ChanBeDu/relevant_section_length · Datasets at Hugging Face

70,386

183,158

41918

Discharge summary

report

Admission Date: [**2119-11-21**] Discharge Date: [**2119-11-24**] Date of Birth: [**2089-1-7**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 9160**] Chief Complaint: DKA Major Surgical or Invasive Procedure: Placement of a subclavian central line History of Present Illness: This is a 30 year old lady with a history of needle phobia, poor [**First Name3 (LF) 31217**] compliance and recurrent DKA who presents with nausea, emesis, abdominal pain in the setting of missing [**First Name3 (LF) 31217**] humalog yesterday. . The patient reports a strong history of aversion to needles. She had done well since her most recent discharge. She took her insuln as directed on Sunday evening. On Monday morning her blood sugar was elevated above 300 and she did not take her [**First Name3 (LF) 31217**] sliding scale. She developed abdominal pain and nausea and self corrected several times during the day with increasing doses of humulog. In the afternoon her blood sugar was 50 prompting her to skip dinner and her PM lantus. By 3AM this AM, her abdominal pain and nausea and emesis had worsened prompting referral to the ED. She endores a 2 day history of burning with urination. She denies cough, fever, chills or diarrhea. . Of note the patient was recently admitted on [**10-22**] and [**11-9**] for DKA requiring brief ICU admissions for administration of an [**Month/Year (2) 31217**] drip. She reports seeing a psychiatrist through [**Last Name (un) **] for CBT to work on her needle phobia. She was seen by [**Last Name (un) **] during her last admission and her PM [**Last Name (un) 31217**] dose was increased to 44 units. She was due to follow-up with [**Last Name (un) **] tomorrow for initiation of an [**Last Name (un) 31217**] pump trial. Shes a psychiatrist and psychologist in the outpatient setting for management of her blood sugars. . In the ED inital vitals were, 98.2 128 104/83 18 100%. Initial labs were significant for an anion gap of 29 and a lactate of 1.0. She was given 4mg morphine sulfate, 4mg IV zofran and started on an [**Last Name (un) 31217**] drip with a 5unit regular [**Last Name (un) 31217**] bolus. . On arrival to the ICU, initial vitals were: 97.7 120 99/59 68 16 100% RA. She was tearful and not initially cooperative with exam for fear of future blood draw. Most of this history was obtained from her mother with the patients agreement. She was able to sign an ICU consent form. Past Medical History: Type 1 Diabetes Mellitus, diagnosed at age 25 Needle Phobia, recently started seeing psychiatrist at [**Last Name (un) **] Inguinal hernia Social History: - Tobacco: None - Alcohol: Rare, has not had any drinks over past week - Illicits: None Lives with parents, works as hostess at a restaurant. Family History: Sister: [**Name (NI) 91015**] 1- since age 14; 22 now paternal uncle: [**Name (NI) 91015**] 1 paternal cousins: [**Name (NI) 91015**] 1 Father: [**Name (NI) **] 62 alive & well Mother: [**Name (NI) **] 60 alive & well Comments: Paternal side with T1DM and T2DM Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.7 120 99/59 68 16 100% RA. General: Alert, crying 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, mildly-tender in all quadrants, 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 Skin: multiple small circular well demarcated patches along waist band, 2 small lesions on left shin and 1 large 3x3cm patch erythematous on left shin. Stable in appearance per pt report for past several months. Pertinent Results: Admission labs: WBC-7.7# RBC-4.40 HGB-13.3 HCT-41.1 MCV-94 MCH-30.3 MCHC-32.4 RDW-14.0 NEUTS-87.0* LYMPHS-10.7* MONOS-1.8* EOS-0 BASOS-0.4 [**2119-11-21**] 05:00AM GLUCOSE-506* UREA N-18 CREAT-0.8 SODIUM-140 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-<5 [**2119-11-21**] 05:00AM CALCIUM-8.0* PHOSPHATE-4.3# MAGNESIUM-1.9 [**2119-11-21**] 07:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-MOD [**2119-11-21**] 07:00AM URINE RBC-2 WBC-4 BACTERIA-NONE YEAST-NONE EPI-1 [**2119-11-21**] 07:00AM URINE MUCOUS-RARE [**2119-11-21**] 05:18AM LACTATE-1.0 [**2119-11-21**] 12:55PM %HbA1c-12.5* eAG-312* Urine culture- MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Discharge labs: [**2119-11-23**] 05:26AM BLOOD WBC-3.3* RBC-3.81* Hgb-11.5* Hct-32.6* MCV-86 MCH-30.1 MCHC-35.2* RDW-14.4 Plt Ct-187 [**2119-11-24**] 09:50AM BLOOD Glucose-304* UreaN-10 Creat-0.5 Na-142 K-3.6 Cl-104 HCO3-33* AnGap-9 Brief Hospital Course: BRIEF HOSPITAL COURSE: 30F with h/o poorly complaint type I DM c/b recurrent episodes of DKA, anxiety, fear of needles presenting with DKA. 1. Diabetic Ketoacidosis ?????? Ms. [**Known lastname 91012**] presented with DKA with anion gap of 29 after self-discontinuing her [**Known lastname 31217**] [**1-18**] needle phobia. There were no focal signs of infection or other precipitant for hyperglycemia. She was admitted to the ICU where a subclavian CVL was placed to allow initiation of [**Month/Day (2) 31217**] gtt, fluid/ electrolyte repletion and frequent electrolyte monitoring (see below). Once blood glucose was less than 250, she was placed on D51/2NS to prevent hypoglycemia. Electrolytes, especially potassium, were followed carefully and repleted as needed. After anion gap had closed and patient was taking orals, subcutaneous [**Month/Day (2) 31217**] was given and then [**Month/Day (2) 31217**] gtt was discontinued. Under the guidance of [**Last Name (un) **], she was restarted on her glargine and SSI. Due to subsequent morning hypoglycemia, glargine dose was reduced from 44U to 42U on discharge. Prandial sliding scale [**Last Name (un) 31217**] was uptitrated due to postprandial hyperglycemia. Upon discharge, close follow up was arranged with multiple providers at [**Hospital **] clinic. Plan for initiation of [**Hospital 31217**] pump as it would require fewer injections, resulting in better patient compliance with [**Hospital 31217**] regimen. 2. Psych/SI/Anxiety ?????? Patient has debilitating fear of needles which resulted in current and multiple prior admissions with DKA. Upon admission to the ICU, she refused blood draws, despite being continuously informed that she was critically ill and this was interfering with her medical care. She was evaluated by psychiatry and reported suicidal ideation. She initially wanted to be DNR/DNI, however it was unclear whether or not she had capacity to make this decision. A central line was placed under sedation for blood draws and medication administration. Patient was on 1:1 sitter. She was continued on her home fluoxetine 30mg po daily. Patient was found to be not capable of making medical decisions, and paperwork was started to obtain temporary guardianship. However, once DKA had resolved and patient was transferred out of the intensive care unit, she became more compliant with therapy and denied suicidal ideation. Psychiatry did not feel the patient needed inpatient psychiatric admission and recommended close follow up with ouptatient providers upon discharge, Patient will continuing treatment of depression and CBT for needle phobia at [**Last Name (un) **]. She was also referred to the [**University/College 14925**]anxiety center for further management. 3. leukopenia: patient noted to have borderline leukopenia of 3.3 which was attributed to dilution in the setting of aggressive IVF. However, this should be followed as an outpatient with repeat blood work in 1 weeks. TRANSITIONS OF CARE: type I DM: - continued psychiatric care for needle phobia - contract with patient and mother for continued [**University/College 31217**] therapy according to [**University/College 7219**] - initiation of [**University/College 31217**] pump to allow improved compliance anxiety/ depression - follow up with [**Last Name (un) **] providers - referral to BU anxiety center leukopenia: recheck CBC Medications on Admission: 1. ethyl chloride 100 % Aerosol, Spray Sig: One (1) spray Topical PRN as needed for pain from injections. 2. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety . 4. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. [**Last Name (un) 31217**] glargine 100 unit/mL Solution Sig: Forty Four (44) units Subcutaneous qHS. 6. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous four times a day. Discharge Medications: 1. fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 3. Lantus 100 unit/mL Solution Sig: Forty Two (42) units Subcutaneous at bedtime. 4. [**Last Name (un) 31217**] lispro 100 unit/mL [**Last Name (un) **] Pen Sig: per sliding scale Subcutaneous per sliding scale. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Diabetic Ketoacidosis needle phobia anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 91012**], You were admitted to the hospital with diabetic ketoacidosis after stopping your [**Known lastname 31217**]. You were initially treated with an [**Known lastname 31217**] drip in the intensive care unit but then transitioned to your home regimen. It is VERY important that you take your [**Known lastname 31217**] as prescribed and take [**Known lastname 31217**] before every meal. You may find it easier to adhere to your regimen using an [**Known lastname 31217**] pump. You should continue working with your psychiatrist to help treat your fear of needles. Please make the following changes to your medication regimen: DECREASE your lantus to 42 Units CHANGE your sliding scale (see attached sheet) Please continue to take all of your other medications as previously prescribed Followup Instructions: Please ensure that you attend the following appointments: Please go to [**Hospital **] Clinic for the following appoinments: who: [**Doctor First Name 24592**] O' [**Doctor First Name **] when: [**12-1**] at 1pm who: Dr. [**Last Name (STitle) **] When: [**12-5**] at 1:30pm who: Dr. [**Last Name (STitle) 16471**] when: [**12-5**] at 4pm who: Dr. [**Last Name (STitle) **] when: [**12-5**] at 3:15pm Please call the BU anxiety center to schedule an appointment Name: [**Last Name (un) **] [**Last Name (LF) **],[**First Name3 (LF) **] T Location: [**Hospital **] COMMUNITY HEALTH CENTER Address: [**Hospital1 **], [**Location (un) **],[**Numeric Identifier 91016**] Phone: [**Telephone/Fax (1) 47544**] *Please call your primary care physician to book [**Name Initial (PRE) **] follow up appointment for your hospitalization. It is recommended you follow up within 2 weeks of discharge. If you have any questions or concerns please call the office. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]

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27431

Discharge summary

report

Admission Date: [**2174-5-31**] Discharge Date: [**2174-6-7**] Date of Birth: [**2115-5-16**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 65686**] Chief Complaint: seizure Major Surgical or Invasive Procedure: [**6-3**] Right frontal craniotomy for tumor History of Present Illness: In brief, this patient is a 59M w/ a hx of prostate cancer, followed here by Dr. [**Last Name (STitle) **], that was originally diagnosed in [**2167**]. Pt is s/p surgical resection that demonstrated local extra-prostatic invasion. He then followed therapy with salvage radiation therapy, followed by casodex. The casodex was discontinued recently (w/in past year) because of constitutional side effects and back pain. The patient has had rising PSA since then. On [**2174-5-27**], had a tonic clonic seizure, was evaluated at an OSH with a CT head and MRI non-contrast that demonstrated R frontal lobe lesion. The patient received dexamethasone and dilantin, and had no further seizures after arriving to that floor. On OMED service, multiple attempts were made on MRI, and eventually able to obtain. Neurosurgery was consulted and took the pt for right partial frontal lobectomy on [**2174-6-3**]. He tolerated the procedure well without complications. Preliminarily, frozen section shows malignant glioma. Post-op he is neurologically intact, has large black eye, normal sequelae per d/w neurosurgery resident. He is A&Ox3, no focal findings. He had repeat MRI today with 1mg Ativan prior. He requires neuro checks q4hrs. His last dilantin level 4.5 today, on 100mg TID, currently. After review with neurosurgery attending, dilantin uptitrated to 300mg additional dose now, and then to increase to 150mg TID tomorrow, and check dilantin level in am. He has no specific BP goals. He is being transferred to the OMED service under Dr. [**Last Name (STitle) 6570**] for further management. Currently, he has mild headache, but says that he is otherwise feeling much better. Denies any weakness, numbness, tingling or other new sensations. He last had BM 2 days ago, but is passing gas. Denies SOB, chest pain. Denies n/v/abdominal pain. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies blurry vision, diplopia, loss of vision, photophobia. Denies chest pain or tightness, palpitations, lower extremity edema. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. Past Medical History: PAST ONCOLOGIC HISTORY: Prostate cancer (originally diagnosed [**2167**] [**Doctor Last Name 51884**] 3+4) who had a recurrence after both surgery and then salvage radiation therapy. The patient started Casodex in [**2172**], but stopped [**Month (only) **] [**2172**] due to constitutional symptoms/side effects. Since that time, he has been off of the casodex and PSA has been rising. PAST MEDICAL HISTORY: - Hypertension. - Hyperlipidemia. - anxiety - insomnia - Prostate cancer as noted above. Social History: Lives in [**Location **] with his wife. [**Name (NI) **] continues to work fulltime as a UPS driver. He quit smoking in [**2167**], and previously had a 50-pack-year smoking history. He does not drink alcohol or any other illicit drugs. Family History: Pt denies hx of prostate cancer. The patient has a nephew who has epilepsy. Physical Exam: ADMIT PHYSICAL EXAM: Vitals - 98.5 122/79 HR 58 RR 18 O2 sat 97%RA GENERAL: NAD, comfortable, pleasant HEENT: AT/NC, EOMI, ecchymoses and edema over right eye closed from edema and slight erythema, L eye PERRLA, anicteric sclera, MMM CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, 5/5 strength in all upper and lower extremities; sensation intact bilaterally; patient alert, attentive and oriented x3, 2+ patellar DTR's, finger to nose testing intact, gait not assessed SKIN: warm and well perfused, tatoo on L arm NEUROSURGERY INITIAL EXAM: T 98.7 BP 137/77 P 64 R 18 95% RA. Mental status is satisfactory in areas of alertness, orientation, concentration memory and language. On cranial nerve examination, eye movements are full, pupils are equal and reactive. Full visual fields. No facial weakness, no dysarthria. No tongue weakness. On motor examination, there is no weakness. Coordination is normal. Fine movements are satisfactory. Light touch is perceived well throughout. Reflexes are brisker on the left. Gait and station are normal. On general examination, the oropharynx is clear, the lungs are clear, the heart is regular, the legs are without edema or tenderness. DISCHARGE PHYSICAL EXAM: GENERAL: NAD, comfortable, pleasant HEENT: AT/NC, EOMI, PERRL improved ecchymoses and edema over right eye, anicteric sclera, MMM CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, 5/5 strength in all upper and lower extremities; sensation intact bilaterally; patient alert, attentive and oriented x3, 2+ patellar DTR's, finger to nose testing intact, gait normal SKIN: warm and well perfused, craniotomy incision site c/d/i, tattoo on L arm. Pertinent Results: STUDIES: MRI Brain [**6-1**] 2.2 x 2.9 cm cortical-based right frontal mass with imaging characteristics most consistent with lymphoma. Given the limited degree of white matter infiltration and edema, etiologies such as glioma or metastatic disease are somewhat less likely. MRI Brain [**6-4**] (post-surgical): 1. Post-surgical changes in the right frontal region with blood products in the right frontal lobe at the surgical resection site. Hence assessment for abnormal enhancement is limited. There is persistent cortical thickening with surrounding FLAIR hyperintense signal as on the preoperative study. However, the majority of the enhancing lesion noted on the preoperative study is not seen on the present study indicating interval removal, with limited assessment for subtle changes. Consider followup to assess for stability/progression. Other details as above. INITIAL LABS: [**2174-5-30**] 03:15PM BLOOD WBC-21.6* RBC-5.02 Hgb-14.2 Hct-41.5 MCV-83 MCH-28.4 MCHC-34.3 RDW-14.1 Plt Ct-361 [**2174-5-30**] 03:15PM BLOOD Glucose-81 UreaN-25* Creat-1.2 Na-139 K-3.5 Cl-97 HCO3-27 AnGap-19 [**2174-6-1**] 07:04AM BLOOD ALT-78* AST-126* LD(LDH)-339* AlkPhos-68 TotBili-0.5 [**2174-5-30**] 03:15PM BLOOD Calcium-9.7 Phos-3.7 Mg-2.0 [**2174-5-31**] 04:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG OTHER PERTINENT LABS: [**2174-6-7**] 07:31AM BLOOD WBC-12.8* RBC-4.74 Hgb-13.0* Hct-40.0 MCV-84 MCH-27.4 MCHC-32.5 RDW-13.8 Plt Ct-296 [**2174-6-2**] 07:45AM BLOOD WBC-18.1* RBC-5.15 Hgb-14.2 Hct-43.1 MCV-84 MCH-27.5 MCHC-32.9 RDW-13.1 Plt Ct-341 [**2174-5-31**] 04:30AM BLOOD Neuts-79.0* Lymphs-15.5* Monos-5.1 Eos-0.1 Baso-0.2 [**2174-6-5**] 09:00AM BLOOD PT-10.6 PTT-26.5 INR(PT)-1.0 [**2174-6-4**] 02:33AM BLOOD PT-10.8 PTT-26.1 INR(PT)-1.0 [**2174-6-7**] 07:31AM BLOOD Glucose-88 UreaN-20 Creat-0.8 Na-138 K-3.9 Cl-102 HCO3-28 AnGap-12 [**2174-6-5**] 09:00AM BLOOD Glucose-195* UreaN-20 Creat-0.9 Na-137 K-3.3 Cl-99 HCO3-27 AnGap-14 [**2174-6-2**] 07:45AM BLOOD Glucose-90 UreaN-24* Creat-0.9 Na-138 K-3.4 Cl-98 HCO3-28 AnGap-15 [**2174-6-2**] 07:45AM BLOOD ALT-76* AST-89* LD(LDH)-254* AlkPhos-63 TotBili-0.3 [**2174-6-1**] 07:04AM BLOOD ALT-78* AST-126* LD(LDH)-339* AlkPhos-68 TotBili-0.5 [**2174-6-7**] 07:31AM BLOOD Calcium-9.6 Phos-3.0 Mg-2.1 [**2174-6-4**] 02:33AM BLOOD Calcium-7.9* Phos-2.6*# Mg-1.8 [**2174-6-7**] 07:31AM BLOOD Valproa-25* [**2174-6-6**] 01:20PM BLOOD Valproa-40* [**2174-6-5**] 09:00AM BLOOD Phenyto-5.1* [**2174-6-1**] 07:20PM BLOOD Phenyto-12.0 [**2174-5-31**] 10:40AM BLOOD Phenyto-1.7* MICROBIOLOGY/PATH: []Frontal Tumor Specimen ([**6-3**]) DIAGNOSIS: 1. Specimen labeled "right tumor - superficial" (including FS1, SM1): GLIOBLASTOMA, W.H.O. Grade IV (ICD-O 9440/3), see NOTE. 2. Specimen labeled "right tumor - deep" (including FS2, SM2): GLIOBLASTOMA, W.H.O. Grade IV (ICD-O 9440/3), see NOTE. 3. Specimen labeled "right frontal tumor": GLIOBLASTOMA, W.H.O. Grade IV (ICD-O 9440/3), see NOTE. NOTE: The sections show an infiltrative, mitotically active glial neoplasm composed of cells with hyperchromatic, pleomorphic nuclei enmeshed in a fibrillary background. Necrosis and vascular proliferation are present. Focal spread into the subarachnoid space is noted. The overall size of the resection is large. Tumor infiltrates adjacent brain parenchyma. The tumor is newly diagnosed Brief Hospital Course: NEUROSURGERY COURSE: Patient was admitted on [**5-30**] for seizure and found to have right brain mass. neurosurgery was consulted for evalaution for possible biopsy vs resection. He was loaded with dilantin and high dose dexamethasone was started. On [**5-31**] the patient eloped from the hospital and was brought back in by police. His dilantin level was low and he was bolused to improve his levels. On [**6-1**] he underwent an MRI witha dn without contrast after many failed attempts and it was determine that the patient woul go to the OR for resection of the right frontal lesion on [**6-3**]. He remained stable and underwent pre-op on [**6-2**]. On the morning of [**6-3**] he was transferred to [**Hospital Ward Name **] for surgery. he went to the OR and was intuabted, he subsequently went to MRI and had his WAND study. He was then transported back to the OR intubated and underwent resection of his lesion. He tolerated the procuedure well, was extubateed in the operating room. He was transferred to the PACU post-operatively as there were no ICU beds. His Post op check was stable and his CT showed no signs of complications. He received an ICU bed and was trasnferred there from htere. BRIEF CLINICAL SUMMARY: Mr. [**Known lastname 13959**] is a 59M with history of prostate CA, who presented from OSH with seizures, new brain mass. Pt is now s/p partial right frontal lobectomy, with pathology suspicious for glioblastoma. The patient tolerated the surgery well and will follow-up in [**Hospital **] clinic. ACTIVE ISSUES: #. Brain tumor: The patient initially presented with seizures, and was placed on seizure prophylaxis. Seizures thought to be [**12-30**] intracranial tumor, which was identified on CT and MRI. Neurosurgery and neuro-oncology initially consulted on this patient. The patient had a partial frontal lobectomy to resect the lesion. Prelim frozen pathology c/w malignant glioma, final pathology consistent with glioblastoma. The patient was transferred back to the neuro-oncology service. The patient was monitored s/p surgery, without complication. The patient initially received phenytoin and high-dose dexamethasone, then was transitioned to valproic acid and dexamethasone dose decreased s/p surgical intervention. The patient's most recent valproic acid level was 25 upon discharge. Patient's dose was increased to 750mg [**Hospital1 **]. Dexamethasone was 4mg qAM upon discharge. The patient was continued omeprazole while on dexamethasone. No calcium/vit d or insulin was prescribed as dexamethasone will most likely be further weaned in future. Pt received oxycodone for surgical pain. # Impulsivity, bahavioral issues: Patient with impulsivity, aggressive and atypical behavior on admission. Most likelys econdary to frontal lobe lesion. Patient eloped x2 throughout admission, requiring interception by the police at one point. The patient required 1:1 sitter until surgical resection. Patient's behavior improved s/p surgery, very polite and gentle. #. Prostate Cancer: pt followed by Dr. [**Last Name (STitle) **]. PSA has been increasing. CT torso to evaluate for further mets performed [**2174-5-29**]. #. HTN: stable. cont atenolol at home dose. chlorthalidone discontinued [**2174-6-5**] considering potential interaction w/ valproate. SBPs in 120s on day of discharge. #. HLD: stable. continued home atorvastatin. #. Anxiety / depression: continue buspirone at home dose. TRANSITIONAL ISSUES: 1. follow-up with Dr. [**Last Name (STitle) 67139**] in [**Hospital **] clinic (assess valproic acid level at that time, address dexamethasone at that appointment, wound assessment at that meeting) Medications on Admission: 1. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush 2. Dexamethasone 4 mg IV Q6H 3. Atorvastatin 20 mg PO DAILY 4. Chlorthalidone 25 mg PO DAILY 5. BusPIRone 30 mg PO BID 6. Atenolol 50 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Acetaminophen 325-650 mg PO Q6H:PRN pain, HA 9. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO QID:PRN indigestion 10. Heparin 5000 UNIT SC TID 11. Lorazepam 0.5-2 mg PO Q4H:PRN anxiety 12. Haloperidol 1 mg IV ONCE Duration: 1 Doses please give 15 min prior to going to MRI 13. Haloperidol 1 mg PO HS 14. Phenytoin Sodium Extended 300 mg PO DAILY Start: In am 15. Phenytoin Sodium Extended 200 mg PO ONCE 16. IV access: Peripheral line 0 17. IV 1000 mL NS 150 ml/hr for 1000 ml Discharge Medications: 1. pravastatin Oral 2. doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. buspirone 30 mg Tablet Sig: One (1) Tablet PO once a day. 4. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. valproic acid 250 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). Disp:*180 Capsule(s)* Refills:*0* 6. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO qAM. Disp:*30 Tablet(s)* Refills:*0* 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, HA. Disp:*75 Tablet(s)* Refills:*0* 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 9. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for pruritis. Disp:*30 Capsule(s)* Refills:*0* 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain: Do not drive or take alcohol while taking this medication. . Disp:*45 Tablet(s)* Refills:*0* 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Continue to take while taking oxycodone. Hold for loose stools. Disp:*60 Capsule(s)* Refills:*0* 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: continue to take while taking oxycodone. hold for loose stools. . Disp:*60 Tablet(s)* Refills:*0* 13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation: hold for loose stools . Disp:*15 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Right Frontal Brain Lesion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 13959**], You were admitted to the [**Hospital1 69**] after you had the onset of seizures. It was found that you had a tumor in the right frontal lobe of your brain, which was resected by our neurosurgeons. You will need to follow up with a neuro-oncologist, Dr. [**Last Name (STitle) 6570**]. He will be making an appointment to see him within the next week to 10 days. You should continue taking all of your medications as you had prior to your hospitalization, EXCEPT: STOP atenolol/chlorthalidone STOP aspirin START atenolol 50mg per day START valproic acid 250mg twice per day START dexamethasone 4mg every morning START acetaminophen 325mg, take 2 tablets every 6 hours as needed for pain START omeprazole 20mg once per day START diphenydramine 25mg by mouth every six hours as needed for itching START oxycodone 5mg, one tablet every 4-6 hours as needed for pain. START colace, senna and bisacodyl as needed for constipation. Hold for loose stools. = = = = = ================================================================ Instructions - Craniotomy for Tumor Excision Dr. [**Last Name (STitle) 14354**] [**Name (STitle) **] ?????? 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. ?????? Dressing may be removed on Day 2 after surgery. **You have dissolvable sutures you may wash your hair and get your incision wet day 3 after surgery. 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) & Senna 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. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? 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. 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: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101.5?????? F. Followup Instructions: *NEUROSURGERY: Please return to the office in [**6-7**] days (from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Physician [**Name9 (PRE) 14355**] or [**Name9 (PRE) **] Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You will also have an appointment in the Brain [**Hospital 341**] Clinic. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. If you have not heard from them 48 hours after discharge, you should call them to make an appointment approximately one week after discharge. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. Name:[**Known firstname 275**] [**Last Name (NamePattern4) **],MD Location: [**Hospital **] MEDICAL GROUP Address: [**Street Address(2) 9646**], [**Hospital1 **],[**Numeric Identifier 9647**] Phone: [**Telephone/Fax (1) 3183**] When: Wednesday, [**6-15**] at 10:00am Department: NUCLEAR MEDICINE When: FRIDAY [**2174-6-17**] at 12:30 PM With: NUCLEAR MEDICINE EAST [**Telephone/Fax (1) 2103**] Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 859**] Campus: EAST Best Parking: Main Garage Department: RADIOLOGY When: FRIDAY [**2174-6-17**] at 10:45 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage Department: NUCLEAR MEDICINE When: FRIDAY [**2174-6-17**] at 9:30 AM With: NUCLEAR MEDICINE EAST [**Telephone/Fax (1) 2103**] Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 859**] Campus: EAST Best Parking: Main Garage

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icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

15457, 15463

9373, 10903

313, 360

15534, 15534

5965, 7309

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3588, 3666

13813, 15434

15484, 15513

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388, 2234

7331, 9350

15549, 15661

3220, 3316

3332, 3572

5196, 5946

6,540

131,660

46899

Discharge summary

report

Admission Date: [**2108-6-18**] Discharge Date: [**2108-6-25**] Date of Birth: [**2033-8-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Chest Pain x 1 day Major Surgical or Invasive Procedure: Cardiac catheterization and ICD placement on [**2108-6-21**] History of Present Illness: 74y/o male patient with history of CAD S/P recent STEMI ([**4-19**]) 2 LAD stents presents with sub-sternal chest discomfort. Patient began feeling discomfort last night @ 1AM. Patient got out of bed and took some maalox for what he presumed to be integestion. patient said he did not sleep well thru the night. Pt. denies and F/C/V/N/NS/SOB/COUGH. patient took ASA, and 2 nitroglcerin, and states pain is now [**2-23**] Past Medical History: CAD S/P recent MI GERD (Hiatal Hernia) Social History: Married, lives at home w/ his wife. [**Name (NI) **] alcohol usage, no tobacco, no IVDU Family History: N/C Physical Exam: Vitals- 98.4, 78, 100/59, 16, 94%RA GEN- AAOx3, NAD, lying in stretcher comfortably HEENT- PERRL, MMM, EOMI CV- RRR, pos. S1, S2, no murmurs present Lungs- CTA B/L Abd- soft NT/ND, pos. BS LE- No edema present Pertinent Results: EKG- abnormal extreme QRS axis deviation, R. Bundle branch block Ejection fraction- 30% CXR- Pending Brief Hospital Course: Mr. [**Known lastname **] is a 74 y/o male patient with a history of CAD S/P recent STEMI ([**4-19**]) and 2 LAD stents who presented with sub-sternal chest discomfort times 1 day with intermittent pain. He was admitted on [**2108-6-18**] for further workup of the chest pain. Three sets of enzymes were negative after admission, and his EKG showed no new changes compared to his old EKGs. His previous tracings demonstrated sinus rhythm borderline first degree A-V delay, left atrial abnormality,right bundle branch block, left anterior fascicular block, and an old anterolateral myocardial infarct. We continued him on ASA, plavix, BB, statin, and ACE-I, and scheduled him for a p-MIBI the following morning on [**2108-6-19**]. His p-MIBI demonstrated no exercise-induced ischemic changes, an EF of 40%, LV dilation with stress, and reversible inferior wall motion defects. It was decided by cardiology and EP to take the patient for a cardiac catheterization and an EP study for placement of an ICD. However, the patient's INR was supratherapeutic at 3.8 at admission, so his Coumadin was held for two days, which brought his INR to 2.6. He was given 5 mg po Vitamin K x 1 on [**2108-6-20**], which brought his INR down to 1.7 on [**2108-6-21**]. He was taken to cath that day with a following EP study, during which the ICD was placed. Following cardiac catheterization (clean coronaries, patent stents, 40% OM2, mild disease) and AICD placement by EP, patient's blood pressure fell to 70s-80s systolic. The patient was taken to the CCU. Given elevated neck veins and muffled heart sounds as well as difficulty placing RV lead and elevated heart rate to 100s, concern was for tamponade physiology secondary to RV perforation. STAT Echo revealed small percardial effusion without evidence of tamponade. Pulsus was 4-6mmHg. Given the suspicion of tamponade physiologhy, patient was given additional preload in the form of 1.5L IVNS, 2U FFP to correct coagulopathy (INR 2.3), 3U PRBCs. On this, patient's heart rate began to trend downwards and blood pressures began to rise to SBP100s. At the time of transfer from the CCU to the [**Hospital Unit Name 196**] floor, the patient's hematocrit continued to trend downward (28.5, 27) despite initial unit of PRBCs, and so patient continued to receive 2 additional doses of PRBCs. Follow-up echo's done while the patient was in the CCU were all stable, without evidence of tamponade or expansion of the effusion. After the patient was transferred to the [**Hospital Unit Name 196**], a CT scan of the pelvis without contrast was ordered to look for a retroperitoneal bleed, as the patient's Hct was still low and his blood pressure also low. The CT was negative for any RP bleed, and showed a dense pericardial effusion and a 3.6 x 3.6 cm hematoma in the right groin. The patient's Hct after transfer began to improve, and he did not require any additional units of blood. His Hct at the time of discharge was 32.9. His pressures also began to improve during the next two days (SBP in 110-120's), and we were able to add his antihypertensives back to his regimen which were held because of the low SBP in the 90's. He was discharged on [**2108-6-25**], in stable condition, on his BB, ASA, plavix, lisinopril, lasix, and statin. The coumadin was taken off his regimen per EP and cardiology. The patient is to see Dr. [**Last Name (STitle) **] in 2 weeks, Dr. [**Last Name (STitle) **] in 4 weeks, and have a follow-up TTE in 4 weeks. He is to have a wound check of his ICD site on the [**5-29**]. Secondary issues: 1. CAD -- on ASA, plavix, lisinopril, statin, BB. 3. GERD - Pt on protonix and maalox while in house, prilosec at home. Medications on Admission: 1. Aspirin 325 mg daily 2. Clopidogrel 75 mg daily 3. Atorvastatin 80 mg daily 4. Lisinopril 5 mg daily 5. Metoprolol XL 50 mg daily 6. Prilosec 7. Lasix 20 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 6. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*15 Tablet(s)* Refills:*0* 7. Lasix 20 mg daily 8. Prilosec Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: decreased ejection fraction, atypical chest pain Secondary: coronary artery disease, s/p STEMI, GERD Discharge Condition: Good Discharge Instructions: Continue medications discharged on. If you experience any chest pain, shortness of breath, dizziness, or any other symptoms, please see your PCP or return to the ED. Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks, and Dr. [**Last Name (STitle) **] in 4 weeks. Also have an echo in 4 weeks. Follow-up on wound-check appointment at [**Hospital Ward Name 23**] 7 on [**2108-6-28**] at 3pm. Do not take Coumadin. Followup Instructions: 1) DEVICE CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2108-6-28**] 3:00 2) Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 6197**] Date/Time:[**2108-7-3**] 9:00 3) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2108-7-11**] 3:30 Completed by:[**2108-6-25**]

[ "998.11", "420.90", "458.29", "411.1", "V43.64", "V45.82", "414.01", "412", "530.81", "414.8" ]

icd9cm

[ [ [] ] ]

