens you should inform your PCP. [**Name10 (NameIs) **] discharge you were not confused and able to carry on full conversations. Your [**Name10 (NameIs) **] sugar was difficult to control while in-house. It initially was very low, so you were taken off of standing lantus. Prior to discharge your [**Name10 (NameIs) **] sugar was elevated, so we placed you back on 20 U lantus. Your sugars should be checked at least 4 times daily in your rehab facility, and insulin should be adjusted accordingly. Psychiatry visited you while you were here because of your depressed mood. They restarted you back on effexor. You will continue this at rehab, and gradually increase your dose. Once you reach the maximum dose, you can then start your wellbutrin. You will need to keep your hemodialysis line in place for now. You will need to follow up with your outpatient nephrologist in order to image your fistula in your left arm. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Will need to schedule follow-up with PCP [**Name Initial (PRE) 176**] 4-8 days of discharge from the rehab facility: [**Doctor Last Name 4610**], Lauraine E. MD [**Last Name (Titles) **]:[**Telephone/Fax (1) 91335**] You will need to follow-up with your nephrologist Dr. [**Last Name (STitle) 4883**]. You need to have an outpatient fistulagram. Address: [**Street Address(2) 7160**], [**Hospital Ward Name **] 8, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 721**] Fax: [**Telephone/Fax (1) 9420**] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "38.97", "86.05", "00.14", "38.91", "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

21975, 22018

11903, 18595

340, 471

22420, 22420

5564, 5564

25112, 25770

4302, 4417

20484, 21952

22039, 22039

18621, 20461

22596, 25089

6724, 7262

4432, 5133

5149, 5545

292, 302

499, 3112

5580, 6708

22058, 22399

22435, 22572

7278, 11880

3134, 3913

3929, 4286

40,738

137,564

39698

Discharge summary

report

Admission Date: [**2124-9-13**] Discharge Date: [**2124-9-30**] Date of Birth: [**2058-2-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1377**] Chief Complaint: Nausea, vomiting, coffee ground emesis Major Surgical or Invasive Procedure: Inutbation EGD History of Present Illness: 66 yo male with recent dx of alcoholic hepatitis and alcoholic cirrhosis just discharged [**9-9**] who presents with nausea and vomiting. He was admitted to [**Hospital1 18**] [**Date range (1) **] with peripheral edema, jaundice and progressive abdominal distention and was diagnosed with acute alcoholic hepatitis and alcoholic cirrhosis. He also had an NG tube placed for dietary supplementations. He was discharged 5 days ago. Since then, he reports feeling tired. Last night he developed the acute onset of nausea with 2 episodes of vomiting. He had been on continuous tube feeds at 60cc/hr. He reports dark vomitus but no overt blood. At that time he vomited up his NG tube. Also reports dark, loose, occasionally sticky stools for multiple weeks, unchanged in last few days. He reports having 1 BM per hour for multiple days. He went to [**Hospital3 **] where he was noted to have coffee ground emesis and guaiac-positive melena. He was also hyponatremia to 125, hyperkalemia to 6.2 with peaked T waves, and abnormal LFTs. He was given 150mg IV solumedrol, kayexelate, and protonix and transferred here. In our ED, initial vitals were 97.6 112 152/80 18 95%4L. Labs were notable for Na 128, K 6.9, Hct 33.0 (baseline 39), WBC 20.8, plts 108. ECG showed hyperacute T waves. He was given 2g IV calcium gluconate. 1 amp D50W, 10mg IV insulin. Did diagnostic paracentesis which had WBC 95. NG lavage was attempted but when he sat up, he felt ill and had an episode of chest pain and dropped his SBP 90's. He was given another dose of protonix and zofran, as well as morphine for chest pain. ECG was reportedly unchanged with the chest pain episode. 2 PIV 18g were placed. Type and crossed x 4 units, not transfused. Vitals on transfer were BP 120/70 HR 120 RR 28-32 94-96%2L. Hct 6 points lower than at discharge. Not gotten blood, type and screened, add on cross x4. Review of Systems: Negative for fever, chills, night sweats, HA, chest pain (prior to admission), SOB, abdominal pain, constipation, urinary changes. Past Medical History: Alcoholic cirrhosis, recently diagnosed with acute alcoholic hepatitis Hepatic mass: Found to have 10mm hypodensity posteriorly in the right lobe of the liver, AFP was 4.7. History of GIB with positive NG lavage but couldn't tolerate EGD in the past, patient says was told he had polyps BPH HTN GERD Social History: Hispanic, speaks Spanish & English, married to his wife [**Name (NI) 1439**]. [**Name2 (NI) **] heavy EtOH consumption (1 L hard liquor/day) since age of 17 (x50yrs) but quit 2 months ago. No drinking since recent discharge. Denies tobacco or IVDU. Works for department of transportation. Family History: Father died of gall bladder cancer, mother died of "poor diet." Physical Exam: VS: T 98.2 BP 118/81 HR 127 RR 20 O2 Sat 95%3L GEN: Awake, alert, lying in bed in NAD. HEENT: PERRLA, EOMI, sclera icteric. MM slightly dry without lesions. No palpable lymphadenopathy. No thyromegaly. RESP: CTA b/l with good air movement throughout CV: RRR with III/VI systolic murmur at LUSB ABD: Distended with +BS, no tenderness, + fluid wave, ? palpbale spleen EXT: 1+ peripheral edema, nonpitting SKIN: Spider angioma notble across chest, skin jaundiced throughout NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. Pertinent Results: Admission Labs: [**2124-9-13**] 10:15AM WBC-20.8*# RBC-3.26* HGB-11.4* HCT-33.0* MCV-101* MCH-35.0* MCHC-34.6 RDW-18.6* [**2124-9-13**] 10:15AM NEUTS-90* BANDS-1 LYMPHS-3* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-1* NUC RBCS-1* [**2124-9-13**] 10:15AM PLT SMR-LOW PLT COUNT-108*# [**2124-9-13**] 10:15AM PT-20.3* PTT-36.8* INR(PT)-1.9* [**2124-9-13**] 10:15AM CALCIUM-8.2* PHOSPHATE-5.1*# MAGNESIUM-2.1 [**2124-9-13**] 10:15AM ALT(SGPT)-135* AST(SGOT)-140* TOT BILI-13.6* [**2124-9-13**] 10:15AM LIPASE-54 [**2124-9-13**] 10:15AM cTropnT-0.01 [**2124-9-13**] 10:15AM GLUCOSE-208* UREA N-47* CREAT-0.9 SODIUM-128* POTASSIUM-6.9* CHLORIDE-96 TOTAL CO2-23 ANION GAP-16 [**2124-9-13**] 10:55AM ASCITES WBC-95* RBC-925* POLYS-9* LYMPHS-9* MONOS-0 PLASMA-1* MESOTHELI-5* MACROPHAG-74* OTHER-2* [**2124-9-13**] 10:21AM K+-6.8* [**2124-9-13**] 10:55AM ASCITES ALBUMIN-LESS THAN [**2124-9-13**] 11:43AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-15 BILIRUBIN-MOD UROBILNGN-4* PH-6.5 LEUK-NEG [**2124-9-13**] 11:43AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.023 [**2124-9-13**] 03:10PM LACTATE-9.3* [**2124-9-13**] 03:10PM TYPE-[**Last Name (un) **] PO2-153* PCO2-31* PH-7.44 TOTAL CO2-22 BASE XS--1 COMMENTS-GREEN TOP Micro: [**9-13**] Urine cx- no growth [**9-13**] Peritoneal fluid- no growth (prelim) [**9-13**] Blood cx- pending [**9-13**] C. diff- negative [**9-14**] C. diff- negative [**9-15**] CMV VL- pending Studies: CXR [**2124-9-13**]: Low lung volumes and bibasilar atelectasis. [**9-14**] EGD Impression: Varices at the middle third of the esophagus, lower third of the esophagus and gastroesophageal junction (ligation) Erythema, congestion, abnormal vascularity and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy Otherwise normal EGD to third part of the duodenum Recommendations: Clear liquid diet for the next 24 hours, then soft diet for the following 24 hours. Continue PPI and Octreotide gtts, start Carafate slurry 1gram PO QID, continue antibiotics. Will need f/u endoscopy in 2 weeks. [**2124-9-14**] Echo: The left atrium is normal in size. Left ventricular wall thicknesses are normal. Left ventricular systolic function is hyperdynamic (EF 80%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: hyperdynamic left ventricle; mild left ventricular outflow tract obstruction [**2124-9-15**] Abd U/S w/ Dopplers: 1. Patent main, right, and left portal veins. 2. Cirrhosis with portal hypertension, mild splenomegaly, moderate ascites, as before. Brief Hospital Course: 66 yo male with recent dx of alcoholic hepatitis and alcoholic cirrhosis just discharged [**9-9**] who presents with nausea and vomiting and likely upper GI bleed. * Pt's condition deteriorated and family decided to take him home with [**Month/Year (2) **] when recovery of liver function was very unlikely. . #. Upper GI bleed: Had melena in the ED with reports of coffee ground emesis at the OSH. Hct was as low as 28. Given initial concern for active bleeding, patient was transfused 2u PRBCs on admission. EGD here with 2 grade III varices with stigmata of recent bleeding and portal hypertensive gastropathy. Treated with iv PPI, octreotide, CTX x5 days. HCT was stable at 32 for several days, and patient required no further transfusions. His metoprolol was stopped, and he was started on Nadolol 40mg po daily for prophylaxis. No active bleeding throughout admission. # Decompensated Alcoholic Cirrhosis: Recent diagnosis of alcoholic hepatitis and alcoholic cirrhosis. Tbili was initially 13.6 on admission, and climbed to.... transaminases peaked in the 800s. A RUQ US was performed that showed no portal vein thrombosis. Patient's acute on chronic liver decompensation was attributed to shock liver in the setting of likely hypotension during his UGIB. Last drink was 2 months ago. [**Hospital **] hospital course was complicated by encephelopathy for which he was treated with lactulose and rifaximin. He was continued on thiamine, folic acid, MVI. Held steroids and diuretics on admission. Diuretics (lasix 40 and spironolactone 100) were restarted when patient was transferred out of the ICU. Came to the floor and had progressively worsening MELD to 45. Had likely shock liver from bleed followed by cholestasis of sepsis [**1-25**] UTI. Pt was not transplant candidate and decision was made with family to take him home with [**Month/Day (2) **] because his liver function was not recovering. # HRS - renal fxn began to decline, Cr rose to >5 over 4 days despite volume challenges, octreotide and midodrine. Started on HD but were unable to take off sufficient volume due to hypotension. Decided to stop HD when family decided to take him home with [**Month/Day (2) **]. #. Chest pain and elevated troponin: Had episode of chest pain in the ED. No known h/o CAD. Trop 0.01-->0.08--->0.05 felt to be [**1-25**] tachycardia in setting of acute Hct drop. ECG with some new TWI in lateral precordial leads but rate also increased and in the setting of hyperkalemia. CK and MB did not bump. No ASA given GIB. #. Leukocytosis: WBC elevated to 20.8 on admission (was 9.2 on [**9-9**]). No e/o infection, CXR, UA, stool, and blood negative. Thought to be [**1-25**] steroids given on last admission. Initially treated for severe c/diff with iv flagyl and po vanco, but negative x2. Patient was continued on Ceftriaxone for variceal bleed. Found to have enterococcal UTI, copmleted course of linezolid. #. Hyponatremia: Had slowly downtrending Na at the time of prior discharge on [**9-9**]. Thought this is most likely related to his new use of diuretics which were held on admission. Na normalized to 135. #. Hepatic mass: Needs outpatient MRI to evaluate. Concern for HCC. AFP at last admission 4.7. #. GERD: Patient was initally on IV PPI which was transitioned to a PO PPI. #. Code: DNR/DNI. Medications on Admission: Thiamine HCl 100mg po daily Folic acid 1mg po daily Omeprazole 20mg po daily Metoprolol 25mg po bid Prednisone 40mg po daily x 24 days Spironolactone 100mg po daily Furosemide 40mg po daily Sulfamethoxazole-Trimethoprim 800-160mg po daily MVI 1 tab po daily Discharge Medications: 1. morphine concentrate 20 mg/mL Solution Sig: 0.1-0.2 ml PO every 4-6 hours as needed. Disp:*10 mL* Refills:*0* 2. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:*60 Tablet(s)* Refills:*0* 3. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day: Take for volume overload to increase urine output. Disp:*30 Tablet(s)* Refills:*2* 4. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for Dry eyes. 6. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q2H (every 2 hours). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Home With Service Facility: comunity nurse [**First Name (Titles) **] [**Last Name (Titles) **] care Discharge Diagnosis: Primary: Esophageal variceal bleed UTI Hepatorenal syndrome Liver failure Secondary: Alcoholic hepatitis and cirrhosis HTN Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with bleeding from your varices. You were taken to the ICU and stabilized there. When you came to the floor, your liver began to fail from the lack of blood flow during the bleed. With the liver failure, your kidney function began to decline as well. You also developed a urinary tract infection which we treated with antibiotics. Unfortunately, your liver function did not recover as well as we hoped and your kidneys continued to worsen. We started hemodialysis to attempt to recover your kidney function, but were not able to remove enough fluid with each session due to your blood pressure being too low. With the bleed that brought you to the hospital and the subsequent infection, your liver continued to fail. After a long discussion with you and the family, it was decided that you would go home with [**Last Name (Titles) **] services. It was a pleasure taking care of you in the hospital. Your [**Last Name (Titles) **] team will manage all of your medications and services at home. Followup Instructions: [**Last Name (Titles) **] at home [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**] Completed by:[**2124-9-30**]

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icd9cm

[ [ [] ] ]

[ "54.91", "42.33", "38.95", "39.95", "96.6" ]

icd9pcs

[ [ [] ] ]

11339, 11442

6859, 10184

354, 371

11610, 11610

3774, 3774

12851, 13038

3095, 3160

10492, 11316

11463, 11589

10210, 10469

11797, 12828

3175, 3755

2315, 2447

276, 316

399, 2296

3791, 6836

11625, 11773

2469, 2770

2786, 3079

15,761

181,336

17747

Discharge summary

report

Admission Date: [**2131-7-4**] Discharge Date: [**2131-7-11**] Date of Birth: [**2066-8-15**] Sex: Service: BMT HISTORY OF PRESENT ILLNESS: This is a 64-year-old male with a history of non-Hodgkin's lymphoma diagnosed in [**2126**] status post autologous bone marrow transplant in [**2130-11-25**]; status post recent admission in [**2131-6-13**] for community- acquired pneumonia, now transferred from [**Hospital6 14430**]. The patient had onset of mild low back pain in mid [**Month (only) 116**]. On [**2131-6-16**], he had the onset of severe low back pain and went to the [**Hospital1 1474**] ED where he was treated and released. Next day, he had worsening pain, urinary retention, and leg numbness. MRI showed T10-T11 cord compression and on [**2131-6-19**], he was transferred to [**Hospital1 2177**] for laminectomy. Pathology was positive for a lymphoma. Since the operation, his leg strength has improved; although, he still needs a walker. He is still having urinary retention. He is still continuing to have some nocturnal back pain radiating to his chest, described as dull pressure [**6-4**]. PAST MEDICAL HISTORY: 1. Non-Hodgkin's lymphoma, stage 4 follicular center cell grade 1, diagnosed in [**2126**] status post CVP; achieved complete remission until [**2129**], then it transformed to large cell lymphoma with mesenteric involvement status post CHOP times 6 cycles and status post auto-BMT in [**2130-11-25**]. He is also status post Zevalin in [**Month (only) **] [**2130**]. 2. History of pneumonitis status post transplant. 3. History of community acquired pneumonia treated with Levaquin in [**2131-5-26**] and cefpodoxime for 14 days. 4. Status post hernia repair. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: 1. Colace 100 mg b.i.d. 2. Terazosin. 3. Percocet. 4. Ambien. 5. Protonix. 6. Dexamethasone 4 mg b.i.d. 7. Dulcolax. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Former truck driver, widowed with 2 children, no alcohol, prior 25-pack-year tobacco history. PHYSICAL EXAMINATION: Temperature 99.8 degrees, blood pressure 133/86, heart rate 101, respiratory rate 16. In general, he is in no acute distress. Head, neck, cardiac, pulmonary, abdominal exams were normal. Extremity exam showed trace edema. Neurologic exam revealed full strength except 4 plus out of 5 left knee flexion. Sensory exam was normal. Deep tendon reflexes were 1 plus in the upper extremities, trace at the knee on the left; absent at the knee on the right with down going toes. LABORATORY DATA: Biopsy at the outside hospital showed 80 to 90 percent large lymphoid cells and flow cytometry was consistent with lymphoma. IMPRESSION: This is a 64-year-old man with a history of non- Hodgkin's lymphoma status post auto-BMT in [**2130-11-25**]; admitted to outside hospital with cord compression now status post laminectomy secondary to transformed mantle cell lymphoma. HOSPITAL COURSE: The patient was emergently started on DHAP chemotherapy which he tolerated well; although, he did have significant tumor lysis, LDH peaked at 9 to 10 thousand, phosphate was elevated and uric acid was controlled with allopurinol. On [**2131-7-6**] and [**2131-7-7**], the patient had increasing O2 requirement and on the afternoon of [**2131-7-7**] at approximately 4 p.m., he acutely desaturated and had decreased blood pressure in the setting of Lasix; in addition to spiking a temperature to 102 and he was transferred to the Sennard ICU for further care. In the ICU, the etiology of his pulmonary infiltrates and hypoxemia was unclear, infectious including fungal, PCP, [**Name10 (NameIs) **] bacterial versus CHF. He was started on voriconazole; azithromycin, cefepime, and vancomycin were continued. Echocardiogram showed severe right ventricular global hypokinesis and mild left ventricular dysfunction. Additionally, he developed acute non-oliguric renal failure and ATN likely secondary to a combination of Lasix, chemotherapy medications, and decreased blood pressure. On [**2131-7-10**], he started having mental status changes and paranoia. By the morning of the [**2131-7-11**], he was only responsive to painful stimuli. After family meeting with the ICU team and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], it was decided to make the patient comfort measures only and he was transferred back to the BMT service. The patient was treated with morphine and Ativan as necessary for comfort. At 10:25 p.m. on the night of [**2131-7-11**], the patient was found with no respirations, pulse and not responsive to painful stimuli. DISCHARGE CONDITION: Deceased. DISCHARGE DIAGNOSES: 1. Relapse non-Hodgkin's lymphoma with cord compression. 2. Acute renal failure. 3. Hypoxemia. 4. Pulmonary infiltrates. 5. Tumor lysis syndrome. DISCHARGE MEDICATIONS: No discharge medications or followup plans as the patient is deceased. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 36051**] Dictated By:[**Last Name (NamePattern1) 49323**] MEDQUIST36 D: [**2131-12-6**] 13:30:01 T: [**2131-12-7**] 14:52:12 Job#: [**Job Number 49324**]

[ "284.8", "486", "336.3", "788.20", "996.85", "V58.1", "584.9", "202.80", "518.81" ]

icd9cm

[ [ [] ] ]

[ "99.25", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

4687, 4698

1945, 1963

4719, 4867

4891, 5232

2989, 4665

2098, 2971

161, 1138

1809, 1928

1160, 1784

1980, 2075

22,766

165,735

53735

Discharge summary

report

Admission Date: [**2198-1-23**] Discharge Date: [**2198-1-29**] Date of Birth: [**2131-12-7**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old gentleman with 2-vessel coronary artery disease, status post massive anterior myocardial infarction in [**2197-6-6**] with failed thrombolysis at an outside hospital and incomplete revascularization after left anterior descending artery stent at [**Hospital1 69**] with course complicated by cardiogenic shock and intra-aortic balloon pump placement. This event resulted in cardiomyopathy with an ejection fraction of 25% to 30%. Also of note, the patient developed atrial flutter in [**2197-8-7**] which was ablated with implantable cardioverter-defibrillator pacemaker placement. In the past couple months, the patient has complained of increasing fatigue, nausea, and dyspnea on exertion occurring with one flight of stairs. The patient otherwise denied any chest pain or other symptoms. Outpatient therapy by his cardiologist was limited by hypotension with a systolic blood pressure in the 80s to 90s. The patient is admitted now for pulmonary artery catheterization for tailored hemodynamic therapy with milrinone. Primary results from the cardiac catheterization on the day of admission revealed a right atrial pressure of 5, right ventricular pressure was 41/7, pulmonary artery pressure was 42/17, mean was 28, and a wedge pressure of 22, with a capillary wedge pressure of 2.9, and a cardiac index of 1.6. PAST MEDICAL HISTORY: 1. Ischemic cardiomyopathy (with an ejection fraction of 25% to 30%). 2. Coronary artery disease (with an ST-elevation myocardial infarction of the anterior in [**2197-6-6**]); see History of Present Illness. 3. Hyperlipidemia. 4. Atrial flutter; status post ablation. 5. Gastroesophageal reflux disease. 6. Prostate cancer; status post prostatectomy. 7. Implantable cardioverter-defibrillator placement in [**2197-8-7**]. 8. A laminectomy in [**2178**]. MEDICATIONS ON ADMISSION: 1. Digoxin 0.125 mg by mouth once per day. 2. Plavix 75 mg by mouth once per day. 3. Lisinopril 5 mg by mouth once per day. 4. Multivitamin. 5. Lasix 40 mg by mouth once per day. 6. Coumadin. 7. Protonix 40 mg by mouth once per day. 8. Lipitor 20 mg by mouth once per day. 9. Clonazepam 5 mg by mouth once per day. 10. Aspirin 81 mg by mouth once per day. ALLERGIES: ATIVAN (reportedly resulting in agitation). FAMILY HISTORY: Maternal sisters and brothers with coronary artery disease. SOCIAL HISTORY: The patient is married. He works as a lawyer. [**Name (NI) **] quit tobacco in [**2171**]. He denies alcohol or drug use. PHYSICAL EXAMINATION ON PRESENTATION: His heart rate was 77, his blood pressure was 113/73, his respiratory rate was 12, he was afebrile. Physical examination notable for a jugular venous distention to the angle of the mandible. Normal first heart sounds and second heart sounds as well as a present third heart sound. No fourth heart sound appreciated. Pulses were 2+ throughout. Otherwise, physical examination was within normal limits. PERTINENT LABORATORY VALUES ON PRESENTATION: Blood urea nitrogen and creatinine from [**1-17**] were 31 and 1.4. Otherwise, laboratories were within normal limits. PERTINENT RADIOLOGY/IMAGING: Last echocardiogram in [**2197-7-7**] revealed an ejection fraction of 25% to 30%. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient is a 66-year-old gentleman with coronary artery disease and resultant ischemic congestive heart failure who presented with an increasing signs of heart failure with outpatient therapy limited by hypotension. The patient was admitted for pulmonary artery catheterization for tailored hemodynamic therapy. 1. PUMP ISSUES: The patient with decompensated congestive heart failure with elevated filling pressures with a pulmonary capillary wedge pressure of 22 at catheterization on the day of admission. The patient also with a decreased cardiac index. Therefore, the patient was started on milrinone upon arrival to the Coronary Care Unit for anatropic support with a goal mean arterial pressure of greater than 60, a pulmonary capillary wedge pressure of 15 to 20, and a cardiac index of greater than 2. The patient tolerated this well, and the milrinone was eventually discontinued on [**1-26**]. The patient's pulmonary capillary wedge pressure and cardiac index were at goal. The patient was started on captopril at initially 6.25 mg three times per day which was titrated up. The patient tolerated this well. The patient was also continued on digoxin. The patient was also restarted on his Coumadin on [**1-25**]. At the time of discharge, the patient's congestive heart failure seemed to be stabilized after aggressive therapy with milrinone. The patient was to follow up with his outpatient cardiologist for further titration of his medications. A repeat transthoracic echocardiogram on [**Month (only) 956**] revealed an ejection fraction of 20% and 2+ mitral regurgitation. 2. CORONARY ARTERY DISEASE ISSUES: The patient 2-vessel coronary artery disease, status post anterior myocardial infarction in [**2197-6-6**]. The patient was continued on his aspirin as well as statin. The patient without signs or symptoms of acute cardiac ischemia throughout his hospital stay. 3. RHYTHM ISSUES: The patient was in a normal sinus rhythm throughout his hospital stay, and status post ablation for atrial fibrillation and atrial flutter in [**2197-7-7**]. 4. PULMONARY ISSUES: Dyspnea on exertion was likely due to lower output congestive heart failure. The patient without other pulmonary issues throughout his hospital stay. 5. RENAL ISSUES: The patient with a baseline creatinine of 1 to 1.2; which was slightly elevated on admission but was at baseline at the time of discharge. 6. HEMATOLOGIC ISSUES: The patient with macrocytic anemia; per laboratory tests. The patient was started on iron three times per day. 7. GASTROINTESTINAL ISSUES: The patient with chronic nausea that reportedly was likely from bowel edema/congestive heart failure. The patient is followed by Gastroenterology as an outpatient. 8. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was maintained on a cardiac diet which he tolerated well. 9. PROPHYLAXIS ISSUES: The patient was maintained on pneumatic boots and a proton pump inhibitor throughout his hospital stay. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Coronary artery disease. 3. Hyperlipidemia. MEDICATIONS ON DISCHARGE: 1. Lipitor 20 mg by mouth once per day. 2. Aspirin 325 mg by mouth once per day. 3. Pantoprazole 40 mg by mouth once per day. 4. Digoxin 125 mcg by mouth every day. 5. Ferrous sulfate 325 mg by mouth once per day. 6. Coumadin 5 mg by mouth at hour of sleep. 7. Captopril 37.5 mg by mouth three times per day. 8. Ambien 5 mg by mouth at hour of sleep as needed. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [**Last Name (STitle) 17234**]. 2. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as well as Dr. [**First Name (STitle) 2031**] of Cardiology as well. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Name8 (MD) 6906**] MEDQUIST36 D: [**2198-3-30**] 12:45 T: [**2198-3-30**] 18:06 JOB#: [**Job Number 110306**]

[ "412", "V45.82", "272.0", "425.4", "V10.46", "428.0", "414.01" ]

icd9cm

[ [ [] ] ]

[ "89.64" ]

icd9pcs

[ [ [] ] ]

2477, 2538

6545, 6625

6651, 7021

2028, 2460

7054, 7595

3460, 6471

6486, 6524

161, 1515

1537, 2001

2555, 3425

81,096

125,890

42933+58571

Discharge summary

report+addendum

Admission Date: [**2190-10-3**] Discharge Date: [**2190-10-6**] Service: MEDICINE Allergies: Iodine / Aspirin / Nsaids / E-Mycin / Ciprofloxacin / Levofloxacin / Phenylephrine Attending:[**First Name3 (LF) 800**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 89-year-old man with h/o dementia, blind and hard of hearing, weight loss, ESRD on hemodialysis complicated by AV fistula thrombosis and stenosis admitted to the MICU from home for altered mental status being transfered to the medicine floor. Per team report his family found him with an empty pill box at bedside the morning of admission that had 8, 0.5mg pills of ativan in it. On presentation, he was somnolent but arousable. He knew his name but was unable to give details about history but denied a suicide attempt last night. His wife said that he came back from dialysis yesterday more confused and not himself. His wife says he usually is lethargic and tired after dialysis but that this was different. He went to a family Bat Mitzvah and he kept falling asleep. Per wife patient was found this am in bed and somnolent with labored breathing associated with a gurgling sound. His walker was near the bathroom, 2 glasses of water in the bathroom, and an empty pill bottle. Of note, patient's effexor was stopped yesterday. Wife says patient has good days and bad days but does not usually orient to place or time. Also of note patient had stool incontinence at time of dens fx in [**3-15**] which improved but has recently returned in past 3 weeks. Wife also reports he does not take nephrocaps or inhalers on regular basis. ROS: Difficult to obtain but denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -ESRD on HD -AV graft thrombosis and stenosis -Dementia -Malnutrition/Failure to Thrive -Asthma -pulmonary hypertension secondary to VSD -Anxiety/Depression -Chronic Bronchitis/COPD -Traumatic Type II Dens fracture with chronic left jaw, eye, ear, and neck pain as it is inoperable -Hypertension -Hypercholesterolemia -Incontinence of stool -Benign prostatic hypertrophy -12-mm left superior parietal meningioma -Macular degeneration and anterior ischemic optic neuropathy -Pancytopenia, possible MDS -Left Renal calculi s/p lithotripsy Social History: 1. The patient was born in [**State 350**]. Married for 55 years. Three children. 2. He attended college at [**University/College **] and got his doctorate in political science from [**University/College **] as well. In [**2168**] he retired as a professor of political science. 3. He smoked a pipe decades ago. No alcohol history. Family History: 1. Father died at age 62. He had renal failure 2. Mother died at age 81. To his knowledge, neither parent had dementia. 3. Had a sister with [**Name (NI) 5895**] disease who, in her final years became demented (but had PD first). Two other siblings were not demented. Siblings all in 80s-90s. No history of Alzheimers. Brother has [**Name (NI) 5895**] disease. Physical Exam: Physical exam on the floor Vitals (on floor) - T: 98.5 BP: 190/80 HR: 96 RR: 20 02 sat: 97% RA General - Resting comfortably in bed, no acute distress. Temporal wasting. HEENT - Sclera anicteric, dry mucous membranes, oropharynx clear. EOMI intact. Neck - Supple, JVP not elevated, no LAD Pulm - Crackles at bilateral bases (L>R). No rhonchi or wheezes CV - Tachycardic. Regular rhythm. Normal S1/S2; III/VI systolic murmur heard best at RUSB. No rubs or gallops Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended Ext - Warm, well perfused. no clubbing, cyanosis or edema Neuro -Oriented to person, but not place or time. 5/5 strength and full sensation in UE/LE. CN II-XII intact. No facial droop. No Babinski sign. Pertinent Results: Admission laboratories: BLOOD WBC-4.7 RBC-3.92* Hgb-12.7* Hct-41.6# MCV-106* MCH-32.4* MCHC-30.6* RDW-18.3* Plt Ct-97* BLOOD Neuts-47* Bands-0 Lymphs-37 Monos-14* Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0 BLOOD Glucose-89 UreaN-19 Creat-3.5* Na-138 K-4.7 Cl-96 HCO3-30 AnGap-17 Calcium-8.8 Phos-3.2 Mg-1.8 [**2190-10-3**] 09:50AM BLOOD CK(CPK)-21* CK-MB-NotDone cTropnT-0.05* [**2190-10-3**] Albumin-4.1 [**2190-10-3**] TSH-4.4* [**2190-10-3**] Type-ART pO2-195* pCO2-42 pH-7.54* calTCO2-37* Base XS-12 Urinalysis: [**2190-10-3**] Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007 [**2190-10-3**] URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-9.0* Leuks-NEG [**2190-10-3**] RBC-0-2 WBC-0 Bacteri-0 Yeast-NONE Epi-0 Toxicology screening: [**2190-10-3**] Blood ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2190-10-3**] URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG EKG: NSR at 90, LAD, NI, Jpoint elevation V2-V3, no acute STTW changes, unchanged from prior CXR: Linear atelectasis and R costophrenic angle. No edema. Prominance of right hilum likely related to kyphoscoliosis. No acute cardiopulmonary process. CT HEAD W/O CONTRAST [**10-3**]: Limited study secondary to motion artifact. No e/o acute intracranial abnormality. Right maxillary sinus disease. Chronic small vessel ischemic disease. Meningiomas not well seen. Evidence of prior dens fracture. Consider MRI if clinical concern for stroke. Brief Hospital Course: 88-year-old man with history significant for dementia, blindness and hard of hearing, failure to thrive with weight loss, ESRD on hemodialysis admitted for altered mental status. . # AMS: Patient noted to be more somnolent on admission in the ICU. Within time his mental status improved to his baseline. A Utox/serum was negative for benzodiazepines, but its utility for Ativan is controversial. Another possibility is poor tolerance to dialysis. The patient was noted to have a change in mental status after dialysis. Infections and metabolic abnormalities have been ruled out on this hospital admission. The UA was WNL, CXR unchanged. CT head negative for acute ischemic etiology. CXR unchanged from prior. Blood glucose within normal limits. D . ESRD on hemodialysis: The patient receives dialysis on Tuesdays, thursdays and Fridays. He has received dialysis while in-house and tolerated it well. He appears clinically dry, so very little fluid was removed on these sessions. There is some concern that his outpatient dialysis has been removing too much fluid. These concerns will be addressed with his outpatient dialysis by the renal fellow. . Hypertension: The patient remained hypertensive and asymtomatic from it while in the hospital. He has been ranging 140-160s on the day of discharge. He was started on Captorpil on this admission and it showed be uptitrated as an outpatient. He has had hypertension in the past, but there was some concern that during dialysis his BP would drop too low, however, during his dialysis sessions while in the hospital, he was never hypotensive. . Pancytopenia: The patient has a macrocytic anemia and thrombocytopenia. These have been attributed to MDS in the past. B12, folate levels have been normal. He was supposed to have outpatient followup with hematology based on a past D/C summary, but it does not remain clear that he had that evaluation. . Monocytosis: The pateint presented with a WBC=4.7 with 14% monocytes. He has had a similar monocytosis in the past. The significance of this monocytosis remains unclear in the acute illness setting. . High TSH: The patient had a high TSH in the hospital setting. TSH=4.4, seems to have been trending upwards. The patient will need outpatient followup with his PCP for the significance of this high TSH. Medications on Admission: MEDICATIONS: Per wife -Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS as needed for insomnia -Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS -B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig PO DAILY -Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY -Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. -Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): hold for SBP<<100. 6. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. Multivitamin Liquid Sig: Five (5) cc PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2732**] & Retirement Home - [**Location (un) 55**] Discharge Diagnosis: Delirium secondary to medications Benzodiazapine overdose Discharge Condition: Mental Status at baseline Discharge Instructions: You were evaluated for a change in your mental status related to taking too much ativan. This medicationn was discontinued and your mental status improved. You were also started on captopril for hypertension. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2190-10-29**] 9:25 Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2190-11-1**] 1:00 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 251**] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2190-11-19**] 9:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Name: [**Known lastname 14569**],[**Known firstname 651**] Unit No: [**Numeric Identifier 14570**] Admission Date: [**2190-10-3**] Discharge Date: [**2190-10-6**] Date of Birth: [**2101-9-15**] Sex: M Service: MEDICINE Allergies: Iodine / Aspirin / Nsaids / E-Mycin / Ciprofloxacin / Levofloxacin / Phenylephrine Attending:[**First Name3 (LF) 877**] Addendum: Hyptertension: Before discharge on the day of discharge, the patient's nephrologist, Dr. [**Last Name (STitle) 690**], called me and said that he does not wish to have the patient placed on any anti-hypertensive medications. It was noted that his SBP have been high around 190s and the lowest since admission have been SBP~146. His nephrologist will address his blood pressure as an outpatient and does not any management of it upon discharge. Brief Hospital Course: Before discharge on the day of discharge, the patient's nephrologist, Dr. [**Last Name (STitle) 690**], called me and said that he does not wish to have the patient placed on any anti-hypertensive medications. It was noted that his SBP have been high around 190s and the lowest since admission have been SBP~146. His nephrologist will address his blood pressure as an outpatient and does not any management of it upon discharge. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Multivitamin Liquid Sig: Five (5) cc PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 728**] & Retirement Home - [**Location (un) 729**] Discharge Diagnosis: Delirium secondary to medications Benzodiazapine overdose Discharge Condition: Mental Status at baseline. Discharge Instructions: You were evaluated for a change in your mental status related to taking too much ativan. This medicationn was discontinued and your mental status improved. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 455**], DPM Phone:[**Telephone/Fax (1) 456**] Date/Time:[**2190-10-29**] 9:25 Provider: [**Name10 (NameIs) 14571**] [**Name11 (NameIs) 14572**], MD Phone:[**Telephone/Fax (1) 944**] Date/Time:[**2190-11-1**] 1:00 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 116**] [**Name (STitle) 14573**] Phone:[**Telephone/Fax (1) 810**] Date/Time:[**2190-11-19**] 9:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 878**] MD, [**MD Number(3) 879**] Completed by:[**2190-10-6**]

[ "292.81", "294.8", "416.8", "300.4", "389.9", "585.6", "362.50", "250.00", "E853.2", "787.6", "V42.0", "969.4", "238.75", "403.91", "493.20" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

12020, 12110

10992, 11422

311, 317

12212, 12241

4013, 5526

12445, 13053

2881, 3243

11445, 11997

12131, 12191

7875, 8374

12265, 12422

3258, 3994

250, 273

345, 1955

1977, 2515

2531, 2865

29,553

191,036

12179

Discharge summary

report

Admission Date: [**2193-6-23**] Discharge Date: [**2193-6-26**] Date of Birth: [**2145-6-8**] Sex: M Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 4162**] Chief Complaint: dypsnea Major Surgical or Invasive Procedure: Peritoneal dialysis History of Present Illness: 48 yo male ESRD on PD, DM1, HTN, ?Cardiomyopathy with EF 40%, presents to ED with dyspnea, chest tighthtess that started 3 days ago. He had noticed more difficult breathing when lying flat, and feeling a chest tightness and neck tightness. He reports having increased swelling in his BLE as well. He has been having a consistent cough, with very little tan sputum production. He denies fevers at home. He also reports elevated BP more recently, which led to increasing his metoprolol by his PCP. [**Name10 (NameIs) **] had made some recent changes to his PD, and when he told his PD nurse about his dyspnea and throat tightness, she recommended he back off the dialysis. His symptoms did not improve, and he continued to be symptomatic. Because of his dyspnea, and chest tightness, he came to [**Hospital1 18**] for further care. . HR 101, 185/100. He was found to have crackles BL and a CXR- diffuse infiltrates. He was given his home dose PO lasix, then given lasix 40 mg IV x 1. He was also started on a nitro gtt which helped with his dyspnea. He had some peaked T waves on his ECG, and with K 6.1, he was given kayexelate, D50, and insulin. Subsequently decreased to 5.5 prior to MICU transfer. He was afebrile in the ED, but given the few patchy infiltrates on his CXR, he was given levofloxacin 750 mg IV x 1. . During his stay in the ICU, his crit remained stable and near his baseline of 21 to 25. His troponin elevation was ultimately thought to be largely [**1-19**] his renal failure. Renal was also consulted and wants to restart him on epo, pending the results of iron studies. Past Medical History: DM Type I x 30 years HTN S/p L vitrectomy and R vitrectomy (diabetic loss of vision) ESRD on PD (recent baseline 6) Gallstones s/p arthroscopic knee surgery Diveriticulosis Social History: medical assistant at [**Last Name (un) **], lives with partner who is HIV+, tobacco (1 pack per week), social EtOH, no IVDU Family History: His mother has diabetes, as does maternal aunt and uncle. There is also history of gastric cancer in his father's side Physical Exam: VS: 97.3, 153/89 (130-170), 92, 18, 98%RA [**Numeric Identifier 7836**]/[**Numeric Identifier 38122**] since midnight GEN: WDWN male, NAD, appears comfortable CV: RRR, 2/6 systolic murmur at RUSB. LUNGS: bilateral crackles both lung fields ABDOMEN: soft, NT, normal BS EXT: no pedal edema; diffuse skin hyperpigmented lesions NEURO: A/O x 3; moves all extremities Pertinent Results: [**2193-6-23**] 11:33PM POTASSIUM-6.0* [**2193-6-23**] 11:33PM CK(CPK)-330* [**2193-6-23**] 09:30PM LACTATE-1.1 K+-5.9* [**2193-6-23**] 11:33PM CK-MB-11* MB INDX-3.3 cTropnT-0.61* [**2193-6-23**] 06:33PM GLUCOSE-67* K+-5.5* [**2193-6-23**] 03:14PM GLUCOSE-118* K+-5.9* [**2193-6-23**] 03:10PM GLUCOSE-131* UREA N-73* CREAT-12.1*# SODIUM-137 POTASSIUM-6.1* CHLORIDE-98 TOTAL CO2-23 ANION GAP-22* [**2193-6-23**] 03:10PM estGFR-Using this [**2193-6-23**] 03:10PM CK(CPK)-467* [**2193-6-23**] 03:10PM cTropnT-0.68* [**2193-6-23**] 03:10PM CK-MB-17* MB INDX-3.6 [**2193-6-23**] 03:10PM CALCIUM-8.9 PHOSPHATE-9.2*# MAGNESIUM-2.2 [**2193-6-23**] 03:10PM WBC-13.8* RBC-3.93*# HGB-10.7*# HCT-32.2*# MCV-82 MCH-27.3 MCHC-33.3 RDW-15.8* [**2193-6-23**] 03:10PM NEUTS-78.5* LYMPHS-11.5* MONOS-3.7 EOS-5.9* BASOS-0.4 [**2193-6-23**] 03:10PM PLT COUNT-204# [**2193-6-23**] 03:10PM PT-12.8 PTT-24.6 INR(PT)-1.1 . Cardiology Report ECG Study Date of [**2193-6-25**] 1:14:42 PM Sinus rhythm Borderline left axis deviation - could be left anterior fascicular block but is nondiagnostic ST-T wave abnormalities with prominent precordial lead/anterior T waves - are nonspecific but clinical correlation is suggested for possible in part ischemia or left ventricular hypertrophy Since previous tracing of [**2193-6-24**], precordial lead T waves appear slightly more prominent but may be no significant change. . Radiology Report CHEST (PORTABLE AP) Study Date of [**2193-6-24**] 3:56 AM Single AP chest radiograph compared to [**2193-6-23**] shows decreased lung volumes and worsening pulmonary edema. Two areas of more confluent opacities in the left upper and right lower lung zones may also be related to edema, however, a focal airspace process cannot be entirely excluded. Recommend followup after dialysis. The cardiomediastinal contour is within normal limits. There is no pneumothorax or substantial pleural effusion Brief Hospital Course: A/P 48 yo male with ESRD on PD, Cardiomyopathy with EF 40%, presents with hypoxemia secondary to volume overload and ? PNA . SUMMARY: Patient is a 48M with ESRD on PD, DM1, HTN, cardiomyopathy (EF 40%) who presented to the ED with dyspnea, SOB x 3 days. He was found to be in congestive failure, was hyperkalemic with EKG changes (peaked Ts), and had a mildly elevated troponin. He was also hypertensive to the 180s and thought to be in hypertensive emergency b/c of the elevation in troponin. His K+ was reduced with kayexolate, insulin, and D5W and his BP was controlled. His CHF became more controlled with lasix and he also received peritoneal dialysis. During his time in the ICU, his crit remained stable and near his baseline of 21 to 25. His troponin elevation was ultimately thought to be largely [**1-19**] his renal failure. Renal was also consulted and wanted to restart him on epo, pending the results of iron studies. His O2 stat and volume status continued to improve and he was discharged home. . #. Hypoxemia: Patient's hypoxemia was thought to be likely secondary to volume overload from insufficient PD, though this was not entirely clear. PNA was less likely given the absence of leukocytosis and fever. He was ultimately put on room air and oxygenated well after significant diuresis. The patient was also thought to have a cardiomyopathy but a [**2191**] ECHO shows normal EF of 60% and no evidence of cardiomyopathy. . #. Chest Tightness: The patient had a slight upward trend in his trop, but this was likely [**1-19**] poor ESRD and not demand ischemia, as he had no evidence of ECG changes except mild T-wave flattening in lateral leads on 1 ECG. We treated him with ASA and metoprolol prophylactically. . #. Hyperkalemia: Patient was hyperkalemic but this improved with PD and furosemide. He did not have signficant ECG changes. . #. Hypertension: Patient has history of hypertension and was hypertensive on admission. His BP improved significantly with PD and titration of labetolol. . #. ESRD on PD: Peritoneal dialysis was continued during the [**Hospital 228**] hospital stay. Patient was discharged on a PD protocol approved by the renal team. . #. DM1: Patient was placed on an ISS and glucose was generally well controlled during his stay. . #. CODE: FULL CODE . #. CONTACT: [**Name (NI) **] [**Telephone/Fax (1) 38121**]-partner Medications on Admission: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Tablet(s) 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QMOWEFR (Monday -Wednesday-Friday). 4. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Insulin Lispro 100 unit/mL Cartridge Sig: see sliding scale see sliding scale Subcutaneous see sliding scale. 10. Lantus 100 unit/mL Cartridge Sig: Twenty Two (22) units Subcutaneous at bedtime. Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Tablet(s) 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QMOWEFR (Monday -Wednesday-Friday). 4. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Insulin Lispro 100 unit/mL Cartridge Sig: see sliding scale see sliding scale Subcutaneous see sliding scale. 10. Lantus 100 unit/mL Cartridge Sig: Twenty Two (22) units Subcutaneous at bedtime. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Dialysis-related volume overload SECONDARY DIAGNOSES Daibetes Mellitus Type I x 30 years Hypertension Left and right vitrectomy (diabetic loss of vision) End stage renal disease on peritoneal dialysis Gallstones Status post arthroscopic knee surgery Diveriticulosis Discharge Condition: Good Discharge Instructions: You were admitted to the hospital for shortness of breath. Over the course of your hospitalization, we determined that your shortness of breath was likely related to your dialysis. It resolved and your dialysis regimen was stabilized. Please follow up with Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **] in 2 to 3 weeks. Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] in 1 to 2 weeks. You should return to the dialysis protocol that you were using before being admitted. Please go to the ER if you become short of breath, have chest pain, fevers, chills, or any other serious concerns. Followup Instructions: Please set up an appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] in 1 to 2 weeks. Operating Unit: [**Hospital1 18**] Office Location: [**Last Name (un) 3911**] Office Phone: ([**Telephone/Fax (1) 817**] Please set up an appointment with Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **] in 2 to 3 weeks. Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 3403**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital3 249**] [**Hospital1 **]/EAST Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 250**] Completed by:[**2193-7-8**]

[ "585.6", "562.10", "428.23", "276.7", "428.0", "250.01", "403.01", "425.4" ]

icd9cm

[ [ [] ] ]

[ "54.98" ]

icd9pcs

[ [ [] ] ]

8959, 8965

4764, 7137

275, 297

9294, 9301

2796, 4741

10006, 10704

2274, 2396

8061, 8936

8986, 9273

7163, 8038

9325, 9983

2411, 2777

228, 237

325, 1920

1942, 2116

2132, 2258

8,762

118,810

46226

Discharge summary

report

Admission Date: [**2138-2-4**] Discharge Date: [**2138-3-3**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Occasional DOE, Critical stenosis found on Echo Major Surgical or Invasive Procedure: CABG X 4 & AVR (21 mm CE) re-op for bleeding History of Present Illness: 82yo F history of AS followed by Dr. [**Last Name (STitle) 20222**]. Mostly symptom free, occasional DOE. Denies CP, PND, orthopnea, syncope, lightheadedness. Echocardiogram in [**9-4**] showed [**Location (un) 109**] 0.6cm2, mean gradient of 42mmHg, Mod to Sev MR, normal LVEF. Cardiac cath [**9-4**] showed 2VD (LAD, LCx). She was noted to have left subclavian stenosis, with bilateral carotid stenosis of 60-81% also in [**9-4**]. Past Medical History: AS MR [**First Name (Titles) **] [**Last Name (Titles) **] Type II DM Hyperlipidemia PVD Asthma Chronic Bronchitis s/p CCY and hysterectomy Social History: lives alone in apartment. Independent in ADL's. remote history of smokng (1-2ppw). Quit 40yrs ago. denies Etoh Family History: father died of MI in his 70's Physical Exam: 82yo F lying in bed NAD HEENT:MMM, O/P clear, -JVD Chest:decreased BS LLL, diffuse wheezing and rales. RRR no m/r/g ABD: S/NT/ND/BS+ Groin:Fatty lipoma present Left groin, stable EXT: Right medial thigh with open SVH, stable with staples mild erythema, small bloody discharge from inferior portion of incision. Left shin with resolving hematoma and seroma of left endovascular SVH. distal pulses 2+. Pertinent Results: Cardiology Report ECHO Study Date of [**2138-2-19**] PATIENT/TEST INFORMATION: Indication: Atrial fibrillation Height: (in) 63 Weight (lb): 145 BSA (m2): 1.69 m2 BP (mm Hg): 160/80 HR (bpm): 80 Status: Inpatient Date/Time: [**2138-2-19**] at 15:51 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W007-0:00 Test Location: West Cath/EP Lab Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Depressed LAA emptying velocity (<0.2m/s) RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Simple atheroma in descending aorta. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR leaflets move normally. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Moderate (2+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. PERICARDIUM: Small pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). Local anesthesia was provided by benzocaine topical spray. The posterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related complications. The rhythm appears to be atrial fibrillation. Conclusions: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. A bioprosthetic aortic valve prosthesis is present. The aortic prosthesis leaflets appear to move normally. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No intracardiac thrombus seen. Electronically signed by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD on [**2138-2-19**] 20:00. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. RADIOLOGY Final Report BILAT LOWER EXT VEINS [**2138-2-20**] 7:11 PM BILAT LOWER EXT VEINS Reason: SWELLING R/O DVT [**Hospital 93**] MEDICAL CONDITION: 82 year old woman with REASON FOR THIS EXAMINATION: r/o dvt INDICATION: 82-year-old woman with rule out DVT. TECHNIQUE: [**Doctor Last Name **] scale and Doppler ultrasound of bilateral lower extremities. FINDINGS: Note is made of marked soft tissue swelling along the left inguinal to femoral area, with visually evident focal mass versus hernia or a large fluid collection, which somewhat limit the evaluation of the vessels. Normal compressibility, flow, augmentations are seen in left common femoral, superficial femoral, and popliteal veins, no evidence of DVT. Note is made of fluid collection in the inner thigh extending from the area of swelling. Normal flow, compressibility, and augmentations are seen in right common and superficial femoral and popliteal veins. IMPRESSION: Technically limited study. No evidence of DVT. Large grossly visible swelling versus mass along the left inguinal to femoral area, which may represent hernia, fluid collection, mass such as lipoma or hematoma if there is a recent iatrogenic intervention. Please correlate clinically. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 7210**] [**Name (STitle) 7211**] [**Doctor Last Name 7205**] DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**] Brief Hospital Course: Mrs. [**Known lastname 98282**] was admitted to the [**Hospital1 18**] on [**2138-2-4**] for further management of her occasional DOE. She was taken to the catheterization lab where she was found to have 3 vessel disease along with her known [**Location (un) 109**] of 0.6cm. She also had a history of left subclavian stenosis for which she was stented on [**2138-2-4**]. Given the severity of her disease, the cardiac surgical service was consulted for surgical revascularization and valve repair. She was worked-up in the usual preoperative manner. An echocardiogram was performed which revealed severe Aortic stenosis, 3+ mitral regurgitation and an ejection fraction of 55%. On [**2138-2-6**], Mrs. [**Known lastname 98282**] was taken to the operating room. An intraoperative transesophageal echocardiogram revealed severe aortic stenosis thus she underwent coronary artery bypass grafting to four vessels and an aortic valve replacement using a 21mm [**Last Name (un) **] [**Doctor Last Name **] pericardial model 2800 bioprosthesis. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. Following surgery she continued to have signigicant chest tube output for which she was taken back to the OR for mediastinal exploration, coagulation of bleeders, and evacuation of clots. On postoperative day one, she awoke neurologically intact. She remained intubated until POD 6, she underwent bronchoscopy on POD 4 to evacuate her left main bronchus of thick secretions. Beta blockade and aspirin were resumed. She was gently diuresed towards his preoperative weight. On POD 6 she had a bedside swallow evaluation for possible aspiration with thin liquids. It was determined that she could safely consume thin liquids and regular consistency. On POD 8 she was transferred to the step down unit for further recovery. The physical therapy service was consulted to assist with her postoperative strength and mobility. Post operatively she developed atrial fibrillation for which she was placed on amiodarone and anticoagulation. She developed a left lower extremity hematoma/seroma with bloody drainage from both of her leg incisions. This progressively improved and was treated with po antibiotics, and dry sterile dressing changes. On POD11 She had a Left pleural effusion and underwent left thoracentesis for approx. 1000cc of serosanguinous fluid. On POD 12 she underwent a TEE which did not show any evidence of left ventricular thrombus and subsequent D/C cardioversion. She remained in sinus rhythm afterward. She had bilateral venous doppler u/s of her lower extremities to assess for DVT which was negative. On POD 16 she became hypotensive which failed to respond to fluid boluses. An emergent abdominal CT scan showed a retropertoneal bleed. She was transfused PRBC's, Platelets and given FFP. The Vascular service was consulted and recommended discontinuing anticoagulation. Heparin and coumadin, and plavix were discontinued. On POD 16 the endocrine service was consulted regarding refractory hypoglycemia. This was attributed to having poor po intake with OHA. Cortisol levels were normal. Over the next several days her blood sugar normalized. On POD 21 Mrs. [**Known lastname 98282**] slipped on the bathroom floor and suffered a scalp hematoma with laceration. A stat head CT was negative for intracranial hemorrhage and her physical exam was unremarkable for fracture or nuerologic insult. She was discharged to an extended care facility on POD 25 Medications on Admission: Verapamil 180' Zocor 10' Glipizide 10' metformin 500' Trusopt 2% OU one drop tid Xalatan one drop qhs ASA 325' Advair 250'' MVI Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days: then re-evaluate need for diuretics. 3. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO BID (2 times a day) for 7 days: continue if remains on diuretics. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): for 1 week, then decrease to 200 mg daily until discontinued by Dr. [**Last Name (STitle) 20222**]. 11. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Glipizide 5 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO DAILY (Daily). 13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 14. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 16. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 17. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 18. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 19. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 20. Glipizide 5 mg Tab, Sust Release Osmotic Push Sig: Two (2) Tab, Sust Release Osmotic Push PO DAILY (Daily). Disp:*60 Tab, Sust Release Osmotic Push(s)* Refills:*2* 21. Warfarin 1 mg Tablet Sig: Dosage will vary based on INR Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 22. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*qs Disk with Device(s)* Refills:*2* 23. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. Disp:*qs qs* Refills:*2* 24. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:*qs qs* Refills:*2* 25. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 26. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 27. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): take two pills daily for five days; then one pill daily thereafter. Disp:*35 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Doctor Last Name **] [**Doctor Last Name **] hospital Discharge Diagnosis: AS [**Doctor Last Name **] DM-2 [**Doctor Last Name **] PVD asthma Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no drivning for 1 month no lifting > 10# for 10 weeks Followup Instructions: with Dr. [**First Name (STitle) 4640**] in [**1-3**] weeks with Dr. [**Last Name (STitle) 20222**] in [**1-3**] weeks with Dr. [**Last Name (STitle) 914**] in 4 weeks Completed by:[**2138-3-3**]

[ "E932.3", "427.31", "585.2", "458.9", "511.9", "998.11", "873.42", "998.12", "250.80", "414.01", "518.5", "396.2", "214.1", "447.1", "E885.9", "286.9" ]

icd9cm

[ [ [] ] ]

[ "35.21", "33.22", "99.05", "99.62", "00.40", "99.06", "99.04", "96.72", "34.03", "39.90", "36.15", "34.91", "39.50", "36.13", "99.07", "88.42", "39.61", "88.72", "00.45" ]

icd9pcs

[ [ [] ] ]

12866, 12949

6232, 9750

313, 360

13060, 13067

1607, 1663

13263, 13460

1138, 1169

9929, 12843

4903, 4926

12970, 13039

9776, 9906

13091, 13240

1689, 4632

1184, 1588

226, 275

4955, 6209

388, 828

4664, 4866

850, 991

1007, 1122

15,346

109,363

9325

Discharge summary

report

Admission Date: [**2160-7-21**] Discharge Date: [**2160-7-25**] Date of Birth: [**2108-7-2**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a right handed 52-year- old male with past medical history significant for [**Year (4 digits) 499**] cancer status post resection in [**2137**] presenting with headaches and neck pain for the past 8 weeks. He states that just after the Fourth of [**Month (only) 205**] he was at work, which was computer repair, and he developed a headache, gradual onset, pressure-type feeling mostly in the back of his head, not accompanied by visual disturbance, diplopia, slurred speech, numbness, weakness, or difficulty with word finding, or comprehension. Tylenol and aspirin did not much help the pain. The headache continued accompanied by neck pain. He said about a week after the headache started he was going to play golf, but he again had the exact same symptoms. He called his primary care physician who told him that he may have meningitis and that it would go away on its own. Mr. [**Known lastname 31905**] had not had any fevers, nausea, vomiting, or diarrhea. He says that he thought he had poison [**Female First Name (un) **] on his hands a couple of weeks before the headaches began. However, the headaches are not resolved. PAST MEDICAL HISTORY: Significant for [**Female First Name (un) 499**] cancer status post resection in [**2137**], gastroesophageal reflux disease, hypertension. ALLERGIES: Penicillin. MEDICATIONS: Prilosec. SOCIAL HISTORY: Works in computer repair. Smokes one pack per day for 25 years; quit 5 years ago. Drinks 12 beers a week. FAMILY HISTORY: Father had [**Name2 (NI) 499**] cancer and died of an myocardial infarction, mother of lung cancer. No strokes in the family. PHYSICAL EXAMINATION: Temperature 97.9, blood pressure 161/84, heart rate 85, respirations 12, O2 sat 98 percent. In general, in no acute distress. HEENT: Anicteric sclerae, no injection. Neck: Supple. Lungs: Clear. Heart: Regular rate and rhythm. Abdomen: Soft. Extremities: Warm. Neurologic: Is awake, alert, oriented times 3. Cooperative with exam. His pupils are equal bilaterally. EOMI is full. Nystagmus is positive with bilateral gaze. Face is symmetric. Tongue deviated to the right. Upper extremities are [**4-2**]. Reflexes are 1 plus in his upper and lower extremities. He has [**4-2**] motor strength. His reflexes are 2 plus throughout. LABORATORY DATA: Sodium was 141, potassium was 3.8, 104/28, 16 for BUN, 1.0 for creatinine, 47 for hematocrit. MRI/MRA: Cystic lesion in the left cerebellum with moderate herniation of the cerebellar tonsil of the foramen magnum. HOSPITAL COURSE: The patient was admitted to the Neurosurgery service with q. 1-hour vital signs. He was admitted to the Intensive Care Unit service. Was started on Decadron 4 mg q. 6h. He was given gastrointestinal prophylaxis and insulin sliding scale and he was preopped for surgery. Neurology and Neuro-Oncology saw the patient and recommended the patient start on Mannitol 25 mg q. 6h. He should start on Dilantin, normal saline, no hypotonic fluids, keep his head of bed at 45 degrees, and frequent neuro signs as had already been done. On [**2160-7-22**] he underwent a craniotomy for resection of cerebellar mass which was felt to be hemangioblastoma. Postoperatively he was awake, alert, oriented times 3, still had nystagmus in his bilateral lateral gaze. Tongue deviated to the right. Face was symmetric. He remained in the PACU overnight where he remained neurologically intact on his first postoperative day. He was transferred to the Surgical unit where he was seen by Physical Therapy, who recommended a home safety evaluation and to help with his balance. On the second postoperative day he was awake, alert, oriented times 3. His Dilantin was weaned and he was discharged to home with the following instructions: To have his staples removed 10 days from his surgery, to follow up in the Brain [**Hospital 341**] Clinic, to watch for any signs and symptoms of infection, and not to get his staples wet. DISCHARGE DIAGNOSES: 1. Cerebellar mass status post craniotomy. 2. History of hypertension. 3. Gastroesophageal reflux disease. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**] Dictated By:[**Last Name (NamePattern1) 8633**] MEDQUIST36 D: [**2160-10-30**] 11:43:53 T: [**2160-10-30**] 14:54:21 Job#: [**Job Number 31906**]

[ "401.9", "V10.05", "530.81", "237.5", "355.8" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

1663, 1791

4151, 4529

2714, 4130

1814, 2696

159, 1306

1329, 1520

1537, 1646

25,317

105,186

12932

Discharge summary

report

Admission Date: [**2133-3-4**] Discharge Date: [**2133-3-12**] Date of Birth: [**2059-1-24**] Sex: M Service: SURGERY Allergies: Morphine Attending:[**First Name3 (LF) 1234**] Chief Complaint: Type I endoleak, rupture Major Surgical or Invasive Procedure: [**3-4**]: endo repair of ruptured AAA w occlusion of L iliac and R-->L fem-fem bypass History of Present Illness: Mr. [**Known lastname 39719**] is a 74-year-old gentleman who underwent endovascular triple A repair in [**2129**] and failed to comply with follow-up CT angiograms. He was admitted to [**Hospital1 **]-[**Hospital1 **] 1 month ago requiring coronary artery bypass graft and, at that time, underwent CTA which revealed migration of his Endograft with a large type 1 proximal endo leak. He was scheduled for elective repair in endovascular fashion for next week. However, presented to his local hospital this evening with abdominal pain and evidence on non-contrast CT for aneurysm rupture. He was transferred to [**Hospital1 18**] for treatment. Past Medical History: Coronary Artery Disease Mitral Regurgitation Heart Failure (systolic) Paroxysmal Atrial Fibrillation Renal Insufficiency Peripheral Vascular disease Hypertension Chronic Anemia AAA s/p Endovascular stent [**2129**] Myocardial Infarction [**2109**] Gout Osteoathritis Venous ligation GI bleeding Social History: retired, worked in plastics factory, Married lives with spouse [**Name (NI) 1139**] - quit 25 years ago, 80 pack year history Denies ETOH Family History: Brother and mother deceased from [**Last Name **] problem Physical Exam: 98.6, 120/70, 57, 99%RA (Uses O2 at night for comfort) GEN: NAD CARDs: RRR Lungs: CTA ABD: soft, +BS Neuro: A+OX3 EXT: no edema Pulses B/L DP/PT dop Pertinent Results: [**2133-3-11**] 08:55AM BLOOD WBC-9.9 RBC-3.58* Hgb-9.8* Hct-30.8* MCV-86 MCH-27.5 MCHC-31.9 RDW-15.4 Plt Ct-242 [**2133-3-11**] 08:55AM BLOOD Plt Ct-242 [**2133-3-11**] 08:55AM BLOOD Glucose-43* UreaN-27* Creat-1.7* Na-137 K-3.8 Cl-104 HCO3-24 AnGap-13 [**2133-3-11**] 08:55AM BLOOD Calcium-8.1* Phos-1.6* Mg-2.1 Brief Hospital Course: Patient transferred from OSH directly to [**Hospital1 18**] OR and underwent Endovascular repair of ruptured abdominal aortic aneurysm using aorta uni-iliac graft (Zenith 32 x125) with occlusion of the contralateral left iliac artery( 18 mm [**Doctor Last Name 4726**] Excluder) and subsequent right to left fem-fem bypass graft with 8mm ringed PTFE. Extension right CIA with 18X 54 Zenith limb. Patient remained intubated and transferred to ICU for management. Renal consulted for Acute on chronic RF. Cr 3.6 (baseline 3.0). POD 2- Extubated, afebrile, Pain controlled with Dilaudid. B/L DP/PT pulses. POD [**2-8**]- Transferred to vascular unit. VSS. B/L groins C/D/I, Foley draining dk urine. Cr 2.4. Renal following, ATN/prerenal-resolving. POD [**4-12**]- VSS. Physical therapy consulted. Non contrast CT obtained showing good placement of graft. Patient with CP- relieved with Nitro. ECG/Enzymes negative. Cr 2.1. Tolerating diet. No diet or fluid restrictions. Coumadin restarted at his home dose. POD7 VSS, Lungs with rales. Chest X-ray showing small pleural effusion. No CHF, no pneumonia. Lasix given. Foley d/ced. Rehab referral for discharge to rehab. POD8 No overnight events. VSS. Cr 1.7. Patient incontinent of urine. UA sent. Lungs clear. Transfer to rehab when bed available. Medications on Admission: aspirin 81', Metoprolol 37.5"', Isosorbide Mononitrate 30', Nitroglycerin 0.4mg tab PRN, Ambien 5mg PRN, atrovent, percocet, renagel 800"', amiodarone 200', flovent", colace 100", mucinex 600", famotadine 20", coumadin 1' Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): D/C when INR therapeutic. 2. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for Pain. 9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): Hold HR<60. 10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): 11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 14. Follow blood sugars Hypoglycemia Follow BS 3-4X per day 15. Labwork Follow INR, CBC, electrolyte panel weekly/prn Discharge Disposition: Extended Care Facility: [**Hospital **] health care Discharge Diagnosis: Type I endoleak, rupture [**3-4**]: endo repair of ruptured AAA w occlusion of L iliac and R-->L fem-fem bypass PMH: MI, gout, OA, CAD, HTN, AF, CRI, anemia PSH: vv ligation, CABG, EVAR '[**29**], s/p CABGx4(LIMA->LAD, SVG->PDA, radial to OM1, OM2)/MV repair [**2133-2-4**] Discharge Condition: Good. Cr 1.7. HCT 30.8 Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**1-10**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**3-13**] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] CARDIAC SURGERY LMOB 2A Date/Time:[**2133-3-18**] 1:15 You have a follow up appointment with Dr. [**Last Name (STitle) **] on [**2133-4-7**] at 815am. You will have an ultrasound at this visit. Do not eat or drink for 6 hours prior to visit/ultrasound. Call [**Telephone/Fax (1) 1241**] with any questions. Completed by:[**2133-3-12**]

[ "996.74", "584.5", "441.3", "274.9", "424.0", "276.2", "496", "V45.81", "403.91", "428.20", "427.31" ]

icd9cm

[ [ [] ] ]

[ "38.91", "99.07", "99.04", "39.29", "39.71", "96.6" ]

icd9pcs

[ [ [] ] ]

4981, 5035

2129, 3423

292, 381

5354, 5379

1791, 2106

7986, 8381

1548, 1607

3696, 4958

5056, 5333

3450, 3673

5403, 7406

7432, 7963

1622, 1772

228, 254

409, 1057

1079, 1376

1392, 1532

6,637

169,635

21957

Discharge summary

report

Admission Date: [**2129-9-17**] Discharge Date: [**2129-10-1**] Date of Birth: [**2050-9-3**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: disseminated coccidiomycosis Major Surgical or Invasive Procedure: placement of chest tube intubation and mechanical ventilation History of Present Illness: Mr. [**Known lastname 57508**] is a 79 year old gentleman with a past medical history significant for myositis on methotrexate and prednisone, from [**State 57509**], who was in his usual state of good health until a month before admission. He first developed a right upper lung pneumonia and was hospitalized in [**State 4565**] from [**8-8**] to [**8-12**]. He then came to [**Location (un) 86**] on [**8-13**] to visit family and finished 2 weeks of levaquin on [**8-20**] with partial resolution of symptoms. He presented to [**Hospital6 **] on [**8-24**] with fever, chills, night sweats, anorexia and cough, and was diagnosed with necrotizing pneumonia due to coccidioides immitis by CT and bronchoalveolar lavage. A chest tube was placed on [**9-5**] due to spontaneous penumothorax. He continued to deteriorate and spike fever while on broad antibiotic coverage. He had been on ceftaz/vanc/flagyl [**8-24**]->unasyn8/26-9/1->levaquine+clinda [**Date range (1) 57510**]->ceftaz+vanc [**Date range (1) 57511**] for bacterial coverage. They started ambisome 250 qd since [**8-31**] for coccidioides coverage. He had been on voriconazole from [**9-6**] to [**9-11**] for double coverage of coccidioides given clinical deterioration. He continued to spike while on broad antibiotic coverage. The voriconazle was switched to intraconazole due to cholestatic hepatitis. Mr. [**Known lastname 57508**] was on itraconazole from [**9-11**] to [**9-16**] but it was discontinued given persistent cholestasis and new drug rashes since [**9-15**]. He was also noticed to have worsening hypoxia. Mr. [**Known lastname 57508**] was transferred here for possible surgical resection of his necrotic lung. Past Medical History: -Inflammatory Myositis s/p biopsy [**6-3**] started on methotrexate and prednisone, unclear as to etiology (not inclusion body myositis) Diagnosed at [**Hospital3 2568**]... -coccidomycosis pneumonia -right sided pneumothorax s/p CT -rectal bleeing [**1-31**] hemorrhoids -ARf -hyponatremia -thrombocytopenia -anasarca -cholestatic hepatitis Social History: retired mechanic married no tobacco occassional etoh born in [**Location (un) 57512**] [**Country **], emigrated here in [**2119**] Family History: not obtained Physical Exam: 98.4, 94/50, 92, 24, 94%5L Gen illapearing jaundiced anasarcic male in nad HEENT icteric, EOMI, PERRLA, dry MM with small ulcer on R tongue Neck supple, no lad, jvp not elevated PULM: R lung with coarse rales and wet throughout, L lung with good air movement CVS rrr nl s1 and s2, no rubs, murmers, gallops Abd soft mildly distended, hypoactive BS, HSM not appreciated Ext 4+ pitting edema, 2+ pulses all extremeties Neuro CN intact, AAOx2, cerebellum intact Skin: Bilateral petechial rashes on LEs Pertinent Results: MRI OF THE BRAIN WITHOUT AND WITH IV CONTRAST: The study is limited by patient motion. Allowing for this, there are no grossly abnormal areas of enhancement of areas of large signal abnormality demonstrated. The ventricles are normal in size. No diffusion signal abnormalities are present to indicate acute infarct. There are no areas of low signal on susceptibility sequences to indicate the present of blood products. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: Limited study secondary to patient motion. No evidence of acute infarction. No grossly abnormal areas of enhancement. No hydrocephalus. MRA OF THE CIRCLE OF [**Location (un) **]: TECHNIQUE: 3D time-of-flight imaging with multiplanar reconstructions. The study is slightly limited by patient motion. Allowing for this, there is grossly normal signal demonstrated in both anterior cerebral, both middle cerebral, both intracranial internal carotid, anterior communicating artery, both posterior cerebral arteries, basilar artery, and both intracranial vertebral arteries. IMPRESSION: Grossly normal MRA of the cirlce of [**Location (un) 431**]. Brief Hospital Course: 1. ID: At outside hospital culture data revealed Coccidomycoses in both blood and sputum, enterobacter on [**8-30**] bronchoscopy and GPCs on [**9-16**] bronchoscopy. Here on admission, the patient was placed on zosyn and vancomycin for anaerobic and GPC coverage, ambisome 400 q24 and caspofungin for coccidioides coverage, all cultures re-sent including washes from bronchoscopy. A lumbar puncture was performed to determine the need for intrathecal ambisome, however no organisms were seen on microscopy or cultured. At this hospital, his blood cultures demonstrated Vancomycin resistant enterococcus bacteremia but no coccidomycosis fungemia, sputum cultures showed coccidomycosis, pleural fluid had VRE and coccidomycosis. Linezolid was started for VRE, and subsequent survellience cultures were negative. 2. Pulm: Patient had Coccidiomycosis and necrotizing PNA. He was started on zosyn and vancomycin for bacterial superinfection. He suffered a spontaneos pneumothorax with significant subcutaneous and mediastinal emphysema. On [**9-19**] Mr. [**Known lastname 57508**] had an elective intubation for bronchocscopy, [**Doctor Last Name 688**] mental status and respiratory distress. The chest tube was replaced for apical suction, the ambisome was increased to 5 mg/kg and caspofungin was added for double coverage. He was not considered a surgical candidate for lobectomy given his poor clinical condition and widely disseminated coccidiomycosis. Bronchoscopy revealed diffusely erythematous airways without purulent secretions and a likely RML empyema. On [**9-22**] chest tube was placed to water seal, no reexpansion of ptx on positive pressure, and he was thought unlikely to have continued broncho-pleural fistula 3. Hepatic: Mr. [**Name14 (STitle) 57513**] had a cholestatic hepatitis induced by azoles at the outside hospital. Ultrasound at outside hospital showed no obstruction. Viral hepatitis panel was negative. His LFTs improved during his course, but the patient remained anasarcic and jaundiced. 4. Derm: Mr. [**Known lastname 57508**] developed a drug rash & a stasis dermatitis in the bilateral lower extremities. Triamcinolone ointment and emolllients provided relief. 5. Renal: The patient developed acute renal failure, thought to be secondary to prerenal azotemia. He was bolused frequently and given PRBCs to keep intravascular oncotic pressure up and to reach goal MAP > 65. 6. FEN: Mr. [**Known lastname 57508**] became grossly edematous with an albumin 1.5. His free water was limited and nutrition was consulted for TPN recommendations. 7. Rheum: Mr. [**Known lastname 57508**] had a history or "myositis" of unknown subtype. His primary care physician from [**Name9 (PRE) 4565**] sent records of a biopsy which indicated that myositis was not inclusion body. He had been on Methotrexate and Prednisone 10 prior to admission. His methotrexate was stopped but his prednisone was continued at a lower dose to avoid an adrenal crisis in this patient under great stress. Rheum was consulted and agreed with discontinuation of immunosuppresion. 8. Cardiac: Mr. [**Known lastname 57508**] was found to be hypotensive, but his EF was 60% at the outside hospital. An EKG done here on [**9-19**], revealed poor Rwave progression. Cardiac output was boosted with IVF boluses for BP and stress dose steriods, started [**9-19**]. He was started on levofed and it was intermittently started and then stopped, based on his MAP. Mr. [**Name14 (STitle) 57513**] did not respond to the aggressive measures detailed above. About 2 weeks following admission, he was made CMO and expired shortly after. Discharge Disposition: Home Facility: patient expired Discharge Diagnosis: disseminated cocciodiomycosis Discharge Condition: patient expired

[ "785.52", "584.9", "287.5", "V58.65", "428.0", "E931.9", "518.81", "253.6", "041.04", "728.0", "513.0", "599.7", "573.8", "273.8", "693.0", "038.8", "510.0", "114.0", "512.1", "995.92", "707.03" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.72", "00.14", "03.31", "99.15", "96.48", "33.24", "38.93", "34.91", "99.04" ]

icd9pcs

[ [ [] ] ]

8033, 8066

4381, 8010

337, 400

8139, 8157

3211, 4358

2663, 2677

8087, 8118

2692, 3192

269, 299

428, 2132

2154, 2498

2514, 2647

76,312

140,821

39276

Discharge summary

report

Admission Date: [**2172-10-20**] Discharge Date: [**2172-10-22**] Date of Birth: [**2096-7-23**] Sex: F Service: NEUROSURGERY Allergies: Penicillins / Demerol / Morphine / Shellfish Derived / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1271**] Chief Complaint: Essential Tremor Major Surgical or Invasive Procedure: Placement of Left VIM Deep Brain Stimulator Stage 1 History of Present Illness: This is a very pleasant 76 year old female with essential tremor diagnosed many years ago. Every attempt with medical management has failed. Her tremor is significant, especially when she is anxious and among public people. She states that alcohol makes the tremor better. She has significant intentional tremor as well as postural tremor with both upper extremities, may be left more than right. She has also moderate resting head tremor. Past Medical History: Hyperlipidemia, depression, pulmonary embolus in [**2166**], protein S deficiency on anticoagulation with Coumadin, status post left retinal detachment surgery, status post cataract surgery, status post right knee replacement surgery, osteoporosis, chol, hypothyroid, H pylori, B12 def, PE x 5 yrs Social History: She is a retired [**Male First Name (un) 1573**] high guidance counselor. She does not smoke. She has 2 ETOH beverages per day. Family History: NC Physical Exam: Pre-op: She has significant intentional tremor as well as postural tremor with both upper extremities, may be left more than right. She has also moderate resting head tremor Pertinent Results: X-ray orbits [**2172-10-20**]: Cranial fixation hardware limits evaluations of the orbit. Within this limitation no radiopaque objects are seen within the orbits. CT Head [**2172-10-20**]: Deep brain stimulator lead through the left frontal approach with the tip at the level of the left thalamus/left subthalamic nucleus. Interval hemorrhage into the adjacent lateral ventricle as well as the third and fourth ventricles. No hydrocephalus. Follow up as clinically indicated. CT head [**2172-10-21**] 1. Left transfrontal deep brain stimulator lead terminates in the left thalamus/left subthalamic nuclei, unchanged in position from [**2172-10-20**]. 2. Unchanged amount and appearance of hemorrhage in the left lateral, third and fourth ventricle, with no evidence of obstructive hydrocephalus. 3. No new hemorrhage. Brief Hospital Course: Ms. [**Known lastname **] was admitted to [**Hospital1 18**] on [**2172-10-20**]. The head frame was placed in the Pre-op area. She had an orbital X-ray to rule out metallic objects in light of her prior eye surgery. She had an MRI of the brain. She was taken to the OR for her Left DBS procedure under local/MAC anesthesia. She had some headache and nausea in the PACU. Her post-op CT showed left lateral, 3rd and 4th IVH. She was transferred to the ICU for close observation and Q1hr neuro checks. She was neurologically intact and her CT head was stable on [**10-21**]. Transfer orders for the floor were written. She was tolerating a regular diet and ambulating. Her Foley was discontinued. She had mild confusion overnight but was oriented and her CT was stable. She was discharged to home. Medications on Admission: Primidone 50 mg one tablet three times daily, levothyroxine, pravastatin, Lovenox, zoledronic acid, calcium supplementation, vitamin B12, multivitamin, and MiraLax as needed. Lovenox bridge 40mg SC QD Discharge Medications: . 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. primidone 50 mg Tablet Sig: One (1) Tablet PO 5 TIMES DAILY (). 6. propranolol 40 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Discharge Disposition: Home Discharge Diagnosis: Essential Tremor Intraventricular Hemorrhage Discharge Condition: Mental Status: Clear and coherent. Mild confusion at times. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Do not take any Coumadin or Lovenox ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow up for Stage 2 as directed. You must have a CT of the head the day of the surgery before the procedure. Please call Paresa at [**Telephone/Fax (1) 1669**] to schedule this. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2172-10-22**]

[ "998.11", "V88.01", "E878.1", "V15.88", "333.1", "272.4", "V43.65", "266.2", "V12.51", "733.00", "V58.61", "289.81" ]

icd9cm

[ [ [] ] ]

[ "01.20", "02.93" ]

icd9pcs

[ [ [] ] ]

4133, 4139

2434, 3232

370, 424

4228, 4228

1589, 2411

5656, 5962

1376, 1380

3484, 4110

4160, 4207

3258, 3461

4404, 5633

1395, 1570

314, 332

452, 893

4243, 4380

915, 1215

1231, 1360

2,128

152,495

42963

Discharge summary

report

Admission Date: [**2166-11-22**] Discharge Date: [**2166-11-28**] Date of Birth: [**2112-9-30**] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old woman who was diagnosed with lung cancer in [**2155**] and is status post radiation treatment, no chemotherapy or surgical treatment. She was admitted to an outside hospital on [**2166-11-19**], with increased shortness of breath. At that time, she was treated with Levaquin and Solu-Medrol. She was also started on dopamine for hypotension. The patient required intubation for hypoxemia. She was then transferred to [**Hospital1 69**] on [**2166-11-22**], for further management of what was felt to be a post-obstructive pneumonia. PAST MEDICAL HISTORY: The patient's history is notable for lung cancer diagnosed in [**2155**], status post radiation therapy. She has a history of pleural effusions. She is status post pericardial window in [**2164-8-8**]. Also status post pleural biopsy done in [**2166-10-9**], which was positive for adenocarcinoma. She also has chronic pericardial effusions, thought to be secondary to radiation therapy. ALLERGIES: Sulfa. MEDICATIONS ON ADMISSION: 1. Ceftazidime 1 gram every eight hours 2. Unasyn 3 grams intravenously every eight hours 3. Solu-Medrol 60 mg intravenously every 12 hours FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: Significant for continued smoking. PHYSICAL EXAMINATION: On admission, temperature was 97.9, heart rate 16, blood pressure 99/50, respiratory rate 20. The patient was on dopamine 8 mcg/kg/minute and morphine 3 mg/hour. She was awake, somnolent, following simple commands, intermittently confused. Her pupils were equal, round and reactive to light. Her chest examination revealed scattered rhonchi. Her heart examination was regular, with normal S1 and a physiologically split S2, no S3 or S4, and a soft systolic murmur at the upper left sternal border. Her abdomen was soft, with bowel sounds present but hypoactive. Neurologically, she was awake and following simple commands. LABORATORY DATA: Significant for a white count of 21.8, hematocrit of 32.2, and platelet count of 306. Her laboratories were otherwise remarkable for an arterial blood gas with a pH of 7.40, a PCO2 of 53, and a PO2 of 87. Chest x-ray showed normal heart size, bilateral pleural effusions, right perihilar mass, patchy infiltrates. Electrocardiogram showed sinus tachycardia at 108 beats per minute, with left axis deviation, low limb voltages, and no ischemic changes. HOSPITAL COURSE: The overall impression is of a 54-year-old woman with Stage IV lung cancer and a post-obstructive pneumonia. 1. Lung cancer: The patient has Stage IV lung cancer with pleural metastases diagnosed by biopsy on [**2166-11-7**], which revealed adenocarcinoma. On [**11-24**], she underwent bronchoscopy which revealed near-total tumor obstruction of the right upper lobe and right middle lobe, and on CT was found to have partial collapse of the right middle lobe and right upper lobe. The patient was intubated for this procedure, and she was self-extubated on [**11-25**], which she tolerated well. However, she was reintubated prior to an attempt to stent the obstruction and ablate the tumor with lasers. This procedure, however, was not successful. After discussion with the patient and the patient's family, it was decided to make her code status comfort measures only after she was transferred home to [**Location (un) 26833**]. [**Location (un) **] transportation was arranged. 2. Pneumonia: The patient was felt to have a post-obstructive pneumonia. She was initially admitted on Unasyn and ceftazidime. The ceftazidime was discontinued. The patient was also admitted on Solu-Medrol, and this was tapered over her hospital stay. 3. Pericardial effusions: The patient had an echocardiogram performed on [**11-25**], which revealed small pericardial effusion but no tamponade physiology. This was unchanged from many previous echocardiograms. 4. Hypotension: The patient was maintained on dopamine drip. The etiology of her hypotension was unclear. She had negative blood cultures and a negative urinalysis, suggesting that this was most likely not sepsis. However, the patient on admission had a Swan-Ganz catheter placed, which revealed a systemic vascular resistance of 1121 on dopamine, right atrial pressure of 10, right ventricular pressure of 30/10, a PA pressure of 30/20, and a pulmonary capillary wedge pressure of 12. The patient was given intravascular volume and her pneumonia was treated, however, she remained hypotensive, requiring dopamine on discharge. 5. Change in mental status: The patient was confused and agitated for much of her admission. Following the first bronchoscopy, the patient self-extubated herself, which she initially tolerated well. Following the second bronchoscopy, the patient again self-extubated herself and removed her central line. She required four-point restraints at this point, and was given Haldol. She is discharged on Haldol 5 mg four times a day with good effect. A CT scan of the brain was performed to rule out brain metastases, and this scan was negative. 6. Code status: It was decided that the patient would remain full code until she returned home to [**Location (un) 26833**], however, the patient and the patient's family feel that she would like to be comfort measures only when she returns home. CONDITION ON DISCHARGE: The patient is returning home to [**Location (un) 26833**] via [**Location (un) **]. DISCHARGE STATUS: The patient is discharged in fair condition. DISCHARGE DIAGNOSIS: 1. Stage IV lung cancer (adenocarcinoma) 2. Post-obstructive pneumonia 3. Hypotension DISCHARGE MEDICATIONS: 1. Solu-Medrol 10 mg intravenously every 12 hours 2. Dopamine 0-20 mcg/kg/minute titrate to mean arterial pressure greater than 60 3. Unasyn 3 grams intravenously every six hours 4. Protonix 40 mg intravenously once daily 5. Haldol 5 mg by mouth every six hours [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Last Name (NamePattern1) 11548**] MEDQUIST36 D: [**2166-11-28**] 01:12 T: [**2166-11-28**] 01:50 JOB#: [**Job Number 92740**]

[ "423.9", "518.89", "162.8", "197.2", "518.82", "486" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "33.22", "32.28" ]

icd9pcs

[ [ [] ] ]

1365, 1380

5790, 6334

5677, 5767

1203, 1347

2581, 4695

1458, 2562

173, 740

4711, 5479

764, 1177

1398, 1434

5505, 5656

70,313

151,456

37223

Discharge summary

report

Admission Date: [**2130-5-18**] Discharge Date: [**2130-5-30**] Date of Birth: [**2100-4-7**] Sex: M Service: NEUROSURGERY Allergies: Cephalexin / Penicillins / morphine / Albay Honey Bee Venom Attending:[**First Name3 (LF) 14802**] Chief Complaint: suboccipital pseudomeningocele Major Surgical or Invasive Procedure: [**2130-5-18**] Suboccipital wond exploration and repair for CSF leak [**2130-5-24**] Lumbar drain placement x 2 History of Present Illness: This is a 30 yearr old gentleman who underwent a suboccipital craniotomy and C1 laminectomy for Chiari decompression on [**2130-3-30**]. He did well initally. On [**2130-4-30**] he presented to an OSH complaining of occipital pressure. Head CT at that time revealed a pseudomeningocele and he was transferred to [**Hospital1 **]. On [**2130-5-2**], he underwent a fluoroscopic-guided lumbar drainage placement, the drain was ultimately removed and patient discharged home on [**2130-5-5**]. On [**5-8**] patient complained of posterior cervical headaches and was admitted to [**Hospital1 18**] CT head showed progression of his pseudo meningocele. Lumbar drain placement was attempted without success. He went to the clinic in follow up complaining of headache that is worse when he gets up from supine position and fluid collection in occipital area. His headache are worse in the am. He also reported blurred vision with coughing and tingling, pins and needle sensation in right hand. He is also complains of nausea due to sensation of pressure in his head, stiff neck. Patient also has tingling tips of toes on left foot. Past Medical History: Asthma, Genital Herpes, Eczema, ADHD, allergic rhinitis, anxiety, asthma, LB, prediabetes, PTSD Social History: He is a truck driver. He has two children. He has smokes [**11-28**] ppd since age 8. He denies ETOH use. Family History: NC Physical Exam: On Admission Gen: WD/WN, comfortable, NAD. HEENT: Pronounced fluid collection occipital area, Pupils: [**1-27**] bilat EOMs bilat Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-1**] throughout. No pronator drift Sensation: Intact to light touch Coordination: normal on finger-nose-finger Upon discharge: Awake, alert, oriented, demonstrates competency, MAE full motor, surgical site is C/D/I and flat. Pertinent Results: MRI Lspine [**2130-5-22**]: IMPRESSION: 1. Abnormal low signal in the thecal sac from L1 through L4 is most likely due to subarachnoid hemorrhage from the recent instrumentation. Very less likely, this could represent an intradural mass. Recommend followup with the repeat lumbar MRI to ensure resolution of the blood products. 2. Increased prominence of the anterior epidural space is likely due to a small amount of post-procedural hemorrhage or CSF leak. 3. Stable degenerative changes in comparison to [**2127**], with a disc protrusion at L4-5. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the Neurosurgery service after surgical wound exploration of a subocciptal pseudomeningocele with dural repair. Please see Operative Reports for full details. A Hemovac drain was placed intraoperatively. Post-operatively, he was taken to the SICU for close monitoring. He was able to tolerate a regular diet starting the evening after surgery and was noted to be neurologically intact. A Foley catheter was placed prior to surgery. He was given prophylactic Vancomycin in light of his allergy to Cephalexin and Penicillins. On [**5-19**], patient doing well, hemovac had an output of 100cc and was left in place. He was encouraged to mobilize and HOB at 90 degrees at all times. He was transferred to the SDU in stable condition. On [**5-20**] he reported burning dysesthetic pain and Neurontin was started. He remained stable on [**5-21**] and on [**5-22**] he was noted to have increased drainage from his hemovac and it was determined that a lumbar drain would be required and IR was contact[**Name (NI) **] to perform it. Given the difficulty of prior lumbar drain placements in this patient an MRI L-Spine was first obtained. IR declined to place lumbar drain. On [**5-23**], a lumbar puncture for large volume tap was attempted and unsuccessful. As such, patient was scheduled to undergo operative drain placement on [**5-24**]. The patient had two lumbar drains (epidural catheters) placed successfully on [**5-24**] under concious sedation in the OR. The procedure was uncomplicated. Drain output was initiated at 15-20 mL/hr with a plan for 7 days of drainage from the Lumbar Drain. On [**5-26**], acyclovir prophylaxis was discontinued. The patient remained stable. On [**5-27**], the patient's hemovac fell out. 2 staples were placed over the hemovac site. The patient remained stable through out his hospital stay. On [**5-30**] he expressed he wanted to discontinue the plan of care and leave against medical advice. He stated he wanted the team to remove the drains or he would. Dr [**Last Name (STitle) **] discussed the risks of discontinueing his current plan. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 83809**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] also discussed this with him. A meeting was held with his wife - [**Name (NI) **] [**Name (NI) 83809**], [**First Name4 (NamePattern1) **] [**Name (NI) **], [**First Name4 (NamePattern1) 2808**] [**Last Name (NamePattern1) 21991**], and [**Doctor First Name 1258**] from Case Management were in attendance. We discussed his plan of care and discharge needs. Upon removal of his drains he refused any closure to be done to close the lumbar drain sites. The risks of this was explained to him by multiple midlevels on the team and he allowed us to place 2 staples. The patient then stated he would remove his staples/sutures independently, he was advised against this, and the option of follow-up on Thursday for removal was given which he declined, Monday was agreed upon. Medications on Admission: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheeze 2. Clobetasol Propionate 0.05% Ointment 1 Appl TP EVERY OTHER DAY to hands every other day 3. Epinephrine 1:1000 0.3 mg IM ONCE:PRN allergic reaction in case of severe allergic reaction 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] 6. Albuterol-Ipratropium 2 PUFF IH Q4H:PRN SOB or wheeze 7. Ranitidine 150 mg PO BID 8. ValACYclovir 500 mg PO Q24H 9. Cetirizine *NF* 10 mg Oral daily 10. Sodium Chloride Nasal [**11-28**] SPRY NU QID:PRN nasal congestion Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB or wheeze 2. Cetirizine *NF* 10 mg Oral daily 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] 5. Clobetasol Propionate 0.05% Ointment 1 Appl TP EVERY OTHER DAY to hands every other day 6. Docusate Sodium 100 mg PO BID RX *Colace 100 mg 1 Capsule(s) by mouth twice a day Disp #*90 Capsule Refills:*0 7. Gabapentin 300 mg PO TID RX *gabapentin 300 mg 1 Capsule(s) by mouth three times a day Disp #*90 Capsule Refills:*0 8. HYDROmorphone (Dilaudid) 2-4 mg PO Q6H:PRN pain RX *Dilaudid 2 mg [**11-28**] Tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 9. Nystatin Oral Suspension 5 mL PO PRN thrush swish and swallow RX *nystatin 100,000 unit/mL 5 mL by mouth Oral thrush Disp #*1 Bottle Refills:*0 10. Acetaminophen 325-650 mg PO Q6H:PRN Pain or fever 11. Mupirocin Cream 2% 1 Appl TP [**Hospital1 **] RX *Bactroban 2 % Apply to the affected areas twice a day Disp #*1 Tube Refills:*0 12. Ranitidine 150 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Psuedomeningocele Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [**Known lastname **], You were admitted to Dr[**Name (NI) 83810**] service with pseudomeninogcele and underwent a suboccipital craniotomy for exploration and repair of a CSF leak. A surgical drain was left in place to help reduce pooling of CSF at the surgical site so healing could be optimal. Two lumbar drains were also placed to promote healing. You removed your wound drain on [**5-27**]. The plan was to maintain the two lumbar drains for a total of 7 days ([**6-1**]) and then remove or clamp the drains and monitor for leaking. On [**5-30**], you expressed desire to go home and not continue the current plan of care. Dr [**Last Name (STitle) **] spoke with you at length regarding the risks of leaving before we can ensure that proper healing was achieved. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 83809**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] also met with you and discussed the risks of discontinueing the current plan of care. We also explained to you that you leaving would be against medical advice. Your lumbar drains were removed and two staples were placed. General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. Weight limitation of 10lbs. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions * Please call [**Telephone/Fax (1) 2731**] to make an appointment for a wound check and staple removal. We would like to see you on Monday, [**6-5**]. Further follow-up can be made at that time. * Please call [**Telephone/Fax (1) 2731**] with any questions or concerns. On off hours, please call [**Telephone/Fax (1) 70484**] and ask for the neurosurgery oncall pager to be paged. Completed by:[**2130-5-30**]

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icd9cm

[ [ [] ] ]

[ "02.12", "03.31" ]

icd9pcs

[ [ [] ] ]

8481, 8487

3733, 6785

355, 470

8549, 8549

3154, 3710

11337, 11786

1888, 1892

7415, 8458

8508, 8528

6811, 7392

8700, 11314

1907, 2088

285, 317

3036, 3135

498, 1628

2340, 3020

8564, 8676

1650, 1748

1764, 1872

46,251

122,493

34276

Discharge summary

report

Admission Date: [**2136-2-11**] Discharge Date: [**2136-3-4**] Date of Birth: [**2104-8-11**] Sex: M Service: MEDICINE Allergies: Ibuprofen Attending:[**First Name3 (LF) 943**] Chief Complaint: Chest pain, SOB Major Surgical or Invasive Procedure: Thoracentesis Chest tube placement Pericardial window and drain Dobhoff placement by IR HD temporary line placement HD tunnelled line placement History of Present Illness: 31 year old male h/o liver [**First Name3 (LF) **] age 5 [**12-27**] biliary atresia and subsequent cirrhosis, ESRD [**12-27**] GN on HD presents with chief complaint of left chest pain when he coughs, non productive, no hemoptysis, no fever or chils. He states that the pain is sharp and pleuritic. His CP does not radiate. He also complains of abdominal pain which is chronic in nature. He denies constipation or diarrhea. He has SOB at rest and 2 pillow orthopnea. No nausea or vomiting. . He denies any other symptoms, at the current moment the patient would like only to sleep, and is asking for benadryl. . In the ER his initial VS were: T 97.6 HR 72 BP 122/83 RR 24 O2 sat: 96% RA. He rec'd 1 L IVF in total in the ER. He was also mildly hypoglycemic in the ER and rec'd 2 amps of D50. He had a WBC of 20 and therefore had a CT of his torso, this revealed possible colonic thickening, possible focal enhancement of the kidney. He rec'd vanc/zosyn/flagyl. His VS prior to transfer to the ICU was HR 110, RR 23, BP 113/73 92% RA. Access is HD line and 18g x 1. Past Medical History: Biliary atresia s/p liver [**Month/Day (2) **] [**2110**] ESRD [**12-27**] post-infectious GN on HD M/W/F asthma, well-controlled right hip avascular necrosis, per ortho may need THR nephrotic syndrome (4.1g proteinuria), hypoalbuminemia s/p small bowel resection Seizure [**12-27**] presumed emoblic event ([**12-4**]) from hepato-pulmonary syndrome Social History: He lives with his parents. He has a child with a prior girlfriend. [**Name (NI) **] does not have a job. No tobacco, alcohol, or illegal drugs. Family History: NC Physical Exam: Vitals: T: 96.8 BP: 139/85 P: 114 R: 22 O2: 98% on 2L General: somewhat drowsy, oriented x 2 (person and place, date is [**2128**] or [**2131**]), mild respiratory distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 10cm, no LAD Lungs: bronchial breath sounds throughout on the L side, clear on the Right CV: Regular rate and rhythm, normal S1 + S2, 3/6 SEM at the USB Abdomen: soft, non-tender, moderatley distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, minimal edema bilaterally Neuro: AOx2. [**3-28**] stregnth in all 4 extremities, normal sensation to light touch, no myoclonus. Drowsy. + asterixis - very prominent. Pertinent Results: ADMISSION LABS: . 134 94 43 AGap=18 ------------<67 4.0 26 5.6 ALT: 19 AP: 338 Tbili: 2.6 Alb: 1.0 AST: 43 Lip: 11 K:4.0 Glu:67 Lactate:4.1 MCV 85 WBC 20.8 HGB 12.8 PLTs 206 HCT 40.0 N:92.7 L:2.4 M:4.3 E:0.4 Bas:0.2 PT: 18.9 PTT: 50.0 INR: 1.7 . MICRO: . [**2136-2-22**] CMV Viral Load: Not detected . [**2136-2-13**] Strongyloides Antibody, IgG ([**Doctor First Name **]): Positive . [**2136-2-11**] Blood Culture, Routine (Final [**2136-2-14**]): STAPH AUREUS COAG +. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Aerobic Bottle Gram Stain (Final [**2136-2-12**]): GRAM POSITIVE COCCI IN CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2136-2-12**]): GRAM POSITIVE COCCI IN CLUSTERS. . [**2136-2-12**] 11:37 am PLEURAL FLUID GRAM STAIN (Final [**2136-2-12**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2136-2-16**]): STAPH AUREUS COAG +. SPARSE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | CLINDAMYCIN-----------<=0.25 S <=0.25 S ERYTHROMYCIN----------<=0.25 S <=0.25 S GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN----------<=0.12 S <=0.12 S OXACILLIN------------- 0.5 S <=0.25 S TETRACYCLINE---------- =>16 R TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Final [**2136-2-16**]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. . [**2136-2-13**] HD Catheter tip cx: MSSA . IMAGING: . [**2136-2-11**] CT head: No acute intracranial process. Consider MRI given the patient's history of prior infarcts if clinically warranted. . [**2136-2-11**] CXR: Congestive heart failure, large left pleural effusion. Follow up post-diuresis is recommended . [**2136-2-11**] CT abdomen: 1. Large left pleural effusion which is incompletely imaged with complete collapse of the left lower lobe and visualized lingula. Right lower lobe probable early pneumonia and/or fluid overload. 2. Apparent wall thickening of collapsed descending colon, sigmoid and rectum may represent mild colitis; however, this may also be secondary to underdistension. 3. Interval decrease in ascites. Persistent body wall and mesenteric edema, likely secondary to underlying liver disease. 4. Cirrhosis with stigmata of portal hypertension. 5. L5 spondylolysis. . [**2136-2-16**] TEE: 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%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is a small pericardial effusion. No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: No valvular vegetations seen. No evidence of vegetation on right atrial line. Small pericardial effusion with no evidence of right atrial or right ventricular collapse. . [**2136-2-19**] TTE: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Mild to moderate ([**11-26**]+) mitral regurgitation is seen. There is a moderate sized pericardial effusion. The pericardium may be thickened. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. . [**2136-2-21**] TTE: Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is a very small pericardial effusion. IMPRESSION: Very small pericardial effusion primarily located anteriorly and posterior to the atria (0.7 maximum dimension). Preserved left ventricular function. . [**2136-2-21**] Hip x-ray: Unchanged right femoral head avascular necrosis. . [**2-26**] CT abd & pelvis: 1)A new pericardiocentesis window has been placed and the pericardial effusion is now small. 2)Unchanged atelectasis in the left lower lobe and lingula suggesting a trapped lung with adjacent locules of gas within a hydropneumothorax. The right pleural effusion has slightly increased and is now moderate. 3)Colitis with pericolonic stranding which has increased since the previous study. Appearances are consistent with a colitis which may be infectious or inflammatory in origin. 4)Right femoral head AVN. . [**2-29**] RUQ u/s: 1. No evidence of intra- or extra-hepatic biliary dilatation. 2. Stable right-sided pleural effusion since CT from [**2136-2-26**]. 3. Stable appearance of the liver with known cirrhosis. No new focal liver lesions. 4. Stable appearance with reversed low flow demonstrated within the main portal vein, left portal and anterior right portal branches and splenic vein. Splenomegaly and extensive splenic varices. 5. No appreciable ascites. . [**3-1**] CXR: Mild pulmonary edema has changed in distribution but not in overall severity. Left lower lobe remains consolidated, and the moderate multiloculated air and fluid collection in the persistent left pleural space at the base of the left hemithorax is stable. Moderate cardiomegaly is longstanding. A hemodialysis catheter ends in the region of the superior cavoatrial junction and upper right atrium, obscuring the tip of the left PIC line. No right pneumothorax. Stable small right pleural effusion. Brief Hospital Course: 31 yo M w/ biliary atresia s/p liver [**Month/Day (4) **], cirrhosis, ESRD on HD presents w/ one week of left chest pain, cough, and generalized malaise. . Patient died on [**2136-3-4**]. . Goals of care: patient initially full code on admission and during much of hospitalization. While in the ICU for the second time, family meeting occurred and given his severely ill state he was changed to DNR, DNI, and the focus shifted to comfort. Patient made CMO, family at bedside, was monitored in the ICU and then transferred to the floor. Patient died. . # MSSA Bacteremia/Pneumonia/Empyema: Patient presented with symptoms of chest pain, shortness of breath and malaise. Found to have MSSA bacteremia, pneumonia and left sided pleural effusion. Most likely source of infection is HD catheter. HD catheter was removed on presentation. Chest tube was placed to drain empyema diagnosed on thoracentesis. Serial blood cultures were negative after [**2136-2-11**]. TTE and TEE found no evidence of vegetations. Due to low cortisol levels (3.9 random cortisol) and persistently low blood pressures he was started on stress dose steroids, these were tapered down with po prednisone. Tapered to hydrocort 50mg IV BID [**2-25**], to prednisone 20mg daily on [**2-27**]. Slow taper of steroids, course set as: 15mg pred [**2-29**], 10mg on [**3-1**].5mg on [**3-2**], 5mg daily thereafter continuous. Was initially on vanc/cefepime for VAP, then changed to nafcillin given MSSA. Then, per ID, was changed to cefazolin with HD dosing. On [**2-29**], increased RR, leukocytosis, and low-grade fever prompted broadening to vanc/cefepime again. ID was directing antibiotic course. Micro data from thoracentesis (pleural fluid) demonstrated enterococcus (VRE) on [**2136-3-1**]. . # Respiratory Failure: During initial evaluation he underwent bronchoscopy to attain sputum samples and to assess cause of collapsed left lower lobe. After bronchoscopy, patient became increasingly tachypneic and his altered mental status progressed. He was electively intubated for concern that he would not be able to protect his airway. After extubation, he was brething well on room air. His altered mental status resolved. Treated for VAP with vanco/cefepime for 7 days, course completed. On the floor, breathing well on room air with SpO2 in mid/high 90s on room air. On [**2-29**], patient had increasing tachypnea but still maintaining SpO2; had thoracentesis by Interventional Pulmonary team on [**3-1**] to look for infection/empyema (prior to [**Female First Name (un) 576**], given ddAVP and FFP). At that procedure, patient had 40 cc hemorrhagic fluid removed, pH 6.72, continued oozing at site prompted transfer from floor to ICU. Ordered for pRBC and FFP upon transfer to unit. Patient still oozing in unit, required blood transfusions. Pleural fluid results from thoracentesis demonstrate VRE. # Leukocytosis: Patient with abdominal pain, CT abdomen/pelvis demonstrated colitis. Started with empiric c.diff coverage with PO vancomycin, even though c.diff negative x3. Sent off c.diff cytotoxin B assay - pending. Abdominal pain also could have been d/t agressive lactulose which has been tapered back and abdominal pain improved. # Cardiac Tamponade: Enlarging pericardial effusion was identified on CT scan. Transthoracic echo showed tamponade physiology. Effusion was not accessible anteriorly for pericardiocentesis by Cardiology. Patient's tachycardia and hypotension were managed overnight with IVF boluses. He underwent pericardial window and drain placement by Thoracic Surgery. Drain was them removed, no further evidence of tamponade while on the floor. # ESRD: [**Female First Name (un) **] per renal team, MWF. Low K and phos were issues that were managed through [**Female First Name (un) 2286**] and electrolyte replacement. Tunnelled HD line was placed in left chest [**2-27**]. Ordered vitamin D to start vitamin D replacement given severely low level. # ESLD: Rising bilirubin in particular prompted RUQ u/s on [**2-29**]: [**2-29**] RUQ u/s: 1. No evidence of intra- or extra-hepatic biliary dilatation. 2. Stable right-sided pleural effusion since CT from [**2136-2-26**]. 3. Stable appearance of the liver with known cirrhosis. No new focal liver lesions. 4. Stable appearance with reversed low flow demonstrated within the main portal vein, left portal and anterior right portal branches and splenic vein. Splenomegaly and extensive splenic varices. 5. No appreciable ascites. Patient on lactulose, tacrolimus, rifaximin. Concern for worsening liver failure; not a [**Year (4 digits) **] candidate due to infection (above). # Strongyloides antibody positive - no need to further monitor O&P. Already got one dose of ivermectin - treatment done per ID. # Nutrition: Tubefeeds via Dobhoff. # Tachycardia: Reviewing records, present through most of hospitalization, likely d/t pain, infection, dehydration. # Headache - resolved. Unclear cause, however very high risk for infection, bleeding; ordered head CT - negative for acute process. EMERGENCY CONTACT: [**Name (NI) 71**] [**Name (NI) 40167**] (Father) [**Telephone/Fax (1) 78901**] Medications on Admission: Keppra 500 mg daily and 500 mg after each hemodialysis session lactulose QID prn tacrolimus 0.5 mg daily vitamin B complex with folic acid daily Reglan 10 mg tablet to take 0.5 tablets p.o. q.i.d. ipratropium bromide inhalation one q.6h. metoprolol tartrate 25 mg 0.5 tablets p.o. b.i.d. lidocaine adhesive patch omeprazole 40 mg daily vitamin D3 800-unit daily oxycodone 5 mg one tablet q.6h. p.r.n. pain sucralfate 1 g p.o. q.i.d. Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: death Discharge Condition: died Discharge Instructions: n/a Followup Instructions: n/a Completed by:[**2136-3-6**]

[ "255.41", "571.5", "038.11", "511.89", "570", "E878.0", "286.9", "511.9", "518.0", "996.82", "262", "423.9", "453.86", "V66.7", "486", "733.42", "493.90", "999.31", "785.52", "510.9", "995.92", "585.6", "E879.1", "518.81", "572.2", "790.01", "V45.11" ]

icd9cm

[ [ [] ] ]

[ "34.04", "96.04", "37.12", "96.72", "38.95", "39.95", "88.72", "96.6", "33.24", "34.91", "38.93" ]

icd9pcs

[ [ [] ] ]

15617, 15626

9955, 15106

284, 429

15675, 15681

2836, 2836

15733, 15766

2089, 2093

15589, 15594

15647, 15654

15132, 15566

15705, 15710

2108, 2817

4951, 5044

229, 246

457, 1537

5053, 9932

2852, 4918

1559, 1911

1927, 2073

20,091

116,425

15526

Discharge summary

report

Admission Date: [**2166-11-8**] Discharge Date: [**2166-11-13**] Date of Birth: [**2103-10-1**] Sex: F Service: [**Hospital1 **] CHIEF COMPLAINT: Hypotension HISTORY OF PRESENT ILLNESS: This is a 63-year-old woman with a history of hypertension, admitted to the Emergency Department after a fall. The patient states that she had about three-fourths of a glass of wine earlier in the night. She said she got out of bed to urinate, did not feel intoxicated, but did feel sleepy and tired. She was also walking in the dark. The patient then fell to the ground, and she believes she had loss of consciousness. She did not remember falling. She hit her left upper face and left elbow on the furniture. She denied any nausea, vomiting, diarrhea, lightheadedness, headache, weakness. She did not have any chest pain, palpitations, or sweating. After falling, the patient could not pick herself up. Every time she tried to pick herself up, she continued to fall again. She described her feeling as generalized weakness. The patient was then found by her daughter, sitting on the floor and unable to move. The daughter described her mother as being very short of breath and staring off into space. EMS was called, who brought the patient to [**Hospital1 69**]. In the Emergency Department, the patient's pressure was initially 90/60, which then dropped to 60/palp. Heart rate continued to stay in the 80s. Initial laboratories revealed white blood cells of 29.4, with a low-grade temperature. Sodium 118. She was treated with aggressive intravenous fluids and dopamine. She was also noted to have elevated CK, MB and troponin, with ST elevations in V2 through V4 in the Emergency Department. Echocardiogram performed in the Emergency Department did not demonstrate any wall motion abnormalities. The patient was transferred to the Intensive Care Unit, and she received a dose of stress-dose steroids. She was weaned off the dopamine. She was given a presumptive diagnosis of adrenal insufficiency, and transferred to the floor. PAST MEDICAL HISTORY: 1. Hypertension of several years' duration 2. Glaucoma 3. Status post cholecystectomy [**96**] years ago for cholangitis MEDICATIONS: 1. Candesartan 60 mg by mouth once daily 2. Lorazepam 0.5 mg by mouth daily at bedtime as needed 3. Timolol 0.5% one drop to both eyes twice a day ALLERGIES: Eggs - diarrhea and fever. FAMILY HISTORY: Father died at age 61 with coronary artery disease, myocardial infarction, question of arrhythmia. Mother had gastric cancer, bleeding ulcers, diabetes, died at 82. Sister died at age 38 with cancer of unknown origin. A brother died of lung cancer at age 67. A brother died of cancer at 58 with question of bone cancer. Her brother is living at 73 with prostate and bladder cancer. SOCIAL HISTORY: The patient lives in a house with her husband. She has been married since [**2127**]. She has a daughter and a son who help care for her husband because he is physically challenged. The patient has six children, all of whom are healthy. She used to smoke approximately 67 pack years, but quit recently. She drinks occasional alcohol, up to three glasses of wine on the weekends. She states that she feels safe at home, and denies any history of domestic violence. PHYSICAL EXAMINATION: In the Medical Intensive Care Unit, general is quiet, pleasant, in no acute distress. Head, eyes, ears, nose and throat: Ecchymosis and swelling at the left periorbital area. Visual acuity roughly intact, oropharynx dry, no lymphadenopathy, wasting of cheeks, temporal area, prominent forehead. Heart: Regular rate and rhythm, no murmurs, gallops or rubs. Lungs: Coarse breath sounds throughout. Abdomen: No hepatosplenomegaly, no inguinal lymphadenopathy. Extremities: No cyanosis, clubbing or edema. Neurologic: Grossly intact. LABORATORY DATA: White blood cells 29.4, hematocrit 41, platelets 405. Differential: 92 neutrophils, 0 bands, 4.6 lymphs. Urinalysis: Large blood, nitrate negative, 30 protein, white blood cells [**11-19**], 0 red blood cells. Chem 7: Sodium 115, potassium 5.1, chloride 79, bicarbonate 17, BUN 8, creatinine 0.8, glucose 80, anion gap 19. CK ranging from 468 to 875 to 933, MB of 12 and 32, MB index of 2.6 and 3.7, troponin 2.8 and 8.5. Toxicology screen: Ethanol 32. Serum osmolality 257. HOSPITAL COURSE: 1. Endocrine: The patient was initially admitted to the Medical Intensive Care Unit. After her blood pressure was unresponsive to a few liters of intravenous fluids and dopamine, the patient was given a stress dose of steroids, with rapid correction of her blood pressure. An initial diagnosis of adrenal insufficiency was made. However, after being transferred to the floor, the patient's cortisol, which was drawn prior to starting on the steroids, came back at 25. Endocrine consult was obtained, and they felt this was inconsistent with adrenal insufficiency. The patient was taken off her stress-dose steroids, and her blood pressure remained stable. Although it appears that the initial cortisol was drawn prior to getting the steroids, the patient will be referred for outpatient ACTH stim test to ensure the patient does not have any underlying adrenal insufficiency. 2. Cardiac: The patient had elevated cardiac enzymes and ST elevations in the setting of hypotension. The patient likely had a small myocardial infarction secondary to decreased blood supply in the setting of hypotension. The patient had initial echocardiogram in the Emergency Department, which was read as mildly depressed systolic function with apical akinesis to hypokinesis. The patient was sent for repeat echocardiogram three days after admission, which revealed an ejection fraction of greater than 50%, a left-to-right shunt across the intra-atrial septum, consistent with a secundum-type atrioseptal defect. Right ventricle was mildly dilated, aortic valve mildly thickened, mitral valve mildly thickened, trivial mitral regurgitation, mild pulmonary artery systolic hypertension. The patient remained stable, with no events on telemetry. Her electrocardiogram continued to demonstrate T wave inversions laterally. The patient was referred for ETT echo. The patient had normalization of her T wave inversions laterally, with mild 0.5 mm of ST segment depression which returned to [**Location 213**] after stopping. This occurred at a high double product. These were not felt to be significant. Echocardiogram final report is unavailable, but preliminary report revealed no wall motion abnormalities, consistent with ischemia. It is unlikely that the patient had a myocardial infarction precipitating her hypotension. 3. Hypotension: The exact cause of the patient's hypotension remains unclear. Should the patient turn out to be adrenally insufficient, this would provide an explanation. This does, however, appear unlikely. Her history is inconsistent with a seizure or cerebrovascular accident. The patient did receive 1 gram of ceftriaxone in the Emergency Department. It is possible she had some type of infection which this treated and allowed her immune system to recover. Again this is not clear to have occurred. It is possible the patient took more substantial doses of her medications than she stated. However, she appears to be a good historian and denies doing this. The patient was observed in-house for five days, and had normal to hypertensive blood pressures. The patient was restarted on her candesartan, and was started on Lopressor 12.5 mg by mouth twice a day, which the patient remained on and had high normal blood pressures. She remained stable and was ready for discharge. Of note, the patient also had a CT of the chest with contrast which demonstrated extensive emphysematous changes, small bilateral pleural effusions, and a multi-nodular goiter. No evidence of pulmonary embolism was seen. She had a CT of the abdomen and pelvis which did not reveal any evidence of hemorrhage. She had a cervical spine film which did not reveal fracture. She had a head CT which did not reveal acute intracranial bleed. It did show an old left caudate head lacunar infarct. 4. Elevated liver enzymes: The patient's liver enzymes initially went up into the several hundreds. This was believed to be the result of her hypotension and the patient having shock liver. Her liver function tests continued to decrease throughout her admission. Hepatitis serologies were drawn, but these are pending at the time of discharge. 5. Fluids, electrolytes and nutrition: The patient was volume depleted on admission. She was given intravenous fluids with some improvement in her symptoms. This may have occurred from decreased oral intake and alcohol use. 6. Alcohol use: The patient admits to drinking up to three glasses of wine on a weekend day. She was advised about the risks of drinking excessive amounts of alcohol, and its possibility to include fall, liver damage. 7. Weight loss: The patient notes a 60 pound weight loss over the past many months. She states this is unintentional, but she has noticed a decrease in her appetite. She had negative head CT, chest, abdomen and pelvis CT, and has had negative colonoscopy in the past year. There is no clear etiology to her weight loss, and this needs to be followed up as an outpatient. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged to home with her family. She will follow up on the day after discharge to have ACTH stim test performed. She will then follow up with her primary care physician in one week. DISCHARGE DIAGNOSIS: 1. Hypotension of unclear etiology 2. Myocardial infarction secondary to hypotension 3. Shock liver 4. Volume depletion 5. Multi-nodular goiter 6. Hypertension 7. Weight loss DISCHARGE MEDICATIONS: 1. Candesartan 60 mg by mouth once daily 2. Lopressor 12.5 mg by mouth twice a day 3. Lorazepam 0.5 mg by mouth daily at bedtime 4. Timolol 0.5% one drop to both eyes twice a day [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**] Dictated By:[**Name8 (MD) 17420**] MEDQUIST36 D: [**2166-11-13**] 21:32 T: [**2166-11-14**] 02:44 JOB#: [**Job Number **]

[ "241.1", "458.9", "E888.9", "410.91", "921.9", "570", "276.5", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2432, 2819

9865, 10316

9659, 9842

4393, 9391

3330, 4376

9406, 9638

168, 181

210, 2064

2086, 2415

2836, 3307

80,081

189,848

37541

Discharge summary

report

Admission Date: [**2133-1-29**] Discharge Date: [**2133-2-3**] Date of Birth: [**2103-11-25**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1854**] Chief Complaint: CC:[****] Major Surgical or Invasive Procedure: [**2133-1-29**] s/p: 3rd ventriculostomy with Dr [**Last Name (STitle) **] [**2133-1-31**] s/p: 4th ventricle cyst resection with Dr [**Last Name (STitle) **] History of Present Illness: 29 year old Spanish speaking female who presented to OSH for c/o headache and dizziness x 1 week. Also reports 1 episode of LOC today with N/V. CT at OSH showed 1.3cm circular hyperdense right frontal lesion and dilatation of the fourth and third ventricles. Past Medical History: unremarkable Social History: unknown Family History: unknown Physical Exam: On Admission: PHYSICAL EXAM: O: T:97.8 BP: 115/57 HR:90 R: 16 O2Sats: 99% Gen: WD/WN, comfortable, NAD. HEENT: normocephalic atraumatic Pupils: [**5-8**] bilat EOMs: intact, without nystagmus Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4mm to 2mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: slight right pronator drift Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-10**] throughout. Sensation: Grossly intact Upon Discharge: Alert and oriented x3, nonfocal, MAE [**6-10**] Pertinent Results: CT: (OSH) appears to be 1.3cm circular hyperdense lesion in right frontal lobe. Also dilatation of the fourth ventricle and temporal horns. no midline shift appreciated. CT [**2133-1-31**] (post-op) IMPRESSION: 1. Postsurgical pneumocephalus, with no acute intracranial hemorrhage. 2. No significant change in previously identified lesions elsewhere within the brain. [**2133-1-29**] 01:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007 [**2133-1-29**] 01:00AM URINE [**Month/Day/Year 3143**]-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2133-1-29**] 01:00AM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 [**2133-1-29**] 01:00AM PT-13.2 PTT-30.8 INR(PT)-1.1 [**2133-1-29**] 01:00AM WBC-10.4 RBC-4.79 HGB-13.5 HCT-38.9 MCV-81* MCH-28.2 MCHC-34.7 RDW-13.1 [**2133-1-29**] 01:00AM NEUTS-76.7* LYMPHS-20.5 MONOS-2.2 EOS-0.5 BASOS-0.2 [**2133-1-29**] 01:00AM PLT COUNT-305 [**2133-1-29**] 01:00AM GLUCOSE-110* UREA N-10 CREAT-0.6 SODIUM-141 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-23 ANION GAP-15 Brief Hospital Course: Patient was admitted to the hospital and monitored closely in the ICU. She underwent MRI which showed lesions consistent with neurocysticercosis. She was readied for the OR and on [**2133-1-29**] was taken to OR and underwent 3rd ventriculostomy from which she had no complications. On [**1-31**] she underwent a 4th ventricle cyst resection. She was monitored overnight in the PACU she remained neurologically intact. She had a opthamology consult which showed no ocular involvement of cysticercosis so Albendazole was started. Medications on Admission: injectable contraceptive(every three months) Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 21 days: Please begin taper down on [**2133-2-23**]. Disp:*63 Tablet(s)* Refills:*0* 8. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours: Until you follow-up appt with ID. Disp:*60 Tablet(s)* Refills:*2* 9. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 10. Albendazole 200 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for neurocysticercosis. Disp:*120 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: brain lesions - neurocysticercosis Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: General Instructions ??????Have a family member check your incision daily for signs of infection. ??????Take your pain medicine as prescribed. ??????Exercise should be limited to walking; no lifting, straining, or excessive bending. ??????You may wash your hair only after sutures and/or staples have been removed. ??????You may shower before this time using a shower cap to cover your head. ??????Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ??????Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. **** Please continue your medications as prescribed. Please call ID at [**Telephone/Fax (1) 457**] with any questions regarding your medications or if you have a fever. **** Please stay out of work for 4 weeks. You may return on [**2132-3-3**] with no restrictions. You may handle food. **** Please call the neurosurgeon if you experience any confusion, increased nausea or headache, lethargy. [**Telephone/Fax (1) 3231**] DEXAMETHASONE 2mg tablets: * You will take 1 tablet every 8 hrs until [**2133-2-23**] then decrease to 1 tablet every 12 hours until you are seen by ID on [**2133-3-2**]. * Continue the Albendazole and Lamivudine until your appointment with ID on [**2133-3-2**] Followup Instructions: Follow-Up Appointment Instructions ??????Suture Removal Tuesday [**2-11**] at .... [**Hospital **] Medical Building on [**Hospital Unit Name 84290**] ??????Please call ([**Telephone/Fax (1) 9403**] to schedule an appointment with Dr. [**Last Name (STitle) **] to be seen in 4 weeks. ??????You will need a CT scan of the brain with / without contrast. ??????You will / will not need an MRI of the brain with/ or without gadolinium contrast. - FU with Opthamology in 1 month as they saw a small retinal hole they want to ensure it is not worsening. Call [**Telephone/Fax (1) 253**] for appt. - Please follow-up with Infectious Disease, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**3-2**] at 08:30 AM. Office is located at the [**Hospital **] Medical Building, ground floor. Please call [**Telephone/Fax (1) 457**] with any questions regarding your medications or if you have a fever. Completed by:[**2133-2-3**]

[ "372.40", "123.1", "331.4", "V12.09", "787.01" ]

icd9cm

[ [ [] ] ]

[ "01.59", "02.2", "93.59" ]

icd9pcs

[ [ [] ] ]

4993, 4999

3139, 3670

328, 488

5078, 5078

2032, 3116

6694, 7664

855, 864

3765, 4970

5020, 5057

3696, 3742

5223, 6671

909, 1082

280, 290

1963, 2013

516, 778

1319, 1947

894, 894

5092, 5199

800, 814

830, 839

83,013

198,083

30331

Discharge summary

report

Admission Date: [**2200-6-3**] Discharge Date: [**2200-6-17**] Date of Birth: [**2131-1-9**] Sex: F Service: SURGERY Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 4748**] Chief Complaint: woresening RLE weakness Major Surgical or Invasive Procedure: [**2200-6-6**]: Attempt at vascular exposure of the spine complicated by tear of the iliac vein and the vena cava [**2200-6-9**]: Exploratory laparotomy and removal of abdominal packing; closure of abdominal wound History of Present Illness: Mrs. [**Known lastname **] is a 69-year-old female who has had a prior upper thoracic spinal fusion. She has had progressive right lower extremity weakness progressing to the point where she can no longer walk. She was planned to have this operation performed in [**Month (only) **] but due to her worsening symptoms she presented to the ED and it was decided to perform earlier intervention. Past Medical History: spinal stenosis, scoliosis, HTN, Gout, GERD, multiple myeloma SurgHx: T9-L5 thoracolumbar fusion [**2196**] Social History: denies tobacco/ etoh/ ilicit drugs Family History: N/C Physical Exam: on discharge Tm 99.7 Tc 98.3 HR 72 BP 112/81 RR 16 SpO2 97% gen: NAD, alert and oriented X3 cardiac: RRR lungs: CTAB abd: soft, nontender, nondistended, no rebound/guarding, midline incision c/d/i ext: b/l pitting edema, L>R Pertinent Results: [**2200-6-3**] 05:30PM BLOOD WBC-5.1 RBC-3.33* Hgb-11.5* Hct-34.6* MCV-104*# MCH-34.5*# MCHC-33.2 RDW-14.6 Plt Ct-306# [**2200-6-5**] 09:20AM BLOOD WBC-5.6 RBC-3.19* Hgb-10.8* Hct-32.8* MCV-103* MCH-34.0* MCHC-33.1 RDW-14.3 Plt Ct-307 [**2200-6-6**] 10:10AM BLOOD WBC-7.5 RBC-2.95* Hgb-9.1* Hct-26.5* MCV-90# MCH-30.9 MCHC-34.4 RDW-15.8* Plt Ct-50*# [**2200-6-6**] 11:05AM BLOOD WBC-4.8 RBC-2.21*# Hgb-7.1* Hct-19.6*# MCV-88 MCH-32.0 MCHC-36.2* RDW-16.0* Plt Ct-85*# [**2200-6-6**] 04:56PM BLOOD WBC-6.6 RBC-3.35*# Hgb-10.6*# Hct-28.4*# MCV-85 MCH-31.7 MCHC-37.4* RDW-15.8* Plt Ct-143*# [**2200-6-6**] 09:46PM BLOOD WBC-6.1 RBC-3.65* Hgb-11.2* Hct-31.1* MCV-85 MCH-30.6 MCHC-35.9* RDW-16.1* Plt Ct-153 [**2200-6-7**] 03:00AM BLOOD WBC-5.7 RBC-3.29* Hgb-10.2* Hct-28.4* MCV-86 MCH-31.0 MCHC-35.9* RDW-16.1* Plt Ct-149* [**2200-6-7**] 02:09PM BLOOD WBC-6.1 RBC-3.10* Hgb-9.4* Hct-27.1* MCV-87 MCH-30.5 MCHC-34.9 RDW-16.1* Plt Ct-123* [**2200-6-7**] 05:15PM BLOOD Hct-28.6* [**2200-6-7**] 10:15PM BLOOD Hct-31.6* [**2200-6-8**] 01:51AM BLOOD WBC-7.2 RBC-3.57* Hgb-11.1* Hct-31.1* MCV-87 MCH-31.1 MCHC-35.7* RDW-15.7* Plt Ct-122* [**2200-6-8**] 12:56PM BLOOD Hct-28.5* [**2200-6-8**] 03:31PM BLOOD Hct-30.3* [**2200-6-8**] 10:23PM BLOOD Hct-30.8* [**2200-6-9**] 12:59AM BLOOD WBC-6.4 RBC-3.59* Hgb-10.6* Hct-30.9* MCV-86 MCH-29.5 MCHC-34.3 RDW-16.4* Plt Ct-103* [**2200-6-9**] 06:02PM BLOOD WBC-6.5 RBC-3.67* Hgb-11.0* Hct-32.4* MCV-88 MCH-30.0 MCHC-34.0 RDW-16.1* Plt Ct-116* [**2200-6-10**] 12:07AM BLOOD WBC-7.2 RBC-3.66* Hgb-11.2* Hct-32.5* MCV-89 MCH-30.7 MCHC-34.5 RDW-16.1* Plt Ct-137* [**2200-6-10**] 04:24PM BLOOD Hct-29.1* [**2200-6-11**] 12:43AM BLOOD WBC-7.3 RBC-3.24* Hgb-9.6* Hct-29.0* MCV-90 MCH-29.6 MCHC-33.0 RDW-15.7* Plt Ct-136* [**2200-6-12**] 05:42AM BLOOD WBC-6.4 RBC-2.73* Hgb-8.4* Hct-24.9* MCV-91 MCH-30.7 MCHC-33.6 RDW-15.4 Plt Ct-158 [**2200-6-12**] 01:53PM BLOOD Hct-30.1* [**2200-6-13**] 03:50AM BLOOD WBC-9.3 RBC-3.36* Hgb-10.0* Hct-29.6* MCV-88 MCH-29.7 MCHC-33.7 RDW-15.4 Plt Ct-200 [**2200-6-14**] 03:08AM BLOOD WBC-10.4 RBC-3.60* Hgb-10.8* Hct-32.2* MCV-90 MCH-29.8 MCHC-33.4 RDW-15.2 Plt Ct-253 [**2200-6-16**] 07:10AM BLOOD WBC-9.7 RBC-3.61* Hgb-10.8* Hct-32.1* MCV-89 MCH-29.9 MCHC-33.7 RDW-14.9 Plt Ct-375 [**2200-6-3**] 05:30PM BLOOD Glucose-115* UreaN-31* Creat-1.0 Na-138 K-4.1 Cl-99 HCO3-30 AnGap-13 [**2200-6-6**] 11:05AM BLOOD Glucose-224* UreaN-19 Creat-0.9 Na-139 K-3.4 Cl-106 HCO3-22 AnGap-14 [**2200-6-6**] 04:56PM BLOOD Glucose-100 UreaN-20 Creat-1.0 Na-141 K-4.4 Cl-104 HCO3-29 AnGap-12 [**2200-6-6**] 09:46PM BLOOD Glucose-128* UreaN-19 Creat-1.1 Na-138 K-4.3 Cl-101 HCO3-26 AnGap-15 [**2200-6-7**] 03:00AM BLOOD Glucose-145* UreaN-19 Creat-1.0 Na-137 K-4.1 Cl-101 HCO3-26 AnGap-14 [**2200-6-8**] 01:51AM BLOOD Glucose-114* UreaN-25* Creat-1.0 Na-139 K-4.1 Cl-103 HCO3-28 AnGap-12 [**2200-6-9**] 12:59AM BLOOD Glucose-71 UreaN-26* Creat-1.0 Na-138 K-3.6 Cl-102 HCO3-26 AnGap-14 [**2200-6-9**] 06:02PM BLOOD Glucose-84 UreaN-27* Creat-0.9 Na-140 K-3.7 Cl-102 HCO3-25 AnGap-17 [**2200-6-10**] 12:07AM BLOOD Glucose-85 UreaN-29* Creat-0.9 Na-137 K-4.4 Cl-101 HCO3-23 AnGap-17 [**2200-6-10**] 08:00PM BLOOD Glucose-108* UreaN-34* Creat-1.0 Na-140 K-3.6 Cl-104 HCO3-26 AnGap-14 [**2200-6-11**] 12:43AM BLOOD Glucose-107* UreaN-33* Creat-1.0 Na-140 K-3.7 Cl-104 HCO3-25 AnGap-15 [**2200-6-11**] 08:02AM BLOOD Glucose-127* UreaN-33* Creat-1.0 Na-139 K-3.6 Cl-103 HCO3-27 AnGap-13 [**2200-6-11**] 02:49PM BLOOD Glucose-134* UreaN-33* Creat-0.9 Na-141 K-3.9 Cl-106 HCO3-29 AnGap-10 [**2200-6-11**] 08:30PM BLOOD Glucose-130* UreaN-32* Creat-0.8 Na-142 K-3.6 Cl-107 HCO3-26 AnGap-13 [**2200-6-12**] 03:30AM BLOOD Glucose-148* UreaN-37* Creat-1.1 Na-141 K-4.1 Cl-103 HCO3-28 AnGap-14 [**2200-6-12**] 01:53PM BLOOD Glucose-139* UreaN-34* Creat-0.9 Na-140 K-3.5 Cl-101 HCO3-29 AnGap-14 [**2200-6-13**] 03:50AM BLOOD Glucose-94 UreaN-31* Creat-0.8 Na-138 K-4.3 Cl-100 HCO3-30 AnGap-12 [**2200-6-14**] 03:08AM BLOOD Glucose-94 UreaN-30* Creat-0.9 Na-134 K-4.2 Cl-97 HCO3-25 AnGap-16 [**2200-6-16**] 07:10AM BLOOD Glucose-88 UreaN-23* Creat-1.1 Na-131* K-4.4 Cl-95* HCO3-26 AnGap-14 [**2200-6-6**] 11:05AM BLOOD ALT-25 AST-34 CK(CPK)-113 AlkPhos-57 TotBili-1.0 [**2200-6-6**] 04:56PM BLOOD ALT-33 AST-44* CK(CPK)-119 AlkPhos-63 TotBili-1.3 [**2200-6-7**] 03:00AM BLOOD ALT-22 AST-25 CK(CPK)-79 AlkPhos-52 TotBili-0.7 [**2200-6-6**] 11:05AM BLOOD CK-MB-3 cTropnT-0.02* [**2200-6-6**] 04:56PM BLOOD CK-MB-3 cTropnT-0.03* [**2200-6-6**] 09:46PM BLOOD CK-MB-3 cTropnT-0.02* [**2200-6-7**] 03:00AM BLOOD CK-MB-3 cTropnT-0.01 [**2200-6-6**] 11:05AM BLOOD Calcium-12.3* Phos-4.9*# Mg-1.2* [**2200-6-6**] 04:56PM BLOOD Calcium-11.1* Phos-5.1* Mg-2.3 [**2200-6-6**] 09:46PM BLOOD Calcium-10.4* Phos-5.7* Mg-1.6 [**2200-6-7**] 03:00AM BLOOD Calcium-9.5 Phos-5.9* Mg-2.6 [**2200-6-8**] 01:51AM BLOOD Calcium-8.9 Phos-4.2# Mg-1.7 [**2200-6-9**] 12:59AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.9 [**2200-6-10**] 12:07AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0 [**2200-6-10**] 08:00PM BLOOD Calcium-7.9* Phos-2.5* Mg-1.8 [**2200-6-11**] 12:43AM BLOOD Calcium-8.0* Phos-2.3* Mg-2.4 [**2200-6-11**] 08:02AM BLOOD Calcium-8.4 Phos-2.2* Mg-2.2 [**2200-6-11**] 02:49PM BLOOD Calcium-8.5 Phos-2.2* Mg-2.0 [**2200-6-11**] 08:30PM BLOOD Calcium-7.5* Phos-2.0* Mg-1.8 [**2200-6-12**] 03:30AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.4 [**2200-6-12**] 01:53PM BLOOD Calcium-7.4* Phos-2.8 Mg-2.0 [**2200-6-13**] 03:50AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.2 [**2200-6-14**] 03:08AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.0 [**2200-6-16**] 07:10AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.8 [**2200-6-3**] CT of thoracic/lumbar spine 1. Status post posterior fusion of T9 through L5 with L1 through L5 laminectomy. There is lack of fusion of L4 and L5 with a 7-mm anterolisthesis at that level. In addition there is advanced degenerative change above and below the fusion levels, with osteophytes and heterotopic bone, greater on the right, severely narrowing the spinal canal at the T8-T9 level, and osteophytes and heterotopic bone, moderately narrowing the right lateral recess of S1, likely compressing traversing nerve roots. 2. Lucency around the tip of the right L5 and around the neck of the left L5 pedicle screws suggestive of lossening. 3. Fracture through the anterior aspect of the T12 vertebral body which does not appear chronic, but the acuity of this fracture is otherwise difficult to assess. 4. Right-sided renal calcifications, partially visualized. These may represent milk of calcium layering within these renal cysts. Correlation with prior imaging would be helpful. If none is available, dedicated renal ultrasound is suggested. Brief Hospital Course: Patient was evaluated in the ED on [**2200-6-3**] for progressive right foot and leg weakness and increasing pain. On exam R leg was noted to held in flexion with 4/5 weakness in plantar flexion and eversion, straight leg raise was positive on the right at 90 degrees, and sensation was decreased in the right S1 distribution. CT of the thoracic and lumbar spine pain was obtained, demonstrating moderate narrowing of the right lateral recess of S1 and L4/5 anterolisthesis. Due to these findings, patient was admitted to Orthopaedics on Dr.[**Name (NI) 12040**] surface and scheduled for an anterior-posterior L4-S1 fusion. On [**2200-6-6**] patient went to the OR for attempted fusion, with exposure by Dr. [**Last Name (STitle) 1391**] of vascular surgery. During the exposure significant bleeding was encountered from the left iliac vein and vena cava, which was packed with Surgicel and sponges. Fusion was aborted and abdomen was closed temporarily with nylon retention sutures. Estimated blood loss was 5200 L and patient received 4 L IVF, 7 u FFP, 2 packs plts, 9 pRBCs, 350 mL cellsaver, 450 mL autologous blood, and 500 mL albumin intraoperatively. Please refer to the operative noted of Drs. [**Last Name (STitle) 1391**] and [**Name5 (PTitle) 363**] for further details. Patient was transferred intubated and sedated to the SICU. Patient required an additional 2U pRBCs post-op for an HCT of 19.6, 2U on [**6-7**], 1U on [**6-8**], and 1 U on [**6-12**] to maintain a goal HCT of 30 for a total of 15 units during her hospitalization. Patient was kept intubated for prevention of evisceration and bladder pressures were closely monitored. Cardiac enzymes and neuro exam was evaluated post-op with no evidence of ischemic injury from intraoperative blood loss. Patient required several fluid boluses for episodic hypotension and low urine output, which resolved. Patient had a fever to 102.8 on [**6-7**] and was pan-cultured; respiratory, blood, and urine cultures were negative. On On [**6-9**] patient returned to the OR for packing removal and abdominal closure. Refer to Dr. [**Name (NI) 4436**] operative note for further details. Patient was returned intubated and sedated to the ICU. Due to edema and difficulty with vent weaning, agressive diuresis with Lasix was started. On [**6-12**] patient was successfully extubated and on [**6-14**], she was transferred to the VICU. Erythema was noted around her incision the morning of [**6-14**] and she was started on Bactrim, with resolution of erythema. Chronic pain service was consulted for pain control and patient was seen by physical therapy and found to benefit from [**Hospital 3058**] rehab for improvement in mobility. On [**6-17**] patient was tolerating a regular diet and had good pain control. She was discharged to rehab. Medications on Admission: hctz 25', allopurinol 300', valsartan 160' Discharge Medications: 1. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) Solution PO Q6H (every 6 hours) as needed for fever or pain. 4. therapeutic multivitamin Liquid Sig: One (1) Tablet PO DAILY (Daily). 5. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold for hr<55, sbp<100 (new medication). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 12. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 15. 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. Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare and Rehab Discharge Diagnosis: Lumbar spondylosis, disc degeneration, stenosis and flat back syndrome. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Non ambulatory. Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Incision Care: Keep clean and dry. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([**10-18**] lbs) until your follow up appointment. Followup Instructions: Please call Dr.[**Name (NI) 1392**] office at [**Telephone/Fax (1) 1393**] for follow up in [**2-6**] weeks. Call Dr.[**Name (NI) 12040**] office ([**Telephone/Fax (1) 11061**] to discuss further management options for your back pain/radiculopathy.

[ "285.1", "V45.4", "719.7", "998.11", "737.30", "E878.8", "721.3", "401.9", "518.5", "738.5", "780.62", "276.69", "530.81", "287.5", "273.1", "458.29", "998.2", "274.9" ]

icd9cm

[ [ [] ] ]

[ "54.19", "54.12", "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

12382, 12445

8050, 10853

296, 514

12561, 12561

1405, 8027

14457, 14711

1140, 1145

10947, 12359

12466, 12540

10879, 10924

12753, 12753

12769, 14434

1160, 1386

233, 258

543, 939

12576, 12729

961, 1072

1088, 1124

22,651

195,621

26374

Discharge summary

report

Admission Date: [**2102-1-5**] Discharge Date: [**2102-1-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: ST elevation and elevated tropinin Major Surgical or Invasive Procedure: 1. percutaneous coronary intervention 2. right femoral and popliteal embolectomy History of Present Illness: This is an 81 year old woman with severe COPD, recent admit to [**Hospital1 46**] with diverticulitis vs. ischemic colitis from [**Date range (1) 65244**] - treated with abx. Patient currently residing at NH when noted to be severely diaphoretic and ??????not feeling well??????, nursing there thought she looked SOB. No chest pain. Sats in the field were 76% on room air although her extremities were very cold. Upon arrival to OSH ER after warmed up, sats 89% on room air. No evidence of CHF on CXR. Upon arrival to ER- HR 130??????s Sinus tach with ST elevation V1-V3. Slowed her down with a total of 20mg of IV diltiazem and HR now 90??????s. Even with better rate control, ST elevation persisted --> [**Hospital1 18**] cath lab. Cath showed 70% mid-diag stenosis (not intervened upon), dyskinetic inf apical segment and ballooning with preserved basal segment consistent with Takatsubos. Post-cath, patient RLE pulses were non-dopplerable, mottled. Taken to OR with SFA and Popliteal thrombectomy now on heparin drip. Intubated in OR, now extubated 97% 2L NC. Overnight in PACU, became hypotensive, started on levophed drip, now off. Continued to be tachycardic tried on esmolol drip -> hypotn -> stopped. Admitted to CCU [**2102-1-6**] for further care. Past Medical History: 1. HTN 2. COPD 3. osteoporosis 4. depressive disorder 5. h/o recent GI bleed/infectious colitis tx'd Flagyl >1wk pta Social History: Lives at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] of [**Location (un) 3320**], NH. Former smoker. Denies ETOH or illict drugs. Family History: NC Physical Exam: 97.2 125/62 120 17 95% 3L NC GEN: elderly woman lying in bed, mild distress HEENT: PERRL, MMM, OP clear CV: nl S1 S2 regular rate tachycardic no murmurs rubs or gallops Lung: clear to auscultation, no wheezes, rales, rhonchi Abd: soft, nontender, +BS Ext: cold, dopplerable DP pulses bilaterally, nonedematous Pertinent Results: [**2102-1-5**] 08:10PM WBC-26.1* RBC-2.93* Hgb-9.5* Hct-28.4* MCV-97 MCH-32.3* MCHC-33.3 RDW-12.7 Plt Ct-522* Glucose-179* UreaN-9 Creat-0.3* Na-138 K-3.8 Cl-107 HCO3-23 AnGap-12 [**2102-1-5**] 05:15PM PT-23.6* PTT-150* INR(PT)-4.0 Fibrino-360 [**2102-1-6**] 03:15PM CK(CPK)-67 CK-MB-7 cTropnT-0.19* [**2102-1-6**] 03:37AM Calcium-7.3* Phos-3.1 Mg-1.9 [**2102-1-5**] 12:38PM Type-ART pO2-243* pCO2-76* pH-7.25* calHCO3-35* Base XS-3 Intubat-NOT INTUBA [**2102-1-7**] URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RBC-[**7-8**]* WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0-2 [**2102-1-11**] 5:45 am SPUTUM STAPH AUREUS COAG +. Oxacillin RESISTANT Staphylococci [**2102-1-10**] 12:50 pm URINE PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP. 10,000-100,000 ORGANISMS/ML.. [**2102-1-10**] 12:50 pm BLOOD CULTURE CENTRAL LINE. 1 out of 4 bottles STAPHYLOCOCCUS, COAGULASE NEGATIVE. CHEST (PORTABLE AP) [**2102-1-17**] 7:19 AM IMPRESSION: 1. Decreased mild pulmonary edema. 2. Moderate, bilateral pleural effusion, right decreased, left stable. CT CHEST W/O CONTRAST [**2102-1-12**] 8:41 AM IMPRESSION: 1. Volume overload, as evidenced by bilateral pleural effusions, small amount of abdominal free fluid, anasarca, and intralobular septal thickening in the lungs. 2. Segmental lung collapse/atelectasis, and superimposed infection cannot be excluded in the right lower lobe. 3. No evidence of hemorrhage within the thoracic, abdominal, or pelvic cavities accounting for the hematocrit drop. ECHO [**2102-1-9**] Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The apex is not fully visualized but no wall motion abnormality is visualized. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. [**2102-1-5**] Cardiac Cath COMMENTS: 1. Selective coronary angiography in this right dominant patient revealed one vessel CAD. The LMCA, LCX and RCA were all angiographically without flow limiting disease. The LAD was also without significant disease but there was a 70% lesion in a mid diagonal. 2. Resting hemodynamics revealed mild elevation of right sided filling pressures with mean RA of 11mmHG. There was mild elevation of PCWP and LVEDP at 18mmHG as well as mild pulmonary hypertension with mean PA of 26mmHG. The cardiac index was preserved at 3.65. There was no trans-aortic gradient. 3. Ventriculography was slightly limited by VT during injection but it did show apical ballooning with preserved basal segments consistent with possible Takotsubo or stress induced cardiomyopathy. The overall EF was 40-45%. 4. Post cath patient was found to have pulseless right leg. She was transferred to vascular surgery for emergent surgery. FINAL DIAGNOSIS: 1. Single vessel CAD in a branch vessel (diagonal) 2. Cardiomyopathy with apical ballooning 3. Mild elevation of left and right sided filling pressures with preserved cardiac index. 4. Procedure complicated by pulseless foot post cath. Brief Hospital Course: This is an 81 yof h/o COPD, HTN p/w Takatsobu's cardiomyopathy s/p right femoral and popliteal thrombectomy. [**Hospital **] hospital course of complicated by hypercarbic respiratory distress likely [**3-2**] pneumonia in setting of severe COPD requiring intubation on [**1-11**]. Sputum culture grew MRSA and urine culture grew Proteus mirabilis. Patient was subsequently placed on vanco and zosyn, respectively. Of note, patient also grew coag negative staph in 1 out of 4 bld cx bottles. Upon extubation, patient requested to be DNI. Unfortunately, patient did not tolerate extubation despite noninvasive support. She passed away the evening of [**2102-1-18**] [**3-2**] respiratory failure. . #Elevated WBC: Unclear etiology of her white count, may be from MRSA pneumonia, Proteus UTI, also pt with recent h/o ischemic colitis vs diverticulitis. Patient was switched from zosyn to ceftriaxone and then switched back to zosyn [**3-2**] increased WBC. Patient continued on IV vanc. Pan cultured, sent stool cx including c diff which were negative and dc central line (sent tip for culture which was negative). . #COPD/O2 requirement: Was likely due to a combination of retention [**3-2**] from oxygenation, COPD, chronic disease with poor lung reserve. CXR and chest CT suggested pleural effusions, bibasilar atelectasis, could not exclude RLL pneumonia. Patient completed a 5 day course of azithromycin. Patient was on IV vancomycin for MRSA pna and IV zosyn with decreased secretions and white count. Repeat CXR decreased pulm edema with persistent bilateral pleural effusions. Due to improved respiratory status, decreased secretions, awake/alertness and RISBI<100, patient was extubated on [**1-18**] however required CPAP [**3-2**] hypoxia on nonrebreather. Despite CPAP, patient was in hypercarbic respiratory distress. . #CARDIAC ischemia: EKG w/ST elevations consistent with Takatsobu cardiomyopathy v ACS. On cath, patient was found to have minor CAD (70% mid-diag stenosis). She was continued on ASA, lisinopril 10 and nifedipine 10. Workup for stressor/trigger of Takatsobu included rechecking UA, metanephrines urine and plasma, TSH and c diff. Urine metanephrines were pending. Free normetanephrine were wnl and not suggestive of pheo. UA was negative and c diff was negative x1. . pump: On presentation, patient's LV fcn was depressed (EF 40-45%) w/apical ballooning and preserved basal segments. These findings were consistent with Takatsobu cardiomyopathy. Patient became fluid overloaded and started on IV lasix 40mg Q8hrs and a levophed drip which was quickly weaned off. Patient's repeat ECHO [**1-9**] showed restored LV fcn (EF >55%), trivial MR and mod PHTN. Patient was grossly positive (~15L) over length of stay however insensible losses not accounted. Patient responded well to lasix 20mg IV for diuresis. . rhythm: NSR - cont telemetry and EKG . #Thrombocytopenia: 567 on admission now 258 over the course of 4 days - likely stress-induced thrombocytosis. Resolved. . #s/p R thrombectomy: Heparin drip dc'd [**1-12**]. - apprec vascular recs - serial doppler . #Depressive disorder - cont zoloft, remeron . #FEN - tube feeds while intubated - repleted lytes . #Access - 2 PIV, dc'd [**1-14**] A-line, RIJ. . #PPx - heparin SQ, bowel regimen Medications on Admission: 1. zoloft 50mg QD 2. duoneb 3. remeron 15mg PO QHS 4. fosamx 70mg PO QSAT 5. ASA 81 QD 6. Cholestyramine 2gm PO QD 7. Advair IH [**Hospital1 **] 8. Lisinopril 20mg PO BID Discharge Disposition: Expired Discharge Diagnosis: Primary diagnosis: 1. Stress-induced cardiomyopathy 2. MRSA pneumonia 3. Proteus mirabilis UTI Secondary diagnosis: 4. severe COPD 5. HTN Discharge Condition: Deceased Discharge Instructions: none Followup Instructions: none Completed by:[**2102-1-27**]

[ "444.22", "518.81", "429.89", "428.0", "482.41", "401.9", "V09.0", "997.2", "287.5", "511.9", "414.01", "427.5", "491.21" ]

icd9cm

[ [ [] ] ]

[ "00.42", "93.90", "96.72", "96.6", "88.53", "96.04", "38.18", "38.93", "88.56", "00.17", "37.23", "88.48" ]

icd9pcs

[ [ [] ] ]

9366, 9375

5871, 9144

296, 378

9557, 9567

2367, 5593

9620, 9655

1997, 2001

9396, 9396

9170, 9343

5610, 5848

9591, 9597

2016, 2348

222, 258

406, 1668

9513, 9536

9415, 9492

1690, 1809

1825, 1981

1,039

149,449

8838

Discharge summary

report

Admission Date: [**2117-4-12**] Discharge Date: [**2117-4-24**] Service: MICU ORANGANGE HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 4401**] was an 83-year-old male with a questionable history of interstitial lung disease for the past 2 [**12-10**] to 3 years, GERD, status post transurethral resection of prostate, appendectomy, knee surgery, and shoulder surgery. He was admitted on [**2117-4-12**] for increasing shortness of breath and cough with productive sputum including some blood-tinged sputum for two to three weeks. The patient did complain of some pleuritic chest pain, general malaise, subjective fevers and chills. He denied orthopnea or chest pain outside of respirations. He had no nausea or vomiting, no diaphoresis, no abdominal or back pain, no sore throat. The patient was admitted to the hospital and treated for community acquired pneumonia with ceftriaxone and Azithromycin. He had an echocardiogram that showed an EF of greater than 60%, chest x-rays which showed alveolar and interstitial patterns bilaterally, suggestive of bilateral pneumonia on chronic lung disease. The patient also had a high-resolution chest CAT scan which showed bilateral apical ground glass and midfield ground glass opacifications, peripheral honeycombing, bilateral effusions. On [**2117-4-14**], a MICU consult was called for the patient's increasing hypoxia on high-flow oxygen. The patient was switched from azithromycin to Levaquin so he was on ceftriaxone and Levaquin. His sats decreased to the mid 80s on 70% face mask, went up to the low 90s on 100% nonrebreather. The patient was tachypneic, using some accessory muscles and speaking in three to four word sentences. PAST MEDICAL HISTORY: 1. Interstitial lung disease. 2. Question of idiopathic pulmonary fibrosis for 2 [**12-10**] to 3 years, never worked up. 3. GERD. 4. Benign prostatic hypertrophy, status post TURP in [**2116-7-9**]. 5. Bilateral total knee replacements. 6. Status post appendectomy. 7. Left shoulder surgery. ADMISSION MEDICATIONS: 1. Aspirin p.r.n. 2. Aciphex. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient lives with his 76-year-old wife and still works part-time in a sporting goods store. He was a retired physical education teacher. The patient had a ten year pack history of smoking, quit 50 years ago. He uses occasional alcohol. No recent travel. No asbestos exposure. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION TO THE ICU: Vital signs: Temperature 98.9, blood pressure 132/73, heart rate 85-90, respiratory rate 20-24, pulse ox 83-93% on nonrebreather. General: He was in minimal distress with difficulty breathing but pleasant. HEENT: Pupils were equal, round, and reactive to light and accommodation. Extraocular motions intact. The patient had moist mucous membranes. Chest: Bilateral rhonchi and crackles at the bases. Cardiac: Questionably irregular rate with S1, S2, no murmur. Abdomen: Positive bowel sounds, soft, nontender, nondistended. Extremities: No edema, bilateral knee scars. Neurologic: Alert and oriented times three, moving all extremities. LABORATORY/RADIOLOGIC DATA ON ADMISSION: Chemistries were unremarkable. The patient had a white count of 15.4, hematocrit 33.5, platelets 261,000. Coagulation studies were unremarkable. The patient had a blood gas which was 7.48/36/66. The patient's urine had some white cells but was essentially unremarkable. The EKG showed atrial fibrillation versus MAT with right axis right bundle branch block and some nonspecific ST changes. Chest x-ray, as in HPI. HOSPITAL COURSE: The patient was brought into the MICU. He spiked a fever and became delirious. Cultures were sent of blood and urine and chest x-ray was repeated. Over his first several days in the unit, the patient was treated conservatively with continued ceftriaxone and Levaquin antibiotics, pulmonary therapy, and supplemental oxygen. He continued to be in moderate distress and from time to time became disoriented and agitated, requiring Haldol and sedation. His atrial fibrillation was treated with anticoagulation and he was started on Lopressor for rate control. After several days of conservative treatment, the patient was semi-electively intubated and had bronchoscopy performed on [**2117-4-17**] with multiple specimens sent. The patient's oxygenation and blood gas improved markedly on the ventilator. However, the bronchoalveolar lavage cultures essentially yielded no data in terms of micro-organism, fungal etiology, or Legionella as all were negative. On [**2117-4-19**], the patient was extubated after appearing to do well on his respirations. However, he gradually became tachypneic into the 40s with decreasing 02 values. He failed mask ventilation and was reintubated. It should also be noted that throughout the course of the patient's Intensive Care stay, his CVP was monitored and initially diuresis was attempted to improve his breathing and oxygenation. However, this failed. Additionally, doxycycline was added for additional atypical antimicrobial coverage. On [**2117-4-21**], a family meeting was held by Dr. [**Last Name (STitle) **] and numerous members of the patient's family to try to ascertain what the care plan should be and what the patient would want done. At this point, the family elected to watch the patient for several more days but fairly unanimously decided that he would most likely want conservative care and extubation eventually. On the patient's final days of MICU hospitalization, his sedation was greatly lightened and he was able to communicate through hand squeezes and gestures with family and staff. The patient stated that he was in no pain. Viral and other cultures continued to remain negative throughout the [**Hospital 228**] hospital stay. He had an additional febrile episode on [**2117-4-22**] and had sputum, blood, and urine cultures sent, all of which remained negative. On [**2117-4-24**], the patient's family felt that they were ready to withdraw. Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] had some final discussions with the family including some thoughts of empiric steroid treatment versus going further with possible VATs and/or tracheostomy. However, the family ultimately decided to make the patient CMO and extubate him. The patient passed away shortly thereafter. The patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 679**] of the Gastroenterology Department, was frequently in to see the patient and aware of the plans during all of these time periods. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By: [**First Name8 (NamePattern2) 275**] [**Last Name (NamePattern1) **], M.D. MEDQUIST36 D: [**2117-4-26**] 04:01 T: [**2117-4-30**] 22:11 JOB#: [**Job Number 30826**]

[ "414.01", "515", "518.81", "427.31", "428.0", "530.81", "486" ]

icd9cm

[ [ [] ] ]

[ "33.24", "38.91", "96.71", "96.72", "96.04" ]

icd9pcs

[ [ [] ] ]

2464, 3204

3659, 6987

2056, 2143

3219, 3641

1732, 2033

2160, 2447

70,221

110,652

36949

Discharge summary

report

Admission Date: [**2192-1-20**] Discharge Date: [**2192-2-2**] Date of Birth: [**2112-9-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4309**] Chief Complaint: fall Major Surgical or Invasive Procedure: lumbar puncture History of Present Illness: Mr. [**Known lastname 1104**] is a 79 yo pt. of [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with alzeihmers who was found down at his living facility after an unwitnessed fall. There is some question of whether there was witnessed shaking. Per his daughter, he has episodes of worsening agitation, but not as bad as today. He was at his baseline before the fall, but after was acutely agitated until receiving Haldol in the emergency department. . He was recently seen by gerontology on [**1-12**] for worsening agitation. At that time, olanzapine 2.5mg was started. . In the ED, initial VS were: HR 99 BP 170/palp RR 21 94%RA He was agitated. He was noted to have gap acidosis with lactate of 8 down to 3 with fluid. CEs were negative. EKG with RBBB, no old EKGs though RBBB is noted on his problem list. [**Name2 (NI) **] received a total of 12.5mg of haldol, IVF fluid, and tetanus shot. He vomited once and was given 4mg zofran. Urine tox and UA ok. Nl CK and LFTs. . He had a CT of his neck and his head without acute findings. . On the floor, he is sleepy but agitated. History is obtained through his daughter. . Review of systems: unable to obtain Past Medical History: hypercholesterolemia low vitamin D osteoarthritis with left knee pain BPH chronic prostatitis Social History: Lives [**Street Address(1) 83359**] [**Hospital3 **]. No smoking history or EtOH history. Mr. [**Known lastname 1104**] was born in the Bronx and grew up in [**State 531**]. He graduated from City College and worked as a chemist. He has been married for many years, now widowed. Family History: His father died at age 75 of prostate cancer. His mother died at age 78 of heart problems. His sister died of heart disease. His brother, [**Name (NI) 3788**] is healthy and his brother [**Name (NI) **] has heart problems. Physical Exam: Vitals: 98.2 125/88 97%RA HR 62 General: responds to voice with agitation, intermittently opens eyes HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, 1/6 sem at RUSB, no rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: moves all extremities Pertinent Results: LABS ON ADMISSION: . [**2192-1-20**] 03:45PM BLOOD WBC-11.2* RBC-3.74* Hgb-11.6* Hct-35.4* MCV-95 MCH-31.0 MCHC-32.7 RDW-13.6 Plt Ct-425 [**2192-1-20**] 03:45PM BLOOD PT-12.1 PTT-20.3* INR(PT)-1.0 [**2192-1-20**] 03:45PM BLOOD Glucose-202* UreaN-20 Creat-1.3* Na-139 K-3.9 Cl-99 HCO3-18* AnGap-26* [**2192-1-20**] 03:45PM BLOOD ALT-23 AST-38 CK(CPK)-197 AlkPhos-80 TotBili-0.5 [**2192-1-20**] 03:45PM BLOOD Lipase-25 [**2192-1-20**] 03:45PM BLOOD cTropnT-<0.01 [**2192-1-20**] 03:45PM BLOOD CK-MB-5 [**2192-1-20**] 03:45PM BLOOD Calcium-9.5 Phos-3.7 Mg-2.5 [**2192-1-21**] 04:45PM BLOOD VitB12-446 Folate-15.9 [**2192-1-21**] 04:45PM BLOOD %HbA1c-6.9* eAG-151* [**2192-1-20**] 03:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2192-1-20**] 03:49PM BLOOD pH-7.31* Comment-GREEN TOP [**2192-1-20**] 11:24PM BLOOD Type-[**Last Name (un) **] pO2-105 pCO2-44 pH-7.38 calTCO2-27 Base XS-0 Comment-GREEN TOP [**2192-1-20**] 03:49PM BLOOD Glucose-200* Lactate-7.8* Na-143 K-3.7 Cl-99* calHCO3-22 . CSF: [**2192-1-22**] 04:15PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-1350* Polys-25 Lymphs-47 Monos-28 [**2192-1-22**] 04:15PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-255* Polys-22 Lymphs-60 Monos-18 [**2192-1-22**] 04:15PM CEREBROSPINAL FLUID (CSF) TotProt-90* Glucose-102 . MICRO: CSF - Bacillus species, felt to be contaminant . STUDIES: [**1-20**] ECG: Sinus rhythm with first degree A-V block. Right bundle-branch block and left anterior fascicular block. Non-specific ST-T wave changes. Ventricular premature beats. No previous tracing available for comparison. . [**1-20**] Head CT: 1. Right frontal subgaleal hematoma. No intracranial hemorrhage. 2. Chronic small vessel ischemic disease. 3. Age-related parenchymal involution. . [**1-20**] C-Spine CT: 1. No fracture or malalignment. 2. Chronic degenerative changes with posterior disc bulges resulting in mild to moderate effacement of the thecal sac at C4-C5, C5-C6 and C6-C7. These findings predispose the patient to cord injury even in the setting of minimal trauma. Clinical correlation is recommended, and MR can be obtained for further evaluation. . [**1-20**] Pelvis film: No fracture or dislocation. . [**1-20**] CXR: Left-sided rib deformity, unknown chronicity. If there is clinical concern a dedicated rib series may be obtained to further assess with skin marker at the site of pain . [**1-22**] EEG: This telemetry captured no pushbutton activations. Routine sampling showed a slow and encephalopathic background. This usually results from medications, metabolic disturbances, or infections although there are many other possible causes. There were no prominently focal findings. There were fairly frequent bifrontal sharp waves, sometimes appearing more prominent on one side or the other but usually with symmetry. These sharp waves may also be seen in encephalopathies, but they likely indicate a greater potential for cortical hypersynchrony or seizures. Nevertheless, despite a prolonged recording and use of seizure detection programs, none of the sharp waves were persistent or rhythmic enough to suggest actual seizures. . [**1-22**] Head CT: Apparent areas of hypodensity in the right frontal lobe and splenium of the corpus callosum may represent sequelae of trauma. In case of clinical concern for intracranial abnormality such as diffuse axonal injury, an MRI may be helpful for further evaluation. No definite acute intracranial hemorrhage. . [**1-22**] CXR: Cardiomediastinal contours are similar in appearance to the prior examination. Lungs are clear except for a subtle area of increased opacification in the left retrocardiac region, which could reflect either atelectasis or a developing area of infection. Postoperative changes are noted in the right hemithorax, similar to the previous exam. . [**1-25**] CT head with contrast: IMPRESSION: No intracranial hemorrhage. Multiple hypodense areas in the right frontal lobe and splenium are likely sequelae of trauma. If there is clinical concern for abnormalities such as diffuse axonal injury, MRI can be ordered. . [**2192-1-25**] Foot xray: IMPRESSION: Small [**Hospital1 **] fracture at the distal tip of the great toe. Brief Hospital Course: 79 y/o male with moderate dementia transferred to ICU for obtundation after an unwitnessed fall 2 days ago and question of possible seizure like activity, subsequently with hyperactive delerium. # Altered Mental Status: markedly improved on discharge. Head CT without intracranial hemorrhage. Highest concern initially for bacterial meningitis given fall and rapid decline in consciousness with fever. Nuchal rigidity concerning in setting of fever to 100.9. Empirically received meningitis dose abx within a few hours of initial change in mental status; however, CSF was not consistent with infection. Bacillus species in CSF was felt to be contaminant. Empiric antibiotics were stopped. Repeat CT without cause for AMS and no evolving change. Status epilepticus unlikely given no overt seizure on EEG. Patient was seen by neurology, and keppra was started for cortical irritability. Mental status markedly improved over the next 24 hours. No source of infection was found. Patient will likely have prolonged recovery regardless of cause given underlying dementia which family is aware of. . # Fever: unclear cause, ddx included meningitis as above vs pulmonary cause given ? LLL atelectatsis vs early infiltrate. Patient defervesced quite rapidly and no source of infection was found. LP was not consistent with meningitis, and all cultures remainded negative. . # Hyperactive delerium: likely in setting of unfamiliar environment and progression of underlying dementia. Has seen his primary care physician who initially started prn olanzapine for agitation. As an inpatient, patient was started on a seroquel regimen, which markedly improved patient's hyperactive delerium. He will take 6.25 mg qAM, and 12.5 mg at 4 pm and 9 pm for a total daily dose of 31.25 mg. He may take olanzapine as prescribed for severe agitation. . # Hyperlipidemia: held in acute setting, but may resume statin and ASA when able to take oral medications. . # left small [**Hospital1 **] fracture at the distal tip of the great toe: no surgical intervention indicated. Scheduled tylenol was provided for patient for pain control. On discharge, healing appropriately with no pain. Medications on Admission: Medications: DONEPEZIL 5 mg by mouth once a day ERGOCALCIFEROL 50,000 unit by mouth once a month OLANZAPINE [ZYPREXA] - 1.25 mg by mouth daily as needed for agitation SIMVASTATIN - 10 mg by mouth once [**Last Name (un) 5490**] . Medications - OTC ASPIRIN 81 mg once a day Discharge Medications: 1. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for agitation. 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Donepezil 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 10. Quetiapine 25 mg Tablet Sig: 0.25 Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* 11. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID AT 4PM AND 9PM (): please dose at 4PM AND at 9PM, in addition to the 6.25mg qAM, for a total daily dose of 31.25mg. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Street Address(1) 19127**] Discharge Diagnosis: PRIMARY: 1. unwitnessed fall 2. delerium . SECONDARY: 1. advanced Alzheimer's disease Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness: Alert and interactive Discharge Instructions: You were admitted to [**Hospital1 69**] after you were found down after an unwitnessed fall at your [**Hospital 4382**] facility. You underwent head imaging, EEG, and lumbar puncture. Head imaging did not show any bleeding in the brain. You were started on a new medication called KEPPRA to reduce the risk of seizure. Your lumbar puncture was not consistent with infection. You were also started on a medication called SEROQUEL during this hospitalization. . NEW MEDICATIONS/MEDICATION CHANGES: - START Keppra 500 mg by mouth at night - START Quetiapine (Seroquel) 6.25 mg by mouth in the morning - START Quetiapine (Seroquel) 12.5 mg by mouth at 4 pm and again at 9 pm - START Olanzapine (zydis) 2.5 mg by mouth for severe agitation . Please seek medical attention for worsening mental status, confusion, anxiety, agitation, fevers, chills, chest pain, shortness of breath, abdominal pain, inability to tolerate food, or any other concerning symptom. Followup Instructions: Please attend the following appointments below. . Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2192-2-7**] 10:00 . Provider [**First Name8 (NamePattern2) 161**] [**Name9 (PRE) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2192-2-13**] 3:30 Completed by:[**2192-2-2**]

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icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

10606, 10662

6994, 7200

319, 336

10791, 10791

2788, 2793

11876, 12265

1972, 2196

9479, 10583

10683, 10770

9182, 9456

10899, 11375

2211, 2769

1525, 1543

11395, 11853

275, 281

364, 1506

5930, 6971

2807, 4386

10806, 10875

1565, 1660

1676, 1956

24,129

169,004

10058+56100

Discharge summary

report+addendum

Admission Date: [**2112-8-28**] Discharge Date: [**2112-9-5**] Date of Birth: [**2063-4-17**] Sex: F Service: MED Allergies: Sulfonamides / Zithromax / Floxin / Penicillins / Neurontin / Demerol / Morphine Sulfate / Ativan Attending:[**First Name3 (LF) 689**] Chief Complaint: R thigh hematoma supratherapeutic INR Major Surgical or Invasive Procedure: Intubated L subclavian line History of Present Illness: Ms. [**Known lastname 33619**] is a 49 y.o. woman with a PMH notable for DVT/PE in [**10-23**] despite a therapeutic INR s/p IVC placement [**11-23**], recently admitted to the [**Hospital1 **] in [**5-24**] s/p fall and associated hematoma in her left thigh. The hematoma resolved and she was placed back on her coumadin upon discharge. The patient presented to the [**Hospital 4199**] hospital ED on [**2112-8-27**] with N/V/anorexia x4 days. Found in the ED to have stable vitals but to be hyponatremia and coagulopathic with an INR of 16. Given 10mg Vit K. Hct at that time was 40.8. The following day, the patient complained of some pain in her right thigh, which on exam appeared warm and swollen. Patient noted to be hypotensive with BP 70/40. INR at that time down to 9. CT scan performed revealed bleeding into the right thigh, but no retroperitoneal hematoma. Patient given VitK 5mg PO, FFP ordered and transfer arranged to [**Hospital1 **] for further intensive management. Prior to transfer the patient was stable. Right thigh 25 inches, left thigh 21.5 inches. However, one unit of FFP was hung at 2:45pm, and at 3:40pm the patient became SOB with change in MS, dusky appearance with decreased O2sat into 80s on 6L. She was intubated for hypoxemia at 3:40pm, given solumedrol and benadryl for presumed transfusion reaction. She was intubated and on arrival at [**Hospital1 18**] the patient was intubated, appeared comfortable, alert and interactive. She was extubated shortly thereafter without complication, hemodynamically stable. Transfered to medicine from ICU on [**2112-8-30**] to monitor improving condition. Past Medical History: 1. S/p gastric bypass in [**2099**], very complicated course including chronic malnutrition, h/o NG/NJ and j-tube placement, most recently in [**5-24**]. But subsequently pulled out by patient. 2. H/o DVT/PE [**10-23**]. DVT first dx in [**10-23**] by LENI, put on lovenox and coumadin, then presented acutely with SOB and found to have another PE by CTA despite INR of 2.5. IVC filter placed on [**2111-11-23**]. A partial hypercoagulability w/u was undertaken at that time revealing: no prothrombin gene mutation, no factor V leiden mutation, lupus anticoag neg, homocystein slightly elevated, anticardiolipin IgG neg, anticardiolipin IgM elevated at 18.1 but thought to be ppt by immobility. Recommended indefinite anticoag, and has been on coumadin since then with a previous history of thigh hematoma 2 months ago. 3. H/o lupus with dermatologic involvement, treated with low dose chronic prednisone. s/p biopsy. 4. Hypothyroidism, treated with levothyroxine. 5. H/o hypoventilation syndrome with CO2 in 60s. 6. Osteoporosis Takes calcium and vitamin d supplements. 7. Barretts esophagus and esophageal stricture. 8. Peripheral neuropathy. 9. H/o htn, tachycardia in previous hospitalizations suspicious for MAT. On BB opt. 10. Anxiety. 11. Chronic malnutrition. Social History: Patient lives in [**Location 3146**] with her sister and 9-year-old son. In [**Name2 (NI) 596**] was living in [**Hospital1 1501**] but on admission this time was back at home. TOB: Former smoker ~[**1-22**] pack x30years ETOH: Negative ILLICITS: Negative Family History: Non contributory Physical Exam: On exam, T 97.9 BP 136/68 P 70 RR18 O2 96% 2L Gen: eyes closed, reclining in bed, arousable HEENT: L eye droop, PERRL, EOM untestable [**2-22**] lack of concentration, OP clear CV: regular Pulm: difficult exam, poor air movement Abd: soft, midline scar [**2-22**] gastric bypass, J tube scar. NT/ND, +BS, no HSM palpable. Ext: w/wp, no edema, 2+ DP pulses. Area outlined on R thigh is soft, tender to palpation. Below this, on her distal R thigh are some echymoses. On her L thigh there are also ecchymoses present. Strength is [**5-25**] on dorsiflexion and plantar flexion. Neuro: oriented to time and place. Unable to concentrate long enough to recite days of the week forward. Admits to being confused. Pertinent Results: Coagulation studies: [**2112-8-28**] 10:37PM BLOOD PT-14.8* PTT-30.2 INR(PT)-1.4 [**2112-8-29**] 04:32AM BLOOD PT-12.2 PTT-32.7 INR(PT)-1.0 [**2112-8-30**] 04:00AM BLOOD PT-10.3* PTT-24.7 INR(PT)-0.7 CBC [**2112-8-28**] 10:37PM BLOOD WBC-5.3 RBC-1.90*# Hgb-5.8*# Hct-19.2*# MCV-101* MCH-30.4 MCHC-30.1* RDW-16.4* Plt Ct-151 [**2112-8-29**] 12:20AM BLOOD Hct-27.8*# [**2112-8-29**] 04:32AM BLOOD Hct-24.5* [**2112-8-29**] 02:07PM BLOOD Hct-25.8* [**2112-8-29**] 06:38PM BLOOD Hct-25.1* [**2112-8-30**] 04:00AM BLOOD Hct-27.9* [**2112-9-1**] 05:00AM BLOOD Hct-25.6* Plt Ct-228 WBC 10.2 [**2112-9-1**] 09:32AM BLOOD Hct-28.5* [**2112-9-1**] 06:46PM BLOOD Hct-26.7* [**2112-9-2**] 04:28AM BLOOD Hct-25.7* Plt Ct-258 WBC 10.9 [**2112-9-4**] 05:58AM BLOOD Hct-27.0* Chemistries [**2112-8-28**] 10:37PM BLOOD Glucose-110* UreaN-11 Creat-0.7 Na-133 K-4.3 Cl-99 HCO3-23 AnGap-15 [**2112-8-30**] 04:00AM BLOOD UreaN-14 Creat-0.6 [**2112-8-28**] 10:37PM BLOOD Calcium-7.9* Phos-5.0* Mg-1.6 Iron-53 [**2112-8-28**] 10:37PM BLOOD calTIBC-224* Ferritn-194* TRF-172* [**2112-8-28**] 10:37PM BLOOD TSH-0.21* [**2112-8-29**] 04:32AM BLOOD Cortsol-23.7* [**2112-8-30**] 04:00AM BLOOD Cortsol-53.1* [**2112-8-28**] 09:47PM BLOOD Type-ART PEEP-5 O2-30 pO2-59* pCO2-53* pH-7.26* calHCO3-25 Base XS--3 Intubat-INTUBATED Thigh CT ([**2112-8-29**]): IMPRESSION: 1. Two acute hematomas within the right thigh, one within the medial soft tissue, the other within the vastus medialis muscle. There is no evidence of active extravasation into either of these. 2. Resolving hematoma in the left buttock. 3. Persistent contrast within the renal collecting system from a CT scan performed at an outside institution as well as contrast in the urinary bladder. This may suggest a component of renal insufficiency. 4. Dilated bowel in the left upper quadrant. This is not significantly changed compared to the prior study. LENI ([**2112-9-1**]): IMPRESSION: 1. No evidence of DVT within the right lower extremity. 2. Hematomas within anterior and medial right thigh. These hematomas are unchanged in transverse dimension when compared to a prior CT from [**2112-8-29**]. U/A ([**9-3**]): [**2112-9-3**] 12:29PM URINE RBC-14* WBC-22* Bacteri-NONE Yeast-NONE Epi-<1 [**2112-9-3**] 12:29PM URINE Blood-LGE Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-7.0 Leuks-SM [**2112-9-3**] 12:29PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 U/A ([**9-4**]): [**2112-9-4**] 01:20AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2112-9-4**] 01:20AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 UCx pending. Central line tip ([**9-4**]) pending. Brief Hospital Course: 1. Right thigh hematoma. The patient initially presented to an outside hospital (OSH) on [**8-27**] with several days of vomiting (but had continued to take her coumadin) and this is the likely etiology of her supratherapeutic INR. This was her second admission recently for bleed while supratherapeutic on her coumadin. The day after her admission to the OSH, she complained of right thigh pain and was found to have a large hematoma. A CT done there (and her [**Hospital1 18**] admission CT on [**8-29**]) showed no retroperitoneal bleed, but showed two hematomas in the right thigh, one in the vastus medialis muscle and one in the medial soft tissues; there was also a resolving hematoma in her left buttock from a previous admission. Objectively, while on the medicine service (starting on [**8-30**]) her right thigh hematomas appeared stable, and the patient was neurovascularly intact distally. The thigh was very painful to the patient initially but once her pain medications were switched she was comfortable. On [**9-1**], the patient underwent a right sided LENI to ensure that there was no DVT in that extremity complicating the picture. This study was negative for DVT and showed interval stability of the hematomas when compared to the admission CT. She was discharged home with her hematoma stable and her pain well controlled. 2. Coagulopathy and h/o PE. The patient had a DVT/PE last [**Month (only) **] while therapeutic on coumadin (2.5) and on lovanox. She had an IVC filter placed and has been on coumadin since that time. Partial hypercoagulability workup done was negative. She has had two bleeds while supratherapeutic in the past two months. This time she was given 15g of VitK and her INR became subtherapeutic, and her coumadin was held. Hematology was consulted regarding her anticoagulation and suggested at least two weeks off of coumadin. Dr. [**Last Name (STitle) 3060**] in the [**Hospital 33620**] clinic felt that her IVC filter should be kept in and that she should either be taken off of anticoagulation altogether, or that anticoagulation with lovanox was a possibility (though expensive). He did not feel that he needed to see the patient in follow up. During hospitalization the patient had pneumoboots in place and worked with physical therapy to increase her ambulation and physical therapy felt that she was capable of [**Doctor Last Name 14762**] home without PT services. Her primary care physician was notified of the hematology recommendations. 3. Anemia. While the patient was hospitalized her HCT remained volatile in the high 20s. However, her CT did not show evidence of continued bleeding into her thigh. While she was in the ICU she was premedicated and transfused 2 units with an appropriate response in her hematocrit from 25.8 to 27.9. On transfer to the floor her HCT was 27.9. On the floor her hematocrit ranged from 25-29, and was followed q8 hours. She did not get transfused. On discharge her hematocrit was 27. 4. Respiratory Distress. In the context of FFP transfusion at the OSH, the patient desatted to the 80s and was intubated. She was given benedryl and solumedrol for presumed transfusion reaction and on arrival at [**Hospital1 18**] was stable. She was extubated the same day without difficulty. Solumedrol was dc'd on transfer to floor. She was premedicated with benadryl and Tylenol before blood products were given during this admission (only needed in unit). On [**8-29**] a left subclavian line was placed, afterwards the patient was noted to have small PTX on CXR. Her oxygen saturation was stable, and she received serial CXRs to follow PTX, which showed stability/resolution. During hospitalization she was continued on combivent, advair as per home COPD regimen. 5. Blood pressure. In the context of the presumed transfusion reaction, the patient's SBP went into the 70s at OSH. Her BP after this episdode remained stable in the 100-110/60-70s. Random a.m. cortisols were performed to exclude the possibility of adrenal insufficiency given chronic steroid therapy. Her outpatient beta blocker was held, and her blood pressures remained within the normal range. Over [**Date range (1) 28751**], the patient's BP rose into the 130s/90s. She was restarted on Metoprolol 12.5bid. She was discharged on 12.5mg metoprolol [**Hospital1 **]. 6. Altered mental status: On transfer to the floor, the patient had a great deal of difficulty concentrating, and though arousable seemed sedated during examination. On reviewing her medications, she was given two doses of fentanyl that morning, one right before transfer from ICU. This was thought to explain her sedation and confusion. Her trazodone was nevertheless decreased to 50bid, and her valium discontinued. Her mental status cleared over the next several hours and she remained lucid throughout her hospitalization. Her trazodone was increased to 50qAm and 100qPM and she was discharged on this regimen. 7. Hyponatremia. Her Na was found to be 129 at OSH. After transfer to [**Hospital1 18**], her Na was followed closely and improved, remaining in the normal range during her hospitalization. 8. CAD. On [**9-1**], the patient complained of chest pain and shortness of breath. Her vital signs were stable during this time and an EKG was done, showing some possible lateral ST depressions. Cardiac enzymes were cycled and were negative, 12 hours apart. The patient described this chest pain as similar to her anxiety. 9. F/E/N. The patient's oral intake was poor. She was s/p gastric bypass done for obesity done in '[**99**], complicated by an eating disorder resulting in NJ and ultimately J tube feedings. During a previous admission she removed her j tube, possibly while delirious. During this admission she tolerated an oral diet. Nutrition was consulted and worked with the patient to increase oral intake. 10. SLE. The patient was continued on her home regimen of prednisone 5mg qd. 11. UTI. The patient has a foley in place on transfer to the floor. It was discontinued and subsequently the patient complained of some urge incontinence. A U/A was sent which was +WBC and small leuk esterase. The U/A was repeated the following day and was negative, urine cultures were pending. The patient has multiple antibiotic allergies and was already being treated with keflex for her cellulitis . The patient was discharged with pyridium as needed, and had an appointment with her primary doctor the day after discharge to follow up on the urine culture and to begin treatment of her urinary symptoms if needed. 12. Hypothyroidism. The patient was continued on her home regimen of levothyroxine 75 mcg qd. 13. Pain control. On transfer, the patient's pain from her right thigh hematomas was significant. She was tried on vicodin 2 tab Q4 hours prn without relief of her symptoms. She asked for percocet instead and was tried on RTC percocet and ibuprofen 600 tid with better pain relief. She was discharged with ibuprofen and a one week supply of percocet until she follows up with her physician. 14. Access. The patient had a left subclavian line placed in the ICU and had a right periperhal IV as well. This infiltrated on [**8-31**] and was removed. She subsequently developed redness and pus around the IV site, and was placed on Keflex for cellulitis. She was discharged with a 7 day course of Keflex. The IV nurse evaluated the patient and felt that her peripheral access was poor. Therefore, the patient had access through her central line during her hospitalization. The central line was removed on [**9-4**] and the tip sent for culture. The culture was pending on discharge. 15. Prophylaxis. While hospitalized, the patient was on MRSA precautions, she was maintained on a PPI given poor oral intake and was kept on pneumoboots. Ambulation was encouraged. She was ambulatory with her walker on discharge. Medications on Admission: Protonix 40mg qd Neurontin 600mg po q8h Metoprolol 25mg po bid (held for now) Levoxyl 75 mcg po qd Prednisone 5mg po qd Trazadone 50 tid po and, 100 qhs Valium prn Discharge Medications: 1. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-22**] Puffs Inhalation Q6H (every 6 hours) as needed for SOB, wheeze. 3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Salmeterol Xinafoate 50 mcg/DOSE Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) for 1 weeks. Disp:*84 Tablet(s)* Refills:*0* 8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*2* 9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 5 days. Disp:*20 Capsule(s)* Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*2* 12. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* 13. Trazodone HCl 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 14. Pyridium 200 mg Tablet Sig: One (1) Tablet PO three times a day as needed for UTI symptoms for 7 days. Disp:*21 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Staff Builders Discharge Diagnosis: 1) Right thigh hematoma 2) h/o bleeds when supratherapeutic on anticoagulation (not on anticoagulation now) 3) h/o DVT/PE while anticoagulated s/p IVC filter 4) chronic malnutrition s/p gastric bypass c/b eating disorder Discharge Condition: Stable, tolerating an oral diet, ambulatory with assist, pain adequately controlled, hematoma resolving, NOT on anticoagulation Discharge Instructions: Please take your full course of antibiotics. Please take the pyridium if needed for symptoms of UTI. Please follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) 3816**] [**9-6**] at 12:15pm. Return to the emergency department or call your doctor if you notice fever, chills, increased swelling, pain, redness in your right thigh, or if you notice numbness, tingling, or difficulty moving your right leg or foot. Also if you notice increased redness, pain, swelling in your right arm or around the site where your central line was (your left chest) please call your doctor or return to the emergency department. Followup Instructions: Please keep your appointment with Dr. [**Last Name (STitle) 6431**] on [**Last Name (STitle) 3816**] [**9-6**] at 12:15pm. Please keep the following appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 22323**], MD Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2112-9-28**] 1:00 Name: [**Known lastname 5875**],[**Known firstname 194**] Unit No: [**Numeric Identifier 5876**] Admission Date: [**2112-8-28**] Discharge Date: [**2112-9-5**] Date of Birth: [**2063-4-17**] Sex: F Service: MED Allergies: Sulfonamides / Zithromax / Floxin / Penicillins / Neurontin / Demerol / Morphine Sulfate / Ativan Attending:[**First Name3 (LF) 161**] Chief Complaint: see dc summary Major Surgical or Invasive Procedure: see dc summary History of Present Illness: see dc summary Past Medical History: see dc summary Social History: see dc summary Family History: see dc summary Physical Exam: see dc summary Pertinent Results: see dc summary Brief Hospital Course: see dc summary Medications on Admission: see dc summary Discharge Medications: Change: Pyridium 200mg po three times a day for UTI symptoms x 2 days. Discharge Disposition: Home With Service Facility: Staff Builders Discharge Diagnosis: see dc summary Discharge Condition: see dc summary Discharge Instructions: see dc summary Followup Instructions: see dc summary [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 165**] MD [**MD Number(1) 166**] Completed by:[**2112-9-5**]