[ "37.94", "37.22", "88.56" ]

icd9pcs

[ [ [] ] ]

5872, 5921

1410, 5097

333, 395

6076, 6082

1285, 1387

6548, 7128

1035, 1040

5313, 5849

5942, 6055

5123, 5290

6106, 6525

1055, 1266

275, 295

423, 851

873, 913

929, 1019

51,060

159,548

40819

Discharge summary

report

Admission Date: [**2171-4-7**] Discharge Date: [**2171-4-24**] Date of Birth: [**2094-4-26**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1257**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 76yo man with Parkinson's disease with dementia, admitted from PCP office to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2171-3-18**] for rapid aflutter treated with diltiazem found to have progressive mental decline (essentially overnight per family). Underwent ECHO (nl EF and function) and stress test (no evidence of ischemia), and started on coumadin. Found to have PNA and treated with Ceft/Azithromycin. Sedation and overall alertness/orientation continued to decline and patient could not take PO and remained on IV dilt gtt. U/A on [**2171-3-25**] negative as was CT-head however CXR with bilateral pleural effusion. Neuro was consulted and planned for EEG which showed generalized slowing. He underwent an MR-head w/o evidence of abscess encephalitis or meningitis. LP was not done [**1-9**] high INR. He was then started on empirin acyclovir Mental status continued to decline during hospitalization. Anticoagulation reversed and LP [**2171-4-6**] showed slightly high protein but nl glucose and WBC - CSF sent for CJD Pt transfered on Dilt gtt with acyclovir for empiric Rx of HSV. Remains arounsable to pain only. He was continued on Dilt gtt. Past Medical History: 1. PArkinson's Disease 2. Dementia 3. BPV 4. Low back pain 5. remote hx of shingles Social History: lives at home with wife, no smoking, alcohol, IV drug use, no regular exercise. Family History: No family hx of premature cardiac disease Physical Exam: Vitals: Afebrile; 107; 179/99 19 96%RA General: Sleeping, difficult to arouse, does not open eyes spontaneously and only slightly to loud voice and pain, unclear whether airway is completely patent HEENT: Sclera anicteric, MMM, oropharynx with a discolored brownish lesion on hard palate Neck: not supple, increased tone, difficult to move neck on its own Lungs: Difficult to ausculate given upper airway sounds, no crackles CV: Rapid rate and irregular rhythm, difficult to ausculate given upper airway sounds. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley present Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, no edema bilaterally Neuro: Opens eyes to pain and loud voice, does not follow commands, moans to sternal rub, Pupils reactive 5-->3mm bilateral Vestibulocular --> difficult to assess given neck rigidity Gag--> [**Doctor Last Name 89181**] on secretions . Motor: increased tone throughout, spasticity and cogwheeling in upperextremities, grasp reflex bilaterally, . Reflexes: symetric 3+ in Lower ext bilaterally, upgoing toes bilaterally, no clonus at ankle (however patient spontaneously plantarflexing continuously during exam). Bicepps/triceps/wrists 2+ bilaterally Pertinent Results: Labs upon admission: . [**2171-4-7**] 06:19PM BLOOD WBC-12.6* RBC-4.33* Hgb-13.8* Hct-39.5* MCV-91 MCH-31.9 MCHC-35.0 RDW-14.3 Plt Ct-286 [**2171-4-8**] 04:08AM BLOOD Neuts-84.5* Lymphs-8.6* Monos-5.2 Eos-1.3 Baso-0.4 [**2171-4-7**] 06:19PM BLOOD PT-42.6* INR(PT)-4.4* [**2171-4-7**] 06:19PM BLOOD Glucose-94 UreaN-14 Creat-1.1 Na-142 K-3.8 Cl-105 HCO3-26 AnGap-15 [**2171-4-7**] 06:19PM BLOOD CK(CPK)-25* [**2171-4-8**] 04:08AM BLOOD ALT-67* AST-32 LD(LDH)-229 AlkPhos-95 TotBili-0.8 [**2171-4-7**] 06:19PM BLOOD CK-MB-2 cTropnT-<0.01 [**2171-4-7**] 06:19PM BLOOD Calcium-9.1 Phos-3.4 Mg-1.6 [**2171-4-8**] 04:08AM BLOOD VitB12-468 Folate-11.8 [**2171-4-8**] 04:08AM BLOOD TSH-0.80 [**2171-4-7**] 06:19PM BLOOD Digoxin-0.7* . Labs upon discharge: . [**2171-4-23**] 06:22AM BLOOD WBC-10.9 RBC-3.14* Hgb-10.5* Hct-30.6* MCV-97 MCH-33.4* MCHC-34.3 RDW-15.8* Plt Ct-291 [**2171-4-17**] 05:32AM BLOOD Neuts-80.2* Lymphs-12.4* Monos-4.4 Eos-2.6 Baso-0.4 [**2171-4-17**] 05:32AM BLOOD PT-14.3* PTT-30.5 INR(PT)-1.2* [**2171-4-23**] 06:22AM BLOOD Glucose-128* UreaN-26* Creat-0.6 Na-142 K-4.2 Cl-105 HCO3-33* AnGap-8 [**2171-4-23**] 06:22AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.1 . MRI brain [**2171-4-11**]: IMPRESSION: No evidence of an acute intracranial process. Small vessel ischemic changes. . CT head [**2171-4-10**]: IMPRESSION: Extremely limited study due to the overlying EEG leads, but no gross intracranial hemorrhage or mass effect identified in the images where parts of the brain are better seen. Consider repeating the study after removal of leads. . CXR [**2171-4-22**]: IMPRESSION: Bibasilar lung opacities are without significant change from prior study ([**2171-4-17**]). Brief Hospital Course: [**Known firstname **] [**Known lastname **] is a 76 y/o w/ Parkinson's and dementia who presented to [**Hospital1 18**] after transfer from [**Hospital3 26615**] Hospital where he initially presented with atrial flutter and agitation in [**Month (only) 547**]. There he developed worsening mental status starting [**2171-3-18**]. Extensive neurologic workup including MRI, CT, EEG were completed, but were unrevealing for a structural brain defect. He received lorazepam at the outside hospital for abnormal EEG and agitation. He was transferred to [**Hospital1 18**] on [**2171-4-7**] at which time he was admitted to the MICU. There he was empirically treated for pneumonia with Vanco/Zosyn for 8 days, thought to be due to inability to control his secretions due to altered mental status. Neurology has been following the patient closely. An MRI and CT were completed here at [**Hospital1 18**] which also failed to show a structural neurologic deficit. Repeated EEG was most suggestive with a toxic-metabolic encephalopathy. The etiology of this encephalopathy is not clearly elucidated. Possibilities include lorazepam, keppra or infection. In close discussions with the family and neurology, we watchfully waited for mental status recovery while continuing tube feeds and supportive care. Over the weeks during his admission, his mental status made slight progress (intermittently opened his eyes to sternal rub, occasionally wiggled his toes to command), however overall his improvement was minimal. On [**2171-4-22**] he developed a fever with leukocytosis and blood cultures grew Staph in [**1-11**] bottles (speciation pending), presumed to be due to a PICC line infection. The PICC line was removed. He received one dose of Vancomycin. A family meeting was held on [**2171-4-23**] with his wife [**Name (NI) **], daughter [**Name (NI) **], and son [**Name (NI) 4468**]. It was decided at the meeting that due to the risk of continued medical complications (including likely recurrent infections) due to immobility, inability to manage his secretions, and malnutrition that he would not have wanted to undergo continued aggressive treatment and the focus was transitioned to comfort care. Medications were transitioned to including only morphine, acetaminophen, zyprexa and scopalamine patch as needed. . The patient's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 41243**] was notified directly by telephone discussion of his admission and transition to hospice care. . Please note the family is requesting an autopsy, preferrable to take place at [**Hospital1 18**] after his passing. Our admitting office instructed us that the physician at the inpatient hospice program can facilite autopsy to take place here after death. . Medications on Admission: Carvidopa-levodopa 100mg/25mg TID asa 81mg daily Discharge Medications: 1. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: [**4-16**] PO Q1H (every hour) as needed for discomfort or SOB. 2. acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours). 3. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal once a day as needed for secretions. 4. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO Q4H (every 4 hours) as needed for agitation. Discharge Disposition: Extended Care Facility: [**Hospital3 **]Hospice House Discharge Diagnosis: Toxic metabolic encephalopathy Hospital acquired pneumonia - likely due to aspiration Gram positive bacteremia Atrial flutter with rapid ventricular response Parkinson's disease Discharge Condition: Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: You came to [**Hospital1 18**] due to altered mental status. You were followed closely by neurology who felt that your altered mental status was likely due to medications and possibly infection. You received an MRI and a CT scan which did not show new stroke. More recently, you were found to have a bacterial infection in your blood. Together with your family we have transitioned your goals of care to comfort. . We have made the following changes to your medications: - STOP carbidopa/levodopa - STOP aspirin - START morphine oral concentrate 5mg every one hour as needed for discomfort, pain or shortness of breath - START scolpalamine patch as needed for copious secretions - START tylenol 650mg rectally every 6 hours - START zyprexa 2.5mg every 4 hours for agitation . It was a pleasure caring for you. Followup Instructions: [**Hospital 1739**] hospice care Completed by:[**2171-4-24**]

[ "349.82", "724.2", "518.0", "790.7", "507.0", "518.81", "294.10", "427.32", "331.82", "427.31", "263.0", "V49.86", "041.89" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

8178, 8234

4831, 7603

325, 331

8456, 8538

3125, 3132

9399, 9463

1769, 1813

7703, 8155

8255, 8435

7629, 7680

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264, 287

3873, 4808

359, 1548

3146, 3857

1570, 1656

1672, 1753

18,152

168,998

1433+1434+55285

Discharge summary

report+report+addendum

Admission Date: [**2196-9-27**] Discharge Date: [**2196-10-24**] Date of Birth: [**2123-12-6**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 72 year-old gentleman with a history of throat cancer from [**2189**] and macular degeneration who presents for altered mental status. According to the family he was in his usual state of health and then hit himself in the head on Saturday. His brother visited him on [**Name (NI) 1017**] and he had a band-aid and a small abrasion on his forehead. He then called his family on Monday and asked to be taken to the ER. He otherwise appeared okay. He was seen at [**Hospital1 2025**] and treated for an abrasion and then discharged. On Monday night he began acting confused by urinating on the floor. While trying to shave during the night he cut his finger and bled throughout the house without notifying his family members. They notice he is less responsive to questions when spoken to him on the phone. He was taken back to the emergency room. He complains of bitemporal headache and possible worsening vision. His health care proxy is his nephew. PAST MEDICAL HISTORY: 1. Cardiac history. 2. Macular degeneration. 3. Status post laser surgery. 4. BPH. 5. Throat cancer. PAST SURGICAL HISTORY: 1. Appendectomy. ALLERGIES: 1. Aldomet. 2. Inderal. PHYSICAL EXAMINATION: On physical exam his blood pressure was 203/87, heart rate 80, respiratory rate 18. His eyes - the scleral are nonicteric. His head - abrasion on the left upper brow. Throat - his pharynx is pink and clear without exudative drainage. Drums were pink, moist and intact. Neck was supple. Heart - distant heart sounds, regular rate and rhythm, small left apical systolic murmur over the apex which is II/VI. His lungs are clear to auscultation. Abdomen is soft, nontender, nondistended without hepatomegaly or splenomegaly. Extremities - no cyanosis, clubbing or edema. Neuro wise he was awake and alert, oriented to person, date of birth, hospital, city and state. His speech was slow but articulate. He answered yes and no questions appropriately. Visual fields represented a left homonymous hemianopsia with decreased peripheral vision on the right, acuity was poor but able to count fingers. His motor strength was [**3-19**]. His other cranial nerve exam was within normal limits. LABORATORY DATA: He was admitted to the Surgical Intensive Care Unit for close monitoring after a CT scan that showed bilateral temporal hemorrhages with right ventricular extension but no shift. He had an elevated PTT at 57.6 seconds and an INR of 13 on admission. Sodium 133, potassium of 4.4, chloride 96, CO2 27, BUN 17, creatinine 0.8, glucose 142. HOSPITAL COURSE: The patient was admitted for close monitoring on the Surgical Intensive Care Unit. The patient had a repeat head CT scan on [**2196-9-28**] which showed no significant change from prior head CT scan. Hematocrit on admission was 37.4. The patient was given Mannitol IV and intubated for airway protection. On [**2196-9-28**] the patient underwent a right temporal craniotomy for evacuation of right temporal hematoma. There were no intraoperative complications postoperative. The patient's vital signs remained stable. He was afebrile. Neurologically pupils were 2.5 down to 2. His dressing was clean, dry and intact. He withdrew on all four extremities with some purposeful movement but did not follow commands. In the emergency room the patient received 10 mg of vitamin K subcutaneously and also 16 units of FFP. He was seen by the Hematology / Oncology Service. Hematology recommended sending tests for Warfarin poisoning and follow DIC screen. On [**2196-10-3**] the patient would open eyes, move all four extremities to noxious stimulation but not following commands. CT scan showed decrease in the right temporal blood and contraction of the left temporal hematoma, no change in the ventricle side. On [**2196-10-4**] the patient had a lumbar tap which showed an opening pressure of 25, 6 cc of tea color CSF was sent for cell count gram stain and culture. Closing pressure was 16 and the patient tolerated the procedure well. CSF did not grow and microorganisms. The patient on Levaquin for Klebsiella pneumonia. On [**2196-10-5**] the patient spiked to 102.4 F. The patient's blood cultures grew out staph aureus, sputum growth Klebsiella pneumonia. He continued on Vancomycin and Levaquin. On [**2196-10-6**] his staph aureus came back as being MRSA. The patient was put on precautions and continued on Vancomycin and Levaquin. On [**2196-10-10**] the patient again had a lumbar puncture done. Opening pressure was 27, closing pressure was 12, 15 cc were sent for culture gram stain and cell count. The patient's antibiotics were DC'd after completing a 10 days course. On [**2196-10-13**] the patient continues to spike temps to 102 F. On exam he would open his eyes, had facial grimace symmetric to pain, pupils were 2.5 down to 2. He did not follow commands. He withdrew to pain in all four extremities. On [**2196-10-11**] the patient was re-cultured for spiking temperature, growth coag negative staph times three out of his blood cultures. The patient was re-started on Vancomycin. The patient was extubated for a total of three to four days and then re-intubated on [**2196-10-15**]. On [**2196-10-18**] the patient was awake and alert, withdraws to pain in the lower extremities and moves the upper extremities somewhat spontaneously and purposeful. He underwent tracheostomy and PEG placement on [**2196-10-18**] and tolerated the procedure well. His vital signs remained stable. On [**2196-10-20**] the patient again had a lumbar puncture. Opening pressure was 15, closing pressure was 10. No growth from the CSF culture sent. The patient is transferred to the regular floor on [**2196-10-20**]. He was seen by physical therapy and occupational therapy and found to require rehab. MEDICATIONS ON DISCHARGE: 1. Neupogen 40,000 units subcutaneous q week. 2. Vancomycin 2 grams IV q 24 hours to be DC'd on [**2196-10-26**] after a 14 day course for staph coag negative bacteremia. 3. Heparin 5,000 units subcutaneous q 12. 4. Dilantin 300 po q P.M., 200 mg po q A.M. 5. Impact 60 cc an hour. 6. Hydralazine 10 mg po tid. 7. Lopressor 125 mg po tid. 8. Tylenol 650 q four prn. 9. Mycostatin powder to the groin prn. 10. Cefzil 100 mg po q eight hours. 11. Protonix 40 mg po q day. The patient's vital signs have been stable. He has been afebrile. Neurologically continues to open his eyes spontaneously, not following commands, and moving upper extremities spontaneously. The lower extremities withdraw to pain. CONDITION AT DISCHARGE: The patient's condition was stable. At the time of discharge vital signs were stable. The patient will follow up with Dr. [**Last Name (STitle) 1327**] in three to four weeks time. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2196-10-24**] 13:53 T: [**2196-10-24**] 13:51 JOB#: [**Job Number 8557**] Admission Date: [**2196-9-27**] Discharge Date: [**2196-10-26**] Date of Birth: [**2123-12-6**] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient had a headache for a couple of days but was not answering questions reliably. The patient is a 72 year old male with a history of throat cancer in [**2189**] and macular degeneration, who presents for an altered mental status. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2196-10-26**] 10:40 T: [**2196-10-26**] 10:41 JOB#: [**Job Number 8558**] Name: [**Known lastname 1136**], [**Known firstname **] Unit No: [**Numeric Identifier 1137**] Admission Date: [**2196-9-27**] Discharge Date: [**2196-10-24**] Date of Birth: [**2123-12-6**] Sex: M Service: ADDENDUM: The patient's discharge was delayed until [**2196-10-26**] due to lack of rehabilitation beds. The patient's condition has been unchanged, stable. He will be discharged to rehabilitation with follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in three to four weeks time. [**Name6 (MD) 863**] [**Last Name (NamePattern4) 864**], M.D. [**MD Number(1) 865**] Dictated By:[**Last Name (NamePattern1) 366**] MEDQUIST36 D: [**2196-10-26**] 14:04 T: [**2196-10-26**] 15:37 JOB#: [**Job Number 1138**]

[ "518.81", "038.11", "996.62", "482.0", "431" ]

icd9cm

[ [ [] ] ]

[ "31.1", "96.04", "03.31", "43.11", "01.39", "96.6", "38.93", "96.72" ]

icd9pcs

[ [ [] ] ]

5977, 6703

2721, 5951

1281, 1335

1357, 2704

6718, 7312

7341, 8664

1156, 1258

65,824

142,509

47519

Discharge summary

report

Admission Date: [**2132-3-9**] Discharge Date: [**2132-3-14**] Date of Birth: [**2049-11-29**] Sex: M Service: MEDICINE Allergies: Vicodin / Percocet / Darvocet A500 / Oxycodone / Vancomycin Attending:[**First Name3 (LF) 2605**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: Pt is an 82-year-old man with past medical history significant for CAD s/p CABG, PVD s/p bypass, AAA s/p repair, ESRD on HD MWF, recent colitis, on ASA and Plavix who presented with bloody diarrhea. On [**2-26**], patient was severely constipated and performed manual disimpaction. Within a few hours, he began experiencing frequent watery diarrhea (5-6x/day) as well as rectal bleeding. He was admitted to an OSH, where his rectal bleeding ceased. He was diagnosed with colitis (infectious v. ischemic v. traumatic from manual disimpaction), and discharged to a [**Hospital1 1501**] on a 7-day course of levo/flagyl. He continued to have diarrhea there. On [**3-8**], he began to have watery stool with bright red blood, and was taken to an OSH ED. . He reports episodes of rectal bleeding while at OSH but none previously. He denied any abdominal pain, N/V, lightheadedness, vision changes, chest pain, palpitations. He denied any subjective fevers and chills. . At OSH, BP ranged from 100-130/40-60, HR 70s. Temp was 100.3 rectally. Labs inc. WBC 15 (78N, 8L, 10 mono, 2 eos), HCT 40. A colonoscopy was not performed. Pt was tranferred to [**Hospital1 18**] ED. Past Medical History: -CAD, s/p CABG in [**2122**] (LIMA-LAD, SVG-RCA--occluded, SVG-OM1/OM3--occluded), s/p NSTEMI (DES in L main) in [**2-3**] -AAA, s/p repair in [**2123**] -PVD, s/p aortobiiliac graft in [**2123**], s/p L CEA in [**2122**] followed by Dr. [**Last Name (STitle) **] [**Name (STitle) 100468**] with LUE AVF, on HD MWF -Severe cervical spinal stenosis with near paraplegia, s/p anterior cervical discectomy and arthrodesis at C5-C6 and C6-C7 by Dr. [**Last Name (STitle) 548**] [**12-6**]. -Abdominal wall abscess, s/p I&D, culture with Actinomyces treated with 6 month course of ampicillin/penicillin, in [**5-5**] -Right renal tumor, suspicious for RCC, undergoing watchful waiting, followed by Dr. [**Last Name (STitle) 3748**] [**Name (STitle) **]/o prostate cancer s/p brachytherapy -h/o choledocholithiasis and cholangitis s/p lap chole [**2130-3-21**] -h/o diverticulosis Social History: Prior to his hospitalization, he was in [**Hospital3 **]. He was discharged to a [**Hospital1 1501**]. Pt is wheelchair bound but is working on ambulating with a walker. He was a manager for Metropolitan Life. He denied tobacco (quit in [**2120**]), etoh, and recreational drug use. Family History: Noncontributory; sister had multiple episodes of diverticulitis Physical Exam: On admission - VS: 98 136/68 72 18 96%(RA) GEN: Well-appearing, NAD, A&Ox3 HEENT: Anicteric sclera, no JVD, no LAD Lungs: Mild expiratory coarse breath sounds bilaterally; no wheezes or rales Heart: RRR, II/VI systolic murmur, no distinct S1/S2, no rubs or gallop Abd: Soft, ND, +BS, mild LLQ/suprapubic tenderness to palpation Ext: No cyanosis/clubbing/edema in LE bilat; mild bilateral edema in hands Neurologic: CNII-XII grossly intact Pertinent Results: ====== Labs ====== CBC [**2132-3-9**] 01:19AM BLOOD WBC-16.8*# RBC-3.44*# Hgb-11.3*# Hct-34.6*# MCV-101* MCH-32.7* MCHC-32.6 RDW-16.2* Plt Ct-408 [**2132-3-9**] 06:46AM BLOOD WBC-14.2* RBC-3.27* Hgb-10.7* Hct-33.0* MCV-101* MCH-32.7* MCHC-32.4 RDW-16.2* Plt Ct-336 [**2132-3-9**] 08:18PM BLOOD WBC-9.3 RBC-3.35* Hgb-10.7* Hct-32.7* MCV-98 MCH-31.9 MCHC-32.7 RDW-17.7* Plt Ct-296 [**2132-3-10**] 03:50AM BLOOD WBC-10.0 RBC-3.69* Hgb-11.5* Hct-35.9* MCV-97 MCH-31.3 MCHC-32.1 RDW-17.8* Plt Ct-339 [**2132-3-11**] 07:50AM BLOOD WBC-9.1 RBC-3.44* Hgb-10.8* Hct-32.7* MCV-95 MCH-31.4 MCHC-33.1 RDW-18.1* Plt Ct-333 [**2132-3-12**] 07:45AM BLOOD WBC-11.1* RBC-3.57* Hgb-10.9* Hct-34.3* MCV-96 MCH-30.7 MCHC-31.9 RDW-17.7* Plt Ct-371 [**2132-3-13**] 10:25AM BLOOD WBC-13.6* RBC-4.07* Hgb-12.5* Hct-39.2* MCV-96 MCH-30.8 MCHC-32.0 RDW-17.0* Plt Ct-359 [**2132-3-14**] 07:00AM BLOOD WBC-11.7* RBC-3.56* Hgb-11.3* Hct-34.0* MCV-96 MCH-31.7 MCHC-33.2 RDW-17.0* Plt Ct-330 [**2132-3-14**] 08:00AM BLOOD WBC-12.2* RBC-3.70* Hgb-11.9* Hct-35.3* MCV-95 MCH-32.3* MCHC-33.8 RDW-17.0* Plt Ct-351 . Chem panel [**2132-3-9**] 01:19AM BLOOD Glucose-111* UreaN-59* Creat-8.2* Na-135 K-6.2* Cl-101 HCO3-19* AnGap-21* [**2132-3-9**] 06:46AM BLOOD Glucose-96 UreaN-54* Creat-7.3* Na-143 K-3.8 Cl-109* HCO3-19* AnGap-19 [**2132-3-10**] 03:50AM BLOOD Glucose-67* UreaN-60* Creat-8.7*# Na-139 K-4.6 Cl-107 HCO3-16* AnGap-21* [**2132-3-11**] 07:50AM BLOOD Glucose-88 UreaN-31* Creat-5.9*# Na-140 K-3.5 Cl-101 HCO3-27 AnGap-16 [**2132-3-12**] 07:45AM BLOOD Glucose-133* UreaN-43* Creat-8.0*# Na-140 K-3.4 Cl-102 HCO3-26 AnGap-15 [**2132-3-13**] 10:25AM BLOOD Glucose-113* UreaN-32* Creat-6.1*# Na-142 K-3.4 Cl-99 HCO3-31 AnGap-15 [**2132-3-14**] 07:00AM BLOOD Glucose-79 UreaN-44* Creat-7.6*# Na-140 K-3.6 Cl-100 HCO3-29 AnGap-15 [**2132-3-14**] 08:00AM BLOOD Glucose-82 UreaN-45* Creat-7.6* Na-138 K-3.5 Cl-99 HCO3-29 AnGap-14 . Micro FECAL CULTURE (Final [**2132-3-11**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2132-3-11**]): NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2132-3-11**]): NO E.COLI 0157:H7 FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2132-3-10**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2132-3-14**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). ========= Endoscopy ========= Colonoscopy: Findings: Mucosa: Localized ulceration, congestion and granularity with contact bleeding were noted in the sigmoid colon at 30-15 cm. These findings are likely compatible with ischemic colitis. Excavated Lesions Several diverticula were seen in the sigmoid colon. Diverticulosis appeared to be of moderate severity. Impression: Diverticulosis of the sigmoid colon Ulceration, congestion and granularity in the sigmoid colon at 30-15 cm compatible with ischemic colitis Otherwise normal colonoscopy to cecum Recommendations: Low residue diet for a few days. hydration. continue antibiotics for 5 dys. . ========= Radiology ========= CT abdomen and pelvis: IMPRESSION: 1. Proctitis likely infectious/inflammatory in etiology (less likley ischemic). Given the involvement of the sigmoid a diverticulitis may co- exist. No perforation or abscess. 2. No retroperitoneal hemorrhage. 3. Native kidneys atrophic with numerous cysts, butright hyperdense renal lesion, increased in size from [**2130**] [**Hospital1 18**] CT, raises the possibility of renal cell carcinoma. Recommend MR 3ithin 3 months for further characterization. Brief Hospital Course: Patient is an 82 yo M with past medical history significant for CAD s/p CABG, PVD s/p bypass, AAA s/p repair, ESRD on HD MWF, and recent colitis on levo/flagyl who presented with lower GI bleed and diarrhea. . In the ED, initial VS were: 98.9 68 111/49 18 97RA. Pt is A&Ox3. Exam was sig. for mild LLQ and suprapubic tenderness. Pt had a large volume dark red blood during rectal exam. SBP also dipped into 80s; BP stablized to 129 with 3L NS and 1 unit PRBC. CT scan showed no retroperitoneal hemorrhage and rectosigmidal centered colitis. GI and surgery was consulted. Renal was notified. Pt received Zosyn. . Patient was sent to the MICU for one day before being transferred to the medicine service. His MICU VS: T-98; supine 122/43, HR 67; sitting 118/46, HR 71. He received an additional 2U PRBC and had HCT bump appropriately to 32.7 in the evening. Stool was brown in the evening and thus a GoLytely colon prep was begun. Morning HCT was 35.9 without further intervention and patient underwent hemodialysis on [**3-10**]. A colonoscopy was performed. . On the floor, the patient remained stable. His diarrhea ceased upon transfer to the floor and his rectal tube was removed. The patient's hematocrit trended upward until discharge. His blood pressure was maintained within normal limits. Initially, Plavix and ASA were withheld along with metoprolol 25mg [**Hospital1 **], but on Day 1 on the floor, Plavix was restarted. ASA will be held for an additional two weeks for recent GI bleed. Metoprolol was continued after patient's blood pressure normalized. He received hemodialysis on [**3-12**] and [**3-14**]. . 1. GI Bleed: Due to the patient's extensive history of vasculopathy/ atherosclerosis, his lack of abdominal pain, colonoscopy findings of congestion in the rectosigmoid colon, negative stool cultures and assays for infectious causes, the most likely diagnosis is ischemic colitis. Dehydration and hypotension may lead to decreased perfusion pressure causing non-gangrenous ischemia in his rectosigmoid colon. Patient is stable upon discharge and will restart his aspirin regimen in 2 weeks. He will follow-up with GI in [**11-30**] months and may warrant a repeat colonoscopy. . 2. ESRD: Patient does not make urine. O2-sat in high 90's on RA. He is on MWF hemodialysis schedule; received hemodialysis twice while inpatient. . 4. Anemia, chronic: MCV normal, RDW increased. Likely due to renal failure and decreased erythropoietin production, exacerbated by GI bleed over past few weeks. Currently stable in low 30's. . 5. CAD, s/p CABG in [**2122**] and NSTEMI (DES in L main) in [**2-3**]: No acute ischemic symptoms. EKG at baseline. Hold ASA for now as above and continue Plavix. Given that pantoprazole is the PPI of choice in the setting of plavix use, patient's PPI was changed to pantoprazole. See reference CMAJ ?????? [**2132-2-26**]; 180 (7). [**Last Name (un) **]:10.1503/cmaj.[**Numeric Identifier 100469**]. Medications on Admission: Prostat 101 30 mL po bid Nephrocaps 1 tablet daily Questran 17 gm po daily Zetia 10 mg daily ASA 325 mg daily Lactobacillus 1 tablet [**Hospital1 **] Lopressor 25 mg [**Hospital1 **] PhosLo 667 mg po daily Plavix 75 mg daily Celexa 10 mg daily Simvastatin 80 mg daily Ambien 5 mg po qhs prn PredForte 1% 1 drop to each eye qhs Nystatin S&S 5 mL po qid Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 6. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 7. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: Baypointe - [**Hospital1 1474**] Discharge Diagnosis: Primary: Ischemic colitis Secondary: CAD, ESRD on HD, AAA s/p repair Discharge Condition: Stable, pain free Discharge Instructions: Dear Mr. [**Known lastname 656**], . You were admitted for GI bleeding and diarrhea from potential ischemic colitis or infectious colitis. We performed stool cultures and tests that helped to rule out infectious causes for blood in your stool. Colonoscopy found signs consistent with ischemic colitis. Over the course of your stay, you were restarted on the antibiotics Levoquin and Flagyl for your diarrhea. Your diarrhea has improved and you are no longer bleeding. Your antibiotics will be discontinued when you leave the hospital. . During your hospital course, you received hemodialysis twice. . For your medication regimen, we are asking that you refrain from taking aspirin over the next two weeks. You may restart after that time period. Please continue your regular home medications. . We would like you to follow up with your primary care physician. [**Name10 (NameIs) **] you experience additional bleeding, fatigue, increased diarrhea, nausea, vomiting, or abdominal pain, please go to the Emergency Room. . Followup Instructions: Primary care physician: [**Name10 (NameIs) 357**] call your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 7728**] to schedule follow-up appointment in the next few weeks. GI specialist: Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2132-4-24**] at 1 pm. If you need to reschedule please call [**Telephone/Fax (1) 463**] . [**Telephone/Fax (1) **] surgery: Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2132-4-10**] 4:00 . Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2132-4-10**] 4:30 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2308**], MD Phone:[**Telephone/Fax (1) 2309**] Date/Time:[**2132-5-1**] 9:45 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2608**] MD, [**MD Number(3) 2609**] Completed by:[**2132-3-14**]

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icd9cm

[ [ [] ] ]

[ "99.04", "39.95", "45.23" ]

icd9pcs

[ [ [] ] ]