[ "276.1", "599.0", "263.9", "280.0", "790.92", "710.0", "459.0", "512.1", "999.8" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

19334, 19379

19158, 19174

18907, 18923

19437, 19453

19119, 19135

19516, 19686

19053, 19069

19239, 19311

19400, 19416

19200, 19216

19477, 19493

19084, 19100

18853, 18869

18951, 18967

11604, 15150

18989, 19005

19021, 19037

31,624

120,501

5688

Discharge summary

report

Admission Date: [**2110-8-6**] Discharge Date: [**2110-8-11**] Date of Birth: [**2054-10-17**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: Back and Abdominal Pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a 55 year old male who is s/p a sigmoid colectomy on [**2110-7-24**]. He was discharged on [**2110-8-1**] after an uncomplicated post-op course, with the exception of an acute gout attack treated with a course of methylprednisolone and prednisone. He experienced mild heartburn with PO intake through the weekend. On the night of of [**7-12**], he awoke with right upper lumbar back pain, [**10-13**], intermittent, positional to dull quality. It occasionally radiated to the RUQ. The is intermittent lasting seconds to minutes. Percocet helped with sleep, but not pain. The pain is currently [**5-13**], described as positional and worse with inspiration in the right upper lumbar with radiation to the RUQ. He reports diarrhea x 1 on [**8-4**]. Past Medical History: He suffers from mild gout. His surgeries include right inguinal hernia repair performed on [**2107-1-13**]. At that time, Dr. [**Last Name (STitle) 519**] also identified a large lymph node at the right internal ring, which upon biopsy proved to be reactive. [**Known firstname **] also underwent repair of an umbilical hernia as a child and lumbar fusion. Social History: [**Known firstname **] is a 55-year-old man who currently works as the chief financial officer for a Rare Book restorer. He is accompanied by his wife, [**Name (NI) 2411**] Family History: His mother in her 70s developed colon cancer, also with a history of breast and uterine carcinoma by [**Known firstname 22721**] description. Physical Exam: VS: 100.1, 110, 139/90, 24, 98 2L Gen: well appearing, NAD, A+O x 3 CV: tachycardic, Reg rhythm, no R/G/M Resp: CTA bilat. Abd: mild RUQ tenderness, no rebound, no peritoneal signs, firm on exam, not rigid, palpable mass/bowel LLQ Pertinent Results: [**2110-8-6**] 10:35AM BLOOD WBC-33.2*# RBC-4.74 Hgb-13.4* Hct-39.4* MCV-83 MCH-28.3 MCHC-34.0 RDW-14.2 Plt Ct-498*# [**2110-8-8**] 01:15AM BLOOD PT-14.3* PTT-58.0* INR(PT)-1.3* [**2110-8-7**] 06:24AM BLOOD Glucose-111* UreaN-10 Creat-0.8 Na-136 K-4.5 Cl-101 HCO3-24 AnGap-16 [**2110-8-6**] 10:35AM BLOOD ALT-71* AST-20 LD(LDH)-196 CK(CPK)-56 AlkPhos-126* Amylase-56 TotBili-1.3 [**2110-8-7**] 06:24AM BLOOD Calcium-9.0 Phos-2.5* . CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2110-8-6**] 11:17 AM IMPRESSION: 1. Acute pulmonary embolism with no CT evidence of associated right heart strain. 2. Extensive ground-glass opacity with more focal areas of consolidation in the right lower lobe along with a moderate right-sided pleural effusion. Aspiration, atelectasis, infection, or possible infarct from embolism are in the differential. 3. 5-mm right middle lobe ground glass nodule, 4-mm right upper lobe nodule, and 1.9- cm peripheral left lower lobe consolidative opacity. 4. Right lower lobe segmental bronchi obstructed - consider aspiration, mucoid impaction. Bronchoscopy could be considered if findings do not resolve over time, once more acute issues are dealt with, as this can be a cause of fever and leukocytosis. 4. Mildly dilated loops of mid small bowel distally decompressed small bowel. Contrast passes freely into the normal-appearing colon. Findings are suggestive of ileus. Early or partial small-bowel obstruction cannot be entirely excluded but is felt not likely. . LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2110-8-7**] 10:58 AM IMPRESSION: Sludge in gallbladder with no cholecystitis. . [**2110-8-10**] 11:15PM BLOOD PT-21.6* PTT-98.5* INR(PT)-2.1* Brief Hospital Course: He was admitted on [**8-6**] with fevers, and back and abdominal pain. He was made NPO and started on IVF. A CT revealed acute pulmonary embolism. Pulmonary Embolism: A US revealed no evidence of right or left lower extremity deep vein thrombosis. He was started on a Heparin drip and kept therapeutic on the gtt, while checking his PTT per protocol. Coumadin was started. He was started on Cipro/Flagyl for question of a pulmonary infection/pneumonia. On the evening of [**8-10**], his INR came back at 2.1. He was discharged on 2.5 mg of Coumadin and will follow-up with his PCP for continued INR checks and Coumadin dosing. Diarrhea: He was empiraically started on Flagyl to cover for C.diff. His WBC on admission was 21K. C.diff was checked and results were neagtive. Flagyl was then D/C'd. Pleuritic and back/abdomen Pain: Pain was controlled with Morphine PCA. Hypovolemia: He was started on IVF and bolused for low urine output. He responded well to fluids. Medications on Admission: allopurinol 200', colchicine 0.6' 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. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 1 weeks. Disp:*30 Tablet(s)* Refills:*0* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks: Please monitor INR with PCP and adjust Coumadin accordingly. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Acute Pulmonary Embolism Abdominal and Back Pain Discharge Condition: Good Pain controlled No SOB 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. * No heavy lifting >10 lbs for 3-4 weeks. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 519**] in 2 weeks. Call ([**Telephone/Fax (1) 5323**] to schedule an appointment. Please follow-up with your PCP for monitoring your INR and Coumadin dosing. Have your INR checked 2 days after discharge. Report to the lab for your blood work on Wednesday [**2110-8-13**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2110-8-11**]

[ "E849.0", "511.9", "414.01", "274.9", "415.11", "E878.8", "276.52", "486" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5767, 5773

3832, 4802

338, 345

5866, 5896

2130, 3809

7028, 7506

1720, 1863

4886, 5744

5794, 5845

4828, 4863

5920, 7005

1878, 2111

275, 300

373, 1129

1151, 1512

1528, 1704

66,745

103,587

35873

Discharge summary

report

Admission Date: [**2145-8-11**] Discharge Date: [**2145-8-17**] Date of Birth: [**2088-1-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 12174**] Chief Complaint: weakness Major Surgical or Invasive Procedure: Paracentesis Endoscopy (EGD) History of Present Illness: 57 year old male with history of liver cirrhosis on [**First Name3 (LF) **] list presents with weakness, vomiting, and confusion for several days. Pt states he has been feeling weak for past 15d but felt much worse yesterday. He had difficulty walking and became tired going up stairs. No muscle pain. He felt as if he did not want to get up from sofa. He had one episode of vomiting food, non-bloody, non-bilious (unclear when this occurred). Pt also noted that 15d ago, he had lower abdominal cramping which was relieved by motrin. Pt states he has felt a little confused and more forgetful over past few days. Denied f/c. Has diarrhea with lactulose, no constipation. Currently without nausea. In the ED, initial VS were: T 97.1 P 58 BP 99/81 R 18 O2 sat. Noted to be jaundiced, with abdominal ascites and asterixis on exam. Guaiac positive, brown stool. Abdominal ultrasound looks stable. Head CT negative. Noted to have new acute renal failure, ABG 7.32/25/152, lactate 2.7. Pt underwent ultrasound guided paracentesis by radiology per liver recommendations. Got IVFs with improvement in pressure to 123/84. Vitals on transfer HR 63, BP 142/111, RR 14, SaO2 100% RA. On the floor, pt was alert and communicative. Review of sytems: (+) Per HPI; + recent weight loss (unclear how much over what period) (-) Denies fever, chills. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denied chest pain or tightness, palpitations. No dysuria. Denied arthralgias or myalgias. Past Medical History: -End stage liver disease, with MELD 18, on [**First Name3 (LF) **] list -alcoholic cirrhosis - decompensated in the past with ascites, peripheral edema and hepatic encephalopathy. -history of esophageal varices, never bled -h/o hepatopulmonary syndrome -HTN Social History: Smoke: quit 5y ago EtOH: stopped [**2143-10-9**]; prior to that: 1 case/week Drugs: never Lives: with wife [**Name (NI) **]: used to work for cable company; no longer working Family History: unknown, except Mother - 90, alive Father - deceased 5y ago Physical Exam: Physical Exam on admission [**2145-8-11**]: Vitals: T: 97.5 BP: 111/64 P:65 R 14 SaO2: 100% RA General: Alert, oriented, no acute distress, jaundiced HEENT: Sclera icteric, MMM Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, [**12-8**] murmur at RUSB non-radiating and LLSB, no rubs, gallops Abdomen: no ascites, no fluid wave shift, no shifting dullness, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: 1+ pitting edema b/l, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: + asterixis, CN II-XII intact, 5/5 strength in UE and LE b/l, sensation intact to light touch b/l Pertinent Results: [**2145-8-11**] 12:30PM BLOOD WBC-10.5 RBC-2.33* Hgb-8.7* Hct-26.7* MCV-115* MCH-37.3* MCHC-32.6 RDW-15.7* Plt Ct-114* [**2145-8-12**] 08:00AM BLOOD WBC-4.6# RBC-1.59*# Hgb-5.8*# Hct-18.2*# MCV-114* MCH-36.1* MCHC-31.6 RDW-16.0* Plt Ct-71* [**2145-8-12**] 03:30PM BLOOD WBC-4.4 RBC-1.76* Hgb-6.3* Hct-19.5* MCV-111* MCH-35.7* MCHC-32.1 RDW-17.5* Plt Ct-58* [**2145-8-12**] 11:40PM BLOOD WBC-4.7 RBC-2.38*# Hgb-8.3*# Hct-24.3* MCV-102*# MCH-34.7* MCHC-34.1 RDW-19.9* Plt Ct-57* [**2145-8-14**] 04:15PM BLOOD WBC-5.8 RBC-2.68* Hgb-9.3* Hct-27.4* MCV-102* MCH-34.7* MCHC-34.0 RDW-21.1* Plt Ct-55* [**2145-8-17**] 06:50AM BLOOD WBC-4.8 RBC-2.51* Hgb-8.8* Hct-25.2* MCV-100* MCH-35.2* MCHC-35.1* RDW-19.5* Plt Ct-65* [**2145-8-11**] 12:30PM BLOOD Neuts-62.2 Lymphs-27.3 Monos-5.8 Eos-3.8 Baso-1.0 [**2145-8-11**] 12:30PM BLOOD PT-20.2* PTT-39.6* INR(PT)-1.9* [**2145-8-14**] 05:13AM BLOOD PT-21.9* PTT-41.9* INR(PT)-2.0* [**2145-8-17**] 06:50AM BLOOD PT-24.0* PTT-45.4* INR(PT)-2.3* [**2145-8-11**] 12:30PM BLOOD Glucose-142* UreaN-55* Creat-4.0*# Na-133 K-4.8 Cl-107 HCO3-14* AnGap-17 [**2145-8-13**] 05:48AM BLOOD Glucose-124* UreaN-35* Creat-1.9*# Na-139 K-4.2 Cl-112* HCO3-16* AnGap-15 [**2145-8-15**] 04:14AM BLOOD Glucose-133* UreaN-19 Creat-1.4* Na-136 K-3.9 Cl-110* HCO3-18* AnGap-12 [**2145-8-17**] 06:50AM BLOOD Glucose-97 UreaN-11 Creat-1.0 Na-137 K-4.7 Cl-108 HCO3-22 AnGap-12 [**2145-8-11**] 12:30PM BLOOD ALT-35 AST-61* AlkPhos-100 TotBili-4.5* [**2145-8-13**] 05:48AM BLOOD ALT-25 AST-43* LD(LDH)-163 AlkPhos-66 TotBili-7.7* DirBili-1.6* IndBili-6.1 [**2145-8-14**] 05:13AM BLOOD ALT-24 AST-44* LD(LDH)-157 AlkPhos-66 TotBili-9.7* [**2145-8-16**] 05:40AM BLOOD ALT-26 AST-43* AlkPhos-82 TotBili-5.8* [**2145-8-17**] 06:50AM BLOOD TotBili-5.5* [**2145-8-17**] 06:50AM BLOOD Calcium-8.4 Phos-1.7* Mg-1.9 [**2145-8-12**] 08:00AM BLOOD VitB12-1870* Folate-9.6 Hapto-30 [**2145-8-11**] 12:45PM BLOOD Ammonia-123* [**2145-8-11**] 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2145-8-11**] 04:39PM BLOOD Lactate-2.7* Micro: [**2145-8-11**] BCx - pending [**2145-8-11**] UCx - no growth [**2145-8-11**] Peritoneal fluid cx - no growth . Images: [**2145-8-11**] Abd US (PRELIM): 1. cirrhosis and moderate ascites. 2. Again no color flow seen in the left portal vein, likely thrombus, but pulsed doppler may indicate a small amount of reverse flow but could also be artifactual. Main portal vein patent. 3. Cholelithasis without cholecystitis. 4. Splenomegaly. Overall, not significantly changed since US study of [**2145-6-30**]. . [**2145-8-11**] CXR IMPRESSION: No evidence of acute cardiopulmonary process. [**2145-8-11**] CT head IMPRESSION: No hemorrhage, edema, or evidence for other acute process. [**2145-8-11**] US - IMPRESSION: 1. Findings consistent with known cirrhosis. Moderate amount of ascites and splenomegaly, sequelae of portal hypertension. 2. Again, no color flow identified within the left portal vein, which may be due to thrombosis. Pulse Doppler demonstrates possible flow although this may be reversed and slow or findings could be artifactual. 3. Cholelithiasis. 4. Previously seen lesion within the pancreatic head cannot be evaluated today due to overlying bowel gas. Diagnositic paracentsis via ultrasound Fluid removed - 20ml IMPRESSION: Successful ultrasound-guided diagnostic paracentesis EGD: Varices at the distal esophagus Mosaic pattern in the diffuse compatible with chronic gastritis Otherwise normal EGD to third part of the duodenum Brief Hospital Course: 57M with end stage liver disease on [**Month/Day/Year **] list presenting with weakness found to be in acute renal failure. # Anemia - pt with 10 point Hct drop on hosptial day 2 with repeat Hct 17 down [**Last Name (un) 834**] 26. Anemia was macrocytic. Pt had hypotension on the floor breifly with SBP in 70s, with no sx and was asleep. He responeded to 1 liter. No evidence of active bleeding during admission. But due to the recent EGD 1 month prior showing grade II vaices, there was concern for a GI bleed and the pt was transfered to the MICU. On exam the pt was guaiac positive with brown stool. He had no abdominal pain. Had emesis once in ER without blood. On HD2, pt received 4 units of blood and 3 units FFP, with appropriate hct response to 27. He was also given vitamin K 5mg PO for INR 2.3. Hemolysis labs and smear were not consistent with hemolysis. Nadolol was stopped to prevent masking of tachycardia in setting of anemia, but later after the EGD was restarted. Pt was started on PPI IV and received cipro 400mg IV for 5 days for empiric coverage during a GI bleed (last day of cipro = [**2145-8-17**]). He had a bowel movement on 2nd day of ICU stay which was guaiac negative. Pt was evaluated by liver with EGD and found to have 4 cords Grade 2 varices with stigmata of recent bleed. Also had gastritis. Banded x 4 (2 varices with 2 bands) without complication. As HCT remained stable during ICU and no evidence of bleeding, pt was called back out to floor. He was also started on carafate per liver recs and kept on soft diet for evening post procedure. Patient was transferred to the floor in stable condition, diet advanced as tolerated and hematocrit remained stable. Transitioned to PO PPI. Patient to follow-up in 1 week for repeat EGD. # Renal failure - Cr 4.0 on admission, 1.5 on [**2145-6-30**]. Pt had albumin challenge on admission with improvement in Cr which suggests he may be pre-renal, possibly from bleed prior to admission. Fe urea 25% suggesting pre-renal. DDx also includes hepato-renal syndrome, ATN, or infection elsewhere worsening liver function. CXR negative. Paracentesis does not suggest SBP. ATN less likely as Urine Eos negative. Diuretics held. Albumin 75 mg x 2 was given with improvement, therefore, was thought to be prerenal. Cr improved throughout his hospital course and his diuretics were restarted with lasix 20mg and aldactone 50mg on [**2145-8-15**]. Patient was discharged on this dose of diuretics, renal function stable, to follow-up in liver center for further management. # End stage liver disease: Due to alcoholic cirrhosis. Now with MELD 33 due to increased Cr, on [**Date Range **] list. Diagnostic and therapeutic paracentesis performed in ED by radiology. Pt has h/o hepatic encephalopathy and non-bleeding esophageal varices. Nadolol stopped initially and then later restarted. Continued lactulose and xifaxan. Pt's home omeprazole changed to pantoprazole 40mg IV BID then transitioned to pantoprazole 40 PO qday on discharge. Was restarted on diuretics as discussed above. # Weakness - Most likely due to anemia as history suggests fatigue or malaise rather than muscle weakness or DOE. Pt denies muscle pain and with full strength during neuro exam. EKG unremarkable. # Metabolic acidosis: Pt with gap and non-gap acidosis on admission (AG 12 but with albumin 2.8 so his normal gap is approx 7.5). Gap acidosis most likely due to lactic acidosis and uremia. Non-gap possibly due to normal saline received in ED or diarrhea due to lactulose. On HD2, Pt with gap acidosis (AG 13 but albumin unknown after albumin challenge). Gap acidosis most likely due to uremia. Gap later resolved with improvement of renal function. Medications on Admission: per OMR list reviewed [**2145-7-15**], unable to confirm with pt as he has no list and does not recall his meds -clotrimazole 10mg Troche 5x/day -furosemide 40mg PO qday - held on admission -lactulose 10gm/15mL - 30cc QID -nadolol 40mg PO daily -xifaxan 400mg TID -spironolactone 75mg PO BID - given once at admission, then held -ferrous sulfate 300mg PO BID - changed to 325mg PO BID -MVI daily -Omeprazole E.C. Delayed Release 20mg PO BID Discharge Medications: 1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane 5X/DAY (5 Times a Day). 2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day): for [**2-3**] Bowel movements per day. 3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 doses. Disp:*1 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: GI Bleed Anemia Cirrhosis Encephalopathy . Discharge Condition: Stable, not encephalopathic, ambulating independently, Discharge Instructions: You were admitted to the hospital for evaluation of bleeding. It was found that you had varices in your esophagus. These are dilated blood vessels that can bleed. You were treated with blood transfusions, IV fluids, and banding of the varices to prevent further bleeding. You were monitored in the ICU and then subsequently on the floor. You required no further interventions. . Please take all medications as directed. Please call your doctor or return to the Emergency Room if you experience any black stools, bright red blood per rectum, shortness of breath, chest pain or any other symptoms concerning to you. . The following changes were made to your medications: 1. Furosemide dose was decreased to 20mg daily 2. Spironolactone dose was decreased to 50mg daily 3. Nadolol dose was decreased to 20mg daily 4. Ferrous Sulfate was changed to 325mg twice daily . Please follow-up as directed below, and call with any questions or concerns. Followup Instructions: 1. [**Last Name (LF) 1447**],[**First Name3 (LF) **] [**Telephone/Fax (1) 81526**], please call for an appointment in the next 2 weeks. . 2. Please present to the Gastroenterology Procedure Suite on the [**Hospital Ward Name 516**] of [**Hospital3 **] Hospital for an Endoscopy on [**2145-8-27**] at 8:30 AM. You should not eat after dinner on the night prior to this procedure. You will receive instructions regarding this procedure in the mail before the appointment. . 3. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] [**Name11 (NameIs) **] SOCIAL WORK Date/Time:[**2145-9-29**] 10:00 . 4. Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2145-9-29**] 10:20 .

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icd9cm

[ [ [] ] ]

[ "42.33", "54.91" ]

icd9pcs

[ [ [] ] ]

12068, 12074

6762, 10464

325, 355

12161, 12218

3217, 6739

13217, 13960

2397, 2459

10955, 12045

12095, 12140

10490, 10932

12242, 13194

2474, 3198

277, 287

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383, 1604

1928, 2188

2204, 2381

28,170

123,499

3950

Discharge summary

report

Admission Date: [**2120-3-3**] Discharge Date: [**2120-3-7**] Date of Birth: [**2046-11-16**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: None History of Present Illness: 73 yo male driver s/p motor vehicle crash vs building, +Etoh, GCS 12, ?restrained. he was transported to [**Hospital1 18**] and intubated for airway control. Past Medical History: CAD s/p CABG Social History: Married +EtOH Family History: Noncontributory Pertinent Results: [**2120-3-3**] 03:50PM CK(CPK)-524* [**2120-3-3**] 11:57AM GLUCOSE-148* LACTATE-2.7* NA+-146 K+-4.0 CL--103 TCO2-22 [**2120-3-3**] 11:47AM ASA-NEG ETHANOL-343* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2120-3-3**] 11:47AM WBC-11.1* RBC-5.29 HGB-16.1 HCT-46.5 MCV-88 MCH-30.4 MCHC-34.5 RDW-13.5 [**2120-3-3**] 11:47AM PT-12.8 PTT-24.2 INR(PT)-1.1 [**2120-3-3**] 11:47AM PLT COUNT-230 CT HEAD W/O CONTRAST IMPRESSION: 1. No acute intracranial hemorrhage or skull fracture. 2. Left subgaleal hematoma. 3. Mild peripheral cerebral atrophy. CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST IMPRESSION: 1. No acute intrathoracic or intra-abdominal injury. 2. Atelectasis in the right lower lobe with probable concurrent aspiration. 3. 4.4 cm infrarenal AAA. Brief Hospital Course: He was admitted to the Trauma Service. He was noted to have a right proximal tib/fib fracture; Orthopedics was consulted and have recommended non operative intervention at this time. He was fitted for a hinged [**Doctor Last Name **] brace and is touch down weight bearing on that leg. He did have some pain control issues and was started on Ultram prn which has been effective. Physical therapy was consulted and have recommended home with services. Social work was also consulted because of the alcohol involvement surrounding his crash. He was provided with counseling and information on alcohol and drug use. Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ultram 50 mg Tablet Sig: [**12-20**] - 1 Tablet PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every four (4) hours as needed for pain. Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: s/p motor vehicle crash Left subgleal hematoma Secondary diagmosis: Infrarenal abdominal aortic aneurysm (4.4 cm) Discharge Condition: Good Discharge Instructions: Return to the Emergency room if you develop any fevers, chills, headache, dizziness, chest pain, shortness of breath, abdominal pain, nause, vomiting, diarrhea and/or any other symptoms that are concerning to you. You may touch down weight bear on your right leg. Continue to wear your hinged knee brace as directed. Followup Instructions: Follow up next Thursday [**3-14**] in [**Hospital **] Clinic with Dr. [**Last Name (STitle) 1005**]; you will need repeat xrays of your right knee. call [**Telephone/Fax (1) 1228**] for an appointment. Follow up for any concerns related to your recent crash with Dr. [**Last Name (STitle) **], Trauma Surgery. Call [**Telephone/Fax (1) 6429**] if an appointment is needed. You should follow up with your primary care doctor within the next 1-2 weeks; you will need to call for an appointment. Completed by:[**2120-3-7**]

[ "V45.81", "414.01", "920", "441.4", "823.02", "E816.0", "305.01" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

2399, 2485

1456, 2071

337, 344

2644, 2651

650, 1433

3018, 3543

614, 631

2094, 2376

2506, 2623

2675, 2995

274, 299

372, 531

553, 567

583, 598

30,162

198,220

5407

Discharge summary

report

Admission Date: [**2119-4-26**] Discharge Date: [**2119-5-2**] Date of Birth: [**2051-3-28**] Sex: M Service: SURGERY Allergies: Simvastatin / Latex / Adhesive Tape Attending:[**First Name3 (LF) 1384**] Chief Complaint: ESRD here for Living unrelated kidney transplant Major Surgical or Invasive Procedure: [**2119-4-26**]: Living unrelated kidney transplant History of Present Illness: This is a 68 y/o male with ESRD and significant cardiac history who is currently maintained on hemodialysis. Despite the informed risks of this surgery, the kidney transplant was scheduled. His cardiologist was contact[**Name (NI) **] by the transplant team and he thought this would be safe to perform the kidney transplant. Past Medical History: DM x30 years, BG at home 160-170. CKD with AV fistula placed [**8-23**] Hypercholesterolemia. CAD s/p MI in 98, s/p stenting in [**2113**], most recent cath at [**Hospital1 **] [**5-23**], 1 stent down w/colateral, no stenosis h/o charcot foot, s/p surgery Hypertension. H/o vitreous hemorrhage/cataract surgery, legally blind R eye. Peripheral neuropathy. S/p R stapedius surgery with residual vertigo (?) 20y ago. Social History: Lives with wife, [**Name (NI) **], smoked 30 yrs 2 PPD, quit 26 y ago, denies etoh now (occ. in past), denies illicit drug use. Family History: Father, MI, DM (deceased age 56), Mother MI, DM (deceased age 61), 3 brothers deceased [**2-18**] MI, 1 brother s/p 5 vessel CABG, no biological children Physical Exam: Post OP VS: 97.7, 87, 125/50, 19, 99% (intubated) Gen: remians intubated Card: RRR, systolic murmur noted at RSB Lungs: bibasilar minimal decrease in BS Extr: 1 + edema noted in feet, L AVF with positive bruit and thrill Pertinent Results: Post Op: [**2119-4-26**] WBC-5.1 RBC-2.83* Hgb-9.1* Hct-27.1* MCV-96 MCH-32.3* MCHC-33.8 RDW-15.2 Plt Ct-210 PT-13.3 PTT-30.4 INR(PT)-1.1 Glucose-188* UreaN-53* Creat-5.8*# Na-145 K-5.4* Cl-109* HCO3-19* AnGap-22* Calcium-8.6 Phos-5.2* Mg-1.5* On Discharge: [**2119-5-2**] WBC-8.1 RBC-3.62* Hgb-11.4* Hct-32.8* MCV-91 MCH-31.4 MCHC-34.6 RDW-15.1 Plt Ct-157 Glucose-132* UreaN-32* Creat-1.3* Na-137 K-5.2* Cl-109* HCO3-19* AnGap-14 Calcium-9.6 Phos-2.1* Mg-1.5* FK506-7.6 Brief Hospital Course: 68 y/o male with ESRD on hemodialysis who underwent living unrelated kidney transplant on [**2119-4-26**] with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Per the operative note, in summary the two arteries needed to be reconstructed. Once this was done, the kidney reperfused. It reperfused well initially and then became dusky but as the case went on it became more pink and began making just a little bit of urine. The kidney was placed in the right iliac fossa. He received routine induction immunosuppression to include cellcept, thymoglobulin and 500 mg solumedrol. He received a total of 3 doses of 125 mg ATG. Please see the operative note for further sugical detail. In the immediate post-operative period, ECG was done that showed Sinus rhythm, with Left axis deviation and ST-T wave abnormalities. Since the previous tracing of [**2119-4-24**] ST-T wave abnormalities are more marked. CK and troponins were cycled with Troponin peak of 1.87. Cardiology consult deemed this an STEMI. He remained intubated and was admitted to the SICU for close monitoring. He was extubated on POD 2. Troponins trended down and the S-T wave abnormalities lessened as well. He remained in the ICU until POD 4 due to bed availability issues, however he made good progress with advancing diet, mobility bed to chair. He was transferred to the regular surgical floor on POD 5, and was evaluated by PT. He will be discharged home with a walker, he was able to climb a flight of stairs. From a cardiology standpoint, he was started on aspirin, and will return to his home dose of Toprol XL. He is to follow-up with his outpatient cardiologist. Blood sugars initially elevated but returning to better control by discharge. He will restart home Lantus and Humalog and is to follow-up with [**Name8 (MD) **] NP who has been following him as an outpatient. Incision was oozing some serous fluid, he was sent with instructions to change the dressing daily and PRN and leave OTA once it dries up. He did have ecchmosis around his scrotum. He was voiding well, with good urine volume, creatinine decresed to 1.3 by day of discharge. Tolerating diet and ambulating with walker. Medications on Admission: [**Doctor First Name **], insulin, Toprol-XL 200 mg, Niaspan, Diovan, vitamin C, aspirin, B vitamins, omeprazole, selenium and vitamin E. Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Continue as long as taking narcotic pain medication and as needed. 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 10. Insulin Glargine 100 unit/mL Solution Sig: 30 - 35 units Subcutaneous at bedtime: Follow humalog sliding scale Call [**Last Name (un) **] for further instructions. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 30 days. Disp:*30 Tablet(s)* Refills:*0* 12. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day. Disp:*180 Capsule(s)* Refills:*2* 13. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: s/p living unrelated kidney transplant STEMI post transplant Discharge Condition: Good/Stable Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, diarrhea, inability to take or keep down medications. Proceed to the emergency room if you experience chest pain or difficulty with your breathing. Monitor the incision for redness, drainage or bleeding. You may shower. Pat incision dry and place dressing over incision if it is still oozing. Otherwise the incision may be left open to air. Weigh yourself daily. Please report weight gain of more than 3 pounds daily to the transplant clinic. Likewise report more than 2 pound weight loss. Labs to be drawn every Monday and Thursday to include CBC, Chem 7, Ca, Phos, AST, T bili, U/A and Trough Prograf level. Results to be faxed to the transplant clinic at [**Telephone/Fax (1) 697**] Monitor blood glucoses daily, taking your lantus and humalog as directed. Please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**] if you are having problems regulating your blood sugar Avoid high potassium foods such as bananas, tomatoes, potatoes, oranges, [**Location (un) 2452**] juice and grapefruit juice Have labs drawn this Thursday [**5-4**] Followup Instructions: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2119-5-11**] 8:30 Follow up with your outpatient Cardiologist [**Last Name (un) **]: [**Telephone/Fax (1) 12648**] for appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**] NP. Call and leave message if you are having difficulty with scheduling. Also call if blood sugar is not well controlled ( < 200) Completed by:[**2119-5-2**]

[ "585.6", "357.2", "428.0", "369.4", "E878.0", "250.60", "E849.7", "V45.81", "410.71", "272.0", "997.1", "403.91", "414.00" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "00.92", "55.69", "88.72" ]

icd9pcs

[ [ [] ] ]

6078, 6136

2262, 4451

343, 396

6241, 6255

1767, 2011

7473, 7964

1355, 1510

4640, 6055

6157, 6220

4477, 4617

6279, 7450

1525, 1748

2025, 2239

255, 305

424, 752

774, 1192

1208, 1338

19,709

151,289

24322

Discharge summary

report

Admission Date: [**2161-7-18**] Discharge Date: [**2161-7-30**] Date of Birth: [**2139-2-24**] Sex: F Service: ORTHOPAEDICS Allergies: Azithromycin / Cefazolin / Vancomycin Attending:[**First Name3 (LF) 11415**] Chief Complaint: motor vehicle collision Major Surgical or Invasive Procedure: ORIF right tibia & fibula fractures Closed reduction right radial head fracture History of Present Illness: The patient was an unrestrained driver in a high-speed motor vehicle collision vs tree. She was ejected approximately 40 feet and arrived to the [**Hospital1 18**] ED amnestic to the event. A passenger in the same vehicle was found to have fixed & dilated pupils and subsequently expired. +EtOH Past Medical History: low back disc herniation chronic back pain Social History: +EtOH, denies smoking, other drugs Family History: noncontributory Physical Exam: 98.8 106 108/p 20 100%RA A&Ox3 PERRLA, EOMI small amount blood in oropharynx, teeth intact, midface stable, TMs clear, nares w/o blood/fluid large approx 8cm cresentic head lac left parieto-occipital trachea midline RRR CTA bilaterally +RUQ tenderness, soft, nondistended pelvis stable + sacral tenderness, no other midline or paraspinous tenderness, no deformity or step-off, no abrasions or ecchymoses to back Right tib/fib deformity, abrasion right lateral knee abrasion left ankle + deformity right elbow + femoral, DP, PT, radial pulses bilaterally guiac negative, normal tone Pertinent Results: [**2161-7-18**] 08:45PM URINE RBC->50 WBC-[**4-11**] BACTERIA-OCC YEAST-NONE EPI-[**4-11**] [**2161-7-18**] 08:45PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-TR [**2161-7-18**] 08:45PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.007 [**2161-7-18**] 08:45PM FIBRINOGE-166 [**2161-7-18**] 08:45PM PT-13.4* PTT-28.1 INR(PT)-1.2 [**2161-7-18**] 08:45PM PLT COUNT-268 [**2161-7-18**] 08:45PM WBC-17.1* RBC-3.62* HGB-12.0 HCT-35.5* MCV-98 MCH-33.2* MCHC-33.9 RDW-13.0 [**2161-7-18**] 08:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2161-7-18**] 08:45PM ASA-NEG ETHANOL-166* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2161-7-18**] 08:45PM AMYLASE-38 [**2161-7-18**] 08:45PM UREA N-9 CREAT-0.6 [**2161-7-18**] 09:01PM HGB-12.8 calcHCT-38 R elbow [**7-18**]: There is a slightly angulated fracture through the right radial neck. There are no other fractures identified. R tib/fib [**7-18**]: Two views of the femur and three views of the right tibia and fibula were obtained. There are obliquely oriented displaced fractures through the distal right tibia and fibula with significant lateral and posterior displacement of the distal fracture fragments. There are several small associated bony fragments. A minimally displaced fracture is also noted through the proximal right fibula. The femur demonstrates no evidence of fracture. CT Head: neg CT Cspine: neg CT Abd: TECHNIQUE: Multidetector CT scanning of the chest, abdomen and pelvis was performed following administration of 150 cc of Optiray contrast. Coronal and sagittal reformations were also obtained. CT OF THE CHEST WITH INTRAVENOUS CONTRAST. The heart, pericardium and great vessels are within normal limits. The airways are patent to the segmental level bilaterally. There are patchy bilateral areas of parenchymal opacity best appreciated in the posterior aspects of the upper lobes as well as the lower lobes bilaterally consistent with contusions. Linear densities are also appreciated in the lower lobes bilaterally which could be consistent with atelectatic change. There is no pneumothorax or effusion. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST. There is a linear defect through the right inferior and posterior aspect of the liver consistent with a laceration. A tiny punctate focus of hyperdensity is appreciated along the medial aspect of this laceration within the liver parenchyma which is felt to be most consistent with a small vessel rather than active extravasation. The remainder of the liver, gallbladder, spleen and pancreas are unremarkable. The intra-abdominal loops of large and small bowel are within normal limits. There is a moderate amount of high density material in the right retroperitoneal region expanding the perirenal space with associated perirenal stranding. The kidneys are otherwise within normal limits with symmetric nephrograms. The adrenals are unremarkable. There is no free air. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST. A Foley is present within the nondistended bladder. The distal ureters, rectum, uterus and adnexa are within normal limits. There is no pathologic adenopathy. BONE WINDOWS: There are no suspicious lytic or sclerotic lesions. No fractures are identified. CT RECONSTRUCTIONS: The above findings were confirmed with coronal and sagittal reformations. IMPRESSION: 1. Liver laceration of the right posterior liver. 2. Right-sided perirenal/retroperitoneal hematoma with preserved renal function. 3. Pulmonary contusions. CXR: [**7-22**]: Patchy opacities in bilateral lower lobes, probably representing combination of contusion and atelectasis in this patient status post motor vehicle accident. Brief Hospital Course: The patient was admitted to the Trauma SICU on [**7-18**] with the injuries listed above. She remained hemodynamically stable on presentation and throughout her stay. On HD#2 she went to the OR with orthopedics for ORIF right tib/fib, closed reduction right radial head. On HD#3 she was transferred to the floor. Her pain was initially controlled with a Dilaudid PCA. SHe was still having persistent pain all over and acute pain service was consulted. She was switched to oral oxycodone and percocet, with adequate pain control during the rest of her stay. On HD#4 her Hct had trended down to 20 and she was transfused 2 units PRBC with appropriate increase of her Hct. Her Hct remained stable during the rest of her stay. Repeat CT of her abdomen showed improved perirenal hematoma, improved liver laceration. She was seen by PT & OT and her activity advanced. She was also seen by social work and psychiatry for occasionally voiced suicidal thoughts. She was cleared by psychiatry, although it was thought that she would benefit from continued evaluation by psychiatry at her rehab center and eventual outpatient psychiatry follow-up. she was seen by dr [**Last Name (STitle) **] and he felt she was developing an eschar on her rt medial leg she was transfered to ortho and started on abx her wound over the next three days remain unchanged and she was accepted to [**Hospital1 **] she was starting to put more effort in to her ot of her rt elbow and was ready for transfer to rehab Medications on Admission: percocet Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 3. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as needed for Pain. 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as needed for Breakthrough Pain. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Haloperidol Lactate 5 mg/mL Solution Sig: 0.5-2 mg Injection Q4H (every 4 hours) as needed for agitation. 10. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous Q 24H (Every 24 Hours). 11. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Clindamycin Phosphate 150 mg/mL Solution Sig: One (1) Injection Q8H (every 8 hours): till follow up with dr [**Last Name (STitle) **] in one week. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: motor vehicle collision liver laceration perirenal hematoma - right bilateral pulmonary contusions Displaced distal right tibia and fibula fractures Minimally displaced proximal right fibula fracture Right radial neck fracture Discharge Condition: Fair Discharge Instructions: Keep your splints and casts clean and dry. Take the pain medication as prescribed as needed. Physical Therapy: Activity: Activity as tolerated Right lower extremity: Non weight bearing Right upper extremity: Non weight bearing walker with arm support Treatments Frequency: Site: R Leg Type: Surgical Cleansing [**Doctor Last Name 360**]: Saline Dressing: Gauze - dry Comment: to remain in AO splint- Ortho Team to do any dressing changes Site: R Arm Type: Other Dressing: Other Comment: Splint with sling- Ortho Team to do any splint changes rt popiteal fossa leave open to iar Followup Instructions: With orthopedics in 1 week. Please call ([**Telephone/Fax (1) 8746**] as soon as possible to schedule a follow-up appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**] Completed by:[**2161-7-30**]

[ "722.10", "285.9", "813.05", "864.02", "305.00", "861.21", "824.8", "E816.0", "E849.5", "309.28", "868.09", "873.0" ]

icd9cm

[ [ [] ] ]

[ "86.59", "99.04", "79.36", "79.06", "79.02" ]

icd9pcs

[ [ [] ] ]

8187, 8257

5308, 6798

327, 409

8528, 8534

1509, 2991

9184, 9472

867, 884

6857, 8164

8278, 8507

6824, 6834

8558, 8652

899, 1490

8670, 8816

8839, 9161

264, 289

437, 733

3000, 5285

755, 799

815, 851

82,128

137,126

4935

Discharge summary

report

Admission Date: [**2144-4-22**] Discharge Date: [**2144-5-2**] Date of Birth: [**2062-2-25**] Sex: F Service: ORTHOPAEDICS Allergies: Percocet / tylenol with codeine Attending:[**First Name3 (LF) 7303**] Chief Complaint: Hypotension, A fib with RVR, right hip pain Major Surgical or Invasive Procedure: Right total hip replacement History of Present Illness: 82F w/hx Afib w/RVR, HTN, osteoporosis, and severe bilateral hip osteoarthritis in need of bilateral hip replacement, presented to [**Hospital6 **] with a complaint of chest pain. . Per [**Hospital3 **] external records, the patient awoke with chest pain at 3 or 4 am that waxed and waned until she arrived in the ED, when she was chest pain-free. She endorsed some palpitations overnight for which she took an extra dose of atenolol. Vitals at [**Hospital3 **] were BP: 84/48, HR: 137, RR: 16, Temp: 97.5 PO, O2 Sat: 99% on RA. After initial OSH ED evaluation (Trop neg, EKG showed Afib w/RVR and lateral ST depressions, CXR without PNA or volume overload), she requested transfer to [**Hospital1 18**] for further management given long-term care and upcoming R hip replacement surgery here. . Regarding her chest pain, pt describes it as dull, L-sided and intermitted but lasting from 3 AM yesterday morning until partway through ED stay here yesterday afternoon. Resolved by arrival in the ICU. Troponins still rising (last 0.13) but MBs flat. No associated SOB, no n/v or diaphoresis. Cardiology was called to the ED to see her when bedside echo showed possible pericardial effusion concerning for tamponade; they did a repeat normal TTE but also notably witnessed a 5-second pause later considered to be a conversion pause. She has been in NSR ever since. No BB or CCB given except the 50 mg atenolol she took yesterday PTA. . Hypotension continued in the ED, requiring 4L IVF. BP only stabilized after afib converted back to NSR. No further fluid required in the MICU - BPs stable >100 systolic since midnight. . ED stay also notably for possible Hct drop, to 28 from 36 on last check 7d prior. No recent GI or GU bleeding reported. Rectal guaiac+ brown stool (hemorrhoids noted). Pt reports hx "more than a few drops blood in the toilet from hemorrhoids" ever since childbirth >30 years ago. Hct nadir was 25, now up to 29.3 without transfusion. Note: pt did not receive blood that was ordered by ED (4U crossed, 2 PIVs placed). In the MICU, pt is without chest pain or palpitations and NSR on telemetry with stable BP 100-120s/60-80s. Most concerned about her need for R hip replacement given significant mobility limitation at home because of pain. Both hips are painful, R>L. Stays in bed most days. Not really taking pain meds - reports dilaudid doesn't help because it takes too long to act. Here she received 1 mg IV morphine twice overnight and once at 6 pm for hip pain w/transfers. _________________________________________________________ long standing history of chronic hip pain. elects for definitive treatment. Past Medical History: - Hypertension - Osteoporosis - Osteoarthritis - Hearing loss - Afib [**2136**] (recently started on warfarin) - Hip pain since [**2138**] - Iron deficiency Anemia (normal colonoscopy [**9-/2141**]) Social History: Widowed 3 years ago. Currently lives with her adult son, who is disabled (wheelchair-bound) from osteoarthritis and Charcot deformity. She is his primary caretaker, which has been difficult with her own pain from her hips. She is in the process of interviewing people to help her to care for her son while she recovers from her upcoming surgery. Reports recently having trouble with ADLs (especially bathing/showering) secondary to her pain. She was a homemaker for most of her life, but at age 53 went to law school and worked for 20 years thereafter. She is a never-smoker, never-drinker, no recreational drug use. . Family History: Patient reports outliving all of her immediate and known extended family by this point. She had an identical twin sister with "less healthy" dietary and exercise habits who died age 67. Malignancies in the mother's and father's families but no breast or ovarian ca; father deceased of metastatic bladder cancer. Physical Exam: ADMISSION EXAM 98.2F 90 114/98 19 100%/2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, [**2-17**] holosystolic murmur at LSB and apex Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: + foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Patient is in left lateral position to minimize hip pain but has significant pain with attempting to move her legs. Neuro: CNII-XII intact, strength not assessed given significant pain with movement, sensation to light touch intact . MEDICINE TO ORTHO TRANSFER EXAM VS 98.6 122/60 69 18 98/RA TELE NSR 70s GEN pale, fatigued- but comfortable-appearing elderly female lying in NAD; winces in pain with any hip movement HEENT NCAT EOMI OP clear MM dry JVP flat PULM CTA, no r/r/w, no extraordinary respiratory effort CV regular rate and rhythm, III/VII holosystolic murmur throughout precordium best RUSB, S1 and S2 distinct. no rub or gallop. PMI nondisplaced. ABD soft nt nd NABS EXT wwp palpable pulses NEURO AOX2 speech fluent, CN intact, upper extremity strength [**4-16**] bilaterally, LE strength testing and gait deferred [**2-13**] hip pain JOINT hip ROM not assessed [**2-13**] pain . DISCHARGE EXAM Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND, +BS x 4 quadrants Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength * SILT, NVI distally * Toes warm Pertinent Results: ADMISSION LABS [**2144-4-22**] 01:35PM BLOOD WBC-5.5 RBC-3.09* Hgb-8.7* Hct-28.1* MCV-91 MCH-28.1 MCHC-30.9* RDW-13.7 Plt Ct-292 [**2144-4-22**] 01:35PM BLOOD PT-19.4* PTT-30.5 INR(PT)-1.8* [**2144-4-22**] 01:35PM BLOOD Glucose-100 UreaN-23* Creat-0.9 Na-143 K-3.8 Cl-114* HCO3-21* AnGap-12 [**2144-4-22**] 03:43PM BLOOD Lactate-1.4 . COAG TREND [**2144-4-22**] 01:35PM BLOOD PT-19.4* PTT-30.5 INR(PT)-1.8* [**2144-4-23**] 02:07AM BLOOD PT-21.6* PTT-31.4 INR(PT)-2.1* . CARDIAC ENZYMES [**2144-4-22**] 01:35PM BLOOD cTropnT-0.05* [**2144-4-22**] 05:59PM BLOOD CK-MB-7 cTropnT-0.10* [**2144-4-23**] 02:07AM BLOOD CK-MB-8 cTropnT-0.12* [**2144-4-23**] 10:05AM BLOOD CK-MB-8 cTropnT-0.13* [**2144-4-24**] 07:29AM BLOOD CK-MB-5 cTropnT-0.12* . DISCHARGE LABS . . . . URINALYSIS [**2144-4-22**] 03:35PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018 [**2144-4-22**] 03:35PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.0 Leuks-TR [**2144-4-22**] 03:35PM URINE RBC-10* WBC-7* Bacteri-MOD Yeast-NONE Epi-<1 [**2144-4-22**] 03:35PM URINE CastHy-7* [**2144-4-22**] 03:35PM URINE Mucous-MANY . MICRO [**2144-4-22**] URINE URINE CULTURE-PENDING INPATIENT [**2144-4-22**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2144-4-22**] BLOOD CULTURE-PENDING EMERGENCY [**Hospital1 **] . STUDIES [**2144-4-22**] TTE There is symmetric left ventricular hypertrophy. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Limited study. No evidence of pericardial effusion or tamponade. Symmetric LVH with near-hyperdynamic LV systolic function. . [**2144-4-22**] CHEST (PORTABLE AP) IMPRESSION: Findings suggesting mild vascular congestion. . EKGs [**2144-4-22**] ([**Hospital3 **]): A-fib with rate in 130s. ST depressions in V4-V6. TWI in I, AVL. [**2144-4-22**] ([**Hospital1 18**] ED): A-fib with rate in s. ST depressions in V4-V6 persist, as do TWI in I and AVL. [**2144-4-22**] (MICU): Sinus rhythm with rate in 80s. ST depressions in the lateral leads are markedly improved, and there is now TWF in AVL and mild TWI in I. [**2144-4-25**] 07:11AM BLOOD WBC-4.3 RBC-3.33* Hgb-9.5* Hct-29.5* MCV-89 MCH-28.4 MCHC-32.1 RDW-13.6 Plt Ct-332 [**2144-4-26**] 11:25AM BLOOD WBC-4.6 RBC-4.18*# Hgb-11.8* Hct-37.1# MCV-89 MCH-28.1 MCHC-31.7 RDW-13.9 Plt Ct-318 [**2144-4-27**] 07:25AM BLOOD WBC-3.9* RBC-3.99* Hgb-11.1* Hct-35.3* MCV-89 MCH-27.9 MCHC-31.5 RDW-13.8 Plt Ct-319 [**2144-4-27**] 08:40PM BLOOD WBC-4.0 RBC-3.95* Hgb-11.5* Hct-35.1* MCV-89 MCH-29.0 MCHC-32.7 RDW-14.0 Plt Ct-323 [**2144-4-28**] 04:18PM BLOOD WBC-8.3# RBC-3.87* Hgb-11.1* Hct-35.0* MCV-91 MCH-28.8 MCHC-31.8 RDW-14.6 Plt Ct-289 [**2144-4-29**] 07:35AM BLOOD WBC-6.3 RBC-2.70*# Hgb-7.9*# Hct-24.3*# MCV-90 MCH-29.1 MCHC-32.4 RDW-14.9 Plt Ct-290 [**2144-4-30**] 07:21AM BLOOD WBC-4.6 RBC-2.34* Hgb-7.0* Hct-23.9* MCV-102*# MCH-29.9 MCHC-29.2* RDW-15.1 Plt Ct-220 [**2144-5-1**] 08:00AM BLOOD WBC-9.1# RBC-3.62*# Hgb-10.7*# Hct-31.9* MCV-88# MCH-29.6 MCHC-33.6# RDW-14.8 Plt Ct-311 [**2144-5-2**] 07:20AM BLOOD WBC-5.9 RBC-3.10* Hgb-9.4* Hct-27.7* MCV-90 MCH-30.2 MCHC-33.8 RDW-15.4 Plt Ct-327 [**2144-4-27**] 08:40PM BLOOD Neuts-69.1 Lymphs-21.3 Monos-4.9 Eos-4.4* Baso-0.2 [**2144-4-25**] 07:11AM BLOOD Glucose-102* UreaN-24* Creat-0.9 Na-142 K-3.9 Cl-108 HCO3-27 AnGap-11 [**2144-4-26**] 11:25AM BLOOD Glucose-98 UreaN-21* Creat-0.9 Na-142 K-4.3 Cl-107 HCO3-28 AnGap-11 [**2144-4-27**] 07:25AM BLOOD Glucose-97 UreaN-28* Creat-0.9 Na-141 K-4.1 Cl-106 HCO3-28 AnGap-11 [**2144-4-28**] 04:18PM BLOOD Glucose-111* UreaN-22* Creat-0.8 Na-141 K-3.6 Cl-108 HCO3-23 AnGap-14 [**2144-4-29**] 07:35AM BLOOD Glucose-176* UreaN-24* Creat-0.9 Na-138 K-3.8 Cl-106 HCO3-22 AnGap-14 [**2144-4-30**] 07:21AM BLOOD Glucose-1065* UreaN-17 Creat-0.7 Na-123* K-8.4* Cl-104 HCO3-17* AnGap-10 [**2144-4-30**] 10:45AM BLOOD Glucose-125* UreaN-19 Creat-0.7 Na-139 K-3.6 Cl-109* HCO3-22 AnGap-12 [**2144-5-1**] 08:00AM BLOOD Glucose-96 UreaN-17 Creat-0.7 Na-137 K-4.0 Cl-105 HCO3-25 AnGap-11 [**2144-5-2**] 07:20AM BLOOD Glucose-100 UreaN-17 Creat-0.8 Na-140 K-3.9 Cl-107 HCO3-28 AnGap-9 Brief Hospital Course: 82F w/hx bilateral hip osteoarthritis and afib w/RVR p/w sudden-onset chest pain, found to have Afib w/RVR and hypotension which resolved when Afib spontaneously converted to NSR on home atenolol. . # AFIB W/RVR, 5 SEC CONVERSION PAUSE Pt developed symptomatic afib at home with corresponding drop in BP and associated chest pain. Acute exacerbation afib possibly related to UTI and/or increased stress at home regarding her upcoming surgery and need for care for her disabled son. TSH wnl. Converted spontaneously in the [**Hospital1 18**] after 5s conversion pause. HR stable 60s-80s on telemetry since. Cardiology consult and EP consultants recommended continuing home medications and ongoing telemetry and/or [**Doctor Last Name **] of Hearts (should pt be discharged). Chronically only anticoagulated w/325 ASA QD given intermittent hemorrhoidal bleeding for >30 years. Had been recently started on coumadin which was held starting [**4-23**] in anticipation of upcoming surgery. . # RESOLVED HYPOTENSION Hypotensive to 80s/40 in the ED was not fluid responsive (5L given) but resolved soon after she spontaneously converted to NSR. BPs stable 120s systolic since. Continued home atenolol, restarted lisinopril prior to transfer to ortho. Will need home spironolactone 12.5 mg QD restarted. . # CHEST PAIN/DEMAND ISCHEMIA Present on admission. Patient reports that she frequently has similar chest pain during RVR episodes but her presenting symptoms this admission lasted longer than usual. Trop trended up to 0.13 max, down thereafter, MB flat throughout. EKG changes were consistent with a possible left circumflex pattern. Given rate in 130s-140s on admission, cardiology consult felt she had likely developed demand ischemia with mild troponin leak and recommended no further intervention. Continued home 325 mg ASA. . # POSSIBLE HCT DROP Baseline Hct mid-30s. On admission in the setting of several L fluids, Hct trended down to 28 then 25. PT without gross evidence of GIB but stools guaiac positive. She reports longstanding history of hemorrhoidal bleeding which can be frank blood per rectum, but none recently. Last Hct in the MICU was up to 29.3 without any intervention - no transfusions received, either here or at OSH. PPi was initiated in the MICU but stopped given very low concern for UGIB. Continued home colace/senna/miralax PRN to minimize hemorrhoidal bleeding. Continued ASA, held coumadin. . # UTI Pt has a history of resistant UTIs. Had been having dysuria at home prior to admission. UA equivocal, UCx pending. Given pt's upcoming surgery and symptoms, she was started on cipro (d1=[**2144-4-24**]). This was changed to cefepime once cultures returned. She completed a 7 day course. . # SOCIAL ISSUES: Patient reports that worsening disabiling from her hip pain (difficulty bathing herself) & is also full-time caretaker for her disabled son. Social work was consulted - they worked with the pt and her daughter [**Name (NI) **] to arrange additional services at home in the pt's abscence. . # The patient was admitted to the orthopaedic surgery service and was taken to the operating room for left total hip arthroplasty. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: Pt was transfused POD#1 2u RBC for Hct 24 and subsequently POD#2 an additional 2uRBC for Hct 26. POD#4 one additional unit PRBCs. Medicine c/s for co-management post op. Urinary retension - multiple failed void trials. will go to rehab with foley. to stay in for 72 then repeat void trial. Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated with 2 crutches/walker x 6 weeks on the operative extremity with posterior precautions. Ms. [**Known lastname **] is discharged to rehab in stable condition. Medications on Admission: - Atenolol 50 mg PO daily - Gabapentin 100 mg PO TID - Hydromorphone 2 mg 0.5-1 tablet by mouth up to three times daily - Lisinopril 40 mg PO daily - Spironolactone 25 mg PO daily - Aspirin 325 mg PO daily - Warfarin 4 mg PO daily - Viactiv 500-100-40 mg-unit-mcg PO BID (not currently taking) - MVI 1 tablet PO daily (not currently taking) - Colace 100 mg PO BID - Miralax PRN Discharge Medications: 1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 6. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 4 weeks. Disp:*28 syringe* Refills:*0* 7. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for pain. 10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. morphine 10 mg/5 mL Solution Sig: 2.5-5 mL PO Q4H (every 4 hours) as needed for pain. Disp:*100 mL* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Hospital1 8**] Discharge Diagnosis: Right hip osteoarthritis Atrial fibrillation with RVR Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse (VNA) or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four (4) weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). [**Male First Name (un) **] STOCKINGS x 6 WEEKS. Follow up with PCP/cardiologist regarding starting coumadin if needed. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two (2) weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated with walker or 2 crutches at all times for six weeks. Posterior precautions. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy: ACTIVITY: Weight bearing as tolerated with walker or 2 crutches at all times for six weeks. Posterior precautions. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Treatments Frequency: dry, sterile dressing changes daily and as needed for drainage wound checks ice staple removal and replace with steri strips POD17 TEDs Followup Instructions: Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/CARDIOLOGY Address: [**Street Address(2) 2687**],STE 7C, [**Location (un) **],[**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 5768**] When: Tuesday, [**2143-5-5**]:00 AM Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2010**] Date/Time:[**2144-4-29**] 2:00 Provider: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2144-5-28**] 3:15 [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 7305**] Completed by:[**2144-5-2**]

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icd9cm

[ [ [] ] ]

[ "81.51" ]

icd9pcs

[ [ [] ] ]

16920, 16985

10660, 15435

339, 369

17083, 17083

6184, 10637

20617, 21349

3908, 4221

15864, 16897

17006, 17062

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19409, 20211

397, 3032

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3271, 3892

67,019

157,089

39447

Discharge summary

report

Admission Date: [**2184-9-2**] Discharge Date: [**2184-9-6**] Date of Birth: [**2166-7-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1257**] Chief Complaint: Tylenol ingestion. Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, Ms [**Known lastname **] is an 18 year old female with a history of polysubstance abuse including oxycontin and percocet, on monthly naltrexone injections, who was transferred from an OSH for management of tylenol ingestion. . Recently, pt's boyfriend was killed in [**Country 84061**] and and has been more anxious and self-medicated with her Klonopin and her mother's benzodiazepines. Of note, she was started on Naltrexone PO last Friday after her BF died, and was given a IM dose of Naltrexone on Monday given her history of opioid abuse. On the morning prior to admission she took cocaine, which she claims helped incite her to take three handfuls of tylenol. She also took two Klonopin pills that morning. She denies EtOH coingestion; she did drink ETOH the previous evening. . She called her mother and presented to the OSH ER sometimes [**3-9**] hours after the ingestion. Her initial tylenol level was 302. Liver enzymes at transfer were AST 273 ALT 319 AlkP 155 TBILI 2.5 INR 1.5. Urine toxicology was positive for benzos and cocaine. Urine and blood tox was otherwise negative. She was treated with NAC and transferred to [**Hospital1 18**] in AM of 2nd hospital day. . In the MICU, Ms. [**Known lastname **] was placed on a [**12-5**] sitter; she was remorseful for the ingestion and claimed to not be suicidal or have thoughts of self-harm. She also [**Month/Day (3) 15797**] thoughts of harming others or auditory/visual hallucinations. Her only symptom was feeling "achy" in her sides and legs, which she attributed to vomiting yesterday. She [**Month/Day (3) 15797**] any confusion, fevers/chills, dypsnea, or other symptoms. . During patient's MICU admission, the patient's initial AST was 239 to trended to 926 and ALT from 422 to 1003. Patient had no s/sx of hepatic decompensation or encephalopathy on examination prior to transfer. The patient was started on NAC for 16 hours, however given her rise in LFTs and unclear data on timing of discontinuing infusion, it was decided to continue infusion until tomorrow morning. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Anxiety Polysubstance abuse Social History: Social History: - Tobacco: quit two years ago - Alcohol: at times - Illicits: 3y hx opioid abuse (oxycontin, percocet) clean for 2 weeks, prior [**Hospital **] rehab at age 15; cocaine use Family History: Father -- EtOH addiction Lung Ca Physical Exam: Vitals: Afebrile, 126/78, 108, 21, 99%RA General: Alert, oriented, slightly anxious, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, no rebound tenderness or guarding GU: foley in place Ext: warm, well perfused, no clubbing, cyanosis or edema Pertinent Results: [**2184-9-2**] 10:13PM TYPE-[**Last Name (un) **] TEMP-37.0 PH-7.38 [**2184-9-2**] 10:13PM freeCa-1.14 [**2184-9-2**] 09:36PM ALT(SGPT)-438* AST(SGOT)-268* ALK PHOS-170* TOT BILI-2.2* [**2184-9-2**] 09:36PM WBC-8.3 RBC-4.31 HGB-12.5 HCT-36.2 MCV-84 MCH-29.0 MCHC-34.6 RDW-13.3 [**2184-9-2**] 09:36PM PLT COUNT-267 [**2184-9-2**] 04:39PM GLUCOSE-92 UREA N-5* CREAT-0.7 SODIUM-140 POTASSIUM-3.4 CHLORIDE-107 TOTAL CO2-23 ANION GAP-13 [**2184-9-2**] 04:39PM GLUCOSE-92 UREA N-5* CREAT-0.7 SODIUM-140 POTASSIUM-3.4 CHLORIDE-107 TOTAL CO2-23 ANION GAP-13 [**2184-9-2**] 04:39PM estGFR-Using this [**2184-9-2**] 04:39PM ALT(SGPT)-422* AST(SGOT)-239* ALK PHOS-183* TOT BILI-3.0* [**2184-9-2**] 04:39PM ALBUMIN-4.4 CALCIUM-9.3 PHOSPHATE-2.4* MAGNESIUM-2.3* [**2184-9-2**] 04:39PM ACETMNPHN-8* [**2184-9-2**] 04:39PM WBC-7.7 RBC-4.58 HGB-13.2 HCT-39.1 MCV-85 MCH-28.8 MCHC-33.8 RDW-13.2 [**2184-9-2**] 04:39PM NEUTS-77.0* LYMPHS-16.7* MONOS-3.2 EOS-1.5 BASOS-1.5 [**2184-9-2**] 04:39PM PLT COUNT-275 [**2184-9-2**] 04:39PM PT-16.9* PTT-25.2 INR(PT)-1.5* Acetaminophen 9/30/10=8, 10/1/10=0 ALT peak was 1328 on [**2184-9-4**]; 628 on discharge AST peak was 928 on [**2184-9-3**]; 106 on discharge INR peak was 1.7 on [**9-2**]; 1.1 on discharge Brief Hospital Course: Upon admission to the MICU Ms. [**Known lastname **] was fully alert, oriented, and had a normal affect. Her family and friends were present. . #Tylenol Overdose: upon admission to the MICU, AST and total BILI trended upwards compared to OSH labs, ALT decreased, and INR stayed constant. On the first night in the MICU Ms. [**Known lastname **] was asymptomatic. Aggressive hydration was continued and, per toxicology, n-acetylcysteine was continued overnight as there was still a blood tylenol level. LFTs were trended every 6 hours with finger sticks q2h. . On HD 2, the patient was transferred to the medicine floor. Her AST peaked at 1328 on HD3, and ALT peaked at 923 on HD2. Her INR peaked at 1.7 on HD1. NAC was continued through HD4. On HD 5, INR decreased to 1.1, AST and ALT trended downward for two consecutive days, the patient remained asymptomatic and was medically cleared. . #Suicidality: Ms. [**Known lastname **] [**Last Name (Titles) 15797**] any thoughts of self-harm after transfer to [**Hospital1 18**]. A [**12-5**] sitter was present for the duration of her hospital stay. A psychiatry consult was called both to evaluate her suicide attempt and for a full psychiactric and polysubstance abuse evaluation in light of possible need for liver transplant. The team recommended in patient psychiatric evaluation given her impulsive tendencies and increased danger to self. Section 12 paperwork was completed. The patient, mother [**Doctor First Name **] and grandmother ([**Name (NI) **]) were disgruntled that [**Known firstname 87161**] would not be able to attend her boyfriends ceremony/[**Name2 (NI) **] and/or his funeral. Both legal and ethical consults were called and security helped to make sure that the patient had visitors only during visiting hours. The patient was seen by psychiatry on each hospital day. On HD 5, it was determined that the patient would benefit from attending the [**Hospital1 **] service and that her support structure, including mother, grandmother, and friends, made it unlikely for her to commit another impulsive act. Close followup was scheduled with her addiction specialist, Dr. [**Last Name (STitle) 13734**], for the day after discharge. PCP followup was scheduled for two days after discharge. . #Electrolytes: Potassium was repleted on the second hospital day and remained within normal limits throughout the remainder of her hospital stay. . #Prophylaxis: The patient was administered heparin subcutaneously for DVT prophylaxis. Medications on Admission: Home Medications: Clonidine Vistaril (Started last Friday) Vivitrol (monthly IM) . Transfer Medications (MICU to Floor) Acetylcysteine (IV) 5700 mg IV INFUSION over 16 hours. Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation Heparin 5000 UNIT SC TID Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: Acetaminophen Overdose Poly-substance abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **]: It was a pleasure to take care of you at [**Hospital1 827**]. You were transferred to our medical intensive care unit for further treatment of an acetaminophen (Tylenol) overdose. You were started on a treatment called N-acetylcysteine or NAC, which was continued for several days. You were transferred to the regular medicine floor and your liver tests all trended towards normal values. Please discuss with your primary care provider and your addiction specialist about restarting your home medications. Followup Instructions: You have a followup appointment with your primary care provider [**Last Name (NamePattern4) **] 11AM on Wednesday, [**2184-9-8**]. Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 87162**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 87163**] Phone: [**Telephone/Fax (1) 52613**] Fax: [**Telephone/Fax (1) 87164**] You have an appointment with your addiction doctor, Dr. [**Last Name (STitle) 13734**], tomorrow Tuesday, [**2184-9-7**] at 9AM. In addition, please make an appointment with your liver doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**], by calling [**Telephone/Fax (1) 673**], within 7-10 days of discharge. Completed by:[**2184-9-6**]

[ "573.3", "305.60", "309.28", "300.00", "E950.0", "305.50", "965.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7884, 7890

4991, 7498

332, 339

7978, 7978

3701, 4968

8692, 9429

3165, 3199

7855, 7861

7911, 7957

7524, 7524

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7542, 7832

2444, 2892

274, 294

367, 2425

7993, 8105

2914, 2943

2975, 3149

19,507

137,153

21913

Discharge summary

report

Admission Date: [**2108-4-26**] Discharge Date: [**2108-4-28**] Date of Birth: [**2059-10-8**] Sex: F Service: MED HISTORY OF PRESENT ILLNESS: The patient is a 48 year old woman with a history of peptic and duodenal ulcer disease and soft palate cancer who was noted [**Known firstname **] have hematemesis on the afternoon of [**2108-4-26**]. Prior [**Known firstname **] the episode, the patient states that she felt a sour and uncomfortable burning discomfort in the epigastric area. The patient also noticed that she had been taking ibuprofen intermittently approximately 1-2 times a day for the preceding 2 days. The patient subsequently vomited a large amount of black/red emesis with clots. The patient was hemodynamically stable, but urgently was brought [**Known firstname **] the emergency room. The patient was lavaged in the emergency room, with 500 cc of normal saline with only partial clearing of the bright red blood. The patient was given intravenous fluid. Large bore IVs were placed. The patient received Protonix in the emergency room and was noted [**Known firstname **] be hemodynamically stable, with a heart rate of 86 and a blood pressure of 100/60. She was given 1 unit of packed red cells and went emergently for EGD. PAST MEDICAL HISTORY: 1. Peptic ulcer disease. 2. Duodenal ulcer diagnosed 2 years ago. 3. Soft palate cancer with surgery in [**2107-11-26**]. CURRENT MEDICATIONS: No medications. ALLERGIES: The patient has a reported allergy [**Known firstname **] codeine and sulfa. SOCIAL HISTORY: The patient is married and denies tobacco use, has one glass of wine with dinner. PHYSICAL EXAMINATION: On presentation [**Known firstname **] the emergency room, blood pressure 107/76, pulse 90, oxygen saturation 100 percent on room air. Mucous membranes were moist. Extraocular movements were intact. Cardiac examination revealed normal S1 and S2, no murmurs, rubs or gallops. Lungs are clear [**Known firstname **] auscultation bilaterally. Abdominal examination - Positive bowel sounds, soft, mild left upper quadrant tenderness. No rebound or guarding. The patient was guaiac positive. There was no costovertebral angle tenderness. Skin examination was within normal limits. Extremities revealed no cyanosis, clubbing or edema. Neurologic examination was grossly intact. LABS UPON ADMISSION [**Known firstname **] THE EMERGENCY ROOM: White count 7.9, hematocrit 33.2 down from 44.1 in [**2107-7-27**], platelets 199. Sodium was 140, potassium 4.0, chloride 108, bicarbonate 23, BUN 33, creatinine 0.6, glucose 183. Urinalysis was negative. Electrocardiogram revealed normal sinus rhythm at 87 beats per minute, normal axis, normal intervals, no ST changes. HOSPITAL COURSE: The patient was admitted [**Known firstname **] the intensive care unit, given the patient's hematemesis. Emergent EGD was done, which revealed normal esophagus, but clotted blood was seen within the fundus of the stomach. There were localized erosions of the mucosa without bleeding in the prepyloric region. Melena was noted in the duodenum, and a superficial 7 mm ulcer was found in the proximal bulb. A visible vessel was present, with stigmata of recent bleeding. Three epinephrine injections were applied for hemostasis, and electrocautery was done as well, with resulting successful hemostasis. The patient's blood was sent off for H. pylori as well as gastrin levels, given her history of peptic ulcer disease and duodenal ulcer in the past. The patient was instructed [**Known firstname **] avoid all NSAIDs. The patient was kept NPO. She had serial hematocrits, which revealed hematocrits between 31 and 32 throughout the rest of her hospital stay. The patient was placed on IV Protonix b.i.d. The patient had no further episodes of hematemesis. The patient did have some dark melena which was in all likelihood old clots that were being passed from her recent bleeding episode. The patient was hemodynamically stable, was advanced [**Known firstname **] a full diet throughout the day of [**4-28**], and did quite well. She was discharged [**Known firstname **] home in good condition, instructed [**Known firstname **] continue taking IV b.i.d. Protonix and follow up with GI for results of her H. pylori serology as well as her gastrin levels. DISCHARGE MEDICATIONS: Protonix p.o. 40 mg b.i.d. FOLLOW UP: The patient will follow up with Gastroenterology, with Dr. [**First Name4 (NamePattern1) 7306**] [**Last Name (NamePattern1) 57445**] and her primary care doctor. The patient will return [**Known firstname **] the emergency room emergently if she notes any hematemesis, lightheadedness with rising, or worsening of abdominal pain. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 5825**] Dictated By:[**Last Name (NamePattern1) 48405**] MEDQUIST36 D: [**2108-4-28**] 17:28:26 T: [**2108-4-28**] 21:33:18 Job#: [**Job Number 57446**]

[ "285.1", "E935.9", "532.40" ]

icd9cm

[ [ [] ] ]

[ "99.04", "44.43" ]

icd9pcs

[ [ [] ] ]

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1666, 2727

1436, 1543

165, 1268

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9,972

177,120

1058

Discharge summary

report

Admission Date: [**2123-3-26**] Discharge Date: [**2123-3-29**] Date of Birth: [**2064-4-28**] Sex: M Service: Coronary Care Unit HISTORY OF PRESENT ILLNESS: Patient is a 58-year-old man with history of coronary artery disease status post inferior myocardial infarction [**2113-4-28**] with stent to the right coronary artery, angioplasty to the obtuse marginal in [**Month (only) 359**] of '[**14**], stent to the right coronary artery in [**2114-11-28**], angioplasty to the posterolateral branch of the right coronary artery in [**2116-6-28**], who presented with unstable angina x3 weeks to an outside hospital. Patient states that he has been chest pain free for approximately seven years prior to approximately three weeks ago when his chest pain recurred. Patient reports that the chest pain was his typical angina, but mild compared to previous experiences and resolved with 1-2 nitroglycerin. these symptoms sometimes occurred at rest over the past three weeks. His episodes have increased in frequency over the past three weeks. Patient denies any associated symptoms such as shortness of breath, nausea, or vomiting. On the evening of admission, the patient awoke from sleep with 9/10 chest pain and diaphoresis, and took six sublingual nitroglycerin as well as aspirin without resolution of chest pain, so he called ambulance. Patient was brought to an outside hospital, where ECG changes showed inferior ST elevations and anterior ST depressions. Patient received Heparin drip, Morphine, and nitroglycerin at the outside hospital and became chest pain free. Patient also received Retavase at the outside hospital. Patient had been scheduled for elective cardiac catheterization at [**Hospital1 **], therefore he was transferred to [**Hospital1 **] [**First Name (Titles) **] [**2123-3-26**] the same evening that he presented to the outside hospital. In the ambulance upon transfer, patient had recurrent chest pain and received a second dose of Retavase. The patient's inferior ST changes had resolved by the time he arrived at the Emergency Room at [**Hospital1 **] and he was originally pain free. However, his pain recurred, and a repeat electrocardiogram showed ST elevations approximately 1 mm in the inferior leads, st depression in V1 and V2 and 1 & avl with t wave inversion in avl.The patient was therefore brought from the Emergency Room to the Coronary Cath Laboratory. At catheterization, the patient was found to have 80% mid left circ stenosis as well as 90% lesion in the RCA between two previous stents. The patient received two hepacoat stents to his right coronary artery with good flow afterwards. Patient was then transferred to the Coronary Care Unit for further management. Upon arrival at the Coronary Care Unit, the patient denied any symptoms such as chest pain or shortness of breath. Review of systems was notable for skin lesions that the patient states has been diagnosed as shingles. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Hypertension. 3. Hypercholesterolemia. 4. Cirrhosis secondary to alcohol use, which per the patient has resolved. 5. Status post cholecystectomy. SOCIAL HISTORY: Patient smokes [**9-7**] cigarettes per day. Also drinks alcohol socially, but denies drug use. FAMILY HISTORY: [**Name (NI) **] mother passed away from a myocardial infarction in her 70s, and patient's father passed away from a myocardial infarction in his 50s. REVIEW OF SYSTEMS: Was otherwise noncontributory. PHYSICAL EXAM ON ADMISSION: Middle-aged gentleman lying in bed in no apparent distress with normal S1, S2, regular rate and rhythm with no murmurs or extra heart sounds. Patient's vital signs: Heart rate in the 70s, respiratory rate 18, blood pressure 104/69, height 6'0", weight 218 pounds. Remainder of the exam was within normal limits including good pulses throughout, stable groin site, as well as clear lungs and no jugular venous distention. Patient did have a ventral hernia in his abdomen, which was reducible. DIAGNOSTICS ON ADMISSION: Patient's ECG with normal sinus rhythm with resolution of inferior-right precordial and lateral ST changes upon arrival to the CCU. LABORATORY DATA: White blood cell count 11.6, hematocrit stable at 42, platelets 256. The ck peaked in the 300's and the troponin was positive. The BUN rose to 34 while the creatinine remained normal, presumably after lasix and contrast induced diuresis given earlier in his course. CONCISE SUMMARY OF HOSPITAL COURSE: Patient is a 58-year-old man with coronary artery disease status post multiple catheterizations in the mid 90s, but without any symptoms and medically stable for about seven years. Patient presented to outside hospital with acute chest pain and found to have inferior-right precordial and lateral ST changes. Patient is status post thrombolytics at the outside hospital, but with recurrence of symptoms and underwent catheterization at [**Hospital1 18**]. 1. Status post repeat cardiac catheterization with stent placement and resolution of symptoms: Patient's ECG changes normalized after coronary catheterization and the patient remained asymptomatic throughout the remainder of his hospital stay. Patient was continued on his daily aspirin of 325 mg. Patient was also started on Plavix 75 once a day. Patient was maintained on his beta blocker of Toprol XL 50 mg q.d. Patient had not been on a statin for approximately 1.5 years due to leg cramping, however, he was started on pravastatin 20 mg once a day with planned close followup with his primary care physician. [**Name10 (NameIs) **] is to followup with Dr. [**Last Name (STitle) **] within two weeks of discharge from the hospital. The patient was also continued on his Heparin drip, which he was on upon transfer from the outside hospital, and this was continued for 48 hours post catheterization. Patient was also encouraged to quit smoking. 2. Pump: Patient had not an echocardiogram or left ventriculogram for many years, and he therefore underwent a repeat echocardiogram on [**3-26**], which revealed an ejection fraction of 55-60% with normal wall motion and no visualized valvular defects. However, this was a suboptimal study. 3. Rhythm: Patient remained in normal sinus rhythm throughout his hospital stay and is seen on telemetry. 4. Fluids, electrolytes, and nutrition: Patient was maintained on a cardiac diet and his electrolytes especially potassium and magnesium were repleted as needed. 5. Prophylaxis: Patient was on a Heparin drip throughout his hospital stay and was eating well without history of gastroesophageal reflux disease or peptic ulcer disease. Patient was also ambulating well by the time of discharge. 6. Code status: Full. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: Acute inferoposterior and lateral non- transmural myocardial infarction. DISCHARGE MEDICATIONS: 1. Aspirin 325 once a day. 2. Plavix 75 once a day. 3. Toprol XL 50 mg once a day. 4. Pravastatin was discontinued at discharge because of the severe episode of leg weakness on Lipitor. 5. Nitroglycerine tabs FOLLOW-UP INSTRUCTIONS: Patient is to followup with Dr. [**Last Name (STitle) **] within two weeks of discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1544**], M.D. [**MD Number(1) 1545**] Dictated By:[**Name8 (MD) 6906**] MEDQUIST36 D: [**2123-3-28**] 23:01 T: [**2123-3-29**] 04:57 JOB#: [**Job Number 6907**]

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icd9cm

[ [ [] ] ]

[ "36.06", "37.23", "36.01", "88.56" ]

icd9pcs

[ [ [] ] ]

3300, 3452

6930, 7140

6833, 6907

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3472, 3518

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121,412

28574

Discharge summary

report

Admission Date: [**2120-3-12**] Discharge Date: [**2120-3-15**] Date of Birth: [**2073-2-26**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 3043**] Chief Complaint: Hyponatremia. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 47 year old woman with a history of DM, alcohol abuse c/b numerous episodes of alcoholic pancreatitis and hepatitis (not known to have cirrhosis) and anoxic brain injury in [**2115**], poor historian, who presented to her PCP for [**Name Initial (PRE) **] routine appointment for refill of her klonopin which ran out 10 days prior. Labs drawn at that visit revealed hyponatremia with a sodium of 119, potassium of 1.7, bicarb reportedly very high with a pH of 7.6 and pCO2 of 70. She was given 80meq of potassium (40meq PO and 40meq in 1LNS) and sent to an OSH ED. She received 1gm of Ceftriaxone for a UTI and then was transferred here. . In the ED, initial vs were: T 98.1, P 76, BP 86/54, RR 12, O2sat 100. Pt had slow, slurred speech which is at baseline; neuro exam nonfocal. Guaiac positive. Her labs were notable for Na 120, K 2.6, Cl 72, Bicarb 45, lipase 206. U/A dirty. EKG showed diffuse TWI. CXR and CT head were unremarkable. Pt was asx with UOP intact but concer for SBP in 80s. ED did not want to bolus IVF given quick rise in Na to 134 after 3L NS, so a central line was placed for possible pressors and pt admitted to MICU. . On the floor, pt reports feeling at baseline. She does report 2 weeks of nausea and nonbloody emesis ~ 1 pint/day. She has been constipated for several days. No h/o black or bloody stools. Per her PCP, [**Name10 (NameIs) **] has a h/o hypokalemia and had not been taking potassium or magnesium supplements due to inability to swallow. Past Medical History: 1. Pancreatitis - hospitalized in [**Month (only) 205**] for kidney, liver and pancreas problems (left AMA). 2. Alcoholism 3. Diabetes (on insulin) 4. Anxiety/agoraphobia 5. Chronic back pain Social History: Long history of EtOH abuse. Her three children were raised by husband. Narcotic abuse, Klonopin abuse. Smokes 2 ppd. Unemployed on disability. Lives with brother and boyfriend. Ex-husband had hep C. Family History: Pt was adopted. Hx of "kidney disease" in birth family. Physical Exam: General: Alert, oriented, no acute distress, thin/cachectic appearing HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, mild diffuse tenderness on deep palpation w/o g/r, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Speech slow and difficult to understand but AAOx3, exam otherwise nonfocal. Pertinent Results: Complete Blood Count: [**2120-3-12**] 05:44AM BLOOD WBC-4.2 RBC-4.18*# Hgb-12.1 Hct-33.8* MCV-81*# MCH-29.0# MCHC-35.9* RDW-17.2* Plt Ct-107* [**2120-3-12**] 01:40PM BLOOD WBC-2.0* RBC-3.39* Hgb-10.1* Hct-27.9* MCV-82 MCH-29.7 MCHC-36.1* RDW-17.7* Plt Ct-91* [**2120-3-13**] 03:00AM BLOOD WBC-2.4* RBC-3.41* Hgb-9.9* Hct-28.2* MCV-83 MCH-29.0 MCHC-35.0 RDW-18.0* Plt Ct-100* [**2120-3-14**] 08:10AM BLOOD WBC-3.3* RBC-3.58* Hgb-10.3* Hct-30.0* MCV-84 MCH-28.8 MCHC-34.3 RDW-18.3* Plt Ct-99* [**2120-3-15**] 05:54AM BLOOD WBC-3.0* RBC-3.62* Hgb-10.1* Hct-29.1* MCV-80* MCH-27.8 MCHC-34.6 RDW-18.7* Plt Ct-101* [**2120-3-12**] 05:44AM BLOOD Neuts-60.6 Lymphs-29.2 Monos-8.0 Eos-1.4 Baso-0.8 [**2120-3-12**] 11:48PM BLOOD Ret Aut-1.0* . Basic Metabolic Panel: [**2120-3-12**] 05:44AM BLOOD Glucose-244* UreaN-16 Creat-0.6 Na-120* K-2.6* Cl-72* HCO3-45* AnGap-6* [**2120-3-13**] 03:00AM BLOOD Glucose-103* UreaN-9 Creat-0.5 Na-134 K-3.2* Cl-95* HCO3-36* AnGap-6* [**2120-3-14**] 08:10AM BLOOD Glucose-189* UreaN-8 Creat-0.4 Na-133 K-4.0 Cl-101 HCO3-27 AnGap-9 [**2120-3-15**] 05:54AM BLOOD Glucose-170* UreaN-8 Creat-0.3* Na-133 K-3.7 Cl-102 HCO3-26 AnGap-9 [**2120-3-12**] 05:44AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8 [**2120-3-13**] 03:00AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.0 [**2120-3-14**] 08:10AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.5* [**2120-3-15**] 05:54AM BLOOD Calcium-7.9* Phos-2.8 Mg-1.6 . Liver Function Tests: [**2120-3-12**] 05:44AM BLOOD ALT-13 AST-41* AlkPhos-100 TotBili-0.3 [**2120-3-12**] 09:10AM BLOOD ALT-12 AST-29 AlkPhos-77 TotBili-0.3 . Lipase: [**2120-3-12**] 05:44AM BLOOD Lipase-206* [**2120-3-12**] 09:10AM BLOOD Lipase-185* [**2120-3-13**] 01:15PM BLOOD Lipase-85* [**2120-3-14**] 08:10AM BLOOD Lipase-99* . [**2120-3-12**] 05:44AM BLOOD cTropnT-<0.01 . [**2120-3-14**] 08:10AM BLOOD VitB12-1059* Folate-13.6 [**2120-3-12**] 11:48PM BLOOD calTIBC-179* Ferritn-33 TRF-138* . [**2120-3-12**] 09:10AM BLOOD Ammonia-39 . [**2120-3-12**] 01:40PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE [**2120-3-13**] 01:15PM BLOOD HIV Ab-NEGATIVE [**2120-3-12**] 01:40PM BLOOD HCV Ab-NEGATIVE . [**2120-3-12**] 01:40PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . [**2120-3-12**] 10:27AM BLOOD pH-7.48* Comment-GREEN TOP [**2120-3-12**] 10:27AM BLOOD Lactate-0.9 . Urine: [**2120-3-12**] 06:40AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018 [**2120-3-12**] 06:40AM URINE Blood-SM Nitrite-NEG Protein-25 Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-4* pH-8.0 Leuks-NEG [**2120-3-12**] 06:40AM URINE RBC-[**5-16**]* WBC-[**5-16**]* Bacteri-OCC Yeast-NONE Epi-0-2 TransE-0-2 . Microbiology: Urine Culture [**2120-3-12**]: <10,000 organisms/ml. . Blood Culture [**2120-3-12**]: No growth to date. . CT HEAD: NON-CONTRAST HEAD CT: There is no intracranial hemorrhage, mass effect, edema, shift of normally midline structures, or major vascular territorial infarct. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Ventricles, sulci, and bifrontal extra-axial CSF spaces appear minimally prominent for age. Suprasellar and basilar cisterns are patent. Paranasal sinuses and mastoid air cells are well aerated. Soft tissues and globes are intact. IMPRESSION: No intracranial hemorrhage or major vascular territorial infarct. . ECG [**2120-3-12**]: Sinus rhythm. Low limb lead QRS voltage. Delayed R wave progression. ST-T wave abnormalities with prolonged QTc interval. Findings are non-specific but clinical correlation is suggested. Since the previous tracing of same date precordial lead ST-T wave changes appear less prominent. . Chest Radiograph [**2120-3-12**]: No acute cardiopulmonary process. Brief Hospital Course: 47 year old woman with a history of DMII, polysubstance abuse c/b recurrent alcoholic pancreatitis and hepatitis, anoxic brain injury secondary to OD, anxiety/depression who presents status post one day in the MICU due to metabolic derangements found at outpatient clinic and borderline BPs in ED. Now with complete resolution of metabolic disarray. . # Hyponatremia: Labs drawn by PCP demonstrated sodium level of 119. In the setting of prolonged vomiting, likely hypovolemic hyponatremia. With IV normal saline resuscitation, sodium level normalized and was 133 at the time of discharge. No changes in baseline mental status were observed. . # Hypokalemia: Patient with history of hypokalemia per primary care physician. [**Name10 (NameIs) 4289**] exacerbation likely secondary to GI losses from nausea and vomiting. Is on potassium supplements. Discharged home with instructions to continue liquid form of potassium. . # Elevated Bicarbonate: Likely secondary to emesis and subsequent contraction alkalosis. Resolved with IV normal saline as above. Nausea successfully treated with zofran. . # Nausea/vomiting: Unclear etiology with reported [**12-9**] week duration. [**Month (only) 116**] be secondary to viral syndrome. While lipase was elevated at presentation, it trended down and abdominal exam was not consistent with acute pancreatitis. Patient denied any alcohol intake in several months. Diet was advanced and supplemented with pancrease at meals. Patient also not uremic. Resolved by the time of discharge with IV fluids and zofran PRN. . # Hypotension: Found to have systolic blood pressure in the 80s upon admission. Asymptomatic, and likely secondary to poor PO intake. Blood pressure responded appropriately to IV normal saline resuscitation. Patient was initially treated with vancomycin/ceftriaxone and transitioned to single [**Doctor Last Name 360**] ceftriaxone after clinical picture was deemed not consistent with sepsis. . # Urinary Tract Infection: Found to have a positive urine analysis, with no growth found on culture. Given history of MRSA UTI in the past, was empirically treated with vancomycin/ceftriaxone in the ICU. Was transitioned to single [**Doctor Last Name 360**] ceftriaxone upon transfer to medicine floor to complete 3 days course. . # Pancytopenia: Likely multifactorial, with component of nutritional deficiency given low albumin, vs. splenic sequestration from liver disease vs. bone marrow suppression secondary to alcohol consumption. Is on B12 and folate supplementation as an outpatient. Will be followed by primary care physician as an outpatient. [**Month (only) 116**] require outpatient colonoscopy. . # History of Anoxic Brain Injury: With dysarthric, slurred speech at baseline. Neuro exam stable. . # History of Alcohol Abuse: Denied any alcohol consumption for several months, though suspicion of continued alcohol consumption per PCP. [**Name10 (NameIs) **] evidence of withdrawal. Patient was seen by physical therapy, occupational therapy, and social work prior to discharge home. Was deemed to be safe at home by all teams. VNA set up to review that patient is taking all medications as prescribed. PCP appointment in place for several days after discharge. Medications on Admission: Potassium Chloride SR 10 mEq Tab Oral [**Hospital1 **] (pt could not swallow) Compazine 5 mg Tab Oral PO TID Pancrease MT 20 20,000-44,000-56,000 unit Cap Oral TID Magnesium Oxide 400 mg Tab Oral PO TID Ferrous Sulfate 325 mg (65 mg Iron) Tab Oral daily Vitamin B-12 100 mcg Tab Oral Daily Keppra 500 mg Tab Oral [**Hospital1 **] Metformin SR 500 mg daily Clonazepam 0.5 mg Tab Oral TID Folic Acid 1 mg Tab Oral qday MVI 1 tab PO qday Prilosec 20 mg Cap Oral PO qday Celexa 40 mg Tab Oral PO qday Colace 200 mg Cap Oral PO qday Senna Oxycodone - prescribed 30 tabs monthly per PCP, [**Name10 (NameIs) **] had been taking tid Discharge Medications: 1. Compazine 5 mg Tablet Sig: One (1) Tablet PO three times a day. 2. Lipase-Protease-Amylase 16,000-48,000 -48,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO three times a day. 4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Vitamin B-12 100 mcg Tablet Sig: One (1) Tablet PO once a day. 6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 8. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO once a day. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*28 Tablet(s)* Refills:*2* 16. Potassium Chloride 10 % Liquid Sig: One (1) PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Primary: - Hyponatremia - Hypokalemia - Hypotension - Vomiting - Pancytopenia - Urinary tract infection . Secondary: - Alcohol abuse - Anoxic brain injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 827**]. You were originally admitted due to persistent vomiting and with abnormal blood work. You were briefly monitored in the Intensive Care Unit, where you improved with IV fluids. Your blood work is now back to normal. You met with our physical therapy, occupational therapy, and social work teams who deemed you stable for discharge to home. . We have made the following changes to your medications. - started thiamine 1 pill daily - please take all other medication as previously directed prior to your hospitalization. Please ask your primary care physician in regards to having a colonoscopy as an outpatient. Followup Instructions: Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 69189**],MD Specialty: Primary Care Location: [**Hospital3 **]HEALTH CARE Address: [**Location (un) 29815**] STE 4B, [**Location (un) **],[**Numeric Identifier 29816**] Phone: [**Telephone/Fax (1) 11376**] Appointment: [**Last Name (LF) 766**], [**3-18**] at 11:15am

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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29,163

194,933

10231

Discharge summary

report

Admission Date: [**2139-7-17**] Discharge Date: [**2139-9-24**] Date of Birth: [**2076-8-7**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Right liver lobe mass Major Surgical or Invasive Procedure: Right hepatic trisegmentectomy, segment III wedge resection, cholecystectomy. History of Present Illness: This is a 62-year-old male who developed right upper quadrant abdominal pain in [**Month (only) 958**] of this year. He saw his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) **], who felt a liver mass. He [**Name (STitle) 1834**] an ultrasound that demonstrated a 9-cm mass in the right lobe of the liver. He then [**Name (STitle) 1834**] a CT scan of the abdomen at [**Hospital3 1443**] Hospital on [**2139-3-19**]. This demonstrated a 9-cm mass appearing to be rising in the medial segment of the left lobe and invading the anterior segment of the right lobe. There was also portacaval adenopathy and celiac adenopathy. A liver biopsy of the mass was performed on [**2139-4-10**]. This demonstrated a moderately differentiated adenocarcinoma that was positive for CK7, CK20, CAM 5.2, and negative for AFP, hepar-1, CA19-9, and CDX-2. He subsequently [**Year (4 digits) 1834**] upper GI endoscopy and colonoscopy that was unremarkable. Biopsies of random gastric mucosal biopsies were normal. He had a sigmoid polyp removed that was read as an adenoma. He states that he is eating and tolerating a regular diet, having normal formed bowel movements without change in bowel habits, and denies any weight loss. He denies any fever, chills, nausea, vomiting, diarrhea, constipation, or history of liver disease. He is now referred for consideration of hepatic resection. Past Medical History: elevated cholesterol diabetes mellitus hypertension Social History: Works in a factory as an assembler and polisher, has been exposed to asbestos and other toxins. Stopped working on [**4-20**] He is married and has adult children. Family History: brother with lung cancer, a sister with lymphoma and breast cancer, and his mother with diabetes mellitus, coronary artery disease, and gastric cancer. Physical Exam: BP=120/66, HR=64, RR=16, Temp. 99.2, height 5 feet 8 inches, weight 82.3 kg On physical exam he is a well-developed, well-nourished male in no acute distress. Skin: no stigmata of chronic liver disease. No palmar erythema or spider angiomata. HEENT: no scleral icterus. Oropharynx clear. Neck: no lymphadenopathy or thyromegaly. Carotids 2+/4+ without bruits. Lungs: clear to auscultation and percussion. Cardiac exam: normal S1-S2. No S3, S4, murmurs, or rubs. Regular rate and rhythm. Abdominal exam: benign. Normal bowel sounds. No splenomegaly. The liver is palpable 2 cm below the right costal margin with deep inspiration. There is some tenderness in the midclavicular line subcostally. The liver is firm in this location and there is a hint of a mass. Extremities: no peripheral edema. Neurologically grossly intact. Pertinent Results: Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 34095**],[**Known firstname **] [**2076-8-7**] 62 Male [**-6/3045**] [**Numeric Identifier 34096**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mtd SPECIMEN SUBMITTED: GALLBLADDER, CYSTIC LYMPH NODE; LOBE OF LIVER; SEGMENT 3-MEDIAL MARGIN; SEGMENT 3 RESECTION; PORTAL LYMPH NODE. Procedure date Tissue received Report Date Diagnosed by [**2139-7-17**] [**2139-7-17**] [**2139-7-27**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma?????? Previous biopsies: [**-6/1985**] Consult slides referred to Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 10165**]. [**Numeric Identifier 34097**] GASTRIC AND COLON BXS (2). ************This report contains an addendum*********** DIAGNOSIS: 1. Segment 3, medial margin (A-G): a. Hepatic parenchyma with moderate steatosis, no lobular neutrophils or intracytoplasmic hyalin seen. b. Small bile duct hamartoma. 2. Liver, segment 3, resection (H-J): a. Adenocarcinoma, moderately differentiated morphologically consistent with pancreaticobiliary origin (see synoptic report). b. No tumor is seen at margins. 3. Portal lymph node (K): One lymph node with focal lipogranuloma formation, no carcinoma seen. 4. Gallbladder (L-P): 1. Mild chronic cholecystitis. 2. One lymph node with follicular hyperplasia and lipogranulomas, no carcinoma seen. 5. Liver, right lobe, resection (Q-AJ): a. Adenocarcinoma, moderately differentiated (see synoptic report). b. Cystic spaces consistent with hamartoma seen adjacent to infiltrating adenocarcinoma. c. Focal bile ducts with high grade dysplasia/carcinoma in situ seen. d. Vascular margins are negative. Liver: Resection Synopsis MACROSCOPIC Specimen Type: Extended right lobectomy. Focality: Multiple: Right lobe, segment 3. Tumor Size Greatest dimension: 9.2 cm (right lobe). Greatest dimension: 2.9 cm (segment 3). MICROSCOPIC Histologic Type: Cholangiocarcinoma, intrahepatic. Histologic Grade: G2: Moderately differentiated. EXTENT OF INVASION Primary Tumor: pT3: Multiple tumors more than 5 cm or tumor involving a major branch of the portal or hepatic vein(s). Regional Lymph Nodes: pN0: No regional lymph node metastasis. Lymph Nodes Number examined: 2. Number involved: 0. Distant metastasis: pMX: Cannot be assessed. Margins Parenchymal margin: Uninvolved by invasive carcinoma: Distance from closest margin: 2 mm. Bile duct margin: Will be reported in an addendum. Venous (Large vessel) invasion: Absent. Comments: 1. Bile ducts with high grade dysplasia/carcinoma in-situ are seen. 2. Bile duct hamartomas. ADDENDUM: Addendum is made to Gross and Diagnosis. Gross: Additional sections from the hilar region are in AK. Diagnosis: 1. Hilar large bile ducts show prominent periductal fibrosis with cautery artifact. No definite carcinoma seen (slide AK). 2. Trichrome stain shows increased portal and periportal fibrosis with focal bridging and sinusoidal fibrosis (stage 2 and focally stage 3 fibrosis). 3. Iron stain shows mild iron deposition predominantly in Kupffer cells. 4. [**Country 7018**] red stain has been evaluated. Addendum added by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma?????? Date: [**2139-7-30**] Clinical: Adenocarcinoma of the liver. Gross: The specimen is received fresh in multiple parts in containers labeled with the patient's name, "[**Known lastname **], [**Known firstname **]", and the medical record number. Part 1 is additionally labeled "segment 3 medial margin; stitch-true final" and consists of two tan-red tissue fragments, the larger of which measures 2.3 x 1.6 x 0.8 cm and the smaller that measures 1.8 x 1 x 0.6 cm, respectively. The larger tissue fragment has a surgical suture that has been left in place that designates one surface as the true final resection margin. The smaller fragment is unoriented but based on the appearance and shape of the tissue fragments it appears that it is a piece that has broken off the larger fragment. The true surgical margin on the larger piece and the presumed surgical resection margin on the smaller fragment has been inked in yellow. The surface from the larger piece from which the smaller fragment appears to have broken off has been inked blue. The remaining tissue edges have been inked black leaving only the cauterized surface un-inked on the larger fragment. The smaller fragment has three identifiable surfaces of which one has been inked yellow and the second has been inked black and the remaining cauterized surface remains un-inked. The specimens are serially sectioned revealing unremarkable cut surfaces. The specimen is entirely submitted as follows: A-F=larger fragment, G=smaller fragment. Part 2 is additionally labeled "segment 3" and consists of a tan-red tissue fragment that measures 2.9 x 2.6 x 2.3 cm. The specimen has been oriented with a suture that designates one surface as the medial resection margin. This medial resection margin has been inked yellow and the remaining surfaces of the tissue have been inked a different color (one black, one red, one [**Location (un) 2452**], and one blue). The specimen is serially sectioned to reveal a nodule that measures 1.3 x 1.3 x 1.2 cm which a homogeneous white cut surface. The nodule comes to within 0.2 cm of the medial margin that has been inked yellow. Representative sections are submitted as follows: H=tumor closest to yellow margin, I-J=additional sections of tumor in relation to yellow margin. Part 3 is additionally labeled "portal lymph node" and consists of a tan-red fragment of tissue measuring 1 x 0.7 x 0.4 cm. The specimen is bisected to reveal an unremarkable cut surface. The entire specimen is submitted in cassette K. Part 4 is received fresh for intraoperative consultation and additionally labeled "gallbladder; cystic lymph node". It consists of a previously opened gallbladder that measures 8.5 x 3.5 x 0.2 cm. The cystic duct is identified and is probe patent. A cystic duct lymph node is identified and measures 2 x 1 x 0.8 cm. The mucosa is velvety and bile-stained. The gallbladder wall measures up to 0.4 cm in thickness. An intraoperative consultation was performed. A frozen section was performed on the cystic lymph node. The frozen section diagnosis by Dr. [**Last Name (STitle) **]. [**Doctor Last Name 9885**] is: "No carcinoma seen." Representative sections are submitted as follows: L=cystic duct margin and gallbladder neck, M=gallbladder body and fundus, N=frozen section remnant of lymph node, O-P=remainder of cystic duct lymph node, entirely submitted. Part 5 is received fresh for intraoperative consultation and is additionally labeled "liver right lobe". It consists of a right lobe of liver that measures 19.9 x 16 x 9 cm. The capsular surface of the liver is smooth and shiny; however, there is an irregularly shaped tan white nodular area of puckering on the surface which measures 10.1 x 6.6 x 6 cm. The parenchymal resection margin is cauterized and is inked black. The liver is serially sliced to reveal an irregularly shaped firm nodular tan-white tumor which is continuous with surface puckering that measures approximately 9.2 x 4.8 x 8.5 and is located 2.8 cm from the black-inked resection margin. Multiple satellite lesions are present which measure up to 1.7 cm. Additionally, there is also a separate softer nodule measuring 1.2 x 0.6 cm. The uninvolved liver parenchyma is unremarkable. An intraoperative consultation was performed and the gross diagnosis by Dr. [**Last Name (STitle) **]. Fu is: "Tumor measures up to 9.2 cm, located 2.8 cm from the surgical resection margin. Multiple satellite tumors measuring up to 1.7 cm. Final diagnosis pending permanent section". Of note, the liver weighs 1509 grams. Representative sections are submitted as follows: Q=tumor in relation to capsule, R=tumor in relation to capsule at hilar area, S=satellite lesion in relation to capsule, T=possible thrombosis in relation to capsule. Please note that grossly satellite lesions and tumors are greater than 2 cm of the parenchymal margin and hence no representative sections can be taken, U-V=uninvolved parenchymal margin, W-sections that possibly represent vascular surgical margin where multiple staples were present. X-Y=additional sections of the largest tumor mass, Z=unremarkable liver parenchyma. AA-AJ = additional sections of tumor. Brief Hospital Course: On [**2135-7-17**] Mr. [**Known lastname **] [**Last Name (Titles) 1834**] right hepatic trisegmentectomy, segment III wedge resection and cholecystectomy for metastatic adenocarcinoma to the liver from an unknown primary versus primary hepatocellular carcinoma or intrahepatic cholangiocarcinoma. Surgeon was Dr. [**First Name (STitle) **] W. [**Doctor Last Name **]. There were no intraop complications. Two JPs were placed as well as a T tube. Please see operative report for details. His postop course was long and complicated. Postop, he went to the SICU where he remained intubated. An U/S of the L lobe demonstrated appropriate vascular flow. His wbc increased to 20 for which he was pan cultured. All cultures were negative except sputum which grew citrobacter freundii and enterobacter aerogenes. He remained on unasyn and vancomycin. Fluconazole was added. WBC increased to 30 then trended down. He was fluid overloaded and experienced mental status changes, thereofore he remained intubated. A head CT was negative. A CT of the abdomen showed large bilateral pleural effusions with areas of adjacent passive atelectasis and bilateral ground-glass opacities. A small area of the inferior remaining liver parenchyma that was not perfused. Additionally, a small subphrenic fluid was noted. Diffuse colitis was noted. Stools for C.diff remained negative. Nutritionally he was maintained on TPN until pod 10 when a post pyloric feeding tube was inserted and tube feeds were started. He had high outputs from his JPs and fluid leaking from his incision. IV fluid and albumin replacements were given to match JP/incision fluid outputs. A cholangioram was negative. Peritoneal fluid was positive for vanco sensitive enterococcus. Unasyn was switched to meropenum for 2 weeks. Flagyl continued for 2 weeks as well. On pod 9 the incision was partially opened for and a vac was placed. T. bili continued to trend up to as high as 30. INR trended up to 2.1. Vitamin K was given. Abdomen remained distended. A T tube cholangiogram was normal without leak. The T tube drained small amounts of bile. On pod 13 he was transferred out of the SICU. He remained mildly confused. Tube feedings were continued and po intake was poor. PT worked with him. He required multiple feeding tube replacements for self removal secondary to confusion. On [**8-31**] an abd CT demonstrated an increase in a large right pleural effusion, with a stable small left effusion. There was stable intermediate attenuation perihepatic fluid collection believed to represent a hematoma. New right pericolic gutter fluid collection, without definite air or surrounding fat stranding and continued improvement of previously described colitis. The incision was further opened for purulent drainage. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] from hepatology was consulted for liver failure due to a small left lobe and steatosis noted on pathology. Urosodiol was started. He continued to be confused requiring a 1:1 sitter. T bili remained elevated as well as BUN. He was transferred back to the SICU for cvp monitoring as he required large volume replacments from the drain. Albumin,Octreotide and midodrine and fluids were given to optimize his fluid status. He eventually was transferred out of the SICU only to return for worsening encephalopathy. Rifaximin was continued. The ascites was cultured and grew pseudomonas for which he remained on cipro and zosyn. On pod 27 a urine culture was done for confusion. This grew enterobacter aerogenes sensitive to cipro. He remained on cipro for nine days. Cipro and Zosyn were stopped and changed to Cefepime given concern for possible intersitial nephritis. Creatinine started trending up and u/o decreased. He experienced acute renal failure initially felt to be secondary to antibiotics, but w/u for interstitial nephritis was negative. Protonix iv was also suspected as possible cause, but urine eosinophils were negative. Creatinine continued to increase and he experienced an oliguric ATN. There were muddy brown casts in his urine. Nephrology was consulted and hemodialysis was initiated. Renal u/s was normal. He continued to have a waxing/[**Doctor Last Name 688**] mental status requiring wrist restraints and mitts as well as a 1:1 sitter as he self d/c'd his ppft on a number of occasions as well as the vac and iv line. He was transferred back to the SICU for a severe hypoglycemic episode thought to be due to an infectious process and insulin while feeding tube was out. While in the SICU he [**Doctor Last Name 1834**] a 2 liter pleural tap. Vanco, fluc and zosyn were started. Mental status gradually improved somewhat and t.bili started to decrease. A repeat T tube cholangiogram was normal. The T tube was clamped. Zosyn/fluc were stopped. T.bili decreased to 21 and inr to 1.5. He received PT and ambulated. Tube feedings were continued. Oral intake was poor. He started to complain of abdominal cramping after JP was removed on [**9-18**]. His abdomen was very tender. An abdominal CT showed focal transverse colon colitis, stable perihepatic fluid collection, stable right pericolic gutter fluid collection and no evidence of bowel obstruction. WBC increased to 21. He was started on Daptomycin as the peritoneal fluid was positive for VRE. WBC started to trend down. Tube feedings were stopped and resumed 3 days later. On [**9-23**] abdominal discomfort increased with increased bowel movements. Stool was sent for c.diff and c.diff toxin B. He was very distended. Lactate was 13.6. A repeat ABD CT showed pneumatosis intestinalis, worrisome for ischemia and possible necrosis. This involved the majority of the patient's small bowel. There was no evidence of portal venous air. He was transferred to the SICU were he was intubated. Lactate continued to increasto 18. His condition worsened. His wife and daughter met with Dr. [**Last Name (STitle) **] and the decision to make him DNR was established given poor prognosis. He was then made CMO. Mr. [**Known lastname **] expired that evening in the SICU. Medications on Admission: isosorbide 30', Norvasc 10', Avandia 4' prn fs >190, Glipizide ER 5', Prilosec 20', Lisinopril 20', Toprol XL 100' Discharge Disposition: Expired Discharge Diagnosis: adenocarcinoma of liver ARF Peritonitis Malnutrition DM Discharge Condition: expired [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2139-9-25**]

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Discharge summary

report

Admission Date: [**2125-8-3**] Discharge Date: [**2125-8-7**] Date of Birth: [**2073-1-25**] Sex: M Service: MEDICINE Allergies: Codeine / Compazine / Penicillins / Metformin / Heparin Agents Attending:[**First Name3 (LF) 2485**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: This is a 52 year old ex-smoker and ex-IVDU with severe COPD and multiple COPD exacerbations with respiratory failure requiring intubation, as well as evidence of right hemidiaphragm dysfunction and tracheal stenosis s/p tracheal stent in [**8-16**]. He was in his USOH at his rehab facility, went to [**Hospital **] clinic yesterday for cryo of granulation tissue on the superior edge of the tracheostomy, at which point he became acutely bronchospastic, desatting to low-mid 80's (from low 90's). He was given several nebulizer treatments and the trach was replaced. They suctioned up a little blood. Per IP, the feeling was that he likely became bronchospastic in the setting of some chemical irritation from mild bleeding. With some supplemental O2, his sats came back up. They contemplated giving him some solumedrol prior to sending him home, but felt that his clinical status had improved. Today, at rehab, he became very distressed and hypoxic once again, and was transferred to the [**Hospital1 18**] ED. . In the ED, his trach was adjusted and he was placed on the vent, and his respiratory distress greatly improved. He then transiently became hypotensive to the 80's from the 110's. He was unhooked from the vent temporarily out of concern for auto-peep, but this did not make any difference to his pressures. He received a small NS bolus, and his next blood pressure was back up to the 100's. He also received steroids and antibiotics prior to transfer. . On arrival to the [**Hospital Unit Name 153**], the patient was complaining mainly of back pain and was requesting dilaudid. He also complained of shortness of breath, and felt that he wasn't able to get a good breath in from the vent. Between times of stimulus, he fell asleep and looked much more comfortable, but was also not drawing frequent enough breaths, so he was switched to MMV. He noted that his right leg was more erythematous than it usually is, but denied pain. Past Medical History: 1) Severe O2-dependent COPD 2) Tracheal stenosis s/p stent, stent removal, dilatation, and tracheostomy insertion [**Month (only) 205**]-[**2124-8-9**] (Interventional pulmonology notes report an "A"-shaped stenosis with tracheomalacia at the level of the 1st and 2nd tracheal rings. The stenosis was dilated with a rigid bronchoscope) 3) Diabetes mellitus type 2. 4) Osteoporosis. 5) Hepatitis B. 6) Chronic lower back pain, associated with mid-thoracic vertebral compression fractures from osteoporosis(details unknown). 7) Left 3rd finger amputation. 8) History of intravenous drug use. 9) multi-drug resistant pseudomonas infection, + MRSA sputum/ nasal swab 10) PUD hx of ulcers (gastric/duodenal) 11) chronic right hemidiaphragm elevation - phrenic n. dysfunction Social History: Lives at [**Location **] [**Location **] rehab, extensive smoking history but denies current smoking. Drank heavily in past, last drink long time ago. h/o IVDU but has been clean for past 7 years, does not need methadone maintenance. Family History: NC Physical Exam: Vitals: T: 99.6 BP: 104/68 HR: 76 RR: 19 O2Sat: 95% on MMV 500x10 (+6), peep 10, I:E 1:6.5, PIP 22, autopeep 5. GEN: chronically ill-appearing, no acute distress while asleep, mild respiratory distress once awake HEENT: EOMI, PERRL, sclerae anicteric, no epistaxis or rhinorrhea, MMM, OP Clear, edentulous NECK: No JVD, no bruits, no cervical lymphadenopathy, trach in place COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs with poor airflow, low lung volumes, obvious hyperinflation with barrel chest. Prolonged expiratory phase with wheeze. ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: RLE with erythema and pitting edema, no palpable cords, NT NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, rash or ecchymoses. Evidence of cellulitis in RLE as above. Pertinent Results: =====ADMISSION LABS===== [**2125-8-3**] 07:52PM TYPE-ART TEMP-37.3 PO2-108* PCO2-76* PH-7.29* TOTAL CO2-38* BASE XS-6 INTUBATED-NOT INTUBA [**2125-8-3**] 07:24AM LACTATE-1.6 [**2125-8-3**] 07:00AM GLUCOSE-121* UREA N-9 CREAT-0.6 SODIUM-145 POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-40* ANION GAP-12 [**2125-8-3**] 07:00AM WBC-12.9* RBC-4.87 HGB-11.9* HCT-40.4 MCV-83 MCH-24.4* MCHC-29.4* RDW-12.3 [**2125-8-3**] 07:00AM NEUTS-83.4* LYMPHS-8.8* MONOS-6.5 EOS-1.0 BASOS-0.3 [**2125-8-3**] 07:00AM PLT COUNT-300 CXR [**2125-8-3**] 1. No significant change with low lung volumes somewhat limiting evaluation. 2. Bibasilar atelectasis with crowding of bronchovasculature and small right pleural effusion. 3. Interval removal of PICC line. LE U/S [**2125-8-3**] IMPRESSION: No evidence of DVT involving the right lower extremity. Brief Hospital Course: Assessment: 52 y/o M with severe COPD on home O2 s/p trach, tracheomalacia s/p tracheal stent then dilatation, and right phrenic nerve dysfunction presented with acute respiratory distress. . # Respiratory Failure: The patient presented to the ED after increased respiratory distress and hypoxia. The patient had had an IP procedure the previous day and likely had some mild chemical irritation from blood inhalation and manipulation of his tracheostomy, resulting in easily triggered bronchospasm. Though he responded then to nebulizers, suction of little blood, and O2, he continued to experience respiratory distress the next day, and was taken to the ED. He has very little reserve so it is likely that very small disruptions can initiate an exacerbation. Please see HPI for details of his course in the ED. After transfer to the floor, the patient occasionally complained of shortness of breath. He was continued on MMV, which was appropriate given his periods of apnea (likely due to his pain meds.) The patient had a significant level of anxiety, and constantly requested IV Dilaudid for back pain. There was a concern for auto-peep given the effect of anxiety on his breathing rate/depth, thus anxiety medications were provided as needed. During his stay, no infectious etiology was found for his exacerbation. He was treated initially with IV steroids for COPD exacerbation, and transitioned to PO Prednisone prior to discharge. He was maintained on scheduled nebs, and received Azithromycin in the ED, but it was discontinued early after an infectious trigger was ruled out. The pt was weaned off the vent with no complications, and was oxygenating well (baseline 90s, occasional upper 80s) via 2L nasal cannula and tracheostomy mask on day of discharge. He has not been difficult to arouse throughout his hospitalization. He will need to follow-up in 1 week with his PCP to determine the appropriate Prednisone taper given his hx of frequent COPD exacerbations. His PCP will also adjust his Furosemide dose as needed. . # Cellulitis: The patient presented with a patch of erythema/edema on his right lower extremity which he described as chronic, and usually more edematous. There is evidence of stasis. The erythema is worse per the patient, and has been treated for MRSA cellulitis in the past. During his stay, an additional patch appeared on his left lower extremity, though less erythematous and edematous in comparison. The patient was initiated on Vancomycin 1g IV q12 x 7 days (last day = [**8-9**]) for presumed MRSA celluitis, given his history. On day of discharge, the edema and erythema had improved, and the lower extremities were only mildly tender to palpation. The patient has a PICC line in place. He will be completing the course at rehab. There may also be a component of venous stasis to his lower extremity changes. He was re-started on Furosemide 20mg PO bid, to be adjusted by his PCP as needed. . #Chronic back pain: The patient continued to complain of chronic back pain, worsened after laying supine while intubated, per pt. He has a history of IV drug abuse. His breakthrough pain was initially managed with IV Dilaudid, and he was transitioned to PO Oxycodone (his home regimen) prior to discharge. Pain was well controlled on Oxycodone on day of transfer to rehab. . #Anxiety: The patient appears to have a baseline level of anxiety. He was re-started on his home Celexa. He was also given a dose of Alprazolam at night, which helped his anxiety. He is to follow-up with his PCP [**Name Initial (PRE) 176**] 1 week to re-assess the need for additional anti-anxiety agents. . # DM2: The patient is on a lispro sliding scale as an outpatient. He was continued on a sliding scale here and monitored with fingersticks. He did not have any problems with glucose control during his stay. Medications on Admission: Lispro Insulin SC (per Insulin Flowsheet) Acetaminophen 325-650 mg PO Q6H:PRN Ipratropium Bromide MDI 6 PUFF IH Q4H Albuterol MDI 6 PUFF IH Q4H Lactulose 30 mL PO Q8H:PRN Pantoprazole 40 mg PO Q24H PredniSONE 10 mg PO DAILY Citalopram Hydrobromide 20 mg PO DAILY Pregabalin *NF* 75 mg Oral [**Hospital1 **] Furosemide 20 mg PO BID Oxycodone 5-20mg q3h prn Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): Please continue Insulin Lispro as previously directed. 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 6. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO bid (). 7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 8. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Three (3) ML Intravenous PRN (as needed) as needed for line flush: Flush with 3 mL Normal Saline every 8 hours and PRN. . 9. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) dose Intravenous Q 12H (Every 12 Hours): Give 1000mg IV q12hr x 3 (last dose 7/31.). 10. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): First day on Prednisone 40mg daily = [**8-7**]. 11. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush: PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. . 12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-10**] Sprays Nasal QID (4 times a day) as needed. 13. Oxycodone 5 mg Tablet Sig: 1-4 Tablets PO Q3H (every 3 hours) as needed for pain. 14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) puffs Inhalation every four (4) hours. 15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) puffs Inhalation every four (4) hours. 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: Primary: COPD exacerbation secondary to irritation s/p tracheostomy manipulation Cellulitis Secondary: Chronic back pain Diabetes mellitus Discharge Condition: Good, pt is hemodynamically stable, satting well in upper 80s-90s with 2L NC and tracheostomy mask, breathing unlabored, with bilateral lower extremity erythema and edema improving. Pain is controlled on oral medications. Pt is anxious about his COPD at baseline. Pt has not been difficult to arouse during his stay. Discharge Instructions: You were admitted for treatment of respiratory distress, likely related to the cryo procedure for your tracheostomy site, as well as your extensive history of COPD exacerbations. You have improved after IV steroid treatment and breathing treatments, and will be discharged back to rehab. Please continue to keep your legs elevated. The following changes were made to your medications: - Continue Prednisone 40mg PO daily(your PCP will adjust the dose) - Re-start Furosemide 20mg PO bid If you experience any increasing SOB, chest pain, increased swelling or pain in your lower legs, or have any other concerns, Followup Instructions: Please see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) **] C. [**Telephone/Fax (1) 37824**] in 1 week to follow-up on your COPD exacerbation and adjust your Prednisone medication taper and Furosemide medication. Completed by:[**2125-8-7**]

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icd9cm

[ [ [] ] ]

[ "97.49", "38.93", "96.72" ]

icd9pcs

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329, 336

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Discharge summary

report

Admission Date: [**2178-9-23**] Discharge Date: [**2178-9-25**] Date of Birth: [**2127-4-7**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 13256**] Chief Complaint: Anemia Major Surgical or Invasive Procedure: none History of Present Illness: 51yoM with h/o etoh cirrhosis, complicated by diuretic refractory ascites requiring paracentesis and recurrent hepatic hydrothorax requiring thoracentesis, also SBP and HE, who is admitted for s/p thoracentesis and paracentesis today presenting with abnormal labs including hyponatremia, elevated creatinine, and low HCT. He underwent a paracentesis and thoracentesis this afternoon, with approx. 5.4 liters of fluid drained. He subsequently received 50g of albumin. His labs from the AM prior to his paracentesis and albumin showed a creatinine was 1.6 up from 1.3 and patients sodium was 126 down from 133. Dr. [**Last Name (STitle) **] was notified, and requested admission for further albumin replacement. Patient did receive dose of Dilaudid 2mg for abdominal pain (patient has standing dose of 2mg every 8 hours for pain) pain was initially a [**8-11**] now [**4-11**]. At that time, his vitals were 98.3, 122/70, 84, 18 100%. In the ED, initial VS were 97.8 86 111/62 18 100%. Labs notable for U/A with trace leuks and few bacteria, Na 128, K 5.2, Cl 95, BUN 58, Cr 1.5, HCT 26.6, Plt 37, T bili 4.6, INR 2.3. EKG was unchanged, and CXR to my read showed a decreased R sided pleural effusion. The patient subsequently underwent a CT-non con to assess for bleeding, which showed large volume ascites but no evidence of hemorrhage, as well as fluid containing umbilical and right inguinal hernia. The patient was guiaic negative per the ED, and also received 1 mg Dilaudid, as well as 1 U plt and 1 U plasma. When he was admitted prevoiusly from [**8-12**] - [**8-14**], he admitted for [**Last Name (un) **] with Cr 2.0 from baseline 1.3 after 4 L paracentesis. For his [**Last Name (un) **] at that time, he was given Albumin 1g/kg x 48 hours, and his home diuretics and nadolol were stopped. He was also found to have an Enterococcal UTI from UCx on [**2178-8-7**] patient was continued on Amoxicillin, which is set to finish on [**2178-8-16**]. His hyponatremia at the time was treated with a low Na diet, fluid restriction to 2L, Albumin, and tube feeds. On arrival to the MICU, he is AAOx3 without encephalopathy. He does have diffuse abdominal pain [**6-11**]. (+) Per HPI, endorses weight loss and sore throat after Dobhoff placement. (-) Denies fever, chills, night sweats, recent weight gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -Alcoholic cirrhosis --diuretic refractory ascites requiring paracentesis --recurrent hepatic hydrothorax requiring thoracentesis --HRS type I ([**6-/2178**]) following LBP --malnutrition requiring dophoff tube placement -Kidney stones -Esophageal varices -Renal insufficiency -Hypertension Social History: He lives with his girlfriend and is divorced. Patient previously drank eight to 10 beers a night for 10 years up till [**Month (only) 359**] [**2177**]. Patient previously smoked cigarettes but quit years ago. He denies any illicit drug use. Family History: Non-contributory Physical Exam: ADMISSION EXAM AAOx3. Caucasian male in NAD. Slight jaundice. Interacting appropriately. HEENT: Sclera mildly icteric CARDIAC: RRR, 2/6 SEM appreciated LUNGS: Unlabored breathing. Speaking in full sentences. Decreased breath sounds on the left lower and mid lung. CHEST: Mild gynecomastia. Striae in axilla b/l. Slight jaundice. L thoracentesis site with mildly bloody bandage ABDOMEN: Striae in suprapubic area. Flank protrusion. Distended, Soft, non-tender. Dullness to percussion diffusely. R para site is C/D/I with new bandage. EXTREMITIES: 1+ B LE edema. 2+ pulses. NEUROLOGY: A+Ox3, no asterixes DISCHARGE EXAM: GENERAL: Well appearing 51yo M/F who appears stated age. Comfortable, appropriate and in good humor. HEENT: Sclera icteric. PERRL, EOMI. NECK: Supple with low JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Mildly distended but Soft. Mild diffuse TTP. Dullness to percussion over dependent areas but tympanic anteriorly. No HSM or tenderness. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+ [**Location (un) **] bilaterally to knees. Pertinent Results: ADMISSION LABS [**2178-9-23**] 12:00PM PT-24.4* INR(PT)-2.3* [**2178-9-23**] 12:00PM PLT COUNT-62*# [**2178-9-23**] 12:00PM WBC-6.2# RBC-3.29* HGB-11.1* HCT-31.8* MCV-97 MCH-33.9* MCHC-35.1* RDW-16.1* [**2178-9-23**] 12:00PM ETHANOL-NEG [**2178-9-23**] 12:00PM ALBUMIN-3.5 [**2178-9-23**] 12:00PM TOT BILI-4.6* [**2178-9-23**] 12:00PM estGFR-Using this [**2178-9-23**] 12:00PM GLUCOSE-105* UREA N-62* CREAT-1.6* SODIUM-126* POTASSIUM-5.7* CHLORIDE-94* TOTAL CO2-25 ANION GAP-13 [**2178-9-23**] 12:00PM GLUCOSE-105* UREA N-62* CREAT-1.6* SODIUM-126* POTASSIUM-5.7* CHLORIDE-94* TOTAL CO2-25 ANION GAP-13 [**2178-9-23**] 06:40PM PLT COUNT-37* [**2178-9-23**] 06:40PM NEUTS-68.4 LYMPHS-11.0* MONOS-16.5* EOS-3.8 BASOS-0.4 [**2178-9-23**] 06:40PM WBC-4.3 RBC-2.76* HGB-9.0* HCT-26.6* MCV-96 MCH-32.7* MCHC-33.9 RDW-16.2* [**2178-9-23**] 06:40PM OSMOLAL-283 [**2178-9-23**] 06:40PM ALBUMIN-3.9 [**2178-9-23**] 06:40PM ALT(SGPT)-23 AST(SGOT)-59* ALK PHOS-196* DIR BILI-1.3* [**2178-9-23**] 06:40PM GLUCOSE-99 UREA N-58* CREAT-1.5* SODIUM-128* POTASSIUM-5.2* CHLORIDE-95* TOTAL CO2-24 ANION GAP-14 [**2178-9-23**] 06:43PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE EPI-0 [**2178-9-23**] 06:43PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-TR [**2178-9-23**] 06:43PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2178-9-23**] 08:10PM HCT-25.1* [**2178-9-23**] 08:14PM URINE OSMOLAL-366 [**2178-9-23**] 08:14PM URINE HOURS-RANDOM UREA N-607 CREAT-43 SODIUM-<10 POTASSIUM-63 CHLORIDE-10 [**2178-9-23**] 09:10PM HCT-25.2* . Discharge Labs: [**2178-9-25**] 06:15AM BLOOD WBC-3.4* RBC-2.49* Hgb-8.3* Hct-23.9* MCV-96 MCH-33.3* MCHC-34.6 RDW-16.2* Plt Ct-46* [**2178-9-25**] 06:15AM BLOOD PT-25.7* PTT-52.7* INR(PT)-2.5* [**2178-9-25**] 06:15AM BLOOD Glucose-115* UreaN-63* Creat-1.6* Na-131* K-5.0 Cl-98 HCO3-27 AnGap-11 [**2178-9-25**] 06:15AM BLOOD ALT-20 AST-48* AlkPhos-136* TotBili-3.8* [**2178-9-25**] 06:15AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.4 [**2178-9-25**] 06:15AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.4 . Imaging: CT abd/pelvis [**2178-9-23**]: IMPRESSION: Cirrhosis, splenomegaly, anasarca and mesenteric edema. Large volume ascites without signs of acute hemorrhage. Right fluid-filled inguinal hernia and fluid-filled umbilical hernia. Left pleural effusion with compressive atelectasis. . Micro: [**2178-9-24**] Blood Culture, Routine-PENDING [**2178-9-24**] Blood Culture, Routine-PENDING Brief Hospital Course: 51yoM with h/o etoh cirrhosis, complicated by diuretic refractory ascites requiring weekly paracentesis and recurrent hepatic hydrothorax requiring thoracentesis. Also h/o SBP and HE. Admitted s/p thoracentesis and paracentesis [**3-5**] hyponatremia, elevated creatinine, and low HCT. . Active Issues: # Anemia: Baseline HCT is 25, and patient has had bloody taps as evidenced by prior taps in our system. Information from most recent ascitic fluid was not sent. Hct is 25, which is at his baseline between 23-28; ED values of 31 and 33 are likely spurious. No signs or symptoms of GI bleeding during ED or clinic visit. His Hct were trended and he required no transfusions while in the MICU. His Hct remained unchanged on the floor and was deemed stable at discharge. . # Hyponatremia: Likely was secondary to hyponatremia from hypervolemia, and mild improvement with paracentesis. Urine lytes show FeNa 0.27% and FeUrea 365%. He was given albumin and placed on a fluid restriction. Na improved with 1.5L fluid restricition. No diuretics were given, as these have been held in the past [**3-5**] kidney and electrolyte abnormalities. . Chronic Issues: # Cirrhosis: EtOH Cirrhosis with history of recurrent ascites, right hydrothorax, esophageal varices, hepatic encephalopathy, and SBP in the past. MELD 26 on admission. Patient does have HCC providing points via [**Location (un) 6624**] criteria. Rifaximin and lactulose for HE ppx given. Nadolol 10mg qday given for h/o varices. Tube feeds currently in place and were continued. . # Thrombocytopenia: Secondary to underlying liver disease. did not receive platelet transfusion while in MICU. . # CKD: Cr unchanged from prior labs. Likely 2/2 HRS 2. Patient was given albumin and his electrolytes were trended and repleted. . Transitional Issues: #Lytes check in 1 week #COntinue VNA and tube feeds at home #Follow-up blood cultures Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Ciprofloxacin HCl 500 mg PO Q24H 2. FoLIC Acid 1 mg PO DAILY 3. Lactulose 30 mL PO QID 4. Omeprazole 40 mg PO DAILY 5. Rifaximin 550 mg PO BID 6. Thiamine 100 mg PO DAILY 7. Nadolol 10 mg PO DAILY 8. Isosource 1.5 Cal *NF* (lactose-free food with fiber) 55 ml/hr Oral Daily 55 ml/hr 9. HYDROmorphone (Dilaudid) 2 mg PO Q8H:PRN pain Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO Q24H 2. FoLIC Acid 1 mg PO DAILY 3. HYDROmorphone (Dilaudid) 1-2 mg PO Q4H:PRN pain hold for sedation, RR < 10 4. Lactulose 30 mL PO TID 5. Nadolol 10 mg PO DAILY 6. Omeprazole 40 mg PO DAILY 7. Rifaximin 550 mg PO BID 8. Thiamine 100 mg PO DAILY 9. Isosource 1.5 Cal *NF* (lactose-free food with fiber) 55 ml/hr Oral Daily 55 ml/hr Discharge Disposition: Home With Service Facility: [**Location (un) 6138**] Home Care Services Discharge Diagnosis: Primary diagnosis: hyponatremia acute kidney injury alcoholic cirrhosis Secondary diagnosis: hepatocellular carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for you at [**Hospital1 18**]. You were admitted after a procedure where fluid was drained from your abdomen and chest. After the procedure, your kidney function was minimally decreased. We believed that your red blood cells were also decreased. You were admitted to the ICU where you were given fluid through your veins. This helped improve your kidney function. It was determined that your blood cell count had not actually decreased, it was just diluted with fluid. At discharge your kidney function and red blood cell counts were at a normal level for you. You also had a low sodium on admission. Your underlying liver disease predisoposes you to this condition. Please restrict your [**Last Name (un) 1534**] fluid intke to 1.5L of water per day. This will help keep your sodium normal. If you restrict yourself to less than 1L of water/day, you may worsen your kidney function. You have a follow-up appointment in the liver center on [**2178-9-30**]. They will check your electrolytes and make sure that your kidney function continues to improve. There were NO medication changes on this admission Followup Instructions: Department: TRANSPLANT When: WEDNESDAY [**2178-9-30**] at 11:00 AM With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage ** This appointment replaces the appointment with Dr. [**Last Name (STitle) **] for [**10-8**] which was cancelled.

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icd9cm

[ [ [] ] ]

[ "54.91", "96.6", "34.91" ]

icd9pcs

[ [ [] ] ]

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48184

Discharge summary

report

Admission Date: [**2124-2-21**] Discharge Date: [**2124-2-28**] Date of Birth: [**2065-11-22**] Sex: F Service: MEDICINE Allergies: Penicillins / Clindamycin / Celery / Bee Sting Kit Attending:[**First Name3 (LF) 5119**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Initial history and physical is as per Dr. [**First Name4 (NamePattern1) **] [**Last Name (un) 101568**] . Ms. [**Known lastname **] is a 58 year-old female with a history of morbid obesity s/p gastric bypass, pulmonary hypertension, and asthma who presents with acute on chronic abdominal pain, for which she was discharged on [**2124-2-18**] after a negative evaluation which included abdominal/pelvic CT. She reported improvement in her abdominal pain, which she describes as sharp, epigastric pain radiating to the RUQ and LUQ, after initiation of laxatives and antitussive agents. However, she had worsening pain on the day of presentation. Of note, her family notes that she has been increasing somnolent and confused lately, and has also had decreased po intake. . On arrival to the ED, she was found to have an O2 sat of 55% on room air but her VS were otherwise stable (Temp 98, BP 140/85, RR 20-24). She was mentating appropriately, A&O x 3, and though her primary complaint was abdominal pain and she described no subjective SOB, fevers, chills, cough, or chest pain, her evaluation focused on her hypoxia. She was placed on a NRB with a subsequent O2 sat > 90%. On exam, she was found to be wheezy with decreased BS bilaterally, and was thought to have an asthma exacerbation, for which she was given nebs, steroids, and azithro 500mg x 1 after blood cx were sent. An EKG was performed and demonstrated pseudonormalization of t waves in V2-V6. CEs were sent, though she denied CP, and the first set was negative. She was later placed on a 50% ventimask and had an O2 sat of 96% at that time. A CXR was also performed and was negative for any acute process and no evidence of hyperinflation. Two PIVs were placed. . Of note, during her prior hospitalization, she was found to have a room air sat in the 70s% and 75% on 2L. . ROS otherwise negative. Past Medical History: - morbid obesity s/p hernia repair [**6-1**] and gastric bypass surgery - OSA on nocturnal BIPAP (18/15) and 2-3L home O2 - obesity hypoventilation syndrome - pulmonary HTN thought from OSA and obesity hypoventilation - right heart failure - h/o iron deficiency anemia - asthma: last PFTs in [**4-5**] with marked obstructive defect and FEV1 of 38%. Also had [**Month (only) **] FVC suggestive of restrictive defect - Hypertension - Osteoarthritis of bilateral knees Social History: The patient lives with her two sons. [**Name (NI) **] [**Name2 (NI) 269**] for home support, though family is concerned that this is not enough. Not currently working. She denies any tob/etoh/illicit drug use. Family History: non-contributory Physical Exam: General Appearance: Well nourished, Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Breath Sounds: Crackles : , Wheezes : , Diminished: , Rhonchorous: ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: 1+, Left: 1+ Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: [**2124-2-21**] 10:15PM TYPE-[**Last Name (un) **] O2 FLOW-10 PO2-62* PCO2-91* PH-7.24* TOTAL CO2-41* BASE XS-7 INTUBATED-NOT INTUBA COMMENTS-NEBULIZER [**2124-2-21**] 10:15PM LACTATE-1.2 [**2124-2-21**] 05:40PM GLUCOSE-119* UREA N-36* CREAT-1.6* SODIUM-141 POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-39* ANION GAP-14 [**2124-2-21**] 05:40PM CK(CPK)-230* [**2124-2-21**] 05:40PM cTropnT-<0.01 [**2124-2-21**] 05:40PM CK-MB-3 proBNP-[**Numeric Identifier 85885**]* [**2124-2-21**] 05:40PM WBC-8.5 RBC-5.05 HGB-11.7* HCT-39.8 MCV-79* MCH-23.1* MCHC-29.2* RDW-18.3* [**2124-2-21**] 05:40PM PLT COUNT-261 [**2124-2-21**] 05:40PM PT-15.5* PTT-32.2 INR(PT)-1.4* . EKG [**2124-2-21**]: Unchanged from prior. Sinus rhythm. Right axis deviation. . CXR [**2124-2-21**]: Stable cardiomegaly and mild pulmonary vascular congestion. Pulmonary arterial hypertension with evidence of right heart failure. No change. . [**2-22**] ECHO: The left atrium is normal in size. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 70-80%). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. 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 regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. There is no pericardial effusion. IMPRESSION: advanced cor pulmonale Brief Hospital Course: This is a 58 year old morbidly obese woman with obesity hypoventilation syndrome/OSA/Asthma resulting in marked obstructive lung disease, moderate restrictive lung disease secondary to obesity, and severe pulmonary hypertension and severe right failure. She presented with acute on subacute abdominal pain, and incidentally was noted to be hypoxic and hypercapnic. . # Hypoxia: The working diagnosis was acute asthma exacerbation with component of pulmonary edema. Patient also has severe pulmonary hypertension with cor pulmonale noted on 2D echo. She was treated for asthma exacerbation in the ICU with short overnight stay. Her CO2 was noted to be 85 with marked respiratory alkalosis compensating for respiratory acidosis. She presented with O2 requirement of ~10L compared to her home regimen of 2-4L. VBG showed baseline chronic respiratory acidosis with metabolic compensation. The CXR was unchanged with no focal abnormalities or new effusions. She had evidence of wheezing on exam. She was treated with bronchodilators, steroids, and night CPAP. She was continued on sildenafil for pulmonary hypertension. An echocardiogram showed advanced cor pulmonale. She was also continued on her home dose of torsemide. Her O2 requirement went back to baseline and she was discharged with home oxygen. She will complete a prednisone taper as an outpatient. Patient should follow up with Dr. [**Last Name (STitle) **] from Pulmonary for further assessment. . # Abdominal pain: In regards to her abdomina pain, she had recent abdominal CT at [**Hospital1 2025**] and [**Hospital1 18**] with no acute issues found on the CT. The pain started after coughing and she thought that she had disrupted her mesh. She actually had gastric bypass surgery in [**2113**], s/p abdominal hernia repair in [**5-/2119**] with a mesh placement. In [**7-1**] she had a fat necrosis and separation of incision for which she had a complex repair. During her last hospitalization, abdominal wall pain was diagnosed. During this hospitalization we obtained GI consult who recommended surgical consultation. MRI of the abdomen was considered for further evaluation. However, upon discussion with the radiology team, they felt that an MRI would not reveal any pathology that could not be seen on The CT scan that was already done. Surgery felt that there was no evidence of hernia on prior CT (recent). They felt she most likely had muscular pain from coughing. The patient's pain resolved on its own without any significant intervention Arrangements were made for pt to follow up with Dr. [**Last Name (STitle) **] as an outpatient. . # Failure to thrive: Patient's family reported she had been having difficulty managing at home (she lives alone), reporting symptoms of somnolence and confusion; there was concern that she was transiently hypercapnic during these episodes. There was concern that her underlying pulmonary issues were progressing, making her living situation at home more difficult. PT and OT were consulted and she was cleared for discharge home. They did not feel that she did not meet criteria for inpatient rehab placement. Our case manager arranged for [**Last Name (STitle) 269**] at home. A family meeting was held on [**2124-2-25**] to explain the patient's poor prognosis regarding her advanced pulmonary hypertension. Social work followed the patient throughout her hospitalization. . # ARF: Creatinines were elevated over the past month to 1.4-1.6. Cr improved to 1.0 with IVF hydration. . # OSA: Patient was continued on CPAP QHS. . # PPX: SC heparin given to prevent DVT . #. Dispo: The patient was discharged home with services in fair condition. Her long term prognosis is poor because of her severe pulmonary hypertension. Medications on Admission: 1. Codeine-Guaifenesin 10-100 mg/5 mL Syrup 5-10 MLs PO Q6H prn cough 2. Benzonatate 100 mg PO TID 3. Ferrous Sulfate 325 mg po qd 4. Sildenafil 25 mg po tid 5. Aspirin 81 mg po qd 6. Fluticasone 110 mcg/Actuation Aerosol One Puff [**Hospital1 **] 7. Lidoderm 5 %(700 mg/patch) Adhesive Patch 8. Albuterol 90 mcg/Actuation Aerosol 2 puffs q4h prn SOB 9. Home O2 10. Ketoconazole 2 % Cream Topical twice a day; apply to face. 11. Metronidazole 0.75 % Cream Topical twice a day; apply to face. 12. Torsemide 40 mg po qd Discharge Medications: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Sildenafil 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical ON 12H/OFF 12H (). 7. Outpatient Physical Therapy Outpatient Pulmonary Physical Therapy 8. Oxygen Home oxygen - Patient should use 2.5L at rest and 4L with ambulation. 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation q4h prn as needed for shortness of breath or wheezing. 10. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 11. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Metronidazole 0.75 % Cream Sig: One (1) Topical twice a day: Apply to affected areas of face. 13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO once a day as needed for constipation. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 15. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 6 days: Take 2 tabs po for 3 days then 1 tab for 3 days then stop. Disp:*9 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] [**Location (un) 269**] Discharge Diagnosis: Hypercapnic respiratory failure Abdominal pain of unclear etiology. Discharge Condition: Good Discharge Instructions: You were admittied for 2 reasons - abdominal pain and respiratory failure. . Regarding the abdominal pain, you have had a thorough workup without a clear cause. All worrisome and life threatening causes have been ruled out. Consitipation may contribute and you should take stool softeners and laxatives as needed. You should follow up with Dr. [**Last Name (STitle) **] of general surgery in a few weeks as scheduled. . Regarding your respiratory failure you should be sure to use all of you inhaler medications, use your oxygen at home and use BIPAP at night to prevent respiratory problems in the future. . General instructions: -Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. -Adhere to 2 gm sodium diet. -Take all medications as prescribed. -Take stool softeners and use laxatives as needed for constipation. -Continue O2 at home, 2.5L at rest and 4L with ambulation. -Continue BIPAP at home. -Follow up with Dr. [**Last Name (STitle) 3029**] and Dr, [**Name (NI) **] as scheduled. -Call PCP or return to ED if you have worsening shortness of breath, abd pain, nausea/vomiting, fevers/chills and/or are unable to eat/drink Followup Instructions: Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Date/Time:[**2124-3-17**] 11:10 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2124-3-13**] 1:45 [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2124-3-11**]

[ "278.01", "783.7", "V46.2", "V45.86", "V58.65", "584.9", "789.01", "428.0", "518.84", "715.36", "428.32", "276.4", "493.22", "416.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11544, 11621

5745, 9499

327, 333

11733, 11740

3624, 5722

12943, 13413

2967, 2985

10068, 11521

11642, 11712

9525, 10045

11764, 12920

3000, 3605

273, 289

361, 2233

2255, 2723

2739, 2951

19,911

171,106

21457

Discharge summary

report

Admission Date: [**2132-7-28**] Discharge Date: [**2132-10-28**] Date of Birth: [**2066-3-22**] Sex: F Service: MEDICINE Allergies: Keflex / Erythromycin Base / Fentanyl / Morphine / Linezolid / Dilaudid / Heparin Agents Attending:[**First Name3 (LF) 99**] Chief Complaint: hypotension, lethargy Major Surgical or Invasive Procedure: s/p PICC line ([**10-16**]) s/p EGD x 2 ([**10-7**], [**10-15**]) s/p ileoscopy ([**10-15**]) s/p tunneled dialysis catheter placement ([**10-16**]) History of Present Illness: 66F with hx of COPD s/p trach, ESRD on HD, sacral decubs, hx of MRSA, serratia bacteremia and cdiff who presents from home with lethargy. Per pt's family, she has been more lethargic and hyperglycemia over the past month and a half. Her son states that her blood sugars typically run between 150-200 but over the past 4 weeks, her sugars have been as high as 500. Her physician has been increasing her NPH and finally put her on Glargine recently but her sugars remain uncontrolled. Also, pt's family states that at baseline, she follows some commands and is able to ask for water and ice chips. Lately, she has not been very responsive which is typical for when she is infected. Shje was recently admitted to [**Hospital 5871**] Hospital (d/c'd on [**6-20**]) with similar symptoms and she was diagnosed with endocarditis (records not available). She was discharged on Zosyn and Tygacil. These were stopped 2 weeks ago. They also note that she has been having low grade fevers to 100 at home with normal SBP in the 90s-100s. Also, she has been having clots in both her colostomy and PEG tube. Pt's family states that pt has had no specific complaints. No increased stool output, no complaints of abd pain. . On arrival to the ER, her SBP was in the 70s-80s with HR in the 110s. She improved to 100-110 with 1L of NS. After discussion with the family, the ER decided not to call a code sepsis. She was given cefepime and vanc and admitted to the MICU. Past Medical History: 1. Diastolic heart failure 2. ESRD on HD 3. aortic valve replacement (st. [**Male First Name (un) **], on coumadin 4. paroxysmal a fib 5. Thrombocytopenia 6. COPD, s/p trach [**11-22**] 7. MRSA + sternotomy wound infxn ~2year ago. Treated with ~1years of IV Vanc at [**Hospital1 2177**] (per daughter) 8. MRSA Bacteremia s/p 4 weeks of vanc [**Date range (1) 56643**] 9. h/o PEA arrest 10. left parietal CVA [**37**]. persistent hyperphos 12. Type II DM 13. recent serratia bacteremia (as above) 14. Anemia of chronic dz 15. chronic sacral decub 16. necrotic right toes Social History: HCP: [**Name (NI) 4906**], [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 56644**]. Family spokesperon: [**Doctor First Name 32280**] (daughter) [**Telephone/Fax (1) 56645**] 8 children who live in the area and are involved in pt's care Family History: non-contributory Physical Exam: temp 98.8, BP 108/48, HR 110-120, O2 100% Vent: AC 450 x 16 (breathing at 24) x 5 x 50% ABG: 7.29/33/238 Gen: NAD, does not respond to voice, slightly responsive to pain HEENT: pupils 5mm -> 2mm; MMM Neck: JVD not appreciated CV: irreg irreg, metallic click Chest: clear other than bronchial breath sounds at LUL posteriorly Abd: PEG and colostomy in place; obese; no bowel sounds heard; nontender Ext: 1+ pitting edema bilaterally; DP pulses not palpable Skin: large stage IV sacral ulcer with several surrounding ulcers; largest part of ulcer with black base and deep to bone; also with ulcers on posterior lower extremities and on heels; right toes with necrosis Neuro: PERRL, +corneal reflex, no reflexes, no response to Babinski; increased tone in upper ext, L>R Pertinent Results: [**2132-7-28**] 09:56PM GLUCOSE-291* LACTATE-4.0* NA+-134* K+-3.7 CL--97* [**2132-7-28**] 07:46PM GLUCOSE-321* LACTATE-4.4* [**2132-7-28**] 07:45PM GLUCOSE-327* UREA N-129* CREAT-4.2* SODIUM-130* POTASSIUM-6.5* CHLORIDE-91* TOTAL CO2-17* ANION GAP-29* [**2132-7-28**] 07:45PM CORTISOL-40.6* [**2132-7-28**] 07:45PM WBC-23.3* RBC-3.14* HGB-11.1* HCT-34.1* MCV-109*# MCH-35.3*# MCHC-32.5 RDW-20.5* [**2132-7-28**] 07:45PM NEUTS-78* BANDS-8* LYMPHS-4* MONOS-9 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* NUC RBCS-4* [**2132-7-28**] 07:45PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-2+ SPHEROCYT-1+ OVALOCYT-OCCASIONAL BURR-OCCASIONAL [**2132-7-28**] 07:45PM PLT COUNT-307 [**2132-7-28**] 07:45PM PT-38.6* PTT-40.1* INR(PT)-4.3* . . [**2132-10-28**] 04:03AM BLOOD WBC-4.1 RBC-3.20* Hgb-10.3* Hct-29.5* MCV-92 MCH-32.2* MCHC-34.9 RDW-18.5* Plt Ct-18* [**2132-10-28**] 04:03AM BLOOD Plt Smr-RARE Plt Ct-18* [**2132-10-28**] 04:03AM BLOOD PT-23.3* PTT-55.3* INR(PT)-2.3* [**2132-10-28**] 04:03AM BLOOD Glucose-226* UreaN-29* Creat-2.0* Na-149* K-3.4 Cl-112* HCO3-18* AnGap-22* [**2132-10-27**] 03:12AM BLOOD ALT-5 AST-35 LD(LDH)-190 AlkPhos-294* Amylase-12 TotBili-4.2* [**2132-10-28**] 04:03AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.7 [**2132-9-11**] 03:21PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2132-10-27**] 03:12AM BLOOD Digoxin-1.0 . [**2132-10-21**] 8:00 pm BLOOD CULTURE RECEIVED AT 10:10PM. **FINAL REPORT [**2132-10-24**]** AEROBIC BOTTLE (Final [**2132-10-24**]): REPORTED BY PHONE TO [**Name6 (MD) 56647**] [**Name8 (MD) **], RN CC6B [**Numeric Identifier 56648**] @ 1624 ON [**2132-10-22**]. ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R LINEZOLID------------- 4 I PENICILLIN------------ =>64 R VANCOMYCIN------------ =>32 R ANAEROBIC BOTTLE (Final [**2132-10-24**]): ENTEROCOCCUS FAECIUM. IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE. . . [**2132-10-17**] 1:55 am SPUTUM Site: ENDOTRACHEAL **FINAL REPORT [**2132-10-25**]** GRAM STAIN (Final [**2132-10-17**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2132-10-25**]): OROPHARYNGEAL FLORA ABSENT. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. IDENTIFICATION REQUESTED ON NEGATIVER RODS BY DR. [**Last Name (STitle) **] [**Name (STitle) **] [**Numeric Identifier 56649**] [**2132-10-21**]. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. AMIKACIN 16MCG/ML =S. MINIMAL INHIBITORY CONCENTRATION:. SENSITIVITY PERFORMED BY [**Last Name (un) 56650**]. KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. Trimethoprim/Sulfa sensitivity testing available on request. AMIKACIN 16MCG/ML = S. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. ACINETOBACTER BAUMANNII. MODERATE GROWTH. Trimethoprim/Sulfa sensitivity testing available on request. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". AMIKACIN 16 MCG/ML = S. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | KLEBSIELLA PNEUMONIAE | | ACINETOBACTER BAUMANNII | | | AMPICILLIN/SULBACTAM-- =>32 R 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- 8 S R 32 R CEFTAZIDIME----------- 8 S R =>64 R CEFTRIAXONE----------- R CEFUROXIME------------ 32 R CIPROFLOXACIN--------- =>4 R =>4 R =>4 R GENTAMICIN------------ 8 I =>16 R =>16 R IMIPENEM-------------- 8 I 2 S 8 I LEVOFLOXACIN---------- =>8 R =>8 R MEROPENEM------------- 4 S <=0.25 S PIPERACILLIN---------- 16 S PIPERACILLIN/TAZO----- 16 S =>128 R TOBRAMYCIN------------ <=1 S =>16 R 4 S . . [**2132-10-27**]: CXR FINDINGS: Right PICC line, left dialysis catheter and tracheostomy tube remain in place. Compared to the prior study, there is new increased density in the left upper lung zone, which could be a developing pneumonia. Extremely subtle increase in density is seen adjacent to the right hilar region, which could relate to early pulmonary edema. However, the pulmonary vascular markings are not significantly distended. Right effusion is again demonstrated. IMPRESSION: New airspace finding in the left upper lung zone, possibly in the right mid lung zone. Continued followup is recommended. . Abdominal a-gram: IMPRESSION: 1. Nonselective aortography and selective superior mesenteric artery arteriogram demonstrate no evidence of active gastrointestinal bleeding. Diffuse atheromatous disease was noted. 2. Selective catheterization of the inferior mesenteric artery was unsuccessful, likely due to severe atherosclerotic disease at its origin as shown on a previous CT scan. 3. Endoscopy recommended to better clarify origin of bleeding. . CT head: IMPRESSION: No acute intracranial hemorrhage or change from the prior examination. . MR [**Name13 (STitle) **]: IMPRESSION: No definite evidence of osteomyelitis of the sacrum. Subtle increased signal within the coccyx could be secondary to partial volume averaging from the adjacent decubitus ulcer. Moderate spinal stenosis at L4-5 level. Brief Hospital Course: 66F with chronic trach and PEG, s/p CVA in [**2130**] with residual weakness who presents from home with lethargy and hypotension. . # Sepsis: On admission, WBC elevated to 23 with 8% bands and lactate of 4.4. Patient with hx of c diff, serratia and MRSA bacteremia in the past. During a previous admission, pt had MRSA bacteremia but no source was identified. No hx of diarrhea. Blood, sputum cultures sent. Pt is anuric so no urine culture. Patient however with multiple sources of infection, including sacral decub ulcers, dry gangrene in both feet, tracheostomy and G-tube insertion sites. Pt sx's initially improved dramatically with supportive therapy. cultures returned pseudomonas from sputum and begun on meropenem on [**7-28**]. CT + MRI of sacral and posterior-tibial decubs showed no evidence of Osteomyelitis. Patient initially failed [**Last Name (un) 104**]-stim test and completed a five day course of stress dose steroids. Regarding sacral decub ulcers, plastics was consulted and did not feel there was any role for surgical intervention. During admission, patient with multiple positive cultures including the following: sputum on [**2132-7-28**] growing pseudomonas and GNR; sputum on [**2132-8-11**], [**2132-8-15**], [**2132-8-20**] growing pseudomonas and GNR; sacral decubitus ulcer swab on [**2132-8-21**] growing GNR, Pseudomonas, coag positive staph aureus, and klebsiella; sputum culture on [**2132-8-26**] and [**2132-8-27**] growing Klebsiella, Pseudomonas; blood culture on [**2132-8-29**] growing enterococcus faecium (VRE but sensitive to linezolid). Patient has been treated with tobramycin and zosyn for double coverage of pseudomonas in sacral decubitus ulcers, linezolid for MRSA and VRE, and levofloxacin for chronic aortic abscess with serratia. Patient's HD catheter was removed when patient was found to have VRE. . Patient also with hx of aortic annular abscess with serratia and ? of endocarditis at [**Location (un) 5871**] and is chronically treated with levoquin. Vasc [**Doctor First Name **] performed a partial amp/debridement of the L great toe in the setting of dry gangrene. wound cultures from the tissue returned pseudomonas as well which showed resistance to meropenem. Vasc surgery recommended amputation with BKA due to gangrneous toes bilaterally. Family refused intervention. . Pt had a recurrent episode of VRE in her blood and a PNA with psuedomonas and klesiella. This was again treated with Meropenem and Amikacin for a 14 day course. She was also started on Daptomycin for recurrent VRE in her blood for a 14 day course. . # Lethargy: Patient with lethargy throughout her course, likely secondary to patient's sepsis. Head CT was negative for any intracranial hemorrhage or mass. This improved and pt was at her baseline at time of discharge. . # Resp: s/p trach, on vent at home with settings of assist control 450x22xPEEP of 5x60%. Pt. remained mostly on home vent settings throughout hospital stay. Oxygenating well on FiO2 of 60%. She had her PEEP increased to 8 [**2-21**] increased pleural effusions due to volume resuscitation during bouts of sepsis/GI bleed. Also, during her acute GI bleed, her rate was increased to help offset a lactic acidosis that occured [**2-21**] the large amounts of blood products she received. Other than this her vent settings have remained stable. Will likely be able to decrease her FiO2 over time after her pneumonia completely resolves. Trach is 7.0 extra long shiley. . # CV: ** Ischemia: EKG nml ** Rhythm: PAF; on dilt for rate control. continue amio and digoxin. Pt was taken off all anticoagulation due to recurrent GI bleeding. Cardiology consulted for risk of no anticoag with mechanical valve. Risk of thrombus is approx 10% per year, however pt had large GI bleed on any anticoagulation. Due to liver failure, pts INR has remained elevated to 2.0 throughout admission. ** Pump: EF 55% on [**2130**] echo, diastolic dysfxn. . # ESRD on HD: During this admission, patient was initially on hemodialysis and was converted for a short time to CVVHD. However, once patient's renal function and hemodynamics became more stable, patient should be continued on hemodialysis per home regimen. . # Anemia: baseline hct of 29-30. During this admission, patient became supratherapeutic on coumadin and heparin and developed increased bleeding, including vaginal bleeding, skin tears, and sacral ulcers. Pelvic US demonstrated thickened endometrial stripe. OB-gyn was consulted and did not suggest further work-up given that patient was unlikely to receive any further treatment. Patient's coumadin and heparin drip have been held while concern for active bleeding. Pt then had active GI bleeding and all anticoag has been held for recurrent GIB while on anticoagulation. . # GIB: Pt had bright red blood per ostomy and GI service was consulted. Pt found to have petecial lesion in residual colon, no active bleeding. EGD was negative. Attempted to restart anticoagulation however pt continued to have GIB when on heparin. On one occasion, a bleeding vessel was found at the stomal site and a stitch was placed by Surgery, with no recurrent bleeding from that vessel. Decision made with GI and cardiology to hold anticoagulation. . # Lactic acidosis: Pt was found to be hypotensive to the 50s-60s several times during her hospital course. An arterial line was placed for better monitoring and revealed a difference in cuff pressure of 30 points. Lactate was elevated to 10, which was attributed to Linezolid. This was discontinued and she was started on Daptomycin for VRE bacteremia. She should not receive Linezolid again and it was added to her allergy list. . # DM: Patient with very poorly controlled blood glucose at home. Patient's blood glucose was managed during this hospitalization with the help of [**Last Name (un) **]. She was placed on an insulin drip during her intermittent sepsis, as her sugars were difficult to control. Prior to discharge, her insulin regimen was transitioned to glargine at 7 untis qam and an agressive insulin sliding scale. . # Thrombocytopenia: Pt had progressive thrombocytopenia throughout admission. Hep ab neg. Felt to be 2/2 pts extensive medical illnesses and broad spectrum abx. No furhter intervention at this time. DIC labs normal. Pt did not require plt transfusion. Team was notified after patient was discharged that heparin dependent antibody sent on [**10-25**] had come back as positive. Case management was notified to let the patient's dialysis service and home nursing agency know that the patient should not receive heparin in any form. . # Wound care: Pt has large sacral decub and multiple skin tears [**2-21**] skin breakdown. Wound care followed throughout admission. . # Social: Multiple family meetings were held with medical, nursing, social work, case management, GI and renal consultants throughout this admission where the medical staff made it clear to the family that the patient is dying and that we would recommend comfort measures at this point. The health care proxy refused to convert care to comfort and wanted to continue with aggressive measures. Ethics and palliative care consulted during this admission and fmaily refused to talk to them. . # Code: already intubated, NO SHOCKS, no compressions. DNR. . Medications on Admission: * Flagyl 500mg tid (started 2 days ago) * Levaquin 250mg qod (lifelong for aortic annular abscess) * Prozac 40mg qd * Nephrocaps qd * Nexium 40mg qd * Amiodarone 400mg qd * Phospho-soda 5mL qd * Midodrine 5mg tid * Lactulose 5mL 4x per day * Coumadin 3mg qd * Reglan 5mg once a day * Lopressor 6.25mg [**Hospital1 **] (once a day on HD days) * Digoxin 0.0625 qod * Ativan 0.5mg qid * Zofran 4mg before HD * Glargine 70U [**Hospital1 **] * RISS * Albuterol inh * Atrovent inh * flovent inh Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 8-12 Puffs Inhalation Q6H (every 6 hours). Disp:*qs 1 month * Refills:*3* 2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 8-12 Puffs Inhalation Q6H (every 6 hours). Disp:*qs 1 month * Refills:*3* 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs 1 month * Refills:*2* 4. Fluoxetine 20 mg/5 mL Solution Sig: One (1) 10ml PO DAILY (Daily). Disp:*qs 1 month 10ml* Refills:*3* 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*15 Tablet(s)* Refills:*3* 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:*qs 1 month * Refills:*2* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp:*60 Capsule(s)* Refills:*2* 8. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*3* 9. Midodrine 5 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). Disp:*225 Tablet(s)* Refills:*2* 10. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). Disp:*qs 1 month * Refills:*2* 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for skin care. Disp:*qs 1 month * Refills:*2* 12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 13. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 14. PICC line care PICC line care per protocol 15. Tube feeding supplies 16. tracheostomy supplies 17. tracheostomy 7.0 extra-long Shiley trach 18. ventilator settings Assist Control tidal volume: 450cc respiratory rate: 22 FiO2: 60% PEEP: 8 19. Insulin Syringe Syringe Sig: One (1) syringe Miscell. four times a day as needed for insulin administration: Please administer insulin per sliding scale. Disp:*qs syringe* Refills:*6* 20. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO once a day. Disp:*qs mg* Refills:*6* 21. Lantus 100 unit/mL Solution Sig: Seven (7) units Subcutaneous QAM. Disp:*qs units* Refills:*6* 22. Daptomycin 500 mg Recon Soln Sig: Four [**Age over 90 1230**]y (450) mg Intravenous Q48H (every 48 hours) for 14 days. Disp:*3150 mg* Refills:*0* 23. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 2 days. Disp:*3000 mg* Refills:*0* 24. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000 (8000) units Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*qs units* Refills:*6* 25. Demerol 50 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 26. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for agitation. Disp:*120 Tablet(s)* Refills:*0* 27. Alcohol Pads Pads, Medicated Sig: One (1) pad Topical every 6-8 hours as needed for insulin administration. Disp:*120 pads* Refills:*6* 28. Lancets Misc Sig: One (1) lancet Miscell. every [**4-24**] hours as needed for glucose monitoring. Disp:*180 lancets* Refills:*6* 29. Insulin Needles (Disposable) Needle Sig: One (1) needle Miscell. every 4-6 hours as needed for insulin administration. Disp:*120 needles* Refills:*6* 30. Tube feeds Nepro Full strength + Beneprotein 25 gm/day; 40 ml/hr; Check residuals q4h, hold feeding for residual >=100 ml; Flush w/200 ml water q4h 31. Insulin Regular Human 100 unit/mL Solution Sig: As directed per sliding scale Injection four times a day: As per sliding scale. . Disp:*qs one month qs* Refills:*2* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: COPD s/p trach ventilator dependent diastolic CHF aortic annular abscess ESRD on hemodialysis GI Bleed paroxysmal atrial fibrillation enterococcus bacteremia sacral decubitus ulcer gangrenous toes 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: NPO with tube feeds only . Please continue your home ventilator at tidal volume 450/respiratory rate 22/FiO2 60%/ PEEP 8. Please continue tube feedings at home. Please call your primary care physician [**Last Name (NamePattern4) **] 911 with fevers, pain, difficulty with ventilation or other concerning symptoms. Followup Instructions: Please call your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 30375**] [**Telephone/Fax (1) 56651**] to schedule follow-up. Hemodialysis MWF Completed by:[**2132-10-28**]

[ "286.7", "995.92", "496", "285.21", "250.82", "403.91", "996.62", "707.09", "427.31", "560.9", "707.07", "285.1", "569.69", "682.6", "585.6", "V55.0", "482.0", "785.4", "518.83", "627.1", "V58.67", "041.85", "785.52", "707.04", "578.9", "438.20", "996.61", "287.4", "482.1", "428.32", "038.9", "E934.2", "707.03", "421.0", "730.17", "570" ]

icd9cm

[ [ [] ] ]

[ "33.24", "86.28", "39.95", "38.95", "99.07", "38.93", "99.15", "97.03", "99.05", "97.23", "44.43", "00.14", "86.05", "96.72", "88.42", "45.22", "45.13", "99.04", "88.47", "96.6" ]

icd9pcs

[ [ [] ] ]

21976, 22028

10512, 17126

370, 521

22269, 22277

3698, 10136

22758, 22965

2875, 2893

18353, 21953

22049, 22248

17839, 18330

22301, 22735

2908, 3679

309, 332

17138, 17813

549, 2003

10145, 10489

2025, 2596

2612, 2859

51,145

189,830

40015

Discharge summary

report

Admission Date: [**2136-11-15**] Discharge Date: [**2136-12-3**] Date of Birth: [**2051-9-16**] Sex: M Service: CARDIOTHORACIC Allergies: Amoxicillin / Morphine Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2136-11-20**] 1. Urgent coronary artery bypass graft x5; left internal mammary artery to left anterior descending artery; saphenous vein graft to diagonal ramus obtuse marginal and posterior descending arteries. 2. Endoscopic harvesting of the long saphenous vein. 3. Mitral valve repair(28mm [**Doctor Last Name 405**] annuloplasty band). [**2136-11-15**] left heart catheterization, coronary angiogram History of Present Illness: This 85 year old male with known three vessel disease has been medically managed for the last year due to prostate cancer. He presented to another hospital with a NSTEMI and was transferred to [**Hospital1 18**] for further mangament. He is now being referred to cardiac surgery for revascularization. Past Medical History: Coronary Artery Disease s/p coronary artery bypass graft x 5 Mitral regurgitation s/p mitral valve repair Myocardial infarction endsatge renal disease Gastroesophageal reflux Hypertension Hyperlipidemia Complete Heart Block- s/p pacemaker Prostate CA on hormone therapy Anemia peptic ulcer disease Left AV fistula s/p herniorrhaphy x2 s/p cholecystectomy Social History: Lives with:wife and daughter Contact:Daughter Phone #[**Telephone/Fax (1) 88015**] [**Name2 (NI) 27057**]tion:retired Cigarettes: Smoked no [] yes [x] Hx:quit in [**2091**], smoked for 1 year Other Tobacco use:denies ETOH: < 1 drink/week [x] [**2-13**] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: Father had MI at age 72. Mother had cerebral hemorrhage at 68. No history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: Pulse:61 Resp:20 O2 sat:98/RA B/P Right:110/53 Left: no BP d/t RV fistula Height:5'5" Weight:151 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: palp Left: palp DP Right: dop Left: dop PT [**Name (NI) 167**]: dop Left: dop Radial Right: palp Left: palp Carotid Bruit Right: - Left: - Pertinent Results: Cardiac Cath [**2136-11-15**]: 1. Selective coronary angiography in this right dominant system demonstrated severe native three vessel disease. The LMCA was non-obstructed. The LAD had severe mid-vessel disease up to 90% at D1. The D1 had an ostial 90% stenosis. The LCx had severe diffuse disease. The RI had a 90% ostial stenosis in a long vessel. The RCA was flush occluded at the ostium and fills by left to right collaterals. 2. Limited resting hemodynamics revealed a normal systemic arterial blood pressure with a central aortic pressure of 125/52 mmHg. . TTE [**2136-11-20**]: PRE BYPASS The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is severe regional left ventricular systolic dysfunction with akiesis of all distal segments and apex as well as severe hypokinesis of the mid portions of all inferior and lateral segments. The overall ejection fraction is in the 25% range. The right ventricular cavity is dilated with moderate global free wall hypokinesis and severe focal hypokinesis of the apical free wall. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are focal calcifications 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 moderately thickened. The left coronary cusp appears to be immobilized. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Due to co-existing aortic regurgitation, the pressure half-time estimate of mitral valve area may be an OVERestimation of true mitral valve area. Moderate to severe (3+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST-BYPASS The patient is receiving epinephrine, norepinephrine, and milrinone by infusion. The patient is AV paced. Right ventricular systolic function is improved but distal free wall hypokinesis remains. The left ventricle displays improved function of the moderate global hypokinesis but the focal abnormalities noted in the pre-bypass persist. The overall ejection fraction is in the range of 30%. There is a mitral valve annuloplasty ring in situ. It appears well seated. There is trace mitral regurgitation. There is no mitral stenosis. The thoracic aorta is intact after decannulation. . Carotid U/S [**2136-11-16**]: Right ICA <40% stenosis. Left ICA <40% stenosis. . [**2136-12-3**] 04:30AM BLOOD WBC-8.5 RBC-3.61* Hgb-9.8* Hct-29.3* MCV-81* MCH-27.1 MCHC-33.4 RDW-16.5* Plt Ct-211 [**2136-11-15**] 04:00PM BLOOD WBC-8.5 RBC-3.89* Hgb-9.1*# Hct-29.1*# MCV-75* MCH-23.4* MCHC-31.3 RDW-18.8* Plt Ct-95* [**2136-12-3**] 04:30AM BLOOD Glucose-93 UreaN-76* Creat-7.9*# Na-138 K-4.6 Cl-98 HCO3-27 AnGap-18 [**2136-11-20**] 04:58PM BLOOD UreaN-26* Creat-4.7* Na-138 K-4.3 Cl-106 HCO3-22 AnGap-14 [**2136-11-15**] 04:00PM BLOOD Glucose-87 UreaN-35* Creat-6.6* Na-136 K-5.2* Cl-98 HCO3-24 AnGap-19 [**2136-12-1**] 06:00PM BLOOD ALT-33 AST-36 LD(LDH)-212 AlkPhos-102 Amylase-188* TotBili-0.4 Brief Hospital Course: Mr. [**Known lastname 88012**] is an 85 year old male s/p NSTEMI transferred for cardiac catheterization. On [**2136-11-16**] he underwent cardiac cath which revealed severe three vessel coronary artery disease. Echo done on [**11-16**] revealed moderate mitral regurgitation. He was, therefore, referred for cardiac surgery. He received medical management over the next several days and clearance from oncology/hematology for his prostate cancer and nephrology for dialysis. On [**11-20**] he was brought to the Operating Room where he underwent coronary artery bypass graft x 5 and mitral valve repair. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. He weaned off Levophed, Milrinone and Epinephrine on POD 1 and remained hemodynamically stable with an adequate cardiac output. His permanent pacemaker was interrogated on POD 1 and found to be functioning normally. His temporary pacing wires were then removed. CTs remained in place for several days due to the serous output, but were removed without incident on POD 5. He remained on Vasopressin for hypotension for several days post op and was eventually weaned off completely on POD 6. On POD 6 he was transferred to the floor in stable condition. He was followed by the nephrology service and dialyzed for several successive days postoperatively and then on his regular schedule via his left AV fistula. He had poor oral intake and supplements were started as well as calorie counts.low dose beta blocker was subsequently added. He developed abdominal cramping and loose stool which resolved. He remained afebrile with normal white blood cell count and CDiff toxin was negative. He was evaluated by Physical Therapy for strength and mobility. He was transferred to [**Hospital 38**] Rehab on [**2136-12-3**] in stable condition. All follow up appointments were arranged. Medications on Admission: Imdur 15mg daily Simvastatin 20mg daily Eryhthromycin opthalmic ointment [**Hospital1 **] B vitamin comlex with vitamin C daily Folic Acid 1mg daily ASA 81mg daily Metoprolol Succinate 25mg daily Sevelamer 1600mg PO TID Protonix 40mg daily Xanax 0.5mg daily NTG sublingual PRN Ranolazine 1000mg [**Hospital1 **] (started in past week) Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal TID PRN () as needed for hemorrhoid pain. 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO three times a day: hold for SBP<90. 10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 12. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units,SQ Injection TID (3 times a day): Until fully ambulatory. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Coronary Artery Disease s/p coronary artery bypass graft x 5 Mitral regurgitation s/p mitral valve repair Myocardial infarction end satge renal failure gastroesophageal reflux Hypertension Hyperlipidemia Complete Heart Block s/p pacemaker Prostate CA on hormone therapy Anemia peptic ulcer disease Congestive heart failure L inguinal hernia Left AV fistula s/p herniorrhaphy x2 s/p cholecystectomy Discharge Condition: Alert and oriented x3 nonfocal Deconditioned Incisional pain managed with APAP Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Trace edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2136-12-25**] at 1:45PM Cardiologist: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 8725**]on [**12-19**] at 11:30am Hematology/Oncology: Dr. [**Last Name (STitle) **] on [**2136-12-6**] at 8:00 Please call to schedule appointments with your Primary Care Dr. [**Last Name (un) **] in [**4-10**] weeks ([**Telephone/Fax (1) 8725**]) **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2136-12-3**]