11244, 11303

6973, 9919

329, 343

11416, 11436

3293, 6950

12504, 13619

2752, 2817

10322, 11221

11324, 11395

9945, 10299

11460, 12481

2832, 3274

281, 291

371, 1537

1559, 2436

2452, 2736

8,698

188,386

45766

Discharge summary

report

Admission Date: [**2169-1-9**] Discharge Date: [**2169-1-28**] Date of Birth: [**2084-10-17**] Sex: F Service: EMERGENCY Allergies: Protamine Attending:[**First Name3 (LF) 2565**] Chief Complaint: Weakness Major Surgical or Invasive Procedure: Left IJ Central line Placement X 2 Left dialysis catheter interchange arterial line placement Left femoral CVC placement Left temporary HD line placement Left tunneled HD line placement History of Present Illness: The patient is a 84F hx of multiple medical problems: ESRD on HD (MWF), DM2, PVD (s/p multiple stents), Afib (on coumadin), AS s/pmAVR, recurrent GIB [**2-9**] diverticulosis s/p colectomy with ostomy who presents with weakness. She has been feeling weak for the past 3 days, however has no localizing symptoms over that time. 5 days ago, she had an episode where she was trying to reach something no her bedside table but was unable to; she ended up sliding off the bed on her knees - no head strike/LOC. Denies fevers, chills, sweats, sore throat, chest pain, shortness of breath, cough, N/V/D at home. . In the ED, initial VS: 96.4 80 103/54 16 96%. Patient was initially refusing labs and interventions, however spiked a fever to 101.6 in the ED. She received vancomycin, ceftriaxone, azithromycin to cover pneumonia as well as possible line infection as well as 2L NS. CXR was done which showed low lung volumes and unable to rule out RLL infiltrate. Head CT showed no acute intracranial process. Her BP did drop to 89 at one point, but improved with IVF. On transfer vitals were: 97.6 - 83 - 21 102/60 100% 2 liters. . Currently, she feels well. She thinks the IVF made her feel much better than she was previously. . REVIEW OF SYSTEMS: 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: 1. history of repeated GI bleeds: past work up revealing various potential sources along her GI tract including small bowl AVM's, colonic polyps, ascending and transverse colon diverticulosis. Had L hemicolectomy with transverse colostomy and [**Doctor Last Name 3379**] pouch in [**10/2162**] with pathology examination revealing diverticulosis as the source of bleed. 2. Diastolic CHF (EF 65-75%) on 2L O2 at home 3. Severe AS s/p mechanical [**Year (4 digits) 1291**] [**12-15**], [**Hospital3 9642**] 4. HLD 5. ESRD on HD (MWF) 6. Hypothyroidism 7. Atrial fibrillation on amiodarone and coumadin 8. PVD 9. Diabetes Mellitus 10. HTN 11. [**2168-1-27**]: Stenting of left superficial femoral artery/above-knee popliteal artery transition 12. [**2168-1-28**]: Left Calf Ulcer Debridement 13. [**2168-2-26**]: Left lower extremity wound debridement 14. [**2168-3-8**]: Split thickness skin graft from right thigh to left lower calf 15. [**2168-4-19**]: left lower extremity angioplasty 16. [**2168-4-27**]: Debridement of eschar and bone from the posterior aspect of the left heel 17. Bilateral TKR 18. Open cholecystectomy [**76**]. ORIF right periprosthetic femur fracture with RLE plate [**2164**] 20. Left upper arm radiocephalic AV fistula [**2164**] , Left upper arm arteriovenous graft angioplasty , L upper arm AV graft [**2165**]. Angioplasty/fistulogram [**2166**] x 5 and [**2167**] x3 Social History: Denies tobacco, drug or illicit drug use. Lives at home with husband and 53 year old son who prepares her medications. Other sons lives in [**Name (NI) 47**] and [**Name (NI) 4565**], daughter lives in [**Name (NI) 669**]. Pt is a retired work supervisor at Veteran's Hospital in JP. Retired about 10 years ago. Family History: She is an only child. Grandfather died of cancer but son is not sure of what type. Three sons with htn. Pt. denies any other history of CA, DM, or HTN in her parents. Physical Exam: Admission: VS - Temp 98.1F, 101/56BP, 80HR , 18R , O2-sat 100% 2L GENERAL - well-appearing female in NAD, comfortable, appropriate HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, LUNGS - CTA bilat with decreased BS RLL HEART - RRR, systolic murmur heard at apex ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding, colostomy bag in place EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-13**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, bilateral resting hand tremor . Discharge She is unresponsive to mechanical stimuli, does not have any respirations visually or to auscultation, no heart sounds, pupils are fixed and dilated, nonreactive to light. Her son was [**Name (NI) 653**] and notified and he is coming to the hospital Pertinent Results: Admission labs: [**2169-1-9**] 08:07PM WBC-10.5# RBC-3.39*# HGB-10.5*# HCT-31.6*# MCV-93 MCH-31.0 MCHC-33.3 RDW-14.9 [**2169-1-9**] 08:07PM NEUTS-84.3* LYMPHS-7.8* MONOS-7.3 EOS-0.4 BASOS-0.3 [**2169-1-9**] 08:07PM PLT COUNT-211 [**2169-1-9**] 08:07PM PT-30.5* PTT-36.6* INR(PT)-3.0* [**2169-1-9**] 08:10PM GLUCOSE-216* LACTATE-2.1* K+-4.5 [**2169-1-9**] 08:07PM GLUCOSE-234* UREA N-24* CREAT-4.9*# SODIUM-139 POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-28 ANION GAP-16 [**2169-1-9**] 08:07PM ALT(SGPT)-10 AST(SGOT)-24 LD(LDH)-373* CK(CPK)-81 ALK PHOS-137* TOT BILI-0.3 [**2169-1-9**] 08:07PM LIPASE-49 [**2169-1-9**] 08:07PM cTropnT-0.18* [**2169-1-9**] 08:07PM CK-MB-1 [**2169-1-9**] 08:07PM CALCIUM-7.6* PHOSPHATE-1.5* MAGNESIUM-1.7 ECG [**2169-1-9**]: Sinus rhythm with non-diagnostic repolarization abnormalities. Compared to the previous tracing of [**2168-9-30**] there is no significant change. CT HEAD [**2169-1-9**]: IMPRESSION: No acute intracranial process. CXR [**2169-1-9**]: IMPRESSION: Small right pleural effusion and mild pulmonary vascular congestion. Right basilar opacity is most likely atelectasis, but infection cannot be entirely excluded. ECG [**2169-1-10**]: The rhythm appears to be junctional with probable A-V dissociation. The Q-T interval is prolonged. This has replaced sinus rhythm seen on the previous tracing. The previously noted non-specific ST segment abnormalities remain. Clinical correlation is suggested . Discharge Labs [**2169-1-27**] 02:05AM BLOOD WBC-5.3 RBC-2.67* Hgb-8.4* Hct-26.0* MCV-97 MCH-31.6 MCHC-32.4 RDW-19.4* Plt Ct-75* [**2169-1-26**] 04:07AM BLOOD WBC-4.8 RBC-2.79* Hgb-8.6* Hct-27.1* MCV-97 MCH-30.9 MCHC-31.9 RDW-19.5* Plt Ct-92* [**2169-1-25**] 04:25AM BLOOD WBC-5.6 RBC-3.01* Hgb-9.3* Hct-29.1* MCV-97 MCH-30.7 MCHC-31.7 RDW-19.4* Plt Ct-127* [**2169-1-24**] 03:53AM BLOOD WBC-4.5 RBC-3.06* Hgb-9.6* Hct-29.5* MCV-97 MCH-31.3 MCHC-32.4 RDW-17.9* Plt Ct-145* [**2169-1-23**] 04:34PM BLOOD Hct-29.3* [**2169-1-22**] 05:11AM BLOOD WBC-6.3 RBC-3.13* Hgb-9.4* Hct-30.4* MCV-97 MCH-30.2 MCHC-31.0 RDW-17.3* Plt Ct-231 [**2169-1-20**] 03:30AM BLOOD WBC-6.9 RBC-3.09* Hgb-9.2* Hct-29.3* MCV-95 MCH-29.8 MCHC-31.4 RDW-16.7* Plt Ct-299 [**2169-1-27**] 02:05AM BLOOD Plt Ct-75* [**2169-1-26**] 04:07AM BLOOD Plt Ct-92* [**2169-1-26**] 04:07AM BLOOD PT-22.0* PTT-72.2* INR(PT)-2.1* [**2169-1-25**] 10:37AM BLOOD PT-21.0* PTT-110.0* INR(PT)-2.0* [**2169-1-27**] 06:20PM BLOOD Glucose-167* UreaN-33* Creat-3.7*# Na-138 K-4.0 Cl-100 HCO3-18* AnGap-24* [**2169-1-27**] 02:05AM BLOOD Glucose-264* UreaN-82* Creat-7.3*# Na-135 K-4.7 Cl-96 HCO3-20* AnGap-24* [**2169-1-26**] 04:07AM BLOOD Glucose-157* UreaN-52* Creat-5.6* Na-134 K-4.2 Cl-97 HCO3-19* AnGap-22* [**2169-1-25**] 05:10PM BLOOD Glucose-161* UreaN-47* Creat-5.2* Na-138 K-4.1 Cl-100 HCO3-20* AnGap-22* [**2169-1-25**] 04:25AM BLOOD Glucose-180* UreaN-40* Creat-4.5*# Na-137 K-4.4 Cl-99 HCO3-16* AnGap-26* [**2169-1-24**] 03:53AM BLOOD Glucose-155* UreaN-51* Creat-6.3* Na-135 K-4.1 Cl-96 HCO3-22 AnGap-21* [**2169-1-23**] 04:34PM BLOOD Glucose-176* UreaN-47* Creat-5.5* Na-132* K-3.7 Cl-95* HCO3-24 AnGap-17 [**2169-1-23**] 03:29AM BLOOD Glucose-152* UreaN-37* Creat-4.7*# Na-136 K-4.2 Cl-97 HCO3-22 AnGap-21* [**2169-1-25**] 04:25AM BLOOD ALT-67* AST-97* LD(LDH)-410* AlkPhos-124* TotBili-1.2 [**2169-1-20**] 03:30AM BLOOD CK-MB-2 cTropnT-0.13* [**2169-1-9**] 08:07PM BLOOD cTropnT-0.18* [**2169-1-9**] 08:07PM BLOOD CK-MB-1 [**2169-1-27**] 06:20PM BLOOD Calcium-7.9* Phos-4.9*# Mg-2.2 [**2169-1-27**] 02:05AM BLOOD Calcium-7.7* Phos-7.3*# Mg-2.6 [**2169-1-26**] 04:07AM BLOOD Calcium-7.1* Phos-5.5* Mg-2.2 [**2169-1-25**] 05:10PM BLOOD Calcium-7.6* Phos-5.1* Mg-2.2 [**2169-1-25**] 04:25AM BLOOD Albumin-3.1* Calcium-7.5* Phos-5.6* Mg-2.2 [**2169-1-24**] 03:53AM BLOOD Calcium-6.6* Phos-5.7* Mg-2.2 [**2169-1-19**] 02:48PM BLOOD Cortsol-35.1* [**2169-1-19**] 01:11PM BLOOD Cortsol-23.0* [**2169-1-27**] 07:52AM BLOOD Vanco-16.7 [**2169-1-23**] 03:29AM BLOOD Vanco-3.1* [**2169-1-21**] 08:46AM BLOOD Vanco-19.7 [**2169-1-20**] 09:00AM BLOOD Vanco-24.2* [**2169-1-27**] 06:38PM BLOOD Type-CENTRAL VE Temp-36.7 Rates-/17 pO2-28* pCO2-40 pH-7.35 calTCO2-23 Base XS--4 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2169-1-27**] 02:00PM BLOOD Type-CENTRAL VE [**2169-1-26**] 12:05PM BLOOD Type-CENTRAL VE Temp-35.6 Rates-/20 pO2-32* pCO2-40 pH-7.32* calTCO2-22 Base XS--6 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2169-1-26**] 06:24AM BLOOD Type-[**Last Name (un) **] pH-7.30* Comment-GREEN TOP [**2169-1-27**] 06:38PM BLOOD Lactate-5.3* [**2169-1-27**] 02:00PM BLOOD Lactate-3.7* [**2169-1-27**] 02:20AM BLOOD Lactate-3.8* [**2169-1-26**] 10:53AM BLOOD Lactate-4.6* [**2169-1-26**] 06:29AM BLOOD Lactate-3.9* [**2169-1-26**] 04:24AM BLOOD Lactate-3.4* [**2169-1-26**] 01:44AM BLOOD Lactate-3.2* [**2169-1-25**] 10:35PM BLOOD Lactate-3.6* [**2169-1-26**] 06:29AM BLOOD freeCa-0.90* [**2169-1-16**] 10:48AM BLOOD freeCa-1.27 [**2169-1-15**] 10:08PM BLOOD freeCa-1.15 [**2169-1-15**] 04:24PM BLOOD freeCa-1.22 [**2169-1-15**] 10:35AM BLOOD freeCa-1.11* CTA chest [**2169-1-26**] 1. Biatrial cardiomegaly and possible pulmonary arterial hypertension. No pulmonary emboli or acute aortic abnormality. 2. Small non-hemorrhagic right pleural effusion. Bilateral lower lobe atelectasis, worse on the right, makes it difficult to exclude small foci of pneumonia, but there is no good evidence for pulmonary infection. 3. Moderately extensive mediastinal adenopathy, probably not related to heart failure. 4. Left PIC line ends in the mid SVC, subclavian line ends at the superior cavoatrial junction. Surface Echo [**2169-1-25**]: The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size is normal. with borderline normal free wall function. A bileaflet aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Small linear structures under the mitral valve which appear to be consistent with torn mitral chordae are present. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with hyperdynamic function and resting outflow tract gradient. Severe pulmonary hypertension. Normal right ventricular cavity size with borderline normal function. Moderate to severe mitral regurgitation. Moderate to severe tricuspid regurgitation. Well-seated aortic valve prosthesis with mild regurgitation. Brief Hospital Course: MICU Green Course: The patient was initiated on broad spectrum antibiotics on the medicine floor and transferred to the medical intensive care unit for the management of septic shock and cardiogenic shock as follows. 84F hx of multiple medical problems: ESRD on HD (MWF), DM2, PVD (s/p multiple stents), Afib (on coumadin), AS s/pmAVR, recurrent GIB [**2-9**] diverticulosis s/p colectomy with ostomy who presented with hypotension. The patient was intially treated with broad spectrum antibiotics for presumed sepsis. She was found to have a staph. coag negative oxacillin resistent bactremia which was thought to be due to mitral valve endocarditis. For this, she had been on a regimen of Linezolid, Rifampin and Vancomcin per ID consult. Days later, she also grew [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] from one culture taken from the right radial aterial line; this culture was not reproduced and the right radial arterial line tip culture was negative. She competed a course of micafingin for this. Her left tunneled hd line, right radial arterial line, and left femoral CVC were removed; a two day line holiday was completed. She was intermittently on Levophed with SBP from 70-120 in a span of two weeks; she spent a majority of the time requring levophed even after ititiation of midodrine and pseudophed orally. She recieved dialysis until she was below her dry weight and then recieved dialysis per renal and her fluid status. Her platelets were trending down in the last days of life and it was thought to be due to linezolid bone marrow suppression or, less likely, HIT. Her DIC labs were negative. A heme onc consult was obtained which recommended to follow platelets Q daily. After the patient's lactate was found to be 5 with a new anion gap acidosis, a repeat echocardiogram revealed worsening TR and pulm regurgitation, with severe mitral regurgitation. CTA was negative for pulmonary embolism. The patient was on a heparin drip for stroke prophylaxis due to her mechanical aortic valve. Her elevated lactate and new echo findings were consistent with decompensating shock likely of a combined sepsis/cardiogenic. A cardiology consultation was obtained, which indicated continuing cardiogenic shock with a complonent of sepsis as well. A family meeting took place with her son the health care proxy and it decided not to pursue any escalation of care. The patient's vasopressor was weaned off but she became hypotensive again and she expired on the morning of [**2-/2169**] at 8:15 AM. The family was notified and came to see her at the bedside. Medications on Admission: 1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. insulin lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous ASDIR (AS DIRECTED): Continue to use your home Insulin Sliding Scale as prescribed. 4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO once a day. 9. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM: Coumadin dosing should be titrated by your [**Hospital 197**] Clinic for an INR goal 2.5-3.5. Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2169-1-29**]

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icd9cm

[ [ [] ] ]

[ "39.95", "00.14", "38.91", "38.97", "38.95", "88.72" ]

icd9pcs

[ [ [] ] ]

15543, 15552

12005, 14606

280, 467

15603, 15612

4890, 4890

15668, 15706

3757, 3926

15511, 15520

15573, 15582

14632, 15488

15636, 15645

3941, 4871

1738, 1986

232, 242

495, 1719

4906, 11982

2008, 3412

3428, 3741

9,889

116,574

52822

Discharge summary

report

Admission Date: [**2190-5-20**] [**Month/Day/Year **] Date: [**2190-5-27**] Date of Birth: [**2117-9-11**] Sex: F Service: MEDICINE Allergies: Hydralazine / Opioid Analgesics / Compazine Attending:[**First Name3 (LF) 1973**] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 108904**] is a 72 yo female with PMH significant for ESRD. She underwent HD on day PTA but presented to the ED with SOB. Per patient, her breathing has become more difficult over the past 4 days but has not been feeling very well over the past few weeks. Upon arrival to the ED her BP was 210/104 and O2 sat~68% RA. She was placed on CPAP and was started on a nitro gtt. She was transferred to the MICU for emergent dialysis. EKG was unchanged and cardiac enzymes were negative. Upon transfer to the MICU her BPs slowly improved with nitro gtt which was d/c'ed. She was also started on Vancomycin/Levaquin given her leukocytosis. She currently denies any fevers, chills, chest pain, dizziness, abdominal pain. She continues to feel SOB. Past Medical History: 1. Hypertension 2. Hypothyroidism [**2-5**] thyroidectomy in [**2173**] 3. Type 2 DM 4. ESRD on HD T, Th, Sat; s/p Left loop forearm AV graft in [**2187**] 5. s/p CVA 2 years ago 6. Gait disorder 7. s/p splenectomy in [**2145**] [**2-5**] trauma, never prescribed prophylactic antibiotics. 8. SVC stenosis Social History: Lives at home alone locally. Had 8 children, 1 son died recently. Daughter comes to see her frequently, helps with grocery shopping, meds, etc. She is a nonsmoker and no EtOH Family History: Noncontributory Physical Exam: vitals T 98.4 BP 172/78 AR 60 RR 18 O2 sat 95% on 3L Gen: Pleasant female, appears tired HEENT: MMM Heart: distant heart sounds, Lungs: scattered crackles posteriorly Abdomen: soft, NT/ND, +BS Extremities: [**1-5**]+ bilateral edema Pertinent Results: Laboratory results: [**2190-5-20**] 12:10AM BLOOD WBC-20.1*# RBC-3.81* Hgb-12.7# Hct-37.6# MCV-99* MCH-33.2* MCHC-33.6 RDW-16.0* Plt Ct-399 [**2190-5-27**] 06:50AM BLOOD WBC-11.2* RBC-3.48* Hgb-11.2* Hct-34.1* MCV-98 MCH-32.1* MCHC-32.8 RDW-15.8* Plt Ct-348 [**2190-5-27**] 06:50AM BLOOD PT-23.6* PTT-32.0 INR(PT)-2.4* [**2190-5-20**] 12:10AM BLOOD Glucose-220* UreaN-47* Creat-6.6*# Na-131* K-5.1 Cl-91* HCO3-27 AnGap-18 [**2190-5-20**] 12:10AM BLOOD cTropnT-0.04* [**2190-5-20**] 12:10AM BLOOD Calcium-9.3 Phos-3.9# Mg-2.5 Relevant Imaging: 1)Cxray ([**5-19**]): No large pneumothorax. Pulmonary edema. 2)Cxray ([**5-23**]): No radiographic evidence suggestive of volume overload. Small bilateral pleural effusions and underlying massive pulmonary arterial hypertension. 3)EKG: sinus @ 64, LAD, nl intervals, TWI II,III,AVF (old), normalization of T in V5-V6 Brief Hospital Course: Ms. [**Known lastname 108904**] is a 72yo female with ESRD who presents to ED with respiratory distress in the setting of hypertension. 1)Respiratory Distress: Patient presented with acute decline in respiratory status in setting of severely elevated blood pressures. Initial cxray was consistent with pulmonary edema which improved with BP control and dialysis. Troponins slightly elevated in setting of renal insufficiency but no new EKG changes. She was placed on BIPAP in the ED and this was continued upon transfer to the MICU. Upon arrival to the floor she was on NC which was quickly weaned off during the remainder of her stay. She was followed closely by her nephrologist and she was dialyzed T, TH, Sat with improvement in her volume status. 2)Malignant hypertension: Patient presented with extremely elevated blood pressures on admission. Likely due to fluid retention with worsening renal function. She was initially started on a Nitro gtt which was weaned off in the MICU. She was also started on Clonidine PO and her dose of [**Last Name (un) **] was increased. Upon transfer to the floor the Clonidine was stopped and she started on Minoxidil with goal SBP ~140's given her history vertebral insufficiency. Her blood pressures improved with her regimen (Lisinopril, Losartan, Clonidine patch, Minoxidil, and Metoprolol)and dialysis. 3)Leukocytosis: Patient presented with leukocytosis of 20.1 which returned to baseline on [**Last Name (un) **]. She was started on Levaquin and Vancomycin since she was at risk for an infection since she has an HD line in place. 1/2 blood culture bottles grew GPC. She received a 7d course of Levaquin which was stopped at time of [**Last Name (un) **] and she was given Vancomycin at dialysis. Surveillance cultures remained negative. 4)ESRD: Patient was followed closely by her primary renal attending. She was dialyzed 3x/week with improvement in her blood pressures and volume status. 5)Hypothyroidism: Continued on Levoxyl. 6)Type 2 DM: Patient on Glipizide as outpatient. She was placed on Glargine and RISS initially on admission since she had been unable to take adequate PO. Upon transfer to the floor she was started on Glipizide with appropriate control of her blood sugars. 7)H/O of SVC stenosis: Anticoagulation was initially held in the ED but restarted by the MICU team. Medications on Admission: Medications at home: Acetaminophen 325 mg PO Q4-6H Metoprolol Tartrate 150 mg PO TID Losartan 25 mg PO DAILY Lansoprazole 30 mg Tablet DR [**Last Name (STitle) **] DAILY Levothyroxine 100 mcg PO DAILY Clonidine 0.3 mg/24 hr Patch QMON Isosorbide Mononitrate 90 mg Tablet Sustained Release 24 hr PO DAILY Amlodipine 10 mg PO DAILY Lisinopril 40 mg PO DAILY Hexavitamin PO once a day. Glipizide 2.5 mg Tab,Sust Rel PO once a day. Coumadin 5 mg Tablet qhs Calcium Acetate 1334 mg PO TID W/MEALS Medications on transfer: Medications: Vancomycin 1g IV @ HD Levaquin 500mg PO Q48 Acetaminophen 325 mg PO Q4-6H Metoprolol Tartrate 150 mg PO TID Losartan 50 mg PO DAILY Lansoprazole 30 mg Tablet DR [**Last Name (STitle) **] DAILY Levothyroxine 100 mcg PO DAILY Clonidine 0.3 mg/24 hr Patch QMON Clonidine 0.1mg PO TID Imdur 90mg PO daily Amlodipine 10 mg PO DAILY Lisinopril 40 mg PO DAILY Hexavitamin PO once a day. Glipizide 2.5 mg Tab,Sust Rel PO once a day. Coumadin 5 mg Tablet qhs Calcium Acetate 1334 mg PO TID W/MEALS [**Last Name (STitle) **] Medications: 1. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 3. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times a day). 4. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 5. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 6. Glipizide 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily). 7. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Minoxidil 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Losartan 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 11. Levothyroxine 100 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 13. Lactulose 10 g/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q8H (every 8 hours) as needed. 14. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO once a day. 15. Clonidine 0.3 mg/24 hr Patch Weekly [**Last Name (STitle) **]: One (1) Patch Weekly Transdermal QMON (every Monday). 16. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO once a day: please take with 60mg tablet for total of 90mg. [**Last Name (STitle) **] Disposition: Home With Service Facility: [**Location (un) 1468**] VNA [**Location (un) **] Diagnosis: Primary diagnoses: 1) End stage renal disease 2) Malignant hypertension 3) Respiratory failure Secondary diagnoses: 1)Hypothyroidism 2)Type 2 Diabetes 3)Superior vena cava stenosis [**Location (un) **] Condition: Stable [**Location (un) **] Instructions: 1) Please take all medications as listed in the [**Location (un) **] instructions. 2)You have been started on several new medications which you will be given prescriptions for: Norvasc 10mg once daily, Minoxidil 10mg once daily, and your dose of Losartan has been increased to 100mg once daily. You should continue all your other medications as you were taking them at home. 3)Please schedule an appointment with Dr. [**First Name (STitle) 4370**] [**Name (STitle) **] in [**Hospital **] as your new primary care physician. [**Name10 (NameIs) **] information is listed below. 4) If you experience any fevers, chills, chest pain, SOB, dizziness or any other concerning symptoms please return to the emergency room. Followup Instructions: Please call Dr. [**First Name (STitle) 4370**] [**Name (STitle) **] at [**Telephone/Fax (1) 250**] to schedule a follow-up appointment after being discharged from the hospital.

[ "428.33", "404.03", "790.7", "486", "250.02", "428.0", "244.0", "585.6" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

2846, 5189

339, 345

1957, 2483

9267, 9447

1672, 1689

5215, 5215

5236, 5708

1704, 1938

8383, 8450

8266, 8362

277, 301

2501, 2823

8482, 8491

8526, 9244

373, 1133

5733, 8234

1155, 1463

1479, 1656

27,594

137,829

14048

Discharge summary

report

Admission Date: [**2183-8-3**] Discharge Date: [**2183-8-14**] Date of Birth: [**2131-5-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1377**] Chief Complaint: Nausea, hematemesis Major Surgical or Invasive Procedure: [**2183-8-5**] EGD History of Present Illness: 52 yo male with h/o Hep C Cirrhosis, ETOH abuse (recent detox) found by family on the bathroom floor, vomiting coffee ground emesis. Per the family, the patient has had protracted medical course which began about 1 month ago when he was brought into [**Hospital1 18**] for etoh withdrawal and MS changes; he was then brought to Arborway for ETOH detox. The family reports he had been heavily drinking and also had been "different on Ribavarin/IFN" (thus was taken off it at that time). He was then transfered from detox to [**Hospital1 336**] for abdominal pain and treated for pancreatitis. He was discharged home on percocet. He subsequently continued to feel poorly with abdominal pain. Last Monday [**7-28**] he had been vomiting some bloody material and was brought to [**Hospital3 **] where an NG lavage was negative, guiac negative and tx with carafate and PPI and sent home. Per his sister, his mental status was okay at that time. He persisted to vomit bloody material all week and this morning his wife brought him here for furhter managmeent. . Per the family, pt has had ongoing abdominal pain since etoh detox. They are unsure if he is drinking etoh but the patient denies it. he has been taking librium and valium (pt admits to using this). Per family he has been sleeping a lot and had garbled speech for many days. . He was brought to [**Hospital3 **] today; had INR 2.0, Hct 25; NGT showed coffee ground emesis; gave 1 u prbcs, 2700cc of NS and transferred here + 40mg IV protonix. . In ED, vitals on arrival 98.4, 86 108/53 18 98%RA. Pt was lethargic and smelled of ETOH. Repeat hct 26.9, Plts 49 and he received 1 bag of platelets. Vitals remained stable SBP 90s-110s. HR 80s. Pt had slurred speech but A&Ox2. NGT lavage negative. . During his ED course the patient fell out of bed unwitnessed but sustained abrasion to left flank.. no trauma to head but given his coagulpathic state a CT head/Abd were ordered. . Past Medical History: Hep C-acquired in military '[**53**], liver biopsy '[**70**] showed cirrhosis, tx with Ribavarin and IFN '[**73**]-00 and again '[**81**]-'[**82**] stopped 1 month ago; HCV RNA negative GERD HTN Diverticulosis on c-scope'[**80**] Internal Hemorrhoids Depression with SI ETOH and Opiate dependence; s/p detox x2; recent admission [**7-18**] for SI h/o head trauma w/skull fracture Anxiety; started on Buspar 3 weeks ago h/o orthopedic surgeries Chronic Thrombocytopenia . Social History: The patient was born and raised in [**Location (un) 86**]. He has served in the marines for 8 years (submarine) during which he describes periods of depression. No hx of combat (cold war). The patient was employed as a lineman unti 1.5 years ago when he went on disability (work related injury in [**2170**]). He is currently married and has two daughters 17, 19. H/O ETOh abuse; per wife last drink 1 month ago and has been getting Librium/valium for detox at home. No current smoking but previously smoked <1ppd and quit 30 years ago. HIV negative per OSH report. Family History: Father, sister and brother with diverticulitis, no h/o colon cancer Physical Exam: GEN:somnolent but arousable, able to converse with constant re-orientation. HEENT:NC/AT, EOMI, PERRL, purulent material on R. eye Neck:Supple, JVP flat, no lymphadenopathy SKIN: Slight ecchymotic area on R. flank, non-tender CV:RRR, no murmurs/rubs PULM: Coarse bs throughout ABD: Soft, non-tender, ND, +BS, no rebound/guarding EXT:No LE edema NEURO:No asterixis. A&Ox3, knows president, knows wife's name. CN 2-12 grossly intact, sensation intact throughout, strength [**4-5**] b/l in UE/LE Pertinent Results: [**2183-8-5**] ECHO: The left atrium is dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. No vegetations seen (cannot definitively exclude). . [**2183-8-6**] CT ABDOMEN IMPRESSION: 1. No retroperitoneal hematoma. 2. Nodular ground-glass peribronchial opacities in the right middle lobe riases concern for infection. Left lower lobe opacity more has the appearance of a small area of aspiration or atelectasis. 3. Nonobstructing 4 mm renal stone, lower pole of the left kidney with other punctate left and right renal calculi. 4. Colonic diverticulosis, without evidence of diverticulitis. 5. Cholelithiasis. . [**2183-8-5**] EGD: No varices Grade 2 esophagitis in the gastroesophageal junction and lower third of the esophagus compatible with esophagitis Mild portal hypertensive gastropathy changes in the fundus Erosions in the antrum compatible with N G trauma Otherwise normal EGD to second part of the duodenum . [**2183-8-5**] CXR: In comparison with the study of [**8-4**], there is again patchy opacification at the left base. Again, although this could represent atelectatic change, the possibility of pneumonia should be seriously considered. A lateral view would be helpful for further evaluation if the patient's condition permits. . [**2183-8-8**] CXR: Resolution of right infrahilar opacity. Improvement in left lower lobe opacity now strongly suggestive of atelectasis. . [**2183-8-8**] Abdominal US: Son[**Name (NI) 493**] findings are consistent with cholecystitis given the distended gallbladder with wall edema. However, there is no son[**Name (NI) 493**] [**Name2 (NI) 515**] sign and appearance is little changed over two days since prior CT. Would recommend a HIDA scan to further evaluate gallbladder function. The gallbladder wall edema could also be due to the patient's underlying liver disease. Coarse echogenic liver consistent with patient's known prior liver disease. Brief Hospital Course: GI BLEED: Pt had several days of coffee ground emesis before admission. Endoscopy on [**2183-8-5**] showed grade II esophagitis (thought to be the bleeding source) and portal hypertensive gastropathy. He required 3 units PRBCs during course with stable hematocrit following this. Patient was started on PPI [**Hospital1 **] and his hematocrit was closely monitored throughout his hospitalization. FEVER: Pt had fever of 101 F soon after admission. Initially broadly covered with vanco and zosyn. Based on chest xray source thought to be an aspiration pneumonia (right middle lobe in setting of vomiting and altered mental status). Sputum cultures repeatedly too contaminated for evaluation. Regimen trimmed down to levofloxacin and flagyl. With increased right-sided abdominal pain and nausea more imaging was performed. CT abdomen and abdominal ultrasound suggested acute cholecystitis. Surgery was notified and felt that surgery was not indicated at this time. Pt will be considered for surgery when he is not acutely ill. Once pt completed levofloxacin course for pneumonia pt was switched to cipro and continued on flagyl. Pt will complete a two week course of antibiotics for acute cholecystitis. At time of discharge respiratory and GI symptoms had largely resolved with some residual RUQ tenderness. Repeat chest x-ray showed resolution of consolidation. Pt will follow up with Dr. [**First Name (STitle) 679**] in two weeks to be reevaluated. Pt did not complain of any coughing, SOB, or pleuritic pain upon discharge. Pt did continue to have RUQ pain [**6-10**] at baseline, and 7.5/10 with meals. Dr. [**First Name (STitle) 679**] will follow up with pt in clinic and refer to surgery if appropriate. WEAKNESS: Pt said he felt weak s/p ICU. Pt did not have any steriods in the ICU and critical care myopathy was very unlikely considering the pt had [**5-5**] motor strength, and not in the ICU that long. Pt's neuro exam on cordination was fine - with normal FNF and HTS, but unsteady in his gait. Pt was not able to perform tandem gait. Neuro was consulted and found that this was not an acute process but actually subacute to chronic. They believed this was [**2-1**] alcohol use, and likely anterior vermis syndrome. PT did not feel that [**Hospital 3782**] rehab would have helped with this, and neuro recommended to continue current regimen of meds including thiamine, folate, and MVI. AMS: Pt has been on multiple benzos per wife for withdrawal; MS changes occuring over past week; likely related to withdrawal vs acute intoxication. Did not appear overtly encephalopathic & ammonia level 24. CT head negative. This improved significantly over his course with return to baseline. Likely benzo related. ANEMIA: With GI bleed as above. Also concern that having non-GI losses based on dropping hematocrit in abscence of obvious GI bleeding. CT abdomen negative for RP bleed or bleeding associated with fall in the ED. S/P FALL: Pt fell while in ED and given low platelets and elevated INR; CT Head and Abdomen done; CT head negative and no RP bleed. ETOH ABUSE: Pt recently admitted for detox and currently denies ETOh use over past few weeks; however given strong h/o abuse will cover for possible withdrawal. CIWA scale was done without need for benzos. MVI and folate and thiamine given. CONJUNCTIVITIS: red eye with purulent discharge, started on eythromycin opthalmic solution. Course was completed prior to discharge. HEPATITIS C: Followed by Dr [**First Name (STitle) 679**]; recently completed course of Ribavarin in IFN. Pt does not appear encephalopathic. Considered Lactulose but MS improved. Medications on Admission: Buspar 10mg [**Hospital1 **] Atenolol 100mg daily Protonix 40mg daily Valium, Librium and [**Name (NI) 41919**] unclear dose Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days: last dose on [**8-21**]. Disp:*21 Tablet(s)* Refills:*0* 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: last dose on [**8-21**]. Disp:*14 Tablet(s)* Refills:*0* 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:*qs ML(s)* Refills:*2* 9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 10. Outpatient Physical Therapy treatment as per physical therapy 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: UGIB- esophagitis and portal hypertensive gastropathy per EGD Pneumonia Acute cholecystitis Secondary: Hep C cirrhosis h/o EtOH and opiate abuse HTN Depression/Anxiety Chronic thrombocytopenia Discharge Condition: Stable; pt does not require supplemental oxygen; tolerates po diet and meds Discharge Instructions: You were admitted to the hospital after experiencing several episodes of coffee ground emesis suggesting an upper GI bleed. You were admitted to the ICU. In the ICU you were found to have low blood counts so you were given a transfusion. You also underwent an upper GI scope to look for causes of the bleeding. The endoscopy showed inflammation of your esophagus and gastropathy in your stomach. On chest x-ray you were found to have a pneumonia. A CT scan was performed to get a better look at the pneumonia. It showed pneumonia as well as acute cholecystitis (inflammation of your gall bladder). You were started on the appropriate antibiotics. Because you had stopped vomiting and were without fever you were transferred to the floor where you were further managed and monitored for your infections and GI bleeding. . The Surgery team was notified of your acute cholecystitis. They did not feel that surgery was indicated at this time but will likely consider surgery when the inflammation has resolved to prevent future episodes of cholecystitis. Dr. [**First Name (STitle) 679**] will notify them of your status after you follow up in his clinic. . Because you were very weak during your admission Physical Therapy was consulted. They felt that you would greatly benefit from continued physical therapy as an outpatient. The following changes were made to your medications: --You were started on Ciprofloxacin and Metronidazole to treat your acute cholecystitis. You will continue these medications until [**2183-8-21**]. --You should take a multivitamin, thiamine, and folate supplements daily -- Your protonix was increased from 40mg once a day to 40mg twice a day. -- your atenolol was decreased to 50mg once a day -- your Buspar was changed to celexa 20mg once a day . Please notify your physician or return to the ED if your abdominal pains or respiratory symptoms progress or if your vomiting and fever return. Followup Instructions: An appointment has been scheduled for you with Dr. [**First Name (STitle) 679**] on Monday [**8-25**] at 1pm. Telephone number [**Telephone/Fax (1) 682**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**] Completed by:[**2183-8-24**]