[ "585.6", "272.4", "424.0", "403.91", "285.21", "530.81", "276.7", "285.1", "V45.11", "428.22", "V45.01", "458.29", "272.0", "780.1", "185", "414.01", "564.00", "428.0", "410.71" ]

icd9cm

[ [ [] ] ]

[ "39.95", "37.22", "88.56", "36.15", "39.61", "35.12", "36.14" ]

icd9pcs

[ [ [] ] ]

9573, 9670

6012, 7949

300, 709

10112, 10314

2619, 5989

11154, 11942

1765, 1908

8334, 9550

9691, 10091

7975, 8311

10338, 11130

1923, 2600

250, 262

737, 1040

1062, 1418

1434, 1749

67,005

115,139

55170

Discharge summary

report

Admission Date: [**2187-7-21**] Discharge Date: [**2187-7-23**] Date of Birth: [**2140-7-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1115**] Chief Complaint: Near drowning. Major Surgical or Invasive Procedure: Intubation EGD History of Present Illness: 47yo M with PMHx of alcochol dependence who presented from OSH after being found face down in pool where at the OSH, the patient was intubated, transferred to [**Hospital1 18**] for further management and concern for ARDS. Patient was found face down in pool by friends. [**Name (NI) **] family report, the patient was done maybe a minute. He was pulled out of the pool by other people. Patient's family is unsure of whether the patient had been drinking that night. EMS was called and per family report chest compressions were started. During chest compressions, the family reports that blood was noted to be coming from the patient's mouth. EMS attempted intubation in the field, but was unsucessful. The patient was brought to OSH, where the patient was intubed. He initially had a pressor requirement with Levophed which was discontinued as the OSH. He was noted to have EtOH intoxication with level of 400 and urine tox screen returned positive for benzodiazepines. The patient was transferred to the ICU for further management. Head CT, Chest CT, abdominal CT were all negative at OSH. He was started onceftriaxone and azithromycin. Patient was transferred to [**Hospital1 18**] out of concern for ARDS. On arrival to the MICU, patient is sedated, able to follow commands. Review of systems: Unable to obtain [**2-22**] intubation. Past Medical History: History of excessive EtOH abuse, but reportedly none recently. Multiple prior DUI's in the past. Social History: Smokes 2ppd. Patient's family denies recent EtOH consumption, but reports that in the past, the patient has had difficulty to heavy EtOH consumption. Family denies illicit drug use. Family History: Family history anuerysms (brain and thoracic). Physical Exam: Discharge exam: VS: T 97.6 BP 136/78 P 70 R 18 O2 94%RA General: NAD, AAOx3 HEENT: EOMI, PERRL, Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: mild wheezing in upper lung fields, crackles LLQ Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: [**2187-7-21**] 01:15AM BLOOD WBC-13.6* RBC-4.46* Hgb-12.9* Hct-38.8* MCV-87 MCH-29.0 MCHC-33.4 RDW-13.2 Plt Ct-181 [**2187-7-21**] 01:15AM BLOOD PT-12.0 PTT-27.3 INR(PT)-1.1 [**2187-7-21**] 01:15AM BLOOD Glucose-109* UreaN-18 Creat-0.9 Na-147* K-3.6 Cl-112* HCO3-27 AnGap-12 [**2187-7-21**] 01:15AM BLOOD ALT-53* AST-26 LD(LDH)-221 CK(CPK)-339* AlkPhos-47 TotBili-0.4 [**2187-7-21**] 01:15AM BLOOD Albumin-3.6 Calcium-8.0* Phos-2.0* Mg-2.0 [**2187-7-21**] 01:37AM BLOOD Type-ART Temp-38.1 Rates-18/ Tidal V-450 PEEP-10 FiO2-100 pO2-301* pCO2-54* pH-7.36 calTCO2-32* Base XS-3 AADO2-353 REQ O2-64 Intubat-INTUBATED [**2187-7-21**] 01:37AM BLOOD Lactate-1.3 [**2187-7-21**] 04:29AM BLOOD freeCa-1.11* Discharge labs: [**2187-7-23**] 07:16AM BLOOD WBC-7.9 RBC-4.49* Hgb-13.0* Hct-38.1* MCV-85 MCH-28.9 MCHC-34.1 RDW-12.1 Plt Ct-214 [**2187-7-23**] 07:16AM BLOOD Glucose-97 UreaN-18 Creat-0.8 Na-143 K-3.7 Cl-107 HCO3-27 AnGap-13 [**2187-7-22**] 02:55AM BLOOD ALT-38 AST-19 CK(CPK)-166 AlkPhos-47 TotBili-1.0 [**2187-7-23**] 07:16AM BLOOD Calcium-8.7 Phos-3.6# Mg-2.0 Micro: [**2187-7-21**] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY TEST-Negative [**2187-7-21**] MRSA SCREEN MRSA SCREEN-Negative [**2187-7-21**] URINE URINE CULTURE-Negative [**2187-7-21**] BLOOD CULTURE Blood Culture, Routine-No growth at the time of discharge [**2187-7-21**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-Commensal respiratory flora Imaging: [**2187-7-21**] CXR: 1. Endotracheal tube has its tip 5 cm above the carina. There is a nasogastric tube seen coursing below the diaphragm with the tip not identified. There is a 1.6-cm nodule in the right lung base, which, given its density, would favor a benign process such as a granuloma. Comparison to remote chest imaging to assess for stability would be advised. In the absence of these studies, followup imaging with chest plain film in three months versus dedicated chest CT should be considered. Otherwise, the lungs appear grossly clear. No pleural effusions or pneumothoraces. No evidence of pulmonary edema. Cardiac and mediastinal contours are within normal limits. No evidence of focal airspace consolidation to suggest pneumonia. [**2187-7-22**] CXR: Interval extubation and removal of nasogastric tube. New poorly defined opacities have developed at the left lung base, and may be due to atelectasis or aspiration considering recent extubation. Lungs are otherwise clear except for a right lower lobe calcified granuloma. [**2187-7-23**] CT chest w/o contrast: TECHNIQUE: Volumetric, multidetector CT of the chest was performed without intravenous or oral contrast. Images are presented for display in the axial plane at 5-mm and 1.25-mm collimation. A series of multiplanar reformation images were also submitted for review. FINDINGS: A benign diffusely calcified granuloma is present laterally in the right lung base measuring about 1 cm in diameter and corresponding to the recent chest x-ray finding. Within the right infrahilar region, a cluster of calcified peribronchial lymph nodes are present, and results in some extrinsic compression of the lateral segment bronchus. Additional noncalcified nodes are present in this region as well. Multiple peribronchiolar nodules are present involving the left lung to a greater degree than the right, and accompanied by mild bronchial wall thickening. Many of the opacities have a tree-in-[**Male First Name (un) 239**] configuration, particularly within the left lower lobe. Additional involvement is seen within the left upper lobe, right lower lobe, and right upper lobe. Small, dependent pleural effusions are present bilaterally, right greater than left, with adjacent areas of dependent atelectasis. Heart size is normal. Focal coronary artery calcifications are present. No pericardial effusion. Small hiatal hernia incidentally noted. Exam was not specifically tailored to evaluate the subdiaphragmatic region, but no concerning abnormalities are identified in this region on this very limited assessment. No suspicious lytic or blastic skeletal lesions. 2.3 cm diameter low-attenuation well-circumscribed subcutaneous lesion in the posterior chest wall to the right of midline is likely a sebaceous cyst. IMPRESSION: 1. Benign calcified granuloma in right lower lobe requires no further imaging followup. Calcified and noncalcified right infrahilar lymph nodes with extrinsic compression of lateral segment bronchus, likely placing patient at risk for broncholithiasis. Recommend monitoring for symptoms of this condition such as hemoptysis, cough, lithoptysis and recurrent infections. 2. Multifocal peribronchiolar nodules accompanied by bronchial wall thickening, most marked in the left lower lobe. Findings are consistent with either bronchiolar infection or aspiration. 3. Small dependent pleural effusions, right greater than left. [**2187-7-22**] EGD: Ulcers in the antrum and stomach body Abnormal mucosa in the antrum Erythema and friability in the duodenal bulb compatible with duodenitis Otherwise normal EGD to third part of the duodenum Brief Hospital Course: 47yo M with PMHx of alcochol dependence who presented from OSH after being found face down in pool where at the OSH, the patient was intubated, transferred to [**Hospital1 18**] for further management and concern for ARDS, successfully extubated and treated for pneumonia. # Respiratory failure/Pneumonia: Patient intubated upon arrival to the OSH after being found face down in pool for unknown amount of time. Patient was extubated on day 2 of hospitalization. Initially broadly covered with Vanc/CTX/Azithromycin. CXR and CT chest concerning for aspiration PNA. Leukocytosis to 18 at OSH. 7.9 by discharge. Patient with productive cough after extubation, but sputum culture only showed respiratory flora. Patient also does have 60+ year smoking history. O2 sat on discharge was mid 90s on room air. Patient discharged on cefpodoxime (last day [**7-27**]) and azithromycin (last day [**7-25**]) for a total of 7 day course. # History of alcohol abuse: Patient's endorses remote EtOH abuse, but reports this was an isolated incidence. Social worker provided support and education. Patient initially covered with CIWA, but did not have evidence of EtOH withdrawal. # Bloody NGT output: Patient on pantoprazole at OSH 40mg IV daily. EGD showed gastric ulcers without evidence of active bleed. No hematemesis and Hct stable since extubation. DC'd home on PO pantoprazole. Need PCP to help arrange repeat EGD in [**6-29**] weeks. # Lung nodule: Granulomatous lung nodule seen on CXR. CT chest showed benign calcified nodule that require no additional imaging followup. # Transitional issues: - code status: full - follow up: with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**State 108**] - new medications: Cefpodoxime, Azithromycin, pantoprazole - pending studies: blood culture no growth at the time of discharge - follow up issues: needs repeat EGD in [**6-29**] weeks Medications on Admission: Aleeve prn pain Discharge Medications: 1. Azithromycin 250 mg PO Q24H Duration: 3 Days day 1= [**7-21**] RX *azithromycin 250 mg 2 Tablet(s) by mouth daily Disp #*2 Tablet Refills:*0 2. Pantoprazole 40 mg PO DAILY RX *pantoprazole 40 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 3. Cefpodoxime Proxetil 200 mg PO Q12H RX *cefpodoxime 200 mg 1 Tablet(s) by mouth every twelve (12) hours Disp #*8 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Aspiration pneumonia Drowning Alcohol Abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 112528**], It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted after you were found in a pool after drinking alcohol. You were initially intubated (on a breathing machine) to help you breath, and you were treated for pneumonia with antibiotics. Please continue antibiotics as listed below. Please abstain from alcohol to prevent this from occuring in the future. We also found that you have stomach ulcers that are not actively bleeding. You should avoid medications such as Advil, Aleeve, naproxen, ibuprofen, and only take tylenol as needed for pain. Please take pantoprazole for this as directed. You will need a follow up EGD (endoscopy) in [**6-29**] weeks. Please arrange this with Dr. [**Last Name (STitle) **]. We made the following changes to your medications: STARTED Cefpodoxime (last day [**2187-7-27**]) STARTED Azithromycin (last day [**2187-7-25**]) STARTED Pantoprazole daily STOPPED Aleeve Followup Instructions: Please call Dr.[**Name (NI) 97678**] office at [**Telephone/Fax (1) 112529**] to schedule a follow up appointment within a week of your discharge from the hospital. Completed by:[**2187-7-23**]

[ "994.1", "553.3", "E910.8", "518.81", "515", "511.9", "305.91", "531.41", "535.60", "414.01", "305.1", "507.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "45.13" ]

icd9pcs

[ [ [] ] ]

10102, 10108

7709, 9295

319, 336

10196, 10196

2579, 2579

11343, 11539

2041, 2089

9690, 10079

10129, 10175

9650, 9667

10347, 11153

3312, 7686

2104, 2104

2120, 2560

9351, 9624

11182, 11320

1664, 1705

265, 281

364, 1645

2595, 3296

10211, 10323

9318, 9340

1727, 1826

1842, 2025

6,886

145,695

25323

Discharge summary

report

Admission Date: [**2162-7-20**] Discharge Date: [**2162-8-20**] Date of Birth: [**2111-4-13**] Sex: M Service: SURGERY Allergies: Codeine Attending:[**First Name3 (LF) 5880**] Chief Complaint: 51 year old male status post fall from roof 30Ft Major Surgical or Invasive Procedure: 1. L nondisplaced rib fx 2. L PTX s/p CT (since DC'd) 3. R Radius fx s/p ORIF [**8-2**] 4. L2 burst fx, s/p fusion [**7-22**] 5. S1-3 fx, s/p pinning [**7-29**] 6. L calcaneal fx s/p ORIF [**8-2**] 7. IVC placed [**7-23**] History of Present Illness: 51 year old male that falls from a 30 Fl roof with multiple fractures. Past Medical History: Diabetes Mellitus, Miocardial Infarction status post stent x3, seizure with hyperglycemia. Social History: Patient has a daughter and two sons. Lives alone. Cocaine use, stoped [**2159**]. Family History: Non contributory. Physical Exam: On admission, the patient was intubated, chemically sedated. HEENT: Oropharynx clear. Neck: Cervical collar. Chest: Chest tube on the left side. Cor: Tachycardic. Abdomen: soft, right flank abrasion. Rectal Exam: slightly decreased tone, guaiac negative. Extremeties: right upper extremety was splinted. Abrasion over the left knee. Right ankle bruised and swollen. Pertinent Results: [**2162-7-20**] 09:00PM HGB-11.0* calcHCT-33 [**2162-7-20**] 07:45PM PO2-489* PCO2-34* PH-7.40 TOTAL CO2-22 BASE XS--2 [**2162-7-20**] 07:34PM GLUCOSE-224* LACTATE-6.1* NA+-136 K+-4.2 CL--106 TCO2-21 [**2162-7-20**] 07:25PM UREA N-17 CREAT-0.6 [**2162-7-20**] 07:25PM WBC-15.3* RBC-3.54* HGB-10.5* HCT-29.6* MCV-84 MCH-29.6 MCHC-35.5* RDW-13.2 [**2162-7-20**] 07:25PM PLT COUNT-135* [**2162-7-20**] 07:25PM PT-14.4* PTT-28.4 INR(PT)-1.4 [**2162-7-20**] 07:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.036* [**2162-7-20**] 07:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: Patient admited to Trauma Service with multiple fractures. PROCEDURE PERFORMED: 1. Open reduction internal fixation right distal radius fracture. 2. Open reduction internal fixation right calcaneus fracture. 3. Open reduction and internal fixation of right sacral fracture with sacroiliac screw fixation. 4. Laminectomy of L2. 5. Laminotomy of L1 and L3. 6. Fusion of L1 to L3. 7. Segmental instrumentation of L1 to L3. 8. Right iliac crest autograft. Medications on Admission: Insulin Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 3. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 4. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 5. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day): Continue for another two more weeks. 6. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Insulin Glargine 100 unit/mL Solution Sig: One (1) Subcutaneous at bedtime: 36 Units. 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 10. Oxycodone-Acetaminophen 2.5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for for breakthrough pain. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: 51 Male status post fall from roof 30ft. Injuries: 1. L rib fx 2. L PTX 3. R Radius fx 4. L2 fx 5. S1-3 fx 6. L calcaneal fx Discharge Condition: Oriented, Hemodynamically stable, no major complains Discharge Instructions: 1. Transfer to Rehabilitation 2. Follow up afer one month of discharge with Spine Service (Lumbar Fracture) Dr [**Last Name (STitle) 363**] (call to arrange an appointment to [**Telephone/Fax (1) 3573**]) 3. Follow up afer one month of discharge with Orthopedics Trauma Service (Pelvis, Calcaneal and wrist Fracture) Dr [**Last Name (STitle) 1005**] (call to arrange an appointment to [**Telephone/Fax (1) 4845**]) Followup Instructions: Orthopedic follow up.

[ "414.01", "805.4", "860.0", "V45.82", "882.2", "E882", "805.6", "868.04", "813.42", "250.00", "412", "780.39", "825.25", "807.01" ]

icd9cm

[ [ [] ] ]

[ "79.37", "81.62", "99.04", "81.08", "34.04", "38.93", "38.7", "77.89", "03.09", "96.71", "03.53", "79.32", "96.04" ]

icd9pcs

[ [ [] ] ]

3487, 3560

1990, 2448

316, 540

3729, 3783

1291, 1967

4246, 4271

871, 890

2506, 3464

3581, 3708

2474, 2483

3807, 4223

905, 1272

228, 278

568, 641

663, 755

771, 855

4,290

155,880

23314

Discharge summary

report

Admission Date: [**2117-8-4**] Discharge Date: [**2117-8-20**] Date of Birth: [**2086-8-26**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5167**] Chief Complaint: seizure Major Surgical or Invasive Procedure: [**First Name3 (LF) 282**] tube placement History of Present Illness: 30 y/o F with complicated PMH of cerebral palsy, seizure disorder, myoclonus, asthma and hypothyroidism who presents with a new seizure and fever. She had a reported 10 generalized tonic-clonic seizures, a fever to 104. In the ambulance, 2mg of ativan broke her seizure activity. Unclear history as to whether or not she was having diarrhea, constipation, abdominal pain, nausea, vomiting, or any other complaints. She was intubated and sedated at this time. . In the ED, initial vitals were T 104.3, BP 122/77, P 142, R 21 and 99% on RA. She received Fentanyl and midazolam for intubation. She had a CXR that showed proper positioning of her ET tube. She received vancomycin 1 gm x1, cefepime 1 gm x1 and flagyl 500 mg x1. She was initially ordered for IV keppra, but she did not receive it in the ED. She was started on a norepinephrine drip for hypotension. She had a CT head which did not show any intracranial pathology. She had a CT abdomen that showed pan-colitis. . On the floor, she is intubated and sedated; she is unresponsive to painful stimuli. We are decreasing her sedation. She is ventilating well on AC. Past Medical History: Spastic Cerebral Palsy Seizure Disorder Eating Disorder Anxiety Disorder Hx of Psychosis with hallucinations Hx of traumatic brain injury Possible metabolic/mitochondrial disorder Bulbar Dysfunction with drooling (contributing to med non-compliance) Speech and Swallow Limitation Asthma Myoclonus Hx of ileus Hypothyroidism Social History: Lives with a [**Doctor Last Name **] parent. She spends time at a day program and the rest of the time at her adult [**Doctor Last Name **] care program at [**Doctor Last Name **] [**Hospital1 107**]. She does not smoke, drink, or use drugs. She is largely wheelchair bound by report and her baseline is unknown. Family History: presumptive seizures in cousins (myoclonic) *per prior DC summ Physical Exam: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2117-8-3**] 09:57PM FIBRINOGE-372 [**2117-8-3**] 09:57PM PLT COUNT-342 [**2117-8-3**] 09:57PM PT-13.0 PTT-26.3 INR(PT)-1.1 [**2117-8-3**] 09:57PM WBC-15.8* RBC-3.65* HGB-11.1* HCT-34.8* MCV-95 MCH-30.3 MCHC-31.8 RDW-13.4 [**2117-8-3**] 09:57PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2117-8-3**] 09:57PM LIPASE-48 [**2117-8-3**] 09:57PM estGFR-Using this [**2117-8-3**] 09:57PM UREA N-23* CREAT-0.7 [**2117-8-3**] 09:58PM freeCa-1.24 [**2117-8-3**] 09:58PM GLUCOSE-133* LACTATE-8.4* NA+-143 K+-4.7 CL--106 TCO2-16* [**2117-8-3**] 09:58PM PH-7.14* COMMENTS-GREEN TOP [**2117-8-3**] 10:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-<1 [**2117-8-3**] 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2117-8-3**] 10:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2117-8-4**] 12:48AM PLT COUNT-8*# [**2117-8-4**] 12:48AM NEUTS-72.8* LYMPHS-23.5 MONOS-2.9 EOS-0.3 BASOS-0.5 Brief Hospital Course: ICU COURSE: # Seizure: Patient reported to have seizure. Likely secondary to the fever from the presumed colitis or other infectious etiology, given the fever. Head CT was performed and did not show any anatomical changes. LP was deferred in the ED. She has an underlying seizure disorder (possibly from mitochrondrial dysfunction per prior notes) which has not been well controlled. Neuro saw her in the ED and recommended standing ativan after extubation for seizure prophylaxis. Her home seizure medications were continued as patient was transferred to the ICU. EEG monitoring was also started. A workup for possible mitochondrial disorders explaining her seizure history was also started. According to recs by Neurology, CSF lactate dehydrogenase and pyruvate were ordered. A muscle biopsy by Neurosurg was also planned. Levels of Valproic Acid, lamotrigine, and levitiracepam were also taken. # Hypoxic Respiratory Distress: Patient thought to have aspirated in the setting of her seizures. She had depressed mental status while post-ictal. Intubation was performed for airway protection. There was evidence of aspiration on CXR. She was started on continuous mechanical ventilation to await better seizure control. Antibiotic coverage for aspiration pneumonia was started on ceftriaxone and clindamycin. Patient's respiratory distress improved, and the ventilatory settings were successfuly decreased. The patient was ready for extubation by the end of ICU stay, but the ventilator was kept on for imminent muscle biopsy. . # Colitis: There was unclear symptomatic history of diarrhea/abd pain upon admission. She has had frequent hospitalizations and is at risk of c.diff, but the patient did not have marked leukocytosis upon admission. An initial CT of the abdomen was read as having pancolitis. The patient was started PO vanc (avoiding cipro/flagyl because they lower seizure threshold). Stool studies were sent off for C diff. The final read of the CT, however, indicated likely gastroenteritis rather than pancolitis. PO vancomycin was stopped before discharge from ICU. # Hypotension: The patient arrived to the unit with low blood pressures. This was thought to be secondary to septic shock from colitis vs. hypovolemia from diarrhea. Also possible were insensible losses vs. medication induced hypotension from fent/versed gtts. The patient was started on levophed and aggressive fluid resuscitation (CVP>10, UOP>30). The patient did not require pressure support by the second day in the ICU and remained normotensive. Upon arrival to [**Hospital Ward Name 121**] 11 Kathyanne was stable. She became more awake and alert as time went on. The decision was made that a PEB tube would be the best for Kathyanne due to her progressive problems swallowing. Upon discussion with psychiatry it was found that the patient was competant to make the decision to have a [**Hospital Ward Name 282**] placed. The procedure was also discussed with the patients [**Doctor Last Name **] mother. The patient decided that a [**Doctor Last Name 282**] would be best. The patient was consented by GI. The [**Doctor Last Name **] mother was also noted to sign a health care proxy. The [**Name2 (NI) 282**] was placed on [**2117-8-18**]. That evening the patient had low blood pressure that responded to IV fluids. On [**2117-8-19**] the patient was noted to be stable. Her pain was well controlled. Feeds were started. Medications switched to PO/NG. At that point is was decided that the patient would go home with a visiting nurse to care for the [**Date Range 282**] tube. On the day of discharge the patient's guardian received [**Name2 (NI) 282**] teaching. [**Known firstname 59857**] was doing well and cleared to go home. Medications on Admission: Lamotrigine 200 mg qAM Lamotrigine 50 mg qNoon Lamotrigine 200 mg qPM Olanzapine 5 mg qHS Keppra 1500 mg (in 100mg/mL solution - 15mL) [**Hospital1 **] Divalproex 500 mg sprinkles TID Vitamin D2 50,000 units qweek Discharge Medications: 1. Levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Divalproex 125 mg Capsule, Sprinkle [**Hospital1 **]: Four (4) Capsule, Sprinkle PO TID (3 times a day). Disp:*360 Capsule, Sprinkle(s)* Refills:*2* 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [**Hospital1 **]: One (1) Capsule PO 1X/WEEK (MO). 4. Scopolamine Base 1.5 mg Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours) as needed for secretions. 5. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO DAILY (Daily). 7. Lamotrigine 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) PO BID (2 times a day). 9. Keppra 500 mg Tablet [**Hospital1 **]: Four (4) Tablet PO twice a day. Disp:*240 Tablet(s)* Refills:*2* 10. Lamotrigine 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*2* 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Spastic CP Myoclonic Epilepsy Mitochondrial disorder Discharge Condition: Stable Discharge Instructions: Please follow up with Dr. [**Last Name (STitle) **] in 1 month as discussed. Please continue current anti-epileptic regimine. Continued care of the [**Last Name (STitle) 282**] tube. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in 1 month as discussed. Please continue current anti-epileptic regimine. Continued care of the [**Last Name (STitle) 282**] tube. Completed by:[**2117-8-20**]

[ "493.90", "244.9", "038.9", "277.9", "E929.0", "300.00", "276.2", "907.0", "319", "785.52", "345.10", "518.81", "240.9", "995.92", "787.20", "343.9", "345.3", "331.9", "V85.0", "277.87", "293.0", "507.0", "285.9", "276.7", "558.9" ]

icd9cm

[ [ [] ] ]

[ "03.31", "96.04", "83.21", "96.71", "96.6", "43.11", "38.93" ]

icd9pcs

[ [ [] ] ]

9245, 9302

3867, 7635

323, 366

9398, 9406

2804, 3844

9637, 9850

2211, 2275

7900, 9222

9323, 9377

7661, 7877

9430, 9614

2290, 2785

276, 285

394, 1517

1539, 1865

1881, 2195

2,921

193,656

50980

Discharge summary

report

Admission Date: [**2144-7-11**] Discharge Date: [**2144-7-15**] Date of Birth: [**2098-9-22**] Sex: F Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Dialysis History of Present Illness: Ms. [**Known lastname 19407**] is a 45 year-old woman with poorly-controlled hypertension, end-stage renal disease on hemodialysis and schizophrenia, who presented to the emergency department after having hypertension and chest pain during dialysis just prior to completion of dialysis. She reported that she occasionally gets chest pain during dialysis. The pain was sharp, bilateral with associated shortness of breath. On further review of the records, it was apparent that she had missed 2 dialysis sessions prior to presentation. Upon arrival to the ED, Ms. [**Known lastname 19407**] had hypertension to 212/123 HR 88, t 97.8, RR 18, 02 99% . She was started given PO and IV labetalol and started on a labetalol drip. Initial cardiac enzymes were negative. . Upon arrival to the MICU, she had [**4-9**], chest pain that was sharp and located across her chest. She also had mild nausea but no vomiting. She had a headache and dizziness but denies scotomata. Additionally she has no shortness of breath, fever, or chills. She also denied any of her schizophrenic symptoms including no auditory, visual or tactile hallucinations. Past Medical History: 1. Chronic kidney disease stage V on HD 2. Hypertension (per records: Secondary w/u negative including normal TSH, cortisol, and [**Male First Name (un) 2083**] levels, MRI/A abd negative for adrenal masses/no evidence of RAS.) 3. Schizophrenia - gets IM injections 4. Anemia of chronic kidney disease 5. Symmetric LVH, Mild MR - Eccentric Jet. 6. MSSA bacteremia due to dialysis catheter infxn Social History: She smoked approximately [**4-5**] cigarettes/day for one year and quit recently. She denies alcohol or drug use. Family History: Mother, 65, has refractory hypertension and glaucoma. Maternal relatives also have hypertension. No known family history of psychiatric illness (depression, bipolar, schizophrenia). No reported family history of diabetes, renal disease, rheumatologic disease, stroke, or sudden cardiac death. Physical Exam: T97.4 HR 82 BP 172/103 RR 21 02 100 3L GEN: Alert and oriented, sleepy HEENT: OP clear, MMM, EOMI, PERRLA Neck: increase submandibular glands, otherwise no lymphadenopathy, elevated JVP CV: RRR, 3/6 systolic murmur at LLSB-->RUSB Pulm: CTA b Abd: soft, nt, nd, +bs Ext: no edema Neuro: moves all extremities, CN II-XII intact Psych: no hallucinations Pertinent Results: [**2144-7-11**] 08:55PM BLOOD WBC-5.5 RBC-3.53*# Hgb-11.6*# Hct-34.3* MCV-97 MCH-32.7* MCHC-33.8 RDW-15.5 Plt Ct-266 [**2144-7-11**] 08:55PM BLOOD PT-13.2* PTT-64.8* INR(PT)-1.2* [**2144-7-11**] 08:55PM BLOOD Glucose-86 UreaN-25* Creat-5.7*# Na-143 K-3.6 Cl-97 HCO3-33* AnGap-17 [**2144-7-11**] 08:55PM BLOOD CK(CPK)-150* [**2144-7-11**] 08:55PM BLOOD Calcium-8.9 Phos-4.4# Mg-1.8 [**2144-7-11**] 08:55PM BLOOD CK-MB-5 [**2144-7-11**] 08:55PM BLOOD cTropnT-0.04* [**2144-7-12**] 03:20AM BLOOD CK-MB-4 cTropnT-0.04* [**2144-7-11**] 08:55PM BLOOD K-3.6 . [**2144-7-15**] ECG- Sinus rhythm. Left atrial abnormality. Voltage for left ventricular hypertrophy. Non-specific T wave inversions in leads aVL and V5-V6. Compared to the previous tracing of [**2144-7-15**] all abnormalities were previously present except variant RSR' pattern in leads VI-V2. . Chest X-ray [**2144-7-11**]- Cardiomegaly, small bilateral pleural effusions. No evidence of pneumonia or CHF. . Brief Hospital Course: Ms. [**Known lastname 19407**] is a 45 year-old woman with end-stage renal disease on hemodialysis and poorly controlled hypertension who presents with hypertensive urgency. . 1) Hypertension: Patient with baseline poorly controlled hypertension that presented with uncontrolled BPs in 210. Was treated with labetalol drip briefly that was quickly weaned in the MICU. She was then started on her home meds and had improved blood pressures. She was transferred to the floor and her blood pressure was well-controlled after transition to her full home regimen of anti-hypertensives. . 2) Chest pain: ECG did not demonstrate ischemic changes. Three sets of cardiac enzymes were negative. She was started on aspirin and her blood pressure controlled with labetalol. Repeat ECG revealed no new changes. She was discharged home on aspirin 81mg PO daily. . 3) ESRD: Ms. [**Known lastname 19407**] had missed several dialysis sessions prior to presentation because she was not feeling well. She was started on hemodialysis on admission and continued on her regular schedule. She was continued on sevelamer per her outpatient regimen. . 4) Dialysis Fistula- Ms. [**Known lastname 19407**] has a left antecubital AV fistula created in [**2143-10-2**]. Ms. [**Known lastname 19407**] was seen by Dr. [**Last Name (STitle) 816**] and [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**] of transplant surgery who recommended an outpatient fistulogram for further evaluation and treatment of her fistula which has failed to mature. . 4) Schizophrenia: Ms. [**Known lastname 19407**] is scheduled to receive risperidone injections every two weeks at the [**Hospital1 **]. However, her last prior injection had been in [**Month (only) **]. Psychiatry was consulted and and recommended administration of her usual 12.5mg IM. This was administered and she was scheduled for outpatient follow-up with her therapist, psychiatrist and Risperidone injection clinic at the [**Hospital1 **]. Also, it was verified that Ms. [**Known lastname 105924**] aunt is her active legal guardian. . 5) Social Work Consult-Social work was consulted and spoke with outpatient case manager and social worker with the goal of increasing compliance with her dialysis regimen. A plan was made to coordinate increased services for Ms. [**Known lastname 19407**] at home and exploration of group home options. She was discharged home with contact information for social work follow-up. Medications on Admission: Labetalol 600mg PO BID lisinopril 40mg PO daily Risperdal (IM injections that she gets q 2 weeks, she reports "being due") Terazosin 6mg PO BID Amlodipine 5mg PO daily Sevelamer 800mg PO TID Risperdal Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Terazosin 2 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). Disp:*180 Capsule(s)* Refills:*2* 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*qs Tablet(s)* Refills:*2* 6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*qs Tablet(s)* Refills:*2* 7. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Malignant Hypertension, End-Stage Renal Disease on Hemodialysis Secondary Diagnosis- Schizophrenia Discharge Condition: Stable Discharge Instructions: You were admitted after having chest pain following dialysis. An EKG was done as well as lab tests and did not show any sign of a heart attack. You had missed two dialysis appointments prior to coming to the hospital. When you were admitted to the hospital, your blood pressure was very elevated (up to 200/100). You were admitted to the intensive care unit and started on intravenous blood pressure medications. Once your blood pressure was better controlled you were transferred to the general medical floor and were given your home blood pressure medications. You were also given your long-acting Risperidone injection on [**2144-7-14**]. . During this hospitalization, you had two sessions of dialysis and should continue on your regular home dialysis regimen. Your next appointment is tomorrow, [**2144-7-16**]. It is very important that you attend all dialysis appointments. . It is very important that you keep the site of your dialysis catheter clean and dry. You should not remove the dressing. If the catheter becomes dirty, a serious infection may occur. You were seen by [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**] and Dr. [**Last Name (STitle) 816**] who are arranging appointments for further evaluation of your fistula. [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 15170**] will talk about this with you at your dialysis appointment. . Also, it is very important that you take your blood pressure medications as prescribed. Very high blood pressure can cause damage to your brain and heart as well as other organs in your body. . Please call your doctor or return to the hospital immediately if you experience chest pain, shortness of breath, fevers, chills, nausea, vomiting, abdominal pain, severe headache or any other symptoms that concern you. . Please attend all medical appointments listed below. Followup Instructions: You have an appointment with your primary care provider [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] on [**2144-7-23**] at 2:00 pm Phone:[**Telephone/Fax (1) 250**] . You have an appointment with your therapist [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) **] at the [**Hospital1 **] on Wednesday [**2144-7-29**] at 10:00 AM . You have an appointment with the [**Hospital 105928**] Clinic with [**Doctor Last Name 501**] at the [**Hospital1 **] on Wednesday, [**8-29**] at 11 AM. . You have an appointment with your psychiatrist Dr. [**Last Name (STitle) 105929**] on Wednesday [**2144-8-12**] at 2:00pm. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "295.90", "585.6", "V45.1", "403.01", "285.29", "413.9" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

7144, 7150

3694, 6175

279, 290

7313, 7322

2707, 3671

9264, 10072

2025, 2320

6428, 7121

7171, 7292

6201, 6405

7348, 9241

2335, 2688

229, 241

318, 1458

1480, 1877

1893, 2009

17,496

150,506

5541

Discharge summary

report

Admission Date: [**2131-7-16**] Discharge Date: [**2131-7-19**] Date of Birth: [**2053-10-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Urosepsis, MS changes Major Surgical or Invasive Procedure: None History of Present Illness: This is a 77y M w/ DM, HTN, monoclonal gammopathy and anemia who was in his USOH until yesterday evening, when after having dinner he started feeling fatigued and "wiped out". He reportedly had rigors overnight. He woke up this am and continued to feel fatigued. Over the course of the day he started becoming more confused. Since his wife was concerned, she called the EMS. Per pt, he has been urinating more frequently than usual over the last week. He denied dysuria, fever, chills, N/V/D/abdominal pain/HA/chest pain/LBP/neck pain. . His vitals when seen by the EMS: HR:148, BP:160/90, O2 sats:88%ra. On arrival to the ED his VS were: 103.8,135,153/69,29, 97%4L. In the ED the pt was noted to be disoriented (oriented only to name) and incontinent of urine. He had a dirty UA, was in ARF (Cr 2.6<--1.6) and had a lactate of 4.6. He was treated with Tylenol, 2L fluid bolus, a foley was placed for urinary retention (which resulted in outflow of fowl-smelling urine). He was treated w/ Levoflox 500mg IV x1. Blood and urine cx were drawn. . ROS: only sig for fatigue, polyuria. Social History: Married with 3 children. Used to work as a carpet installer. Quit cigs '[**90**] after 15 yrs at 2 ppd. Social ETOH. Denies illicit/IVDA hx. Family History: father MI (40s), mother had bipolar disorder. 2 siblings in good health Physical Exam: Vitals: T: 98.3 P:94 R:14 BP:104/91--> 142/72 SaO2:100% 4LNC Mixed VO2:78 CVP:8 General: Awake, alert, NC in place. HEENT: NC/AT, PERRL, EOMI without nystagmus, mild scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT, distended, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally Skin: depigmented skin over upper extremities. Neurologic: AAOx3. No focal neurologic deficits. Normal tone. No sensory deficits appreciated. Pertinent Results: [**2131-7-16**] 07:50PM BLOOD WBC-9.8 RBC-3.62* Hgb-11.0* Hct-31.2* MCV-86 MCH-30.5 MCHC-35.4* RDW-14.4 Plt Ct-292 [**2131-7-17**] 03:01AM BLOOD WBC-8.8 RBC-3.27* Hgb-10.0* Hct-29.3* MCV-90 MCH-30.4 MCHC-34.0 RDW-15.0 Plt Ct-236 [**2131-7-17**] 10:01AM BLOOD WBC-8.9 RBC-2.88* Hgb-8.8* Hct-25.5* MCV-89 MCH-30.6 MCHC-34.6 RDW-14.9 Plt Ct-211 [**2131-7-17**] 06:38PM BLOOD Hct-30.1* [**2131-7-18**] 04:20AM BLOOD WBC-8.1 RBC-3.22* Hgb-9.7* Hct-28.2* MCV-87 MCH-30.1 MCHC-34.4 RDW-14.9 Plt Ct-238 [**2131-7-18**] 07:07AM BLOOD Hct-29.0* [**2131-7-19**] 06:00AM BLOOD WBC-7.0 RBC-3.01* Hgb-9.2* Hct-26.8* MCV-89 MCH-30.5 MCHC-34.3 RDW-15.1 Plt Ct-266 [**2131-7-16**] 07:50PM BLOOD Ret Aut-1.7 [**2131-7-16**] 07:50PM BLOOD Glucose-312* UreaN-48* Creat-2.6* Na-130* K-5.9* Cl-95* HCO3-16* AnGap-25* [**2131-7-17**] 03:01AM BLOOD Glucose-230* UreaN-43* Creat-2.0* Na-138 K-5.1 Cl-108 HCO3-19* AnGap-16 [**2131-7-17**] 10:01AM BLOOD Glucose-130* UreaN-35* Creat-2.0* Na-141 K-4.3 Cl-111* HCO3-21* AnGap-13 [**2131-7-18**] 04:20AM BLOOD Glucose-184* UreaN-34* Creat-2.0* Na-140 K-4.4 Cl-109* HCO3-21* AnGap-14 [**2131-7-19**] 06:00AM BLOOD Glucose-120* UreaN-33* Creat-2.0* Na-141 K-4.2 Cl-110* HCO3-20* AnGap-15 [**2131-7-17**] 03:01AM BLOOD ALT-86* AST-64* CK(CPK)-139 AlkPhos-475* TotBili-1.1 [**2131-7-18**] 04:20AM BLOOD ALT-72* AST-53* AlkPhos-408* TotBili-0.9 [**2131-7-17**] 03:01AM BLOOD CK-MB-3 cTropnT-0.04* [**2131-7-17**] 10:01AM BLOOD CK-MB-4 cTropnT-0.03* [**2131-7-17**] 03:32PM BLOOD CK-MB-4 cTropnT-0.03* [**2131-7-16**] 07:54PM BLOOD Lactate-4.6* [**2131-7-17**] 03:19AM BLOOD Lactate-3.2* [**2131-7-17**] 04:19AM BLOOD Lactate-1.7 [**2131-7-17**] 06:27AM BLOOD Lactate-1.6 [**2131-7-17**] 10:27AM BLOOD Lactate-1.6 . [**2131-7-17**] CXR: Right internal jugular central venous catheter remains in the lower SVC. Heart is normal sized. Mediastinal and hilar contours are normal. Lungs are clear. Bilateral calcified pleural plaques are unchanged. There is no pleural effusion or pneumothorax. Pulmonary vascularity is normal. IMPRESSION: No pneumonia. Asbestos-related calcified pleural plaques. . [**2131-7-17**] Renal u/s: The right kidney measures 13 cm. The left kidney measures 9.5 cm. There is no evidence of hydronephrosis, masses, or stones bilaterally. A Foley catheter is identified within a decompressed bladder. IMPRESSION: No evidence of hydronephrosis bilaterally. . Sinus rhythm Normal ECG Since previous tracing of [**2131-7-16**], sinus tachycardia absent Intervals Axes Rate PR QRS QT/QTc P QRS T 87 142 94 372/416.42 67 40 49 . [**2131-7-16**] 7:50 pm BLOOD CULTURE **FINAL REPORT [**2131-7-19**]** AEROBIC BOTTLE (Final [**2131-7-19**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 4I 3PM [**2131-7-17**]. ESCHERICHIA COLI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC BOTTLE (Final [**2131-7-19**]): ESCHERICHIA COLI. IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE. . [**2131-7-16**] 9:15 pm URINE Site: CLEAN CATCH **FINAL REPORT [**2131-7-19**]** URINE CULTURE (Final [**2131-7-19**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: Mr. [**Known lastname 10145**] is a 77y M who was admitted to the [**Hospital Unit Name 153**] for management of urosepsis and acute renal failure. He was initially managed on a sepsis protocol and started on a broad antibiotic coverage with Levoflox, Zosyn and Vanc. He was eventually transitioned to a renally adjusted PO Levoflox to complete a 14d course; Zosyn and Vanc were discontinued. The pt was noted to have E.coli in [**5-15**] blood cultures as well as urine culture which grew E. coli. The sensiivities of urine and blood cultures returned pansensitive. His hyperkalemia resolved with IVF as well as his acute on chronic renal failure (creatinine returned to 2.0 (baseline 1.9)). Renal ultrasound was negative for hydronephrosis. His mental status returned to baseline with fluid resuscitation and antibiotics. Foley was discontinued, and a voiding trial was successful. Pt was encouraged to f/u with urology as an outpatient to further elucidate the etiology of his urosepsis. . HTN: No known h/o CAD. His antihypertensive meds were held during his acute septic episode; these were gradually restarted as his BP tolerated once his infection was adequately treated. . DMII: Glucophage was held on admission due to his ARF. He was maintained on ISS until acute issues resolve. Pt was transitioned to glipizide and glucophage for glucose control on the floor prior to discharge. . Hypercholesterolemia: Continued Lipitor . MGUS/Anemia: Known MGUS, with anemia of chronic disease. Remained stable at his baseline. Further treatment as needed per outpatient heme/onc. . Prophylaxis: PPI, sc heparin, bowel regimen FEN: [**Doctor First Name **] diet as tolerate Medications on Admission: -glucotrol 10mg [**Hospital1 **] -zestril 30mg po qd -glucophage 2 AM, 2 PM -HCTZ 12.5mg po qd -lipitor 40mg po qd -Norvasc ?dose Discharge Medications: 1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 11 days. Disp:*11 Tablet(s)* Refills:*0* 2. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: E. coli urosepsis Acute renal failure- resolving . Secondary diagnosis: Diabetes mellitus Hypertension MGUS Hyperlipidemia Discharge Condition: Afebrile, stable Discharge Instructions: Return to emergency department or call your doctor if you develop fever, chills, nausea, vomiting, increasing frequency for urination, burning on urination, bladder fullness, or any other worrisome symptoms. Take medications as instructed, especially your antibiotics and keep your follow-up appointment with your doctors [**First Name (Titles) **] [**Last Name (Titles) **]. We referred you to a [**Last Name (Titles) **] for further prostate exam. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) 410**] on [**2131-7-25**] at 11:30 AM. Phone number [**Telephone/Fax (1) 2660**]. Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], (UROLOGY) MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2131-8-7**] 11:30 Provider: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2131-11-20**] 1:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[**2131-11-20**] 1:30

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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21729

Discharge summary

report

Admission Date: [**2137-8-18**] Discharge Date: [**2137-8-28**] Date of Birth: [**2075-5-29**] Sex: M Service: NEUROLOGY Allergies: Tetracyclines Attending:[**First Name3 (LF) 618**] Chief Complaint: Altered mental status. Major Surgical or Invasive Procedure: None. History of Present Illness: Patient is a 62 year old male with past medical history of intracerebral hemorrhage [**6-/2137**], metastatic liver cancer, hypertension,and possible seizures who initially presented to an outside hospital with altered mental status. Patient reportedly was in his usual state of health post-hemorrhage until evening of [**2137-8-17**]. At that time, his girlfriend came home from work and found him to be disoriented and confused. She had last seen him well and at his baseline earlier that morning. They ate dinner and after dinner he complained of a headache. He took Tylenol and went to sit in their living room. Shortly thereafter, he apparently tried to get up from a chair and had a fall; this was unwitnessed so unclear if any abnormal movements or seizure activity occurred. Girlfriend reports that after the fall, his confusion worsened. She noted that he seemed weak and tired. Upon walking, he was running into things and holding onto the wall for support. Therefore, she brought him to an outside hospital for evaluation. On arrival to [**Hospital 16843**] Hospital, he was afebrile, BP 122/82, HR 75 and RR 20. CT scan showed new left sided parieto-occipital intraparenchymal hemorrhage. He was given Decadron 10 mg IV x1. Patient was transferred to [**Hospital1 18**] for further evaluation on [**2137-8-17**]. In the ED here, received mannitol, labetalol, dilantin, and one unit of plasma. Past Medical History: 1. Intracerebral hemorrhage 8/[**2136**]. Presented with confusion after fall. Post-hemorrhage he has had episodes of confusion and dysarthria. Still has residual right sided weakness but is able to ambulate independently. 2. Possible seizure, after hemorrhage in 8/[**2136**]. On dilantin. 3. Hypertension 4. Liver cancer status post resection with recurrence 3-4 months ago. Metastatic lesions in lungs. 5. Asthma 6. Right knee surgery 7. Status post cholecystectomy Social History: Lives with girlfriend [**Name (NI) **] in [**Name (NI) 16843**]. Retired; formerly worked for the Department of Public Works. Smokes [**1-24**] cigarettes daily. History of alcohol use but quit in [**2137-5-23**]. No drug use. Family History: No family history of stroke. Mother with [**Name (NI) 5895**] disease. Physical Exam: Tc: 96.7 BP: 143/85 HR: 72 RR: 24 O2Sat.: 96%/6L Gen: WD/WN, comfortable appearing, sleepy but arousable, NAD. HEENT: NC/AT. Anicteric. MM dry. Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No carotid bruits. Lungs: CTA anterolaterally. No R/R/W. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Warm and well-perfused. No C/C. Chronic skin changes over left lateral leg. 1+pitting edema bilateral LEs and in right hand. Neuro: Mental status: Sleepy but arousable. Dozes off when not directly stimulated. When awake, is cooperative with exam with normal affect. Oriented to person only. Could not pick out place or year from a list of options. Unabble to recite [**Doctor Last Name 1841**] forwards. Registration intact. Recalled 0/3 objects at 5 minutes and did not improve with prompting. Speech fluent with normal repetition. Able to complete simple 1 step midline and appendicular commands. Naming impaired even with low frequency objects. Moderate dysarthria. Could not demonstrate what a toothbrush is used for. Inconsistent extinguishment on double simultaneous simulation with right> left. Does not recognize right hand when placed in front of face. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3.5 to 2 mm bilaterally. Blinks to threat. Too sleepy to participate in more formal visual field testing. Unable to assess fundi. III, IV, VI: Extraocular movements intact in all fields of gaze. V, VII: Flattening of right nasolabial fold. +corneal reflex bilaterally. VIII: Hearing grossly intact. IX, X: Palatal elevation symmetrical. +Weak gag. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk bilaterally. Decreased tone right upper extremity. No abnormal movements, tremors. Able to lift all four extremities against gravity with pronation of right upper extremity. Sensation: Slow withdrawal to noxious stimuli x4. Reflexes: B T Br Pa Ac Right 2+ 2+ 2+ 2 0 Left 2 2 2 2 0 Grasp reflex absent. Toes downgoing on left, mute on right. Coordination: Unable to assess. Gait: Unable to assess. Pertinent Results: [**2137-8-17**] 10:48PM WBC-5.1 RBC-5.14 HGB-16.3 HCT-46.1 MCV-90 MCH-31.6 MCHC-35.3* RDW-13.7 [**2137-8-17**] 10:48PM NEUTS-68.2 LYMPHS-23.2 MONOS-6.7 EOS-1.5 BASOS-0.4 [**2137-8-17**] 10:48PM PT-13.5 PTT-27.9 INR(PT)-1.2 [**2137-8-17**] 10:48PM GLUCOSE-111* UREA N-11 CREAT-0.9 SODIUM-138 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16 [**2137-8-17**] 10:48PM ALT(SGPT)-70* AST(SGOT)-192* CK(CPK)-60 ALK PHOS-466* AMYLASE-28 TOT BILI-1.1 [**2137-8-17**] 10:48PM CK-MB-NotDone cTropnT-<0.01 [**2137-8-17**] 10:48PM ALBUMIN-3.3* CHOLEST-377* [**2137-8-17**] 10:48PM TRIGLYCER-97 HDL CHOL-48 CHOL/HDL-7.9 LDL(CALC)-310* [**2137-8-17**] 10:48PM PHENYTOIN-4.9* -------------- MRI HEAD W/O CONTRAST [**2137-8-18**]: 1) Motion degraded images. Large left parietal hematoma as visualized on the CT scan with surrounding edema. 2) MRA is not of diagnostic quality. Flow signal is observed in basilar artery and carotid siphon. -------------- CT HEAD W/O CONTRAST [**2137-8-18**]: Large intraparenchymal hemorrhage with surrounding edema in the left parietal lobe. It is impossible to determine whether this has progressed without comparison to prior studies. Should these studies become available, a comparison will gladly be made. -------------- CHEST (PORTABLE AP) [**2137-8-21**]: No obvious consolidating pulmonary infiltrates are identified. The right pleural effusion appears to have increased somewhat in the interval. There is the suggestion of a possible 1.5-cm right midlung nodule. Please correlate with outside films or reports to see if this is a known finding. Otherwise, followup films to see if this persists recommended after an appropriate clinical interval. -------------- MRI HEAD WITH CONTRAST GADOLIN [**2137-8-21**]: No significant interval change in the size of a large intraparenchymal hematoma in the left parietal and occipital lobes. There is no evidence of abnormal vascularity surrounding this hematoma. There is peripheral enhancement of this hematoma which raises the suspicion of an underlying neoplastic process -------------- CT HEAD W/O CONTRAST [**2137-8-22**]: No significant interval change in a large intraparenchymal hematoma in the left occipital lobe when compared to [**2137-8-20**]. -------------- CHEST (LAT DECUB ONLY) [**2137-8-22**]: Freely layering moderate right pleural effusion. ------------- CT ABD W&W/O C [**2137-8-23**]: Findings suggestive of aggressive local recurrence of hepatocellular cancer with invasion through the diaphragm, into the IVC and right atrium, as well as additional masses within the left hepatic lobe, innumerable pulmonary metastases, and large, probably metastatic mass to the right psoas muscle. The tumor thrombus within the IVC and right atrium is nonocclusive. Brief Hospital Course: The patient is a 62 year old male with a history of hepatocellular carcinoma and left parietal intracerebral hemorrhage on [**2137-6-26**] who presented with mental status change and right hemiparesis. Non contrast head CT demonstrated a left parietal hemorrhage with moderate edema. He was admitted to the neurological ICU on [**2137-8-18**] for blood pressure management and frequent neurological checks. Keppra was started for seizure prophylaxis and atorvastatin for hypercholesterolemia. In light of his history of diffusely metastatic hepatocellular carcinoma, there was concern that his episodes of intracerebral hemorrhage were secondary to bleeding into an underlying mass lesion. Multiple attempts at head MRI/MRA were compromised by patient motion. A successful MRI/MRA was obtained on [**2137-8-21**] under conscious sedation and demonstrated an enhancement pattern suspicious for neoplastic disease. Urinalysis on [**2137-8-20**] was suspicious for early urinary tract infection and the patient was treated with levofloxacin. Based on bacterial sensitivities, the patient's urinary tract infection was ultimately treated with a 3 day course of vancomycin. The patient had an oxygen requirement until [**8-22**] and chest-x-ray demonstrated a right lower lobe infiltrate so treatment with levofloxacin and clindamycin for presumptive aspiration pneumonia was briefly institued. Outside hospital records then revealed that the patient had a chronic right pleural effusion so the clindamycin was discontinued. During his stay, the patient's mental status remained confused and he was intermittenly oriented only to his name. Multiple head CT demonstrated no change in the size of the hematoma. Because of moderate vasogenic edema seen on imaging, the patient was started on dexamethasone. Systolic blood pressure was tightly maintained below 140 with captopril, metoprolol, and hydralazine. CT of the abdomen with and without contrast on [**2137-8-23**] revealed findings suggestive of aggressive local recurrence of hepatocellular cancer with invasion through the diaphragm, into the IVC and right atrium, as well as additional masses within the left hepatic lobe, innumerable pulmonary metastases, and large, probably metastatic mass to the right psoas muscle. Results of these studies were communicated to the patient's family, primary care physician and oncologist. Lactulose was instituted for hepatic encephalopathy. At the time of discharge, the patient's mental status improved on [**2137-8-26**] and he was oriented to name and "hospital". He has some impairment of comprehension and has difficulty following multistep commands. He has residual right facial droop and right sided weakness. Medications on Admission: 1. Dilantin 200 mg po bid 2. Captopril 12.5 mg po tid 3. Oxycontin prn 4. Atenolol 50 mg po qd 5. Thalidomide 50 mg po qHS (for cancer therapy) 6. Tylenol prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 5. Captopril 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 6. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO QD (once a day) as needed for constipation. 10. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a day). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a day). 13. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). 14. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 16. Combivent 103-18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 17. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous Q12H (every 12 hours) for 1 days: Needs one additional day of therapy to complete treatment course for UTI. 18. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every eight (8) hours: In 5 days, wean to 2 mg po q12h. In another 5 days, wean to 2mg po qd. After another 5 days, discontinue. Discharge Disposition: Extended Care Facility: [**Hospital 16844**] Hospital - [**Location (un) 1157**] Discharge Diagnosis: 1. Intraparenchymal brain hemorrhage with likely underlying mass lesion 2. Hepatocellular Cancer with metastases to lung, left lobe of liver, infiltrating inferior vena cava/right atrium, right psoas 3. Hypertension 4. Asthma Discharge Condition: Stable; Persistent disorientation, poor comprehension, right sided weakness. Discharge Instructions: Please call your doctor if you have severe headache, vision changes, weakness, numbness or tingling, problems with speech, incoordination, bowel or bladder changes, fever, chills, chest pain, shortness of breath, or any other worrisome symptoms. Followup Instructions: Please call Dr. [**Last Name (STitle) 57111**] (Oncologist) at [**Telephone/Fax (1) 57112**] X 5048 to follow up within one week of discharge from rehab. Please follow up with Dr.[**Name (NI) 20183**], your primary care physician, [**Name10 (NameIs) 176**] two weeks of discharge. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

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icd9cm

[ [ [] ] ]

[ "88.91", "88.41" ]

icd9pcs

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19890

Discharge summary

report

Admission Date: [**2115-12-1**] Discharge Date: [**2115-12-8**] Date of Birth: [**2049-10-29**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old woman with a history of hyperlipidemia, hypertension, peripheral vascular disease, and smoking with no known history of coronary artery disease. The patient was doing well until she awoke on the day of admission (on [**2115-12-1**]). The patient awoke at 5 a.m. with chest pain and diaphoresis. The patient later collapsed in front of her husband. [**Name (NI) **] performed limited cardiopulmonary resuscitation per report (not adequate cardiopulmonary resuscitation) for approximately 10 minutes until Emergency Medical Service arrived. The patient was found in ventricular fibrillation arrest by Emergency Medical Service. Flow sheets not currently available. The patient was defibrillated and rhythm became asystole. The patient was intubated in the field. The patient was given epinephrine and converted back to ventricular fibrillation. The patient was shocked again and started on a lidocaine drip. The patient was taken to [**Hospital3 **] Emergency Department at 0555. In the Emergency Department, the patient was in pulseless electrical activity arrest. The patient was treated with epinephrine with restoration of pulse and blood pressure. The patient went into wide complex tachycardia then narrow complex. The patient was started on amiodarone drip, a heparin drip, and an Integrilin drip. The patient was transferred to [**Hospital1 69**] Catheterization Laboratory. In the Catheterization Laboratory found 95% stenosis with thrombus in major obtuse marginal. Treated with stent. Right heart catheterization demonstrated cardiogenic shock. An intra-aortic balloon pump inserted and a nitroglycerin drip was started for blood pressure control. The patient was sent to the Coronary Care Unit. Now intubated, on an amiodarone drip, heparin drip, Integrilin drip, with intra-aortic balloon pump in place. PAST MEDICAL HISTORY: 1. Peripheral vascular disease; status post left femoral-to-popliteal in [**2113**]. 2. Hypercholesterolemia. 3. Hypertension. 4. Tremor. 5. Status post hysterectomy. 6. Status post lumpectomy. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Medications at home included propanolol, Lipitor, and an ACE inhibitor. MEDICATIONS ON TRANSFER: Medications on transfer included propanolol, Lipitor, ACE inhibitor, amiodarone drip, intravenous heparin, and intravenous Integrilin. FAMILY HISTORY: Family history is unknown. SOCIAL HISTORY: The patient has a +50-pack-year smoking history. Occasional alcohol use. She lives with her husband. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed the patient's weight was 74.6 kilograms, temperature was 95.2 degrees Fahrenheit axillary, his heart rate was 103, her blood pressure was 136/48, her respiratory rate was 25, and her oxygen saturation was 100%. The patient was on the following ventilator settings; synchronized intermittent mandatory ventilation and pressure support 24.5/0.5. Arterial blood gas was 7.22/42/337 on intra-aortic balloon pump 1:1. In general, the patient was intubated and in no acute distress. Head, eyes, ears, nose, and throat examination revealed pupils were faintly reactive to light. Cardiovascular examination revealed distant heart sounds but a regular rate and rhythm. The lungs revealed a few crackles at the bases. The abdomen was mildly distended, soft, and nontender. Bowel sounds were present. No hepatosplenomegaly. Extremity examination revealed the extremities were cold with nonpalpable pulses. Neurologic examination revealed the patient withdrew to pain; intubated. Patellar reflexes were 1+ bilaterally. Pupil equal 4 mm, sluggish, rolled back. No corneal reflex (per nursing). PERTINENT RADIOLOGY/IMAGING: Electrocardiogram here at 1023 revealed a normal sinus rhythm at 99, normal axis, and normal intervals. There were T wave inversions in leads II, III, and aVF. There was T wave flattening in V4, V5, and V6. Echocardiogram preliminary read revealed an ejection fraction of 35% to 40%, inferior and apical akinesis. Final [**Location (un) 1131**] of echocardiogram revealed left ventricular cavity size was top normal/borderline dilated and overall left ventricular systolic function was severely depressed (with an estimated ejection fraction of less than 25%?). These were technically suboptimal. There was lateral and inferior akinesis and septal and apical hypokinesis/akinesis. The anterior wall may also be hypokinetic but was not fully visualized. The right ventricular chamber size was normal. The function appeared preserved (not fully seen). The aortic valve was not well visualized. There was probable mild to 1+ mitral regurgitation (view suboptimal). There was no pericardial effusion. Catheterization results revealed (1) severe systolic and diastolic ventricular dysfunction; (2) acute inferoposterior myocardial infarction; (3) Hepacoat stent to major obtuse marginal with 95% to 0% residual; and, (4) intra-aortic balloon pump placed. Hemodynamics revealed right atrium 9, pulmonary artery 48/30, pulmonary capillary wedge pressure 34, aortic 133/100, cardiac output 2.5, cardiac index 1.41. Electroencephalogram on [**2115-12-1**] revealed abnormalities as follows; (1) Throughout this recording, background rhythms were severely suppressed, and no change was seen in response to noxious stimulation. The recording contaminated with apparent muscle artifact frequently. (2) The suppressed background was interrupted by frequent bursts occurring every five to fifteen seconds and Doppler frequency slowing seen in a generalized fashion. No sharp features were associated with these bursts. Each burst lasted approximately one to one and a half seconds. IMPRESSION: This is a markedly abnormal electroencephalogram due to the bursts suppression countered with brief bursts interrupting the suppressed background every five to fifteen seconds. No reactivity was seen in response to noxious stimulation. No epileptiform features were seen. These findings suggested the presence of severe encephalopathy. The common causes of severe encephalopathy include medications, metabolic causes, infections, and hypoxic and ischemic insults. Electroencephalogram on [**2115-12-6**] revealed abnormalities as follows: (1) Throughout this recording at normal electroencephalogram settings, the background rhythms were extremely suppressed. There was no evidence of any electrical activity or cerebral origin present; (2) In an attempt to bring out any low voltage activity of cerebral origin, the sensitivity was reset to 2 UV and recording took place. During this time, once again, there was no definite electrical activity cerebral in origin. There was a great deal of muscle artifact present throughout. In addition, during this time the patient was stimulated both with auditory and painful stimulation. There was no response to auditory stimulation and no withdrawal response to pain from stimulus only. There was no change in background rhythms or electrical activity which emerged during stimulation. IMPRESSION: This was a markedly abnormal EEG suggestive of severe encephalopathy. There was no electrical activity of cerebral origin detected during this recording. These findings were consistent the patient's known history of severe anoxic brain injury. A CT of the head without contrast done on [**2115-12-2**]; findings without prior study for comparison, considering the patient's age, there was apparent effacement of the sulci diffusely throughout the brain parenchymas suggestive of possible globus swelling. No global areas of hypodensity are appreciated to suggest regional or global infarctions, respectively, at this time. There was no shift of the normally midline structures. No intracranial hemorrhages appreciated. IMPRESSION: Apparent global effacement of sulci suggestive of global swelling. No evidence of global or regional infarctions at this time. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories from outside hospital at 0624 revealed sodium was 128, chloride was 98, bicarbonate was 18, blood urea nitrogen was 20, creatinine was 0.9. and her blood glucose was 282. At 0635 arterial blood gas revealed 7.18/32/238/11. Complete blood count revealed the patient's white blood cell count was 12, her hematocrit was 38.8, and platelets were 311. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories at [**Hospital1 69**] revealed arterial blood gas at 0904 revealed 7.22/43/337/18. Arterial blood gas at 0942 revealed 7.27/36/433/17. SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. CARDIOVASCULAR ISSUES: The patient was originally hemodynamically unstable upon arrival to the Coronary Care Unit. The patient was tried on dobutamine and nitroglycerin drips, and an intra-aortic balloon pump was placed. Over the first couple of days, the patient was stabilized and has had no instability since that time. The patient was taken off of the dobutamine drip and the nitroglycerin drip. The intra-aortic balloon pump was taken down on the third day of admission. However, the patient has become quite tachycardic in the presence of fevers. However, her blood pressure has been stable. The patient was started on an ACE inhibitor and a beta blocker. Both the ACE inhibitor and beta blocker were not titrated rapidly given the patient's prognosis. The patient did arrive to the Coronary Care Unit having had a percutaneous coronary intervention to the obtuse marginal with a Hepacoat stent in place. The patient was transitioned from an amiodarone drip to by mouth amiodarone. 2. NEUROLOGIC ISSUES: The patient reacted to pain upon arrival to the Coronary Care Unit. Hypothermia was considered, but not performed given cardiogenic shock. The patient originally looked like she was having seizures. Neurology was consulted. An electroencephalogram was performed showing no seizure activity but was consistent with a noxious brain injury and toxic metabolic wave forms on preliminary read. The patient was given fosphenytoin load and was subsequently placed on Dilantin 100 mg three times per day. That evening of arrival and subsequent morning, the patient was shown to have upper extremity posturing. An electroencephalogram was taken several days later along with a computed tomography scan. The second electroencephalogram showed no cortical or cerebral activity. The computed tomography showed global effacement of the sulci suggestive of global swelling. Over the course of the week, Neurology continued to consult and warned the family of the poor prognosis. Final [**Location (un) 1131**] of the second electroencephalogram performed on [**12-6**] was presented to the family; during which an explanation was given to them that the patient had no cortical activity and only brain stem function. A second Neurology attending was consulted for a second opinion; in which he confirmed the previous attending's findings of the patient not having any cortical activity and having a poor prognosis. The second attending communicated these findings and the patient's prognosis to the patient's family. The conclusion was brought forth that the patient was to be made do not resuscitate/do not intubate. 3. PULMONARY ISSUES: The patient has been on ventilator since admission to the Coronary Care Unit. Several trials of pressure support resulted in tachypnea and distress; requiring propofol for sedation. The patient was to be extubated over the weekend, but the granddaughter's birthday on [**12-8**], and the family did not want to do it then. Plan for extubation on Monday, [**12-9**]. The patient will likely require a morphine drip for comfort. 4. INFECTIOUS DISEASE ISSUES: On the second day of admission, the patient spiked a fever. Sputum cultures, urine cultures, blood cultures, and a chest x-ray were done. The urine culture was negative. The blood cultures have been negative to date. The chest x-ray showed evidence of pneumonia. The sputum culture grew back Staphylococcus aureus sensitive to several antibiotics. The patient was initially started on vancomycin at the time of the temperature spike and was subsequently changed over to levofloxacin once the sensitivities came back. Since then, the patient has continued to spike with the levofloxacin. Repeat blood cultures were sent and have also been negative to date. 5. ENDOCRINE ISSUES: The patient was started on an insulin drip for very high blood sugars. Once the initial two days had passed, the patient's blood sugars were much less; requiring only a regular insulin sliding-scale. The insulin drip had been discontinued, and the patient continued with very good control of her blood sugar. 6. GASTROINTESTINAL ISSUES: The patient had experienced a nose bleed secondary to a traumatic nasogastric tube placement. The bleed was exacerbated by the blood thinners that the patient was on. Integrilin was stopped to prevent any further exacerbations. The patient was then placed on intravenous Protonix 40 twice per day and subsequently transitioned over to famotidine twice per day. The patient remained hemodynamically stable. On day one and day two of admission, the patient had no bowel sounds. However, throughout the course of the week, the patient regained some bowel sound activity and was placed on tube feeds for nutrition. 7. ANEMIA ISSUES: The patient's decrease in hematocrit was likely secondary to phlebotomy as no other source of bleed has been evidenced. The patient was given one unit of packed red blood cells. 8. PROPHYLAXIS ISSUES: The patient has been maintained on pneumatic boots and famotidine. The patient remainder of this dictation will be done by the subsequent intern. [**Doctor Last Name **] [**Last Name (NamePattern4) 53715**] M.D [**MD Number(1) 53716**] Dictated By:[**Last Name (NamePattern1) 9622**] MEDQUIST36 D: [**2115-12-8**] 07:58 T: [**2115-12-10**] 13:12 JOB#: [**Job Number 53717**]

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icd9cm

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Discharge summary

report

Admission Date: [**2120-10-13**] Discharge Date: [**2120-10-17**] Date of Birth: [**2072-3-14**] Sex: M Service: MEDICINE Allergies: Keflex / Bactrim Attending:[**First Name3 (LF) 12722**] Chief Complaint: bilateral eye redness Major Surgical or Invasive Procedure: Skin biopsy History of Present Illness: This is a 48 year old gentleman with a history of hepatitis C and HIV (last viral load 449 on [**2120-10-8**]) who is presenting with red eyes, blurrying vision, a painful blistering rash and fever. His current course of events begins about 2 weeks ago when he was seen in the ED [**10-1**] for diarrhea. Stool culture showed cryptosporidium parvum oocysts and he was subsequently started on Alinia 500mg 1 tab PO BID last Tuesday. He had been on an unknown antibiotic for the 3 days prior to this. Then, 2-3 days ago he developed a painful red rash on his legs. He was seen in the [**Hospital1 18**] ED on the day prior to admission for this. At that time it was felt likely to be a superinfection of insect bites and was discharged on bactrim, keflex and benadryl which he reports having taken since. At 2pm today he woke up from a nap and noted blurrying of his vision, red eyes, fever, malaise, nausea and loss of appetite and subsequently noted a painful blistering rash on his legs. . On arrival to the ED initial VS were 101.4, 120, 125/55, 24, 95%RA, repeat vitals at 18:41 102.1, 112, 129/65, 22. He was given 4L IVF, tylenol and dilaudid. On exam he was noted to be in significant discomfort with red conjuctiva, nonreactive pupils and dysconjugate gaze. He was evaluated by opthalmology and dermatology who obtained a punch biopsy of his right dorsal foot. He was started on vancomycin and aztreonam. On arrival to the MICU he ws in visible discomfort and complaining of [**6-27**] pain which is mostly in his eyes. . On the floor, he reported improvement in his vision and eye redness. His RLE skin lesions continued to bother him, and he had difficulty weight bearing on that leg. He endorsed anxiety about his personal life in addition to his current medical situation. No chest pain, SOB, diarrhea, or abdominal pain. Past Medical History: 1. HIV - diagnosed [**3-/2115**] - no AIDS-defining illness, no history of HAART. Likely acquired from male sexual contact, denies IVDU. CD4 374 ([**2117-1-17**]). Followed at [**Hospital 778**] Clinic by Dr. [**Last Name (STitle) 19091**]. 2. HCV - diagnosed fall [**2114**] - genotype 1, [**2117**] biopsy showed stage 1 fibrosis and stage 2 inflammation, VL 20,600,000 IU/mL ([**2117-9-7**]) Follow at [**Hospital1 18**] [**Hospital **] [**Hospital **] clinic. Has not yet started therapy due to emotional stress. 3. Hyperlipidemia - untreated 4. Adult varicella/chickenpox - ~[**2092**] - last 3 months 5. Migraines - years past 6. Poor dentition 7. Left facial neuralgia - no etiology identified. Also, childhood history of left facial paralysis of unknown cause. 8. Childhood stye removal 9. Sinusitis - found on imaging 10. Ethanol use Social History: Patient currently living with his mother and grandmother. [**Name (NI) **] frequently travels to [**Location (un) 7349**] to visit friends and to work. He denies any travel outside the Northeast. He has a pet cat x 5 years. He denies any history of tobacco or drug use. He drinks socially (1-2 drinks multiple nights per week). Denies spending any time in prison or shelters. Family History: Adopted father died at age 67 in [**2092**] of heart problems. Adopted mother is alive in good health at the age of 73. Grandfather died three years ago at 93 of old age. Step-father died at 84 of diabetes; patient took care of him for years. Physical Exam: ADMISSION PE: General: Alert and oriented but in significant discomfort HEENT: bilateral erythematous conjunctiva, MMM, no oropharyngeal lesions appreciated, EOMI, pupils nonreactive Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, II/VI SEM, no rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred Skin: bilaterally lower extremities with papules, crusting and painful nodules, tense bullae over posterior aspect of right ankle Discharge PE: VS 97.6 98.6 98-118/62-75 18 96RA General: Pleasant African American male in NAD HEENT: bilateral mild erythematous conjunctiva, MMM, no oropharyngeal lesions appreciated, EOMI, pupils nonreactive Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, II/VI SEM, no rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred Skin: RLE papules, crusted over and TTP on the posterior aspect of the leg, one tense bulla over posterior aspect of right ankle now drained and bandanged. Demarcated area of erythema and warmth along the area of blistering which is improved. Two old healed lesions on the LLE calf. Pertinent Results: ADMISSION LABS: [**2120-10-12**] 07:25PM BLOOD WBC-6.9 RBC-4.68 Hgb-13.5* Hct-39.3* MCV-84 MCH-28.9 MCHC-34.4 RDW-14.2 Plt Ct-186 [**2120-10-12**] 07:25PM BLOOD Neuts-50.4 Lymphs-39.0 Monos-6.2 Eos-3.9 Baso-0.5 [**2120-10-12**] 07:25PM BLOOD PT-11.7 PTT-28.2 INR(PT)-1.1 [**2120-10-12**] 07:25PM BLOOD Glucose-87 UreaN-14 Creat-0.9 Na-140 K-4.1 Cl-105 HCO3-30 AnGap-9 [**2120-10-12**] 07:25PM BLOOD ALT-151* AST-98* AlkPhos-59 TotBili-0.3 [**2120-10-13**] 06:49PM BLOOD Lactate-2.3* Pertinent labs: [**2120-10-13**] 06:30PM BLOOD Lipase-25 [**2120-10-16**] 06:00AM BLOOD Calcium-8.8 Phos-3.5# Mg-2.1 Discharge labs: [**2120-10-17**] 07:05AM BLOOD WBC-4.4 RBC-5.08 Hgb-14.3 Hct-42.0 MCV-83 MCH-28.0 MCHC-34.0 RDW-14.4 Plt Ct-189 [**2120-10-17**] 07:05AM BLOOD Neuts-35.5* Lymphs-55.0* Monos-3.0 Eos-4.4* Baso-2.1* [**2120-10-17**] 07:05AM BLOOD Glucose-106* UreaN-14 Creat-0.7 Na-135 K-4.1 Cl-100 HCO3-26 AnGap-13 [**2120-10-17**] 07:05AM BLOOD ALT-134* AST-108* AlkPhos-47 TotBili-0.4 Pertinent Micro: [**2120-10-15**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2120-10-14**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2120-10-13**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2120-10-13**] URINE Legionella Urinary Antigen -FINAL INPATIENT [**2120-10-13**] URINE URINE CULTURE-FINAL INPATIENT [**2120-10-13**] TISSUE GRAM STAIN-FINAL; TISSUE-FINAL; ANAEROBIC CULTURE-PRELIMINARY; POTASSIUM HYDROXIDE PREPARATION-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY [**Last Name (LF) **],[**First Name3 (LF) **] [**2120-10-13**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE} [**Last Name (LF) **],[**First Name3 (LF) **] [**2120-10-13**] EYE RESPIRATORY CULTURE-FINAL EMERGENCY [**Hospital1 **] [**2120-10-13**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2120-10-13**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] Pertinent Path: SPECIMEN SUBMITTED: RUSH SKIN, RIGHT POSTERIOR CALF. Procedure date Tissue received Report Date Diagnosed by [**2120-10-13**] [**2120-10-14**] [**2120-10-16**] DR. [**Last Name (STitle) **]. ZIMAROWSKI/ttl Previous biopsies: [**Numeric Identifier 102315**] LIVER CORE BX (1 JAR). DIAGNOSIS: Skin, right posterior calf, biopsy (A): Florid superficial and deep perivascular and interstitial eosinophil-[**Doctor First Name **] inflammatory infiltrate involving dermis and subcutis, see note. Note: Focal flame figures are observed in deeper sections. The differential diagnosis includes an arthropod bite reaction and [**Doctor Last Name 3012**] syndrome (which may be a florid hypersensitivity reaction, possibly to arthropods). Less likely, the differential diagnosis includes a parasitic infection or a drug reaction. Special stains (AFB, [**Last Name (un) 18566**], Gram, GMS, and PAS) are negative for organisms. The pattern with numerous eosinophils speaks against a bacterial or mycobacterial infection. The changes are not those of erythema induratum. Dr. [**First Name (STitle) 6164**] discussed the preliminary results with Dr. [**Last Name (STitle) 102316**] on [**2120-10-14**]. Clinical: Right posterior calf. 48 y/o male with history of HIV, HCV, and history of papular eruption on bilateral legs x one week. Presents with somewhat tender, erythematous, indurated nodules, most prominent on the posterior calves with isolated tense bullae on right ankle. Also acute onset spiking fevers, headache, new bilateral keratitis x 1 day. DDX: Infectious (Bacterial cellulitis versus atypical mycobacterial versus deep fungal) versus inflammatory (drug hypersensitivity versus bullous arthropod reaction versus erythema induratum) versus other. Gross: The specimen is received in a formalin-filled container, labeled with the patient's name, "[**Known lastname **], [**Known firstname **]" and the medical record number. It consists of a 4 mm punch biopsy of skin excised to a depth of 0.8 cm. The skin surface is brown and unremarkable. The margin is inked blue, the specimen is bisected and entirely submitted in cassette A. Pertinent Imaging: CHEST RADIOGRAPH PERFORMED ON [**2120-10-13**] Comparison made with a prior study from [**2118-1-22**] CLINICAL HISTORY: HIV, hep C, presents with fever, question pneumonia. FINDINGS: Semi-upright portable AP view of the chest was provided. Diffuse ground-glass opacity within the lungs could reflect the presence of atypical pneumonia. No large effusion or pneumothorax is seen. Cardiomediastinal silhouette is normal. Bony structures are intact. IMPRESSION: Diffuse ground-glass opacities within the lungs could reflect an atypical pneumonia. Please correlate clinically. ECHO [**2120-10-14**] The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal study. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No structural heart disease or pathologic flow identified. Brief Hospital Course: Patient is a 48 year old male with history of HIV and HCV who presents with a bullous rash, fever, eye redness, eosinophilia. Active Issues: # Hypersensitivity reaction: The pt's story begins 3 weeks prior to admission at which time he had diarrhea and went to his PCP. [**Name10 (NameIs) **] was prescribed immodium and stool studies were sent. The following week, stool studies returned showing cryptosporidium. His PCP prescribed him [**Name Initial (PRE) **] 14 day course of Alivia for treatment, and he began to improve over the first several days. Later that week, the patient reports seeing two "mosquito bites" on his right which developed surrounding erythema and became purulent. He also developed tense bullae in the area. He went to the ED and was prescribed bactrim, keflex, and benedryl for a supposed skin infection vs arthropod bite. The following morning, he woke up with bilateral conjunctival injection and blurry vision. He came to the ED, at which point he was found to be febrile, hypoxic, and dyspneic. His labs showed leukocytosis (with eosinophilia), acute kidney injury, and transaminitis. His CXR showed diffuse ground glass opacities concerning for atypical pneumonia. He was treated for presumed infection with IV vanc and aztreonam and transferred to the MICU. In the MICU, his vital signs quickly improved. Dermatology, opthalmology, and ID were all consulted. Derm took a biopsy of the skin lesions, which appeared to most consistent with insect bite, and less likely infection or drug reaction. Opthalmology felt the conjunctival injection was most likely a component of his drug reaction and prescribed moxifloxacin eye drops. It was presumed that his eye reaction, [**Last Name (un) **], hypoxia, eosinophilia, and transaminitis were all a component of DRESS syndrome caused by either keflex or bactrim, and that the bullous rash was originally due to an arthropod bite. Keflex and bactrim were added to the patient's allergy list. Blood and wound cultures were negative for infection. Given the low suspicion for systemic infection, IV vanc and aztreonam were discontinued. His symptoms, vitals, and labs (minus LFTs) improved rapidly over the next 48 hours, at which point he was transferred to the floor. He was discharged with instructions to continue the moxifloxacin eye drops until his appointment with opthalmology the following week, and he was instructed to avoid keflex and bactrim in the future. # [**Last Name (un) **]: Cr was 1.4 in the ED. This resolved with fluid management. # Transaminitis: LFTs on admission were AST 98 ALT 151. They rose slightly to 108 and 134, respectively. When looking back in OMR, it appears that his LFTs have been consistently elevated, even just prior to this admission. It was difficult to ascertain whether the elevation was consistent with his history of HCV, or whether it was a component of DRESS syndrome. He had no tenderness on abdominal exam. Ultimately it was decided that the patient's LFTs were stable enough for discharge. The patient was instructed to have repeat labs the morning of his follow up appointment with PCP and [**Name9 (PRE) 464**] in less than a week. Chronic Issues: # HIV: Most recent labs from [**2120-9-18**]: CD4 516 and VL 489. The patient was kept on his home regimen with adjustments in his dose. He will follow up with Dr. [**Last Name (STitle) **] at the [**Hospital 778**] clinic for HIV management. # HCV: the patient was not on medications for HCV. His LFTs were significantly lower than they had been in the past. He will follow up with Dr. [**Last Name (STitle) **] at the [**Hospital 778**] clinic. Transitional Issues: # Repeat LFTs at outside lab for f/u with new PCP at [**Name9 (PRE) 778**] (Dr. [**Last Name (STitle) **] # Possible allergy to bactrim and/or keflex # HIV medication regimen dosing verification with PCP at [**Name9 (PRE) 778**] Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Alinia *NF* (nitazoxanide) 500 mg Oral [**Hospital1 **] 2. Cephalexin 500 mg PO Q6H 3. Loperamide 2 mg PO QID:PRN diarrhea 4. RiTONAvir 100 mg PO DAILY 5. Darunavir 400 mg PO BID 6. Sulfameth/Trimethoprim DS 2 TAB PO BID 7. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY Discharge Medications: 1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 2. RiTONAvir 100 mg PO DAILY 3. Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl BOTH EYES Q6H RX *bacitracin-polymyxin B 500 unit-[**Unit Number **],000 unit/gram 1 Appl in each eye every six (6) hours Disp #*1 Tube Refills:*0 4. Sarna Lotion 1 Appl TP QID:PRN itching RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % Apply to affected area three times a day Disp #*1 Bottle Refills:*0 5. Vigamox *NF* (moxifloxacin) 0.5 % OU Q2H Reason for Ordering: per opthalmology RX *moxifloxacin [Vigamox] 0.5 % 1 drop in each eye every eight (8) hours Disp #*1 Bottle Refills:*0 6. Outpatient Lab Work ICD-9: 794.8 Abnormal liver enzymes Please check ALT/AST, ALK, and CBC with diff on [**2120-10-20**] Fax Results to: Dr. [**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2392**] Fax: [**Telephone/Fax (1) 34420**] 7. Darunavir 800 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: 1) Drug reaction 2) Unspecified skin infection Secondary diagnoses: 1) HIV 2) Hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to [**Hospital1 18**] for fever, eye redness, and skin wounds and concern for a serious infection. You were seen by specialists in infectious disease, dermatology, and opthalmology. We believe your symptoms are most likely due to an insect bite originating on your lower right leg, which caused a blistering skin reaction. Then, when you were treated with antibiotics for the skin reaction, you developed an allergic reaction which caused the eye redness and fever. In the hospital, we followed you closely and your condition improved. We now feel that it is safe for you to leave the hospital. The opthalmologists here prescribed you eye drops to take when you go home, and they ask that you follow up with them in their clinic next week (the appointment is below). When you were in the hospital, your HIV medication regimen was adjusted. We recommend you continue this same regimen when you leave. While in the hospital, your liver enzymes appeared to be elevating slightly. We would like you to have your liver enzymes rechecked on Tuesday, [**10-22**]. You can go to [**Hospital1 18**] for your lab draw. Then, Dr. [**Last Name (STitle) 2392**] will follow up the result at your appointment that day. Since you had an allergic reaction to either bactrim (TMP-SMX) or keflex (cephalexin), we recommend that you DO NOT take these medications again in the future. We made the following changes to your medications: START Darunavir 800mg po daily START Ritonavir 100mg po daily START Truvada 1 tab po daily START Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl BOTH EYES every 6 hours START Vigamox *NF* (moxifloxacin) 0.5 % OU every 2 hours START Sarna Lotion 1 Appl topical ever:PRN itching STOP KEFLEX (CEPHALEXIN) -- ALLERGY STOP BACTRIM (SULFA-METHOXAZOLE-TRIMETHOPRIM) -- ALLERGY When you leave the hospital, we recommend close follow up with your new physician at [**Name9 (PRE) 778**], Dr. [**Last Name (STitle) 2392**], as well (the appointment is below) about the skin infection, eye redness, and HIV/hepatitis C. Followup Instructions: You have been scheduled the following appointments. Please be sure to attend these appointments. Primary care physician: [**Name Initial (NameIs) 7274**]: [**Last Name (LF) 2392**], [**First Name7 (NamePattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Location (un) **] ASSOCIATES OF [**Hospital1 **] HEALTH Address: [**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 6422**] Phone: [**Telephone/Fax (1) 5723**] Appt: [**10-22**] at 10:20am NOTE: This appointment is with a member of Dr [**Last Name (STitle) **]??????s team as part of your transition from the hospital back to your primary care provider Name: [**Last Name (LF) **],[**First Name3 (LF) **] M. Location: [**Hospital6 5242**] CENTER Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 66357**] Phone: [**Telephone/Fax (1) 798**] Appt: [**12-11**] at 10am ***This doctor will be your new primary care doctor. This appt is for a full physical. OPTHALMOLOGY: Department: [**Hospital3 1935**] CENTER When: TUESDAY [**2120-10-22**] at 8:30 AM With: [**Name6 (MD) **] [**Name8 (MD) 91835**], MD [**Telephone/Fax (1) 253**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BWD Completed by:[**2120-10-18**]

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icd9cm

[ [ [] ] ]

[ "86.11" ]

icd9pcs

[ [ [] ] ]

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303, 316

16758, 16758

5496, 5496

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3470, 3716

15636, 16575

16625, 16692

15232, 15613

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2200, 3056

3072, 3454

43,067

152,337

4957

Discharge summary

report

Admission Date: [**2122-5-25**] Discharge Date: [**2122-5-30**] Service: MEDICINE Allergies: Iodine / Lipitor / Trazamine Attending:[**First Name3 (LF) 2610**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: IVC filter placement History of Present Illness: Ms. [**Known lastname 20576**] is a [**Age over 90 **] year old female NH resident ([**Hospital1 **] of [**Hospital1 8**]) recently admitted [**Date range (1) 20577**]/[**2121**] for sacral decubitus ulcer and pain as well as Enterobacter UTI, also recently admitted [**Date range (1) 20578**]/10 for bilateral pneumonia complicated by [**Last Name (un) **] on CKD started on HD now q week transferred from NH with hypotension, minimal responsiveness. She has been on vancomycin for several weeks for UTI/?bacteremia and was on levofloxacin for 2 weeks for presumed PNA/aspiration with diet recently modified. Daughter noted increased confusion last 2-3 days similar to prior UTIs. Due to concern for worsening uremia, she underwent her weekly dialysis today which was shortened secondary to hypotension then was transferred back to facility where she was later found to be unresponsive with BP 77/44 and O2 sat 86%RA. Upon EMS arrival, SBP 90s, pt in AF with HR 70s-80s and she was AAOx3. She was initially brought to [**Hospital 8**] Hospital where she received 2000cc NS with improvement in BP to 107/palp. She had CXR concerning for PNA, was briefly on BiPap for unclear reasons and had labs significant for troponin 0.05 and WBC 25K so was given ertapenem and vancomycin and transferred to [**Hospital1 18**] for continuity of care. . . In the ED, initial vs were: T97.9 P70 BP104/43 R 100%O2 sat on NRB. Received 2LNS. Blood cx ordered and she was transferred to MICU due to episode of hypotension and concern for developing SIRS/sepsis. Prior to transfer, T97.9 HR70 BP 104/43 HR100. . On the floor, she appears comfortable. She reports feeling lousy last several days and dry cough for several weeks with recent thirst. Denies dysuria, change in ostomy output, fever, chills, palpitations, CP, SOB, LH, dizziness. Past Medical History: 1. Hypertension 2. Peripheral vascular disease 3. Hyperlipidemia 4. Urinary frequency/incontinence 5. Glaucoma 6. Tenosynovitis of wrists bilaterally 7. Colon Cancer status post resection 27 years ago, colonoscopy in [**2113**] normal 8. Chronic renal insufficiency, recent baseline creatinine 2-2.5, recently ([**2-18**]) had [**Last Name (un) **] requiring initiation of HD, now on weekly HD 9. Small bowel obstruction status post resection of gangrenous bowel 10. Pseudogout 11. S/P Cholecystectomy. 12. Bladder resuspension 13. Detached retina 14. Bilateral knee OA 15. ? recent bacteremia/aspiration PNA/UTI on vanco and levoflox 16. s/p CVA [**12/2121**] at [**Hospital1 2025**] Social History: Per OMR: She has a 40 pack-year smoking history, quit 30 years ago. She ambulates with a walker. Family History: per OMR: No history of colon cancer or breast cancer. Physical Exam: On admission General: Awake, alert, oriented to hospital but not name or hospital and not date or year, no acute distress, laying comfortably in bed. Later occasionally screaming out, confused HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased BS R>L base. Minimal crackles bilaterally. No wheezes, rhonchi CV: Tachycardic. irreg irreg. Normal S1 + S2, 3/6 systolic murmur LLSB increased with respiration, 2/6 systolic murmur LUSb radiatign to carotids Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Ostomy with brown stool GU: foley draining purulent urine. Sacral decubitus ulcer stage 4 with intact clean edges and pink granulation tissue Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis. 1+ RLE edema, trace LLE edema R tunnelled line without TTP, erythema or drainage. RUE PICC without erythema Pertinent Results: Labs on Admission: [**2122-5-25**] 09:15PM BLOOD WBC-36.2*# RBC-2.73* Hgb-7.8* Hct-25.4* MCV-93 MCH-28.6 MCHC-30.7* RDW-18.3* Plt Ct-326# [**2122-5-25**] 09:15PM BLOOD PT-22.8* PTT-37.2* INR(PT)-2.1* [**2122-5-25**] 09:15PM BLOOD Glucose-90 UreaN-34* Creat-2.1* Na-144 K-3.3 Cl-104 HCO3-22 AnGap-21* [**2122-5-25**] 11:15PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015 [**2122-5-25**] 11:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-150 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [**2122-5-25**] 11:15PM URINE RBC-[**2-13**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 [**2122-5-25**] 11:15PM URINE MUCOUS-FEW Brief Hospital Course: [**Age over 90 **] year old female with CKD on HD, recent pneumonia and UTI admitted with hypotension responsive to fluids, AMS, leukocytosis, tachycardia and positive UA consistent with sepsis 1. Goals of Care: With multiple medical problems and rapid decompensation over the past several months, family decided to redirect goals of care. Initially, patient was made DNR/ DNI and decision was made to stop dialysis. Palliative care and hospice were consulted and care became focused on comfort measures only. All antibiotics, anticoagulation and other unnecessary medications were discontinued. Unnecessary physical exams, vital signs and laboratory test were also discontinued. Methadone, lidocaine patch and dilaudid IV were used to maintain patient comfort. On [**5-30**] at 10:44 pm the patient passed. Family was notified and declined autopsy 2. Sepsis/Hypotension: Admitted with signs consistent with sepsis: SIRS criteria with tachycardia and leukocytosis in setting of suspected infection given positive UA. Etiology was felt to be multifactorial from UTI, PNA and persistent hemodialysis catheter infection (previously diagnosed with staph epi bacteremia). Antibiotic coverage was broadened to vancomycin, meropenem and flagyl. Hypotension was managed with small fluid bolus 250cc as needed to maintain MAP > 60. Blood and urine cultures remained negative. Leukocytosis initially improved but rose to 18.1 on [**5-29**]. At that time, goals of care were changed (see above) so further aggressive treatment of sepsis was discontinued. 3. Bilateral LE DVT: LENI on [**5-26**] showed progressive bilateral DVTs in the setting of a therapeutic INR. Decision was made to pursue an IVC filter, which was placed without complications on [**5-27**]. Coumadin was continued with goal INR of [**1-14**]. As above, following redefinition of goals of care, anticoagulation and blood draws were discontinued. 4. Atrial Fibrillation: Presented with tachycardia and suboptimal rate conrol in the setting of infection, agitation. Continued on BB for rate control as BP tolerates. Maintained on anticoagulation until all unnecessary medications discontinued. 5. Altered mental status: Likely secondary to infection given delirium, waxing [**Doctor Last Name 688**] pattern and similar history with UTIs in past. Delerium precautions with limitation in telemetry, discontinuation of foley and frequent reorientation. Given discomfort, narcotics were continued. Remained intermittently delerious throughout hospital course. 6. Glaucoma: Continued timolol, brimonidine and latonoprost eye drops 7. Sacral decubitus ulcer: Patient found to have sacral decubitus ulcer on admission with no signs of infection. Wound care was consulted and recommendations were followed. Patient noted to have significant pain from wound, managed with lidocaine patch, acetaminophen and methadone as above 8. Hypothyroidism: Continued levothyroxine 9. ESRD: Pt on HD q week with short session on admission. Through hospitalization had progressive renal failure with complete anuria. As per family wishes, hemodialysis sessions were discontinued. Tunneled HD line was left in place the necessity of surgical intervention if removal was to be pursued. Medications on Admission: Amlodipine 5mg Po BID Tylenol 975mg PO q6 hours prn Calcitriol 0.25mg IV qT Th Sat at HD Darbepoeitin at HD Levofloxacin 500mg Po q48 hours, unclear day 1, plan to complete [**5-30**] Methadone 1mg PO BID, 1-2g PO q6 hours prn Miconazole powder Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS prn Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet PO DAILY Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY Timolol Maleate 0.5% One Drop each eye [**Hospital1 **] Coumadin 1mg PO daily Zinc oxide paste TID Albuterol nebs prn Brimonidine 0.15 % Drops Sig: One Drop each eye [**Hospital1 **] Lumigan 0.03 % Drops Sig: One (1) Drop Left eye Ophthalmic HS Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY prn back pain Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID prn Docusate Sodium 100 mg PO BID Omeprazole 20 mg Capsule PO DAILY Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable PO TID (3 times a day) as needed for gas pain. B Complex-Vitamin C-Folic Acid 1 mg Capsule PO daily Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Lactulose 20g PO daily prn Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "38.7" ]

icd9pcs

[ [ [] ] ]

9326, 9335

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258, 280

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2973, 3028

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158,003

2800

Discharge summary

report

Admission Date: [**2128-12-4**] Discharge Date: [**2128-12-8**] Date of Birth: [**2081-2-27**] Sex: F Service: MEDICINE Allergies: Penicillins / Amoxicillin / Bactrim Attending:[**First Name3 (LF) 603**] Chief Complaint: RUQ pain, nausea, fever, LLE swelling Major Surgical or Invasive Procedure: Incision and drainage of left lower extremity abscess, [**2128-12-6**] History of Present Illness: Ms. [**Known lastname **] is a 47 yo female with IDDM and chronic pancreatitis who presents with worsening right upper quadrant abdominal pain for the past 2 days. She describes the abdominal pain as "throbbing." It radiates from her RUQ to her back. She states that her pain is consistent with previous exacerbations of chronic pancreatitis. She has had two episodes of non-bloody, non-bilious emesis for each of the past two days. She states that she also developed a fluid collection on her left lower extremity approximately one week ago. She states that it started as a boil, then opened and started draining pus. She denies any injury to her leg, insect bites, or precipitating factor for this. She states that she has not taken her insulin since Thursday since she has not been feeling well. . She has had subjective fevers at home. She denies chest pain, shortness of breath, cough, dysuria, diarrhea. She endorses a frontal headache for the past several days, but on arrival to the MICU states that it has resolved. She denies any dizziness, loss of balance, falls, or blurred vision. She denies any recurrence of the perirectal abscess from previous hospitalization and she denies any active genital lesions. . On arrival to the ED, T 98.1, HR 78, BP 103/66, RR 16, SpO2 99% on RA. Her glucose was 633 and anion gap was 33. Patient received 50 units IV regular insulin over 30 minutes by accident (incident report filed). She became lethargic and ABG was performed 7.15/33/55. She subsequently was started on D5NS with 40 meq KCl @ 200 cc/hour. Her repeat fingersticks one hour after insulin was 361, 341, 350, 329. She recieved a total of 3 liters NS. A CXR, RUQ ultrasound, and plain films of the left lower extremity were performed. Foot abscess was cultured, and patient received Vancomycin 1 gram. Prior to transfer, insulin gtt at 7 units/hour was started. Past Medical History: 1. Chronic pancreatitis biopsy proven, followed by Dr. [**Last Name (STitle) 13734**] in the past. On chronic narcotics and Pancrease enzymes. 2. IDDM, secondary to chronic pancreatitis, followed by Dr. [**First Name (STitle) 3636**] at [**Last Name (un) **]. Last HbA1c 10.4 in [**3-12**]. 3. Hypertension 4. History of splenic vein thrombosis 5. Depression 6. Mitral regurgitation 8. h/o MRSA bacteremia 9. Genital herpes Social History: She lives with her 21 year-old son. She also has 2 other children. Long-standing smoker, about 15-20 pack-year smoking history. No EtOh. No illicit drug use. She has a fiance [**First Name4 (NamePattern1) 13740**] [**Last Name (NamePattern1) 13741**] who is her HCP. Family History: Her father died of pancreatic cancer at age 56. Her mother died from anesthesia reaction. + h/o breast cancer in family. Physical Exam: T: 97.2 BP: 110/80 HR: 79 RR: 20 O2 99% RA Gen: Pleasant, well appearing middle-aged woman in NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD, No JVD. No thyromegaly. CV: 2/6 SEM. RRR. Split S2. NL S1 LUNGS: CTAB, good BS BL, No W/R/C ABD: NABS. Soft, NT, ND. No HSM EXT: WWP, NO CCE. 2+ DP pulses BL SKIN: Open sore on dorsal aspect of LLE. Draining purulent fluid. New evolving sore on RLE. Erythematous around border. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**2-4**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant . Pertinent Results: ADMISSION LABS: [**2128-12-4**] 05:50PM BLOOD WBC-14.0* RBC-4.74# Hgb-13.6 Hct-42.7# MCV-90 MCH-28.8 MCHC-32.0 RDW-15.7* Plt Ct-633*# [**2128-12-4**] 05:50PM BLOOD Neuts-69.8 Lymphs-26.9 Monos-2.4 Eos-0.7 Baso-0.3 [**2128-12-4**] 05:50PM BLOOD Plt Ct-633*# [**2128-12-4**] 05:50PM BLOOD Glucose-633* UreaN-22* Creat-1.8*# Na-129* K-5.7* Cl-86* HCO3-11* AnGap-38* [**2128-12-4**] 05:50PM BLOOD ALT-10 AST-30 AlkPhos-122* TotBili-0.2 [**2128-12-5**] 03:16AM BLOOD CK(CPK)-46 [**2128-12-4**] 05:50PM BLOOD CK-MB-5 cTropnT-<0.01 [**2128-12-4**] 11:28PM BLOOD Calcium-7.2* Phos-1.5* Mg-1.6 [**2128-12-4**] 11:28PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2128-12-4**] 05:46PM BLOOD Type-[**Last Name (un) **] pO2-55* pCO2-33* pH-7.15* calTCO2-12* Base XS--16 [**2128-12-4**] 05:46PM BLOOD Glucose-596* K-4.9 . . PERTINENT LABS: WBC: 14.0 ([**12-4**]) -> 12.4 -> 8.6 -> 8.8 -> 12.8 ([**12-8**]) Hct: 42.7 ([**12-4**])-> 30.6 -> 33.6 -> 31.5 -> 30.7 ([**12-8**]) Glucose: 633 ([**12-4**]) -> 338 -> 157 -> 126 -> 147 ([**12-8**]). Serum Toxicology Screen: Negative Urine Toxicology Screen: Positive for opiates . [**2128-12-4**] 6:49 pm BLOOD CULTURE #2. **FINAL REPORT [**2128-12-10**]** Blood Culture, Routine (Final [**2128-12-10**]): NO GROWTH. . [**2128-12-4**] 6:10 pm SWAB ABSCESS. **FINAL REPORT [**2128-12-9**]** GRAM STAIN (Final [**2128-12-4**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. WOUND CULTURE (Final [**2128-12-9**]): STAPH AUREUS COAG +. HEAVY GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. 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. DOXYCYCLINE REQUESTED BY DR.[**Last Name (STitle) **]. DOXYCYCLINE SENSITIVE ; sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2128-12-8**]): NO ANAEROBES ISOLATED. . Time Taken Not Noted Log-In Date/Time: [**2128-12-6**] 3:44 pm SWAB Source: LLE. **FINAL REPORT [**2128-12-10**]** GRAM STAIN (Final [**2128-12-6**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. WOUND CULTURE (Final [**2128-12-8**]): STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2128-12-10**]): NO ANAEROBES ISOLATED. . CXR ([**2128-12-4**]): No acute pulmonary process. . RUQ U/S ([**2128-12-4**]): No evidence of acute cholecystitis. Stable common duct dilatation. No increase in size to left lobe of the liver lesion, presumed hemangioma . Tibial XRay ([**2128-12-4**]): Two views of the left lower extremity show no fracture, dislocation, periosteal thickening, or other osseous abnormality. No subcutaneous emphysema is seen in the soft tissues. . . DISCHARGE LABS: . [**2128-12-8**] 06:35AM BLOOD WBC-12.8* RBC-3.64* Hgb-10.3* Hct-30.7* MCV-85 MCH-28.3 MCHC-33.5 RDW-16.9* Plt Ct-436 [**2128-12-8**] 06:35AM BLOOD Plt Ct-436 [**2128-12-8**] 06:35AM BLOOD Glucose-147* UreaN-12 Creat-0.8 Na-138 K-4.3 Cl-107 HCO3-25 AnGap-10 Brief Hospital Course: Patient is 47 yo female with h/o IDDM and chronic pancreatitis who presented with abdominal pain and hyperglycemia, c/w DKA. . #. Diabetic Ketoacidosis: Patient presented with abdominal pain, glucose of 633, and an anion gap of 33. She was transferred to the MICU, where she was placed on an insulin gtt with potassium repletion. She received ~ 7.7 L NS and her AG returned to [**Location 213**]. The next morning, she was restarted on a Humalog insulin sliding scale. She was seen by [**Last Name (un) **], who adjusted this regimen, and her sugars improved on this new scale. It was thought that this episode of DKA was most likely secondary to her pancreatitis flare and left lower extremity infection. . #. Lower extremity abscess: On admission, the patient had an abscess on her LLE and RLE, which had been present for approximately 1 week. The patient has a h/o MRSA abscesses, and cultures returned positive for MRSA. She was also found to have a fluctuant area superior to the abscess, which was subsequently drained by Surgery. The wound was packed twice daily and the dressing was changed each day. The patient was started on Vancomycin IV for the MRSA abscess, and this was changed to a 10-day course of Doxycycline on discharge. . #. Chronic pancreatitis: The patient was admitted with abdominal pain radiating to her back, which she states is consistent with previous episodes of pancreatitis. She was made NPO on admission for probable pancreatitis and was given aggressive fluid rehydration. Her abdominal pain subsided and she was placed back on a regular diet. She was continued on her home regimen of Fentanyl patch, pancreatic enzymes, and Dilaudid for breakthrough pain. . #. Hypertension: Patient has a history of hypertension. She was continued on her home doses of Norvasc, Lisinopril, and Atenolol, and she did not have any acute events during this admission. . #. Depression: Patient was continued on her home dose of Paxil 20 mg daily. . # FEN: Regular, diabetic diet. Replete K > 4 and Mg > 2 . # CODE: Full . Medications on Admission: Lantus 40 units qHS RISS Norvasc 10 mg daily Atenolol 50 mg daily Lisinopril 40 mg daily Pancrease 2 tabs qAC Omeprazole 20 mg daily Oxycodone 5 mg PRN Fentanyl 75 mcg TD q72 hours Prochlorperazine 10 mg PRN nausea Paxil 20 mg daily Colace 100 mg [**Hospital1 **] Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. Disp:*2 patches* Refills:*0* 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 9 days. Disp:*18 Capsule(s)* Refills:*0* 12. Percocet 5-325 mg Tablet Sig: Two (2) Tablet PO three times a day for 6 days. Disp:*36 Tablet(s)* Refills:*0* 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*6 Adhesive Patch, Medicated(s)* Refills:*0* 14. Insulin [**Hospital1 7452**] 300 unit/3 mL Insulin Pen Sig: Forty (40) Units Subcutaneous at bedtime. Disp:*7 pens* Refills:*2* 15. Humalog Pen 100 unit/mL Insulin Pen Sig: as directed Units Subcutaneous qachs: Please use per sliding scale insulin. Disp:*5 pens* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Diabetic Ketoacidosis MRSA Abscess Chronic pancreatitis Secondary: Hypertension Depression Discharge Condition: Good. Discharge Instructions: You were admitted to the hospital because you had severe abdominal pain and your glucose level was extremely high. You were found to be in diabetic ketoacidosis, and you were monitored in the Medical Intensive Care Unit overnight. Your sugars returned to [**Location 213**] and you were seen by the [**Hospital **] clinic, who made some adjustments to your diabetes management. While you were here, you were also found to have an abscess on your lower extremity. Surgery came to see you, and they drained your abscess. You were started on Doxycycline for this infection, which you should continue to take for 10 days. While you were here, we made the following changes to your medications: 1. We increased your fentanyl patch to 100 mg every 72 hours 2. We started you on Percocet for your pain. Please reevaluate your pain medications with Dr. [**Name (NI) **] on Tuesday. 3. We started you on a daily aspirin. 4. We started you on Doxycycline for your infection. Please take this for 9 more days. 5. We started you on a Lidocaine patch for your leg pain. 6. We changed your insulin sliding scale. 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, increasing abdominal pain, fevers, chills, confusion, loss of consciousness, or any other concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 13532**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2128-12-14**] 1:50 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 13532**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2129-1-6**] 1:30 Completed by:[**2128-12-16**]

[ "250.12", "276.1", "682.6", "680.6", "401.9", "V15.81", "041.12", "577.1", "584.9", "311", "424.0" ]

icd9cm

[ [ [] ] ]

[ "86.04" ]

icd9pcs

[ [ [] ] ]

13463, 13520

9489, 11537

333, 406

13665, 13673

3949, 3949

15132, 15425

3081, 3204

11851, 13440

13541, 13644

11563, 11828

13697, 15109

9206, 9466

3219, 3930

256, 295

434, 2332

3966, 4793

4809, 9190

2354, 2780

2796, 3065

26,685

104,751

3257

Discharge summary

report

Admission Date: [**2174-1-4**] Discharge Date: [**2174-1-13**] Date of Birth: [**2102-12-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 458**] Chief Complaint: ICD firing Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: Mr. [**Known lastname **] is a 71 y.o male with history of [**Known lastname 15196**] disease s/p aortic valve replacement, non-ischemic cardiomyopathy with EF of 30% who presented to the hospital after two episodes of VT that occured on the day of admission. The first episode occured after physical exercise with his visiting physical therapist during which time the patient syncopized. Pacer interrogation showed that the VT was at a rate of 286 bpm, terminated by 25 joule shock. The second episode also caused the patient to syncopize, and interrogation found the that the patient was in VT/VF in the afternoon at a rate of 210-220 beats, accellerated to 300-310 with afib morphology, terminated by 34.5 joule shock. Both times, the patient was in a sitting or supine position, and he did not fall down or hit his head. Of note, the patient reports that over the past several months he has noticed a progressive decline in his overall health. He has been increasing short of breath with decreased exercise tolerance overall, with increased overall weakness. . On review of systems, he denied any increased orthopnea, PND, chest pain, fevers, chills, recent flu-like illnesses or rashes. No nausea, vomiting or diarrhea. He has in fact lost weight over the past several months, going from 330lbs to 315lbs. All of the other review of systems were negative. Past Medical History: Cardiomyopathy, congestive heart failure, EF 30-40% Atrial Flutter Atrial Fibrillation NSVT-->s/p ICD [**1-20**] with upgrade to biventricular ICD [**10-22**] c/b pocket hematoma s/p AV Junctional ablation, pacemaker dependent s/p prior mechanical AVR Mitral regurgitation from [**Month/Year (2) 15196**] heart disease . Cardiac Risk Factors: Dyslipidemia, Hypertension . Percutaneous coronary intervention, in *** anatomy as follows: . Pacemaker/ICD, in [**2170-10-23**] (replacement): [**Company 1543**] Concerto C154DWK ICD generator (initial ICD placed in [**1-20**], upgrage in [**10-22**], pocket revision in [**2168-12-21**]) AVJ ablation [**2168-3-1**] . Other Past History: Obstructive sleep apnea-->BiPAP Obesity Osteoarthritis Social History: Married with grown children. Patient is a computer engineer. Lives with wife, who has medical issues including chronic lung disease on O2 therapy at home. Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Mother passed away of a hypertensive stroke Physical Exam: Discharge Exam: Gen: alert, oriented, pleasant HEENT: supple, no JVD CV: irreg irreg, mechanical click for S2, no other murmurs appreciated RESP: CTAB posteriorly ABD: obese, NT, pos BS EXTR: no peripheral edema, feet warm NEURO: A/O, no focal defecits Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Skin: intact Pertinent Results: [**2174-1-4**] 05:08PM BLOOD WBC-5.8 RBC-4.12* Hgb-11.7* Hct-34.9* MCV-85 MCH-28.5 MCHC-33.7 RDW-13.7 Plt Ct-233 [**2174-1-13**] 05:30AM BLOOD WBC-6.9 RBC-4.00* Hgb-11.7* Hct-33.9* MCV-85 MCH-29.3 MCHC-34.7 RDW-13.6 Plt Ct-203 [**2174-1-4**] 05:08PM BLOOD Neuts-63.2 Lymphs-24.0 Monos-8.0 Eos-4.5* Baso-0.2 [**2174-1-4**] 05:08PM BLOOD PT-30.1* PTT-29.3 INR(PT)-3.0* [**2174-1-8**] 03:40AM BLOOD PT-17.8* PTT-107.7* INR(PT)-1.6* [**2174-1-9**] 06:45AM BLOOD PT-29.9* PTT-: 117.4* INR(PT)-3.0* [**2174-1-10**] 06:05AM BLOOD PT-17.0* PTT-56.7* INR(PT)-1.5* [**2174-1-13**] 05:30AM BLOOD PT-30.1* PTT-32.7 INR(PT)-3.0* [**2174-1-4**] 05:08PM BLOOD Glucose-134* UreaN-22* Creat-1.4* Na-139 K-3.4 Cl-102 HCO3-25 AnGap-15 [**2174-1-8**] 03:40AM BLOOD Glucose-139* UreaN-22* Creat-1.2 Na-138 K-3.6 Cl-102 HCO3-26 AnGap-14 [**2174-1-13**] 05:30AM BLOOD Glucose-118* UreaN-27* Creat-1.7* Na-131* K-4.5 Cl-96 HCO3-24 AnGap-16 [**2174-1-6**] 05:45AM BLOOD ALT-18 AST-21 LD(LDH)-239 AlkPhos-51 TotBili-0.3 [**2174-1-4**] 05:08PM BLOOD CK-MB-3 proBNP-1575* [**2174-1-4**] 05:08PM BLOOD cTropnT-0.03* [**2174-1-4**] 11:27PM BLOOD CK-MB-3 cTropnT-0.03* [**2174-1-5**] 04:41AM BLOOD CK-MB-3 cTropnT-0.03* [**2174-1-7**] 05:45AM BLOOD TSH-4.8* [**2174-1-12**] 05:45AM BLOOD Free T4-1.6 --- Cardiology Report Cardiac Cath Study Date of [**2174-1-7**] COMMENTS: 1. Selective coronary amgiography in this right dominant system demonstrated no obstructive coronary artery disease. The LMCA was normal. The LAD, LCx and RCA were large with minor luminal irregularities. 2. Resting hemodynamics revealed mildly elevated right and left sided filling pressures with RVEDP of 13 mm Hg and mean PCWP of 25 mm Hg. FINAL DIAGNOSIS: 1. No significant coronary artery disease. --- Radiology Report CHEST (PORTABLE AP) Study Date of [**2174-1-4**] 6:07 PM FINDINGS: Single frontal view of the chest reveals an AICD with stable position of three intact leads. There is stable cardiomegaly. Again, there is obscuration of the left lower lobe due to the enlarged heart. However, the lungs appear grossly clear. No pleural effusion or pneumothorax is identified. Status post median sternotomy. IMPRESSION: Stable appearance of the chest with stable cardiomegaly. Stable position of AICD and three leads. --- Cardiology Report ECG Study Date of [**2174-1-4**] 6:12:06 PM Sinus rhythm with A-V conduction delay, atrial sensed and ventricular paced rhythm, intermittent atrial pacing. Since the previous tracing of same date ventricular ectopy is absent. Otherwise, baseline artifact on previous tracing makes comparison difficult. Intervals Axes Rate PR QRS QT/QTc P QRS T 70 0 56 276/293 0 0 0 Brief Hospital Course: 71 year old male with history of atrial tachycardias, s/p failed cardioversion and failure of dofetelide, non-ischemic cardiomyopathy with VT, started on amiodarone. . # Ventricular Tachycardia/ Ventricular Fibrillation - Patient's cardiac enzymes were stable, not trending upwards, and Cardiac Catheterization showed only very mild coronary disease, ruling out ischemia as a cause for his VT. Patient was started on amiodarone, completed a 10gm load then continued on 300mg daily. He was monitored on telemetry and showed no signs of prolonged VT. . # Chronic Systolic Congestive Heart failure - Patient's ejection fraction on last Echocardiogram was 30%. Patient described increased abdominal girth but appeared euvolemic on exam. CXR on admission did not indicate fluid overload. He was continued on his home dose of lasix 80mg twice daily and spironolactone. . # Anticoagulation for Mechanical Aortic Valve - Warfarin was held, and patient was bridged with heparin drip for Cardiac Catheterization; warfarin was restarted after Cath with heparin bridge until INR reached >2.5. Goal INR 2.5-3.5 for mechanical aortic valve. He was discharged on his home warfarin regimen of alternating 8mg with 9mg; however, because amiodarone is known to interact with warfarin metabolism, patient may require adjustment of his warfarin dose at home. He has a home INR monitoring device, and his coumadin is managed by Dr. [**Last Name (STitle) **] as an outpatient. . #Hypertension - Blood pressure was well controlled on home dose losartan 25mg daily and carvedilol 12.5mg twice daily. . #Chronic Kidney disease - Patient's creatinine was 1.4 on admission and relatively stable until discharge when it peaked at 1.7, likely pre-renal. He should follow up with his primary care physician in the next couple of weeks to have his electrolytes and creatinine rechecked. . #Anemia, chronic - Patient's hematocrit remained stable at 33, normocytic. . #Hyperlipidemia - Patient was continued on atorvastatin 80mg. Medications on Admission: atorvastatin 10mg carvedilol 12.5 [**Hospital1 **] dofetilide 500mcg [**Hospital1 **] flomax 0.8 qhs advair 250/50 [**Hospital1 **] furosemide 80mg [**Hospital1 **] losartan 25mg qd nasacort 55mcg 2 puffs each nostril [**Hospital1 **] nitrofurantoin 50mg qd omeprazole 20mg [**Hospital1 **] proscar 5mg qd spironolactone 25mg qd warfarin 9mg STTS, 8mg MWF aspirini 81mg qd Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1) Capsule PO Q 24H (Every 24 Hours). 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 9 days. Disp:*18 Tablet(s)* Refills:*0* 12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Warfarin 1 mg Tablet Sig: Nine (9) mg PO Once Daily at 4 PM: Sun, Tues, thurs, Sat 8mg Mon, Wed, Fri. 14. Amiodarone 100 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Ventricular Tachycardia Mechanical Aortic Valve Replacement Non ischemic cardiomyopathy, EF 30% ATrial Fibrillation Hypertention Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You had some ventricular tachycardia and your device discharged with a shock. We discontinued dofetalide and started amiodaorone. This has helped tremendously with preventing ventricular tachycardia. You had a cardiac catheterization that did not show any significant blockage that would cause ventricular tachycadia. You were in the hospital on a heparin drip waiting for your INR to increase again. . Medication changes: 1. Stop Dofetalide 2. Start Amiodarone, 200mg twice daily for 9 days, then 300 mg daily thereafter. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Primary Care: [**Last Name (LF) 7476**],[**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 7477**] Date/time: [**1-20**] at 4:30pm. Pulmonary: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2174-3-22**] 11:00 Cardiology: Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time: [**2174-3-10**] 8:40 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-6-16**] 9:30 Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-6-16**] 10:20

[ "425.4", "403.90", "272.4", "427.1", "496", "278.00", "585.9", "428.22", "V43.3", "715.90", "428.0", "427.41", "285.21" ]

icd9cm

[ [ [] ] ]

[ "89.49", "37.23", "88.56" ]

icd9pcs

[ [ [] ] ]

9725, 9788

5974, 7978

325, 351

9961, 9961

3277, 4966

10778, 11639

2812, 2939

8401, 9702

9809, 9940

8004, 8378

4983, 5951

10109, 10512

2954, 2954

2970, 3258

10532, 10755

275, 287

379, 1750

9976, 10085

1772, 2515

2531, 2796

2,846

195,990

5649

Discharge summary

report

Admission Date: [**2209-2-9**] Discharge Date: [**2209-2-14**] Date of Birth: [**2158-8-2**] Sex: F Service: ORTHOPAEDICS Allergies: Aspirin / Clonidine / Codeine / Compazine / Decadron / Depakote / Dilantin / Doxycycline / Elavil / Equagesic / Fentanyl / Gabapentin / Halcion / Klonopin / Lanolin / Lasix / Mefoxin / Methadone / Motrin / Naprosyn / Parafon Forte Dsc / Percodan / Septra Ds / Stadol / Sulfonamides / Talwin / Tegretol / Tetracycline / Zaroxolyn / Ciprofloxacin / Prochlorperazine / Amitriptyline / Albuterol / Iodine; Iodine Containing / Protonix / Food Suppl,Misc. Combo.No.1 / Sumatriptan / Zolmitriptan / Adhesive Tape / Doxycycline / Depakene Attending:[**First Name3 (LF) 64**] Chief Complaint: Right Knee Pain Major Surgical or Invasive Procedure: Right Total Knee Arthroplasty Reintubation Post-operatively History of Present Illness: ORTHO Summary: Patient is a 50 yo F with bilateral knee pain for several years. The pain began insidiously and has progressively gotten worse. She experiences locking in both knees, as well as medial and lateral-sided joint line pain. She has pain on a daily basis and the pain is as severe as [**10-22**] with activity and [**7-22**] at rest. She has had multiple corticosteroid injections in the past bilaterally. These have provided short-term relief. She takes Vicodin and tramadol for the pain. Of note, she has an atypical form of complex regional pain syndrome affecting her entire body for which she takes periodic ketamine infusions. She has also lost her right upper extremity due to what was described as a form of RSD. She now presents for elective right TKR. MICU Summary: Patient is a 50 yo F with PMHx sig. for reflex sympathetic dystrophy of the R arm s/p forearm amputation and osteoarthritis who was admitted for elective R total knee replacement and failed extubation due to depressed mental status and apnea. She had a lumbar epidural placed and also received general anesthesia with propofol, midazolam, and ketamine gtt. She also received dilaudid, total of 3 mg. When she was extubated in the [**Month/Year (2) 13042**], she was noted to be somnolent and apneic and was reintubated. Currently, per report, patient is more alert. However, [**Name6 (MD) **] [**Name8 (MD) 13042**] RN, on 0/5 sje would have falling tidal volumes. Per family, this has happened in the past. Past Medical History: ORTHO Summary: PMH: Complex regional pain syndrome as described above, Hirschsprung disease, bleeding gastric ulcers, gastroesophageal reflux disease. PSH: Previous foot surgery, hysterectomy for endometriosis, colostomy which was previously reversed, [**2184**] right hand amputation. MICU Summary: -Complex regional pain syndrome since injury of R hand in [**2181**]; s/p amputation of R arm after gangrene (due to clenched fist/contractures which caused nail growth into palm) in [**2184**], CRPS now involving bilateral lower extremities. -Myofascial pain syndrome -Rashes/hypersensitivity to a wide range of drugs and products -History of alcoholism -Migraines. -Hirshsprung's disease s/p colostomy takedown in teenage years. -Chronic back pain due to disc disease -GERD -s/p hysterectomy Social History: Lives alone; has two personal care assistants who spend 7-8 hrs a day with her. Previous alcoholism, sober since [**2180**]. Smoked cigarettes for 20 years at 1-2 ppd, has not smoked for many years. Does not use recreational drugs. Family History: Family hx of ovarian CA (grandparent) Physical Exam: ORTHO Summary: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosantguinous drainage * No calf tenderness * 5/5 strength TA/GS/[**Last Name (un) 938**]/FHL * SILT DP/SP/T/S/S * Toes warm MICU Summary: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2209-2-10**] 04:34AM BLOOD WBC-13.9*# RBC-3.63* Hgb-11.3* Hct-33.1* MCV-91 MCH-31.2 MCHC-34.1 RDW-12.3 Plt Ct-195 [**2209-2-10**] 04:34AM BLOOD Glucose-127* UreaN-16 Creat-0.5 Na-140 K-3.7 Cl-108 HCO3-25 AnGap-11 [**2209-2-11**] 05:17AM BLOOD WBC-11.0 RBC-3.29* Hgb-10.5* Hct-29.9* MCV-91 MCH-31.9 MCHC-35.1* RDW-12.6 Plt Ct-183 [**2209-2-11**] 05:17AM BLOOD Glucose-96 UreaN-12 Creat-0.5 Na-142 K-3.4 Cl-109* HCO3-27 AnGap-9 Calcium-8.4 Phos-1.6*# Mg-1.9 [**2209-2-11**] 05:17AM BLOOD PT-17.2* PTT-37.4* INR(PT)-1.5* [**2209-2-12**] 05:32AM BLOOD WBC-10.7 RBC-3.33* Hgb-10.6* Hct-29.8* MCV-89 MCH-31.7 MCHC-35.4* RDW-12.5 Plt Ct-202 [**2209-2-12**] 05:32AM BLOOD PT-23.4* PTT-39.7* INR(PT)-2.2* [**2209-2-13**] 07:15AM BLOOD WBC-9.8 RBC-3.14* Hgb-10.2* Hct-28.5* MCV-91 MCH-32.4* MCHC-35.6* RDW-12.3 Plt Ct-207 [**2209-2-13**] 07:15AM BLOOD PT-29.7* INR(PT)-2.9* [**2209-2-14**] 05:44AM BLOOD WBC-8.7 RBC-3.12* Hgb-9.7* Hct-28.3* MCV-90 MCH-31.1 MCHC-34.4 RDW-12.4 Plt Ct-231 [**2209-2-14**] 05:44AM BLOOD PT-21.7* INR(PT)-2.0* Brief Hospital Course: ORTHO Summary: The patient was admitted on [**2209-2-9**] and was taken to the operating room by Dr. [**Last Name (STitle) **] for a right total knee arthroplasty without complication. Please see operative report for details. Postoperatively the patient was extubated and arrived in the [**Last Name (STitle) 13042**] with respiratory distress. She was reintubated emergently and stabilized by the anesthesia team. She was then transferred to the MICU and extubated uneventfully the following day. Pain was controlled by the Chronic Pain Service using a ketamine gtt that was transitioned to PO dilaudid. The patient was placed in a CPM machine with range of motion that started at 0-45 degrees of flexion before being increased to 90 degrees as tolerated. The patient received IV antibiotics for 24 hours postoperatively, as well as a lovenox bridge to coumadin for DVT prophylaxis. The surgical drain was removed without incident. The foley catheter was removed and the patient initially failed to void. She underwent a straight-cath x1 was subsequently voiding independently. The surgical dressing was changed on and the surgical incision was found to be clean and intact without erythema or abnormal drainage. While in the hospital, the patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. Her hematocrit was accepatable and her pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. Post-operative Xrays demonstrated hardware in good position. On the day of discharge the patient reported right-sided crampy calf pain. An ultrasound to r/o DVT was negative. The patient was discharged to home with services in stable condition. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. MICU Summary: 50 yo F who was admitted for elective R total knee replacement and failed extubation due to depressed mental status and apnea. . # Failed extubation: Possibly due to sedative effect on respiratory drive as pt has a history of relatively prolonged intubation postoperatively. Patient herself was awake and interactive. She had apneic periods overnight after intubation, again likely due to sedatives peri-op. These resolved and she was successfully extubated [**2-10**], and she had no further apnea. She was stable on room air after extubation. . # R total knee replacement: Pain controlled with ketamine and Dilaudid. Pain service was involved in managing transition to home regimen. Received perioperative cefazolin. Started lovenox for DVT ppx. Medications on Admission: ALMOTRIPTAN MALATE [AXERT] - 12.5 mg Tablet - 1 Tablet(s) by mouth once as needed for HA may repeat in 2 hours if still having symptoms. NOT for Daily use. Axert is ONLY Migraine Med working for her CLOBETASOL - 0.05 % Cream - apply to affected area twice a day CONJUGATED ESTROGENS [PREMARIN] - (Prescribed by Other Provider) - 0.3 mg Tablet - 1 Tablet(s) by mouth once a day DARIFENACIN [ENABLEX] - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] - 7.5 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day takes 15 qAM and 7.5 qHD EFLORNITHINE [VANIQA] - 13.9 % Cream - apply to affected areas twice a day seperate by 8 hours. leave on for at least 8 hours FLUOCINONIDE [LIDEX] - 0.05 % Cream - apply to area twice a day HYDROCODONE-ACETAMINOPHEN [VICODIN ES] - (Prescribed by Other Provider) - 7.5 mg-750 mg Tablet - 1 to 2 Tablet(s) by mouth 5 times a day as needed OMEPRAZOLE [PRILOSEC] - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day TRAMADOL [ULTRAM] - 50 mg Tablet - 1 Tablet(s) by mouth q6 hours as needed for pain GLUCOSAMINE HCL & SULFATE MIX [GLUCOSAMINE COMPLEX] - 500 mg-400 mg Capsule - 2 Capsule(s) by mouth qday LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day as needed for allergy symptoms Discharge Medications: 1. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM for 6 weeks: For DVT prophylaxis after TKA. Coumadin dosing per INR results: goal INR 2-2.5. Disp:*84 Tablet(s)* Refills:*0* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): Do not exceed 4000mg Tylenol in 24hrs. . 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for loose stools. Disp:*60 Capsule(s)* Refills:*0* 4. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:*90 Tablet, Chewable(s)* Refills:*2* 8. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): To affected areas. 9. Conjugated Estrogens 0.3 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): To affected areas. 11. Enablex 15 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO QAM (once a day (in the morning)). 12. Enablex 7.5 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO QPM (once a day (in the evening)). 13. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML Intravenous PRN (as needed) as needed for 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. . Disp:*60 ML(s)* Refills:*2* 14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Five (5) ML Intravenous PRN (as needed) as needed for DE-ACCESSING port: Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. . Disp:*60 ML(s)* Refills:*2* 15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 16. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 17. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**1-14**] Sprays Nasal DAILY (Daily). 18. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain: Do not drive, operate machinery, or drink alcohol while taking this medication. As your pain decreases, take fewer tablets and increase the time between doses. Take a stool softener to prevent constipation. Disp:*100 Tablet(s)* Refills:*0* 19. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain with increased activity only: Do not drive, operate machinery, or drink alcohol while taking this medication. As your pain decreases, take fewer tablets and increase the time between doses. FOR BREAKTHROUGH PAIN ONLY. Disp:*80 Tablet(s)* Refills:*0* 20. CPM Machine Please use CPM machine as directed by PT, 0 to 90 degrees [**2-15**] times per day for 2-3 hours per day. Discharge Disposition: Home With Service Facility: [**Hospital 17718**] Health Care Discharge Diagnosis: Right Knee Osteoarthritis Failed Extubation Discharge Condition: AVSS, hemodynamically stable, pain well-controlled, tolerating a regular diet, voiding independently, ambulating with crutches, neurovascularly intact distally. Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may shower starting five days after surgery, but no tub baths or swimming for at least four weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in two to four weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue the coumadin for six weeks to help prevent deep vein thrombosis (blood clots). Your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and the [**Hospital1 18**] anticoagulation service will coordinate INR checks and coumadin dosing. Your VNA should take care of the blood draws. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two weeks. 11. VNA (once at home): Home PT/OT, INR blood draws and coumadin monitoring, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. No strenuous exercise or heavy lifting until follow up appointment. Please use CPM machine as directed by PT, 0 to 90 degrees 2-3 times per day for 2-3 hours per day. Physical Therapy: ACTIVITY: Weight bearing as tolerated on the operative extremity. No strenuous exercise or heavy lifting until follow up appointment. Please use CPM machine as directed by PT, 0 to 90 degrees 2-3 times per day for 2-3 hours per day. Treatments Frequency: WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two weeks. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2209-3-10**] 12:40 Completed by:[**2209-2-14**]

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Discharge summary

report

Admission Date: [**2129-7-18**] Discharge Date: [**2129-7-26**] Service: MEDICINE Allergies: [**Doctor First Name **] Attending:[**First Name3 (LF) 30**] Chief Complaint: Increased lower extremity edema and change in mental status Major Surgical or Invasive Procedure: None History of Present Illness: This is an 84 yo female with a history of dementia, htn, hypothyroidism, TIA ([**9-1**]) who is being transferred to the CCU for hypotension, hypoxia, and altered mental status. She was initially admitted overnight on [**7-18**] to the general medicine service. She presented from a long term care facility with increased confusion and new lower extremity edema. Her daugheter expressed that her mother had decreased appetite and confusion over the last 10 days. Doctors at [**Name5 (PTitle) **] nursing home started her on Remeron. Per her nursing facility records she gained 10 lbs in 2 days. Presumably for this reason she was referred for a cardiology evaluation (appt scheduled with Dr. [**First Name (STitle) 437**] [**7-25**].) However, she became increasingly confused and unable to take [**Last Name (LF) **], [**First Name3 (LF) **] she was referred to [**Hospital1 18**] ED. . In the ED, VS: 96.4 73 123/91 18 97% on 4L. Patient agitated and given haldol 5mg IV x 1. She also received 1mg IV ativan prior to CT head which was negative. A CXR showed bilateral pleural effusions L>R and moderate pulmonary edema. ECG was read as unchanged from prior tracing [**9-1**]. Troponin was .29, rising to 0.36. BNP was >8000. Cardiology was consulted and felt this troponin bump most likely attributed to heart failure rather than ACS. Patient admitted to medicine for further work-up of CHF. . Upon arrival to the floor, patient had a 4 L O2 requirement and appeared volume overloaded. ABG 7.44/73/32 on 4L. She was given 80 mg IV lasix, after which she made 700 cc urine within 1 hour. SBP fell from baseline 140s to a low of 67. Her mental status continued to be arousable but drowsy. She was given ~100 cc NS and SBP rose into the 80s. Notably, her respiratory status apparently improved and O2 Sats rose to upper 90s on 4L. . There was suspicion for pulmonary embolism as a cause of her hypoxia. CT for PE could not be done secondary to poor renal function. Echocardiocardiogram was done to evaluate for signs of R heart strain, and indeed demonstrated severe RV dilatation and abnormal septal motion consistent with RV pressure/volume overload new compared to prior echo 10/[**2127**]. PA pressures could not be estimated. Small pericardial effusion was also noted. Heparin gtt without initial bolus was started for empiric treatment of PE. . The patient's urine output trailed off to ~15cc/h, her SBP remained in the 80s, and her mental status continued to be suboptimal. [**Hospital 75195**] transfer to the CCU was initiated for workup of new RV dilatation, apparent R sided heart failure, further diuresis in the setting of borderline hypotension and preload dependence, and altered mental status. . On arrival to the CCU, patient was initially lethargic and could provide only limited information. She denied any difficulty breathing or chest pain. She further denied nausea or abdominal pain. Her only complaint is feeling extremely cold. Past Medical History: (per nursing facility records and OMR): HTN TIA Dementia Hypothyroidism, hx [**Doctor Last Name 933**] disease, s/p RAI Rx [**2059**] Anemia Urge Incontinence Osteopenia Vitamin B12 deficiency Social History: Patient currently resides at [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing center in [**Location (un) 538**] after being hospitalized at [**Hospital1 18**] for burns she sustained on her legs 2/[**2127**]. At that time she was found to be living in sub-optimal conditions with her daughter in a run-down house which was poorly insulated therefore needing a lot of space heaters that led to pts burns. Pt was also appointed a healthcare proxy. [**Name (NI) **] current tobacco, alcohol, or IVDA. (Per OMR) Family History: Per daughter: Brother with [**Name2 (NI) 499**] cancer in his 60s or 70s. Sister with breast cancer in her 70s. Another sister with thyroid cancer, ?kidney/pancreas mass. Per OMR: Her mother "dropped dead" in her 40s/50s in front of her (sudden death). Her sister "dropped dead" at age 23 in front of her (sudden death). Her father died in his 50s of unknown cause, and had a history of arthritis. She has 11 siblings who have died, none suddenly or from known cardiac causes. Physical Exam: Vitals - Temp 99.6 Rectally BP 146/53 HR 71 RR 23 Sat 99% 3L NC GENERAL: lethargic appearing African American female, arousable to sternal rub and drowsy during examination HEENT: Normocephalic, atraumatic. No scleral icterus. pupils constricted bilaterally. MMM. OP clear. Neck Supple, No LAD CARDIAC: Regular rhythm, normal rate. Normal S1, Split S2. No murmurs, rubs or gallops. No pericardial knock. Appropriate decrease in JVP with respirations. No pulsus parodoxus. No hepatojugular reflex appreciated. LUNGS: Dependent crackles currently laying on the left side. Decreased breath sounds at the bases. ABDOMEN: Normal active BS. Soft, NT, ND. No HSM EXTREMITIES: 2+ LE edema R>L Dopplerable DP/PT bilaterally. SKIN: No rashes/lesions, ecchymoses. Scar on right shin well healed. NEURO: AOx 1 (person) she is under the impression that she's currently at "[**Location (un) **]." Moving all 4 extremities. Unable to perform rest of neurologic evaluation given pt would not comply. Grossly face is symmetric. Pertinent Results: LABS ON ADMISSION: [**2129-7-18**] 07:45PM BLOOD WBC-4.7 RBC-5.97*# Hgb-14.8 Hct-44.3# MCV-74* MCH-24.7*# MCHC-33.4 RDW-17.7* Plt Ct-144* [**2129-7-18**] 07:45PM BLOOD Neuts-71.8* Lymphs-20.8 Monos-6.8 Eos-0.4 Baso-0.2 [**2129-7-19**] 11:30AM BLOOD PT-15.7* PTT-40.1* INR(PT)-1.4* [**2129-7-18**] 07:45PM BLOOD Glucose-131* UreaN-21* Creat-1.3* Na-134 K-4.6 Cl-104 HCO3-22 AnGap-13 [**2129-7-18**] 07:45PM BLOOD Free T4-1.3 [**2129-7-18**] 07:45PM BLOOD TSH-3.7 [**2129-7-18**] 07:45PM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1 CARDIAC ENZYMES: [**2129-7-18**] 07:45PM BLOOD CK(CPK)-55; CK-MB-5 proBNP-8096*; cTropnT-0.29* [**2129-7-19**] 01:08AM BLOOD CK-MB-5; cTropnT-0.36* [**2129-7-19**] 11:30AM BLOOD CK(CPK)-135; CK-MB-5 cTropnT-0.43* [**2129-7-19**] 07:00PM BLOOD CK(CPK)-114; CK-MB-5 cTropnT-0.44* [**2129-7-20**] 01:25AM BLOOD CK(CPK)-97; CK-MB-NotDone cTropnT-0.46* [**2129-7-22**] 04:45AM BLOOD cTropnT-0.36* RELEVANT INTERVAL LABS [**2129-7-21**] 11:40PM BLOOD LMWH-0.4 [**2129-7-19**] 11:30AM BLOOD Albumin-3.1* Calcium-8.3* Phos-3.5 Mg-2.0 [**2129-7-19**] 11:30AM BLOOD D-Dimer-5451* LABS AT DISCHARGE: [**2129-7-26**] 07:30AM BLOOD WBC-4.4 RBC-5.37 Hgb-13.1 Hct-40.1 MCV-75* MCH-24.4* MCHC-32.7 RDW-18.7* Plt Ct-134* [**2129-7-26**] 07:30AM BLOOD PT-31.7* PTT-68.9* INR(PT)-3.2* [**2129-7-26**] 07:30AM BLOOD Glucose-101 UreaN-20 Creat-1.1 Na-145 K-4.0 Cl-110* HCO3-26 AnGap-13 MICROBIOLOGY [**2129-7-18**] Urine Cx: No growth. [**2129-7-18**] Blood Cx: No growth. [**2129-7-19**] Blood Cx: No growth. STUDIES: ECG [**2129-7-18**]: Sinus rhythm. Consider left atrial abnormality. Indeterminate axis. There is an SI-Q3-T3 pattern. Modest right ventricular conduction delay pattern. Delayed R wave progression with late precordial QRS transition. Diffuse T wave abnormalities. Findings are non-specific but clinical correlation is suggested for possible right ventricular overload. Compared to the previous tracing of [**2128-9-19**] findings as outlined are now present. ECHO [**2129-7-19**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is markedly dilated. Right ventricular regional function cannot be assessed. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild mitral valve prolapse. Trivial mitral regurgitation is seen. The supporting structures of the tricuspid valve are thickened/fibrotic. There is at least borderline pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. IMPRESSION: Suboptimal image quality. Severe right ventricular dilation. Abnormal septal motion consistent with right ventricular pressure/volume overload. Pulmonary pressures cannot be adequately assessed. Preserved global systolic function. Small circumferential pericardial effusion. Compared with the prior study (images reviewed) of [**2128-9-20**], severe right ventircular dilation is now present. The right ventricle appears to have been mild to moderately dilated on prior study, but views were limited. CXR [**2129-7-19**]: AP chest compared to [**7-19**], 3:46 a.m., heterogeneous bibasilar opacification has worsened. In the setting of progressive moderate-to-severe cardiomegaly and upper lobe vascular engorgement, this is most readily explained by dependent pulmonary edema, but pneumonia particularly aspiration could be contributing. Bilateral pleural effusion is at least small. Leftward deviation of the trachea at the thoracic inlet developed since [**2128-8-25**] could be due to progressive tortuosity of the innominate artery or interval development of a space-occupying lesion, most commonly a goiter but not necessarily benign. When feasible, clinical evaluation is recommended. CXR [**2129-7-20**]: Opacification at the lung bases is improving and moderate cardiomegaly may have improved as well all pointing toward decreasing cardiac decompensation and improving pulmonary edema. Small bilateral pleural effusions persist left greater than right. The greater extent of opacification at the left lung base makes pneumonia a possibility. Leftward displacement of the trachea at the thoracic inlet points to a space occupying lesion such as a goiter, but requires evaluation since this is a new finding since [**2128-8-25**]. Dr. [**Last Name (STitle) 303**] was paged. EKG [**2129-7-21**]: Sinus rhythm. Non-specific ST-T wave changes. Compared to the previous tracing of [**2129-7-20**] ventricular ectopy is resolved. CTA Chest [**2129-7-21**]: Dilatation of the right atrium, ventricle, and pulmonary artery with filling defect in the main pulmonary artery which extends into the left pulmonary arteries. There is also bowing of the interventricular septum suggesting right heart strain. This filling defect in the pulmonary artery could represent a saddle embolism, however, due to the increased density of contrast and early bolus timing, mixing artifact in the pulmonary artery should also be considered. The case was discussed with Dr. [**Last Name (STitle) **] and a decision to anticoagulate and repeat the study at a later date was planned due to elevated creatinine. Moderate-to-large bilateral pleural effusions. Brief Hospital Course: 84 yo female with dementia (AAO x [**11-26**]), CAD s/p NSTEMI in [**1-2**], TIA in [**9-1**], hypothyroidism, stable meningioma p/w increased lethargy, weight gain, and LE edema, hypoxic to 94% 4L on presentation found to be in acute right sided diastolic failure secondary to pulmonary embolism. 1. Acute diastolic right heart failure: On [**Name (NI) **], pt with severe RV dilatation new since [**9-1**], at least borderline PA systolic HTN, and nl LVEF. LENIs negative and subsequent CTA equivocal (saddle-embolic v. mixing artifact w/ suboptimal study) but submassive-massive subacute PE most likely etiology of RV failure; LV failure may have been due to RV impingement of LV filling. Pt was started on heparin for treatment of PE, and later transitioned to warfarin 5mg with lovenox bridging. Lovenox was discontinued on [**7-25**] given supratherapeutic INR of 3.2, and warfarin held [**7-25**] and restarted at 2.5mg on [**2129-7-26**]. Pt's INR to be monitored at longterm nursing facility with goal INR [**12-28**]. She will likely require at least a one-year course of anticoagulation given her degree of cardiac impairment, with the duration to be weighed against the risk of bleed. Her ASA was decreased to 81mg daily given starting of warfarin. 2. Left heart failure: Pt fluid overloaded on presentation. [**Month/Day (3) **] showed nl EF although some degree of diastolic dysfunction was suspected. It was postulated that RV dilatation have been impinging on LV filling and forward flow due to the septal wall motion abnormality observed. Pt was transferred to CCU initially as she became hemodynamically unstable in the setting of diuresis, likely due to her preload dependence. In the CCU, she was first diuresed with a furosemide drip, then transitioned to IV boluses and with good effect. She was transferred back to the floor after ~2.5L diuresis with stable BP and O2 sats 90-94% RA. She appeared to have improving forward flow and on discharge, O2sat 93% on RA and furosemide requirement 20 mg PO daily, with possibility of weaning patient off furosemide in outpatient setting. Patient did have some desaturation to 80s% during night, possibly OSA, but CPAP would not be tolerated due to her dementia. . 3. Acute renal failure: Baseline creatinine 0.9. On admission, it was 1.3, reaching a peak of 1.4 in the CCU. This was thought secondary to poor forward flow in the setting of CHF. This improved back to baseline with diuresis. She did receive Mucomyst for her CTA chest, and all of her medications were renally dosed. . 4. Confusion/Lethargy: Patient with waxing and [**Doctor Last Name 688**] level of consciousness on admission as well as intermittent disorientation. This was likely secondary to medication effect from ativan and haldol received in the ED as well as due to acute illness including hypoxia and hypotension. CT head negative; urine culture negative, and blood cultures with no growth; TFTs nl; electrolytes nl; BUN elevated but not frankly uremic level. Her Remeron (started recently for anorexia) was held. Her mental status significantly improved within 48 hrs with pt becoming more animated and interactive although she was unable to state the season, DOB, and where she currently resides. She did have several nights of agitation requiring soft restraints and IV Haldol, but 2 nights before discharge, patient slept through the night and did not require chemical or mechanical restraints. Patient was oriented x1 by discharge, which appears to be similar to baseline dementia. . 5. Anorexia: Daughter and HCP reported declining ability to take PO. Possibly secondary to worsening dementia vs. subacute medical illness. Remeron was recently started for this, unclear if this had been helpful. As mentioned above her Remeron was held since it was thought to possibly be contributing to her change in mental status. A nutrition consult was requested, and they recommended low sodium diet of pureed solids, thin liquids, and Ensure supplements. Because the patient did not consistently finish PO meals, nutrition recommended 1584 Kcal/70g protein tube feeds at 55 ml/hr if it was consistent with the patient's goals of care. The patient's guardian [**Name (NI) **] [**Name (NI) 96421**] stated that tube feeds were not desired at this time. A speech and swallow consult was sought since patient has dementia and is at risk for aspiration. We encourage supervised feedings once the patient returns to her nursing home. . 6. Bradycardia: Pt had been on metoprolol per NH records although this had been discontinued per her most recent PCP note in [**10-2**] due to possible role in TIA. She also had been noted to have asymptomatic episodes of bradycardia to 30s in the past which were also observed on this admission. For these reasons, her metoprolol was once again discontinued on this admission. Medications on Admission: Senna 2 tabs qhs ASA 325 mg daily Vitamin B12 1000mcg daily Synthroid 125 mcg daily Simvastatin 40mg daily Colace 1 cap [**Hospital1 **] Mylanta 30ml [**Hospital1 **] Robitussin 10mg Q4: PRN cough Tylenol 650mg Q6hrs:PRN Milk of Mag PRN Fleet Enema PRN Remeron Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for constipation. 5. Cyanocobalamin 100 mcg Tablet Sig: Ten (10) Tablet PO DAILY (Daily). 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day) as needed for constipation. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 10. Milk of Magnesia 400 mg/5 mL Suspension Sig: [**4-8**] ml PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**] Discharge Diagnosis: Primary: - Massive pulmonary embolism - Acute diastolic heart failure - Non-thrombotic troponin elevation - Acute renal failure - Delirium Secondary diagnosis: - Hypothyroidism - Hypertension - Dementia Discharge Condition: Stable Discharge Instructions: You were admitted with increased lower extremity swelling, increased weakness, weight gain, and decreased oxygenation. You were found to have a clot in your lung that was responsible for fluid overload. You were initially admitted to the cardiac intensive care unit and was treated with medications to decrease fluid overload. You were also started on blood thinning medications. Please continue your home medications with the following additions and changes: - You need to take warfarin (Coumadin) blood thinning pills. - You need to take furosemide (Lasix) to prevent fluid buildup. - Please stop taking your metoprolol due to slow heart rate. - Please stop taking your Remeron due to leading to increased sleepiness. Please weigh yourself daily. Please call your primary care physician or return to the hospital if you experience any increased shortness of breath, palpitations, chest pain, lower extremity swelling, if you gain more than 3 lbs, or for any other concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2129-8-2**] 10:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 94291**], M.D. Date/Time:[**2129-8-30**] 12:20 Completed by:[**2129-7-27**]

[ "788.31", "799.02", "V12.54", "415.19", "790.5", "780.79", "427.89", "293.0", "428.0", "733.90", "783.0", "428.31", "412", "225.2", "401.9", "244.1", "294.8", "584.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

17212, 17366

11201, 16051

290, 297

17614, 17623

5616, 5621

18660, 18933

4089, 4569

16362, 17189

17387, 17527

16077, 16339

17647, 18637

4584, 5597

6154, 6709

191, 252

6728, 11178

325, 3301

17548, 17593

5635, 6137

3323, 3518

3534, 4073

82,820

159,575

36692

Discharge summary

report

Admission Date: [**2138-7-7**] Discharge Date: [**2138-7-11**] Date of Birth: [**2089-12-1**] Sex: M Service: CARDIOTHORACIC Allergies: Shellfish Derived Attending:[**First Name3 (LF) 1505**] Chief Complaint: Abnormal stress test Major Surgical or Invasive Procedure: [**2138-7-7**] Two Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending with vein graft to obtuse marginal. History of Present Illness: Mr. [**Known lastname 72596**] is a 48-year- old gentleman who ruled in for a non-ST-elevation myocardial infarction back in [**2137-11-14**] following an emergent appendectomy. Subsequent stress testing was consistent with ischemia revealing inferior and inferolateral defects. Since that time, he has been maintained on medical therapy andunderwent a cardiac catheterization in [**2138-6-14**] which revealed severe three-vessel coronary artery disease. Based on transthoracic echocardiogram in [**2138-5-14**], he has a normal ejection fraction with no significant valvular disease. Based on the above results, he was referred for surgical revascularization. Past Medical History: Coronary artery disease, non-ST-elevation MI in [**2137-11-14**] Hypertension Type 2 diabetes mellitus Elevated cholesterol Appendectomy Social History: Active smoker for 30 years. Social ETOH. Family History: Negative for premature coronary artery disease. Physical Exam: BP 134/71, P 91, 100% sat on RA, RR 18 well developed male in no acute distress lungs were clear bilaterally heart had regular rate and rhythm, normal s1s2 no murmur or rub abdomen was soft, nontender, nondistended with normoactive bowel sounds extremities were warm, no edema [**11-15**]+ distal pulses, no carotid bruits were noted alert and oriented, cranial nerves grossly intact, normal gait no focal motor deficits noted Pertinent Results: [**2138-7-7**] Intraop TEE: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. 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. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: Preserved biventricular systolic function. Trace MR, no AI. Aorta intact. Other parameters as pre-bypass. LABS: [**2138-7-11**] 03:14AM BLOOD WBC-9.5 RBC-3.08* Hgb-7.5* Hct-23.7* MCV-77* MCH-24.5* MCHC-31.8 RDW-15.3 Plt Ct-184 [**2138-7-10**] 04:15AM BLOOD WBC-11.7* RBC-3.11* Hgb-7.7* Hct-24.0* MCV-77* MCH-24.7* MCHC-32.1 RDW-15.8* Plt Ct-151 [**2138-7-9**] 02:22AM BLOOD WBC-15.6* RBC-3.38* Hgb-8.2* Hct-25.7* MCV-76* MCH-24.4* MCHC-32.0 RDW-14.9 Plt Ct-166 [**2138-7-11**] 03:14AM BLOOD Glucose-129* UreaN-21* Creat-0.9 Na-137 K-4.0 Cl-100 HCO3-30 AnGap-11 [**2138-7-10**] 04:15AM BLOOD Glucose-184* UreaN-24* Creat-1.0 Na-134 K-3.9 Cl-98 HCO3-29 AnGap-11 [**2138-7-9**] 02:22AM BLOOD Glucose-163* UreaN-23* Creat-1.1 Na-136 K-4.3 Cl-102 HCO3-24 AnGap-14 [**2138-7-11**] 03:14AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.1 [**2138-7-9**] 03:32PM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE [**2138-7-9**] 03:32PM BLOOD RheuFac-14 [**2138-7-10**] 10:05AM BLOOD HIV Ab-NEGATIVE [**2138-7-9**] 03:32PM BLOOD HCV Ab-NEGATIVE Brief Hospital Course: Mr. [**Known lastname 72596**] was admitted and underwent coronary artery bypass grafting surgery by Dr. [**Last Name (STitle) **]. Operative findings were notable for severe pericarditis. For additional surgical details, please see dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Due to intraoperative findings of thickened/inflamed pericardium, the rheumatology and infectious disease services were consulted. Due to concern for tuberculosis, he was initially placed into a negative pressure room. Within 24 hours of the operation, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics as beta blockade was resumed. Initial sputum cultures were negative for acid fast bacilli. He remained in a normal sinus rhythm and continued to make clinical improvement with diuresis. On [**2138-7-11**], Mr. [**Known lastname 72596**] was ready for discharge. He will follow-up with Dr. [**Last Name (STitle) 914**], his cardiologist and his primary care physician as an outpatient. Auto-immune serologies were pending at time of discharge. He was instructed to followup with rheumatology as an outpatient. Medications on Admission: Aspirin 81 qd, Atenolol 25 qd, Lantus 50 [**Hospital1 **], Lisinopril 10 qd, Vitamin D, ??Metoprolol 12.5 [**Hospital1 **] ?? Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 7. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 11. Lantus 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous twice a day. Disp:*qs qs* Refills:*0* 12. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection AC and HS : resume home sliding scale . Disp:*qs qs* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary Artery Disease, s/p CABG Pericarditis History of Myocardial Infarction Hypertension Type 2 Diabetes Dyslipidemia Discharge Condition: Stable Discharge Instructions: 1)No driving for one month 2)No lifting more than 10 lbs for at least 10 weeks from the date of surgery 3)Please shower daily. Wash surgical incisions with soap and water only. 4)Do not apply lotions, creams or ointments to any surgical incision. 5)Please call cardiac surgeon immediately if you experience fever, excessive weight gain and/or signs of a wound infection(erythema, drainage, etc...). Office number is [**Telephone/Fax (1) 170**]. 6)Call with any additional questions or concerns. Followup Instructions: Please call to schedule appointments Surgeon Dr [**Last Name (STitle) **] in [**12-17**] weeks at [**Hospital1 **] heart center ([**Telephone/Fax (2) 6256**]) Primary care Dr [**Last Name (STitle) 10755**] in [**11-15**] weeks Cardiologist Dr [**Last Name (STitle) 14334**] 1-2 weeks [**Hospital1 **] heart center ([**Telephone/Fax (2) 6256**]) Follow up with rheumatology Completed by:[**2138-7-11**]

[ "412", "357.2", "414.01", "250.60", "272.0", "401.9", "413.9", "276.7", "423.2" ]

icd9cm

[ [ [] ] ]

[ "37.31", "36.11", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

6298, 6357

3505, 4707

304, 471

6523, 6532

1912, 3482

7076, 7480

1401, 1450

4883, 6275

6378, 6502

4733, 4860

6556, 7053

1465, 1893

244, 266

499, 1166

1188, 1327

1343, 1385

54,536

169,927

35727

Discharge summary

report

Admission Date: [**2181-4-23**] Discharge Date: [**2181-5-9**] Date of Birth: [**2101-12-3**] Sex: F Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 26411**] Chief Complaint: Cranial defect Major Surgical or Invasive Procedure: [**2181-4-24**]: 1. Re-exploration of right latissimus flap microvascular anastomoses. 2. Drainage of right neck hematoma. 3. Repair of bleeding branch of reverse saphenous vein graft. 4. Autologous muscle graft from the sternocleidomastoid to the site of the anastomosis. . [**2181-4-23**]: 1. Removal of exposed methyl methacrylate with excision of significant amount of skin of this previously radiated scalp. 2. Cranioplasty greater than 5 cm2. 3. Washout and debridement of scalp wound. 4. Placement of free latissimus muscle transfer to the scalp with microvascular anastomosis. 5. Re-exploration of microvascular anastomosis with redo of microvascular anastomosis with reverse saphenous vein after a reverse greater saphenous vein graft from the right lower extremity. 6. Split-thickness skin grafting greater than 100 cm2 of scalp. History of Present Illness: The patient is a 79-year old female who presents for an evaluation for a cranial defect. The patient has a complex past medical history with a hemangiopericytoma that was discovered approximately 11 years ago and operated on at an outside facility. The patient then underwent radiation therapy. The patient recovered well from that surgery. Approximately three years ago, the patient apparently bumped her head from a fall and developed an approximately 1cm lesion that remained compromised and showed a skin breakdown. A second fall in [**2180-7-14**] created another hematoma and a progressive scalp laceration that tripled in size until [**2180-10-14**]. The patient has since tried to cover the wound with topical medication and the wound has not developed any florid infection. However, there is a growing defect over her previous cranioplasty site and the patient is now presenting for surgical reevaluation. Past Medical History: PMH: HTN, hypercholesterolemia, h/o TB, hemangiopericytoma s/p excision . PSH: R craniectomy [**2169**] Social History: The patient is retired. She is a nonsmoker, nondrinker. Family History: Her family history is noncontributory. Physical Exam: On day of discharge: Tm 98.2, Tc 96.0, HR 67, BP 130/60, R 18, Sat 96% RA GEN: conversant, comfortable in bed HEENT: Pt has a large ~8cm diameter flap over her calvarium. The flap has areas of pink and areas of darker purple interspersed. 2x3cm area of purplish tissue over the right ear. Pulses can be dopplered superior to the right ear as well as the middle-right of the flap, though not in the area marked with a suture at the middle-posterior of the flap. PERRL, EOMI, visual fields intact. NECK: Supple CHEST: CTAB CV: RRR w/o m/r/g Extremities: no c/c/e. RLE with healing calf incision w/o erythema. Back: R-sided healing surgical scar Neuro: CN II-XII intact. No sensory defecits other than the flap. 5/5 strength. Ambulatory with walker. Pertinent Results: [**2181-5-7**] 06:35AM BLOOD WBC-9.0 RBC-3.30* Hgb-9.8* Hct-28.4* MCV-86 MCH-29.7 MCHC-34.5 RDW-16.3* Plt Ct-520* [**2181-5-6**] 05:50AM BLOOD WBC-10.1 RBC-3.07* Hgb-9.2* Hct-26.6* MCV-87 MCH-29.9 MCHC-34.6 RDW-16.6* Plt Ct-450* [**2181-4-26**] 03:57AM BLOOD WBC-8.6 RBC-2.85* Hgb-8.8* Hct-24.6* MCV-86 MCH-30.7 MCHC-35.6* RDW-15.0 Plt Ct-131* [**2181-4-23**] 11:00PM BLOOD WBC-10.3# RBC-2.79*# Hgb-8.0*# Hct-24.1*# MCV-87 MCH-28.8 MCHC-33.3 RDW-13.6 Plt Ct-163 [**2181-5-5**] 02:09AM BLOOD Neuts-88.4* Lymphs-6.9* Monos-2.2 Eos-2.4 Baso-0.1 [**2181-5-7**] 06:35AM BLOOD Plt Ct-520* [**2181-4-23**] 11:00PM BLOOD PT-15.7* PTT-150* INR(PT)-1.4* [**2181-5-5**] 02:09AM BLOOD PTT-72.7* [**2181-5-3**] 03:30AM BLOOD Glucose-124* UreaN-24* Creat-0.5 Na-143 K-3.5 Cl-107 HCO3-29 AnGap-11 [**2181-4-24**] 02:22AM BLOOD Glucose-178* UreaN-16 Creat-0.5 Na-146* K-3.8 Cl-116* HCO3-19* AnGap-15 [**2181-4-26**] 06:59AM BLOOD Vanco-4.1* [**2181-5-1**] 01:20PM BLOOD Type-ART pO2-188* pCO2-39 pH-7.47* calTCO2-29 Base XS-5 Comment-NASAL [**Last Name (un) 154**] RADIOLOGY: [**2181-4-24**] CT head: Expected post-operative changes following right free flap reconstruction. No evidence for acute intracranial hemorrhage. Brief Hospital Course: The patient was admitted to the plastic surgery service on [**2181-4-23**] and had 1. Removal of exposed methyl methacrylate with excision of significant amount of skin of this previously radiated scalp. 2. Cranioplasty greater than 5 cm2. 3. Washout and debridement of scalp wound. 4. Placement of free latissimus muscle transfer to the scalp with microvascular anastomosis. 5. Re-exploration of microvascular anastomosis with redo of microvascular anastomosis with reverse saphenous vein after a reverse greater saphenous vein graft from the right lower extremity. 6. Split-thickness skin grafting greater than 100 cm2 of scalp. The patient tolerated the procedure well. On [**2181-4-24**], the patient's flap lost its doppler signal. She was noted to have a right-sided scalp hematoma. She was taken back to the operating room for 1. Re-exploration of right latissimus flap microvascular anastomoses. 2. Drainage of right neck hematoma. 3. Repair of bleeding branch of reverse saphenous vein graft. 4. Autologous muscle graft from the sternocleidomastoid to the site of the anastomosis. Neuro: Post-operatively, patient was kept intubated in order to decrease the risk of movement to the flap. She had no signs of underlying neurologic dysfunction. On [**5-1**], the patient was extubated. She was neurologically intact throughout the rest of her course. She was ambulatory prior to discharge. CV: The pt remained hemodynamically stable throughout. She was given Diltiazem for 2 days in order to prevent vasospasm to the flap, but her pressures and HR stayed within normal range. Pulmonary: The patient was kept intubated for 1 week after the operations to protect the flap. She did not have evidence of underlying pulmomonary dysfunction. Upon first attempt at extubation, she did not have a cuff leak. This was presumed to be due to edema. The patient was given IV Lasix, which led to 2L of diuresis. The following day, the pt was extubated without difficulty. She has had no respiratory complaints since. GI/GU: The patient has had guaiac positive brown stools with a low Hct. She has a history of hemorrhoids and has had hemorrhoidal bleeding while inpatient. Her hematocrit stabilized during her stay. The patient was fed through a Dauboff while intubated. After extubation, she failed her initial speech and swallow evaluation for aspiration risk. The following day, she was able to tolerate soft solids. Her diet was advanced to soft solids and thin liquids. ID: Post-operatively, the patient was started on IV ceftazidime. When the patient's flap lost it's pulses, the patient was placed on broad spectrum IV antibiotics to prevent meningitis - Vancomycin and Ceftazidime. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on POD#16, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. OPERATIONS DURING ADMISSION [**4-23**] Removal of exposed methyl methacrylate with excision of significant amount of skin of this previously radiated scalp; Cranioplasty greater than 5 cm2; Washout and debridement of scalp wound; Placement of free latissimus muscle transfer to the scalp with microvascular anastomosis; Re-exploration of microvascular anastomosis with redo of microvascular anastomosis with reverse saphenous vein after a reverse greater saphenous vein graft from the right lower extremity; Split-thickness skin grafting greater than 100 cm2 of scalp. [**4-24**]: Take back to OR, Exploration, removal of hematoma, Basic course of events: [**4-23**] to OR; remained intubated, sedation; lost doppler signal intraop, started on hep gtt, regained prior to floor; oozing, low Hct, hypotensive, 1 u PRBC, hep gtt [**4-24**] lost dopper signal at 2 pm, taken back to OR for reexploration, hematoma found, kink in flap, straightened out; pt received 2u pRBC, restarted hep gtt [**4-25**] 2 u pRBC; hep gtt subtherapeutic [**4-26**] 2 u pRBC. Tube feeds started [**4-27**] lost signals in AM; started on bair hugger; albumin x2 [**4-28**] Botox, Diltiazem used to prevent flap vasospasm. Signals episodicall heard [**4-29**]: attempted to extubate pt. No cuff leak. Pt remained tubed. Started on Lasix 10mg IV for goal 2L neg overnight. Tube feeds started. Signals lost. [**4-30**]: heparin adjusted with goal PTT 50-60. [**5-1**]: pt succesfully extubated [**5-3**]: Pt's Hct 20.6 --> pt transfused 2U pRBC. Transferred out of SICU. [**5-5**]: Tfuse 1U pRBC. Pt developed a small flap hematoma overnight, drained at bedside. Was noted to be constipated and straining when hematoma started, so was given an enema and bowel regimen. [**5-6**]: Advanced to nectar thickened liquid diet, tolerated well [**5-9**]: Pt has been ambulating, taking good POs, and urinating appropriately. Stable for discharge. Medications on Admission: ASA, Lipitor, moexipril Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain for 10 days. Disp:*200 ML(s)* Refills:*0* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 6 weeks. Disp:*84 gram* Refills:*0* 4. Ceftazidime 1 gram Recon Soln Sig: One (1) Gram Recon Soln Intravenous Q8H (every 8 hours) for 6 weeks. Disp:*126 Gram Recon Soln(s)* Refills:*0* 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-15**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. Disp:*1 bottle* Refills:*2* 6. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal Q4H (every 4 hours) as needed for hemorrhoid pain. Disp:*1 bottle* Refills:*2* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*1* 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush for 6 weeks. Disp:*50 ML(s)* Refills:*2* 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain for 10 days. Disp:*200 ML(s)* Refills:*0* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 6 weeks. Disp:*84 gram* Refills:*0* 4. Ceftazidime 1 gram Recon Soln Sig: One (1) Gram Recon Soln Intravenous Q8H (every 8 hours) for 6 weeks. Disp:*126 Gram Recon Soln(s)* Refills:*0* 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-15**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. Disp:*1 bottle* Refills:*2* 6. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal Q4H (every 4 hours) as needed for hemorrhoid pain. Disp:*1 bottle* Refills:*2* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*1* 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush for 6 weeks. Disp:*50 ML(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 24402**], ME Discharge Diagnosis: - Hemangiopericytoma of the scalp/meninges with exposed methylmethacrylate and open scalp wound. - Ischemic latissimus flap to the scalp with neck hematoma. Discharge Condition: Patient is ambulatory, taking good POs, and urinating appropriately. Stable for discharge. Discharge Instructions: 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. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Keep your wound clean and dry. Cover the head wound with Xeroform and gauze. Change daily. Followup Instructions: Please call Dr.[**Name (NI) 29526**] clinic at ([**Telephone/Fax (1) 26412**] for an appointment. . You should follow up for a colonoscopy on [**Last Name (LF) 766**], [**5-14**] at 9am with Dr. [**Last Name (STitle) 349**]. Please call [**Telephone/Fax (1) 463**] to confirm. [**Hospital Ward Name **] - [**Hospital Ward Name 1950**] 3. Instructions for the preparations will be in your discharge paperwork. Completed by:[**2181-5-9**]

[ "998.31", "738.19", "E849.8", "285.1", "996.79", "996.52", "E878.2", "401.9", "272.0", "998.83", "996.74", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "86.69", "83.82", "86.75", "96.04", "39.49", "96.72", "38.93", "02.06", "96.6", "84.57" ]

icd9pcs

[ [ [] ] ]

12380, 12458

4434, 9418

329, 1212

12659, 12752

3202, 4279

13676, 14115

2379, 2419

9492, 12357

12479, 12638

9444, 9469

12776, 13653

2434, 3183

275, 291

1240, 2163

4288, 4411

2185, 2290

2306, 2363

31,232

185,793

54357

Discharge summary

report

Admission Date: [**2179-9-7**] Discharge Date: [**2179-9-12**] Date of Birth: [**2114-12-23**] Sex: F Service: CARDIOTHORACIC Allergies: Percocet / Tylenol Attending:[**First Name3 (LF) 1505**] Chief Complaint: CAD Major Surgical or Invasive Procedure: CABGx3(LIMA->LAD, SVG->OM, PDA) [**9-8**] History of Present Illness: 64F with coronary artery desease, referred for CABG Past Medical History: PMHx: HTN, hyperparathyroidism, osteoporosis, s/p partial hysterectomy, s/p thyroidectomy, s/p renal calculi removal Social History: not known Family History: not known Physical Exam: a/o nad rrr cta pos bs surgical inc c/d/i palp distal pulses Pertinent Results: [**2179-9-12**] 06:50AM BLOOD WBC-8.0 RBC-2.66* Hgb-8.0* Hct-23.4* MCV-88 MCH-30.0 MCHC-34.2 RDW-15.1 Plt Ct-182 [**2179-9-8**] 07:38PM BLOOD PT-14.9* PTT-60.2* INR(PT)-1.3* [**2179-9-12**] 06:50AM BLOOD Glucose-94 UreaN-13 Creat-0.6 Na-141 K-4.3 Cl-112* HCO3-25 AnGap-8 [**2179-9-7**] 09:00AM BLOOD ALT-19 AST-19 CK(CPK)-57 AlkPhos-55 Amylase-51 TotBili-0.4 [**2179-9-7**] 09:00AM BLOOD VitB12-705 [**2179-9-7**] 09:00AM BLOOD %HbA1c-5.7 [**2179-9-7**] 08:11PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012 URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG URINE RBC-[**6-8**]* WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 Brief Hospital Course: Pt admitted Underwent CABGx3(LIMA->LAD, SVG->OM, PDA) without complications Transfered to the CVIU in stable condition Did require pressores Extubated POD # 1 Transferd to regular cardiac floor Foley catheter emoved / on DC urinating CT removed POD # 2 Pt consult / cleared for home CXR stable without acute process pt was tachy / Lopressor increased POD # 3 Pacing wires reved without incidence POD # 4 pt stable for DC Medications on Admission: [**Last Name (un) 1724**]: ASA 81', Lopressor 25", HCTZ 12.5', Lipitor 10', Lorazepam 0.5 qhs, Boniva 150 once a month P:d/c to home sun Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. [**Last Name (un) **]:*14 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily): please have allmedications refilled by your PCP. [**Name Initial (NameIs) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*6* 3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days: please have allmedications refilled by your PCP. [**Name Initial (NameIs) **]:*28 Capsule, Sustained Release(s)* Refills:*0* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please have allmedications refilled by your PCP. [**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*2* 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed: please have allmedications refilled by your PCP. [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please have allmedications refilled by your PCP. [**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*2* 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for 10 days: please have allmedications refilled by your PCP. [**Name Initial (NameIs) **]:*40 Tablet(s)* Refills:*0* 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please have allmedications refilled by your PCP. [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2* 9. Boniva Oral Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: CAD HTN, hyperparathyroidism Discharge Condition: Good Discharge Instructions: Danger Sign Information Danger Signs: Redness that is spreading Pain not adequately relieved with medication Chest pain Drainage from wound Blurred Vision Dizziness Weight Gain Weakness Palpitations Nausea & Vomiting Shortness of Breath Temperature >100F Opening of incision Danger Signs(Other): Weight gain >2-3lbs. in 24hrs. or >5lbs. in 1 week. Drainage or signs of infection at incision site. Danger Sign Contact: [**Name (NI) **],[**First Name3 (LF) **] R. Danger Sign Contact Phone: [**Telephone/Fax (1) 170**] Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment should be in 1 month Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 5068**] Follow-up appointment should be in 2 weeks Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3393**] Follow-up appointment should be in 2 weeks Completed by:[**2179-9-12**]

[ "414.01", "733.00", "V45.89", "413.9", "401.9", "272.4", "285.9", "252.00", "785.0" ]

icd9cm

[ [ [] ] ]

[ "88.53", "36.15", "39.64", "88.56", "37.22", "36.12", "39.61" ]

icd9pcs

[ [ [] ] ]

3644, 3693

1428, 1862

289, 333

3767, 3774

704, 1405

4345, 4857

597, 608

2050, 3621

3714, 3746

1888, 2027

3798, 4322

623, 685

246, 251

361, 414

436, 554

570, 581

49,314

117,643

5023+55628

Discharge summary

report+addendum

Admission Date: [**2147-12-8**] Discharge Date: [**2147-12-13**] Date of Birth: [**2072-1-22**] Sex: M Service: CARDIOTHORACIC Allergies: Zestril Attending:[**First Name3 (LF) 1505**] Chief Complaint: Worsening fatigue Major Surgical or Invasive Procedure: [**2147-12-8**] Coronary artery bypass grafts x 3 (LIMA-LAD, SVG-OM, SVG-PDA) History of Present Illness: This 75 year old white male has had known coronary disease and prior silent myocardial infarction. He underwent bare metal stenting to his LAD in [**2136**]. Since that time, he has been relatively asymptomatic. Recently, he denies chest pain but admits to worsening fatiuge. Following a recent stress test that was positive for inferior wall ischemia and hypotension, cardiac catheterization revealed triple vessel disease. He was, therefore, admitted for coronary surgical revascularization. Past Medical History: parotid carcinoma - treated with surgery and radiation hypertension s/p bilateral knee and hip replacements paroxysmal atrial fibrillation dyslipidemia hiatal hernia history of renal calculi bilateral cataract surgery prior shoulder surgery Social History: He is a psychologist. Denies tobacco. Admits to one bourbon per day. No history of ETOH abuse. Married, wife is an ER nurse. Family History: Mother died of stroke at age 64. Physical Exam: discharge exam: vitals -stable, awake and alert heart - atrial fibrillation wit ventricular rate 70s lungs -clear ext -with out edema wounds - clean and dry. Sternum stable Pertinent Results: [**2147-12-8**] 06:00PM BLOOD PT-16.7* PTT-47.1* INR(PT)-1.5* [**2147-12-10**] 05:55AM BLOOD PT-14.8* PTT-34.6 INR(PT)-1.3* [**2147-12-11**] 05:33AM BLOOD PT-14.7* INR(PT)-1.3* [**2147-12-12**] 05:30AM BLOOD PT-22.4* INR(PT)-2.1* [**2147-12-11**] 05:33AM BLOOD Mg-1.9 [**2147-12-13**] 05:40AM BLOOD PT-28.5* INR(PT)-2.9* Brief Hospital Course: Mr. [**Known lastname 20763**] was admitted and underwent coronary artery bypass grafting surgery by Dr. [**Last Name (STitle) **]. For surgical details, please see separate 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. He was noted to have episodes of atrial fibrillation but otherwise maintained stable hemodynamics. On postoperative day one, he transferred to the SDU. Given his paroxysmal atrial fibrillation, he was started on Warfarin. Low dose beta blockade was also resumed. INRs were monitored daily and Warfarin was adjusted for goal INR between 2.0 - 3.0. K+ and Mg levels were monitored closely and repleted per protocol. Over several days, he continued to make clinical improvements with diuresis. He was eventually cleared for discharge to home on postoperative day 5. His ventricular rate was well controlled. Prior to discharge, arrangements were made with Dr. [**Last Name (STitle) 20764**] who will monitor his Warfarin as an outpatient. His first blood draw is scheduled for [**12-15**]. Discharge medications, instructions and precautions were discussed with the patient prior to discharge. Medications on Admission: ASA 325mg/D Simvastatin 20mg/D Atenolol 6.25mg [**Hospital1 **] MVI Viagra prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. 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* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 4. Aspirin Low Dose Oral 5. Ibuprofen 200 mg Tablet Sig: Two (2) Tablet PO Q6hours prn as needed for pain. 6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: decrease to one tablet twice daily beginning [**12-18**]. Disp:*100 Tablet(s)* Refills:*2* 9. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day: take as directed. INR goal 2-2.5. Disp:*100 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts paroxysmal atrial fibrillation hypertension s/p bilateral knee replacements s/p bilateral hip replacements h/o parotid cancer Discharge Condition: good Discharge Instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks shower daily, no baths or swimming no lotions, creams or powders to incisions report any weight gain greater than 2 pounds a day or 5 pounds a week report any drainage from, or redness of incisions report any temperature greater than 100.5 take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**First Name8 (NamePattern2) 20765**] [**Last Name (NamePattern1) 20764**] or [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 1295**] in [**2-15**] weeks Dr. [**Last Name (STitle) 17567**] in [**3-19**] weeks Please call for appointments Completed by:[**2147-12-13**] Name: [**Known lastname 3457**],[**Known firstname 3458**] [**Last Name (NamePattern1) 3459**] Unit No: [**Numeric Identifier 3460**] Admission Date: [**2147-12-8**] Discharge Date: [**2147-12-13**] Date of Birth: [**2072-1-22**] Sex: M Service: CARDIOTHORACIC Allergies: Zestril Attending:[**First Name3 (LF) 741**] Addendum: The patient's INR will be monitered by Dr. [**Last Name (STitle) 3461**], not Sidiquii. Major Surgical or Invasive Procedure: [**2147-12-8**] Coronary artery bypass grafts x 3 (LIMA-LAD, SVG-OM,SVG-PDA) Discharge Disposition: Home With Service Facility: [**Hospital 2057**] Hospice and VNA [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2147-12-13**]

[ "V10.02", "427.31", "414.01", "553.3", "V45.82", "V58.61", "412", "401.9", "V43.64", "424.0", "V15.3", "V43.65", "272.4", "V13.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5943, 6133

1906, 3159

5841, 5920

4561, 4568

1561, 1883

4978, 5803

1319, 1353

3288, 4248

4354, 4540

3185, 3265

4592, 4955

1368, 1368

1384, 1542

236, 255

401, 897

919, 1161

1177, 1303

56,849

152,114

36847

Discharge summary

report

Admission Date: [**2104-8-27**] Discharge Date: [**2104-9-2**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2782**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Intubation History of Present Illness: Mr. [**Known lastname **] is an 88M with h/o systolic CHF (LVEF 35-40% in [**2100**]), COPD, CAD, AF on ASA, bradycardia s/p PM placement transferred on [**8-27**] from [**Hospital **] Hospital, where he was intubated for respiratory distress, after p/w SOB x4 days. He initially presented to [**Hospital **] Hospital with SOB at rest and on minimal exertion x4 days. He reports that at baseline, he has no SOB at rest or on ambulation on 2L NC home oxygen, noting that he experiences dyspnea only when hammering or doing other strenuous activity; he denies orthopnea/PND or peripheral edema either at baseline or in the setting of his recent OSH presentation. He endorses occasional nonproductive cough, duration uncertain, as well as rhinorrhea, but denies f/c, CP, pleuritic CP, wheeze, sick contacts, or dietary indiscretion. On arrival to the OSH ED, oxygen saturation was reportedly 88%, prompting intubation for respiratory distress and confusion and subsequent transfer to [**Hospital1 18**] for further management; DD reportedly 4.55. On arrival to [**Hospital1 18**], he was intubated and sedated on propofol with rhonchorous BS. Initial VS were as follows: 97, 60, 112/61, 16, 98% on MV (TV = 450, RR = 16, FiO2 = 50%, PEEP = 5). Admission labs were notable for negative TnT, BNP to 9478, and UA with few bacteria and positive leukocytes. ABG was 7.37/61/133/37. CXR was notable for diffuse infiltrates concerning for CHF v. COPD exacerbation. Head CT was negative for acute intracranial process, and CT-A was negative for PE, but notable for moderate emphysema, bibasilar atelectasis, and moderate cardiomegaly with a small pericardial effusion. He received Lasix, nitropaste, methylprednisolone, azithromycin, and Combivent nebs. Past Medical History: CHF (LVEF 35-40% in [**2100**]) COPD CAD AF on ASA due to h/o falls Bradycardia s/p PM placement Dementia HTN BPH s/p AAA repair s/p cataract surgery glaucoma Social History: He lives with his wife, who is wheelchair-bound with h/o CVA, but remains functional and assists in his care. He has 5 children, who are involved in his care; daughter is HCP. 40 pack-year h/o cigarette smoking; quit at uncertain point. EtOH and illicit/IVDU uncertain. Family History: Unable to elicit. Physical Exam: ADMISSION EXAM General: Intubated and sedated HEENT: Sclera anicteric, MMM, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Wheezes and ronchi throughout Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: WWP 2+ pulses palpable bilaterally, hyperpigmentation c/w chronic venous stasis changes, L>R, with pitting edema bilaterally to mid-calves Neuro: Deferred DISCHARGE EXAM VS Tm 98.7 Tc 97.2 BP 117/53 (110s-120s) HR 61 (50s-70s) RR 18 95% RA GEN Alert, oriented only to self, no acute distress HEENT MMM, EOMI, sclera anicteric, OP clear NECK supple, JVP difficult to apprehend due to habitus/neck positioning PULM Good aeration, no wheezes, no crackles, no rhonchi CV RRR normal S1/S2, no mrg ABD soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, hyperpigmentation c/w chronic venous stasis changes, no peripheral edema NEURO A0x1, pleasantly tangential, motor function grossly normal Pertinent Results: On admission: UA: 1 rbc, <1 wbc, few bacteria, neg nitrite/leuks, 30 protein CBC: 5 (90.2P)/37.1/114 Cardiac studies: TnT <0.01, proBNP 9478 Lytes: 138/5.8 (hemolyzed)/100/33/26/1.3/117 ABG: 7.37/61/133/37, lactate 1.2 (intubated, FiO2 100%) LFTs: 31/27/0.7/74 At discharge: CBC: 6.6/43.4/130 Lytes: 139/4/97/38/34/1.4/170 Noncontrast head CT ([**8-27**]): No evidence of acute intracranial process. CT-A chest ([**8-27**]): 1. No evidence of pulmonary embolism. 2. Moderate emphysema. 3. Bibasilar atelectasis with secretion/aspiration seen within left mainstem and right maintstem bronchus and bronchi to the right lower lobe. 4. Moderate cardiomegaly and small pericardial effusion. 5. Ascending thoracic aortic dilation. Enlarged main pulmonary artery which may indicate pulmonary hypertension. TTE ([**2104-8-30**]): The left atrium is moderately 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 ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**1-21**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild-moderate aortic regurgitation. Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Pulmonary artery hypertension. Dilated ascending aorta. Brief Hospital Course: Mr. [**Known lastname **] is an 88M with h/o systolic CHF (LVEF 35-40% in [**2100**]), COPD, CAD, AF on ASA, bradycardia s/p PM placement transferred on [**8-27**] from [**Hospital **] Hospital, where he was intubated for respiratory distress, after p/w SOB x4 days, now breathing well post-extubation. #Hypoxemic respiratory failure: He presented from an OSH intubated and sedated and received aggressive diuresis for CHF (noted below), as well as steroids for COPD exacerbation (noted below). He was extubated successfully on [**8-27**] without fever, HD instability, leukocytosis, or other e/o infection throughout admission. #Acute-on-chronic CHF: Patient with known sytolic CHF (LVEF 35-40% in [**2100**]) p/w clinical e/o fluid overload and CXR with prominent pulmonary vasculature in the absence of clear inciting event. He was diuresed with IV Lasix, with good effect, followed by 80mg PO daily, up from his home dose of 40mg PO daily, with resulting mild hypervolemia and return to his home supplemental oxygen requirement of 2L, prompting transfer from the MICU to the medical floor. On attainment of euvolemia on the floor, his home dose of Lasix 40mg PO daily was continued. Home atenolol and lisinopril were continued. TTE demonstrated mild-moderate AR, mild symmetric LVH with preserved regional and global biventricular systolic function (LVEF >55%), mild PA HTN, and dilated ascending aorta. By the time of discharge, he was breathing comfortable without supplemental oxygen requirement. #COPD: Patient with known COPD was noted to be hypercarbic while ventilated. He initially received methylprednisolone, followed by prednisone burst 30mg x5 days, though azithromycin was held following an initial dose since his symptoms were felt to be largely reflective of CHF exacerbation in the presence of clinical hypervolemia and in the absence of prominent wheeze. Albuterol/ipratropium nebs were continued throughout. #CKI: Cr of 1.3 on admission, c/w baselin, remained relatively stable throughout (1.3-1.5) despite aggressive diuresis. #AF on ASA: Admission EKG demonstrated AF, but he remained in SR thereafter and V-paced at 60bpm. He is on ASA 325mg as an outpatient in place of Coumadin due to h/o falls and supratherapeutic INR (as high as 9.7 in [**2102**]) c/b GI bleed, and ASA was continued on this admission. #Thrombocytopenia: He displayed stable thrombocytopenia (100s-140s) throughout admission, c/w baseline, without active signs of bleeding. Further evaluation was deferred to the outpatient setting. #CAD/HTN: Home atenolol, lisinopril, and ASA were continued on this admission. #Dementia: Patient with h/o dementia of uncertain etiology was rarely agitated, but largely calmly AOx1/confused throughout admission. #BPH: Home tamsulosin was continued on this admission. #Transitional issues: -Acute-on-chronic CHF: Home atenolol was continued on the current admission, but switch to metoprolol or carvedilol may be considered on PCP [**Name9 (PRE) 702**] for maximal therapeutic benefit. -AF on ASA: ASA was continued for prophylactic management, given h/o falls and supratherapeutic INR, but anticoagulation with warfarin or Pradaxa may be considered on PCP [**Name9 (PRE) 702**] if felt to be appropriate. -Thrombocytopenia: Low platelet count was stable without active signs of bleeding, and further evaluation was deferred to PCP [**Last Name (NamePattern4) 702**]. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PCP. 1. Aspirin 325 mg PO DAILY 2. Tamsulosin 0.4 mg PO HS 3. Atenolol 50 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Lisinopril 2.5 mg PO DAILY Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Furosemide 40 mg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. Tamsulosin 0.4 mg PO HS Discharge Disposition: Extended Care Facility: [**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**] Discharge Diagnosis: acute respiratory failure requiring mechanical ventilation Acute-on-chronic diastolic congestive heart failure Chronic obstructive pulmonary disease, exacerbation afib Discharge Condition: Discharge condition: Improved Mental status: Oriented to self, reportedly consistent with baseline dementia Ambulatory status: With walker, consistent with baseline Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure participating in your care while you were admitted to [**Hospital1 69**]. As you know, you were admitted for shortness of breath and arrived from another hospital with a tube down your throat on a ventilator for help with your breathing. After the tube was removed, you were able to breathe well on your own with supplemental oxygen, which you use at home. Your shortness of breath was likely due to fluid in your lungs, and you received increased doses of your home diuretic (Lasix) to remove the fluid. It will be important to continue to take Lasix at home to ensure that fluid does not reaccumulate in your lungs. Given the possibility that your chronic obstructive pulmonary disease (COPD) was contributing to your shortness of breath, you also received steroids to help with your breathing. Followup Instructions: NName:[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **] Address: [**Street Address(2) 10534**], [**Location (un) **],[**Numeric Identifier 12541**] Phone: [**Telephone/Fax (1) 9347**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Please discuss with your PCP [**Name Initial (PRE) **] follow up in our [**Hospital 2182**] clinic at [**Hospital1 69**] as needed. The number to the clinic is [**Telephone/Fax (1) 612**].