[ "285.1", "070.54", "300.4", "575.0", "303.90", "287.5", "537.89", "787.29", "372.00", "507.0", "530.12", "401.9", "577.0", "284.1" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

11672, 11678

6421, 10065

334, 354

11925, 12003

4009, 6398

13984, 14293

3412, 3481

10241, 11649

11699, 11904

10091, 10218

12027, 13961

3496, 3990

275, 296

382, 2317

2339, 2812

2829, 3396

53,377

165,842

39100

Discharge summary

report

Admission Date: [**2123-6-23**] Discharge Date: [**2123-6-28**] Date of Birth: [**2071-5-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3276**] Chief Complaint: Fatigue and hematocrit drop Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 52-year-old gentleman with a pmhx. of newly diagnosed metastatic esophageal CA s/p stenting (started treatment last week with EOX, epirubicin, oxaliplatin and xeloda) who presents to the ED with weakness, fatigue, and a 10 point hematocrit drop over the last 6 days (20 point drop since late [**Month (only) 547**]). Patient states that he was doing well at home, though noticed increasing fatigue and shortness of breath with minimal exertion for the past few days. He was seen by VNA who checked blood and told him to go to the ED because of marked anemia. Initial vitals in the ED were: T: 97.4, BP: 101/58, HR: 140, RR: 16, SP02: 100% on RA. Hct noted to be 16.8, K 5.6, and sodium 125 (Na has been slowly trending down since [**Month (only) 547**]). Stools were trace guiac positive. Patient was typed and crossed 4 units and sent to the ICU. Vitals on transfer were: HR: 118, BP: 110/50, RR: 16, SP02: 100% RA, afebrile. ROS: (+) Per HPI. Reports weight loss of 30lbs in the last few months. Cannot tolerate solid food and drinks milkshakes and ensure. Significant lower extremity edema, worked up previously and negative for DVT. Reports [**9-14**] pain in his epigastric region, which comes in spasms, especially when he burps. (-) Patient denies fevers, chills, night sweats, chest pain or tightness, palpitations. Past Medical History: GERD Torn R ACL - not repaired Social History: Patient lives with his wife and 2 children (aged 14 and 11). They have a pet lizard. He works as a CFO at a software company. Has never smoked and drinks only occassionally. No other drug use. Family History: Grandfather with melanoma. Physical Exam: Vitals: afebrile, HR: 110, RR: 16, SP02: 99% on RA, BP: 107/61 General: Eyes closed but responds to voice, lying in bed, no acute distress SKIN: Slightly icteric, excoriations (crusted lesions) over upper extremities HEENT: Sclera anicteric, PEARLA, mucous membranes dry NECK: Supple, no LAD LUNGS: Clear to auscultation bilaterally; no wheezes, rales, or rhonchi ABDOMEN: +BS, distended, tender to light palpation in epigastric region, mildly tender to deep palpations throughout EXTREMITIES: 2+ edema bilaterally up to knees Pertinent Results: Admission labs: [**2123-6-23**] 03:51PM BLOOD WBC-8.9 RBC-2.02*# Hgb-5.4*# Hct-16.8*# MCV-83 MCH-27.0 MCHC-32.4 RDW-15.0 Plt Ct-771* [**2123-6-23**] 03:51PM BLOOD Neuts-88.1* Lymphs-10.8* Monos-0.7* Eos-0.2 Baso-0.3 [**2123-6-23**] 04:25PM BLOOD PT-14.9* PTT-26.3 INR(PT)-1.3* [**2123-6-23**] 10:58PM BLOOD Ret Aut-0.8* [**2123-6-23**] 03:51PM BLOOD Glucose-107* UreaN-21* Creat-0.9 Na-125* K-5.6* Cl-87* HCO3-24 AnGap-20 [**2123-6-23**] 03:51PM BLOOD ALT-30 AST-122* AlkPhos-312* TotBili-0.3 [**2123-6-23**] 03:51PM BLOOD Lipase-69* [**2123-6-23**] 03:51PM BLOOD Albumin-2.8* [**2123-6-23**] 03:51PM BLOOD TSH-5.3* [**2123-6-25**] 09:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.030 [**2123-6-25**] 09:20AM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-6.5 Leuks-NEG [**2123-6-25**] 09:20AM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0 TransE-<1 [**2123-6-25**] 09:20AM URINE CastGr-8* [**2123-6-24**] 10:30AM URINE Osmolal-651 Reports: [**6-23**] ECG: Resting sinus tachycardia. Borderline low precordial voltage. S1-Q3 pattern which is non-diagnostic and was present on the previous tracing of [**2123-6-3**]. Compared to the previous tracing resting heart rate is faster [**6-24**] CTA Abd/Pelvis: 1. Large mass centered within the lesser sac, larger in size compared to [**2123-5-25**]. The distal tip of the esophageal stent has the suggestion of extending directly into this mass rather than entering the lumen of the stomach. Newly developed within the mass are multiple areas of air and high density contents, concerning for representing ingested contents or interval development of necrosis within the mass. For confirmation of stent positioning, a repeat limited CT of the upper abdomen immediately following the administration of water soluble oral contrast could be considered. 2. Hepatic metastases, larger in size from prior study. 3. Retroperitoneal lymphadenopathy, also larger in size. [**6-25**] EGD: Esophagus contains large amount of debris and fluid, noted immediately upon intubation. Unable to clear. Scope withdrawn, discussed with anesthesia, for intubation. prior to proceeding further. Therapeutic large channel endoscope introduced, esophagus cleared of debris, rapid influx of debris and blood stained fluid into esophagus. Esophageal stent appears to have migrated proximally. Esophagus cleared again and note was made of debris partially occluding distal end of stent. Scope advanced to distal end of stent. Immediately entered cavity lined with large amount of debris. This may be gastric cavity but given the findings of recent CT may also be erosion of stent into mass in lesser sac. Scope immediately withdrawn. Impression: Proximal migration of stent Large volume of fluid and debris noted in stent Distal end may have eroded into observed mass [**6-26**] CT non-contrast Abdomen: 1. Large mass centered in the lesser sac is redemonstrated, with low-density areas consistent with necrosis. Swallow study confirms that the previously described fluid- and gas-containing collection in the center of this mass communicates with the esophagus and stomach. 2. Circumferential wall thickening of the distal esophagus redemonstrated, with unchanged position of esophageal stent. 3. Fluid layering in dilated distal esophagus, increasing risk for aspiration. 4. Retroperitoneal lymphadenopathy and large liver masses redemonstrated. 5. Small bilateral pleural effusions, slightly larger than two days prior. Brief Hospital Course: This is a 52-year-old gentleman with newly diagnosed metastatic esophageal CA who presented from home with a hematocrit drop of 10 points over the last 6 days. . ANEMIA: Unclear source, but looking back in OMR, appears as though hct has been slowly trending down since [**Month (only) 547**]. On admission, hct was at its nadir of 16.8 likely in the setting of a slow bleed from his GI tract. Stool was weakly guiac positive which made a brisk bleed unlikely. He remained hemodynamically stable aside from tachycardia. Decreased marrow production may also be contributing with a low reticulocyte count. He received a total of 9 units of pRBCs until his hematocrit stabilized in the low to mid 30s. He was started on a PPI IV BID and continued on telemetry. . ESOPHAGEAL CA: Chemotherapy was started 1 week prior to presentation with Xeloda; however, it was unclear whether the medication was passing beyond the large necrotic esophageal tumor to be absorbed so it was stopped. Long discussions were held with patient and his wife regarding his poor prognosis and palliative nature of his current regimen. EGD and CT abdomen were both consistent with a large, necrotic mass that was metastatic to the liver. He was made NPO for fear of esophageal rupture with continued PO intake. The patient wanted to leave the hospital AMA to maximize time spent with his family before meeting with IV access team to get a Portacath for future chemo or to meet with surgery to have a J-tube placed. Follow-up appointments were made with Dr. [**First Name (STitle) **] for J tube placement and with Dr. [**Last Name (STitle) 3274**] for oncology follow-up. . TACHYCARDIA: Resolved after treatent of hypovolemia and pain. . RIGHT UPPER EXTREMITY DVT: Patient with swollen, cold right upper extremity in the setting of PICC line placement. An ultrasound showed evidence of thrombus and the PICC was removed. No anticoagulation was pursued. . LOWER EXTREMITY EDEMA: Patient with marked lower extremity swelling, worked up previously and negative for DVT. Likely marked third spacing from decreased PO intake, poor synthetic function, and low intravascular oncotic pressure, given albumin levels ranging from 2.1-2.8. . PAIN CONTROL: Patient had been taking home oxycontin and oxycodone. He has had mild mental status changes; was slow to respond and tangential, thought to possibly be adverse effect from narcotics. Palliative care was consulted for recommendations on the patient's analgesic regimen and the patient did well on oxycontin 10 mg Q12 and oxycodone 5 mg PO Q4 hrs PRN. . PRURITIS: Patient was seen by dermatology for long-standing pruritus of upper and lower extremities with evidence of excoriated lesions. He was started on clobetasol .05% ointment applied to his arms and legs [**Hospital1 **] (covered with ACE bandage wrap after application) and Mupirocin 2% ointment to apply to the open areas TID. . Code: Confirmed full code Medications on Admission: Omeprazole 20 mg QD Oxycodone SR (OxyconTIN) 20 mg Q12 OxycoDONE (Immediate Release) 5-10 mg Q4 prn Compazine Zolpidem 10mg QHS Discharge Medications: 1. Clobetasol 0.05 % Ointment Sig: Apply sparingly Topical twice a day: Apply to arms and legs and then cover the areas with an ACE bandage. Disp:*120 grams* Refills:*10* 2. Mupirocin 2 % Ointment Sig: Appy to open areas Topical three times a day. Disp:*QS grams* Refills:*10* 3. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. Disp:*30 * Refills:*2* 4. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO every [**4-8**] hours as needed for pain: Please place 5mLs under your tongue. Disp:*240 mLs* Refills:*0* 5. Compazine 25 mg Suppository Sig: One (1) suppository Rectal twice a day as needed for nausea. Disp:*60 * Refills:*2* 6. Outpatient Lab Work Please check CBC on [**6-30**] and fax results to Dr. [**Last Name (STitle) 3274**] at fax number [**Telephone/Fax (1) 22294**]. Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Primary diagnosis: Metastatic espohageal cancer, upper GI bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 **] Hospital for evaluation of fatigue. You were found to have significant blood loss and were admitted to the intensive care unit. You received 9 units of blood and your blood level remained stable thereafter. Please continue to monitor your stools for blood. You will need to follow-up with Dr. [**Last Name (STitle) 3274**] and Dr. [**First Name (STitle) **] as an outpatient to discuss possible J-tube placement and further chemotherapy. Followup Instructions: Please follow-up with all of your outpatient medical appointments listed below: . 1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**] Date/Time:[**2123-6-29**] 9:00 on [**Hospital Ward Name 23**] [**Location (un) **] . 2. Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**] Date/Time:[**2123-7-6**] 9:30 . 3. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2123-7-6**] 12:00 [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]

[ "197.7", "453.82", "276.1", "280.0", "698.9", "151.0", "584.9", "578.9" ]

icd9cm

[ [ [] ] ]

[ "45.13", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

10129, 10192

6152, 9103

343, 350

10300, 10300

2604, 2604

10954, 11619

2011, 2039

9282, 10106

10213, 10213

9129, 9259

10451, 10931

2054, 2585

276, 305

378, 1728

2620, 6129

10232, 10279

10315, 10427

1750, 1782

1798, 1995

43,098

103,331

4393

Discharge summary

report

Admission Date: [**2182-7-16**] Discharge Date: [**2182-7-17**] Date of Birth: [**2122-5-6**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1145**] Chief Complaint: Chest pain and palpitations Major Surgical or Invasive Procedure: Cardiac cath s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] to LAD History of Present Illness: 60-year-old female with HTN, hyperlipidemia, and multinodular goiter who presented to the ED with progressive chest pains and palpitations over the past 4 months. She reports that she has had intermittent chest pressures associated with palpitations that usually last 2-3 minutes and occur mostly at rest. They are not associated with exertion, and stressful/emotional situations tend to exacerbate her symptoms. She was recently admitted to [**Hospital1 2177**] over the weekend (although per ED resident, no record of this at [**Hospital1 2177**]) with chest pains and, per pt, they wanted to do a cardiac cath but she was not comfortable with the facilities there. She presents here now with chest pressures and palpitations since 5 AM this morning that woke her from sleep. They are a bit more severe than usual, and have been intermittent throughout the morning. Patient also had excrcise stress test in [**2182-7-4**] ischemic EKG changes in the absence of anginal symptoms at a high cardiac demand good exercise tolerance. . In the ED, initial vitals were T 97.0, HR 99, BP 159/81, RR 16, and SpO2 100% on RA. EKG showed SR at 72 bpm with NA, NI, and TWI in III similar to prior EKG. Initial Troponin was negative. Labs were otherwise unremarkable. Cardiology consult was called and recommended Aspirin 325 mg PO, Nitroglycerin SL PRN, and urgent coronary catheterization. . Patient was taken directly to the cath lab, with no heparin. Patient was loaded with prasugrel and started on integrillin. In the cath lab patient was found to have single vessle CAD with moderate LAD lesion at the takeoff of the D2. The diag ostial lesion was 80-90% stenosis. She had successful POBA of the D2 and then successful stening of LAD with [**Date Range **]. During the procedure patient became diaphoretic and dropped BPs to the 70-80s with HR in the 60s treated with atropine and rewuired dopamine which was weaned off over few minutes with improvemnt in BP to 110s-110s. Limited echo showed no effusion. Patient was admitted to CCU for monitoring. . In the CCU, patient denies any chest pain, shortness of breath, lightheadedness, dizziness, fevers. No diaphoresis or nausea/vomiting. Also denies orthopnea, PND. All other ROS negative. Past Medical History: 1. CARDIAC RISK FACTORS: (Pre)Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: # PERCUTANEOUS CORONARY INTERVENTIONS: 3. OTHER PAST MEDICAL HISTORY: # Multinodular goiter -- negative FNA per notes # Borderline diabetes-- per patient was told she had elevated sugars at recent admission. Social History: # Tobacco: None # ETOH: None # Illicit: None Family History: No family history of early MIs. Physical Exam: GENERAL: Appears well in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple with flat JVP. 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: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No lesions PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission/Relevant Labs: [**2182-7-16**] 08:25AM BLOOD WBC-6.6 RBC-4.18* Hgb-13.7 Hct-39.9 MCV-96 MCH-32.7* MCHC-34.3 RDW-13.5 Plt Ct-257 [**2182-7-16**] 08:25AM BLOOD Neuts-57.2 Lymphs-33.3 Monos-7.0 Eos-1.9 Baso-0.6 [**2182-7-16**] 08:25AM BLOOD PT-11.6 PTT-29.1 INR(PT)-1.1 [**2182-7-16**] 08:25AM BLOOD Glucose-139* UreaN-10 Creat-0.6 Na-142 K-3.6 Cl-105 HCO3-27 AnGap-14 [**2182-7-16**] 08:25AM BLOOD cTropnT-<0.01 [**2182-7-17**] 06:15AM BLOOD CK-MB-10 [**2182-7-16**] 08:25AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.1 . Discharged Labs: [**2182-7-17**] 06:15AM BLOOD WBC-9.7 RBC-3.69* Hgb-11.8* Hct-35.3* MCV-96 MCH-32.0 MCHC-33.5 RDW-13.3 Plt Ct-242 [**2182-7-17**] 06:15AM BLOOD Glucose-104* UreaN-8 Creat-0.5 Na-140 K-3.7 Cl-104 HCO3-30 AnGap-10 [**2182-7-17**] 06:15AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.2 . Cath: [**2182-7-16**]: 1. Coronary angriography in this right dominant system demonstrated single vessel disease. The LMCA was a long vessel with a 10% mid-vessel lesion. The LAD had mild luminal irregularities proximally and 60% hazy mid vessel at the take off of the D2. The D2 had an 80% ostial lesion. The distal LAD was otherwise patent and long, wrapping around the apex. The LCx had mild luminal irregularities and gave a large bifurcating OM with relatively large upper and lower poles. The RCA was patent with mild luminal irregularities. 2. Resting hemodynamics revealed normal left sided filling pressures and mild systemic arterial systolic hypertension with SBP 146 mmHg. 3. FFR of the LAD lesion 0.82 with [**Month (only) **] showing the MLA at 2.7-2.8m2 4. Successful POBA of D2 5. Succesful stenting of mid LAD with 3.0 x 12 [**Month (only) **] 6. Likely vagal reaction following LAD stenting requiring fluids, atropine and transient dopamine infusion. 7. Non flow limiting dissection of D2 with antegrade flow. FINAL DIAGNOSIS: 1. One vessel coronary artery disease with moderate hazy mid LAD lesion at the takeoff of the D2. D2 ostial lesion was 80-90%. 2. FFR of mid LAD lesion of 0.82 and [**Month (only) **] showing the LAD lesion area of 2.7-2.8m2. 3. Successful POBA of D2 with 2.0mm balloon. 4. Succesful stenting of LAD with 3.0 X 12mm Promus element [**Month (only) **] 5. Vagal reaction following LAD stent post dilation treated with atropine, fluids and brief dopamine gtt with normalization of hemodynamics 6. Non flow limiting ostial D2 dissection with normal antegrade flow 7. Closure of right radial artery access site with TR band. . CXR: [**2182-7-16**] FINDINGS: Frontal and lateral views of the chest were obtained. The heart is of normal size with normal cardiomediastinal contours. The pulmonary vasculature is unremarkable. The lungs are clear without focal or diffuse abnormality. No pleural effusion or pneumothorax is visualized. Osseous structures are unremarkable. No radiopaque foreign body. IMPRESSION: No acute cardiopulmonary process. No pneumothorax. Brief Hospital Course: 60 yo F with HTN, hyperlipidemia presented with recurrent progressively worsening chest pains with recent abnormal stress test concerning for unstable angina and CAD. Negative troponins and now s/p cath with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] to LAD. . # Coronary Artery Disease: Patient presented with 3-4 months of worsening chest pains at rest lasting 2-3 minutes. Patient had recent exercise tolerance test which showed ischemic EKG changes without any symptoms. ON the day of admission patient was awakened by [**6-4**] constant chest pain. In the ED, EKG showed non-Specific ST changes, initial troponins were negative. Given concern fro unstable angina and CAD, patient had cardiac cath which showed single vessel CAD with moderate LAD lesion at the takeoff of the D2. The diag ostial lesion had 80-90% stenosis. She had successful POBA of the D2 and then successful stenting of LAD with [**Month/Year (2) **]. During the procedure patient became diaphoretic with drop in BP to 70s and HR 60s most likely vagal reaction. She was briefly on pressors for BP support. Post cath EKG was essentially unchanged. She was prasugrel loaded in the cath lab and started on 18 hours of Integrilin. She was transferred to CCU for further hemodynamic monitoring. During her CCU stay her blood pressure stayed stable and she did not have any chest pain or shortness of breath. She was continued on aspirin, valsartan, prasugrel. Her simvastatin was changed to atorvastatin. She will follow up with Dr. [**First Name (STitle) **] for further care who will make decision regarding patient's anti-platelet therapy and getting a follow up TTE in one month. . # Hypertension: Patient was hypotensive in the cath lab requiring atropine and dopamine. Patient has remained stable in the 120s-130s systolic in the CCU. She was discharged on her home valsartan and HCT combination med. - Continue HCTZ 12.5mg daily . # Hyperlipidemia: Her simvastatin was switched to atorvastatin 80mg daily . # Prediabetes: Patient blood sugars continued to be in the 120-130s. Patient will follow up with PCP who will check an A1C level. . CODE: Full EMERGENCY CONTACT: [**Name (NI) **] [**Name (NI) 18913**] [**Telephone/Fax (1) 18914**] Transitions of Care: - Patient will follow up with PCP who will check A1C level on patient and start appropriate meds if indicated. - Patient had [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] placed in LAD and started on Prasugrel 10mg daily. She will follow up with Dr. [**First Name (STitle) **] who will make further decision regarding patient's antiplatelet therapy and consider TTE one month after cath. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from webOMR. 1. valsartan-hydrochlorothiazide *NF* 160-12.5 mg Oral Daily 2. Atenolol 50 mg PO DAILY 3. Simvastatin 20 mg PO DAILY 4. Aspirin 100 mg PO DAILY Discharge Medications: 1. Prasugrel 10 mg PO DAILY RX *prasugrel [Effient] 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*3 2. Aspirin 100 mg PO DAILY 3. Atenolol 50 mg PO DAILY 4. valsartan-hydrochlorothiazide *NF* 160-12.5 mg Oral Daily 5. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: 1. Coronary Artery Disease s/p cardiac catherization with placement of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] to LAD. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname 18915**], It was a pleasure taking care of your during your hospitalization at [**Hospital1 18**]. You had a procedure to place a stent in your heart because of your recurrent chest pains. You did not have a heart attack. You were admitted to cardiac intensive unit because of brief episode of low blood pressure during the procedure. You were monitored overnight in the cardiac intensive unit and your blood pressures remained normal. On the day of discharge you did not have any chest pain or shortness of breath. Following your heart procedure you have been started on a blood thinning medication called prasugrel which you should continue to take for at least one year unless told otherwise by Dr. [**First Name (STitle) **]. You should follow up with Dr. [**First Name (STitle) **]. (see below) Your simvastain is also being replaced with atorvastain. . You can pick up your Prasugrel and atorvastatain medication from CarePlus Pharmacy [**Hospital1 18916**]. Phone: [**Telephone/Fax (1) 18917**] Followup Instructions: Department: [**Hospital1 7975**] INTERNAL MEDICINE When: MONDAY [**2182-7-22**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIAC SERVICES When: THURSDAY [**2182-8-15**] at 9:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2182-7-17**]

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Discharge summary

report

Admission Date: [**2124-6-17**] Discharge Date: [**2124-6-27**] Date of Birth: [**2045-8-27**] Sex: M Service: MEDICINE Allergies: Penicillins / simvastatin Attending:[**First Name3 (LF) 2290**] Chief Complaint: Abdominal pain x 2-3 weeks Major Surgical or Invasive Procedure: Placement of percutatenous chole drain History of Present Illness: 78 y/o Cantonese speaking man with history of CAD s/p CABG ([**2118**]), HTN, HLD, and emphysema who presented on [**2124-6-17**] to the medical floor with 2 weeks epigastric pain. CT abdomen showed severe duodenitis; surgery and GI were consulted. His original abdominal exam was consistent with guarding and surgery was concerned about a perforation but a repeat CT and abdominal X-ray were not consistent with free air. However, gallbladder wall thickening with pericholecystic fluid were noted, and his LFTs were consistent with obstruction, leading to concern for cholecystittis/cholangitis, and the patient was started on meropenem and vancomycin. Shortly after his repeat CT scan, he developed SOB and was tachycardic to the 140s with 3mm ST elevations in the lateral leads but troponins were negative and he did not complain of chest pain. There was a concern for demand ischemia and he was started on heparin gtt. The patient became hypotensive to an SBP in the 80s after he received metoprolol, and was transferred to the ICU. He was bolused with IV fluids and his metoprolol and lisinopril were held; he received a percutaneous chole drain and he continued to receive meropenem and vancomycin pending results of blood cultures. His vital signs stabilized nicely and he was transferred to medicine for further management. On arrival to the medicine floor, his vitals were T99 BP 101/47 HR 75 94% 4L. He complains of RUQ pain. He denies SOB or chest pain. Past Medical History: - Coronary artery disease s/p CABG [**3-/2119**] (LIMA to the LAD and -separate SVGs to the PDA and an OM) - HLD - HTN - BPH - Emphysema per ct scan - TB many years ago, treated for 2 years Social History: 20-pack-year smoker, discontinued 20 years ago. Occupation, retired machine operator. Lives with his family. Alcohol, none. Exposure, none. Family History: Mother had hypertension and history of cancer. Coronary artery disease in the family. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 98.5 74 137/54 18 96%5L. GENERAL: Elderly chinese man, alert oriented, uncomfortable with movement in bed, ambulatory HEENT: PERRL, EOMI +arcus senilis NECK: no carotid bruits, JVD LUNGS: CTA b/l no wrc HEART: RRR, normal S1 S2, no MRG. Sternal scar c/w CABG ABDOMEN: Tense abdomen with guarding diffusely. TTP diffusely, more so in epigastrium. Moderate distension. +BS. No palpable masses. EXTREMITIES: No c/c/e NEUROLOGIC: A+OX3 Discharge exam: Pertinent Results: Admission Labs: [**2124-6-16**] 06:00PM BLOOD WBC-10.2# RBC-4.79 Hgb-15.3 Hct-44.4 MCV-93 MCH-31.8 MCHC-34.4 RDW-13.5 Plt Ct-294 [**2124-6-16**] 06:00PM BLOOD Neuts-88.6* Lymphs-7.8* Monos-2.8 Eos-0.7 Baso-0.1 [**2124-6-16**] 06:00PM BLOOD Plt Ct-294 [**2124-6-16**] 06:00PM BLOOD Glucose-126* UreaN-15 Creat-0.9 Na-137 K-3.9 Cl-101 HCO3-26 AnGap-14 [**2124-6-16**] 06:00PM BLOOD ALT-31 AST-26 AlkPhos-99 TotBili-0.4 [**2124-6-16**] 06:00PM BLOOD cTropnT-<0.01 [**2124-6-16**] 06:00PM BLOOD cTropnT-<0.01 [**2124-6-16**] 06:00PM BLOOD Albumin-4.2 [**2124-6-17**] 10:15AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.7 [**2124-6-16**] 08:09PM BLOOD Lactate-2.9* CT AP ([**2124-6-17**]) ======================== INDICATION: Abdominal pain for two to three weeks. Comparison chest CT available from [**2121-11-20**]. TECHNIQUE: MDCT-acquired 5-mm axial images through the abdomen and pelvis were obtained following the uneventful administration of 130 ml of Omnipaque intravenous contrast. Coronal and sagittal reformations were performed at 5-mm slice thickness. CT OF THE ABDOMEN WITH IV CONTRAST: Included views of the lung bases demonstrate moderate-to-severe emphysema with superimposed bibasilar fibrosis which has progressed since the most recent chest CT examination from [**2121-11-20**]. There is no pericardial or pleural effusion. The heart size is top normal. Extensive stranding surrounds the proximal duodenum (2:26, 27). No focal fluid collections are identified. There is no free air. Perihepatic free fluid is present. A short segment of the proximal jejunum is mildly distended (2:48), with neighboring loops demonstrating mild fecalization (2:31). No transition point is seen. The remaining loops of small and large bowel are within normal limits. The stomach, spleen, pancreas, adrenal glands, kidneys, and gallbladder are normal. A well-circumscribed hypodense hepatic lesion within segment [**Doctor First Name 690**] (2:11) is minimally enlarged since [**2120**], likely representing a small cyst or biliary hamartoma. A 15 mm partially exophytic cyst arising from the interpolar region of the right kidney (2:35) is slightly enlarged since [**2120**]. There are moderate atherosclerotic calcifications throughout the abdominal aorta and iliac branches. The celiac trunk, SMA, and [**Female First Name (un) 899**] are patent and normal in caliber. There is no mesenteric or retroperitoneal lymphadenopathy. CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, urinary bladder, intrapelvic loops of small and large bowel are normal. The prostate is moderately enlarged (2:83). There is no intrapelvic free fluid or lymphadenopathy. OSSEOUS STRUCTURES: The patient is post-median sternotomy. No acute fracture is detected. There are no bony lesions concerning for malignancy or infection. IMPRESSION: 1. Severe duodenitis. No secondary signs of perforation. EGD is recommended to assess for further evaluation. 2. Mild dilatation of a short segment of jejunum, with fecalization of contents without transition point. Findings may represent a focal ileus. 3. Progression of moderate to severe emphysema and bibasilar interstitial fibrosis compared to the [**2120**] CT chest examination. 4. Small amount of perihepatic ascites. No drainable fluid collections. 5. Moderately enlarged prostate. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] KUB [**2124-6-17**] ====================== ABDOMEN INDICATION: Duodenitis, evaluation for free air. COMPARISON: No comparison available at the time of dictation. FINDINGS: Documentation is provided by two radiographic images. No free intra-abdominal air. Several small air-fluid levels projecting over nondistended bowel loops in the mid abdomen. Colonic air filling and stool filling of the ascending and descending colon. Contrast material in the bladder. Diffuse gas feeling of small bowel loops without evidence of wall thickening. No pathologic calcifications. No foreign bodies. CT AP [**2124-6-18**] ========================== INDICATION: Duodenitis with increasing abdominal tenderness. COMPARISON: CT available from [**2123-12-17**]. TECHNIQUE: MDCT-acquired 5-mm axial images of the abdomen and pelvis were obtained following the uneventful administration of Gastrografin and 130 ml of Omnipaque intravenous contrast. Coronal and sagittal reformations were performed at 5-mm slice thickness. DLP: 363 mGy-cm CT OF THE ABDOMEN WITH IV CONTRAST: Moderate right basilar atelectasis is new since the [**2123-12-17**] examination (2:5). Again seen is moderate-to-severe bibasilar emphysema with superimposed peripheral fibrosis. There is no pericardial or pleural effusion. The heart size is normal. Mild heterogenous liver perfusion is noted, predominantly in the right anterior and left medial lobes (2:19). A well-circumscribed subcentimeter hypodense hepatic lesion within segment [**Doctor First Name 690**] (2:11) likely represents a small cyst or biliary hamartoma. The portal and hepatic veins remain patent. Again seen is moderate stranding around the proximal duodenum (2:27), minimally changed since [**2124-6-16**], now with new mild stranding about the proximal CBD and gallbladder. The gallbladder and CBD remain non-distended though gallbladder is mimially hyperemic. The pancreas, adrenal glands, kidneys, and intraabdominal loops of small and large bowel are normal. A 15 mm partially exophytic cyst arising from the interpolar region of the right kidney (300B:40) is unchanged. There is no free air or free fluid. There is no mesenteric or retroperitoneal lymphadenopathy. CT OF THE PELVIS WITH IV CONTRAST: A small amount of intrapelvic free fluid (2:83) is new since [**2124-6-16**]. The rectum and bladder are normal. Moderate prostate hypertrophy is again seen (2:86). There is no intrapelvic lymphadenopathy. Small fat-containing bilateral inguinal hernias are again seen (2:81). OSSEOUS STRUCTURES: There is no fracture. There are no bony lesions concerning for malignancy or infection. The patient is post-median sternotomy. IMPRESSION: 1. Moderate stranding about the proximal duodenum appears minimally changed since [**2124-6-16**], but hyperemia and minimal stranding about the gallbladder and proximal CBD appears new. Cholecystitis would be somewhat unusual given the non-distended appearance of the gallbladder. Nonethelesse, correlate with clinical presentation and consider US examination for further evaluation. 2. Small amount of intrapelvic free fluid is new since [**2124-6-16**]. 3. Slight hyperenhancement of the right anterior and left medial liver of uncertain significance. It is unclear if this is related to the adjacent gallbladder. 4. No free air. 5. Moderate prostate hypertrophy. The study and the report were reviewed by the staff radiologist. CXR ([**2124-6-18**]) ======================= CHEST RADIOGRAPH INDICATION: Hypoxemia, evaluation for pulmonary edema. COMPARISON: [**2123-12-17**]. FINDINGS: As compared to the previous radiograph, the lung volumes have decreased, likely reflecting a lesser inspiratory effort. Widespread bilateral interstitial opacities, better characterized on previous CT examinations. No additional or secondary parenchymal opacities. Sternal wires, moderate cardiomegaly, no larger pleural effusions. No pneumothorax. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] [**2124-6-19**] - CXR FINDINGS: Compared to the previous radiograph, there are new focal parenchymal opacities that have occurred in both the left lung and at the right lung base. The distribution and morphology of these opacities are highly suspicious for pneumonia. Unchanged borderline size of the cardiac silhouette without overt pulmonary edema. No pleural effusions. No pneumothorax. Unchanged mild right apical pleural thickening. EKG [**2124-6-21**]: Sinus rhythm. Non-specific anterior T wave changes. Compared to the previous tracing of [**2124-6-18**] anterior T wave changes are new. Clinical correlation is suggested. Rate PR QRS QT/QTc P QRS T 66 148 82 [**Telephone/Fax (2) 46125**] 32 Brief Hospital Course: 78 yo Cantonese-speaking male w/ PMH HTN, BPH, CAD s/p CABG [**2118**] p/w 2-3 weeks abdominal pain, found to have cholecystitis. ACTIVE ISSUES: #Acute cholecystitis with Septic Shock: Patient presented complaining of new RUQ pain and was found to have leukocytosis (15-17) with fever (T101) while on medicine floor. Repeat CT done on [**6-18**] showed gallbladder wall thickening and pericholecystic fluid and LFTs were drawn and found to be elevated. Shortly after repeat CT the patient triggered for low oxygen saturation, tachycardia, and hypotension and was found with ST changes on EKG. He was transferred to the ICU. In the ICU, the patient was put on meropenem and vancomycin, and had a percutaneous chole drain placed with IR with bile cultures positive for E. coli. He drained serosanguinous fluid until [**2124-6-24**] until he started to drain bile. He stabilized nicely in the ICU with fluid boluses and did not require pressor support. He was transferred back to the floor and switched to cefepime once E. coli sensitivities returned. He will need cefepime until [**7-5**] and he is planned to have a cholecystectomy on [**2124-7-6**]. #Ileus: On the evening of [**2124-6-23**], patient complained of epigastric pain. KUB showed ileus. Bowel regimen was started and his pain resolved and bowel movements became regular. # Duodenitis: Patient reported 2-3 weeks of intermittent epigastric abdominal pain and nausea, with no noted melena, hematemesis, hematochezia. On abdominal CT, the patient was noted to have severe duodenitis although no free air/fluid and surgery and GI were consulted. Surgery felt no intervention necessary at that time, and GI plans to do EGD on [**2124-6-29**]. An abdominal plain film was done to evaluate for free air which was negative. A repeat CT was also obtained which showed no signs of perforation, minimal change in duodenitis from prior study, no free air/fluid. H. pylori serology was sent and was positive, but stool antigen remains pending. # Myocardial strain: Patient triggered on [**6-18**] - nursing found patient did not look well after returning to floor from CT, found with oxygen saturation in 60s and HR 150s; patient reported shortness of breath but not chest pain. EKG showed ST-depressions in V3-V6, I, aVL, II. Nebulizers, aspirin, morphine, and Metoprolol were given, and repeat EKG was improved but still with ST-changes, and the patient had troponins of 0.05 x2. These changes resolved on his next EKG. Troponins 0.05 x 2. Cardiology was consulted felt that the EKG changes were secondary to demand ischemia. The patient was started on heparin gtt in addition to his regimen. His heparin was drip was discontinued after transfer to medicine and the patient has not complained of shortness or chest pain and was stable on tele and repeat EKGs were unchanged. # PNA: The patient was diagnosed with bilateral pneumonia on hospital day 2 and developed hemoptysis. Because of his history of TB, the patient was placed in respiratory isolation and ruled out for TB with 4 negative sputums. Because of concern for MRSA pneumonia, pt was started on vancomycin, which was continued until [**6-26**]. He has no respiratory symptoms on discharge. CHRONIC ISSUES: # Coronary artery disease s/p CABG. # HLD - On atorvastation per cardio reccs. # HTN - cont lisinopril, metoprolol # BPH - held doxazosin given hypotension. # Restless leg syndrome - held Requip. TRANSITIONAL ISSUES: He will need to obtain a follow up appointment with cardiology EGD on [**2124-6-29**] Cholecystectomy on [**2124-7-6**] Cefepime to continue until [**2124-7-5**] (total 14 day course) Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Doxazosin 4 mg PO DAILY 2. Ropinirole 1 mg PO TID 3. Omeprazole 40 mg PO DAILY 4. Lisinopril 2.5 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Lisinopril 2.5 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Doxazosin 4 mg PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Ropinirole 1 mg PO TID 7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheezing 8. Atorvastatin 10 mg PO DAILY 9. CefePIME 2 g IV Q12H Duration: 9 Days 10. Docusate Sodium 100 mg PO BID:PRN constipation 11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 12. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB/wheeze 13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *Oxecta 5 mg 1 tablet(s) by mouth q6H PRN pain Disp #*15 Tablet Refills:*0 RX *oxycodone 5 mg 1 tablet(s) by mouth q6H PRN pain Disp #*15 Tablet Refills:*0 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation 15. Senna 1 TAB PO BID:PRN constipation 16. Pantoprazole 40 mg PO Q24H Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) **] Discharge Diagnosis: Cholecystitis Pneumonia Demand myocardial ischemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you during your stay at the [**Hospital1 18**]. You were admitted for evaluation of abdominal pain. You were found to have an infection in your gallbladder which was treated with placement of a drain and use of antibiotics. You were also found to have developed pneumonia and were treated for antibiotics. You tested negative for tuberculosis. The stress associated with your gallbladder and infection caused your blood pressure to decrease during your stay and may have lead to minor damage to your heart. Please follow up with surgery for evaluation for surgery to remove your gallbladder on [**2124-7-6**], at 3:15 PM. In addition, please make an appointment to follow up with cardiology in the future. Followup Instructions: Department: WEST PROCEDURAL CENTER When: THURSDAY [**2124-6-29**] at 1:15 PM With: WPC ROOM THREE [**Telephone/Fax (1) 5072**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: GI-WEST PROCEDURAL CENTER When: THURSDAY [**2124-6-29**] at 1:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7937**], MD [**Telephone/Fax (1) 463**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2124-7-6**] at 3:15 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 Completed by:[**2124-6-28**]

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icd9cm

[ [ [] ] ]

[ "51.01", "38.97" ]

icd9pcs

[ [ [] ] ]

16132, 16215

11210, 11341

314, 354

16310, 16310

2850, 2850

17260, 18272

2238, 2326

15184, 16109

16236, 16289

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11356, 14428

382, 1850

2866, 11187

16325, 16437

14444, 14641

1872, 2064

2080, 2222

81,691

191,962

38517

Discharge summary

report

Admission Date: [**2183-1-3**] Discharge Date: [**2183-1-11**] Date of Birth: [**2134-12-22**] Sex: F Service: CARDIOTHORACIC Allergies: Levaquin / Augmentin / Pamelor / adhesive tape / Shellfish Derived Attending:[**First Name3 (LF) 5790**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2183-1-3**] Right thoracotomy, thoracic tracheoplasty with mesh, right mainstem bronchus/bronchus intermedius bronchoplasty with mesh, left mainstem bronchus bronchoplasty with mesh. History of Present Illness: The patient is a 48-year-old woman with COPD and significant tracheobronchomalacia. She underwent a stent trial and despite running into complications and side effects with the stent, she reported marked improvement in her overall dyspnea and quality of life with the stent in place. Therefore, we recommended a tracheobronchoplasty to stabilize the airway. Past Medical History: cholecystectomy, hysterectomy; DM- poorly controlled especially with steroids reflux dx'ed 15 years ago on zantac Social History: Married, lives with family Family History: Mother- thyroid (?cancer) Father- heart attack Physical Exam: Discharge Vital Signs: BP:126/60mmHg HR:95/min RR:22/min SPO2:95% on 3 L/min O2 TEMP:98.0F Discharge Physical Exam: GEN: alert & oriented x 3 CVS:S1S2+ RS:b/l lungs clear ABD: soft, non tender, non distended Pertinent Results: [**2183-1-10**] 05:18AM BLOOD WBC-14.3* RBC-3.19* Hgb-9.2* Hct-28.4* MCV-89 MCH-28.7 MCHC-32.2 RDW-17.8* Plt Ct-313 [**2183-1-10**] 05:18AM BLOOD Glucose-172* UreaN-13 Creat-0.9 Na-133 K-4.0 Cl-95* HCO3-28 AnGap-14 [**2183-1-10**] 05:18AM BLOOD Albumin-3.0* Calcium-8.4 Phos-3.7 Mg-2.2 CXR:[**2183-1-11**]- No relevant change as compared to the previous examination. Moderate vascular distention indicative of mild-to-moderate pulmonary edema. No evidence of interval appearance of focal parenchymal opacity suggesting pneumonia. Moderate cardiomegaly with tortuosity of the thoracic aorta. No larger pleural effusions. Unchanged position of right-sided central venous access line. Brief Hospital Course: Mrs. [**Known firstname **] [**Known lastname 14837**] was taken to the operating room on [**2183-1-3**] where she underwent right thoractomy and tracheoplasty by Dr. [**Last Name (STitle) **] for tracheobronchomalacia. She was kept intubated and went to the ICU following surgery due to airway edema. She was diuresed with lasix and on neosynephrine drip for hypotension. She was given a dose of stress dose steroids intraoperatively. The patient was extubated on [**2183-1-5**], and remained on neosynephrine drip in the ICU, which was titrated off on [**2183-1-7**]. The patient was transferred to the floor on the evening of [**2183-1-7**], with acceptable blood pressures, in normal sinus rhythm. The following is a systems review of the [**Hospital 228**] hospital course. Neuro/Pain: The patient was kept on bupivicaine with dilaudid epidural which was removed on [**2183-1-7**], and started on oxycodone with tylenol which was effective. Pulmonary: Aggressive pulmonary toilet was maintained throughout admission with around the clock nebulizers, mucolytics and chest physiotherapy. Serial chest xrays were taken daily. The patient exhibited signs of increased volume overload on [**2183-1-8**], therefore was aggressively diuresed with IV lasix. Subsequent films improved. She was unable to wean completely off oxygen. She was discharged with 2Liters NC, with TID mucomyst and albuterol nebulizers. CV: The patient remained in normal sinus rhythm with blood pressures in the 100-120 range systolic, on the floor. Abd: The patient advanced her diet to regular diabetic diet. She was kept on stool softeners, passing gas. Renal: Her foley was kept initially during epidural but then for urine output monitoring. It was discontinued [**2183-1-9**]. A UA was checked due to bump in white count which was positive. Bactrim was started [**2183-1-10**]. She was aggressively diuresed for volume overload with IV lasix. Her electrolytes were repleted. Endocrine: Her insulin pump was discontinued preoperatively. Postoperatively she remained on insulin drip then SQ long acting, managed by [**Last Name (un) **] endocrinology. On [**2183-1-8**] the patient's insulin pump was restarted with normal blood sugars. Prophylactic: SCD's, TEDS and heparin SQ were given for VTE prophylaxis. The patient was seen by physical therapy who deemed her safe for discharge home with home PT. The patient was discharged home on [**2183-1-11**]. Medications on Admission: omeprazole, prednisone, advair, spiriva, budesonide, diovan, lantus and humalog, demasex, burporion, zantac, simavstatin, amiloride, zyrtec, requip Discharge Medications: 1. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q12H (every 12 hours). 2. paroxetine HCl 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. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. bupropion HCl 150 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 7. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily): as you were taking prior to surgery. 9. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while on narcotics to prevent constipation. 11. insulin regular hum U-500 conc 500 unit/mL Solution Sig: 0.5 unit Injection continuous: take as directed by endocrinologist. 12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation: available over the counter . 13. valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day. 15. potassium chloride 20 mEq Packet Sig: One (1) packet PO once a day: or as you were taking. 16. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 17. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation [**Hospital1 **] (). 18. amiloride-hydrochlorothiazide 5-50 mg Tablet Sig: One (1) Tablet PO once a day. 19. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 20. ropinirole 1 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). 21. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 22. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily): or as your were taking prior to surgery. 23. Home oxygen 2Liter Nasal cannula continuous, pulse dose for portablitity for tracheobronchomalacia s/p tracheoplasty, to keep RA saturations >92% 24. nebulizer kits please give pt a nebulizer kits for home nebulizer. s/p tracheoplasty 25. albuterol sulfate 1.25 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every eight (8) hours for 2 weeks. Disp:*42 nebs* Refills:*1* 26. acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ml Miscellaneous every eight (8) hours. Disp:*50 ml* Refills:*1* 27. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day. 28. Singulair 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 29. potassium chloride 10 % Liquid Sig: Two (2) tsp PO once a day: as directec by PCP. 30. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 doses. Disp:*2 Tablet(s)* Refills:*0* 31. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA & Hospice Services Discharge Diagnosis: Tracheobronchomalacia Diabetes Mellitus GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 2347**] office at [**Telephone/Fax (1) 2348**] if you have: -fevers greater than 101.5, chills or shakes -worsening cough or shortness of breath -drainage, swelling or redness from right incisions -uncontrolled surgical pain Walk several times a day and use your incentive spirometer. While on narcotics for pain do not drive, and talk stool softeners to avoid constipation. No tub bathing or submerging in water until incisions fully healed (usually 4 weeks) You should change your chest tube site with a bandaid, changing daily. You may shower Tuesday. Check your weight daily and if greater than 2 pounds in a day or more than 3 pounds in a week call Dr. [**Last Name (STitle) 85693**] to change torsemide and potassium dosing. Use mucomyst and albuterol nebulizers three times a day. Use oxygen to keep oxygen saturation >92%. Followup Instructions: Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2183-1-28**] 11:00am [**Hospital1 **] 116 [**Hospital Ward Name 517**]. Get a chest xray 30 minutes prior to you appointment in Clinical Center [**Location (un) 470**] radiology Followup with Dr. [**Last Name (STitle) 85693**] for followup on fluid status, and labs, and adjustment of diuretics and potassium on [**2183-1-17**] at 10:45 am. Call the office if you get leg cramps or severe weakness prior to check your electrolytes. Followup with your endocrinologist regarding insulin pump. Completed by:[**2183-1-13**]

[ "250.00", "458.29", "278.01", "496", "519.19", "276.69", "530.81", "599.0", "V58.67", "V45.85" ]

icd9cm

[ [ [] ] ]

[ "33.24", "31.79", "33.48" ]

icd9pcs

[ [ [] ] ]

7872, 7942

2131, 4573

353, 541

8031, 8031

1423, 2108

9068, 9718

1129, 1178

4772, 7849

7963, 8010

4599, 4749

8182, 9045

1193, 1285

294, 315

569, 931

8046, 8158

953, 1069

1085, 1113

1310, 1404

72,329

133,473

36527

Discharge summary

report

Admission Date: [**2125-2-15**] Discharge Date: [**2125-2-27**] Date of Birth: [**2046-10-16**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1406**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: 1. Coronary artery bypass x 3 (Left internal mammary to left anterior descending artery, reverse saphenous vein grafts to the posterior descending artery and obtuse marginal artery) 2. Aortic valve replacement with 19mm St. [**Male First Name (un) 923**] Epic tissue valve model#ESP [**Medical Record Number 82702**] History of Present Illness: 78 year old woman with known aortic stenosis which has worsened, a recent cath revealed 3 Vessel coronary artery disease and she was transferred to [**Hospital1 18**] for surgical evaluation. Past Medical History: mild dementia, asthma, OA, hypothyroidism, mod AS, polymyalgia, anemia, afib, Right renal cyst, GERD, vaginal enterocele, PVD, open CCY ([**2105**]) Social History: from [**Location (un) 32944**] Village Family History: non contributory Physical Exam: Pulse: 60 Resp: 18 O2 sat: 95 RA B/P Left: 189/79 Height: 4'[**26**]" Weight:69 General:obese Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally []distant breath sounds Heart: RRR [x] Irregular [] Murmur II/VI SEM across precordium Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds + [x]Tender right lower back, but no bruising and area is soft Extremities: Warm [x], well-perfused [x] Edema (none)Varicosities: None [x] L leg with medial incision down length of leg Neuro: Gait disturbance, uses cane Pulses: Femoral Right:1+ Left:1+ DP Right:d Left:d PT [**Name (NI) 167**]:d Left:d Radial Right:1+ Left:1+ Carotid Bruit Right: - Left: - Right cardiac cath site with dressing clean, dry, intact. No bruit, no hematoma noted at site. Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82703**] (Complete) Done [**2125-2-20**] at 11:25:40 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18**] - Department of Cardiac S [**Last Name (NamePattern1) 439**], 2A [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2046-10-16**] Age (years): 78 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Intraoperative TEE for CABG, AVR, ? Left atrial appendage resection ICD-9 Codes: 424.1, 424.0, 424.2 Test Information Date/Time: [**2125-2-20**] at 11:25 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW4-: Machine: AW1 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.5 cm <= 5.2 cm Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.9 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 65% >= 55% Aorta - Ascending: 2.7 cm <= 3.4 cm Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm Aortic Valve - Peak Gradient: *85 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 55 mm Hg Aortic Valve - LVOT diam: 1.7 cm Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Moderate LA enlargement. Elongated LA. Mild spontaneous echo contrast in the body of the LA. No thrombus/mass in the body of the LA. Moderate to severe spontaneous echo contrast in the LAA. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Focal calcifications in aortic root. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Focal calcifications in ascending aorta. Simple atheroma in aortic arch. Focal calcifications in aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. Focal calcifications in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). Trace AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate mitral annular calcification. Mild (1+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Mild to moderate [[**2-10**]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Left pleural effusion. Conclusions PRE BYPASS The left atrium is moderately dilated. The left atrium is elongated. Mild spontaneous echo contrast is seen in the body of the left atrium. No thrombus/mass is seen in the body of the left atrium. Moderate spontaneous echo contrast is present in the left atrial appendage. No thrombus is seen in the left atrial appendage. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are 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 severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. There is a left pleural effusion. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is being AV paced. There is normal biventricular systolic function. Thre is a bioprosthesis in the aortic position. It is well seated. The leaflets are not well seen. No aortic regurgitation is seen. The maximum gradient through the aortic valve is 27 mmHg with a mean gradient of 16 mmHg at a cardiac output of 3.2 liters/minute. The effective orifice area is approximately 1.1 cm2. The tricuspid regurgitation appears slightly improved - now mild. The thoracic aorta appers intact. No other changes from the pre bypass findings. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2125-2-20**] 13:57 Brief Hospital Course: Transferred for surgical evaluation with known aortic stenosis and coronary artery disease. Underwent preoperative workup including pulmonary function test, carotid ultrasound, and vein mapping. CT scan revealed esophageal thickening and GI was consulted, EGD revealed small hiatial hernia and no further interventions were indicated. Then on [**2125-2-20**] was taking to operating room for coronary artery bypass graft surgery and aortic valve replacement. See operative report for further details. She received vancomycin for perioperative antibiotics. She was transferred to the intensive care unit for hemodynamic management. She was weaned from sedation and was extubated on postoperative day one. Her home medications were resumed and she continued to progress. She remained in the intensive care unit for hemodynamic and pulmonary monitoring with atrial fibrillation treated with amiodarone and lopressor, however she had prolonged conversion pause and amiodarone was stopped. She remains on lopressor in normal sinus rhythm no further pauses last forty eight hours. Physical therapy worked with her on strength and mobility. She developed a productive cough and had left lower lobe collapse on CXR. She was placed on levaquin for emperic respiratory coverage. Was discharged to nursing home were she resided prior to surgery [**2125-2-27**]. Medications on Admission: prednisone 1mg daily, synthroid 75mcg daily, omeprazole 20mg [**Hospital1 **], advair diskus 100/50 1 puff [**Hospital1 **], seroquel 25mg qhs, mysoline 50mg HS, lasix 20mg QOD, aricept 10mg daily, bismuth, combivent 2 puffs Q6hrs, tylenol, MOM, dulcolax, coumadin 4.5mg daily, lisinopril 10mg daily, citalopram 40mg daily, lopressor 50mg [**Hospital1 **] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Primidone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 16. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing . 18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 19. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1 doses: Goal INR [**3-14**] for Atrial Filbrillation. 20. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 months. 21. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 22. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 10 days. 23. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day for 2 months. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Health of [**Hospital3 **] - [**Location (un) 32944**] Discharge Diagnosis: Coronary artery disease s/p CABG Aortic stenosis s/p AVR mild dementia asthma OA hypothyroidism polymyalgia, anemia Atrial fibrillation Right renal cyst CRI (1.2) GERD vaginal enterocele Peripheral vasular disease arthritis MI open cholecystectomy ([**2105**]) s/p Left superficial femoral artery to anterior tibial bypass with in situ saphenous vein graft, [**2124-6-1**] Discharge Condition: Alert and oriented x1 nonfocal Ambulating with assistance Sternal pain managed with ultram and tylenol Discharge Instructions: Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Recommended Follow-up:Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]. Needs CXR at F/U visit Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-10**] weeks Cardiologist Dr. [**First Name (STitle) 82704**] [**Name (STitle) 82705**] in [**2-10**] weeks Check INR/Hct with goal INR [**3-14**] for Atrial fibrillation Completed by:[**2125-2-27**]

[ "496", "585.9", "424.1", "725", "276.2", "427.31", "433.10", "458.29", "294.8", "V02.54", "553.3", "530.81", "414.01", "440.20", "416.8", "530.6", "465.9", "412", "244.9", "403.90", "427.89", "518.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21", "36.12", "36.15", "45.16" ]

icd9pcs

[ [ [] ] ]

11932, 12030

7969, 9333

342, 661

12447, 12552

2055, 7946

13143, 13597

1129, 1147

9741, 11909

12051, 12426

9359, 9718

12600, 13120

1162, 2036

283, 304

689, 883

905, 1056

1072, 1113

2,186

103,057

53440

Discharge summary

report

Admission Date: [**2136-5-17**] Discharge Date: [**2136-6-8**] Date of Birth: [**2064-5-24**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2160**] Chief Complaint: Jaundice Major Surgical or Invasive Procedure: PTC - biliary drain Multiple cholangiographies ERCP Embolization of hepatic artery PICC placement History of Present Illness: Ms. [**Known lastname 11622**] is a 71 y/o F w/ DM2, pancreatic CA (dx'd [**3-31**]), who was admitted on [**5-17**] after she had presented with biliary obstruction. ERCP attempted [**5-17**] but unable to cannulate CBD. On [**5-18**] the patient underwent placement of a percutaneous biliary drain. She tolerated the procedure well and bili was trending down. On [**5-18**] she began complaining of RUQ pain and Hct trended down from 33 -> 28 -> 26.9 from [**Date range (1) **]. On the morning of [**5-22**] Hct was seen to drop from 28.9 to 19.1 and pt became hypotensive with sBP's in the 80's and HR in the 110's. She was complaining of diffuse tenderness in her abdomen and had guaiac positive brown stool. Transferred to ICU. . [**Hospital Unit Name 153**] brief course: A R subclavian line was attempted but not successful, and R IJ was similarly unsuccessful. A cordis was placed in the R groin and she received a total of 5 units pRBC's over the next few hours (17->29). She was taken to IR but pullback cholangiogram was normal. She was then taken for a pRBC scan which revealed bleeding in the liver parenchyma. Arteriogram performed w/ positive bleeding from pseudoaneurysm at a posterior branch of the right hepatic artery. Successful embolization of the lesion w/ 2 straight coils. She was given another two units of packed red blood cells on morning of [**5-23**] when hct dropped from 29 -> 22. Her hct remained stable (31->32->27->29->29). Her CT abdomen [**5-23**] noon showed no retroperitoneal bleed but did show hemoperitoneum and two sources within the liver. Past Medical History: Type 2 DM with Retinopathy h/o Gastric Ulcer as per [**3-/2136**] EGD, H. pylori (-) HTN Pancreatic CA underwent EUS at [**Hospital1 18**] with bx which demonstrated mass in the head of the pancreas) Hypercholesterolemia . Social History: Retired cook, lives with dtr. 40pk-year tob history. No EtOH or IV drug use. Family History: Father with HTN and Cancer; many Aunts with [**Name2 (NI) **]. Physical Exam: : laying in bed, NAD HEENT: NCAT, +Jaundiced Neck: supple, JVD flat, no carotid bruits Chest: crackles at bases CVS: rrr, no m/r/g Abd: soft, hypoactive bs's, RUQ drain in place Extrem: no c/c/e Neuro: CN II-XII intact MSK: no joint effusions, normal ROM Pertinent Results: [**2136-6-8**] 06:30AM BLOOD WBC-26.9* RBC-3.24* Hgb-10.0* Hct-29.2* MCV-90 MCH-30.8 MCHC-34.2 RDW-16.4* Plt Ct-397 [**2136-6-7**] 07:18PM BLOOD Hct-29.8* [**2136-6-4**] 05:00AM BLOOD WBC-26.2* RBC-3.37* Hgb-10.2* Hct-30.3* MCV-90 MCH-30.2 MCHC-33.6 RDW-16.1* Plt Ct-532* [**2136-5-17**] 08:30AM BLOOD WBC-11.8* RBC-4.11* Hgb-11.7* Hct-34.5* MCV-84 MCH-28.5 MCHC-34.0 RDW-16.0* Plt Ct-435 [**2136-5-22**] 04:39AM BLOOD WBC-17.3* RBC-2.26*# Hgb-6.7*# Hct-19.1*# MCV-84 MCH-29.6 MCHC-35.1* RDW-17.1* Plt Ct-394 [**2136-6-2**] 06:22AM BLOOD PT-18.9* PTT-31.9 INR(PT)-1.8* [**2136-6-8**] 06:30AM BLOOD Glucose-84 UreaN-33* Creat-1.2* Na-124* K-5.0 Cl-86* HCO3-25 AnGap-18 [**2136-6-1**] 05:00AM BLOOD Glucose-82 UreaN-16 Creat-1.0 Na-129* K-4.8 Cl-91* HCO3-26 AnGap-17 [**2136-5-17**] 05:20PM BLOOD Glucose-79 UreaN-18 Creat-0.8 Na-131* K-3.8 Cl-94* HCO3-28 AnGap-13 [**2136-6-8**] 06:30AM BLOOD ALT-53* AST-127* AlkPhos-514* TotBili-20.9* [**2136-5-28**] 05:52AM BLOOD ALT-196* AST-94* AlkPhos-436* Amylase-30 TotBili-10.9* [**2136-5-22**] 08:14AM BLOOD ALT-374* AST-875* AlkPhos-527* TotBili-3.9* [**2136-5-17**] 05:20PM BLOOD ALT-374* AST-260* AlkPhos-1177* Amylase-78 TotBili-10.1* [**2136-6-4**] 05:00AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.2 [**2136-5-31**] 06:06AM BLOOD Osmolal-261* [**2136-5-21**] 07:30AM BLOOD Cortsol-28.0* [**2136-5-21**] 07:30AM BLOOD TSH-0.72 [**2136-5-22**] 03:33PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE [**2136-5-22**] 03:37PM BLOOD HIV Ab-NEGATIVE [**2136-5-17**] 05:54PM BLOOD CA [**47**]-9 -Test [**2136-5-29**] 12:13PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.005 [**2136-5-29**] 12:13PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-250 Ketone-NEG Bilirub-MOD Urobiln-NEG pH-7.0 Leuks-NEG [**2136-6-2**] 04:18PM URINE Hours-RANDOM Creat-78 Na-17 [**2136-6-7**] 4:46 pm BILE **FINAL REPORT [**2136-6-10**]** GRAM STAIN (Final [**2136-6-7**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): BUDDING YEAST. FLUID CULTURE (Final [**2136-6-10**]): YEAST, PRESUMPTIVELY NOT C. ALBICANS. MODERATE GROWTH. [**2136-5-28**] 12:19 pm BILE **FINAL REPORT [**2136-6-3**]** GRAM STAIN (Final [**2136-5-28**]): REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 109900**] 5PM [**2136-5-28**]. 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Final [**2136-6-3**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). ENTEROCOCCUS SP.. HEAVY GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. ENTEROCOCCUS SP.. MODERATE GROWTH. 2ND STRAIN. ENTEROCOCCUS SP.. Isolated from broth media only, INDICATING VERY LOW NUMBERS OF ORGANISMS. 3RD STRAIN. GRAM POSITIVE RODS. GROWING IN BROTH ONLY. UNABLE TO GROW FOR FURTHER IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | ENTEROCOCCUS SP. | | ENTEROCOCCUS SP. | | | AMPICILLIN------------ =>32 R <=2 S =>32 R LINEZOLID------------- 2 S 2 S PENICILLIN------------ =>64 R 8 S =>64 R VANCOMYCIN------------ =>32 R <=1 S =>32 R [**2136-5-22**] 8:14 am BILE **FINAL REPORT [**2136-5-25**]** GRAM STAIN (Final [**2136-5-22**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). FLUID CULTURE (Final [**2136-5-25**]): RESEMBLING MICROCOCCUS/STOMATOCOCCUS SPECIES. MODERATE GROWTH. LACTOBACILLUS SPECIES. SPARSE GROWTH. Cholangiogram - IMPRESSION: 1. Pullback cholangiogram demonstrates biliary leak at the posterior and inferior aspect of the right hepatic lobe with extravasation of contrast into the abdominal cavity. There is no communication with vascular structures. 2. Successful placement of a 10 French biliary catheter with side holes draining the left biliary system and the common bile duct. The pigtail was coiled within the duodenum. An ultrasound of the abdomen is recommended in order to determine if there is any abdominal collections in the right upper quadrant. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] PreliminaryApproved: [**Doctor First Name **] [**2136-6-7**] 2:28 PM CT abdomen: IMPRESSION: 1. Contrast administered during recent cholangiogram collects at the base of the liver extending subhepatically and represents a biloma. Previously described heterogeneous hepatic intraparenchymal lesions demonstrate hyperdense material within and it is difficult to tell whether this represents bleeding or recent contrast administration. Previously noted evolving hemoperitoneum has decreased in size. 2. Poor evaluation of pancreatic head mass extending into portahepatus and portal vein thrombosis without IV contrast. 3. Increased size of small right pleural effusion. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**] DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**] Approved: FRI [**2136-6-8**] 5:28 PM Cholangiogram: IMPRESSION: 1. Cholangiogram via existing catheter demonstrates decompressed intrahepatic ducts and good drainage of contrast through the catheter into the duodenum. 2. 10 cc of bile were sent for culture analysis. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**] Approved: [**Doctor First Name **] [**2136-5-31**] 11:25 AM IMPRESSION: Active extravasation originating from the region around the right liver edge. The findings were discussed with Dr. [**Last Name (STitle) 15785**] by Dr. [**Last Name (STitle) **]. Brief Hospital Course: 72 F with Metastatic pancreatic cancer - with a complicated hospital ourse - 1. Blood loss anemia - due to hemoperitoneum as a complication of the procedur (PTC) - after transfusion, hepatic artery branches were embolised with stoppage of bleeding. The hematocrit remained stable thereafter. 2. Obstructive jaundice, s/p biliary drain placed by IR. After initial decrease in bilirubin, the bili started rising and peaked >20. Cholangigram showed a bile leak. The patient did not want further interventions as her goal was home with hospice. the cath was left in and hospice/VNA arranged for cath checks/dressings. 3. Bile infection with micrococcus, VRE, yeast - to complete 2 weeks on linezolid, metronidazole and fluconazole as per our ID service. Blood culures remained negative at the time of discharge. 4. Leucocytosis - likely due to 3. above. No other source of infection found. 5. SIADH - Na maintained in the mid-120's with 1 lit water restriction/day. 6. Hypertension - po meds as below. 7. Metastatic pancreatic cancer - deemed inoperable by surgery. Med oncology did not think chemo would be indicated unless the current bleeding, infection clear up. The patient did not wish any further treatment for cancer and her goal was to go home with her family. She was disharged to her daghter, [**Doctor First Name 109901**] home with hospice. Case management, SW, palliative care all involved in a safe and appropriate discahrge plan. Pain control was fairly well achieved. There was a concern that one of the patient's son has psychiatric issues ([**Name (NI) 5656**]) and would occasionally verbally abuse patient. SW involved and elder svcs were contact[**Name (NI) **] who refused to take report as the patient was in hospital. The patient was not dicharged to her home (where [**Doctor Last Name **] lives) but to [**Doctor First Name **] (daughter's) home. Patient did not want to file a restraining order against this son. Our palliative care SW, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10794**] will relay this to the hospice palliative care SW. The above was communicated to Dr [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 42604**] (PCP) on the [**Last Name (un) **] of discharge. Medications on Admission: Metformin Lisinopril Avandia Glipizide ASA Plavix (recently held) Prilosec Insulin (15-20U) qam Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO every [**6-1**] hours as needed for constipation. Disp:*3 ML(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 6. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0* 7. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable PO QID (4 times a day) as needed. Disp:*60 Tablet, Chewable(s)* Refills:*0* 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-27**] Drops Ophthalmic Q4H (every 4 hours) as needed. Disp:*2 * Refills:*0* 9. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:*14 Tablet(s)* Refills:*0* 10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days. Disp:*18 Tablet(s)* Refills:*0* 12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:*8 Tablet(s)* Refills:*0* 13. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units Subcutaneous before breakfast every morning. Disp:*3 * Refills:*0* 14. [**Hospital 12106**] Hospital bed, Bedside commode, Shower chair Discharge Disposition: Home With Service Facility: [**Hospital 109902**] HealthCare of [**Location (un) 86**] Discharge Diagnosis: Metastatic pancreatic cancer Blood loss anemia Obstructive jaundice, s/p biliary drain Bile infection with micrococcus, VRE, yeast Leucocytosis SIADH Acute renal failure Hypertension Discharge Condition: Fair Discharge Instructions: Please contact the hospice services or your primary doctor if you have worsening pain or any other symptoms of concern to you. Take medicines as prescribed. Followup Instructions: Provider: [**Name10 (NameIs) 1948**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2136-6-22**] 12:30 Provider: [**Name10 (NameIs) **] WEST,ROOM THREE GI ROOMS Date/Time:[**2136-6-22**] 12:30 If you decide on further treatment for cancer - call Dr [**Last Name (STitle) **] and make a follow up appointment -- [**Telephone/Fax (1) 13006**]. Dr [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 109903**] - your primary doctor will care for your further medical needs.