[ "287.5", "585.9", "403.90", "414.01", "294.20", "428.0", "518.81", "V45.01", "600.00", "427.31", "428.23", "496" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

9217, 9331

5355, 8167

238, 250

9564, 9573

3610, 3610

10607, 11170

2509, 2529

9054, 9194

9352, 9522

8795, 9031

9734, 10584

2544, 3591

3886, 5332

8188, 8769

179, 200

278, 2023

3624, 3872

9588, 9710

2045, 2206

2222, 2493

57,617

143,319

39465

Discharge summary

report

Admission Date: [**2107-7-19**] Discharge Date: [**2107-7-30**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8961**] Chief Complaint: Fall Major Surgical or Invasive Procedure: [**2107-7-20**]: s/p Open reduction internal fixation, left hip. History of Present Illness: 88 year old male s/p fall resulting in a left hip fracture requiring surgical management. Past Medical History: Alzhiemers Hypertension Hypercholexterolemia BPH Social History: Nursing home patient, no alcohol, tobacco or drug use Family History: n/a Physical Exam: Temp:96.3 HR:97 BP:138/78 Resp:16 O(2)Sat:94 Constitutional: Awake, agitated HEENT: Pupils equal, round and reactive to light, Extraocular muscles intact Oropharynx within normal limits C-collar in place Chest: Clear to auscultation Abdominal: Soft, Nontender, Nondistended GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Neuro: Unable to answer basic questions. Moves all extremities Pertinent Results: [**2107-7-19**] 06:00PM GLUCOSE-134* UREA N-18 CREAT-0.6 SODIUM-144 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-27 ANION GAP-13 [**2107-7-19**] 06:00PM estGFR-Using this [**2107-7-19**] 06:00PM WBC-5.5 RBC-3.44* HGB-10.6* HCT-31.8* MCV-92 MCH-30.8 MCHC-33.4 RDW-14.3 [**2107-7-19**] 06:00PM NEUTS-69.4 LYMPHS-19.4 MONOS-9.9 EOS-0.6 BASOS-0.8 [**2107-7-19**] 06:00PM PLT COUNT-177 [**2107-7-19**] 06:00PM PT-13.2 PTT-21.4* INR(PT)-1.1 Brief Hospital Course: SUMMARY: Mr. [**Known lastname **] is an 88 year old gentleman with a past medical history significant for hyperlipidemia, hypertension, and dementia admitted for a fall with a left hip fracture on [**7-19**] s/p ORIF on [**2107-7-20**] with hospital course complicated by tachycardia, hypotension, and hypoxia. . Hip Fracture s/p ORIF: Pt. tolerated the procedure well after [**7-20**] with no major complications from the surgery. Orthopedic surgery followed him during his admission and they recommended weight-bearing activity on the left leg. His dressings on his left leg were changed twice a day to reduce the risk of infection to the joint. In addition, they recommended follow-up in 2 weeks post-operatively. . Hypoxia: Post-operatively, the patient had one episode of aspiration. His O2 saturations were persitently low after this event and he was unreposnsive to neublizer treatments. He was transferred to the MICU on [**7-23**] due to persistently low O2 saturations. After transfer to the MICU, the patient was found to have a bibasilar infiltrates that were concerning for an aspiration event. He was started on vancomycin and cefepime in the unit for concern for possible hospital-acquired pneumonia in addition to his recent aspiration event. Once his O2 saturations were stable, he was transferred back to the medicine floor. His antibiotics were changed from Cefepime to Zosyn because this antibiotic had better anaerobic coverage. He was continued on the Vancomycin and Zosyn and he remained afebrile during his time out of the intensive care unit. He should continue vancomycin (day 7) and zosyn (day 5). for a 10 day course. . Tachycardia: Had intermitent atrial flutter in setting of his recent ORIF and his aspiration pneumonia. He was started on telemetry when he was transferred to the MICU. We discontinued his home dose of amlodipine and started AV nodal blockade with metoprolol 10mg IV q6h in the MICU. His heart rate declined into the after he was started on IV metoprolol. There were no acute changes on telemetry after his transfer to the unit. He can be switched to metoprolol by mouth twice a day once he is able to tolerate PO intake. . Urinary retention: Pt. had distended bladder after he was transferred from the MICU. He had a bladder scan that showed greater than 1L in his bladder. Pt. was noted to have hyospadias on examination and a small urethra. He was maintained on his home dose of terazosin. A 14 coude catheter was placed with some difficulty into the urethra and his urine output has been adequate since the Foley was placed. He should follow-up with urology as an outpatient. . Delirium: Likely multifactorial, with contributing factors including aspiration pneumonitis/HCAP, recent surgery, hearing loss, and hospital admission. Geriatrics was consulted and they recommeded zydis to control his delirium. We started with low doses of zydis and his medication was adjust so that he takes Zydis at 10mg qHS and increased to 5mg in the mornings yesterday and Zydis 2.5mg q6h prn agitation. . Nutrition: Was unable to take food by mouth post-operatively d/t risk of aspiration. Speech and swallow evaluated the patient and agreed after his aspiration event that it was safer to keep the patient NPO than to give him food. He was started on PPN on [**7-28**]. Nutrition recommended switching over to TPN until his mental status improved. A PICC line was placed on [**7-30**] to deliver antibiotics. The PICC line will also be his main access for nutrition with TPN. . Neck pain: Pt. currently in soft collar. There was concern about injury to the cervical spine on admission. An MRI was ordered, but was not completed during the admission because the patient developed worsening shortness of breath and was sent to the intensive care unit. Neurosurgery followed the patient and there were no signs of fracture/misalignment based on CT scan on admission. They recommended continuing with a soft collar and having the patient follow-up in 1 to 2 weeks. On CT scan, there was a large hypodense right thyroid lobe lesion, measuring 3.0 x 1.3 cm. You should see your primary care physician to discuss this finding further. . HTN: Amlodipine was discontinued during hospitalization. Metoprolol was started for better rate control and some blood pressure control. . BPH: Continued home dose of finasteride and terazosin. A Foley catheter was placed and continues to drain clear urine. . Hyperlipidemia: Continued atorvastatin throughout admission. . PPx: Enoxaparin. Will continue for 4 weeks post-operatively from [**7-19**]. Access: PICC line placed on [**2107-7-30**] Code: Full Medications on Admission: OUTPATIENT MEDICATIONS: 1. amlodipine 5mg PO 2. finasteride 5mg PO 3. lovastatin 40mg PO 4. terazosin 2mg PO Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 5. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Constipation. 7. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every four (4) hours as needed for Pain. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 14. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 16. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 18. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 19. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO Q6H (every 6 hours) as needed for agitation. 20. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QAM (once a day (in the morning)). 21. Metoprolol Tartrate 10 mg IV Q6H hold for sbp < 100 or HR < 60 22. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours): Please give 1250mg IV q12hrs. 23. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [**Hospital 8**] Nursing Home - [**Hospital1 8**] Discharge Diagnosis: Left hip fracture s/p ORIF Delirium Aspiration Pneumonia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted for hip fracture on [**7-18**]. During your hospitalization, you had an open reduction internal fixation of your hip on [**7-20**]. After your surgery, however, your hospital course was complicated by persistently low oxygen levels in your blood and low blood pressure. You were transferred to the medical intensive care unit for further management and you were found have an aspiration pneumonia. You were started on two antibiotics known as Vancomycin and Zosyn. You should complete a full antibiotic course for 14 days. You are currently on day 8 of Vancomycin and day 6 of Zosyn. . You were evaluated by speech and swallow and they believe that you are at high risk of aspiration when you ingest food. Therefore, we kept you without food during your hospital admission. We ordered a nutrition consult and they recommended starting total parenteral nutrition. Nutrition has made several recommendations and these recommendations are available for review on page 1 of the discharge paperwork. . In addition, a geriatrics consult was ordered to evaluate your delirium post-operatively and they made several additions to your home medication that will help to control the delirium more effectively. The medication recommended was Zydis and the dosages can be found on the attached medication list. . During your hospitalization, the orthopedic surgeons followed you post-operatively and they recommended keeping your incision clean and dry with daily dressings. They also encouraged physical therapy to work with you in the post-operative period and you are encouraged to be full weight-bearing on the left leg. . Please follow-up to see your orthopedic surgery in 2 weeks. In addition, you should also continue to wear a soft collar until you complete an MRI of your cervical spine as an outpatient. Followup Instructions: You should follow up in 2 weeks in the [**Hospital **] clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. Please call [**Telephone/Fax (1) 1228**] to make this appointment. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]

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Discharge summary

report

Admission Date: [**2140-5-21**] Discharge Date: [**2140-5-27**] Service: CME HISTORY OF PRESENT ILLNESS: This is an 81 year-old Russian speaking male with three vessel coronary artery disease refusing coronary artery bypass graft, congestive heart failure with an ejection fraction of 20 percent, hypercholesterolemia, hypertension, atrial fibrillation, and diabetes mellitus type 2 who presented to the Emergency Department with acute onset of malaise and generalized weakness. The patient had been in his usual state of health able to slowly walk up stairs when on the day of admission he was walking through the park with his family and after five minutes experienced the acute onset of generalized weakness and malaise. The patient sat down and his family noted him to be somewhat confused. The patient did not report any chest pain, shortness of breath, palpitations, facial droop, slurred speech or recent paroxysmal nocturnal dyspnea, orthopnea or edema. The family brought the patient to the Emergency Department where he was noted to have a heart rate in the 40s with a systolic blood pressure around 110. Transcutaneous pacing was attempted in the Emergency Department, but they could not capture. The patient subsequently got 1 mg of Atropine three times without improvement in his mental status, but an increase in his heart rate to the 60s to 80s. A Dopamine drip was subsequently started with the patient's heart rate increasing to the 100s and a systolic blood pressure in the 130s, but no improvement in his mental status. The patient subsequently became hypoxic and hypotensive and was intubated for airway protection prior to going for a head CT. The patient was subsequently transferred to the Coronary Care Unit after getting 500 cc of normal saline. PAST MEDICAL HISTORY: Three vessel coronary artery disease. The patient refusing coronary artery bypass graft. Congestive heart failure with an ejection fractio of 20 percent. Diabetes mellitus type 2. Atrial fibrillation. Hypertension. Hypercholesterolemia. MEDICATIONS: 1. Aldactone 25 mg q.d. 2. Aspirin 325 mg q.d. 3. Coumadin 5 mg q.h.s. 4. Toprol 25 mg q.d. 5. Lipitor 10 mg q.d. 6. Enalapril 2.5 mg q.d. 7. Lasix 80 mg q.d. 8. Metformin 500 mg po b.i.d. 9. Zyprexa. 10. Albuterol prn. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient currently lives with his wife. She reports no current tobacco use. PHYSICAL EXAMINATION: Temperature 99. Blood pressure 123/37. Heart rate 54. Respirations 16. Oxygen saturation 99 percent on room air. In general, the patient is a confused elderly male in no acute distress though lethargic. HEENT pupils are 4 mm and reactive bilaterally. Dry mucous membranes. Oropharynx is clear. Neck supple, full range of motion. No thyromegaly. 2 plus bilateral carotid pulses without bruits bilaterally. Lungs clear to auscultation bilaterally. Cardiovascular irregular irregular, bradycardic. Normal S1 and S2. There is a 2 out of 6 holosystolic murmur. Abdomen is obese, soft, nontender, nondistended. Normoactive bowel sounds. Extremities, warm and well perfuse, 1 plus dorsalis pedis pulses bilaterally and 1 plus posterior tibial pulses bilaterally. There is 1 plus pitting edema in the bilateral lower extremities. Neurological the patient is arousable, responding to voice, though intermittently lethargic. Did not cooperate with a full neurological examination. LABORATORIES ON ADMISSION: White blood cell count 6.3, hematocrit 38.4, platelets 159, PT 19, PTT 34, INR 2.4, sodium 143, potassium 4.0,chloride 108, bicarb 25, BUN 58, creatinine 1.5, glucose 131. ALT 23, AST 23, alkaline phosphatase 93, total bili 0.9, albumin 3.6. Digoxin less then 0.2. Chest x-ray cardiomegaly with congestive heart failure. There is asymptomatic pulmonary edema versus a right middle lobe infiltrate. Electrocardiogram slow atrial fibrillation at a rate between 35 and 40 with a right bundle branch pattern. There are multiple premature ventricular contractions and no ST T wave changes. HOSPITAL COURSE: 1. Arrythmia: The patient was admitted with slow atrial fibrillation and treated initially with Dopamine, which increased his heart rate on transfer to the Coronary Care Unit. The patient's Dopamine drip was eventually titrated to off. The patient was briefly on Isopril for rate control. The patient was taken for a automatic implanted cardioverter defibrillator/pacemaker placement on [**2140-5-23**], which was uncomplicated. The patient's heart rate was subsequently noted to be around 90 and the etiology of his arrythmia was considered to be likely sick sinus syndrome with a tachy/brady syndrome. The patient was monitored on telemetry while in the Coronary Care Unit and started on Amiodarone for rhythm control and a beta blocker for rate control. The patient's beta blocker dose was titrated up as tolerated by his blood pressure. 1. Coronary artery disease: The patient was admitted with a history of three vessel coronary artery disease having refused a coronary artery bypass graft in the past. The patient had no elevation and his cardiac enzymes and had no complaints of chest pains throughout his hospitalization. He was continued on an aspirin, beta blocker and ace inhibitor throughout his stay in the Coronary Care Unit. 1. Congestive heart failure: The patient was admitted with a history of congestive heart failure with an ejection fraction of 20 percent. The patient appeared to be well compensated throughout his stay in the Coronary Care Unit and was continued on a beta blocker and ace inhibitor, which were titrated up as tolerated by the patient's blood pressure. 1. Pulmonary: The patient was intubated in the Emergency Department for airway protection. His oxygen and ventilation were normal on transfer to the Coronary Care Unit and he was quickly weaned from the ventilator and extubated on hospital day number two. The patient had a stable respiratory status throughout the remainder of his hospitalization. 1. Renal: The patient's creatinine was elevated on admission to 1.5. This had improved to 1.1, but had again trended up to 1.7 prior to discharge. It is notable that the patient has a baseline renal insufficiency with a creatinine ranging between 1.1 to 1.5. The etiology of the patient's elevated creatinine was considered likely secondary to dehydration given a calculated fractional excretion of sodium of 0.16 percent, which suggested a prerenal etiology. The patient was given gentle hydration with intravenous fluids and po intake was encouraged. 1. Psychiatric: The patient was noted to be somewhat confused on admission and throughout his stay in the Coronary Care Unit. It is notable that the patient received 14 mg of Ativan in the Emergency Department and later received 15 mg of Haldol in the Coronary Care Unit. Once these medications were held the patient's mental status improved dramatically and he was alert and oriented times three. The patient was evaluated with a head CT on admission and on the day prior to discharge that were negative for acute changes. 1. Endocrine: The patient was admitted with a history of diabetes mellitus type 2. His oral hypoglycemics were held while he was hospitalized and he was covered with an insulin sliding scale. The patient had moderately well controlled blood sugars and it is anticipated that his oral hypoglycemics will be restarted as an outpatient. 1. FEN: The patient was evaluated by the speech and swallow consult service and demonstrated no evidence of aspiration. He was given a soft, solid, thin liquid, cardiac diabetic diet, which he tolerated. 1. Hematology: The patient's Coumadin dose was held on admission and was restarted once he received his automatic implanted cardioverter defibrillator. His INR was therapeutic prior to discharge. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient is discharged to a rehabilitation facility. DISCHARGE DIAGNOSES: Atrial fibrillation/sick sinus syndrome status post automatic implanted cardioverter defibrillator placement. Congestive heart failure with an ejection fraction of 20 percent. Three vessel coronary artery disease. Diabetes mellitus type 2. Dementia. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q.d. 2. Toprol XL 100 mg po q.d. 3. Enalapril 2.5 mg po q.d. 4. Atorvastatin 40 mg po q.d. 5. Amiodarone 400 mg po b.i.d. times four days and then 300 mg po q.d. for two weeks and then 200 mg q.d. thereafter. 6. Pantoprazole 40 mg po q.d. 7. Coumadin 2.5 mg po q.h.s. 8. Acetaminophen 325 mg one to two tablets po q 4 to 6 hours prn. FOLLOW UP: The patient will be followed by the physicians at the rehabilitation facility where his INR and weights will be monitored with his Coumadin and Lasix doses adjusted accordingly. The patient's family is encouraged to contact his primary care physician to schedule [**Name Initial (PRE) **] follow up appointment in one to two weeks after discharge. The patient has a follow up appointment with cardiology on [**2140-6-8**] at 10:00 a.m. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 4958**] Dictated By:[**Last Name (NamePattern1) 12325**] MEDQUIST36 D: [**2140-5-27**] 12:07:45 T: [**2140-5-27**] 12:54:07 Job#: [**Job Number 12326**]

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icd9cm

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2109-12-23**] Discharge Date: [**2109-12-27**] Date of Birth: [**2033-9-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4616**] Chief Complaint: Malaise and fever Major Surgical or Invasive Procedure: central line placement History of Present Illness: This is a 76 yo F w/h/o pancreatic cancer s/p whipple and s/p external beam XRT concurrent with xeloda, currently being treated with Gemcitabine weekly w/last chemo [**2109-12-18**]. At home, pt had persistant malaise, light-headedness, and LE myalgias which normally last ~2 days after chemotherapy but this time persisted. She also noted 2 days of fever to max of 101.5, along with rhinorrhea, sore throat, and epistaxis which had been bothering her for ~1 week. She normally checks her BP at home, but for the past few days her automated BP cuff had been saying "unreadable" when she tried to measure it. Pt's baseline BP is reportedly in 120s, but in the past after chemo it would dip to the 100s. With chemo, pt reports decreased apetite, and her daughter notes that she has lost 2 lbs in the past week. Also of note, pt has had chronic diarrhea for ~6 months, but after starting Lomotil, Immodium, and Viokase 8 (pancreatic enzyme replacment) her #of BMs has decreased from 4 to 2 per day. On the morning of admission, the fever and light-headedness prompted the pt's family to call her oncology NP, who told them to call EMS. On EMS arrival BP was 100/50. . On ROS Pt denies SOB, chest pain, cough, headache, sinus pressure, neck stiffness, visual changes, nausea, vommiting, worsening diarrhea, melena, hematochezia, dysuria, and hematuria. . In the [**Hospital1 18**] ED SBP was initially in the low 100s, and temp=100.6. 2L IVF where given, and despite the administraton of fluid SBP fell to the 80s. Right IJ placed (MAP 58 CVP 10) and pt was started on norepinephrine gtt and Vanco/Ceftaz were administered. Pt was never tachycardic or hypoxic. Lactate 1.0, HCT 25. Guiac (-) brown stool. CXR was clear, and U/A clear. Past Medical History: -pancreatic cancer diagnosed at [**Hospital6 1597**] [**4-16**], s/p Whipple [**2109-5-10**]. S/p Cyber Knife and external beam XRT concurrent with xeloda. Currently getting Gemcitabine weekly w/last chemo [**2109-12-18**]. -CBD obstruction with stent - s/p PE on coumadin - h/o uterine sarcoma: stage Ib, grade III endometrial carcinoma: s/p TAH-BSO [**9-13**], - Aortic stenosis - Hypertension - Type 2 diabetes - Glaucoma - herpes in L eye Social History: No smoking, No alcohol, no drug use. Lives alone in home in [**Location (un) 583**], but son or daughter stays with her at night. Independent when well. Children have been staying with her because they are concerned about her. Dtr. is HCP. Family History: daughter with endometrial carcinoma, sister with liver cancer, father with lung cancer, no fam h/o blood clots Physical Exam: VS: Temp: 97.3 BP: 102/42 HR:71 RR:16 O2sat 98 RA CVP 11 GEN: pleasant, comfortable, NAD HEENT: R PERRL, L Pupil Surgical, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no blowing [**2-13**] creshendo/decreshendo M heard throughout precorium but best at RUSB ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No clonus. RECTAL (in ED): Guiac (-) brown stool Pertinent Results: CBC: [**2109-12-23**] WBC-4.4 RBC-2.66* Hgb-9.2* Hct-24.5* MCV-92 MCH-34.5* MCHC-37.6* RDW-13.5 Plt Ct-93* [**2109-12-23**] WBC-3.9* RBC-1.94*# Hgb-6.6*# Hct-18.7* MCV-97 MCH-34.0* MCHC-35.1* RDW-14.0 Plt Ct-75* [**2109-12-27**] WBC-3.7* RBC-2.63* Hgb-8.7* Hct-24.5* MCV-93 MCH-33.2* MCHC-35.6* RDW-13.9 Plt Ct-88* . COAGS: [**2109-12-23**] PT-36.1* PTT-51.4* INR(PT)-3.8* [**2109-12-27**] PT-18.9* PTT-30.4 INR(PT)-1.7* . CHEM: [**2109-12-23**] Glucose-154* UreaN-37* Creat-1.6* Na-131* K-3.9 Cl-97 HCO3-18* AnGap-20 [**2109-12-27**] Glucose-153* UreaN-14 Creat-0.9 Na-133 K-3.8 Cl-105 HCO3-22 AnGap-10 . ANEMIA LABS: [**2109-12-26**] Iron-36 calTIBC-139* Folate-9.2 Ferritn-GREATER TH TRF-107* . URINE: [**2109-12-23**] Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM RBC-0 WBC-[**5-20**]* Bacteri-MOD Yeast-MOD Epi-[**2-12**] . [**12-23**] BCx: negative [**12-23**] UCx: YEAST. 10,000-100,000 ORGANISMS/ML.. [**12-24**] UCx: YEAST. ~6OOO/ML. [**12-26**] Stool: FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. . [**2109-12-23**] CXR AP UPRIGHT CHEST: The tip of a new right internal jugular central venous catheter terminates in the distal SVC. The cardiac, mediastinal and hilar contours appear stable. The lungs are clear. The pulmonary vasculature is normal. There is no pleural effusion or pneumothorax. The visualized osseous structures appear unremarkable. IMPRESSION: 1. Standard position of the right IJ central venous catheter, terminating in the distal SVC. 2. No acute cardiopulmonary process. . [**12-23**] EKG Sinus rhythm. Compared to the previous tracing of [**2109-7-3**] R wave progression is improved. Brief Hospital Course: A/P: 76 yo F w/ h/o pancreatic cancer, currently receiving chemotherapy who presented with fever and hypotension requiring pressors: pt initially admitted to ICU for r/o sepsis. Pt with mildly positive UA and no other clear source of infection, . . # Hypotension: on presentation had hypotension that was not responisve to fluids. She was started on levophed in the ED and after 12 hours in ICU levofed was successfully weaned and BP was stable. Hypotension was most likely [**1-11**] decreased PO intake in the setting of chronic diarrhea and outpatient antihypertensive medications. Sepsis was considered since pt continued to have hypotension despite CVP of 12. Before D/C from the ICU BP was stable for 24 hours and pt was afebrile. Pt had initially been started on cipro and flagyl for weakly positive UA and empiric coverage for possible intra-abdominal process. These antibiotics were stopped shortly thereafter due to lack of data c/w infectious etiology (see below). Remained afebrile and BP stable off of antibiotics. On the Onc floor, her BPs were stable off of her antihypertensive regimen. We were able to restart her atenolol but ACE was held on discharge, to be restarted as tolerated as an outpatient. . # Pancreatic Cancer: Chemo side effects likely contributed to diarrhea. Onc plans were held and deferred to outpatient oncology team. . # Diarrhea: Pt was continued on home viokase for pancreatic enzyme replacement. She also takes immodium and lomotil for chronic diarrhea. A Ciff assay was negative. . # Pancytopenia: All cell lines were depressed -- likely pancytopenia [**1-11**] chemotherapy. No signs of bleeding aside from epistaxis in the setting of supratherapeutic INR. Pt was transfused a total of 2 units pRBCs with appropriate HCT response. Also received 1 unit platelets (see below). . # Fever: Fever resolved by the time of call out from the ICU. Pt was afebrile on floor. Culture data did not reveal a clear source. Likely that fever on presentation was due to a viral URI, given history of rhinorrhea and sore throat. Because Cx data was negative cipro and flagyl were discontinued on the day that she was called out from the MICU. Abx not resumed on floor. . # Hx of PE: treated with coumadin at home. INR was supratherapeutic throughout time in the ICU. On the day of call-out she was having epistaxis. Likely that quinolone administration was prolonging the INR. Given FFP before transfer to the floor. Had some persistent bleeding on floor. Was transfused 1 unit of platelets (nadir value was 40 with bleeding), with resolution of epistaxis. Resumed coumadin regimen prior to d/c, but was still not therapeutic prior to discharge. Therefore, given enoxaparin daily injections with plan for outpt INR checks. . # Myalgias: most likley [**1-11**] chemo. Gave tylenol PRN. . # DM: On glyburide at home, which was held and HISS was given. Restarted on discharge. . # Code: Full Medications on Admission: Atenolol 50 mg PO DAILY Enalapril 10 mg PO DAILY Warfarin 2.5 mg TTSS and 3 mg MWF Glyburide 2.5 mg PO BID Ativan 0.5-1 mg QDay PRN Compazine 10 mg TID PRN Lomotil 2.5 mg PO BID Viokase 8 1-2 tabs QIDAC Vit B12 Immodium Discharge Medications: 1. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA). 2. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK (MO,WE,FR). 3. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as needed for Anxiety. 7. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet Sig: 1-2 Tablets PO QIDAC (). 8. GlyBURIDE 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO as directed as needed for diarrhea. 10. Enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg Subcutaneous once a day: until otherwise instructed by MD. [**Last Name (Titles) **]:*5 syringes* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Primary: Hypotension . Secondary: # pancreatic cancer diagnosed at [**Hospital6 1597**] [**4-16**], s/p Whipple [**2109-5-10**]. S/p Cyber Knife and external beam XRT concurrent with xeloda. Currently getting Gemcitabine weekly w/last chemo [**2109-12-18**]. # CBD obstruction with stent # s/p PE on coumadin # h/o uterine sarcoma: stage Ib, grade III endometrial carcinoma: s/p TAH-BSO [**9-13**], # Aortic stenosis # Hypertension # Type 2 diabetes # Glaucoma # herpes in L eye Discharge Condition: stable, normotensive, ambulating independently Discharge Instructions: You were admitted to the hospital with fevers and low blood pressure. You were briefly in our ICU because you needed medicine to suppport your blood pressure. However, you were quickly able to come off that medicine. We checked for any signs of infection but there were none. . We are restarting one of your blood pressure medicines, atenolol. However, given your recent low blood pressures, you should not take you enalapril until instructed by your PCP or oncologist. . You will be going home with physical therapy and a visiting nurse to check your blood counts as well as the level of couadin in your blood. In the meantime, you will need to take an injection of Lovenox once per day to make sure your blood is thin enough. . Please make sure to take all your medicines as prescribed. Please keep all your followup appointments. If you experience any fevers/chills, lightheadedness, or other symptoms which concern you, please call your doctor or go to the ED. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2110-1-8**] 1:00 Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2110-1-8**] 1:00 Provider: [**Name10 (NameIs) **] FELT, RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2110-1-8**] 2:00 . Please see your PCP: [**Name10 (NameIs) **],[**First Name3 (LF) 251**] R [**Telephone/Fax (1) 57021**], in the next 2 weeks.

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icd9cm

[ [ [] ] ]

[ "99.07", "38.93" ]

icd9pcs

[ [ [] ] ]

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334, 359

10199, 10248

3734, 5466

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277, 296

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2614, 2858

47,862

199,399

38415

Discharge summary

report

Admission Date: [**2161-5-9**] Discharge Date: [**2161-6-17**] Date of Birth: [**2090-3-29**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7591**] Chief Complaint: Dyspnea, SOB Major Surgical or Invasive Procedure: Bone Marrow Biopsy, [**2161-5-9**] History of Present Illness: 71 year old female with h/o HTN and HL who presents with SOB, fatigue, multiple tooth infections and BRBPR. She is being admitted to [**Hospital Unit Name 153**] for pancytopenia and a Hct of 13.9. . About 4-5 months ago, she began to develop dyspnea on exertion and intermittent bilateral leg swelling. She also started to have tooth bleeding and swelling, and has had 4-5 visits to her dentist in the last several months for recurrent tooth infections. She has had 8 teeth extracted, and has intermittently been on amoxicillin and then azithromycin for these infections (last course of azithro from [**4-28**] to [**5-5**]). . Over the last 2 weeks, her leg swelling and dyspnea have gotten significantly worse. She reports bilateral lower extremity edema, right greater than left. She also has dyspnea on exertion - over the last several months she has been able to leave the house but needed to rest intermittently while walking due to dyspnea. Over the last 2 weeks she has been unable to leave the house due to SOB. She also describes intermittent pain on the lower right side of her chest and RUQ with exertion that improves with rest. This has been intermittent over the last several months but also worse in the last few weeks. Last episode was earlier today but currently she denies SOB or chest pain. Denies any n/v/diaphoresis with these episodes. Her chest pain is not pleuritic. . She also endorses BRBPR over the last 6 weeks associated with worsening constipation. She describes painful, infrequent bowel movements and blood is present on the stool when her bowel movements are most painful. The frequency or amount of blood has not changed over 6 weeks. The most blood present is about 10cc. Denies abdominal pain (except for RUQ pain described above). Has occasional nausea in the mornings. Denies vomiting, diarrhea. She reports dizziness when she stands in the mornings. She reportedly had a colonoscopy earlier this month ("in downtown [**Location (un) 86**]") due to a PCP referral for these symptoms that was reportedly normal. . She denies any recent viral illness. Denies any medication changes other than lidocaine and Anusol for hemorrhoids and azithromycin for her tooth infections. Denies sexual activity. Denies fever, but has occasional chills. Nonproductive cough has also been present over 4-5 months. . Today she went to her PCP who noted bilateral lower extremity edema and was concerned for right sided CHF and sent her to the ED. In the [**Hospital3 **] ED where workup was notable for pancytopenia (Hct 13.9, WBC 0.67 (>90% lymphocytes), platelets 75). She was given 1 unit PRBCs. Their heme/onc team recommended transfer to [**Hospital1 18**]. . In our ED, initial vitals were 97.8 71 124/77 16 100%4L. Rectal exam showed mild BRBPR and was guaiac positive. Labs were significant for a WBC of 0.7, Hct 17.3, Plt 84. The ED resident spoke with heme/onc who felt this was possibly MDS vs aplastic anemia. She was given 1 unit PRBCs. GI was not consulted. Latest vitals 76 143/69 18 100%on4L. Has 3 PIVs. . On the floor, she states she is feeling tired, but without SOB or chest pain. Past Medical History: Hypertension Hyperlipidemia Unclear history of heart disease (says she was seen in [**Country 651**] for chest pain, had many ECGs, may have had an MI but no cath done, no TTE) Hernia repair OSA on CPAP at home Botox injections monthly for blepharospasm Social History: Lives with extended family (husband, daughter, son-in-law) in [**Name (NI) **]. Speaks Mandarin. Denies current or previous smoking, alcohol, or drug history. Family History: 2 brothers and sister died of MI (in 60's and 70's). No FH of cancer, DM, bleeding, or clotting disorders. Physical Exam: On admission Vitals: 98.1 68 131/81 18 100%2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, mouth with multiple recent tooth extractions with well-healed sites, +thrush Neck: Supple, JVP mildy elevated to 8cm, one very small (<1cm) LN on right submandibular region Lungs: Clear to auscultation bilaterally except for scant crackles at the bases CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no hepatomegaly or splenomegaly palpable GU: No foley Ext: Warm, well perfused, 2+ pulses, trace peripheral edema, symmetric bilaterally Rectal: Brown stool, faintly guaiac positive, small external hemorrhoids Pertinent Results: [**Hospital3 2568**] labs [**5-8**]: WBC 0.67 (3%N 96%L 1%M) Hgb 4.5 Hct 13.9 Plt 75 MCV 120.9 MCH 39.1 MCHC 32.4 RDW 15.4 Smear: Slight anisocytosis, marked hypochromia, moderate macroovalocytes Retic 2.3 Na 140 K 4.7 Cl 104 CO2 28 BUN 21 Crt 0.9 Gluc 114 Ca 9.3 Mag 2.1 Phos 4.3 Uric acid 5.9 Albumin 4.3 TP 7.9 AST 659 ALT 21 AP 99 TB 0.5 DB 0.1 Lip 147 (23-300) CK 121 Trop 0.04 PT 13.1 INR 1.1 PTT 25.8 BNP 47.2 ADMISSION LABS: [**2161-5-8**] 10:25PM RET AUT-1.7 [**2161-5-8**] 10:25PM PT-13.8* PTT-25.7 INR(PT)-1.2* [**2161-5-8**] 10:25PM NEUTS-3* BANDS-0 LYMPHS-97* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2161-5-8**] 10:25PM WBC-0.7* RBC-1.57* HGB-6.0* HCT-17.3* MCV-110* MCH-38.6* MCHC-35.0 RDW-20.7* [**2161-5-8**] 10:25PM CK-MB-1 cTropnT-<0.01 proBNP-167 [**2161-5-8**] 10:25PM ALT(SGPT)-13 AST(SGOT)-15 LD(LDH)-197 CK(CPK)-108 ALK PHOS-73 TOT BILI-0.9 [**2161-5-8**] 10:43PM GLUCOSE-95 LACTATE-1.2 K+-4.3 [**2161-5-9**] 07:14AM GRAN CT-21* [**2161-5-9**] 07:14AM RET AUT-1.3 [**2161-5-9**] 07:14AM FIBRINOGE-101* [**2161-5-9**] 07:14AM PT-13.8* PTT-27.7 INR(PT)-1.2* DISCHARGE LABS: [**2161-6-17**] 08:01AM BLOOD WBC-2.4* RBC-3.39* Hgb-10.9* Hct-31.5* MCV-93 MCH-32.3* MCHC-34.7 RDW-16.3* Plt Ct-291 [**2161-6-17**] 08:01AM BLOOD Neuts-49* Bands-0 Lymphs-23 Monos-25* Eos-0 Baso-3* Atyps-0 Metas-0 Myelos-0 [**2161-6-17**] 08:01AM BLOOD Gran Ct-1160* [**2161-6-16**] 06:09AM BLOOD Gran Ct-374* [**2161-6-15**] 12:30AM BLOOD Gran Ct-476* [**2161-6-14**] 12:00AM BLOOD Gran Ct-649* [**2161-6-17**] 08:01AM BLOOD Glucose-155* UreaN-21* Creat-0.6 Na-140 K-3.7 Cl-106 HCO3-27 AnGap-11 [**2161-6-17**] 08:01AM BLOOD ALT-51* AST-45* LD(LDH)-292* AlkPhos-284* TotBili-0.4 [**2161-6-17**] 08:01AM BLOOD Calcium-9.3 Phos-2.7 Mg-2.2 MICROBIOLOGY: [**2161-5-13**] 12:26PM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-POSITIVE HAV Ab-POSITIVE [**2161-5-9**] 07:14AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-POSITIVE HAV Ab-POSITIVE [**2161-5-13**] 12:26PM BLOOD HCV Ab-NEGATIVE Test Result Reference Range/Units QUANTIFERON(R)-TB GOLD INDETERMINATE A NEGATIVE IMAGING: BM Biopsy [**5-10**]: Morphologic and immunophenotypic findings consistent with involvement by acute promyelocytic leukemia. DIAGNOSIS: Acute promyelocytic Leukemia with t(15;17) (W.H.O.), (FAB subtype AML-M3), see note. Note: Concurrent FISH studies demonstrate a PML-RARA (i.e. t (15;17) (q22; q21)) rearrangement (see separate complete report). [**5-11**] ECHO: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Suboptimal image quality. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. The LV apex is particularly poorly seen and may be hypokinetic. Moderate tricuspid regurgitation. Borderline pulmonary artery systolic hypertension. There is a catheter in the right atrium. [**5-12**] ECHO: Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. IMPRESSION: Normal global and regional left ventricular systolic function. Compared with the prior study (images reviewed) of [**2161-5-11**], LV wall motion is better assessed with use of contrast. Current study focused on LV function only. [**5-27**] CT-A Chest: IMPRESSION: 1. No CT evidence of acute pulmonary embolism. 2. Smooth interlobular septal thickening, likely due to interstitial edema. 3. Mild lower lobe bronchiectasis and mucoid impaction. Although nonspecific, this raises the possibility of chronic aspiration. 4. No substantial pleural or pericardial effusion. [**5-29**] LE U/S: IMPRESSION: Normal Doppler ultrasound of both lower extremities, no evidence for DVT. Findings are stable and unchanged when compared to prior ultrasound from [**2161-5-9**]. [**6-8**] CXR: IMPRESSION: No evidence of acute cardiopulmonary process within the limitation of the chest radiograph is seen. Brief Hospital Course: 71 year old female with h/o HTN, HL, and multiple recent tooth infections who presents with pancytopenia, dyspnea, bilateral leg swelling, and BRBPR, found to have promyelocytic leukemia on BM biopsy with course complicated by coagulopathy. . #. Promyelocytic leukemia: Constellation of anemia, neutropenia, and thrombocytopenia with inappropriately low reticulocytosis was consistent with bone marrow pathology. ANC 21. Reticulocyte index = 0.3 so abnl marrow response to anemia. BMT was consulted, and bone marrow was pursued. Biopsy confirmed promyelocytic leukemia. Hemolysis labs wnl, but coag panels abnormal (see below). TSH wnl. B12 and folate wnl. As per protocol, the pt and family were informed and consented for treatment. The patient was transferred to the BMT service and started on ATRA and Idarubicin. Her counts had an initial recovery but then a prolonged nadir after treatment. Her counts began to recover on [**6-10**] and reached ANC 1160 at the time of discharge. She was discharged with follow up with Dr. [**Last Name (STitle) 29469**]. . # Disseminated Intravascular Coagulopathy: Elevation of coags, decrease in PLTs and fibrinogen, concerning for DIC. Received 1 bag (10U cryo), 1unit FFP, 2unit pRBCs transfusion while in ICU. Central line was placed for access. Transferred to BMT service. We monitored labs first Q8h, and spaced to daily when DIC was reversed with transfusions of appropriate blood products. ATRA was continued as above. . # Neutropenic fever: Febrile to 100.8 on HD1 in context of receiving transfusion, and was intermittantly febrile throughout her course after chemotherapy treatment. Urine initially grew out ESBL and Enterococcus, and she was treated with meropenem and defervesced. She again became febrile almost two weeks later, in the setting of her blood count nadir, and was treated with Vancomycin, Meropenem and Micafungin. Blood cultures and urine cultures remained negative. Antibiotics were discontinued and she remained afebrle x 4 days at the time of discharge. She remained with a dry, non-productive cough at the time of discharge however this was not thought to be related to an infectious process. . #. Bright Red Blood Per Rectum: Had reports of BRBPR and seen to have small amount of BRBPR in the ED. Most likely lower GI bleed in the setting of thrombocytopenia and DIC. While admitted, only scantly guaiac positive. Did have recent normal colonoscopy and currently hemodynamically stable. . #. Dyspnea and Chest pain: Felt her dyspnea and overall fatigue was likely related to her profound anemia given that it subacutely developed over the course of several months. Dyspnea improved after transfusion of PRBCs. Most consistent with demand ischemia in the setting of anemia. ECG normal on admission. CEs negative. LENIs negative. . # Episodes of 'throat tightening': After starting ATRA, the patient had episodes of feeling like her throat had tightened. She was never hypoxic during these episodes and had no stridor on exam. She was initially treated with steroids for concern for ATRA syndrome but when she developed no further symptoms it was felt that this was instead likely anxiety. Steroids were tapered off and she was treated with Ativan. . #. Lower extremity edema: Does have report of bilateral lower extremity edema over the last several weeks. Does have elevated d-dimer and likely at risk for thrombosis. Did have mildly elevated JVP and some dyspnea that could be related to CHF as well, although no signs of left-sided CHF and feel this is less likely. LENIS negative and Echo showed normal systolic function. . # Elevated AST/ALT: Following admission, patient developed mild elevation of AST and ALT likely related to chemotherapy. HBV surface Ag was negative, HBV surf Ab was borderline and HBV core Ab was positive. HBV VL was negative but started Lamivudine after discussio nwith hepatology. Repeat viral load prior to discharge was negative. After discussion with Hepatology it was decided to continue lamviudine while patient is receiving chemotherapy. . # TB prophylaxis: Patient with a history of TB exposure and negative chest xray. Quantiferon gold test was intermdiate, Infectious disease consult recommended INH treatment however given elevated transaminases, treatment with INH was deferred. She was given an appointment for outpatient followup with infectious disease. . # HTN: Normotensive. Continued amlodipine at home dose. . # Constipation: Discharged with senna and colace. Medications on Admission: Anusol HC 2.5% appl [**Hospital1 **] Lidocaine topical 3% 1 app tid Pravachol 20mg po daily Amlodipine 5mg po daily Omeprazole 20mg po daily ASA 81mg po daily - not taking MVI 1 tab po daily Calcium with D 500mg/400units po bid OPC-3 1 cap daily - not taking Azithromycin - took until [**2161-5-5**] Fiber OTC for constipation Dulcolax 5mg po prn constipation Ibuprofen 800mg po prn Botox injections for blepharospasm (monthly) Denies other OTC or Chinese herbal medications Discharge Medications: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 2. multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 3. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 4. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*0* 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:*50 Tablet(s)* Refills:*0* 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*50 Capsule(s)* Refills:*0* 7. lamivudine 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 9. tretinoin (chemotherapy) 10 mg Capsule Sig: Four (4) Capsule PO twice a day. Disp:*240 Capsule(s)* Refills:*0* 10. lamivudine 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 11. hydrocortisone acetate 1 % Ointment Sig: One (1) appl Rectal twice a day as needed for hemorrhoids. 12. Botox Cosmetic Injection 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Acute Promyelocytic leukemia. . Secondary Diagnosis Pancytopenia Neutropenic Fever Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname **], It was a pleasure taking care of you during your hospitalization. You were admitted to [**Hospital1 18**] with low blood counts, and a bone marrow biopsy showed that you have Acute Promyelocytic Leukemia. We started you on the treatment for this (ATRA and Idarubicin), and we monitored you in the hospital during this course. . Given your history of tuberculosis exposure, we recommend that you follow up with the infectious diseases clinic, we have made an appointment for you. . Your medications have changed since you were admitted to the hospital. Please see the attached list of medications to know what you should be taking. Do not take any medications that are not on this list. . Specifically, STOP taking Pravachol and Aspirin, discuss resuming these medications with Dr. [**Last Name (STitle) 29469**]. . Please follow up with you physicians as indicated below. Followup Instructions: Department: HEMATOLOGY/BMT When: FRIDAY [**2161-6-26**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: INFECTIOUS DISEASE When: FRIDAY [**2161-6-26**] at 2:00 PM 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

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icd9cm

[ [ [] ] ]

[ "38.97", "99.25", "41.31" ]

icd9pcs

[ [ [] ] ]

16327, 16333

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316, 352

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28633

Discharge summary

report

Admission Date: [**2116-3-21**] Discharge Date: [**2116-4-1**] Date of Birth: [**2042-10-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1436**] Chief Complaint: DATE: [**2116-3-21**] . OUTPATIENT CARDIOLOGIST: [**Last Name (LF) **],[**First Name3 (LF) **] . Chief Complaint: SSCP Major Surgical or Invasive Procedure: Cardiac Cath History of Present Illness: HISTORY OF PRESENTING ILLNESS: . Patient is a 73 y/o F w/ a hx of CAD, s/p DES to OM1, [**7-29**], CHF no echo on file, Paroxysmal Afib, not on anticoagulation, Severe Pulmonary HTN on Viagra 20mg TID, hx of COPD home oxygen of 4L, PVD, PUD, who presents on [**3-20**] to [**Hospital 487**] hospital with Nausea/Vomiting, Abdominal Pain, Acute on Chronic renal failure w/ Cr of 2.1, found to have BP in [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) **] of 196/99, dig level of 4.6, w/ 5mg IV morphine, 2.5mg IV lopressor w/ improvement of BP to 140/60 and HR in 90s. Nausea and vomiting had been going on for 3 days prior to presentation. . Patient's N/V and Renal failure were thought to be secondary to dig toxicity. An abdominal non-contrast CT scan was done which showed no acute finding, atrophic R kidney, and sigmoid diverticula. They suspected patients findings were secondary to dig toxicity. . At 4am on [**3-21**] patient developed Severe [**10-2**] SSCP w/ radiation to her back the pain continued for 30minutes. Patient was noted to have ECG findings significant for 3mm ST depression in leads v3-v6, 2mm ST elevation in AVR, 2-3mm downward sloping ST depressions in leads 2, 3, avf. Patient was noted to have BP 183/88 in L arm and 155/97 in L arm. . Patient was transferred to [**Hospital1 18**] for work up of a possible aortic dissection. Past Medical History: Percutaneous coronary intervention, in [**7-29**] anatomy as follows: . COMMENTS: 1. Coronary angiography of this right dominant system demonstrated single vessel coronary artery disease. The LMCA had a 30% distal stenosis. The LAD had diffuse irregularities. The LCx had 70% disease in the mid-OM1. There was a 70% ostial stenosis of a small AV branch. The RCA had diffuse irregularities. 2. Limited resting hemodynamics revealed normal systemic arterial hypertension (125/57 mm Hg). 3. Successful PTCA and stenting of a 70% OM1 lesion was performed with a 2.5x23 mm Cypher stent. Final angiography revealed 0% residual stenosis, no dissection, and TIMI 3 flow. (See PTCA comments) . FINAL DIAGNOSIS: 1. Single vessel coronary artery disease. 2. Successful PTCA and drug-eluting stenting of OM1 . Other Past History: PMHX: PVD CAD w/ known stents Oxygen dependent w/ chronic dyspnea, 4L home o2. Pulmonary HTN, came in on viagra Afib COPD Past GI bleeds CHF Prior left carotid endarerectomy Social History: Patient quit smoking 10 years ago. She started at age 12 for a greater than 50 pack year history. No etoh or illicit drugs. Lives at home with husband. [**Name (NI) **] to complete daily ADLs. Family History: NC Physical Exam: PHYSICAL EXAMINATION: VS - T 96.9, HR 90, BP L arm 170/90, R arm 160/80 Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 14 cm at 90 degree CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. distant heart sounds. No thrills, lifts. No S3 or S4. Chest: Crackles bilaterally, [**12-25**] way up posteriorly. Abd: Soft, NTND. No HSM or tenderness. Ext: trace edema lower ext, weak dp/pt bilaterally Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Pertinent Results: OSH LABS sodium 138=>133 K 4.7 Cl 99 bicarb 26 BUN 27=>37 Cr1.5=>2.1 Glucose 180-210 . BNP 3395 . Normal LFTs . Lipase 37 . Dig level 4.7 . WBC 11.78=>10.5 Hct 32.6 Plt 248 . CK 60 Trop 0.06=>0.10 . ABG=7.47/35/72/ ADMISSION LABS: . [**2116-3-21**] 09:30AM BLOOD WBC-8.9 RBC-4.53 Hgb-12.5 Hct-37.8 MCV-83 MCH-27.6 MCHC-33.0 RDW-16.2* Plt Ct-251 [**2116-3-21**] 09:30AM BLOOD Neuts-91.6* Bands-0 Lymphs-6.5* Monos-1.7* Eos-0.1 Baso-0.1 [**2116-3-21**] 09:30AM BLOOD PT-11.8 PTT-23.5 INR(PT)-1.0 [**2116-3-21**] 09:30AM BLOOD Glucose-197* UreaN-34* Creat-1.6* Na-130* K-4.7 Cl-92* HCO3-25 AnGap-18 [**2116-3-21**] 09:30AM BLOOD ALT-18 AST-31 LD(LDH)-326* CK(CPK)-264* AlkPhos-56 Amylase-65 TotBili-0.6 [**2116-3-21**] 09:30AM BLOOD Albumin-3.9 Calcium-8.8 Phos-4.2 Mg-1.5* Cholest-156 [**2116-3-21**] 09:30AM BLOOD Triglyc-144 HDL-47 CHOL/HD-3.3 LDLcalc-80 [**2116-3-21**] 09:30AM BLOOD TSH-0.65 CARDIAC ENZYMES . [**2116-3-21**] 09:30AM BLOOD ALT-18 AST-31 LD(LDH)-326* CK(CPK)-264* AlkPhos-56 Amylase-65 TotBili-0.6 [**2116-3-21**] 02:40PM BLOOD CK(CPK)-837* [**2116-3-22**] 12:20AM BLOOD CK(CPK)-244* [**2116-3-22**] 06:00AM BLOOD CK(CPK)-606* [**2116-3-23**] 05:15AM BLOOD CK(CPK)-PND [**2116-3-21**] 09:30AM BLOOD CK-MB-26* MB Indx-9.8* cTropnT-0.21* [**2116-3-21**] 02:40PM BLOOD CK-MB-88* MB Indx-10.5* cTropnT-2.04* [**2116-3-22**] 12:20AM BLOOD CK-MB-88* MB Indx-36.1* cTropnT-3.95* [**2116-3-22**] 06:00AM BLOOD CK-MB-65* MB Indx-10.7* cTropnT-3.54* Digoxin levels . [**2116-3-21**] 09:30AM BLOOD Digoxin-5.0* [**2116-3-22**] 06:00AM BLOOD Digoxin-4.5* [**2116-3-23**] 05:15AM BLOOD Digoxin-3.2* [**3-21**] TTE The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with focal basal inferior/inferolateral hypokinesis. The remaining segments contract normally (LVEF = 50%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch and in the descending thoracic aorta. No dissection flap seen in the aortic arch. The aortic valve leaflets (?number) are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Symmetric left ventricular hypertrophy with mild regional systolic dysfunction, c/w CAD. Calcific aortic valve disease with minimal stenosis and mild regurgitation. Diastolic LV dysfunction with elevated filling pressures. Moderate pulmonary hypertension. . Findings discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] at 1305 hours on the day of the study. [**3-21**] CXR CHEST (PA & LAT) . Reason: mediastinal widening. . INDICATION: Possible aortic dissection. Evaluate for mediastinal widening. . Mediastinal width is normal. The aorta is tortuous and calcified. The heart is mildly enlarged, and there is slight upper zone vascular redistribution, accompanied by vascular indistinctness and a bilateral interstitial pattern affecting the right lung to a greater degree than the left. Additionally, there are subtle patchy areas of increased opacification in the right mid and both lower lung regions. No pleural effusions or acute skeletal abnormalities are identified. . IMPRESSION: . 1. Diffusely tortuous and calcified thoracic aorta, but no direct radiographic signs to suggest aortic dissection. Because chest radiographs are not very sensitive for detecting dissection, an MRA of the aorta could be considered given clinical concern for avoiding iodinated contrast. . 2. Cardiomegaly and asymmetrical parenchymal opacities that are likely due to asymmetrical edema from CHF. Followup radiographs after diuresis would be helpful to confirm resolution and to exclude a more chronic interstitial abnormality. CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2116-3-27**] 1:44 PM . CT CHEST POST-ADMINISTRATION OF INTRAVENOUS CONTRAST: . There are extensive increased interstitial markings throughout both lungs. The appearances are suggestive of diffuse pulmonary fibrosis. There are scattered pulmonary nodules within the background interstitial change with the largest measuring 9 x 8 mm in the left lower lobe. There are several tiny mediastinal lymph nodes with the largest measuring 17 x 10 mm. The pulmonary arteries are enlarged. There is no definite pulmonary embolism. There is coronary artery atherosclerosis present. There is extensive calcified and noncalcified plaque in the aorta. There is no pericardial or pleural effusion. . The liver and spleen appear unremarkable. . MUSCULOSKELETAL: There is a wedge compression through the superior end plate of one of the mid-thoracic vertebral bodies. There are no worrisome bone lesions. . CONCLUSION: . 1. Extensive interstitial changes in the lungs are consistent with diffuse fibrosis. There are several scattered pulmonary nodules and enlarged mediastinal lymph nodes. A PET CT is advised to rule out an underlying malignancy. . 2. Enlarged pulmonary arteries suggestive of pulmonary arterial hypertension. Coronary and aortic atherosclerosis is present. . The findings were added to the critical results communication dashboard. Cardiac cath [**2116-3-24**]: R dominant. LMCA 40-50% with distal taper LAD: modest diffuse calcification, no critical lesion LCX; previous stent widely patent RCA: dominant vessel with origin dampening and 70% with mid-segment 60% hazy lesion. Intervention: Cyper stent proximal RCA 70% lesions, POBA to midsegment lesion. [**2116-3-24**] CT ABD/PELVIS: 1. No evidence of intraperitoneal or retroperitoneal hematoma. 2. Retention of contrast within the renal cortices bilaterally. Correlation with the time of previous administration of contrast is recommended as ATN cannot be excluded. Segmental lack of enhancement of thinned areas of renal cortex bilaterally likely relates to chronic scarring. 3. Cardiomegaly, coronary artery calcifications and pulmonary edema. Small bilateral pleural effusions. 4. Sigmoid diverticulosis, without evidence of diverticulitis. TTE [**2116-3-24**] There is mild symmetric left ventricular hypertrophy. There is mild regional left ventricular systolic dysfunction with inferior hypokinesis. There is no ventricular septal defect. There is mild global RV free wall hypokinesis. The aortic valve leaflets are moderately thickened. The study is inadequate to exclude significant aortic valve stenosis. Mild to moderate ([**12-25**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mitral regurgitation is present but cannot be quantified. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2116-3-21**], RV systolic function is less vigorous. Brief Hospital Course: Mrs. [**Known lastname 3012**] is a 73 y/o F w/ hx of COPD, home o2 of 4L, Paroxysmal Afib in NSR, not on anti-coagulation, moderate pulm HTN, CAD s/p DES to OM1, CHF w/ EF of 50% who presents to OSH w/ nausea, vomiting, digoxin toxicity, Acute on Chronic renal failure who was then transferred to [**Hospital1 18**] for [**10-2**] SSCP. SSCP lasted for 30 min radiating to the back, initial ? of aortic disection at OSH. Patient arrived at [**Hospital1 18**], CTA not done because of renal failure. No enlarged medistinum on CXR. TTE did not show any AI. Discussed checking for Aortic disection on TEE, but felt to be high risk if patient was ischemic, which we felt more likely the case. Patient ruled in for an NSTEMI trop peak 3.95. Kept on heparin for the first 48 hours as TIMI was 6. Viagra was held, so that nitrates could be given. . On 3rd day, patient was taken to cardiac cath where successful stenting of the ostial RCA was completed. PTCA of the mid RCA also done, but unable to deploy stent. Post-cath one hour after angioseal removal patient became hypotensive BP 60/40 and hypoxic 77% on 4L. Patient mentating through out time period. A code was called. Patient received fluids and BP came up to mid 90s. Patient was transferred to CCU for further monitoring. Noted to have stable hct. No RP bleed on CT, no groin hematoma, or other vascular access issue. Bedside TTE was done and there was no signs of tamponade, but new RV dysfunction was noted. Thought to be due to long procedure involving RCA where there were time periods of diminished coronary flow. Patients anti-bp meds, diltiazem, BB, hydralazine and nitrates were held. Pt received 2.5 L of fluid in CCU. SBP in mid 80s then 90s. Called out to the general cardiology wards. On that time on a much reduced dose of lopressor. Patient was still relatively hypotensive SBP in 90s on only one [**Doctor Last Name 360**], BP had been in 160s, before on 4 bp agents. Concern that their might have been RV infarct. BP meds held for this reason. . In the evening on [**3-26**] patient had a large amount of epistaxis, followed by elevation in blood pressure to 200 mmHg and went into atrial fibrillation with rapid ventricular response. She also became acutely short of breath. RVR was controlled with metoprolol. It was felt that shortness of breath was due to hypertension causing elevated filling pressures and pulmonary edema. Chest xray did not show significant pulmonary edema, but this would not necessarily be expected during the acute event as some time is required for transudate to develop. She was taken to CCU where BP was controlled and patient was diuresed. . Patient came out to the general cardiology floor the following evening, and then the next morning triggered for respiratory distress and hypoxia 77% on 4L. She was placed on NRB, felt to be fluid overloaded. Question of PNA on CXR pt received one day of antibiotics, but on further pulm consultation not thought to be pna and abx stopped. She had been maintained on IV heparin, but still sub-therapeutic at times. Pt still had impaired renal function w/ cr 1.4, but felt it necessary to r/o PE w/ CTA. No pulmonary embolism on CTA. CT also showed multiple pulmonary nodules, enlarged mediastinal lymphnodes and interstitial markings consistent with fibrosis. The pulmonary team was consulted for management of pulmonary issues and recommended diuresis intially and the addition of CCB. Pt was diuresed w/ PRN IV lasix, but renal function worsened in the setting of diuresis and dye load and becaome hypoinatremic, with rising BUN. Over 3 days Cr 1.4=>2.3. Diuresis was stopped and renal fn normalized. Patients BP, Resp, HR issues stabilized and she was transferred to rehab. . Problems: . #Hypoxia: Problem at baseline at the time of d/c to rehab with O2 sat >93% on 4L. Multifactorial due to COPD, moderate pulmonary hypertension, question of underlying pulmonary fibrosis based on CT scan. [**Month (only) 116**] also have had an element of fluid overload after the MI as she appears to have improved somewhat with diuresis but definitely dry on discharge with preserved EF and no need for further diuresis. CCB started for HTN as well as for pulmonary hypertension. Viagra held given the hypotension and MI but should be considered in f/u with her primary pulmonologist although if she takes this will not be able to take nitrates if has chest pain. . #COPD: Patient not felt to be in flare. Continued on home dose of 10mg prednisone. Received ipratropium nebs and advair. . #NSTEMI: Patient ruled in for nstemi, trop max 3.95, DES to RCA and PTCA of mid-rca. Patient continued on aspirin, plavix, bb, atorvastatin 40mg. . #HTN: Hypotension and hypertension as in above narrative. Patient BP regimen was modified to include a BB for post-MI benefit and rate control as well as a CCB for pulm hypertension and rate control. . #Acute on Chronic Diastolic CHF: Preserved EF >55%. BB and CCB as above. . #Paroxsysmal Atrial Fibrillation: Patient was in NSR on admission, discharge and most of hospitalization. During period of BB withdrawal patient flipped into afib w/ RVR. Patient later converted on her own. Patient was kept on heparin and bridged over to coumadin and rate controlled with CCB and BB. ON this regiment whe was maintained in NSR for most of the time and well rate controlled. . #. Elevated Digoxin: Patient was noted to have elevated digoxin. All dig was held while pt at [**Hospital1 18**]. Dig level of 5.0=>3.2, trending down. . #. Acute on Chronic renal failure: On admission Cr 1.6 reported to be 2.1 at OSH, patient received dye load from cath and CTA on [**3-24**] and [**3-27**] respectively, and was overdiuresed causing renal failure with Cr 1.4=>2.3 in matter of 3 days. At this point diuretics were held with creatinine improving and at the time of discharge ot was 2.0. Pls check in the next few days to make sure this continues to improve. . #Pulmonary HTN: Held home viagra, so that nitrates could be given instead w/ out risking synergy leading to hypotension. . #GERD: Cont Pantoprazole while inpatient -episode of nausea and heart burn after eating yesterday [**3-23**] . #Full code . #Patient was evaluated by physical therapy who thought that rehab was appropriate. #Pt needs pulmonary, cardiac and PCP f/u within 2 weeks Medications on Admission: CURRENT MEDICATIONS: MEDICATIONS Advair 250/50 1puff [**Hospital1 **] Spiriva 1mg daily Nexium 40mg daily Nitro-[**Hospital1 **] 6.5mg TID Lipitor 40mg qhs Lasix 20mg PO prn Lopressor 25mg PO BID ASA EC 325mg daily [**Last Name (un) **]-dur 200mg PO BID Cardizem 30mg PO TID Prednisone 10mg daily Plavix 75mg daily Citracal unknown daily Potassium 10mg daily viagra 20mg TID Cozaar ? PO daily . Discharge Medications: 1. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Primary Diagnosis: NSTEMI Elevated digoxin Acute on Chronic Renal Failure COPD Pulmonary Artertial Hypertension Diastolic Heart failure Paroxysmal Atrial Fibrillation . Secondary Diagnosis GERD Hypertension Discharge Condition: Stable, 98% on 4L Discharge Instructions: Mrs. [**Known lastname 3012**] you were transferred to [**Hospital1 18**] out of concern for your chest pain. You were found to have had a Non-ST elevation myocardial infarction or heart attack. You were also noted to have an abnormal elevation in your digoxin and worsening kidney function. . Please keep all of your follow up appointment. . Please take all of your medications as prescribed. . We have given you sublingual nitroglycerin to take in the case that you have another episode of chest pain. If you have chest pain place one pill under your tongue every 5 minutes (ONLY IF YOU HAVE NOT TAKEN ANY VIAGRA), until you have done this 3 times. If you have to do this please call 911. . Please call 911 or go to the Emergency Department if you develop chest pain, worsening shortness of breath, or any other worsening of your overall condition. Followup Instructions: Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] Jr,Ph#[**Telephone/Fax (1) 69287**], in the next two weeks. . Please follow up with your Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] in the next 2 weeks. [**Street Address(2) 26336**], [**Location (un) 1468**], [**Numeric Identifier 11562**] Phone: ([**Telephone/Fax (1) 5687**] . Please also schedule an appointment with your pulmonologist to be seen within 2 weeks. [**First Name9 (NamePattern2) 69288**] [**Location (un) 20473**] [**Telephone/Fax (1) 69289**]. . Please draw creatinine in the next couple of days and early next week to make sure creatinine continues to improve.

[ "458.29", "799.02", "V15.82", "428.0", "427.31", "410.71", "584.9", "E879.0", "403.90", "424.1", "414.01", "585.9", "515", "530.81", "428.33", "E942.1", "416.8", "V46.2", "443.9" ]

icd9cm

[ [ [] ] ]

[ "00.40", "36.07", "00.66", "37.22", "00.45", "88.53", "88.44", "88.56", "87.41" ]

icd9pcs

[ [ [] ] ]

19349, 19421

11121, 17433

434, 448

19672, 19692

3855, 4070

20591, 21352

3098, 3102

17879, 19326

19442, 19442

17459, 17459

2580, 2872

19716, 20568

3117, 3117

3139, 3836

389, 396

17480, 17856

476, 1853

4086, 11098

19461, 19651

1875, 2563

2888, 3082

17,174

178,195

26853

Discharge summary

report

Admission Date: [**2151-2-24**] Discharge Date: [**2151-3-2**] Date of Birth: [**2107-9-13**] Sex: F Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: This is a 43 year-old female who was transferred in from a hospital in [**Location (un) 3844**] after suffering a right breast bite by her 18 month old boy. She presented to an outside hospital with significant swelling and erythema that was rapidly progressive in her right breast. She was then transferred to [**Hospital1 190**] for urgent intervention due to the significantly progressive nature of this spreading erythema. Upon presentation, she was found to be hypotensive with her systolic blood pressure in the low 90's. PHYSICAL EXAMINATION: On admission, her temperature was 99.9 with a heart rate of 99 and normal sinus rhythm; blood pressure 91/51 not on any pressor agents. Respiratory rate of 18. Her saturation was 98% on assist control of 50% FI02, 530 by 20 and a PEEP of 5. At this time, she was toxic appearing and also appeared sedated. She was normocephalic, atraumatic, with pupils equally round and reactive to light. Her neck was without swelling or masses or erythema at this time and her right breast was significantly erythematous and swollen throughout with signs of necrotic tissue in the right breast. This erythema was demarcated at this point and was extending over to the left breast, up over the level of the clavicle and down her right flank. There was also warmth at the site and no obvious purulent drainage or signs of a punctum. The patient was sedated and this could not be assessed for tenderness. Her abdominal exam was non distended with normoactive bowel sounds and soft and nontender throughout. There was no rebound or guarding. Extremity exam revealed no clubbing, cyanosis or edema. Neurologic exam revealed normal tone in all the extremities. She could not be adequately assessed for strength at this time. HOSPITAL COURSE: At this time, the patient was brought to the operating room for urgent intervention by Dr. [**Last Name (STitle) 10656**] with a working diagnosis of abscess and cellulitis of the right breast. She underwent at this time a left breast incision and drainage of the abscess with extensive debridement of necrotic tissue and skin. This was done under general endotracheal anesthesia. An incision was made in the inferior aspect of the breast and a small amount of [**Doctor Last Name 352**] fluid was obtained that was sent for culture. Tissue from the breast was also sent for culture as well as biopsy at this time. Extensive loculations were broken up. However, no significant pus was noted. Hemostasis was achieved adequately. The wound was then irrigated and copiously packed with large Kerlix dressings with subsequent dressing changes to occur. There were no drains placed at this time. The patient was then aggressively resuscitated in the ICU and received approximately 5 liters since the incision and drainage. She was now on clindamycin, Zosyn and Vancomycin for broad spectrum empiric coverage. She was monitored carefully in the ICU for any signs of increasing erythema or signs of septic response. She was now, at this time, able to be weaned off of Levophed on this first postoperative day. Also at this time, plastic surgery was consulted to determine the extent of the final breast defect and the possible eventual reconstruction. Also infectious disease was consulted at this point due to this extensive infection and their recommendations at this point were to add Zosyn to the regimen but to continue the rest of the antibiotics until we had further data from the operating room cultures. They would continue to follow the patient throughout her hospital stay. On the afternoon of postoperative day number 1, the patient's cellulitis seemed to be increasing and there was concern at this point of necrotizing fasciitis. She was brought back to the operating room for a second debridement and to search for any other signs of infection or collection. At this point, general surgery was also consulted to participate in this case. Concern at this point was due to the continued septic physiology and despite aggressive surgical treatment the prior day and broad spectrum antibiotics. During this procedure, a counter incision was made below the inframammary crease and the area cellulitis that appeared to have spread from her prior procedure. This was carried down to the fascia and there appeared to be no signs of infection at the level of the fascia. Thus, the patient had an extensive debridement of this infected breast tissue and significant debridement occurred until the skin edges showed brisk bleeding and viability. The patient was then brought to the PACU and the surgical ICU on Levophed. There were no drains placed at this time and there were no complications to this second operative procedure. Of note, at this time, her laboratory values revealed a likely compromise of renal function with a creatinine of 2.0 on postoperative day number one. She had been admitted with a creatinine of 1.9 with no known baseline. She was also persistently acidemic during this time. The plan continued to consist of aggressive resuscitation with goal to wean off the pressors that she was requiring. At this point, we had an identification of organisms as gram positive cocci but was still awaiting speciation at this time. The patient, at this point, was also on vasopressin per suggestion of the following general surgery team. This was done to decrease the volume requirement slightly. She was maintained with a urine output of approximately 30 ml an hour and was continued on the antibiotics. On postoperative day number 3, [**2-27**], the patient was started on tube feeds to provide enteral nutrition and was continued on pressors. She had chest x-rays that revealed her to likely to be in ARDS versus pulmonary edema but she was maintaining her urinary output at this time. She was also carefully being followed by the surgical ICU team. Infectious disease continued to follow the patient who suggested continued antibiotics unless we gained speciation, at which point they would recommend tailoring them. On Sunday [**2-28**], the patient received a cortisone stimulation test which she did not respond to. Hydrocortisone was started shortly thereafter at a dose of 50 mg q.i.d. . Enzymes were also checked at this time, due to the fact that the patient received a small bolus of Levophed in the ICU. The enzymes were elevated at this time with a troponin T peaking at 0.51 initially and a CK MB fraction of 9.8. We followed these enzymes serially as they decreased during this time to 0.32 the following day. Cardiology was consulted at this point and did not suggest any treatment with anticoagulation or other additions. They attributed this likely to a demand ischemia at this time, due to septic physiology and the increased Levophed. On [**2151-3-1**], the patient received an echocardiogram that revealed a normal left ventricular function. She also received a Swan-Ganz catheter at this time with slightly elevated pulmonary capillary wedge pressures. This revealed her to more than likely be adequately resuscitation. This still did not explain her low urine output at this time with her adequate left ventricular function and her continued septic physiology requiring multiple pressors. Levophed and Vasopressin were being given at high doses. We were unable to wean these at this time. We again discussed the case with infectious disease and they suggested a follow-up ultrasound of her right breast. We were unable to find any other collections to drain and it appeared that her mastitis had largely resolved with no signs of erythema, no signs of pus and adequate drainage of the wound, with continued Kerlix dressing changes. Also of note, there were no signs of any vegetations on the transthoracic echocardiogram. Her urine output continued to be marginal at this time. Also checked during this time were thyroid and hormone levels which revealed her free T4 to be 0.5 which was decreased, leading to a possible thought of this being a failure of the pituitary and the adrenal access having failed the cortisone stimulation. She was continued on hydrocortisone although she had really no response to this and continued to need all of the pressors, with no signs of improvement of her hypotension at this time. Early in the morning of postoperative day number 5 and 4, the patient was noted to have developed a wide complex tachycardia on EKG. She then was given 100 mg of Lidocaine IV at which point she went into cardiac arrest. CPR was started. ACLS protocol was initiated and a code was called. At this time, she was asystolic and after being given epinephrine IV and attempts at CPR, she developed ventricular fibrillation and was defibrillated at this time. The first one was successful; however, then she relapsed into ventricular fibrillation again. She was then given 300 mg of Amiodarone. She was given insulin, glucose and calcium for hyperkalemia for cardiac protection. Her acidosis was attempted to be corrected with bicarbonate solution; however, the patient did not respond. The ACLS protocol was stopped at 5:37 a.m. and the patient was declared expired at this time. The husband was reached during this time and notified of the events. He declined an autopsy. The case was reported to the medical examiner as well and they also declined the case. Dr. [**Last Name (STitle) 10656**] also at this time immediately discussed the case with the husband and they discussed all the events that occurred. DISCHARGE DIAGNOSES: Right breast mastitis and subsequent expiration. DISPOSITION: Medical examiner denied case and patient's husband refused autopsy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 66091**] Dictated By:[**Last Name (NamePattern1) 15912**] MEDQUIST36 D: [**2151-3-2**] 18:38:18 T: [**2151-3-2**] 19:23:44 Job#: [**Job Number 66092**]

[ "038.0", "785.52", "E928.3", "427.41", "E849.0", "728.86", "427.5", "041.01", "785.4", "879.1", "995.92", "276.2" ]

icd9cm

[ [ [] ] ]

[ "99.60", "96.71", "38.91", "96.04", "89.64", "88.72", "85.21", "83.21" ]

icd9pcs

[ [ [] ] ]

9687, 10090

1966, 9665

735, 1948

182, 712

19,908

195,374

44668

Discharge summary

report

Admission Date: [**2199-11-4**] Discharge Date: [**2199-11-14**] Date of Birth: [**2138-12-2**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: DOE, chest pain Major Surgical or Invasive Procedure: [**2199-11-8**] Three vessel CABG(LIMA to LAD, SVG to Diag, SVG to OM) History of Present Illness: This is a 60 yo M w/ HTN, NIDDM, tobacco abuse, hep C who presents with intermittent periods of chest pain, increasing dyspnea on exertion over the past month and particularly over the last week. Earlier today at approx 7-7:20 pm, he was walking to the store when he developed acute onset SOB and "pin-like" SSCP lasting approximately 20 minutes. No radiation, no N/V. +little diaphoresis. Pain not pleuritic or positional. Reports similar symptoms awoke him from sleep last Saturday night. Reports cough productive of yellowish sputum x 1 week. no fever, chills. No orthopnea/PND. No abd pain, diarrhea, constipation, melena, hematochezia, hematemesis, HA, dysuria. Somewhat active at home. In ED, given ASA, metoprolol. Currently reports no chest pain, breathing feels normal. Subsequently admitted for further medical evaluation and treatment. Past Medical History: HTN, NIDDM, Hepatitis C, History of Esophageal Varices, Erectile Dysfunction, Gout, Neuropathy Social History: Lives with wife. + tob (10 cig/day), approx 20-30 pk-yr. h/o EtOH abuse- quit 2 yrs ago. no drugs, IVDA. Daughter with SLE who recently passed away. Drives Zamboni. Family History: Mother with DM, died from MI at age 68. Daughter with SLE recently died. Physical Exam: 96.8 73 106/64 13 97% RA Gen: alert, pleasant, NAD, differs some questions to wife [**Name (NI) 4459**]: anicteric, PERRL, mmm, OP clear CV: Reg, S1, S2, no m/r/g lungs: decreased BS diffusely Abd: soft, NT/ND, periumbilical scar Ext: warm, symmetric, no edema, no femoral bruit, slightly diminished pulses bilaterally Neuro: A+O x 3, CN 2-12 intact, 5/5 strength in all ext Rectal: guaiac negative, light brown stool Pertinent Results: [**2199-11-4**] GLUCOSE-192* UREA N-20 CREAT-1.0 SODIUM-139 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14 [**2199-11-4**] CK(CPK)-128 CK-MB-4 cTropnT-<0.01 [**2199-11-4**] WBC-7.9 RBC-4.72 HGB-14.4 HCT-42.1 MCV-89 MCH-30.6 MCHC-34.3 RDW-13.4 PLT COUNT-408 PT-12.8 PTT-30.1 INR(PT)-1.1 [**2199-11-4**] EKG: NSR@78, Q wave III, AvF, STE V1-V2 [**2199-11-4**] CXR: The cardiac silhouette, mediastinal and hilar contours are normal. The pulmonary vasculature is normal. Both lungs are clear without consolidations or effusions. The surrounding soft tissue and osseous structures are unremarkable. [**2199-11-5**] %HbA1c-9.9* [Hgb]-DONE [A1c]-DONE [**2199-11-5**] Triglyc-178* HDL-36 CHOL/HD-4.3 LDLcalc-83 [**2199-11-14**] Hct-28.4* [**2199-11-13**] WBC-9.5 RBC-2.94* Hgb-9.5* Hct-26.3* MCV-90 MCH-32.5* MCHC-36.3* RDW-13.6 Plt Ct-513* [**2199-11-12**] PT-12.5 PTT-25.9 INR(PT)-1.0 [**2199-11-14**] UreaN-11 Creat-0.7 K-4.6 [**2199-11-12**] Glucose-171* UreaN-11 Creat-0.6 Na-135 K-4.8 Cl-99 HCO3-30 [**2199-11-14**] Mg-1.7 Brief Hospital Course: Patient was admitted to a monitored bed on the [**Hospital Unit Name 196**] service. He went for cardiac catheterization the next morning and was found to have severe three vessel coronary artery disease. Coronary angiography showed a 30% lesion in the left main; 50% lesion in the proximal RCA; 90% stenosis of the acute marginal; 80% lesion in the proximal LAD; and 80% stenosis in the circumflex. Left ventriculography revealed no mitral regurgitation and an LVEF of 50-55%. Based on the above results, cardiac surgery was consulted and further evaluation was peformed. He underwent a carotid ultrasound which showed minimal plaque in both internal carotid arteries. Given his history of Hepatitis C and prior esophageal varices, he was evaluated by GI/Liver service. A most recent EGD was negative for varices and LFTs were within normal limits. There was no evidence of cirrhosis, only stage III fibrosis. He was therefore deemed a low-risk surgical candidate and cleared for surgery. He remained pain free on medical therapy. On [**2199-11-8**], Dr. [**Last Name (STitle) **] performed three vessel coronary artery bypass grafting. The operation was uneventful and he was brought to the CSRU on minimal inotropic support. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and gradually weaned from pressor support. On postoperative day three, he transferred to the SDU. He tolerated beta blockade and remained in a normal sinus rhythm. No postoperative dysrhythmias were noted. He responed well to diuresis and by discharge was very close to his preoperative weight. Over several days, medical therapy was optimized as he continued to make steady clinical improvements. He was cleared for discharge to home on postoperative day six. At discharge, his BP was 130/60 with a HR of 85 in sinus. His room air saturations were 98% and all surgical wounds were clean, dry and intact. Medications on Admission: Ursodiol 300 [**Hospital1 **] Neurontin 400 tid Cimetidine 400 qhs Colchicine 0.6 [**Hospital1 **] Lisinopril 5 qd Nadolol 20 qd Metformin 100 qd Glyburide 10 [**Hospital1 **] MVI ASA 81 Vit B-1 Discharge Medications: 1. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 7 days. Disp:*14 Capsule, Sustained Release(s)* Refills:*0* 12. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-1**] hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every [**5-1**] hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: CAD, HTN, NIDDM, Hepatitis C with evidence of non-cirrhotic liver fibrosis, History of Esophageal Varices, Erectile Dysfunction, Gout, Neuropathy Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: [**Hospital 409**] clinic in 2 weeks on [**Hospital Ward Name 121**] 2 Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**2-26**] weeks([**Telephone/Fax (1) 170**]) Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**] in [**12-27**] weeks([**Telephone/Fax (1) 608**]) Dr. [**Last Name (STitle) 1266**] will arrange cardiology follow up as outpatient. Completed by:[**2199-11-14**]