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icd9cm

[ [ [] ] ]

[ "99.07", "39.79", "51.98", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

13696, 13785

9522, 11773

280, 380

14012, 14019

2703, 9499

14226, 14742

2348, 2413

11919, 13673

13806, 13991

11799, 11896

14043, 14203

2429, 2684

232, 242

408, 1992

2014, 2238

2254, 2332

10,623

147,264

7934

Discharge summary

report

Admission Date: [**2169-2-7**] Discharge Date: [**2169-2-11**] Date of Birth: [**2116-11-10**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3376**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Pelvic drain placement by Intervnetional Radiology ([**2169-2-9**]) History of Present Illness: 52yM with Crohns colitis who underwent previous TAC with ileostomy, recently underwent a completion proctotectomy for possible diversion proctitis [**2169-1-16**]. Since that time has had some intermittent bleeding from her anorectal area. She had a wound open up in the posterior midline post-op which has been slowly healing. Her and the family believe her bleeding has been coming from this wound. Over the past 24 hours she developed fevers, chills, abdominal pain, and worsening rectal pain and bleeding. Past Medical History: PMH: Crohn's Dz, [**Doctor Last Name 933**], anemia, colitis PSH: subtotal colectomy, end ileostomy [**3-27**]; open CCY [**1-26**]; completion proctocolectomy and right salpingectomy and resection pelvic inclusion cyst [**1-4**] Social History: Non smoker Family History: Non contributory Physical Exam: PE: Temp 104 HR 138 BP 133/87 RR 20 O2Sats 99% Gen-NAD, AAOx3 mildly diaphoretic HEENT-anicteric CV-sinus tach Pulm-CTA b/l Abd-soft, mildly distended, diffuse but very mild abdominal tenderness, ostomy with good output, mucosa healthy appearing Rectal- Bright red blood and clots per rectum, granulating wound in posterior midline. Ext-no edema discharge: VS: temp 98.7, hr 87, bp 104/60, RR 16, O2 sat 94% on RA gen: WA/ WD, NAD CV: rrr, no m/r/g pulm: cta b/l abd: +bs, soft, nd/nt rectal: the drain is in place, nice granulating wound in posterior midline extremities: no edema Pertinent Results: admission: [**2169-2-7**] 02:25PM BLOOD WBC-11.9* RBC-4.76 Hgb-9.2* Hct-30.7* MCV-65* MCH-19.3* MCHC-29.9* RDW-19.3* Plt Ct-431 [**2169-2-8**] 05:23AM BLOOD WBC-6.7 RBC-3.21*# Hgb-6.5*# Hct-21.3*# MCV-66* MCH-20.2* MCHC-30.5* RDW-19.3* Plt Ct-271 [**2169-2-8**] 06:26AM BLOOD Hct-21.4* discharge: [**2169-2-10**] 06:08AM BLOOD Hct-26.8* [**2169-2-8**] 05:23AM BLOOD Neuts-84.5* Lymphs-8.3* Monos-4.9 Eos-2.2 Baso-0.1 [**2169-2-8**] 05:23AM BLOOD Glucose-95 UreaN-4* Creat-0.6 Na-139 K-3.6 Cl-109* HCO3-23 AnGap-11 imaging: [**2169-2-7**] CT abdomen/pelvis 1. Multiloculated air and fluid collection with rim enhancement abutting the resection site in the anus, with discontinuity in the suture line suggesting anastamotic leakage. Findings are consistent with pelvic abscess. 2. Small pocket of rim-enhancing fluid adjacent to the stoma in the right anterior abdominal wall, suggesting an additional site of infection. 3. Mild stranding and fluid tracking throughout the mesentery, without bowel wall thickening or obstruction. 4. Trace bilateral pleural effusions. [**2169-2-10**] CT pelvis Rim-enhancing presacral fluid collection with drainage catheter in good position. We were able to flush and aspirate back easily and therefore recommend more aggressive catheter management with flushing and aspiration at least three times a day. In addition, the drainage bag was exchanged for a JP bulb. Brief Hospital Course: Patient was admitted to the surgical service after undergoing pelvic drainage with drain placement in Interventional Radiology. She was initially admitted to the intensive care unit secondary to her low blood pressures, tachycardia and high fevers (to 104) in the Emergency Department. She was started on IV vancomycin and zosyn and kept NPO with IVF resuscitation. Her blood pressures and tachycardia improved overnight, and her fevers resolved. She was transferred the floor on hospital day 2. She was started on a regular diet and transitioned to oral medications. Cultures were sent from her abscess drainage which demonstrated mixed bacterial flora. Patient continued to be hemodynamically stable. The drain output was monitored and the positioning of the drain was confirmed on [**2-10**]. The drain was found to be in the proper position. Patient was discharged home with the drain on IV antibiotics, ertapenem. At the time of discharge she denied any pelvic pain or pressure. She was tolerating regular diet, urinating regularly, she was afebrile with stable vital signs. Medications on Admission: Tylenol OTC, dilaudid prn, clonazepam prn Discharge Medications: 1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. 2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 3. Ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous once a day for 2 weeks. Disp:*14 gram* Refills:*0* 4. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: Five (5) ml PO DAILY (Daily). Disp:*100 ml* Refills:*2* 5. saline flushes 10 cc syringes - quantity 40, to be used for flushing the drain 6. drain flushes Sterile water 1L bottle, quantity 2. To be used for flushes of the drain. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Pelvic abscess Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Continued or increased drainage per rectum or from the JP drain. * Increased pelvic pressure or discomfort. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or [**Month/Year (2) 269**] nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. General Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or [**Month/Year (2) 269**] nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. PICC Line: *Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is significantly soiled for further instructions. ANTIBIOTIC ADMINISTRATION: You will be taking ertapenem 1 gm once daily for the total of 14 days. MAKE SURE TO FLUSH THE DRAIN WITH 10CC OF STERILE WATER TWICE A DAY. That will prevent the drain from becoming obstructed. Followup Instructions: Please call Dr.[**Name (NI) 3377**] office at [**Telephone/Fax (1) 274**] to set up a CT scan prior to your visit with Dr. [**Last Name (STitle) 1120**]. The CT scan is intended to evaluate the size of the pelvic collection and will determine further managment of the drain. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5777**] Date/Time:[**2169-2-16**] 9:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2169-2-28**] 2:00 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2169-6-8**] 12:00 Completed by:[**2169-2-12**]

[ "567.22", "242.00", "998.59", "998.11", "566", "285.9", "555.9", "300.00", "458.9", "998.12", "427.89" ]

icd9cm

[ [ [] ] ]

[ "54.91", "38.93" ]

icd9pcs

[ [ [] ] ]

5141, 5193

3322, 4410

342, 412

5252, 5252

1896, 3299

9025, 9801

1255, 1273

4502, 5118

5214, 5231

4436, 4479

5400, 9002

1288, 1877

275, 304

440, 956

5267, 5376

978, 1210

1226, 1239

26,101

145,001

50945+50946+59299

Discharge summary

report+report+addendum

Admission Date: [**2141-10-3**] Discharge Date: [**2141-10-12**] Service: PRIMARY DIAGNOSIS: Seizure disorder SECONDARY DIAGNOSIS: Alzheimer's disease HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 4702**] is an 84-year-old woman with a history of a recent myocardial infarction, hypertension, insulin dependent diabetes mellitus and Alzheimer's disease. She was in her usual state of health at a nursing home when, at about 9 a.m., the nurse was walking past Mrs. [**Known lastname 4702**] and noticed the patient was having a general tonoclonic seizure that started while she was eating breakfast in a chair. She was lowered to the ground, her airway was cleared and she continued to have general tonoclonic convulsions for approximately one to two minutes. Afterward, she did not regain consciousness. EMS was called. At about 9 ? she had another GTC in the ambulance and received 5 mg of Valium en route to [**Hospital6 649**]. After arrival, she was unresponsive, moving all four extremities and had systolic blood pressure of approximately 215. She was intubated to protect her airway. In total, she received 40 mg of Valium and 10 mg of morphine prior to this examination. She was also loaded with Dilantin 1 gm. CT showed no mass or hemorrhage. MRI/MRA showed no infarct, no mass or vascular abnormalities. PAST MEDICAL HISTORY: Historian was Emergency Department staff and primary care physician. 1. Hypertension 2. Insulin dependent diabetes mellitus 3. Coronary artery disease - myocardial infarction x3 - most recent [**2141-9-15**] 4. Chronic renal failure (usual creatinine is approximately 2.7) 5. Alzheimer's dementia 6. History of hip fracture - no more information available 7. Anemia of unknown etiology - GI work up including endoscopy not yet done 8. Cataracts 9. Glaucoma ALLERGIES: PENICILLIN AND SULFA MEDICATIONS ON MOST RECENT DISCHARGE: 1. Enteric coated aspirin 325 mg po q day 2. Brimonidine 0.15% eyedrops, 1 drop both eyes [**Hospital1 **] 3. Peri-Colace 1 tablet po bid prn 4. Senna 1 tablet po bid prn 5. Multivitamins 1 tablet po q day 6. Sublingual nitroglycerin 0.3 mg prn 7. Acetaminophen 325 to 650 mg po q 4 to 6 hours prn 8. Insulin NPH 56 units q a.m. subcutaneous 9. Lasix 40 mg po prn 10. Protonix 40 mg po q day 11. Isosorbide dinitrate 10 mg po tid 12. Hydralazine 10 mg po q6h 13. Diltiazem Extended Relief 240 mg po q day to be titrated down 14. Metoprolol 25 mg po bid to be titrated up 15. Calcium carbonate 500 mg po bid SOCIAL HISTORY: The patient is a resident of [**Hospital3 2558**]. She has many family members involved in her care. She does not have any known history of smoking, alcohol or drug use. PHYSICAL EXAM ON ADMISSION: VITAL SIGNS: Blood pressure 156/68, heart rate 72, respiratory rate 18, temperature 98.1??????. GENERAL: Well developed, obese, intubated and sedated. HEAD, EARS, EYES, NOSE AND THROAT: Clear, mucous membranes moist, anicteric. ETT in place. CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs or gallops. No jugular venous distention. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Obese, soft, nontender, nondistended. NEUROLOGIC: Intubated, sedated, does not respond to voice, grimaces and moves all extremities to pain. Pupils approximately 2 mm and reactive with dense cataracts. Fundi could not be seen. Absent oculocephalic reflex. Attenuated corneal reflex in the left upper arm. Intact cough, could not elicit gag. Withdraws all four extremities to nail bed pressure, 2+ deep tendon reflexes in the upper extremities, 1+ patellar and ankle jerks. Plantars upgoing bilaterally, unable to test gait. IMAGING: Chest x-ray - bibasilar densities consistent with congestive heart failure and left lower lobe infiltrate. LABS: White count on admission 12, hematocrit 41, hemoglobin 9.6, platelets 267. Sodium 138, potassium 4.7, chloride 100, CO2 21, BUN 31, creatinine 2.8, glucose 130, CK 148, MB 2, troponin less than 0.3. PT 13.0, INR 1.2, PTT 24. LP was attempted several times, but did not get CSF. HOSPITAL COURSE: Mrs. [**Known lastname 4702**] was admitted to the Neurology Intensive Care Unit. She was continued on Dilantin and 300 mg po q day. She was found to have a urinary tract infection which was treated with antibiotics. Mrs. [**Known lastname 4702**] was extubated on the 19th without difficulty and transferred to the Neurology floor on [**Hospital Ward Name 121**] Five. No LP was able to be obtained still, but the addition of CNS infection was extremely low, presumed that the patient's features were secondary to her urinary tract infection in the setting of severe Alzheimer's. After consultation with the family, it was decided to place a PEG tube, as the patient had been unable to swallow effectively. At the bedside, a swallowing evaluation was performed on the 23rd which the patient failed. PEG tube was placed on [**2141-10-11**] without complication. Tube feeds and PEG tube feeds were began on [**2141-10-12**]. Addendum with discharge medications will be added at a later date. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] R. 13-130 Dictated By:[**Last Name (NamePattern1) 22084**] MEDQUIST36 D: [**2141-10-12**] 07:15 T: [**2141-10-12**] 07:13 JOB#: [**Job Number 105875**] Admission Date: [**2141-10-3**] Discharge Date: [**2141-10-12**] Service: ADDENDUM TO HOSPITAL COURSE: The patient switched from Levofloxacin to Augmentin on discharge to continue a ten day course as sensitivities returned showing Enterococcal urinary tract infection to be resistant to Levofloxacin. DISCHARGE MEDICATIONS: Aspirin 325 mg po q day, Metoprolol 25 mg po b.i.d., Pantoprazole 30 mg po q day, Dilantin suspension 200 mg po q 12, Piminodine eye drops 0.15% one drop OU b.i.d., Pericolace one tab po b.i.d., Senna one tab po b.i.d. prn, sublingual nitrogen 0.3 mg sublingual prn, Tylenol 325 to 650 mg po q 4 to 6 prn, sliding scale insulin, NPH insulin 40 units subQ q.a.m., Hydralazine 10 mg po q 6 to 8 prn, subQ heparin 5000 units q 12, Augmentin 250 mg po q 12 times ten days. FOLLOW UP: Follow up with [**Hospital3 4262**] Group and with her outpatient neurologist at the next available appointment. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 13-130 Dictated By:[**Last Name (NamePattern1) 22084**] MEDQUIST36 D: [**2141-10-12**] 09:52 T: [**2141-10-12**] 10:13 JOB#: [**Job Number **] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 17241**] Admission Date: [**2141-10-3**] Discharge Date: [**2141-10-12**] Date of Birth: [**2057-3-4**] Sex: F Service: ADDENDUM: The patient was found to be allergic both to penicillin and sulfa drugs, therefore she was started instead on nitrofurantoin 100 mg po qid x7 days for her urinary tract infection. Please follow up with a repeat urinalysis and culture in [**1-18**] weeks. DR.[**Last Name (STitle) **],[**First Name3 (LF) 657**] 13-130 Dictated By:[**Last Name (NamePattern1) 3694**] MEDQUIST36 D: [**2141-10-12**] 10:02 T: [**2141-10-12**] 10:32 JOB#: [**Job Number 17244**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

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145, 166

105, 123

2742, 4083

1367, 2525

2542, 2728

12,110

119,340

1439

Discharge summary

report

Admission Date: [**2172-7-27**] Discharge Date: [**2172-7-31**] Date of Birth: [**2097-8-29**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine / lisinopril / Toprol XL Attending:[**First Name3 (LF) 1505**] Chief Complaint: Expanding anterior chest hematoma Major Surgical or Invasive Procedure: [**7-28**]: Evacuation of Hematoma in the anterior chest. History of Present Illness: The patient has a long complicated cardiac history, who underwent a re-do sternotomy which was complicated by a sterile dehiscence. Back earlier in the year, he had a plating done which unfortunately lead to infection required for plate removal. He had a long postoperative course including an air leak from his left lung that took weeks and weeks to heal. He was seen in the office periodically with seroma fluid but nothing of major importance and then suddenly the day prior to admission developed a very large collection. CT scan did not show a source of bleeding and ther was no sign of contrast in the hematoma at the time of the CT. He was brought to the operating room for evacuation. Past Medical History: subcutaneous emphysema PMH: sternal dehiscence s/p plating and pectoral flaps Coronary artery disease Chronic Systolic Congestive Heart Failure chronic obstructive pulmonary disease Asthma Hypertension Hyperlipidemia paroxysmal Atrial fibrillation Peptic Ulcer Disease Descending aortic aneurysm 2.8cm (followed by Dr. [**Last Name (STitle) **] s/p removal of bladder cancer [**2166**] - s/p coronary artery bypass [**2152**] s/p coronary artery bypass grafts s/p redo sternotomy, mitral valve replacement/MAZE [**2164**] s/p redo,redo sternotomy, mitral valve replacement Social History: -Tobacco history: quit 20 years ago, 65 pack year history -ETOH: occasional wine with dinner -Illicit drugs: no reported illicit drug use Retired UPS trailer driver (20 years), lives at home with wife. 3 children, 1 grandchild. Active lifestyle (rides bikes, motorcycles, golfs) Family History: Family history is significant for a mother who died in her 60s of cardiac causes, a father who died in his 40s of unknown (?cancer) causes, a sister who died in her 40s from an MVC (with known CAD) and a brother who has significant CAD Physical Exam: Enlarging fluid collection of anterior chest, approx 29 x 28.5 cm, soft, non-tender to palpation. Patient only complains of chronic pain in R shoulder and down R back not associated with size of chest fluid collection. Labs on admission: CBC 10.1>35.1<194; Panel 142, 4.7, 106, 26, 28, 1.6, 109; INR 1.1, PTT 32 PHYSICAL EXAM: Height: Weight: Temp: 98.7 HR: 67 BP: 139/52 RR: 18 O2 Sat:99% 2LNC GENERAL [x] All findings normal [ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings: HEENT [x] All findings normal [ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric [ ] OP/NP mucosa normal [ ] Tongue midline [ ] Palate symmetric [ ] Neck supple/NT/without mass [ ] Trachea midline [ ] Thyroid nl size/contour [ ] Abnormal findings: RESPIRATORY [x] All findings normal [ ] CTA/P [ ] Excursion normal [ ] No fremitus [ ] No egophony [ ] No spine/CVAT [ ] Abnormal findings: CARDIOVASCULAR [x] All findings normal [ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema [ ] Peripheral pulses nl [ ] No abd/carotid bruit [ ] Abnormal findings: GI [x] All findings normal [ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia [ ] Abnormal findings: GU [x] Deferred [ ] All findings normal [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] All findings normal [ ] Strength intact/symmetric [ ] Sensation intact/ symmetric [ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact [ ] Cranial nerves intact [ ] Abnormal findings: MS [x] All findings normal [ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl [ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl [ ] Nails nl [ ] Abnormal findings: LYMPH NODES [x] All findings normal [ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl [ ] Inguinal nl [ ] Abnormal findings: SKIN [x] All findings normal [ ] No rashes/lesions/ulcers [ ] No induration/nodules/tightening [ ] Abnormal findings: PSYCHIATRIC [x] All findings normal [ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect [ ] Abnormal findings: Pertinent Results: [**2172-7-30**] 05:30AM BLOOD WBC-7.8 RBC-3.03* Hgb-8.6* Hct-27.5* MCV-91 MCH-28.5 MCHC-31.4 RDW-14.6 Plt Ct-158 [**2172-7-29**] 02:49AM BLOOD WBC-9.4 RBC-3.24* Hgb-9.5* Hct-29.2* MCV-90 MCH-29.2 MCHC-32.4 RDW-14.6 Plt Ct-187 [**2172-7-28**] 10:02PM BLOOD WBC-10.4 RBC-3.59* Hgb-10.3* Hct-32.4* MCV-90 MCH-28.8 MCHC-31.9 RDW-14.4 Plt Ct-216 [**2172-7-28**] 02:00PM BLOOD Hct-32.4* [**2172-7-30**] 05:30AM BLOOD Glucose-91 UreaN-30* Creat-1.5* Na-139 K-4.1 Cl-104 HCO3-28 AnGap-11 [**2172-7-29**] 02:49AM BLOOD Glucose-138* UreaN-35* Creat-1.7* Na-139 K-4.5 Cl-106 HCO3-27 AnGap-11 [**2172-7-28**] 02:00PM BLOOD Na-143 K-4.3 Cl-108 [**2172-7-28**] 10:16AM BLOOD UreaN-27* Creat-1.4* Na-140 K-4.3 Cl-107 HCO3-26 AnGap-11 [**2172-7-28**] 01:56AM BLOOD Glucose-91 UreaN-26* Creat-1.2 Na-143 K-3.6 Cl-111* HCO3-25 AnGap-11 Chest CT: Large transthoracic submuscular hematoma and fluid collection has developed in the anterior chest wall in the midline from the suprasternal notch to the subxiphoid upper abdomen in the space previously occupied by an air and fluid collection in the bed of the widely debrided sternum. Approximately 15% of the abnormality is intrathoracic extending through the open sternum to the prevascular mediastinum, where it is entirely separate from the adjacent vital structures, specifically the left brachiocephalic vein and ascending thoracic aorta. The intrathoracic component is roughly twice the volume it was in [**Month (only) 547**]; the extrathoracic component is entirely new filling what was previously an air-filled submuscular space and bulging the pre-muscular sternal soft tissue anteriorly. At the level of its greatest cross-seEctional area, the underside of the aortic arch, the diameters are 92x 157 mm, for a lesion that is roughly 24 cm in vertical diameter. Subcutaneous fat is intact. Cortical surfaces of the resected sternum, anterior costal cartilages, and clavicles are intact. There is no pleural or pericardial effusion. Atherosclerotic calcification and mural thrombus or plaque are heavy in the descending aorta, aortic arch, and aortic annulus as well as the native coronary arteries. Moderate left ventricular enlargement is unchanged. [**2172-7-31**] 05:30AM BLOOD WBC-7.5 RBC-3.18* Hgb-9.3* Hct-28.7* MCV-90 MCH-29.1 MCHC-32.3 RDW-14.4 Plt Ct-216 [**2172-7-31**] 05:30AM BLOOD Plt Ct-216 [**2172-7-31**] 05:30AM BLOOD PT-10.5 INR(PT)-1.0 [**2172-7-31**] 05:30AM BLOOD Glucose-105* UreaN-27* Creat-1.4* Na-141 K-4.2 Cl-106 HCO3-29 AnGap-10 Brief Hospital Course: On [**7-28**] he was brought to the operating room. A 1 cm incision was made and were liquidified blood was removed. A liposuction cannula was used and standard pool sucker and approximately 800 cc of mostly liquid blood and some clot was removed. A 5 mm 30 degree endoscope was put in the hole to completely examine the cavity. The cavity was a mature seroma cavity and it appeared that most likely 1 of his pectoralis flaps had pulled away from the left side of the sternum leading to the bleeding. It could be seen into the mediastinum, and the heart beating was visulazed. There was absolutely no sign of bleeding down in this area. Of note, there was great mobility in his 2 sternal halves with the left half riding over the right half. It was agreed he was likely going to do this again unless some sort of fixation was offered to him. Post op, he was brought to the CVICU and was hemodynamically stable. He had 2 [**Doctor Last Name **] drains which showed no signs of air leak when put on a Pleuravac and were subsequently put to bulb suction. They were draining serous fluid at the time of discharge. The patient ambulated several times on the day of discharge and showed no signs of reaccumulation in his chest. He was felt safe to be discharged home with VNA services and with a plan to follow up with Dr [**First Name (STitle) **] on [**8-11**] to plan for his sternal fixation surgery. Medications on Admission: - verapamil 240 mg daily - lovastatin 40 mg daily - aspirin 81 mg daily - losartan 25 mg daily - albuterol MDI 2puffs prn - ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler: Two (2) Puff Inhalation QID (4 times a day). - tramadol 50 mg as needed for pain - fluticasone-salmeterol 250-50 mcg/dose Disk: One (1) Disk with Device Inhalation once a day - furosemide 20 mg every other day - iron 325 mg daily Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **] 3. Docusate Sodium 100 mg PO BID 4. Furosemide 20 mg PO QOD 5. Minocycline 50 mg PO BID Dispense only once daily on days when he takes lasix 6. Ranitidine 150 mg PO DAILY 7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX *Ultram 50 mg 1 tablet(s) by mouth Q 4 hrs Disp #*30 Tablet Refills:*0 8. Verapamil 240 mg PO Q24H Hold for SBP<90 or HR<60 and notify HO if held Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Hematoma in the anterior chest Secondary Diagnosis - Coronary artery disease - Chronic Systolic Congestive Heart Failure, last EF 30-35% - COPD/Asthma - Hypertension - Hyperlipidemia - History of Atrial fibrillation - Peptic Ulcer Disease - Descending aortic anuerysm 2.8cm (followed by Dr. [**Last Name (STitle) **] - Bladder CA s/p removal of tumor [**2166**] (last seen in [**7-/2171**]) - s/p coronary artery bypass [**2152**] - s/p redo sternotomy, mitral valve replacement/MAZE [**2164**] - s/p redo redo sternotomy, mitral valve replacement [**2171**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram - JP's x [**Street Address(2) 8582**] Incisions: Healing well, no erythema or drainage No 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 Dr [**First Name (STitle) **] in [**2172-8-11**] at 9:00 AM [**Street Address(2) **]. [**Location (un) **] [**Telephone/Fax (1) 1416**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2172-7-31**]

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icd9cm

[ [ [] ] ]

[ "34.1" ]

icd9pcs

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32,412

163,508

2111

Discharge summary

report

Admission Date: [**2114-2-13**] Discharge Date: [**2114-2-16**] Date of Birth: [**2055-7-21**] Sex: M Service: MEDICINE Allergies: Crixivan Attending:[**First Name3 (LF) 10682**] Chief Complaint: Fever and diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: This is a 58 yo M w/ HIV/AIDS (CD4 160, VL undetectable), HBV, CKD (Cr 2.5-2.8) p/w nausea, vomiting, diarhea and fever. N/v/d started Sunday, with multiple episodes (20 lg amt watery diarrhea/day, 10 non-bloody emesis/day). Vomiting stopped Monday, but diarrhea worsened with new fever yesterday to 103 with chills and sweats. Also with 1 day of periumbilical abd pain (nonradiating), lightheadedness, weakness, dyspnea, pain in legs. Has been trying to drink Gatorade and broth. Had small amt red blood after BM on Sunday, none since. No melena. In the ED, initial VS: 100.9 114 119/68 22 96%. Exam notable for [**3-18**] midepigastric abdominal pain, mental status intact. Diarrhea persistent, but vomiting resolved. Labs showed elevated lactate, [**Last Name (un) **], metabolic acidosis, bili above baseline. CT abdomen negative (ED discussed GB with rads, no evidence of acute pathology). Patient with history of [**Last Name (un) 1074**]. Given cipro/flagyl. Triggered for BP 88/44 - foley placed, 2nd piv, repeat lactate, fluids with bolus (total 6L). Current VS: 99.2 101/49 94 12 100RA. Access is 2 18g PIV. On the floor, patient feels urgent need to have a BM, no nausea currently. Still SOB. Notes some slight vision blurring and floaters for past day. ROS also positive for rhinorrhea, wheezing, arthralgias and myalgias of LE. Denies recent travel, sick contacts, undercooked/unusual foods, fresh water exposure. Of note, patient states he had prior ICU stay for diarrhea ~1 yr ago at [**Hospital1 18**]. Review of systems: (+) Per HPI (-) Denies recent weight loss or gain. Denies headache, sinus tenderness, congestion. Denies cough, sputum. Denies chest pain, chest pressure, palpitations, syncope. Denies dysuria, frequency, or urgency. Denies rashes or skin changes. No sore throat. Past Medical History: HIV (diagnosed in 8/94 via PCP): CD4 167, VL undetectable [**Month (only) **] [**2113**] History of PCP, [**Name10 (NameIs) 11395**], [**Doctor First Name **], [**Doctor First Name 1074**] retinitis, [**Doctor First Name 1074**] pancreatitis, enterobacter sepsis, wasting syndrome HIV neuropathy Chronic renal insufficiency Hepatitis B Nephrolithiasis [**1-10**] crixivan PTX [**1-10**] pentamidine Depression Right nephrectomy (kidney donor for brother) [**2079**] Retinal implants bilaterally HTN Social History: He lives with his girlfriend [**Name (NI) **] in [**Location (un) 686**], MA in his house with his two daughters and his grandchildren. Works as substance abuse counselor for drug abusers with HIV/AIDS. He has not used drugs, tobacco, or alcohol for 18 years. Drugs: None currently. Heroin 2g/d IV from age 14-38 (quit 18 years ago). Cocaine 0.5 g/d (speedball) IV from age 21-38. Tobacco: 2 packs per day for 20 years (40 pack-years), quit 18 years ago. Alcohol: 1 pint/week, quit 18 years ago. Family History: Father killed, died of head trauma at age 25. Mother died of stomach CA at age 62. 2 brothers deceased from [**Name (NI) 11398**] (one of which had juvenile DM and received a kidney from pt). 1 brother alive at 57 with DM1. Physical Exam: On Admission: Vitals: 99.2 101/49 94 12 100RA. General: Alert, appropriate, some respiratory distress but no accessory muscle use, +chills HEENT: MMM, mild scleral browning/?icterus, EOMI Neck: Supple, ~1cm soft compressible mass in R supraclav area Lungs: Coarse expiratory crackles that are not consistently present, mild inspiratory wheezing, good air movement CV: Regular rate and rhythm, no murmurs, rubs, gallops appreciated Abdomen: Mildly tense, TTP in lower abdomen, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: warm, well perfused, 2+ pulses, no edema Lymph: No cervical, axillary or inguinal LAD Pertinent Results: Admission Labs: [**2114-2-12**] 10:30PM BLOOD WBC-10.6# RBC-4.44* Hgb-16.7 Hct-48.0 MCV-108* MCH-37.5* MCHC-34.7 RDW-14.5 Plt Ct-209 [**2114-2-12**] 10:30PM BLOOD Neuts-89.2* Lymphs-6.4* Monos-3.1 Eos-1.1 Baso-0.3 [**2114-2-12**] 10:30PM BLOOD Glucose-95 UreaN-28* Creat-3.4* Na-130* K-8.9* Cl-108 HCO3-13* AnGap-18 [**2114-2-12**] 10:30PM BLOOD ALT-40 AST-132* AlkPhos-88 TotBili-5.8* [**2114-2-12**] 10:20PM BLOOD Glucose-132* Lactate-3.1* Na-139 K-4.4 Discharge labs: [**2114-2-15**] 07:00AM BLOOD WBC-4.5 RBC-3.75* Hgb-14.1 Hct-39.8* MCV-106* MCH-37.5* MCHC-35.3* RDW-13.4 Plt Ct-192 [**2114-2-16**] 07:15AM BLOOD Glucose-88 UreaN-16 Creat-2.8* Na-141 K-4.0 Cl-115* HCO3-17* AnGap-13 [**2114-2-15**] 07:00AM BLOOD ALT-28 AST-47* AlkPhos-87 TotBili-2.6* Imaging: CHEST (PA & LAT) Study Date of [**2114-2-12**] The heart is enlarged, increased in size since the prior exam. The central pulmonary vessels are increased in caliber since the prior radiograph from [**10/2113**] and appear hazier, compatible with mild edema. The hilar and mediastinal contours are within normal limits. The lung volumes are low. Bibasilar linear opacities are compatible with mild-to-moderate atelectasis. There is no pleural effusion, pneumothorax, or focal consolidation. No bony abnormalities are seen. CT ABD & PELVIS W/O CONTRAST Study Date of [**2114-2-13**] 12:04 AM IMPRESSION: 1. No acute intra-abdominal or intrapelvic process seen. 2. Status post right nephrectomy. 3. Diffuse para-aortic lymphadenopathy, overall decreased since [**2110**]. The differential remains infection or lymphoproliferative disorder. 4. A 2.5 cm area of soft tissue thickening is seen within the proximal stomach, new since the [**1-/2111**] study, and may represent focal wall thickening, food, or a confluent node. Attention to this location on subsequent imaging is recommended, or an EGD can be considered for further evaluation, if clinically indicated. Brief Hospital Course: Patient is a 58 yo M w/ HIV/AIDS (CD4 160, VL undetectable), HBV, CKD (Cr 2.5-2.8) p/w nausea, vomiting, diarrhea and fever. # Infectious diarrhea: This is most likley viral gastroenteritis; viral studies are pending. Stool cultures and C. diff returned negative. CT did not show colitis. However, given his immunosuppressed state he was covered with broad spectrum antibiotics. He was covered with Vanco, Cefepime, and Flagyl. ID was consulted and recommended narrowing to cipro and flagyl x 5 days. By discharge, he was afebrile and his symptoms hhad improved. # Acute on chronic renal failure: This was likely prerenal from GI losses, and his Cr returned to baseline after IVFs. # Non-anion gap metabolic acidosis: This is likely from diarrhea, and copious GI losses as well as renal failure causing bicarb wasting. He was given IVFs with bicarb briefly in the ICU. His bicarb improved by discharge. # HIV: He was continued on his [**Year (4 digits) 2775**] and PCP [**Name Initial (PRE) **]. # HTN: His home atenolol was held on admission, and when it was restarted it was changed to metoprolol due to his chronic renal failure. Medications on Admission: Atazanavir 300 mg daily Lamivudine-Zidovudine 150-300 mg [**Hospital1 **] Ritonavir 100 mg daily Atenolol 100mg daily TMP-SMX DS TIW Discharge Medications: 1. atazanavir 300 mg Capsule Sig: One (1) Capsule PO once a day. 2. lamivudine-zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO twice a day. 3. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day for 2 days. Disp:*6 Tablet(s)* Refills:*0* 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. Discharge Disposition: Home Discharge Diagnosis: Infectious diarrhea Acute on chronic renal failure 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 for nausea, vomiting, and diarrhea. This is most likely due to a virus. Bacterial stool cultures have been negative; however, to be safe, please complete a 5 day course of the antibiotics ciprofloxacin and metronidazole. Your diarrhea has improved by discharge. Your medications changes are: 1. Please take ciprofloxacin and metronidazole until tomorros [**2114-2-17**]. 2. Your atenolol has been changed to metoprolol due to your decreased kidney function. Please continue to take your other medications as prescribed previously. Followup Instructions: Please follow up with your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within 2 weeks. Her clinic number is [**Telephone/Fax (1) 3581**].

[ "276.2", "584.9", "042", "585.3", "355.9", "070.32", "008.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8213, 8219

6040, 7188

289, 295

8314, 8314

4083, 4083

9078, 9257

3183, 3409

7372, 8190

8240, 8293

7214, 7349

8465, 9055

4555, 6017

3424, 3424

1864, 2130

231, 251

323, 1845

4099, 4539

3438, 4064

8329, 8441

2152, 2653

2669, 3167

10,425

147,243

48323

Discharge summary

report

Admission Date: [**2199-8-16**] Discharge Date: [**2199-9-11**] Date of Birth: [**2138-9-5**] Sex: M Service: SURGERY Allergies: Captopril / Iron / Prednisone Attending:[**First Name3 (LF) 5569**] Chief Complaint: Massive GI bleed Major Surgical or Invasive Procedure: [**2199-8-17**] Exploratory laparotomy with ligation of arterial inflow to pancreatic allograft, small bowel resection, bilateral chest tube placement, and removal of percutaneously placed right common iliac balloon. [**2199-8-19**] Exploratory laparotomy with enteroenterostomy and abdominal wall closure. [**2199-8-23**] Placement of a 10 x 38 mm balloon expandable covered stent in the right common iliac artery [**2199-9-9**] post pyloric feeding tube placement History of Present Illness: 60 yo M PMH Kidney t/p [**2192**], pancreas t/p [**2193**], CAD s/p RCA stent [**2192**] who presents with gi bleeding. The pt was in his usual state of health until the morning before admission when he became nauseas and began to vomit, and then had loose BM. Shortly after the bowel movement he felt weak, laid down, and 911 was called. While on the floor he had a large volume bloody stool. Per his wife, he had not complained of fevers, chills, abdominal pain or any other symptoms prior to this sequence of events. He has no prior history of either upper or lower GI bleeding. He was initially transported to the [**Hospital1 **] [**Location (un) 620**] ED and noted to have BRBPR. He wouldn't tolerate NG lavage. SBP initially 105 and went to 140's with fluid bolus. He received 1 unit of irradiated PRBCs. On ECG at [**Location (un) 620**] noted to have anterior lateral ST depressions that improved after transfusion. He was admitted to the MICU and went to IR for angiography. He had appeared to stop bleeding approximately 40 minutes prior to angiography and no bleeding was discovered at the time of the procedure. He was brought back to the MICU and continued to be monitored. He was on levophed overnight and received 5 RBC, 2 FFP, and 1 platelet transfusion. Large volume hematochezia then ensued at approximately 6:30-7:00 AM on [**2199-8-17**] and the massive transfusion protocol was activated by Dr. [**Last Name (STitle) **]. He is being actively transfused at the time of this note. NG lavage was performed by Drs. [**First Name (STitle) **] and [**Name5 (PTitle) **] with return of BRB. This had been done earlier by the MICU attending overnight with return of bile and water. GI has been emergently consulted for EGD. Past Medical History: Past Medical History: diabetes with ESRD, osteoarthritis, celiac sprue, cardiac cath, s/p stent placement in [**2192**], TIA in [**2190**], AFIB, HTN, history of microsporidiosis [**2193**] Past Surgical History: s/p LURT [**7-10**] now with CRI, PAK [**4-/2194**] with acute rejection episode treated with OKT3, h/o peripancreatic hematoma, s/p washout [**2199-8-17**] Exploratory laparotomy with ligation of arterial inflow to pancreatic allograft, small bowel resection, bilateral chest tube placement, and removal of percutaneously placed right common iliac balloon. [**2199-8-19**] Exploratory laparotomy with enteroenterostomy and abdominal wall closure. [**2199-8-23**] Placement of a 10 x 38 mm balloon expandable covered stent in the right common iliac artery [**2199-9-9**] post pyloric feeding tube placement Social History: Lives with his wife. [**Name (NI) **] ETOH, tobacco or illicit drug use Family History: Father with bleeding stomach ulcer Physical Exam: HR 120 BP 130/80 RR 16 on Vent SpO2 97% GEN: intubated, sedated HEENT: NGT in place, no blood in mouth CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Increasing distension of the abdomen, massive BRBPR. Ext: LE cool, becoming somewhat mottled. Laboratory: [**2199-8-17**]: 02:25 CBC 14.2>10.6/29.3<139 [**2199-8-17**]: 07:27 CBC 8.4>5.5/15.5<96 ACTIVELY BEING TRANSFUSED Imaging: [**Female First Name (un) 899**] and SMA angiography without mesenteric bleed. Pertinent Results: [**2199-8-16**] 03:53PM BLOOD WBC-13.8*# RBC-3.31* Hgb-9.5* Hct-29.4* MCV-89 MCH-28.7 MCHC-32.3 RDW-14.2 Plt Ct-260 [**2199-8-17**] 07:27AM BLOOD WBC-8.4 RBC-1.77*# Hgb-5.3*# Hct-15.5*# MCV-87 MCH-29.9 MCHC-34.2 RDW-15.3 Plt Ct-96* [**2199-8-17**] 08:08AM BLOOD Hct-28.1*# [**2199-9-10**] 06:00AM BLOOD WBC-5.8 RBC-3.26* Hgb-9.8* Hct-28.9* MCV-89 MCH-30.1 MCHC-33.9 RDW-16.5* Plt Ct-279 [**2199-9-2**] 03:18PM BLOOD PT-14.4* PTT-28.6 INR(PT)-1.2* [**2199-9-10**] 06:00AM BLOOD Glucose-111* UreaN-43* Creat-1.8* Na-139 K-4.2 Cl-106 HCO3-26 AnGap-11 [**2199-8-31**] 01:48AM BLOOD ALT-53* AST-27 LD(LDH)-240 AlkPhos-130 TotBili-0.9 [**2199-8-30**] 01:52AM BLOOD Triglyc-202* [**2199-8-31**] 01:48AM BLOOD TSH-2.0 [**2199-8-31**] 01:48AM BLOOD T4-1.9* T3-31* [**2199-9-10**] 06:00AM BLOOD tacroFK-6.6 Brief Hospital Course: 60 yo M with h/o LURT and pancreas (failed) after kidney presented to the ED with massive GI bleed concerning for fistula between pancreatic allograft and bowel. He was sent emergently to IR for localization of bleed. Mesenteric Angiogram did not reveal any extravasation. Several hours later, he experienced another massive GI bleed and was taken back for angiography that demonstrated likely fistula from the artery in the pancreatic allograft to the small bowel. The balloon was inflated in the right common iliac artery to achieve control. He experienced hypovolemia as well as compartment syndrome and coded. ACLS protocol was initiated with resuscitation. He required emergent exploratory laparotomy in radiology with ligation of arterial inflow to pancreatic allograft, small bowel resection, bilateral chest tube placement, and removal of percutaneously placed right common iliac balloon. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. See operative note for complete details. Postop, he was taken intubated to the SICU. Chest tubes remained to water seal without pneumothorax noted on CXR. Insulin drip was started. On [**2199-8-19**], he was taken to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for exploratory laparotomy with enteroenterostomy and abdominal wall closure. Postop, he returned to the SICU intubated. On [**8-20**], a bronchoscopy was done for mucus plugs. BAL was negative. He received broad spectrum antibiotic coverage. A lasix drip was started for massive edema. On [**8-22**], he was extubated with chest tubes remaining to water seal. Lasix drip continued. On [**8-23**], interventional radiology placed a right common iliac artery covered stent over the arterio-jejunal fistula. A post pyloric tube was also placed by radiology. Radiology removed the bilateral groin sheaths without incident. On [**8-23**], bilateral CT's were removed with post CXR demonstrating a tiny L apical PTX that resolved spontaneously. Plavix 300mg was initiated. Trophic trophic tube feeds were started and advanced to goal. Free water flushes were given for hypernatremia. On [**8-25**] 2 units of PRBC were given for a Hct of 23.4. Hct remained stable. On [**8-25**], Vanco and Zosyn were started for empiric pneumonia coverage. CXR showed bilateral perihilar (right greater than left)and bibasilar (left greater than right) opacities and bilateral pleural effusions. Lasix drip was continued for generalized edema. NG tube was removed and diet was advanced to a DM diet. Insulin drip continued. Aspirin was restarted. Oxycodone was given for pain control. He developed a metabolic alkalosis and Lasix drip was held. Diamox was given x2. Urine output remained adequate. On [**8-27**], he was pancultured for leukocytosis (13.6, 12.8). Blood and urine cultures remained negative. CXR showed improved pleural effusions. CMV and BK viral loads were sent and returned negative. On [**8-28**], he self-d/c'd the feeding tube and was experiencing nausea and bilious emesis. KUB did not show signs of obstruction. On [**8-29**], a CT scan with PO contrast demonstrated partial SBO dilated bowel proximal to anastomosis and decompressed bowel distally, positive contrast in colon. He was kept NPO and was started on TPN. NG continued with bilious output. On [**8-30**], Hct was 21 and he was transfused with 2U RBC. BMs appeared bloody. He also experienced mental status changes and decreased movement of LLE. Head CT demonstrated no evidence of territorial infarction or hemorrhage. Of note on [**8-29**], LENIS were done for R>L leg swelling. No DVT was seen. On [**9-2**] PRBC were given for Hct of 23 with increase to 29 where he stabilized. Mental status improved. NG was removed. On [**9-4**], he was transferred out of the SICU. Diet was slowly advanced and TPN continued. Insulin drip was converted to Glargine and regular sliding scale. He experienced frequent non-bloody stools. Stool was sent for C.diff and was negative X2. A postpyloric feeding tube was placed on [**9-9**] for insufficient Kcals. Isosource 1.5 was started with goal of 50cc/hr identified by the Dietician. TPN was stopped on [**9-10**]. Insulin was adjusted. PT was consulted and worked with him daily initially noting orthostasis and patient complaints of dizziness. These signs and symptoms improved with improved mobility. PT recommended rehab due to deconditioning from long hospitalization. The day of discharge, patient is tolerating scant amounts of a regular diet and receiving tube feeds. Patient is alert and oriented. Midline incision is clean, dry, and intact with steri strips. Vital signs are stable. Insulin basal dose and sliding scale were adjusted to lantus 10 units in AM/ 18 units in PM. Patient is pending discharge to [**Hospital 3058**] rehab. Medications on Admission: CALCITONIN intranasally 200', CLOPIDOGREL [PLAVIX] 75', DOXERCALCIFEROL 0.5 mcg', LEFLUNOMIDE 40', LEVOTHYROXINE 100', OMEPRAZOLE 20', PREDNISONE 5', SERTRALINE 150', Bactrim', TACROLIMUS 2.5'', VALSARTAN 320', ASPIRIN 325', MULTIVITAMIN' Discharge Medications: 1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. insulin regular human Subcutaneous 5. doxercalciferol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. leflunomide 10 mg Tablet Sig: Four (4) Tablet PO daily (). Tablet(s) 7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-8**] Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 9. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 12. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 15. tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours): follow up drug levels for dose adjustment. 16. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: pancreatic/duodenal bleed partial SBO DM h/o renal transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You will be discharged to [**Hospital **] Rehab You will continue on the tube feeds and will have blood draws twice weekly Please call the Tranplant Office [**Telephone/Fax (1) 673**] if you have any of the warning signs listed below Followup Instructions: Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-9-20**] 1:30

[ "998.6", "511.9", "996.86", "E878.0", "585.6", "578.1", "997.1", "998.11", "996.81", "584.5", "250.40", "E878.4", "427.5", "276.3", "V58.67", "285.1", "V12.54", "785.59", "729.73", "427.31", "579.0", "403.91", "486" ]

icd9cm

[ [ [] ] ]

[ "99.15", "39.50", "96.6", "88.42", "45.13", "45.62", "99.60", "45.02", "38.93", "54.62", "00.40", "45.91", "39.79", "96.72", "88.47", "34.09", "38.86", "39.90", "33.24", "96.04", "00.45" ]

icd9pcs

[ [ [] ] ]

11348, 11431

4876, 9711

305, 775

11537, 11537

4055, 4853

11981, 12137

3503, 3540

10001, 11325

11452, 11516

9737, 9978

11720, 11958

2787, 3398

3555, 4036

249, 267

803, 2549

11552, 11696

2594, 2763

3414, 3487

2,343

124,053

50656

Discharge summary

report

Admission Date: [**2188-6-4**] Discharge Date: [**2188-6-18**] Date of Birth: [**2137-7-30**] Sex: M Service: MEDICINE Allergies: Penicillins / Inderal / Fentanyl / Abacavir Attending:[**First Name3 (LF) 297**] Chief Complaint: Reason for transfer to MICU: sepsis protocol, tachypnea Major Surgical or Invasive Procedure: Endotracheal intubation Central venous catheter placement History of Present Illness: This is a 50 year old male smoker w/last CD4 of 115, VL <15copies([**2188-4-24**]) from HIV, CAD h/o 7 MIs, antiphospholipid antibody syndrome who presented to the ED w/one week of increasing SOB and cough productive of yellow sputum, no blood. He reports that he has not taken PO X 2d [**3-13**] lack of desire. Reports recently went home to [**State 1727**] for [**Holiday **] with his family and several of his family members were recently hospitalized including his mother for a respiratory illness (she has lung ca). No known exposures to TB and no pets at home. No recent travel outside of the US. Patient has been adherent with his HAART therapy and bactrim and acyclovir ppx. He's been admitted to the hospital in the past for worsening shortness of breath and treated for asthma exacerbations. . In the ED, his VS were T101.5, HR122, BP106/55, RR26. His RR peaked at 40 and his BP hit low of 85/38. He was almost intubated, but instead sent to CTA, which revealed multifocal PNA, but no PE. His RR improved with nebulizers. He given solumedrol. . ROS: Denies fevers/chills, chest pain, palpitations, fevers/chills, diarrhea, dysuria/frequency. Past Medical History: 1. CAD s/p MI x 7 (1st in [**2171**]). x2 stents 2. FHx of premature CAD (1 brother with CABG at 43) 3. Antiphospholipid antibody syndrome 4. PE in '[**75**] on coumadin 5. H/O paroxysmal atrial fibrillation 6. HIV with CD4 115 on HAART, diagnosed in '[**75**] 7. COPD/asthma 8. Current smoker 9. Hemorrhoids 10. [**12-14**] PFTs FVC 84%; FEV1 49%; FEV1/FVC 58%; TLC 7.87, 105% DLCO moderately reduced, Social History: Retired, used to work in restaurant and accounting business. Smokes <1PPD currently has approx 160 pack year history. Occas ETOH and no IVDU/cocaine. Remote hx of marijuana use. No known occupational exposures including asbestos/silica/beryllium. Family History: Brother - CABG at age 43 Father - Deceased from anaphylactic reaction to bee-sting Mother - [**Name (NI) **] with lung cancer Physical Exam: 65.1kg VS: Temp 96.9 BP 110/45 HR 100 RR 23 O2 sat 95 50% cool neb FM GEN: breathing hard between sentences, cachectic, pleasant man HEENT: fat redistribution with hollow cheeks, mmm, OP clear no thrush, PERRL, EOMI, no palpable LAD CV: distant heart sounds, nl s1 s2 PULM: wheezes R>L, L crackles, use of excessory muscles of abdomen ABD: soft slightly distended, NT, BS EXT: nonedematous, clubbing hands, good pulses NEURO: AOx3, nonfocal SKIN: warm and dry Pertinent Results: Labs on admission: WBC-11.1*# RBC-3.13* Hgb-12.8* Hct-36.8* MCV-118* MCH-40.8* MCHC-34.7 RDW-15.5 Plt Ct-163 Neuts-88.0* Lymphs-6.2* Monos-5.6 Eos-0 Baso-0.1 Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-3+ Microcy-NORMAL Polychr-NORMAL PT-26.0* PTT-31.8 INR(PT)-2.6* D-Dimer-220 Fibrino-452* FDP-10-40 WBC-6.9 Lymph-2.9* Abs [**Last Name (un) **]-200 CD3%-56 Abs CD3-112* CD4%-11 Abs CD4-22* CD8%-44 Abs CD8-87* CD4/CD8-0.3* Glucose-130* UreaN-29* Creat-2.3*# Na-133 K-3.7 Cl-97 HCO3-16* AnGap-24* Calcium-6.9* Phos-3.9 Mg-1.8 Albumin-3.9 [**2188-6-4**] 03:00PM BLOOD CK(CPK)-2370* CK-MB-5 cTropnT-0.02* ALT-23 AST-69* LD(LDH)-429* CK(CPK)-4747* AlkPhos-54 Amylase-74 TotBili-0.2 [**2188-6-4**] 10:00PM BLOOD Lipase-27 Osmolal-294 Cortsol-29.3* Lactate-4.2* freeCa-1.22 URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005 Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 Hours-RANDOM UreaN-287 Na-86 Osmolal-313 URINE HISTOPLASMA ANTIGEN-PND PLEURAL FLUID WBC-[**2182**]* RBC-[**Numeric Identifier 65489**]* Polys-88* Lymphs-4* Monos-8* Microbiology: [**2188-6-6**] 9:07 am Rapid Respiratory Viral Screen & Culture POSITIVE FOR ADENOVIRUS VIRAL ANTIGEN. CULTURE CONFIRMATION PENDING. [**2188-6-6**] 9:07 am BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2188-6-6**]): 1+ POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final [**2188-6-6**]): PNEUMOCYSTIS CARINII NOT SEEN. FUNGAL CULTURE (Pending): VIRAL CULTURE (Pending): Imaging: [**6-4**] No evidence of PE. Bone windows unchanged, one healed right rib fracture. Multifocal pneumonia with likely reactive hilar lymphadenopathy. Stable right upper lobe nodule and bronchiectasis. . CXR ([**6-16**])Endotracheal tube remains in standard position. Nasogastric tube terminates in the stomach with side port near the GE junction level. Heart size is normal. There has been improvement in bilateral asymmetrical hazy areas of increased opacity with residual opacities predominantly in the lower lobes. Underlying emphysema is present. No pneumothorax is identified on this semi-upright radiograph. EKG - NSR 92, nl axis, PR&QRS intervals wnl, poor R wave progression, 0.5-1.0mm ST depression in V4-V5, q waves in II, III, AVF Brief Hospital Course: A/P: 50 M smoker w/last CD4 of 111 from HIV, CAD h/o 7 MIs, antiphospholipid antibody syndrome who presented to the ED w/one week of increasing SOB and cough productive of yellow sputum. . # Resp distress - Suspect inciting event combination of PCP/PNA, asthma and CHF, now with concern for developing ARDS given hypoxemia. Viral/legionella neg (cultures pending). Chest CT with multifocal PNA; started on IV bactrim & steroids for concern for PCP (esp given very low CD4 count). [**Name (NI) **], pt resisted BiPAP with tachypnea throughout day; abd he was intubated. Pt. had acidosis and continued to have bad gases throughout his stay. Multiple attempts to wean FiO2 not well-tolerated. CXR concerning for ARDS. Pt. was on ceftriaxone/azithromycin for empiric 1wk course . # hypotension/sepsis - Sepsis protocol activated on admission, but unable to get central line; has not needed pressors, however. Suspect pt hypovolemic on admission [**3-13**] poor PO intake. Likely still dehydrated from full day of tachypnea but careful with IVF given CHF. Pt. diuresed throughout stay. Once pt. was no longer febrile, he continued to have hypotension and require fluid boluses to maintain b.p. . # CAD/NSTEMI - h/o 7 MIs s/p stentx2. last ECHO [**12-14**] WMA inf/inflt hypokinesis/akinesis. LVEF ?30-35%, 1+MR/(1+), E/A ratio 0.73. Atypical CP overnight with ST changes in setting of tachycardia and tachypnea before intubation, troponin increased. On ASA and anticoagulation, given NTG for pain. Holding lipitor for slight increase in LFTs. Pt. continued on ASA. BB hard to give b/c of hypotension. . # Antiphospholipid antibody syndrome - goal INR is 3.5-4.0 as with APLA syndrome as well as a history of PE in the past ('[**75**]). Pt. was on a heparin drip and then coumadin . #. Acute renal failure- Creatinine 1.0 baseline and on admission. This improved w/ adequate fluid resuscitation. . #. AIDS/HIV - CD4 count 22, down from 115 ([**2188-4-24**]) - Cont HAART meds Epivir 150 [**Hospital1 **], Viread 300 QD, Sustiva 600 QHS, Zerit 30 [**Hospital1 **] - PPX Ayclovir 400 [**Hospital1 **] . # Anemia - stable; Hct threshold <28 given NSTEMI On [**6-18**], pt's family was contact[**Name (NI) **] and discussed the possibility of a PEG and trach given difficult wean. Family decided that pt. would not want this and it was decided that pt. would be made comfort care only. Pt. died of cardiopulmonary arrest shortly after this decision. Medications on Admission: Cardizem 150 tid Verapamil SR 240QD Lisinopril 7.5QD Lipitor 40mg QD Plavix 75 QD Coumadin 3.5-4QD Enteric ASA 325 QD Nitrostat .4qid Serax 15-30 QHS Protonix 40 [**Hospital1 **] centrum 1 QD Epivir 150 [**Hospital1 **] Viread 300 QD Sustiva 600 QHS Ayclovir 400 [**Hospital1 **] Bactrim DS 800/160 QD Zerit 30 [**Hospital1 **] Senakot 17.2 QD Theophylline ER 300 TID Albuterol IH 2 puffs TID Atrovent IH 2 puffs QID Flovent 2 puffs [**Hospital1 **] Discharge Medications: Pt. expired Discharge Disposition: Expired Discharge Diagnosis: Pt. expired Discharge Condition: Pt. expired Discharge Instructions: Pt. expired Followup Instructions: Pt. expired

[ "486", "V45.82", "799.02", "584.9", "493.20", "518.81", "995.91", "428.0", "038.9", "V10.11", "276.4", "305.1", "410.71", "042", "494.0", "276.51", "414.01" ]

icd9cm

[ [ [] ] ]

[ "38.91", "99.04", "93.90", "96.72", "96.04", "38.93", "33.24" ]

icd9pcs

[ [ [] ] ]

8444, 8453

5457, 7907

359, 419

8508, 8521

2939, 2944

8581, 8595

2311, 2439

8408, 8421

8474, 8487

7933, 8385

8545, 8558

2454, 2920

4421, 5434

263, 321

447, 1604

2958, 4383

1626, 2031

2047, 2295

60,274

150,804

42167

Discharge summary

report

Admission Date: [**2132-11-27**] Discharge Date: [**2132-12-17**] Date of Birth: [**2088-2-15**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 668**] Chief Complaint: Right Upper Quadrant pain Major Surgical or Invasive Procedure: [**2132-11-27**]: Exploratory Laparotomy with hematoma evacuation History of Present Illness: This is a 44 yo lady well known to the transplant surgery service with ESLD from PSC who is s/p OLT on [**2132-11-11**]. She had been discharged to rehab the previous day and was doing well until this morning when she started experiencing RUQ pain accompained by nausea and vomiting after her HD session. She denies fevers or chills, reports somewhat decreased output from her ostomy. No blood in her stool. Denies chest pain but reports mild shortness of breath which she attributes to her severe abdominal pain. Reports a feeling of urinary urgency and lower abdominal fullness although she is making minimal urine at his time. At the time of consultation she looks uncomfortable and is reluctant to be examined. She exhibits voluntary guarding and every movement of the bed causes her great pain. Past Medical History: -UC s/p total colectomy in [**2129**] -PSC diagnosed in [**2111**] -cirrhosis diagnosed in [**2129**] (c/b jaundice and ascites) -CML on gleevac (since [**2127**]) -foot fracture s/p surgery -deaf in R Social History: Prior to liver transplant, Ms. [**Known lastname 91442**] was independent with her ADLs. Currently in rehab s/p liver transplant. She is a stay at home mom that is fully functioning and active with her two teenage children, a 13 year old son and a 15 year old daughter. She and her husband recently relocated to RI from PA for her husband's job. Pt denies any substance use or abuse history, including: smoking, alcohol, marijuana, or any other illicit drugs. She has a degree in business from CAL State and worked as an account manager for an HMO prior to having children. Import Social History Family History: Father (and likely son) - ulcerative colitis; grandmother died of CHF; DM II in all 4 grandparents, mother with htn, mom, brother, daughter with asthma Physical Exam: Vitals: Temp: 99.5 HR: 124 BP: 154/100 Resp: 22 O(2)Sat: 100 RA GEN: A&O, visibly uncomfortable HEENT: scleral icterus and jaundice CV: RRR, No M/G/R PULM: slightly decreased breath sounds at b/l lung bases. No wheezing, ronchi or rales ABD: Soft, mildly distended, exquisitely tender to palpation diffusely, more in the RUQ. Surgical incision with staples in place, c/d/i, minimal erythema Ext: mild peripheral edema. Pertinent Results: On Admission [**2132-11-26**] WBC-27.9*# RBC-3.68* Hgb-10.6* Hct-32.9* MCV-89 MCH-28.8 MCHC-32.3 RDW-16.1* Plt Ct-224 Neuts-95.4* Lymphs-2.6* Monos-1.0* Eos-0.6 Baso-0.4 PT-12.6* PTT-26.1 INR(PT)-1.2* Glucose-164* UreaN-32* Creat-3.0* Na-135 K-4.8 Cl-93* HCO3-27 AnGap-20 ALT-24 AST-32 AlkPhos-210* TotBili-5.5* [**2132-11-26**] 07:21PM BLOOD Lipase-55 Calcium-9.5 Phos-2.7 Mg-2.1 tacroFK-9.6 Brief Hospital Course: 44 y/o female discharged previous day after prolonged hospitalization following liver transplant who returns with significant abdominal pain. A duplex of the liver obtained on admission shows an expanding hematoma adjacent to the liver, which was measured approximately 17 x 17 x 9 cm in size. She was taken to the OR on [**2132-11-27**] by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who performed an exlap and evacuation of old hematoma with approximately 2.5 liters of old blood evacuated from the abdomen. There was no evidence of active extravasation. A liver biopsy was also obtained at the time of this surgery. The biopsy results were consistent with mild acute cellular rejection. Prograf levels were increased and no other treatment was done. On [**12-7**] the patient was noted to have increasing shortness of breath and chest xray revealed large right pleural effusion collapsing the lower half of the right lung and shifting the mediastinum to the left> Although this finding was relatively stable from previous chest xrays, her symptoms warranted a pleural aspiration. 1.4 liters of fluid were aspirated from the right hemithorax, she tolerated the procedure without complication. Symptoms have since improved, however the right pleural effusion has remained consistent in size. She does not have an oxygen requirement. On [**12-11**] the patient developed significant nausea with vomiting and complaint of chest tightness. CK/Troponins were negative, however despite not having fever, blood cultures were obtained and grew out Vanco resistant enterococcus and E coli. She was initially started on Zosyn but was switched to Ceftriaxone and Dapto once the sensitivities were returned. Further surveillance cultures after the 6th have all been negative to date. Regarding the patients acute kidney injury, her last hemodialysis session was [**2132-12-6**]. The creatinine has improved to 1.5 by day of discharge. The dialysis line has been removed, edema is minimal. Patient has also been noted to have a very weak voice, since time of transplant. She initially underwent video stroboscopy which showed a complete immobility of the right vocal cord.In office attempt was made to inject the vocal cord, however the patient was unable to tolerate and on [**12-10**] she went to the OR for microsuspension laryngoscopy with operating microscope; right vocal fold injection with Radiesse Voice gel. Afetr some voice rest, her voice has become stronger. She was evaluated by speech and swallow after the procedure with a video swallow study, and there is still slight aspiration risk and she has been ordered for Mechanical soft diet with Thin liquids. This can be re-evaluated as appropriate. Patient has a waxing/[**Doctor Last Name 688**] but persistent complaint of nausea, relieved by zofran. She is ambulatory with a [**Last Name (LF) **], [**First Name3 (LF) **] continue tube feeds and has a PICC line in place to complete antibiotic course. Medications on Admission: prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 4. insulin regular human 100 unit/mL Solution Sig: follow sliding scale units Injection ASDIR (AS DIRECTED). 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection [**Hospital1 **] (2 times a day). 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. ursodiol 250 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (MO,TH). 10. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Discharge Medications: 1. insulin regular human 100 unit/mL Solution Sig: per sliding scale Injection every six (6) hours. 2. fluconazole 40 mg/mL Suspension for Reconstitution Sig: One (1) PO Q24H (every 24 hours). 3. B-complex with vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension Sig: Ten (10) ML PO DAILY (Daily). 5. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO every eight (8) hours as needed for pain: maximum 2 grams daily. 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): per transplant clinic taper . 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. mycophenolate mofetil 200 mg/mL Suspension for Reconstitution Sig: Five Hundred (500) mg PO TID (3 times a day). 10. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. tacrolimus 1 mg Capsule Sig: Seven (7) Capsule PO Q12H (every 12 hours). 13. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea: may increase prn. 14. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: Two (2) grams Intravenous Q24H (every 24 hours) for 10 days: Through [**2132-12-26**]. 15. daptomycin 500 mg Recon Soln Sig: Three Hundred (300) mg Intravenous Q24H (every 24 hours) for 12 days: Through [**2132-12-29**]. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Abdominal hematoma Right vocal fold paralysis and dysphonia. Bacteremia Acute kidney injury; resolving (off hemodialysis) Malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid ([**Location (un) **] or cane). Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] if the patient develops fever > 101, chills, increased cough, nausea, vomiting, increased stool output in ostomy bag, lack of stool output, increased abdominal pain, inability to tolerate food, fluids or medications, incisional redness or drainage (staples have been removed) or any other concerning symptoms. Patient should continue on twice weekly lab draws, every Monday and Thursday with results faxed to the transplant clinic at [**Telephone/Fax (1) 697**]. Continue tube feeds as ordered and see dietary restrictions. Continue antibiotics via PICC line No heavy lifting Patient may shower, no tub baths or swimming Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2132-12-24**] 9:40, [**Hospital **] Medical Office Building, [**Location (un) **], [**Last Name (NamePattern1) **], [**Location (un) 86**], MA Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2132-12-31**] 10:20 Completed by:[**2132-12-17**]

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icd9cm

[ [ [] ] ]

[ "50.11", "99.29", "34.91", "96.6", "38.93", "39.95", "38.97", "31.42", "54.25", "31.0", "54.12" ]

icd9pcs

[ [ [] ] ]