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icd9cm

[ [ [] ] ]

[ "37.22", "36.12", "88.57", "36.15", "39.61", "88.53", "88.72" ]

icd9pcs

[ [ [] ] ]

6953, 7011

3190, 5146

338, 411

7201, 7208

2138, 3167

7527, 7933

1606, 1680

5391, 6930

7032, 7180

5172, 5368

7232, 7504

1695, 2119

283, 300

439, 1287

1309, 1406

1422, 1590

24,631

160,730

48176

Discharge summary

report

Admission Date: [**2128-11-23**] Discharge Date: [**2128-12-4**] Date of Birth: [**2050-7-30**] Sex: M Service: MED Allergies: Aldactone / Iodine; Iodine Containing Attending:[**First Name3 (LF) 4052**] Chief Complaint: 78 yo m with h/o coronary artery disease, congestive heart failure, (dilated cardiomyopathy w/ EF 20-25%), hypertension, type II diabetes, peripheral vascular disease, positive ppd, who was admitted to MICU after he was found at nursing home with respiratory distress (hypoxic to 84% O2 sat and tachypneic to 38). Major Surgical or Invasive Procedure: PEG tube placement History of Present Illness: 78 yo m w/ h/o cad, chf (dilated cm w/ ef 20-25%), htn, type II dm, pvd, asd, positive ppd, who was BIB by ambulance after he was found at NSH w/ sao2 84% and tacypneic to 38. At baseline, pt largely non-verbal but communicates his needs, follows commands, incontinent of bladder/bowel. In ED, found to be febrile to 100.8, bp 199/96, 92%ra. Initial ABG 7.26/83/306, lactate 0.7. Rec'd 500cc BS bolus. Past Medical History: 1. Coronary artery disease: The patient has known cardiomyopathy with an ejection fraction of 30%. 2. Congestive heart failure: The patient was hospitalized in the summer of [**2126**] for CHF exacerbation. 3. History of an admission in [**2127-4-29**] for a rib contusion and fracture that was managed conservatively. 4. Hypertension. 5. Noninsulin-dependent diabetes mellitus with peripheral neuropathy. 6. Peripheral vascular disease, status post right great toe and third left toe amputation for osteomyelitis. 7. Gout. 8. Question of senile dementia. 9. History of falls. 10. Atrial septal defect. 11. Positive PPD in the past. 12. Hypercholesterolemia. 13. B12 deficiency. 14. prior CVA with residual left-sided weakness Social History: He is a resident of [**Hospital3 **]. He has seven children. He is not married. He is unemployed now. He worked previously in a warehouse. He has a history of smoking. He quit in [**2092**]. He denied current alcohol use. He also quit in [**2092**]. He has an extensive past history of both smoking and alcohol use up until the time of quitting. He denied prior use of cocaine and heroin. Family History: noncontributory Physical Exam: t 97.3, bp 189/89, p 77, r 32 97% on 26% on bipap Responsive to voice but non-verbal, follows simple commands OP clear. MMM Regular s1,s2, II/VI SEM at apex B/L crackles diffuse crackles at both bases. +bs. soft. nt. nd. no le edema On admission to the floor: Gen: pt breathing comfortably, NAD; NG tube in place Neuro: pupils reactive, pt cannot blink eyes to command; can slightly squeeze fingers bilaterally; cannot follow other commands; occasionally moans HEENT: Small red lesion on roof of mouth, appears raised, not bleeding, no pus; small petechial lesions; edentulous CV: RRR, nl S1/S2, 2/6 systolic murmur loudest at apex Pulm: anterior exam only, could not cooperate with taking deep breaths; scattered crackles Abd: soft, NT/ND, +BS Ext: [**1-30**]+ LE edema up to knees; amputation of R great toe with red lesion over medial aspect of hallux; edema in UE to elbows; soft restraints in place Pertinent Results: CBC: [**2128-11-23**] 10:00PM BLOOD WBC-5.6 RBC-4.54* Hgb-13.4* Hct-43.8 MCV-97 MCH-29.6 MCHC-30.6* RDW-13.3 Plt Ct-192 [**2128-11-23**] 08:29AM BLOOD Neuts-73.7* Lymphs-19.8 Monos-4.0 Eos-1.8 Baso-0.7 Coags: [**2128-11-23**] 10:00PM BLOOD PT-13.3 PTT-28.7 INR(PT)-1.1 Chemistry: [**2128-11-23**] 10:00PM BLOOD Glucose-128* UreaN-24* Creat-0.7 Na-155* K-4.5 Cl-116* HCO3-34* AnGap-10 [**2128-11-23**] 08:29AM BLOOD ALT-32 AST-26 CK(CPK)-39 AlkPhos-93 Amylase-62 TotBili-0.5 Cardiac Enzymes: [**2128-11-23**] 08:29AM BLOOD cTropnT-0.04* [**2128-11-23**] 05:02PM BLOOD CK-MB-NotDone cTropnT-0.03* [**2128-11-23**] 10:00PM BLOOD Calcium-8.5 Phos-3.9 Mg-2.4 [**2128-11-23**] 09:07AM BLOOD Type-ART pO2-306* pCO2-83* pH-7.26* calHCO3-39* Base XS-7 [**2128-11-23**] 02:35PM BLOOD Type-ART pO2-145* pCO2-60* pH-7.26* calHCO3-28 Base XS--1 [**2128-11-23**] 10:15PM BLOOD Type-ART PEEP-5 O2-26 pO2-80* pCO2-74* pH-7.27* calHCO3-35* Base XS-3 Intubat-NOT INTUBA [**2128-11-24**] 12:45AM BLOOD Type-ART pO2-111* pCO2-71* pH-7.24* calHCO3-32* Base XS-0 Intubat-NOT INTUBA [**2128-11-24**] 02:02AM BLOOD Type-ART pO2-86 pCO2-68* pH-7.28* calHCO3-33* Base XS-2 [**2128-11-24**] 04:29AM BLOOD Type-ART pO2-145* pCO2-64* pH-7.29* calHCO3-32* Base XS-2 Intubat-NOT INTUBA [**2128-11-23**] 09:07AM BLOOD Lactate-0.7 CXR: Cardiac enlargement with mild congestive heart failure. CTA: 1. No pulmonary embolus. 2. Moderate to large bilateral pleural effusions with bibasilar atelectasis. A consolidation in the left lower lobe cannot be excluded. 3. Small pulmonary nodules seen on the prior study are not visualized on the current study. CT Head: No evidence of intracranial hemorrhage. No evidence of infarction. Mild left maxillary sinus disease ECG: 60 bpm, L axis, sinus, no st-tw changes Brief Hospital Course: Plan: 1. respiratory failure--initial thinking was pneumonia vs chf vs central cause. unclear if pt is chronic [**Name (NI) 101557**] retainer; no hx COPD. ABGs with pH 7.26 then 7.24 then 7.28 on bipap. No longer on BiPAP. CXR with LLL effusion vs consolidation vs atelectasis, not significantly changed from old films (has had pleural effusions consistently since [**2127**]). retrocardiac density. R base with small effusion. CT without evidence of PE. Pt was put on clinda temporarily. By the time pt was transferred to floor, respiratory status had stabilized and pt required about 1-2L O2 by NC with good O2 sats. 2. hypernatremia--Na on presentation 154. Given NS to rehydrate, as initially thought to have hypovolemic hypernatremia given limited diet, NH residence, limited ability feed himself, on lasix 40mg daily at baseline. On prior admissions has had sodium of 145 but not as high as 154. Free water flushes were given through the NG tube, and his sodium came down to 148, then 141. 3. mental status change--seen by neuro in the EW. Unclear if L sided weakness is worse as can't cooperate w/full neuro exam. Head CT neg; no anticoagulation per neuro recs. Would have needed intubation to obtain MRI; not done per neuro. Systolic BP was kept around 150 initially with concern of stroke. Mental status continued to improve on transfer to the floor, and pt was somewhat responsive and somewhat able to follow commands. Pt's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**], notes that this is still far from his baseline, when he was able to communicate somewhat. 4. CHF--systolic and diastolic. CXR without evidence significant failure. Stable for now. Pt was diuresed with lasix; lungs remained clear with no increase in O2 requirement. Weights were measured but difficult to interpret as different numbers of bed clothes/sheets/pillows were on the bed each morning. 5. DM--takes glyburide at baseline. Covered with insulin scale, qid checks and dosing of humalog (correction doses). QID fingersticks were continued, which showed good glucose control. On addition of NG tube feeds, NPH insulin was given at 4 units [**Hospital1 **], which resulted in good control of glucose, around 90s-130s. 6. bradycardia--pt bradys down to 30s-40s. Likely has some AV nodal dysfunction. However, is asymptomatic and maintains his BP adequately. Telemetry was discontinued after discussion with cardiology, as pt is not a candidate for a pacer. Remained asymptomatic with bradycardia, and actually was noted to have a more normal pulse in the last few days prior to discharge. 7. HTN--BP kept slightly high initially given concern for CVA. Was put back on lisinopril and titrated up; giving 40mg daily on discharge. 8. Nutrition - initially an NG tube was placed, and pt received tube feeds with nutrition on consult for particular recommendations. Pt continued to pull out NG tube, and soft restraints were placed to prevent this. As pt's mental status did not seem to improve substantially, and a speech/swallow evaluation revealed that pt was aspirating anything placed in his mouth, the family was contact[**Name (NI) **] and met with Dr. [**Name (NI) 1266**], pt's PCP to discuss options for long-term nutrition. Pt's family corroborated that they had discussed this with him in the past and he would want a G tube. Therefore, a PEG was placed by GI, which pt tolerated well. Tube feeds were restarted, and pt was discharged back to nursing home 24 hours after tube feeds through G tube were begun. 9. prophylaxis--sq heparin, IV protonix 10. code--full. Daughter corroborated this on several occasions. Medications on Admission: asa 325 tylenol lasix 40 po qd protonix 40 po qd lipitor 10 qhs mirtazapine allopurinol 150 qod glyburide 2.5 zyrtec 10 lisinopril 30mg qd mvi senna colace vitamin c Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 3. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY (Every Other Day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg PO TID (3 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic QID (4 times a day). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for pain: no more than 4g tylenol total in one day. 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. insulin sliding scale insulin as per attached sliding scale 4 units NPH insulin [**Hospital1 **] 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] - [**Location (un) **] Discharge Diagnosis: 1. Coronary artery disease 2. Congestive heart failure 3. History of rib contusion and fracture that was managed conservatively. 4. Hypertension. 5. Noninsulin-dependent diabetes mellitus with peripheral neuropathy. 6. Peripheral vascular disease, status post right great toe and third left toe amputation for osteomyelitis. 7. Gout. 8. Question of senile dementia. 9. History of falls. 10. Atrial septal defect. 11. Positive PPD in the past. 12. Hypercholesterolemia. 13. B12 deficiency. 14. prior CVA with residual left-sided weakness 15. hypernatremia Discharge Condition: stable, PEG tube in place, tolerating feeds Discharge Instructions: Please have patient follow up with his primary care doctor. Followup Instructions: Pt should see his primary care doctor in [**1-30**] weeks. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]

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icd9cm

[ [ [] ] ]

[ "43.11", "96.6" ]

icd9pcs

[ [ [] ] ]

10169, 10239

5018, 8676

608, 629

10838, 10883

3217, 3694

10991, 11175

2256, 2273

8892, 10146

10260, 10817

8702, 8869

10907, 10968

2288, 3198

3711, 4838

255, 570

657, 1066

4847, 4995

1088, 1826

1842, 2240

2,287

160,864

22933

Discharge summary

report

Admission Date: [**2130-12-18**] Transfer to NBN: [**2130-12-22**] Date of Birth: [**2130-12-18**] Sex: F Service: Neonatology HISTORY: Baby Girl [**Known lastname 26812**] is a term infant who was 4.1 kilos born to a 31 year old gravida II, para II whose pregnancy was uncomplicated. Prenatal screens were unremarkable, A positive, antibody negative, RPR nonreactive, hepatitis B surface antigen negative, Rubella immune. Mother was GBS positive. Rupture of membranes was at the time of delivery. It was an uncomplicated by planned C/S. No maternal fever was noted and no maternal antibiotics were given intrapartum. There was no history of HSV lesions. Mother reports a URI within one week prior to delivery. The infant was doing well in the newborn nursery and on day of life #1 was noted to have low grade temperatures up to 100. Otherwise was acting well and bottle feeding well. On DOL #2 the infant was noted to have an axillary temperature to 101.1 and the repeat rectal temperature was 101.4. The infant was triaged in the Newborn Intensive Care Unit for a septic work up. A spinal tap was initially unsuccessful. Ampicillin and gentacmicin were initiated and the infant was sent to NBN for further care. Due to persistent fevers with temp over 101.5, infant was brought back to the NICU for admission. A repeat LP was attempted and results are below. Acyclovir was started after herpes PCR CSF test was sent. PHYSICAL EXAMINATION: On admission the infant was active, alert and appropriate. The skin had some erythematous areas on the legs--macular, no papules or vesicles. Head, eyes, ears, nose and throat examination was normal. Heart was regular rate and rhythm with normal S1 and S2 without murmurs. Lungs were clear. Abdomen was benign. There was no hepatosplenomegaly and neurologic was a nonfocal examination with normal tone and age appropriate. The hips were normal. Spine was intact. Anus was patent. The weight on admission was 4.11 kilos. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Upon initial admission, the infant had some occasional desaturations and was placed on nasal oxygen for several hours but weaned quickly off. She soon was on room air and has had no subsequent issues. A chest x-ray was obtained with the initial requirement of oxygen and had low lung volumes but otherwise looked normal. CARDIOVASCULAR: There have been no issues from this standpoint. No murmurs have been heard and blood pressure has been completely normal. FLUID, ELECTROLYTES AND NUTRITION: The infant has been bottle feeding well throughout. She received one normal saline bolus with her first dose of acyclovir but otherwise has been eating very well and there have been no concerns. GASTROINTESTINAL: There have been no issues. She is bottle feeding Similac quite well. HEMATOLOGY: The infant has mild jaundice and a bilirubin was obtained on day of life three which was 5.6 on admission. She also had liver function tests performed at that time which were normal. ALT 29, AST 43, alkaline phosphatase 189. INFECTIOUS DISEASE: The infant was admitted for rule out sepsis. Blood culture and CBC were obtained on admission. So far the blood cultures have remained negative. Also on admission a lumbar puncture was attempted. It was unsuccessful and a repeat lumbar puncture the following day showed 0 white cells and 80 red cells. Protein was normal and glucose was normal. The laboratory data that are still pending - a viral work up. We have an HSV, PCR on the cerebrospinal fluid (CSF). In addition, an enteroviral CSF test was also sent. We also have sent throat swab and stool culture for enteroviral culture. In addition, we have sent eye, nasopharynx and rectal swabs for HSV culture. These are all still pending. Finally, a nasal pharyngeal swab was sent for general viral culture. The infant was started on ampicillin, gentamicin and acyclovir. She will continue on these antibiotics for 48 hours if the blood culture is negative and will continue on acyclovir until HSV PCR is negative. Of note, the infant's rash progressed had currently is diffusely maculopapular rash over entire trunk, not involving palms or soles. This is most consistent with a viral exanthem. It is morbilliform in nature and on the chest and in the groin significantly it comes with heat and looks fairly consistent with a viral syndrome. The infant has been afebrile for 24 hours. The infant will be transferred to newborn nursery today and if the blood and CSF cultures remain negative, the antibiotics can be discontinued. (Of note, the CSF culture was obtained after 1 dose of antibiotics but the finding of 0WBC is not consistent with bacterial meningitis). Please note, that if the infant to spike a fever, we would repeat blood cultures and consider continuous the antibiotics prior to d/c home. NEUROLOGY: There have not been any neurologic tests done and she has been completely appropriate throughout her hospitalization. SENSORY: An initial hearing screen was done and normal. A repeat hearing screen will need to be done prior to discharge due to infant's need for gentamicin. PSYCHOSOCIAL: [**Hospital1 69**] Social Worker has been involved with the family and they can be contact[**Name (NI) **] at [**Telephone/Fax (1) **]. CONDITION AT DISCHARGE: The infant was stable and the infant was transferred to the Newborn Nursery. The name of the primary care pediatrician is Dr. [**Last Name (STitle) 37903**] in [**Location (un) 4444**], FAX: [**Telephone/Fax (1) 59247**]. We have transferred the baby to continue feeding and antibiotics to the newborn nursery under care of the [**Doctor Last Name 46742**] Newborn Service. Current medications include ampicillin, Gentamicin and acyclovir. She has not received Tylenol in 24 hours. The infant has not received hepatitis B or other immunizations. DISCHARGE DIAGNOSES: 1. Fever of uncertain etiology (bacterial meningitis ruled out, herpes evaluation pending at time of d/c summary), most probable viral syndrome. enterovirus CSF and nasal culture pending, viral culture pending, herpes skin cultures pending. 2. Rash, probable viral exanthem [**First Name11 (Name Pattern1) **] [**Known lastname **], [**MD Number(1) 56662**] Dictated By:[**Last Name (NamePattern1) 59248**] MEDQUIST36 D: [**2130-12-22**] 13:28:16 T: [**2130-12-22**] 14:14:18 Job#: [**Job Number 59249**]

[ "V30.01", "778.8", "782.1", "778.4", "V29.0" ]

icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

5928, 6468

2048, 5339

1477, 2019

5354, 5907

30,183

115,246

32877

Discharge summary

report

Admission Date: [**2154-5-21**] Discharge Date: [**2154-5-28**] Date of Birth: [**2120-11-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: RUE pain and SOB x 1 day Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 33yo male with ESRD on HD since [**12/2152**], HTN and h/o noncompliance who p/w RUE pain and SOB X1 day, the morning after dialysis. Pt was dialyzed the night before admission and then awoke 6/24AM with SOB and pain in his right arm. He describes the RUE pain as sharp, localized to site of port-a-cath. Pt admits to HTN medication non-compliance the night before admission. He denies associated chest pain/palpitations, fever/chills/cough. He notes some abdominal pain and nausea earlier in the day which had since resolved. No HA/dizziness. No diarrhea/constipation. At baseline is able to climb steps w/o SOB. Does not check his BP at home. In the ED he had a set of cardiac enzymes that was lower than his baseline and EKG unchanged from baseline. CTA was negative for acute PE, but did reveal chronic segmental PE in RUL. RUE U/S showed a non-occlusive thrombus in the R IJ and a heparin drip was started. Pt was noted to have BP of 205/144 in the ED and was subsequently treated with a nitro drip. CXR in the ED showed pulmonary edema. Past Medical History: -ESRD [**12-29**] HTN - started on dialysis in [**12/2152**] -HTN -medication non-compliance -h/o intubation in the setting of hypertensive urgency/flash pulmonary edema Social History: He used to work as a plasterer, but is now on disability. tobacco - 1PPD x 20 years, recently decreased to two cigarettes a day. no recent alcohol use, + cocaine- denies recent use, does endorse recent marijuana use, denies any intravenous drugs; spent time in jail. Family History: Father - dead at age 36 from unknown cancer Mother - alive, 56, + HTN maternal grandmother - on hemodialysis for end-stage renal disease. - The patient has a younger sister and an older brother, both alive and well. - son - 7, alive and well Physical Exam: T 97.4 BP 130-140/90-100 HR 64 RR 20 SaO2 99% on 4L N/C General: speaks in complete sentences, NAD HEENT: NCAT PERRL EOMI o/p clear +JVD Chest: no palpable cord/tenderness at site of line, no erythema/edema noted Heart: RRR, [**1-31**] holosystolic murmur radiating to L axilla Pulmonary: bilateral basilar crackles Abdomen: scar noted, S/NT/ND +BS Extremity: + ecchymoses RUE, no C/C/E Neuro: AOX3, CN3-12 intact Skin: no rashes, warm and dry Pertinent Results: [**2154-5-28**] 07:00AM BLOOD WBC-4.9 RBC-3.65* Hgb-10.6* Hct-32.8* MCV-90 MCH-28.9 MCHC-32.2 RDW-15.8* Plt Ct-257 [**2154-5-27**] 06:55AM BLOOD WBC-4.7 RBC-3.60* Hgb-10.5* Hct-32.6* MCV-91 MCH-29.3 MCHC-32.3 RDW-16.5* Plt Ct-265 [**2154-5-26**] 06:18AM BLOOD WBC-5.0 RBC-3.72* Hgb-10.8* Hct-33.8* MCV-91 MCH-29.2 MCHC-32.0 RDW-16.1* Plt Ct-240 [**2154-5-25**] 07:15AM BLOOD WBC-5.0 RBC-3.50* Hgb-10.2* Hct-32.5* MCV-93 MCH-29.0 MCHC-31.3 RDW-15.9* Plt Ct-231 [**2154-5-24**] 07:47AM BLOOD WBC-5.5 RBC-3.92* Hgb-11.1* Hct-35.6* MCV-91 MCH-28.4 MCHC-31.2 RDW-16.0* Plt Ct-237 [**2154-5-23**] 04:10AM BLOOD WBC-5.9 RBC-3.51* Hgb-10.4* Hct-31.2* MCV-89 MCH-29.7 MCHC-33.5 RDW-16.4* Plt Ct-220 [**2154-5-22**] 05:09AM BLOOD WBC-7.6 RBC-3.58* Hgb-10.3* Hct-31.9* MCV-89 MCH-28.8 MCHC-32.4 RDW-16.0* Plt Ct-225 [**2154-5-21**] 02:58PM BLOOD WBC-6.7 RBC-3.77* Hgb-11.2* Hct-33.7* MCV-90 MCH-29.7 MCHC-33.2 RDW-16.1* Plt Ct-238 [**2154-5-28**] 07:00AM BLOOD PT-20.5* PTT-70.3* INR(PT)-1.9* [**2154-5-27**] 06:55AM BLOOD PT-18.7* PTT-102.3* INR(PT)-1.7* [**2154-5-26**] 06:18AM BLOOD PT-16.9* PTT-95.7* INR(PT)-1.5* [**2154-5-25**] 07:15AM BLOOD PT-15.1* PTT-84.9* INR(PT)-1.3* [**2154-5-24**] 07:30AM BLOOD PT-13.3 PTT-65.3* INR(PT)-1.1 [**2154-5-23**] 04:10AM BLOOD PT-13.3 PTT-92.6* INR(PT)-1.1 [**2154-5-21**] 10:54PM BLOOD PT-14.3* PTT-130.0* INR(PT)-1.2* [**2154-5-21**] 02:58PM BLOOD Glucose-106* UreaN-53* Creat-11.1*# Na-145 K-4.7 Cl-102 HCO3-26 AnGap-22* [**2154-5-21**] 02:58PM BLOOD ALT-42* AST-31 LD(LDH)-384* CK(CPK)-261* AlkPhos-76 Amylase-97 TotBili-0.3 [**2154-5-21**] 02:58PM BLOOD Lipase-24 [**2154-5-21**] 02:58PM BLOOD cTropnT-0.07* [**2154-5-28**] 07:00AM BLOOD Calcium-9.1 Phos-5.0* Mg-2.6 [**2154-5-22**] 05:09AM BLOOD Calcium-7.4* Phos-8.2*# Mg-2.0 [**5-21**] CXR (Portable AP): Pulmonary edema without evidence of focal infiltrate. [**5-21**] U/S: Findings suggestive of a nonocclusive thrombus within the right internal jugular vein, immediately upstream from the expected location of the hemodialysis catheter. [**5-21**] CTA Chest: 1. Diffuse ground-glass opacities bilaterally, with intralobular septal thickening. These findings are similar to prior CT from [**2154-5-6**], with marked improvement on subsequent radiograph of [**2154-5-7**]. Given these time course of findings, as well as a history of end-stage renal disease on hemodialysis, these findings likely reflect pulmonary edema. 2. Previously noted chronic segmental pulmonary embolism in the right upper lobe is not fully assessed on this study due to respiratory motion. No large central or large segmental pulmonary embolism identified. 3. Large calcified right upper pole renal lesion, incompletely evaluated, and appears largely unchanged. [**5-23**] Renal U/S: Limited study with delayed systolic upstroke in the left parenchymal arteries. Renal artery stenosis in the setting cannot be excluded. Brief Hospital Course: In the MICU: Pt continued his heparin gtt from the ED for his R IJ tunneled-cath clot. Blood pressure elevated to 205/144 and was controlled with a labetalol gtt and a nitro gtt. Pt presented in pulmonary edema and was subsequently taken to HD the night of admission - pt did not require additional intervention. Pt developed one episode of bloody emesis and was taken off of his heparin gtt. By the time of transfer the pt was weaned off of his labetalol/nitro gtt and was down to 4L of O2 with adequate sats. . On the general medicine floor: . Nonocclusive right IJ thrombus: Pt was treated with heparin to coumadin bridge. The plan was discussed with Vascular and Renal and it was decided that the R IJ tunneled-cath would be left in place. The catheter was accessed for HD throughout the pt's stay. Transplant surgery will evaluate the pt for placement of a fistula. Pt has missed last 5 appointments as an outpatient. Social work was contact[**Name (NI) **] and will help facilitate the outpatient appointment. Scheduled appointment with transplant surgery on [**6-6**] with Dr. [**Last Name (STitle) 816**]. The pt was treated with warfarin 5mg x 3 days, warfarin 7.5mg x 3 days and finally warfarin 10mg x 1 day to reach the target INR. On the day of discharge pt had been therapeutic on heparin for 7 days, had an INR of 1.9 and was given lovenox 30mg x 1 dose before leaving. This plan was discussed with renal and they approved the use of lovenox in the setting of this pt's end stage renal disease managed with dialysis. Pt will follow with Dr. [**Last Name (STitle) **] in dialysis for coumadin management until he sees his PCP (pt never had a regular PCP, [**Name10 (NameIs) **] appointment) Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12101**] this Thursday for further management. . Bloody emesis: The pt had only 1 episode in the MICU [**5-22**]. Heparin and coumadin were briefly held and restarted once the pt's HCT was stable. Pt was placed on pantoprazole [**Hospital1 **] and had no further issues on the floor. . Fluid overload: Pt initially presented with a BNP >[**Numeric Identifier **] and with pulmonary edema. Once stabilized in the MICU pt was able to maintain adequate O2 sats on the floor without supplemental O2 and demonstrated no clinical evidence of pulmonary congestion. . Hypertension: Pt was weaned off of nitro gtt and labetalol gtt in the MICU. Pt typically with BP 160s/100s on the floor with elevation to 180-200/110-120 in the early AM. Pt asymptomatic with these episodes. BP responded to hydralazine IV prn. Pt was initially treated with nifedipine 40mg q6h, labetalol 300mg [**Hospital1 **] and lisinopril 40mg [**Hospital1 **]. Given the pt's history of non-compliance and difficult to control BP within the hospital, the pt's nifedipine was switched to 90mg [**Hospital1 **] to facilitate compliance and minoxidil 5mg qdaily was added for better BP control. Renal doppler was ordered for RAS w/u and could not r/o RAS on the L. MRA was not pursued in the setting of ESRD [**12-29**] the risk of NSF. Pt may continue w/u as an outpatient with renal. . ESRD: Pt tolerated HD throughout hospital stay without issues. Pt was maintained on nephrocaps and sevelamer. Pt required increased dosing of both nephrocaps and sevelamer. Appreciate input from Renal - no new recommendations. Pt will resume outpatient regimen of MWF at the [**Hospital **] Clinic. . FEN: Pt tolerated PO intake. Electrolytes managed with HD. . PPX: Maintained on heparin, coumadin (once HCT stabilized) and PPI. . # Access: PIV and tunneled R IJ for HD . # Code: FULL Medications on Admission: Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day. 4. 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* 5. Labetalol 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Nifedipine 10 mg Capsule Sig: Four (4) Capsule PO Q6H (every 6 hours). Discharge Medications: 1. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*180 Capsule(s)* Refills:*2* 2. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*2* 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). Disp:*60 Tablet Sustained Release(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Right internal jugular vein thrombus Hypertension Pulmonary edema End stage renal disease Discharge Condition: Good, hemodynamically stable, adequate O2 sats. Discharge Instructions: You were diagnosed with a blood clot in the neck vein that contains your dialysis catheter and also had an elevated blood pressure which caused fluid to accumulate in your lungs. You were started on a blood thinner for your blood clot with a medication called coumadin and received dialysis to remove the excess fluid from your body. You will need to continue coumadin (blood thinner) until further notified to prevent future blood clots from forming. You will need to get blood tests at your dialysis clinic to monitor your coumadin levels. This will be done by Dr. [**Last Name (STitle) **] until you see your new PCP. Your blood test should be drawn tomorrow at dialysis. The following changes were made to your medications: Your Nifedipine, renagel and PhosLo regimens were changed. You were also started on a new BP med called minoxidil. Please continue with your outpatient dialysis regimen MWF at the [**Hospital **] clinic. Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Thursday. Please follow-up with your transplant clinic appointment so that you can be evaluated to have new dialysis access placed. Please call your doctor or go to the ED for worsening symptoms including headache, blurry vision, shortness of breath, chest pain, arm pain or other concerning symptoms. Followup Instructions: Please continue your outpatient dialysis regimen at the [**Hospital **] clinic beginning this Wednesday ([**5-29**]). Dr. [**Last Name (STitle) **] at the dialysis clinic will monitor your coumadin levels and adjust your medication as necessary. Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12101**] on [**5-30**] at 2:00 PM. Your appointment is in the [**Hospital Ward Name 23**] Building, [**Location (un) 6750**], North Suite. Please call ([**Telephone/Fax (1) 1300**] with any questions. Please follow-up at the [**Hospital 1326**] clinic with Dr. [**Last Name (STitle) 816**] on [**6-6**] at 10AM. Please call [**Telephone/Fax (1) 5537**] with any questions. Completed by:[**2154-5-28**]

[ "453.8", "V45.1", "V15.81", "996.73", "V12.51", "403.01", "428.0", "428.23", "786.3", "305.60", "585.6", "E879.1" ]

icd9cm

[ [ [] ] ]

[ "88.44", "39.95", "87.41" ]

icd9pcs

[ [ [] ] ]

10582, 10588

5565, 9200

339, 345

10731, 10781

2646, 5542

12206, 12988

1924, 2167

9847, 10559

10609, 10710

9226, 9824

10805, 12183

2182, 2627

275, 301

373, 1431

1453, 1624

1640, 1908

17,531

104,010

25892

Discharge summary

report

Admission Date: [**2113-8-7**] Discharge Date: [**2113-8-10**] Date of Birth: [**2069-12-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2113-8-7**] Catherization for Anterior STEMI (3VD, LAD 99%): Cypher drug eluting stent in proximal LAD History of Present Illness: 43 y/o Caucasian man s/p stent [**2105**] presented to [**Hospital1 5979**] ED c/o jaw pain beginning 40 minutes prior to presenting to OSH. Pt reports having 2 alcoholic beverages and later had burning in his chest which felt like "heart burn". Pt reports burning in jaw bilaterally and mild diaphoresis. He denied CP, arm pain, or shortness of breath. Pt denies anginal episodes or CP since intervention in [**2105**]. In [**Hospital3 **] ED an EKG show ST elevation in the anterior leads, V1-V5 and ST depression in II, III, and aVF. Pt went into Vfib arrest, shocked (200J, 300J, 360J) and started on amiodarone gtt, integrillin gtt and transferred to [**Hospital1 18**] cath [**Hospital1 **]. Past Medical History: CAD s/p PCI [**2105**] Social History: Tobacco: 0.5 pack X 15 years EtOH: 1qwk Limited exercise Publisher of a magazine, lives in [**Location 5028**] with wife Family History: Mother w/ CAD Physical Exam: Physical Exam (on admission) VS T97.1 P76 BP124/69 RR20 O2Sat88%4LNC->93% on face tent GENERAL: NAD, lying flat in bed w/ face tent, speaking in complete sentences. HEENT: PERRL, EOMI, MMM NECK: Supple, JVP 7cm, CARDIOVASCULAR: S1, S2, Reg, no murmurs LUNGS: CTAB by anterior exam only due to sheath in place ABDOMEN: Active bowel sounds, obese, soft, NT, ND, no HSM. EXTREMITIES: DP/PT 2+ bilat. Cool feet bilat. Otherwise, UE warm, well-perfused. NEURO: A/OX3, strength and sensation grossly intact Pertinent Results: [**2113-8-7**] 11:02PM BLOOD WBC-19.3* RBC-4.48* Hgb-14.5 Hct-41.4 MCV-92 MCH-32.4* MCHC-35.1* RDW-13.2 Plt Ct-352 [**2113-8-7**] 11:02PM BLOOD Glucose-151* UreaN-15 Creat-1.0 Na-142 K-4.0 Cl-111* HCO3-20* AnGap-15 [**2113-8-7**] 11:02PM BLOOD ALT-97* AST-194* LD(LDH)-439* CK(CPK)-2665* AlkPhos-72 TotBili-0.7 . [**2113-8-8**] 06:20AM BLOOD CK(CPK)-3863* [**2113-8-8**] 01:00PM BLOOD CK(CPK)-3442* [**2113-8-9**] 06:31AM BLOOD CK(CPK)-1792* . [**2113-8-7**] 11:02PM BLOOD CK-MB-319* MB Indx-12.0* cTropnT-3.44* [**2113-8-8**] 06:20AM BLOOD CK-MB-461* MB Indx-11.9* cTropnT-7.30* [**2113-8-8**] 01:00PM BLOOD CK-MB-308* MB Indx-8.9* cTropnT-7.23* [**2113-8-9**] 06:31AM BLOOD CK-MB-47* MB Indx-2.6 cTropnT-4.38* . [**2113-8-7**] 11:02PM BLOOD Calcium-8.4 Phos-2.4* Mg-1.8 [**2113-8-8**] 06:20AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.2 [**2113-8-9**] 06:31AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.7 . [**2113-8-7**] 09:35PM BLOOD Type-ART O2 Flow-10 pO2-57* pCO2-37 pH-7.33* calHCO3-20* Base XS--5 Intubat-NOT INTUBA Comment-NON-REBREA [**2113-8-9**] 06:31AM BLOOD WBC-13.6* RBC-3.98* Hgb-12.6* Hct-36.7* MCV-92 MCH-31.8 MCHC-34.4 RDW-13.5 Plt Ct-243 . [**2113-8-7**] ECG Sinus rhythm. There are Q waves in leads VI-V2 with ST segment elevations of one to two millimeters in leads I, aVL and VI-V5 consistent with acute extensive anterolateral myocardial infarction. Generalized low QRS voltage. ST segment depression in leads III and aVF with inverted T waves consistent with reciprocal changes. No previous tracing available for comparison. Clinical correlation is suggested. . [**2113-8-7**] Cath Report FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Elevated right and left sided filling pressures. 3. Successful treatment of proximal LAD with drug-eluting stent. 4. Successful treatment of ostial D1 with balloon angioplasty. . [**2113-8-8**] ECHO Conclusions: The left atrium is mildly elongated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with hypokinesis of the disal half of the anterior septum and anterior walls and of the distal anterior and inferior walls. The apex is near akinetic. The remaining segments contract well. No intraventricular thrombus is seen and the apex is not focally aneurysmal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . IMPRESSION: Regional left ventricular systolic dysfunction c/w CAD (mid-LAD lesion). Mild mitral regurgitation. EF 35%-40% Brief Hospital Course: 43M 3V CAD here w/ anterior STEMI, s/p successful LAD cypher stent. * Ischemia: The patient underwent cardiac catheterization which showed 3 vessel disease. A drug eluting stent was placed in the proximal LAD. The patient had 2 vessel unrevascularized disease, and which may require a re-look once he stabilizes. His enzymes were cycled until they trended downward. His trop peaked at 7.30. At discharge it was 4.38. The [**Hospital 228**] medical management consistent of the following: integrillin X 18 hrs, ASA 325, Plavix 75, Lipitor 80, Metop 12.5 TID advanced to Toprol 100 at discharge and lisinopril 10mg daily.. * Pump: The patient's cardiac index in the cath [**Hospital **] was 1.8, this was of unclear etiology. He received lasix for diuresis in cath [**Hospital **] due to PCWP and PAD elevation and increasing O2 requirement. He received Lasix overnight with good response. An ECHO was later done to evaluate pump function and showed an EF on 35-40%, with an akinetic apex. The patient was anticoagulated with Heparin and Coumadin. At the time of discharge he was started on Lovenox. Other medical management included lisinopril 10 mg daily and Toprol 100 daily. * Rhythm: The patient maintained NSR throughout his course, but s/p VF at OSH(suspect ischemic). He was maintained on Amiodarone gtt initially and this was later discontinued. The patient was monitored on telemetry with no ectopy noted. K was kept >4 and Mg was kept >2. * Smoking cessation: The patient was counseled on the importance of smoking cessation as it pertained to his heart disease. * EtOH Use: The patient was kept on a CIWA scale. * High WBC: UA and CXR were negative. Cyst drainage on back prior to admission may have contributed to elevated wbc. The patient remained HD stable throughout his course. * FEN: Cardiac heart healthy diet. K was kept > 4 and Mg was kept > 2. * PROPHYLAXIS: SCDs while in bed. PPI. *DISPOSITION: The patient was discharged home with VNA teaching for his Lovenox. He was scheduled to have his INR monitored at his PCPs office. The patient was chest pain free and hemodynamically stable at the time of discharge. Medications on Admission: none Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 5. 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* 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous once a day: 100mg daily . Disp:*14 syringes* Refills:*0* 8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual PRN as needed for chest pain. Disp:*30 * Refills:*2* 9. Outpatient [**Name (NI) **] Work Pt is on Coumadin. INR is 1.2 on discharge [**2113-8-10**]. Pt must have blood drawn on [**2113-8-14**]. INR therapeutic range is 1.5-2.0. Pt must have labs drawn every 2 days until therapeutic. Thereafter pt must have weekly blood draws. [**Date Range **] results must be reported to PCP's office Dr. [**First Name (STitle) 6164**] 1-[**Telephone/Fax (1) 64400**] or 1-[**Telephone/Fax (1) 64401**]. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Myocardial infarction: Anterior ST elevation myocardial infarction Discharge Condition: Good Discharge Instructions: Pt has been instructed that he can drive and go back to work. He has been advised not to resume any type of strenuos activity. Pt has been instructed to call 911 immediately if he should have any chest discomfort, is diaphoretic, nauseous or becomes short of breath. Pt has been instructed to adhere strictly to medications and to a cardiac heart healthy diet. . VNA services has been set up to provide the patient with instruction on Lovenox. . Pt has been instructed to have blood draws initially every 2 days from date of discharge on [**2113-8-14**] until INR is therapeutic (1.5-2.0). Thereafter, pt has been instructed to have weekly blood draws. Therapeutic goal is 1.5-2.0 Followup Instructions: 1)Pt must follow up with Dr. [**First Name (STitle) 6164**] at [**Hospital **] Medical Associates on [**2113-8-14**] at 9:15am.(1-[**Telephone/Fax (1) 32949**]). Pt also has an appointment at 8:30am with the [**Telephone/Fax (1) **] to have his INR checked. The [**Telephone/Fax (1) **] is located in the same building as Dr. [**Last Name (STitle) 15321**] office. 2)Pt must follow up with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] (cardiologist) in 3 months at [**Hospital1 69**]. Appt has been made for [**11-21**] @ 2:45pm. Location: [**Hospital Ward Name 23**] Building [**Location (un) **], [**Hospital Ward Name 516**] Tel: (1-[**Telephone/Fax (1) 920**]). Completed by:[**2114-9-1**]

[ "414.01", "410.71", "V45.82", "V15.82", "427.1" ]

icd9cm

[ [ [] ] ]

[ "36.07", "36.05", "37.23", "99.20" ]

icd9pcs

[ [ [] ] ]

8407, 8478

4743, 6907

325, 432

8588, 8595

1921, 3519

9327, 10053

1366, 1381

6962, 8384

8499, 8567

6933, 6939

3536, 4720

8619, 9304

1396, 1902

275, 287

460, 1166

1188, 1212

1228, 1350

66,419

174,256

42515

Discharge summary

report

Admission Date: [**2146-1-9**] Discharge Date: [**2146-1-15**] Date of Birth: [**2106-11-9**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4691**] Chief Complaint: Status-post crush injury by car Major Surgical or Invasive Procedure: Epidural catheter placement History of Present Illness: Mr. [**Known lastname **] is a 39 year-old male transferred from [**Hospital3 **] w/chest injuries. He was working under a car and apparently the [**Doctor Last Name **] malfunctioned and the car came down on him. He was transferred to [**Hospital1 18**] for further management of his injuries. His GCS was 15 upon arrival to the ED. He noted mostly pain in his sides, right worse than left, with increased pain with inspiration. He was initially evaluated in the trauma bay, CXR showing multiple right-sided rib fractures, a small apical pneumothorax and subcutaneous emphysema. Past Medical History: Thalassemia minor Social History: Works as a mechanic, 1 pack-per-day smoking, drinks socially Family History: Noncontributory Physical Exam: Upon presentation to [**Hospital1 18**]: HR: 71 BP: 128/79 Resp: 20 O(2)Sat: 100 Normal Constitutional: uncomofortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Oropharynx within normal limits Chest: Clear to auscultation. crepitance anterior chest wall on R. Normal chest rise, no evidence of flail. Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, mild upper abd ttp. Extr/Back: No cyanosis, clubbing or edema Skin: No rash Neuro: Speech fluent. normal strength and sensation all 4 ext. Psych: Normal mood, Normal mentation Upon discharge: VS: AVSS O2 saturations 94-96%RA General: in no acute distress,no increased work of breathing HEENT:mucus membranes moist, no perioral cyanosis, nares clear, trachea at midline CV:regular rate, rhythm. no murmurs, rubs, gallops Chest:resolving crepitance to right anterior chest. Pulm:Bilateral breath sounds, clear. Abd:soft, nontender, nondistended MSK:warm, well perfused. Pertinent Results: [**2146-1-9**] 09:00PM GLUCOSE-122* UREA N-14 CREAT-0.7 SODIUM-138 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-14 [**2146-1-9**] 09:00PM CALCIUM-8.4 PHOSPHATE-3.8 MAGNESIUM-1.9 [**2146-1-9**] 09:00PM WBC-19.2* RBC-4.85 HGB-10.5* HCT-32.8* MCV-68* MCH-21.8* MCHC-32.2 RDW-16.2* [**2146-1-9**] 09:00PM PLT COUNT-257 [**2146-1-11**] 06:03AM BLOOD WBC-10.9 RBC-4.43* Hgb-9.5* Hct-30.9* MCV-70* MCH-21.5* MCHC-30.9* RDW-16.0* Plt Ct-187 [**2146-1-14**] 05:09AM BLOOD WBC-5.6 RBC-4.00* Hgb-8.8* Hct-27.4* MCV-69* MCH-21.9* MCHC-32.0 RDW-16.3* Plt Ct-213 [**2146-1-13**] 05:12AM BLOOD WBC-5.9 RBC-3.77* Hgb-8.5* Hct-26.0* MCV-69* MCH-22.6* MCHC-32.7 RDW-16.1* Plt Ct-194 [**2146-1-9**] 06:30PM BLOOD PT-12.7* PTT-25.3 INR(PT)-1.2* [**2146-1-10**] 04:00AM BLOOD Glucose-137* UreaN-13 Creat-0.7 Na-137 K-4.1 Cl-105 HCO3-26 AnGap-10 IMAGING: [**1-9**] OSH CT torso: chest: no effusion. small right pneumothorax and air over the right chest wall, with fractures of the right 1st and 2nd ribs anteriorly (small contusion adjacent to first rib fracture), right 1st posteriorly, and nondisplaced fracture or posterior right ribs 4, 5, 7, 8, 9. left 3 and 4 posterolateral fractures, nondisplaced. No left pneumothorax or contusion. bibasilar atelectasis. vertebral bodies and sternum unremarkable. no evidence of aortic or other mediastinal injury. no solid organ injury. no free fluid or air. no pelvic or lumbar fractures. [**1-9**] OSH CT head and c-spine: head: no intra-cranial hemorrhage or other acute process; no fractures. C-spine: no fracture or malalignment. Rib fractures as noted on concurrent torso. [**1-10**]: CXR: Minimal opacification in the right apical region could reflect post-traumatic bleeding. Several displaced rib fractures are seen on the left. No evidence of acute vascular congestion or pneumonia. [**1-14**]: CXR: A small right pneumothorax is less conspicuous than before. Right subcutaneous emphysema has improved. Bilateral pleural effusions larger on the right side are unchanged. Right upper lobe atelectasis is stable. Right lower lobe opacity has increased due to increasing atelectasis. The left lung is grossly clear besides the small pleural effusion with minimal adjacent atelectasis Brief Hospital Course: He was admitted to the Acute Care Surgery team and transferred to the Trauma ICU for close monitoring of his respiratory status and pain management for his multiple rib fractures. Dilaudid PCA was started with minimal effect. On HD 2 the Acute Pain Service was consulted, and an epidural catheter was placed for better pain control. After placement of the epidural he was transferred to the regular nursing unit. His epidural remained in place for 2 days, during this time Toradol and Neurontin were added. The Toradol was stopped after 24 hours for concern over his low hematocrits; serial hematocrits were followed and remained low but stable. On HD 5 the epidural was removed and he was noted with increased pain requiring several adjustments in his oral regimen including adding IV Toradol back to his regimen and switching from Oxycodone to Dilaudid. He continued to have moderate pain, particularly with deep inspirationr or hiccups, of new onset; Chronic Pain service was consulted a this point to continue his current regimen with motrin and tylenol in addition to lidoderm patch. He was noted with bilateral subcutaneous emphysema; serial chest xrays were followed which showed resolving bilateral effusions and small anterior pneumothorax. He was started on nebulizers and instructed on use of incentive spirometer. He was evaluated by Physical therapy and cleared for home once medically stable. Upon discharge, he was afebrile, maintaining O2sats between 94-95% on room-air, was ambulating and tolerating a regular diet. Medications on Admission: Denies Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 7. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 9. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day for 3 weeks: apply to posterior right ribs 12 hours on, then 12 hours off. Disp:*21 * Refills:*0* Discharge Disposition: Home Discharge Diagnosis: s/p Crush Injury Rib fractures: -Right [**12-14**] anteriorly -Right 1, [**3-21**] posteriorly -Left [**2-13**] posterolateral Small right pneumothorax Small right pulmonary contusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a crsh injury where you sustained multiple rib fractures on both sides. You were monitored closley in the hopsital and evalauted by the Pain Specialisits who placed a special catheter into your back called an epidural in order to deliver medications in a manner that would help control your rib pain. After this catheter was removed you were given oral pain medications and you will be discharged to home on these. * Pain from rib fractures can cause you to take shallow breaths. It is important that you use your incentive spirometer to take [**7-22**] deep breaths every hour that you are awake. Coughing and deep breathing should be done at the end of your incentive spirometer excersises. * You should take your pain medication as directed to stay ahead of the pain otherwise you won't be able to take deep breaths. If the pain medication is too sedating take half the dose and notify your physician. * Pneumonia is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer 4 times every hour while awake. This will help expand the small airways in your lungs and assist in coughing up secretions that pool in the lungs. * You will be more comfortable if you use a cough pillow to hold against your chest and guard your rib cage while coughing and deep breathing. * Symptomatic relief with ice packs or heating pads for short periods may ease the pain. * Narcotic pain medication can cause constipation therefore you should take a stool softener twice daily and increase your fluid and fiber intake if possible. * Do NOT smoke * If your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have their own set of side effects so make sure your doctor approves. * Return to the Emergency Room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: MONDAY [**2146-2-7**] at 2:00 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage **You will need a chest x-ray prior to this appointment. Please go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **] Radiology 30 minutes prior to your appointment. Completed by:[**2146-1-15**]

[ "860.0", "861.21", "338.11", "282.46", "E916", "786.8", "807.08", "958.7", "862.29", "305.1" ]

icd9cm

[ [ [] ] ]

[ "03.90" ]

icd9pcs

[ [ [] ] ]

7063, 7069

4449, 5988

334, 364

7297, 7297

2192, 4426

9483, 10029

1111, 1128

6045, 7040

7090, 7276

6014, 6022

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1143, 1780

263, 296

1796, 2173

392, 974

7312, 7424

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1033, 1095

22,283

109,253

12761

Discharge summary

report

Admission Date: [**2105-6-18**] Discharge Date: [**2105-6-23**] Date of Birth: [**2045-12-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: paracentesis intubation esophageal balloon placement History of Present Illness: 59 y/o M who per notes was brought to ED by EMS for altered mental status. Pt was agitated on exam and unable to give hx. In the ED he was hypothermic at 91 degrees, with pulse 60, bp 78/50. He had a potassium of 7.4 which was treated with calcium gluconate, insulin/glucose, and kayexalate. ABG was 7.38/32/70. Utox demonstrated benzos and opiates. Also noted to have a bicarb of 12, creatinine of 6.1, BUN 124. In the ED had a diagnostic paracentesis, which revealed a WBC count of 1200 w/35% polys, 52% lymphs, RBC count 7575. He received ceftriaxone 2 grams and 4.5 liters of IVF. Past Medical History: IDDM poorly differentiated large cell carcinoma found in ascitic fluid several months prior to admission, assumed to be HCC Hep C EtOH abuse Social History: unknown amt of EtOH, tobacco, drugs Family History: unknown Physical Exam: T: 97 BP 81/48 P: 95 R: 36 95%4LNC Gen: alert but not answering questions HEENT: NC, AT. perrl. mm dry. Lungs: coarse breath sounds with scattered rhonchi CV: reg rhythm, tachycardic, no m/r/g Abd: hugely distended. appears TTP. +bs. Ext: no edema, 1+ dp pulses bilaterally Pertinent Results: [**2105-6-18**] 05:34AM BLOOD WBC-12.7* RBC-4.32* Hgb-14.8 Hct-42.6 MCV-99* MCH-34.2* MCHC-34.7 RDW-16.1* Plt Ct-364 [**2105-6-22**] 02:38PM BLOOD PT-15.4* PTT-31.6 INR(PT)-1.6 [**2105-6-18**] 05:34AM BLOOD PT-16.8* PTT-31.3 INR(PT)-1.9 [**2105-6-22**] 02:38PM BLOOD Glucose-143* UreaN-103* Creat-5.2* Na-144 K-4.5 Cl-108 HCO3-15* AnGap-26* [**2105-6-18**] 05:34AM BLOOD Glucose-228* UreaN-124* Creat-6.1* Na-129* K-7.6* Cl-94* HCO3-12* AnGap-31* [**2105-6-22**] 04:00AM BLOOD ALT-64* AST-118* AlkPhos-212* TotBili-2.2* [**2105-6-18**] 02:23PM BLOOD Acetone-NEGATIVE [**2105-6-18**] 05:57AM BLOOD Ammonia-78* [**2105-6-18**] 01:54PM BLOOD Cortsol-43.4* [**2105-6-18**] 12:40PM BLOOD Cortsol-45.0* [**2105-6-18**] 07:00AM BLOOD PEP-NO SPECIFI [**2105-6-18**] 05:34AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2105-6-22**] 04:35AM BLOOD Type-ART Temp-36.1 Rates-20/ Tidal V-550 PEEP-10 FiO2-40 pO2-88 pCO2-35 pH-7.32* calHCO3-19* Base XS--7 -ASSIST/CON Intubat-INTUBATED [**2105-6-21**] 07:57PM BLOOD Lactate-4.0* [**2105-6-19**] 12:19PM BLOOD Lactate-6.8* K-5.2 CTA AORTA: The aorta demonstrates a normal contour and caliber throughout its visualized course without any filling defects. No filling defects or pulmonary emboli are identified within the pulmonary arterial system. CT OF THE CHEST W/IV CONTRAST: Soft tissue window image demonstrate multiple lymph nodes within the mediastinum, within the pretracheal, subcarinal, and perivascular spaces. Several of these are enlarged by CT criteria, measuring up to 13 mm in short axis diameter. The great vessels, heart, pericardium are normal. No axillary lymphadenopathy is seen. No pleural effusions. Lung window images demonstrate innumerable nodules within both lungs diffusely, likely representing metastatic foci. No parenchymal consolidation is seen. The airways are patent to the level of the segmental bronchi bilaterally. CT OF THE ABDOMEN W/IV CONTRAST: There is massive ascites. Within the liver, there are several focal masses in the right lobe of the liver, the largest of these measures 9 x 5.9 cm. In the left lobe of the liver, a smaller nodule, measuring 2.3 x 2.2 cm is seen. Additionally, in the inferior tip of the right lobe of the liver, there is a lesion measuring 6 x 2.5 cm. These findings may represent a primary hepatic malignancy. Additionally, there is caking of the omentum, representing omental metastatic disease. The spleen, kidneys, and pancreas are normal. The bowel appears normal, without any evidence of bowel wall dilatation. The small bowel is floating within the ascites. There is increased density within the gallbladder, and within the large colon. These findings suggest the patient has had recent ERCP, and this density represents contrast. Correlation to clinical history is recommended. No free intraperitoneal air is seen. CT OF THE PELVIS W/IV CONTRAST: A large amount of pelvic fluid can be seen. The bladder contains a Foley catheter. The rectum appears normal. BONE WINDOWS: No suspicious lytic or sclerotic lesion identified. CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were essential in delineating the anatomy and pathology. IMPRESSION: 1) No aortic dissection. 2) Several masses are seen within the liver, in both lobes. These may represent a primary hepatic malignancy. There is diffuse metastatic disease within the lungs, with innumerable pulmonary nodules. Additionally, there are omental metastases. Further evaluation of the liver with a multiphasic liver CT is recommended. 3) Massive ascites. 4) The gallbladder contains dense material, which most likely represents contrast from recent ERCP. Correlation to clinical history is recommended. CT HEAD WITHOUT IV CONTRAST: No intraparenchymal, subarachnoid, or subdural hemorrhage is seen. The [**Doctor Last Name 352**]-white matter differentiation is preserved. No intracranial mass effect is identified. The ventricles are prominent, symmetric, and there is no shift of normally midline structures. There is a small area of decreased attenuation in the right anterior putamen/internal capsule which is probably a chronic infarction. The density of the cortex is within normal limits. Soft tissue and osseous structures are normal. IMPRESSION: No intracranial hemorrhage or mass effect. Peritoneal fluid cytology: Peritoneal fluid, cell block: Highly atypical scattered cells mostly seen in cytology preparation (see cytology report C05-[**Numeric Identifier 39373**]). Immunohistochemical studies for AE1/AE3, CAM 5.2, CEA, Leum1, Calrentinin, B72.3, Hepar-1, CD10 are non contributory. Brief Hospital Course: He was admitted to the MICU on the sepsis protocol. It was felt that he had SBP and likely had malignant ascites. His primary malignancy was likely hepatocellular, as CT chest/abd/pelvis demonstrated large lesions in the liver as well as innumerable pulmonary nodules. He was intubated on the night of admission [**3-11**] inability to continue compensating for his acidosis. He was increasingly hypotensive and was placed on levophed. He was anuric. It was felt that one of the reasons he couldn't be ventilated was that his distended abdomen was restricting his diaphragm, so an esophageal balloon was placed to monitor transpulmonary pressures. He also underwent repeat paracentesis to attempt to decrease ascites and help his respiratory status. 5 liters of ascites were removed. 2 days later he had another paracentesis, with another 5 liters removed. The renal service was following him but he did not require dialysis. His wife and daughter arrived from [**Name (NI) 19061**], and felt that he would have wanted everything done. However, after repeat meetings, and because of the fact that the pt did not pursue Oncology f/u when his cancer was diagnosed per PCP, [**Name10 (NameIs) **] was decided to make him DNR. His family did not want to withdraw care, but they did not want to escalate care. He became increasingly hypotensive and then became asystolic. He died on [**2105-6-23**] with his family by his side. Medications on Admission: vicodin prn humulin lasix indural protonix multivitamin Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: metastatic hepatocellular carcinoma sepsis respiratory failure renal failure Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "54.91", "38.93", "99.07", "96.04", "00.17", "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

7782, 7791

6209, 7647

338, 392

7911, 7920

1573, 6186

7973, 7980

1246, 1255

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1270, 1554

277, 300

420, 1013

1035, 1177

1193, 1230

4,368

137,799

45534+45552+58834

Discharge summary

report+report+addendum

Admission Date: [**2184-5-3**] Discharge Date: [**2184-5-21**] Date of Birth: [**2107-12-3**] Sex: F Service: Neuro-MEDICINE CHIEF COMPLAINT: Seizure. HISTORY OF PRESENT ILLNESS: [**Known firstname 8214**] [**Known lastname **] is a 76-year-old woman with a history of prior transient ischemic attacks and a complicated past medical history that includes three vessel preoperative evaluation to have a carotid endarterectomy, a subsequent right anterior cerebral artery infarction in [**2182**], and a secondary hemorrhagic conversion, a prior hip fracture with deep venous thrombosis and PE being treated with Coumadin, who presented with convulsions. At baseline, the patient is described as being confused. She refers to her husband as both her husband and her father interchangeably. She uses a wheelchair to move around her home and over the past 2-3 weeks, her daughter has noticed that she is having increased difficulty transferring to the bed because of difficulty raising her legs. Her daughter also notes that she seems to be slightly more confused than normal. Over the last week, her husband had noticed that for less than three minutes, she had two episodes where she would extend one leg and shake it rhythmically in a course, high amplitude, low frequency tremor. Her husband noted that this occurred every 2-4 days and could involve either leg. On the day of admission, she was in her usual state of health until approximately 5:10 pm, when she developed right leg tremor. After approximately three minutes, her left leg began shaking as well, and she leaned forward onto her husband's chest, clenching his jacket. He was unaware of whether she had stiffened and noticed no other focal arm or face jerking, but he also had difficulty providing details of the history. She presented to the Emergency Room and was described as having generalized tonic clonic seizures. She received Ativan 2 mg x5 (14 mg total). She was intubated for airway protection and loaded with Dilantin initially, but this was stopped because of a history of a drug allergy to Dilantin. On review of systems, there has been no recent fevers, chills, nausea, vomiting, headache, visual change, hearing difficulties, chest pain, abdominal pain, change in bowel or bladder habits including melena, blood, dysuria, or increased frequency. She has had a history of constipation and intermittent lower back pain. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Left internal carotid stenosis at 80-99% and right internal carotid artery stenosis at 40-59%. 4. Three vessel coronary artery disease that involves the left anterior descending artery at 80%, left circumflex at 80%, and right coronary artery at 100%. Her ejection fraction was 39% in [**2182-7-6**]. 5. Right anterior carotid artery infarction with secondary hemorrhagic conversion in [**2182-7-6**]. 6. A PE and DVT in [**2183-12-6**]. 7. Left hip fracture in [**2183-12-6**] status post open reduction internal fixation. 8. Seizures. 9. Peripheral vascular disease. ALLERGIES: Dilantin causes a rash. MEDICATIONS ON ADMISSION: 1. Lopressor 25 mg po bid. 2. Coumadin 3 mg po q day. 3. Zantac 150 mg po bid. 4. Lipitor. SOCIAL HISTORY: The patient lives with her husband. She has one daughter, who is present during the initial history and physical. She smoked tobacco for approximately 54 years and quit in [**2182**]. There is no history of alcohol use. On general physical examination, her pulse was 93. Her respirations were 23. Her temperature was 96.0 F. Her O2 saturation was 100% on room air. In general, the patient appeared stated age, was lying in bed, intubated, and motionless with her arms at her sides. Her head appeared normocephalic, atraumatic, and her sclerae were white. Her neck was supple and no bruits were appreciated, however, these may have been obscured by ventilator sounds. Her lungs demonstrated vented breath sounds bilaterally. Cardiovascular examination revealed a distant regular, rate, and rhythm with no murmurs, rubs, or gallops. Her abdomen was soft and appeared nontender and nondistended. There was no hepatosplenomegaly. Her extremities were warm without clubbing, cyanosis, or edema. On neurologic examination, the patient was unarousable by voice. There was a flicker of eye blinking with sternal rub. There were no localizing movements. Her face appeared symmetric. Her eyes have forward conjugate gaze. An OCR could not elicited. There was a bilateral blink reflex. There was no blink to threat. Her pupils are equal, round, and reactive to light both directly and consentially from 3 mm to 2.5 mm. Fundoscopic examination was limited by cataracts. She swallowed spontaneously and a gag was present. She withdrew her left upper extremity more than her right to painful stimuli. Tone in the upper extremities particularly in the triceps was increased to almost a "led pipe quality." She tended to keep her arms extended at her sides. There was a bilateral brisk triple flexion response to painful stimuli. There was no clear grimacing. Her reflexes were brisk throughout and her toes showed a brisk extensor-plantar response bilaterally. LABORATORIES ON ADMISSION: Her complete blood count was normal. Her bicarbonate was 11. Her BUN was 29. Her creatinine was 1.5. Her glucose was 163 and her amylase was 124. A CK was obtained which was 58 and a troponin was elevated at [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 11278**], M.D. [**MD Number(1) 11279**] Dictated By:[**Name8 (MD) 27429**] MEDQUIST36 D: [**2184-5-21**] 14:15 T: [**2184-5-21**] 14:35 JOB#: [**Job Number 21591**] Admission Date: [**2184-5-3**] Discharge Date: [**2184-5-25**] Date of Birth: [**2107-12-3**] Sex: F Service: Neurology DISCHARGE SUMMARY ADDENDUM: The patient had an additinal episode of slightly increased lethargy in the morning of [**2184-5-25**] and increased left upper extremity weakness, which led to a second head CT, which was unchanged from prior. A chest x-ray was obtained that demonstrated increased right started on Ceftriaxone and Flagyl on [**5-24**] and was to continue a fourteen day course. Otherwise her hospital course was unremarkable for the remainder of her stay. ADDITIONAL DISCHARGE MEDICATIONS: 1. Ceftriaxone 1 gram intravenous q 24 hours. 2. Flagyl 500 mg intravenous q 8 hours. Please refer to the prior discharge summary for details of her discharge plans. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 12114**] Dictated By:[**Doctor First Name 38670**] MEDQUIST36 D: [**2184-9-13**] T: [**2184-9-13**] 15:25 JOB#: [**Job Number **] Name: [**Known lastname **], [**Known firstname 2175**] Unit No: [**Numeric Identifier 15491**] Admission Date: [**2184-5-3**] Discharge Date: [**2184-5-21**] Date of Birth: [**2107-12-3**] Sex: F THIS IS AN ADDENDUM: The patient had a troponin level which was 15.6, which was elevated. This raised the suspicion for a prior myocardial screen was obtained which was negative. Her initial INR was 4.6. Her Dilantin level was less than 0.6. On a head CT scan there was evidence of an old right frontal infarction with associated encephalomalacia and a new left parietal occipital region of edema within the white matter as well as evidence of a central abnormality suggestive of a On MRI there was T2 hyperintensity in the same region as the edema seen on head CT scan, but there was also a well demarcated, heterogenous lesion in the medial parietal occipital region without evidence of susceptibility. MRA demonstrated a left internal carotid artery occlusion and right internal carotid artery stenosis. Impression: The patient is a 76 year old woman with a history of coronary artery disease, carotid stenosis, pulmonary embolism and deep vein thrombosis on Coumadin, prior right frontal hemorrhage and prior seizure, who presents with convulsions requiring Ativan and intubation. Examination demonstrated decreased withdrawal of her right upper extremity which suggested a left hemispheric lesion. This is likely due to the left occipital parietal mass surrounding edema noted on MRI. The patient was admitted to the Neurology Intensive Care Unit for continued care. SUMMARY OF HOSPITAL COURSE: 1. Left parietal occipital mass: A Neurosurgical consultation was obtained and the patient's left parietal occipital mass was resected on [**5-12**]. After the resection, the patient was noted to have a right foot drop which is likely due to the removal of her mass. Pathology of the mass demonstrated a papillary adenocarcinoma. A body CT scan was obtained that demonstrated an approximately 1 centimeter spiculated nodule in the peripheral left upper lobe. This was not seen on the chest CT scan of [**2182-12-6**]. Tiny bilateral pleural effusions were also noted as well as evidence of emphysema. A small amount of free fluid was noted in the pelvis. After transfer to the floor, the patient complained of right hip pain which led to plain films of the right hip, that demonstrated diffuse osteopenia as well as a 4 centimeter by 1 centimeter region of lucency in the right subtrochanteric femur. The presence of this lucency led to a bone scan that did not demonstrate evidence of metastatic disease. The patient had also complained of pain her right heel and plain films of the heel were obtained that did not show evidence of metastatic disease. An Oncology consultation was obtained and it was felt that given the patient's decreased mobility and current physical condition and poor functional status that the benefits of systemic chemotherapy did not outweigh the risks and chemotherapy was not advised. She is to follow-up with Oncology as an outpatient. A Neuro-Oncology consultation was also obtain with Dr. [**First Name8 (NamePattern2) 55**] [**Last Name (NamePattern1) 25**], who will also follow-up with the patient as an outpatient. She will most likely undergo palliative radiosurgery to the lesion. She is to have follow- up with the Neurosurgical Service as well. The patient should undergo an outpatient mammogram to help exclude breast cancer as a possible etiology, even though there is evidence of a mass in the left lung. Regarding the patient's seizure, she was started on Depakote and has remained seizure free through her hospital stay. An EEG was obtained that demonstrated slow and disorganized background activities with bursts of generalized slowing, as well as prominent focal high voltage sharp wave discharged in the left posterior quadrant that occasionally extended more generally. This was thought to represent widespread encephalopathic condition as well as a focal left posterior quadrant abnormality. There was no evidence of repetitive discharges to suggest ongoing seizure activity. Her liver function tests and amylase were followed intermittently through her hospital stay since she is taking Depakote; this should continue to be done as an outpatient to insure that there is not evidence of transaminitis or pancreatitis. Her ammonia was also followed and there was no evidence of hyperammonemia. Her Depakote level on [**5-20**] was 60, and that was a random level, and her Depakote trough on [**5-17**] was 58. Her blood count indices should also be followed while she is receiving Depakote. With regard to her elevated troponin on admission, the patient was continued on Lopressor, however, at the time of discharge her Lopressor dosage was decreased to 25 twice a day to prevent hypoperfusion of her brain given her carotid stenosis. The patient also should continue her Lipitor. Any platelet agents are currently being held, both because of her recent intracranial surgery and also because of the presence of metastatic intracranial disease. In regards to the patient's anemia, her hematocrit was closely followed through her hospital stay. It has averaged approximately 28, and at the time of discharge, is 26. Given the patient's coronary artery disease and carotid stenosis, her hematocrit should be closely followed and blood transfusions should be performed as needed. The patient should have her stool guaiac closely monitored. NOTE: This is an addendum to one of the prior paragraphs where I discussed the patient's intracranial lesions and her surgeries: To continue, the patient has been evaluated by Radiation Oncology and is to begin radiation therapy for additional intracranial lesions. In addition to the left parietal occipital lesion, the patient was also noted to have additional lesions, including a 5 millimeter contrast enhancing lesion in the right superficial parietal lobe. 2. Left upper extremity swelling: During the patient's Intensive Care stay, she was noted to have swelling in the left upper extremity that was concerning for the possibility of a subclavian vein thrombosis. A left upper extremity ultrasound was obtained that did not demonstrate evidence of deep vein thrombosis. She was also noted to have decreased movement of the left upper extremity and, although the etiology is not demonstrated on her prior imaging studies, this may reflect a small subcortical infarction. 3. In regards to nutrition, the patient received tube feeds through most of her hospital stay, and a swallowing evaluation was performed during which the patient frankly aspirated; this led to the placement of a PEG tube. The patient should continue on tube feeds and may benefit from a swallowing study in the future. Her tube feed residuals should be closely monitored and she should continue on aspiration precautions. After the patient's swallowing evaluation, she was noted to have continued hoarseness of voice that was initially felt to be related to her intubation. An ENT evaluation was obtained to insure that the patient did not have evidence of vocal cord paralysis. They did not feel that vocal cord paralysis was present. 4. From a respiratory perspective, the patient had undergone extubation after her hospital stay, but failed secondary to increased secretions. She was subsequently re-intubated and was extubated after her surgical procedure. While intubated, she was noted to have excessive secretions and this led to a bronchoscopy and broncho-alveolar lavage that demonstrated many PMNs and Gram positive cocci. Cultures subsequently demonstrated Staphylococcus aureus and the patient was placed on Oxacillin for a 14 day course to treat possible Staphylococcus aureus pneumonia. A PICC line was placed to continue antibiotic therapy and the patient should continue Oxacillin treatments that were started on [**5-13**], to continue a 14 day course. Deep vein thrombosis prophylaxis was maintained with heparin subcutaneously. This is particularly important given the patient's past history of deep vein thrombosis and pulmonary embolism and her current diagnosis of adenocarcinoma. On admission, it was felt that the patient's Coumadin was likely present because of her prior deep vein thromboses and her primary care physician was attempted to be contact[**Name (NI) **] at the time of this dictation to help clarify the need of continued anti-coagulation with Coumadin. Regardless, from a Neurosurgical perspective, it is felt that the patient should be maintained off anticoagulation unless emergent, for approximately two to three weeks. Given her metastatic adenocarcinoma within the brain, she would be at increased risk for intracranial hemorrhage. She should continue on heparin subcutaneously as an outpatient. During the last two days of the [**Hospital 1325**] hospital stay, she initially was noted to be slightly more lethargic than prior days. She has, however, continued to be alert and oriented to person, place and time. A repeat head CT scan was obtained to rule out possible mass effect from edema, and there did not appear to be increased mass effect to account for her slightly increased lethargy. She is continued on Decadron 4 mg intravenously q. eight hours, which will be changed to per PEG at discharge. An infectious work-up was obtained for additional causes of her lethargy and there is no evidence of ongoing infection. While to patient is receiving steroid treatment she should have her fingerstick blood glucose levels closely followed and covered with an insulin sliding scale. She should also continue on a proton pump inhibitor. DISCHARGE DIAGNOSES: 1. Papillary adenocarcinoma of likely lung primary, metastatic to brain. 2. Seizure disorder. 3. Anemia. 4. Coronary artery disease. 5. High grade carotid stenosis. 6. History of deep vein thrombosis and pulmonary embolism. 7. Staphylococcus aureus pneumonia. DISCHARGE MEDICATIONS: 1. Atorvastatin 10 mg per PEG q. day. 2. Docusate 100 mg per PEG twice a day. 3. Bisacodyl 10 mg per PEG or rectum p.r.n. q. day. 4. Insulin sliding scale. 5. Lansoprazole 30 mg per PEG q. day. 6. Metoprolol 25 mg per PEG twice a day to be held for heart rate less than 55, for blood pressure less than 110. 7. Oxacillin 2 grams intravenous q. six hours started [**2184-5-12**], and should be continued for 14 days. 8. Valproate 500 mg per PEG three times a day. Valproic levels should be checked q. week as a trough level, and the patient's amylase, liver function tests should be followed approximately every two weeks. 9. Furosemide 10 mg per PEG q. day; the patient's potassium should be followed q. week. 10. Dexamethasone 4 mg per PEG three times a day. The patient should continue her insulin sliding scale and gastrointestinal prophylaxis while taking Dexamethasone. 11. Heparin 5000 units subcutaneously twice a day. 12. Acetaminophen 650 mg per rectum or per PEG q. four to six hours p.r.n. 13. [**Doctor Last Name 10346**] Lotion applied to patient's right toes as needed p.r.n. DISCHARGE INSTRUCTIONS: 1. Nutrition: The patient is to continue with tube feeds of ProMod with fiber to be slowly increased to a goal of 55 cc. per hour. 2. Water flushes should be applied at 100 cc. twice daily. 3. The patient should continue on a multivitamin per PEG q. day. 4. The patient's abdominal examination should be closely followed. 5. PEG tube residuals may be checked. 6. Activity as defined by Physical Therapy. DISPOSITION: The patient is to be discharged to a rehabilitation facility. CONDITION ON DISCHARGE: Fair. FOLLOW-UP INSTRUCTIONS: 1. The patient is to follow-up with Dr. [**Last Name (STitle) 25**] in Neuro-Oncology. 2. The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24**] in Neurosurgery. 3. The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2681**], with Radiation Oncology on [**2184-6-7**], at 01:00 p.m. in the Brain [**Hospital 26**] Clinic. 4. The patient should also follow-up at her primary care physician in one to two weeks after discharge from hospital. PROGNOSIS: Poor. [**First Name11 (Name Pattern1) 194**] [**Last Name (NamePattern4) 544**], M.D. [**MD Number(1) 545**] Dictated By:[**Name8 (MD) 15492**] MEDQUIST36 D: [**2184-5-21**] 15:02 T: [**2184-5-21**] 15:33 JOB#: [**Job Number **]

[ "162.8", "997.09", "198.3", "482.41", "V58.61", "492.8", "414.01", "287.5", "780.39" ]

icd9cm

[ [ [] ] ]

[ "33.24", "38.93", "96.04", "03.31", "01.59", "96.6", "96.71", "43.11" ]

icd9pcs

[ [ [] ] ]

16568, 16836

16859, 17961

3134, 3226

17985, 18475

8433, 16547

162, 172

201, 2433

5247, 6356

18531, 19348

2455, 3108

3243, 5232

18500, 18507

15,852

171,615

52228

Discharge summary

report

Admission Date: [**2149-5-11**] Discharge Date: [**2149-5-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 663**] Chief Complaint: melena, chest pains Major Surgical or Invasive Procedure: esophagogastroduodenoscopy colonoscopy History of Present Illness: Mr. [**Known lastname **] is an 85M with h/o CAD, DM, PE on warfarin, and CRI who was admitted on [**5-8**] with complaints of lightheadedness at home and recent chest pains. Patient apparently developed dark stools approximatley 1 week prior to presentation. One day prior to presentation, he had an episode of lightheadedness on ambulation leading to a fall. Of note, he had intermittent dull discomfort in his abdomen for which he was taking Maalox. He also reported chest discomfort on ambulation and had been taking sublingual nitroglycerin at home. . On ROS, patient denies recent change to his medications including warfarin, EtoH consumption, history of liver disease. He has never had a colonoscopy. He does use ibuprofen occasionally. Had been having increased frequency of BMs at home, no constipation, nausea, vomiting, fevers. . In the ED, patient was hemodynamically stable. Rectal exam showed guiac positive stool. Admission labs were notable for Hct of 20 with INR of 3.6. EKG at admission showed ST depressions in precordial and lateral leads. He received 2units PRBCs, 2units FFP, and 5mg vitamin K and was started on IV pantoprazole. The patient was admitted to the MICU for further monitoring. . In the MICU, blood pressures remained stable. He was transfused and additional 2 units PRBCs with lasix (given EF 25%). MI was ruled out with serial cardiac enzymes. ASA and plavix were held. He was seen by the GI consult service who plan EGD. . Current, the patient has no complaints. He denies chest or abdominal discomfort or dyspnea. Past Medical History: Diabetes Mellitus- most recent HgbA1c 6.3 Hypertension Coronary Artery Disease - s/p 3v CABG in [**2142**] (SVG->LAD, PDA, and OM) - s/p cath [**2148-1-25**]: 3VD, no intervention Pulmonary artery hypertension Hyperlipidemia Chronic renal insufficiency, b/l Cr 1.8 H/o pulmonary embolus ([**1-20**]) Gout Right carotid artery stenosis: 100% h/o focal motor seizure x 1 in [**7-/2143**] Social History: Son lives with him at home. Needs some help with cooking, but otherwise fairly independent. Ambulates with cane. Quit smoking cigars years ago, no EtoH. Family History: No known colon cancer. Son, deceased with ?pancreatic cancer. Father and sister with heart disease, details unknown. Physical Exam: Exam on transfer from MICU T 99.2 P 94 BP 108/58 RR 20 O2 100% on RA General: Comfortable appearing elderly man in no acute distress HEENT: Sclera white, conjunctiva pale, MMM Neck: JVP ~7 CV: Regular tachycardic, no m/r/g appreciated Pulm: Lungs with few rales R base, no wheezing Abd: Soft, nontender, +bowel sounds, no organomegaly or masses Extrem: Warm, no edema, 2+ distal pulses Neuro: Alert, answering appropriately, moving all extremities without gross deficits. Hard of hearing. Has foley in place Pertinent Results: [**2149-5-11**] 11:50AM WBC-8.6 RBC-2.44* HGB-6.8*# HCT-20.8* MCV-85 MCH-27.8 MCHC-32.6 RDW-15.7* [**2149-5-11**] 11:50AM PLT COUNT-385 [**2149-5-11**] 11:50AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-1+ [**2149-5-11**] 11:50AM NEUTS-64.1 BANDS-0 LYMPHS-27.2 MONOS-6.8 EOS-1.5 BASOS-0.4 [**2149-5-11**] 11:50AM PT-34.2* PTT-36.3* INR(PT)-3.6* [**2149-5-11**] 11:50AM CK(CPK)-218* [**2149-5-11**] 11:50AM CK-MB-3 [**2149-5-11**] 11:50AM CK(CPK)-218* [**2149-5-11**] 11:50AM GLUCOSE-240* UREA N-40* CREAT-2.5* SODIUM-136 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-21* ANION GAP-17 [**2149-5-11**] 11:58AM LACTATE-3.5* [**2149-5-11**] 12:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2149-5-11**] 12:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2149-5-11**] 12:50PM URINE RBC-<1 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 . [**2069-5-10**] Tropn 0.02->0.08->0.03 [**5-16**] 5p CK 187 MB 3 Tropn <0.01 [**5-17**] 9a CK 175 MB 3 Tropn <0.01 . Discharge labs WBC 8.5, Hct 34, Plts 318, Cr 1.5 . [**5-14**] H. pylori antibody negative Micro 4/27,[**5-12**] blood cx no growth 4/27,[**5-12**] urine cx no growth [**5-13**] urine cx mixed flora . [**5-16**] Colonoscopy Findings: Mucosa: Edematous mucosa with decreased vascularity and mild patchy erythema with no bleeding were noted in the cecum, proximal ascending colon, splenic flexure and descending colon. Cold forceps biopsies were performed for histology at the ascending colon and splenic flexure . Protruding Lesions A single sessile 3 mm non-bleeding polyp of benign appearance was found in the cecum. A single-piece polypectomy was performed using a cold forceps. The polyp was completely removed. Impression: Polyp in the cecum (polypectomy) Edematous mucosa with decreased vascularity and mild patchy erythema in the cecum, proximal ascending colon, splenic flexure and descending colon (biopsy) Otherwise normal colonoscopy to terminal ileum . [**5-14**] EGD Findings: Esophagus: Normal esophagus. Stomach: Excavated Lesions A few small, non-bleeding erosions were noted in the antrum. Other Gastric folds converging on a 1cm depression along the greater curvature of the stomach body were noted. These findings are consistent with a healed ulcer. Biopsies were not taken because the patient's INR is 2.2. Duodenum: Normal duodenum. Impression: Erosions in the antrum Healed gastric ulcer Otherwise normal EGD to third part of the duodenum . [**5-11**] CXR IMPRESSION: No acute intrathoracic pathology is identified. . [**5-11**] EKG SR nl axis and intervals, ST depressions V2-V6, I, vL. Brief Hospital Course: 1. Gastrointestinal bleeding The patient presented with Hct of 20 down nearly 7 points from prior Hct 9/[**2148**]. Of note, he was taking both warfarin, aspirin, and plavix. His initial INR was supratherapeutic at 3.6. Given melena, initial concern was for upper source vs slow lower bleed. His antiplatelet agents and warfarin were held, IV PPI was initiated, and he was given FFP, vitamin K, and transfused PRBCs. He was initially admitted to the MICU for close monitoring; he remained hemodynamically stable there. On the medical floor, his hematocrit remained stable and he required no further RBC transfusions. He underwent EGD which showed some antral erosions and a healed ulcer, but no active bleeding. Serology showed no evidence of H. pylori infection. He subsequently underwent a colonoscopy which also showed no source of active bleeding. A benign-appearing 3mm cecal polyp was removed, the pathology of which remains PENDING at discharge and will need to be followed up by his outpatient providers. He will need to follow up with GI as an outpatient for consideration of a possible capsule study. He was given instructions to call for any further concerns of melena or other bleeding. He will NOT be continuing warfarin, but was restarted on aspirin and plavix prior to discharge and will continue taking a PPI. . 2. CAD The patient reported worsening symptoms of chest discomfort at home requiring nitroglycerin. He was ruled out for myocardial infarction. It is likely that his angina was provoked by his GI bleeding. His antiplatelet agents, metoprolol, and imdur were initially held. He did experience chest discomfort during admission that reponded to nitroglycerin, and repeat cardiac enzymes were again negative. He resumed his home metoprolol, imdur, and antiplatelet agents following colonoscopy. Both metoprolol and isosorbide were subsequently increased. He will need to follow up with his PCP and cardiology for further treatment of his CAD. . 3. Acute on chronic renal failure The patient's creatinine was elevated at 2.5 at admission, returning to baseline 1.5 at discharge. He was likely pre-renal at admission, improved with blood and IV fluids. . 4. Fever The patient experienced low grade fever following transfer from the MICU. Of note, he had had a foley catheter. As his urinalysis showed pyuria, he was empirically treated with ceftriaxone for suspected UTI. Ceftriaxone was subsequently discontinued when the urine culture returned negative. His blood culture was negative. He had no significant fevers at discharge and was hemodynamically stable. . 5. History of PE Patient will not resume warfarin at discharge per discussion with PCP given concern for increased risk of GI bleeding. . 6. Tachycardia Of note, patient had frequent atrial ectopy on telemetry with occasional brief episodes of atrial tachycardia. His metoprolol was increased and he may benefit from changing to metoprolol succinate. He will follow up with cardiology for further evaluation and treatment as needed. . 7. DM Patient was continued on insulin, to continue prior home schedule at discharge Medications on Admission: ASA 325 QD Metoprolol 12.5 [**Hospital1 **] Insulin humalin 70/30 15 U qam, 10 U qhs Imdur 30 qam Lipitor 80 qd plavix 75 qday Coumadin 2 mg daily Colchicine 0.6 prn Triamterene-Hydrochlorothiazide 37.5/25 daily SLNTG prn Discharge Medications: 1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual as directed: Take 1 tab for chest pain, may take up to 3 tabs every 5 minutes if no relief. Call 911 if chest pain not relieved 5 minutes after 1 tab taken. Sit down to take. Disp:*30 Tablet, Sublingual(s)* Refills:*2* 2. Aspirin 81 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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: as below units Subcutaneous as directed: 15 units in the morning, 10 units in the evening. 8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary 1. Upper GI bleed 2. Coronary artery disease 3. Acute on chronic renal failure 4. Colon polyp 5. Tachycardia Discharge Condition: Fair, with pain under control and with stable hematocrit, no gross bleeding Discharge Instructions: You came into the hospital because of black stools, lightheadedness, and chest pain at home. You were found to be very anemic and were given blood. You had endoscopy studies to determine the source of bleeding in your gut. You had some irritation of the stomache that might have been responsible for the bleeding, but you will need to follow up with the gastroenterology clinic for further testing. You had a small colon polyp removed as well. . In the hospital you had blood tests and EKG tests that showed no evidence of a heart attack. It is very important that you followup with your heart doctor for further treatment of your heart disease. . Take your medications as directed and keep your followup appointments **** IMPORTANT **** Please stop taking your warfarin (coumadin). In the hospital, your Metoprolol was changed from 12.5mg twice a day to 25mg twice a day. Your Isosorbide Mononitrate was changed from 30mg to 60mg once a day. You were started on omeprazole once a day. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases more than 3 lbs. Adhere to 2 gm sodium diet . Call Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 250**] and seek medical attention if you develop: Recurrent black or bloody stools, abdominal pain, lightheadedness, dizziness, fainting, chest pain or shortness of breath, or any other symptoms that worry you or your family` Followup Instructions: Please call Dr.[**Name (NI) 17410**] office at [**Telephone/Fax (1) 250**] Monday morning [**2149-5-19**] to be seen in clinic as soon as possible that week. You also need to followup with the gastroenterology and cardiology clinics in the next 1-2 weeks. Dr.[**Name (NI) 17410**] office can help you set this up. You also have the following appointments Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2149-5-26**] 10:00

[ "285.1", "585.9", "V45.81", "V58.61", "V12.51", "578.9", "413.9", "584.9", "E934.2", "274.9", "250.00", "272.4", "211.3", "790.92" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.07", "45.42", "45.25", "99.04" ]

icd9pcs

[ [ [] ] ]

10577, 10634

5924, 9032

281, 322

10795, 10873

3161, 5901

12315, 12856

2500, 2618

9304, 10554

10655, 10774

9058, 9281

10897, 12292

2633, 3142

222, 243

350, 1905

1927, 2314

2330, 2484