8935, 9005

3108, 6093

330, 397

9184, 9184

2691, 3085

10092, 10593

2083, 2236

7306, 8912

9026, 9163

6120, 7283

9381, 10069

2251, 2672

265, 292

425, 1227

9199, 9357

1249, 1453

1469, 2067

31,036

180,690

34240

Discharge summary

report

Admission Date: [**2108-4-26**] Discharge Date: [**2108-5-2**] Date of Birth: [**2091-5-25**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p Mulitple stab wound assault to chest abdomen and extremities with shock Major Surgical or Invasive Procedure: [**2108-4-26**] Exploratory lapararotomy, left chest tube insertion, repair of left diaphragm, pericardial window, exploratory sternotomy & suture right atrium, irrigation/suture/closure of multiple complex soft tissue injuries. History of Present Illness: 16 yo female who was reportedly assaulted with a butcher knife. She sustained multiple lacerations of the chest, abdomen, back and extremities. She was taken to an area hospital where she was intubated. A left chest tube was placed. She was then transferred to [**Hospital1 18**] via Med Flight for further care. She was hypotensive en route to [**Hospital1 18**]; upon arrival during the initial assessment the FAST suggested fluid in the pericardium but because of marked obesity and relative stability, there was also concern for the FAST being a false positive. Fluids were therefore administered judiciously with a targeted SBP of 80 mmHg and the patient remained stable enough for transport to the OR. She was brought up to the OR emergently for further resuscitation, TEE and definitive repair of her injuries. Past Medical History: Unknown Social History: Lives with her mother Family History: Noncontrbutory Pertinent Results: Upon admission: [**2108-4-26**] 05:36PM TYPE-ART PO2-155* PCO2-40 PH-7.41 TOTAL CO2-26 BASE XS-1 [**2108-4-26**] 04:47AM GLUCOSE-130* UREA N-8 CREAT-0.6 SODIUM-140 POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-22 ANION GAP-14 [**2108-4-26**] 04:47AM CK(CPK)-1051* [**2108-4-26**] 04:47AM CK-MB-16* MB INDX-1.5 cTropnT-0.07* [**2108-4-26**] 04:47AM CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-1.3* [**2108-4-26**] 04:47AM WBC-11.3* RBC-4.26# HGB-13.2# HCT-38.0# MCV-89 MCH-31.0 MCHC-34.8 RDW-14.2 [**2108-4-26**] 04:47AM PLT COUNT-197 [**2108-4-26**] 04:47AM PT-13.5* PTT-30.9 INR(PT)-1.2* [**2108-4-26**] 12:35AM WBC-14.4* RBC-2.26*# HGB-7.3*# HCT-20.8*# MCV-92 MCH-32.3* MCHC-35.0 RDW-13.5 [**2108-4-26**] 12:35AM PLT COUNT-255 [**2108-4-26**] 12:35AM PT-14.6* PTT-32.3 INR(PT)-1.3* [**2108-4-26**] 12:35AM FIBRINOGE-192 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT (Complete) Done [**2108-4-26**] at 2:31:14 AM FINAL Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.2 cm Left Ventricle - Fractional Shortening: 0.43 >= 0.29 Pericardium - Effusion Size: 0.9 cm Findings 16 years old with multiple stab wounds, stab wound to the chest. Cxray with enlarged cardiac shadow. On echo examination there is 0.9cm pericardial effusion around the R artium. On trangastric view the effusion is around the R and L ventricle and is 2cm in size with thick echogenic filamentous clot floating in the pericardial cavity. No tamponade physiology around the atrium and right ventricle. Hyperdynamic L ventricle. Rest of the examination within normal limits. LEFT ATRIUM: Normal LA size. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Overall normal LVEF (>55%). Transmitral Doppler and TVI c/w normal LV diastolic function. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Nl interventricular septal motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Normal descending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Small pericardial effusion. No echocardiographic signs of tamponade. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is normal in size. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with normal LV diastolic function. Right ventricular chamber size and free wall motion are normal. Interventricular septal motion is normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. CHEST (PA & LAT) [**2108-5-1**] 11:07 AM FINDINGS: In comparison with the study of [**4-30**], there is poor definition of the pulmonary vessels, suggesting some overhydration. Extensive opacification of the left base is consistent with some combination of atelectasis, pneumonia, and pleural effusion. No convincing evidence of pneumothorax at this time. Brief Hospital Course: She was admitted to the Trauma Service and taken directly to the operating room for exploration and repair of her injuries. Thoracics was consulted intraoperatively due to the cardiac wound. The patient required crystalloids, platelets and multiple units of packed red cells during the operation. Postoperatively she was taken to the Trauma ICU where she remained intubated for several days. She manifested some congestive failure due to her massive resuscitation that responded to diuresis. She was eventually weaned and extubated and was transferred to the regular nursing unit. Social work was involved; initially providing support to family during the acute phase and then once patient was extubated the Center for Violence Prevention and Recovery were consulted. Patient and her mother were provided with information pertaining to counseling post hospitalization. Psychiatry was also consulted for concerns related to later development os PTSD. Their recommendations at the time were to monitor for signs of insomnia, agitation and hypervigilance and to prescribe low dose Ativan prn for this. She was discharged to home with instructions for follow up. An appointment had already been made by her mother for outpatient counseling for the week of discharge. Medications on Admission: Unknown Discharge Medications: 1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*80 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 4. Povidone-Iodine 10 % Solution Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*500 ML's* Refills:*0* 5. Ambien 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: s/p Multiple stab wound assault to chest, abdomen, back, extremities. Right atrial injury Multiple soft tissue injuries chest, abdomen, back, extremities. Acute blood loss anemia Discharge Condition: Good Discharge Instructions: Return to the Emergency room if you develop any fevers, chills, headache, dizziness, chest pain, shortness of breath, productive cough, increased redness/drainage from your incisions/wounds, abdominal pain, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. Clean the top section of your chest with the betadine solution and cover with a damp betadine 2x2 gauze and secure with tape. Followup Instructions: Follow up next Tuesday in clinic with Dr. [**Last Name (STitle) **] to have your staples removed, call [**Telephone/Fax (1) 6429**] for an appointment. Follow up next week with Dr. [**Last Name (STitle) 78851**], Thoracics [**Telephone/Fax (1) 170**] for an appointment. Follow up with your primary care doctor in the next 1-2 weeks for a general physical. Completed by:[**2108-5-9**]

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icd9cm

[ [ [] ] ]

[ "54.11", "37.12", "77.31", "34.04", "83.65", "37.49", "86.59", "34.82", "96.71" ]

icd9pcs

[ [ [] ] ]

7607, 7613

5651, 6917

346, 577

7836, 7843

1546, 1548

8306, 8695

1511, 1527

6975, 7584

7634, 7815

6943, 6952

7867, 8283

4493, 5628

231, 308

605, 1425

1562, 4447

1447, 1456

1472, 1495

65,219

182,497

37690

Discharge summary

report

Admission Date: [**2104-5-20**] Discharge Date: [**2104-5-29**] Date of Birth: [**2030-6-26**] Sex: F Service: MEDICINE Allergies: Quinine Sulfate / Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending:[**First Name3 (LF) 4980**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: diagnostic paracentesis History of Present Illness: 73 with history of HTN, Type 2 DM, recent recurrent cholecystitis non-operatively managed, newly diagnosed cirrhosis c/b ascites transferred from [**Hospital 671**] [**Hospital 4094**] Hospital to [**Hospital1 18**] for abdominal pain. Patient has had recent admissions for RUQ abdominal pain, diagnosed with cholecystitis, non-operatively managed due to poor surgical candidate. Most recently, she was discharged from [**Hospital3 3583**] on [**2104-5-13**] after treatment for LLL pneumonia. She was transferred to [**Hospital 671**] [**Hospital 4094**] Hospital. Per her son, he was notified that she had decreased PO intake, no stooling. On day prior to admission, patient was found to have abdominal pain, KUB at that time showed possible early SBO. Due to worsening pain, she was transferred to [**Hospital1 18**] for further evaluation. In the ED, initial vitals were 96F 126/84 60 16 99%RA. She underwent CT abdomen and pelvis that showed small bowel distention and mild dilation with air-fluid levels and possible point of subtle caliber transition in the right lower quadrant, ascites, no free air. Surgery was consulted and recommended CT with contrast to rule out ischemia. CT with contrast showed small bowel/colonic wall thickening/edema, likely secondary to third spacing. Slight terminal ileal hyperemia in the right lower quadrant could indicate infectious or inflammatory process. She was given Zosyn empirically. Patient developed transient hypotension to systolic 70's, resuscitated wtih 4L IVF. At that time, diagnostic para was done and she recieved IV Ceftriaxone. Right Groin line placed. She was transferred to the ICU for hypotension. On arrival, she is uncomfortable with pain, unable to articulate her exact symptoms. Past Medical History: 1. Fibromyalgia. 2. CVA [**2099**] 3. HL 4. Coronary artery disease with an LAD stent [**4-7**] 5. Congestive heart failure. 6. Hypertension. 7. Bradycardia. 8. Type 2 diabetes on insulin and metformin 9. History of thyroid cancer s/p thyroidectomy [**2091**] 10. Spinal stenosis 11. Depression with prior hospitalizations 12. E. coli septicemia in [**2101**] 13. [**2103-5-3**] Bilateral renal lesions on MRI suspicious for renal cell carcinoma 14. radiographic evidence of cirrhosis, seen on recent CT scan and MRI ([**10-11**]) 15. Pancytopenia 16. +[**Doctor First Name **] 17. Oophorectomy. She still has one ovary remaining. 18. Hysterectomy secondary to fibroids. 19. s/p laminectomy [**2056**] Social History: She is divorced. In [**10-10**] she moved to [**Location (un) 86**] to live with her son [**Name (NI) **] in [**Name (NI) 392**]. She recently has been living at Harbour House in [**Location (un) 5087**] where she is dependent for all of her ADL's except eating. She is [**Doctor Last Name **] lift dependent. She was an administrative assistant for a technical editor to a biotech research and development firm and also worked in the IRS. She retired at age 70. She never smoke or drank alcohol. HCP: [**Name (NI) 122**] [**Name (NI) **] [**2104**] Family History: Father who died of complication of diabetes at age 50. Mother died of a stroke at age 67 and had a MI at age 65. Brother with [**Name (NI) 5895**] disease and bladder cancer. Sister [**Name (NI) 2048**] is diabetic and hypertensive. Physical Exam: VS: Temp: 95.5 BP: 107/56 HR: 85 RR: 15 O2sat: 99%RA GEN: lying in bed, intermittantly moving in pain HEENT: dry mucous membranes, EOMI, no scleral icterus, poor dentition, JVD not elevated RESP: Decreased BS L>R at bases, upper lung [**Last Name (un) 8434**] clear CV: RR, S1 and S2 wnl, no m/r/g ABD: distended with non-tense ascites, no bowel sounds appreciated, tenderness to deep palpation, minimal rebound tenderness. When distracted, pain response not as great. EXT: dependent pitting edema. bilateral DP pulses by doppler. no cyanosis. right fem line in place, gauze surrounding. SKIN: no jaundice, multiple ecchymoses on bilateral arms in various stages of healing. NEURO: alert, oriented to self. spontaneously moves all 4 extremities. trace asterexis. Pertinent Results: [**2104-5-20**] 12:10PM BLOOD WBC-4.1# RBC-3.44* Hgb-11.9* Hct-36.9 MCV-107*# MCH-34.5*# MCHC-32.2 RDW-19.7* Plt Ct-66* [**2104-5-20**] 11:30PM BLOOD WBC-1.7*# RBC-2.51*# Hgb-8.7*# Hct-26.7*# MCV-107* MCH-34.5* MCHC-32.4 RDW-19.6* Plt Ct-37* [**2104-5-20**] 11:50PM BLOOD WBC-1.9* RBC-2.59* Hgb-9.3* Hct-27.3* MCV-105* MCH-35.8* MCHC-34.0 RDW-19.4* Plt Ct-39* [**2104-5-20**] 11:30PM BLOOD PT-21.7* PTT-150* INR(PT)-2.0* [**2104-5-20**] 12:10PM BLOOD Glucose-152* UreaN-20 Creat-1.0 Na-153* K-3.7 Cl-118* HCO3-25 AnGap-14 [**2104-5-21**] 01:10AM BLOOD Glucose-90 UreaN-19 Creat-0.9 Na-154* K-3.5 Cl-122* HCO3-23 AnGap-13 [**2104-5-20**] 12:10PM BLOOD ALT-16 AST-41* AlkPhos-333* TotBili-1.5 [**2104-5-21**] 01:10AM BLOOD ALT-14 AST-31 AlkPhos-253* TotBili-1.3 [**2104-5-21**] 01:10AM BLOOD Calcium-7.4* Phos-2.2* Mg-1.8 [**2104-5-21**] 06:04AM BLOOD Calcium-7.2* Phos-2.1* Mg-1.7 [**2104-5-20**] 12:15PM BLOOD Lactate-2.6* K-3.7 [**2104-5-21**] 12:08PM BLOOD Lactate-1.8 [**2104-5-20**] 10:50PM ASCITES WBC-51* RBC-6083* Polys-3* Lymphs-16* Monos-0 Mesothe-6* Macroph-75* [**2104-5-20**] 10:50PM ASCITES TotPro-1.4 Glucose-113 1. Multifocal small bowel and colonic wall thickening and edema, most likely related to third spacing and low protein state secondary to cirrhosis. Mild hyperemia of the terminal ileum could be seen in the setting of infection or inflammation with ischemia considered less likely. 2. Cirrhosis with splenomegaly and ascites. 3. Moderate bilateral pleural effusions. Brief Hospital Course: ICU Course: 73 female with history of cirrhosis, pancytopenia/presumed MDS, medically managed cholecystitis, recent LLL pna admitted for abdominal pain and hypotension. 1. Hypotension - Treated empirically with antibiotcis to cover intraabdominal source. Responded to IVF. Held diuretics/anti-hypertensives. Morning cortisol 23 ruling out adrenal insufficiency. 2. Abdominal Pain - Initial concern for SBO based on OSH radiology. Seen by surgery. They were not concerned for SBO. CT with contrast showed hyperemic bowel. Lactate of 2.6--> not consistent with ischemic bowel or perforation. Passing flatus and small amounts of stool. 3. Pleural Effusions - Bilateral, found on CT. Recent treatment for LLL PNA at [**Hospital3 **]. No tachypnea, on room air with good O2 saturations. Diff includes hepatic hydrothorax, parapneumonic effusion, CHF, effusion related to thyroid disease. 4. Hypernatremia - 154 on arrival to floor, concern for decreased Po in rehab hospital. Also hyperchloremic, which may correlate. Free water deficit 2.7L. Given D5 but held after sodium dropped 154-149. 5. Cirrhosis - Hepatitis serlogy, anti-smooth muscle, anca all negative in late [**2103**]. + AScites, para negative for SBP. Restarted lactulose. Held diuretics. Will need outpatient liver follow-up. 6. Coagulopathy - likely [**3-5**] underlying liver disease. Fibrinogen normal. Trended. 7. Elevated Alkaline Phosphatase - trending down, monitor. While has chronic elevation, if this presentation was from cholecystitis, would expect acute change. 8. Pancytopenia - Long-standing, concern for MDS. Repeat labs in ED with acute drop in all cell lines in setting of IVF resuscitation. Emailed heme-onc to comment on bone marrow. 9. UTI - on cefepime 10. history of VTach - continued amiodarone 11. Hypothyroidism - continued Levothyroxine 175mcg/day, checked TSH/FT4. 12. GERD - continued PPI. 13. Depression - continued zoloft 50 mg daily . 14: Multiple medical problems/several re-admissions: Following discussion with HCP and PCP and overall unclear diagnosis but subsequent decline and several admissions consulted palliative care. . Medical Floor Course: Ms. [**Known lastname **] was transferred to the regular medical floor from the ICU. Her blood pressure was stable, but it was clear to the medical team that she would not recover from her complicated illness. A family meeting was held prior to transfer, and her code status was changed to DNR/DNI keeping with the wishes of her health care proxy and son, Mr. [**First Name8 (NamePattern2) **] [**Known lastname **]. Two days passed without improvement in her condition. During this time, the management that had been initiated in the ICU, including antibiotics, were continued. Another family meeting was held, resulting in the decision to apply comfort focused care. Initially, a concentrated morphine elixir was administered. This resulted in copious vomiting. The morphine was administered subcutaneously with a patient controlled analgesic device, which had to be operated by the nursing staff. Ms. [**Known lastname **] looked comfortable after this intervention. Her other son was also able to visit her. She expired on [**2104-5-29**] at 7:02 AM. A death note was written by hand in the chart, a death report was filed, the PCP and in house attending were notified, and the family was notified. The HCP declined autopsy. Medications on Admission: Potassium chloride 20 mEq daily Furosemide 40 mg daily Lactulose 20 gram [**Hospital1 **] Prilosec 20 mg daily Magnesium Oxide 400 mg [**Hospital1 **] Folic Acid 1 mg daily Aspirin 81 mg daily Ferrous Sulfate 325 mg daily Amiodarone 200 mg daily Docusate 100 mg [**Hospital1 **] Zoloft 50 mg daily Lisinopril 5 mg daily Albuterol nebulizer QID Levothyroxine 175 mcg daily Levaquin 500 mg daily ([**Date range (1) **]) Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2104-5-31**]

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icd9cm

[ [ [] ] ]

[ "38.93", "54.91" ]

icd9pcs

[ [ [] ] ]

9894, 9903

6006, 9393

339, 364

9954, 9963

4486, 5983

10019, 10057

3450, 3687

9862, 9871

9924, 9933

9419, 9839

9987, 9996

3702, 4467

285, 301

392, 2140

2162, 2866

2882, 3434

735

140,547

7944

Discharge summary

report

Admission Date: [**2128-5-24**] Discharge Date: [**2128-6-10**] Date of Birth: [**2068-3-6**] Sex: F Service: MEDICINE Allergies: Latex / Lisinopril Attending:[**First Name3 (LF) 3016**] Chief Complaint: Left Femur Fracture Major Surgical or Invasive Procedure: Left distal femur ORIF History of Present Illness: 60 yo female with history of PAF, HL, hypothyroidism, HTN and metastatic renal cell carcinoma s/p chemo/XRT, R nephrectomy [**2120**], adrenalextomy [**2122**], T11-L1 lami/tumor resection/T9-L2 fusion who presented with new L distal [**1-25**] femur fracture upon standing up and is now s/p ORIF on [**2128-5-25**]. Patient was noted to be in afib with RVR in the OR and was started on neo gtt. She remained in the PACU for >24 hr and subsequently spontaneously converted to NSR and was able to be weaned off the neo gtt. She was then transferred to the floor but after arriving on the floor the she went back in afib with RVR and had hypotension down to SBP 80s. She was given Lopressor 5 mg x 1 without good effect and a cards consult was obtained. Cardiology recommended resuming home BB when able, pain control and digoxin if BP could tolerate. She was dig loaded but continued to be hemodynamically unstable and was transferred to SICU. . In the SICU, she was treated with metoprolol, her dig was discontinued and she converted to NSR. She has had issues with pain control and has been noted to be delirious at times but mostly AOx3. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Metastatic Renal Cell Carcinoma (s/p surgery/XRT/chemo) Paroxysmal AF HTN Hypothyroidism Dyslipidemia Right nephretomy [**2120**] Adrenalectomy [**2122**] Left knee surgery [**2121**] Tonsillectomy and Adenoidectomy Polypectomies Social History: -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: Noncontributory Physical Exam: VS: T= 98.1, BP=118/70, HR=95, RR=22, O2 sat=100% 3L NC GENERAL: 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 *** cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. . Pertinent Results: Imaging . [**2128-5-24**] Femur Film IMPRESSION: Distal femur diaphyseal fracture. . [**2128-5-24**] Chest Xray IMPRESSION: Unchanged bilateral pulmonary metastases. No acute process identified. . [**2128-5-25**] Left femoral reamings 1. Fragments of bone and bone marrow with maturing trilineage hematopiesis, no evidence of malignancy; multiple levels are examined, see note. 2. Fibroadipose tissue and skeletal muscle. . [**2128-5-25**] Intraop Films 28 spot fluoroscopic images were obtained intraoperatively without the presence of a radiologist. Flouro time recorded as 533.1 s on the electronic requisition. Views demonstrate steps related to fixation of a distal femoral shaft fracture. FCorrelaiton with real-time findings and,when appropriate, conventional radiographs is recommended for full assessment. . [**2128-5-28**] CTA Chest IMPRESSION: 1. No evidence of pulmonary embolism. 2. Interval progression of metastatic disease since [**2128-5-4**] with increase in the size and number of metastatic foci. 3. Interval development of pulmonary edema and small bilateral pleural effusion. . [**2128-5-29**] Femur Right The film is listed as two views of the femur. However, the study consists of a single view of the femur and a single view of the right lower extremity. The right hip and proximal femoral neck are not well evaluated on this scan. No acute fracture is detected on this limited exam. No suspicious lytic or sclerotic lesions are detected. Some non-aggressive periosteal new bone seen in the proximal tibial diaphysis medially likely relates to a muscle insertion site. However, if this corresponds to the site of symptoms, then conventional AP and lateral views of the right lower extremity or alternatively an MRI scan would be recommended for further assessment. There are degenerative changes of the right knee. . [**2128-6-7**] Bilateral LENIs: There is nonocclusive thrombus of some age in one of the left posterior tibial veins. The other deep veins of the lower extremities show no ultrasound evidence of deep venous thrombosis. Brief Hospital Course: Ms. [**Known lastname 26818**] is a 60 year old woman with metastatic renal cell carcinoma. She underwent an ORIF on [**2128-5-25**]. Her post-operative course was complicated by atrial fibrillation with RVR and hypotension. . # DVT: Patient was found on LENI to have left posterior tibial vein deep vein thrombosis. It was unclear how long the blood clot had been there (chronic or new). Patient was started on Lovenox (therapeutic dosing) and given her hemoptysis, closely monitored. Patient did not have any issues with increased bleeding on Lovenox. - Continue Lovenox 110mcg q12 daily . # Hemoptysis: On [**6-3**] and [**6-5**] Ms. [**Known lastname 26818**] had an episode of hemoptysis. Each episode was approximately 1 teaspoon. Pulmonary was consulted who felt this was likely related to known pulmonary metastatic disease in the presence of lovenox for DVT prophylaxis. Patient did benefit from 2L nasal cannula at night, more for OSA. Ultimately, patient's lovenox had to be increased to therapeutic doses given her left lower extremity DVT. She did not have any hemoptysis for >48 hours, however, prior to discharge - with close supervision. - Continue 2L nasal cannula at night, room air during the day - Continue Lovenox at DVT treatment dosing . #. s/p left ORIF: She underwent a ORIF. She was started on enoxaparin post-operatively. She worked with physical therapy. - Patient has follow-up appointment in Orthopedic Surgery Clinic on [**7-1**] at 10:40am (for [**Month (only) 1957**] Xrays on [**Hospital Ward Name 23**] 2nd fl) and 11am (w/ [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP) - Please encourage patient to continue working with physical therapy. She should get extra pain medications as needed prior/during work with physical therapy. . # Pain Control: The pain service was consulted to help manage Ms. [**Known lastname 28510**] pain. She was started on nortriptyline and increased morphine. Nortriptyline was eventually stopped given some concerns for tremor and weakness in her upper extremities. Patient was started on gabapentin, MS Contin (titrated up to 90mg TID) and lidocaine patches with control of her pain. - Continue Morphine Sulfate IR 15-30mg every 4 hours for breakthrough pain - Continue MS Contin 90mg TID for ongoing pain (can decrease to 90/60/90mg if overly sedated) - Continue gabapentin and lidocaine patches - the latter has been particularly helpful in controlling patient's pain . #. Atrial fibrillation: Her post-operative course was complicated by atrial fibrillation with RVR and hypotension. She required care in the SICU. Cardiology was consulted. She was loaded with digoxin and converted into a regular rate. She maintained a regular rate throughout the rest of the hospitalization. She was placed on metoprolol TID. - Continue current metoprolol TID dose . #. Delirium: Post-op course complicated by delirium. This resolved outside of the ICU. - Continue lorazepam PRN for anxiety and before bed to help with sleep . #. Metastatic renal cell: Ms. [**Known lastname 26818**] is s/p nephrectomy/adrenalectomy, spinal tumor resection/T9-L2 fusion, and left ORIF on [**2128-5-25**]. A family meeting was held on [**6-4**] which discussed her treatement plans. She will restart her Sutent after allowing a couple of weeks for her fracture to heal. Patient does also have a number of metastasis to her skin (left flank purplish nodules), confirmed by biopsy pathology reports. . # Hypothyroidism: Continue home dose of levothyroxine. . # Skin Nodules: Per review of path reports, she has nodules on her back which were consistent with known metastatic disease. . # Oxygen Saturation: Desaturates slightly when sleeping. Likely due to obstructive sleep apnea. - Continue 2L nasal cannula when sleeping - Continue incentive spirometry, mobilization, and avoid increasing sedating meds. . CODE: Ms. [**Known lastname 26818**] is full code. Medications on Admission: Lopressor 25 qAM/50 qPM ASA 325 QD Gabapentin 800 mg TID Levothyroxine 200 mcg QD Lorazepam 2mg QHS MS Contin 60 mg Q12 MS IR 15-30 mg Q4 Nystation cream Omeprazole 20 mg [**Hospital1 **] Prochlorperazine 10 mg Q8 prn nausea Extra strength tylenol Q6 prn pain Fish oil Ibuprofen 400 mg [**Hospital1 **] Methylsulfonylmethane 1 gram QD Miralax Pyridoxine 100 mg QD Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 4. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily). 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) for 5 days. 8. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: Please use for increased pain with movement. Be sparing during the evenings. Hold for sedation, RR<12. 10. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash on bilateral thighs and groin. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea/vomiting. 17. MS Contin 30 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO three times a day. 18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Three (3) Adhesive Patch, Medicated Topical DAILY (Daily): Please keep ON 12 hours, OFF 12 hours. One for sacrum, one for hip, one for knee. 19. Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL Mouthwash Sig: 15-30 mL Mucous membrane four times a day as needed for oral pain: Swish and spit. 20. Lovenox 80 mg/0.8 mL Syringe Sig: One [**Age over 90 881**]y (160) mg Subcutaneous once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary Diagnosis: Metastatic Renal Cell Cancer Left distal femur fracture. Hemoptysis 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: Thank you for allowing us to take part in your care. You were admitted to the hospital after a fracture of your left femur. You had a surgery to repair the fracture. Your post-operative course was complicated by an irregular rhythm which has now resolved. Your post-operative pain is also being controlled with a specific medication regimen. You were also found to have a blood clot in your left leg, so you were started on blood thinners. You were discharged to a rehab facility. . We made several changes to your medications. The important ones are as follows: We STARTED Lovenox injections for the blood clot We STARTED Morphine Intermediate Release as needed for breakthrough pain and MS Contin for ongoing pain We STARTED Lidocaine patches for pain control We STOPPED nortriptyline because of tremors/weakness. We STOPPED ibuprofen. We STOPPED fish oil. We STOPPED methylsulfonylmethane. We CHANGED acetaminophen. We CHANGED your dosing of metoprolol to better control your irregular heart rate. Followup Instructions: Please follow up with the Orthopedics Department. You have an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP on Thursday, [**7-1**] at 11am. You are to get x-rays PRIOR to the appointment at 10:40. Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2128-7-1**] 10:40 Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2128-7-1**] 11:00 . Please follow up with Dr. [**Last Name (STitle) **] once you are discharged from rehab. If you are in rehab longer than two weeks, please call his office for an appointment. His office will also check-in with the Rehab Facility weekly on your discharge progress. You can reach Dr.[**Name (NI) 28511**] office at ([**Telephone/Fax (1) 1300**]. [**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]

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icd9cm

[ [ [] ] ]

[ "79.35", "38.91" ]

icd9pcs

[ [ [] ] ]

11591, 11661

5112, 9033

298, 323

11792, 11792

3024, 5089

13000, 13970

2235, 2252

9448, 11568

11682, 11682

9059, 9425

11975, 12977

2267, 3005

239, 260

1511, 1891

351, 1493

11701, 11771

11807, 11951

1913, 2145

2161, 2219

7,095

191,813

8298

Discharge summary

report

Admission Date: [**2201-7-13**] Discharge Date: [**2201-7-24**] Date of Birth: [**2123-7-21**] Sex: M Service: SURGERY Allergies: Cefazolin Attending:[**First Name3 (LF) 4748**] Chief Complaint: Left lower extremity pain; left lower extremity gangrene Major Surgical or Invasive Procedure: [**2201-7-14**] left below-knee amputation History of Present Illness: 77 year-old male with a history of PVD, s/p left BK popliteal to DP with RGSVG ([**6-20**]), s/p LUE AVF ([**12-19**]) s/p multiple angioplasties, HTN, DM, ESRD on dialysis M,W,F presenting with gangrene of his left 1st and 4th toes. Patient has a recent history of frequent minor accidental trauma to left 1st toe with poor healing and progression of gangrene. The patient presented to [**Hospital1 18**] on [**2201-6-14**] with an unroofed left toe blood blister and left fourth toe gangrene, and LLE angiography was done at that time. It was later decided to proceed with a BKA. On admission, patient denied CP/SOB, f/c, GI or GU complaints. Past Medical History: ESRD on HD MWF, PVD, CAD, CHF (EF 30-35%), DM, 5.4cm infrarenal AAA, penetrating thoracic aortic ulcerations, MSSA bacteremia, carotid stenosis 70%, HTN, DVT ([**2195**]), dementia, UC, R adrenal adenoma, gout, prostate ca, nephrolithiasis, Fe deficiency anemia, ?CVA (aphasic episode), pulmonary HTN (2L O2 at home) PM ([**Company 1543**] pacemaker, Sensia SEDR01) 3/10 L below-knee popliteal to dorsalis pedis bypass [**Company **] with reversed saphenous vein ([**Doctor Last Name **] [**2197-7-3**]), multiple LLE angios, balloon angioplasty L peroneal ([**Doctor Last Name **] [**2199-6-24**]), L 2nd toe amputation ([**2200-11-25**]), CABG, AV fistula ([**12-19**]), multiple angioplasties of fistula, PM ([**2-19**]), prostatectomy ([**2189**]), L ureteral stent ([**2192**]) Social History: Quit smoking at age 73. Retired as a chemical mixer from a leather tannery. No alcohol or illicit drug use. Family History: Brother: liver cancer. Father/mother: CVA. Paternal grandfather: rectal cancer. Physical Exam: VSS HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. Neck supple without lymphadenopathy. CVS: Regular rate and rhythm, without murmurs, rubs or gallops. S1 and S2. RESP: Clear to auscultation bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. ABD: soft, non-tender, non-distended, with normoactive bowel sounds. No masses or peritoneal signs. EXTR: s/p left BKA; RLE warm and dry. Dopplerable R DP/PT. INCISION: incision without drainage; mild erythema of amputation site. Dressing c/d/i. Pertinent Results: [**2201-7-13**] 07:05PM BLOOD WBC-10.3# RBC-2.76* Hgb-8.9* Hct-27.6* MCV-100* MCH-32.1* MCHC-32.2 RDW-19.2* Plt Ct-86* [**2201-7-23**] 06:00AM BLOOD WBC-6.6 RBC-2.64* Hgb-8.5* Hct-26.5* MCV-101* MCH-32.2* MCHC-32.0 RDW-18.1* Plt Ct-112* [**2201-7-13**] 07:05PM BLOOD Glucose-88 UreaN-27* Creat-4.4* Na-144 K-3.4 Cl-98 HCO3-36* AnGap-13 [**2201-7-23**] 06:00AM BLOOD Glucose-70 UreaN-23* Creat-3.6*# Na-140 K-4.0 Cl-97 HCO3-31 AnGap-16 Blood Culture [**2201-7-14**]: no growth Pathology, [**2201-7-14**]: Leg, right, below knee amputation: a) Gangrene. b) Severe atherosclerosis. c) Resection margins appear viable. Upper endoscopy, [**2201-7-23**]: Nodularity and atrophy of mucosa in the whole stomach (biopsy) Multiple nodules were noted at the apex of the duodenal bulb (biopsy) No obvious source of GI bleeding was noted Otherwise normal EGD to third part of the duodenum Colonoscopy, [**2201-7-23**]: Large pedunculated polyp in the sigmoid colon - not removed given recent GI bleed. (biopsy, injection) Diverticulosis of the sigmoid colon and descending colon The IC valve appeared thickened and nodular. Dark stool was noted upon intubation of terminal ileum. Solid and liquid stool was found at several regions of the colon precluding optimal visualization Otherwise normal colonoscopy to cecum and terminal ileum Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**2201-7-13**] with left lower extremity gangrene. He agreed to have an elective below-knee amputation. Pre-operatively, he was consented. A CXR, EKG, labs, and type and cross were obtained. He started a 14-day course of vancomycin, ciprofloxicin, and metronidazole. He was prepped, and brought to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well. Please see the operative report on [**2201-7-14**] for further details. Post-operatively, he was extubated and transferred to the PACU for further stabilization and monitoring. Due to persistent hypotension with SBPs in the 70s, he was started on a levophed drip and then transferred to the ICU for management while on pressors. His diet was advanced. Once he was weaned from levophed and maintaining a MAP above 60, he was transferred to the VICU for further recovery. While in the VICU he recieved monitored care. When stable his arterial line was discontinued. PT followed the patient. He was then transferred to floor status. On the floor, he remained hemodynamically stable with his pain controlled. he received hemodialysis, per his outpatient regimen, throughout his stay. His vancomycin was admiinstered during HD. He was followed by physical therapy. He was restarted on his home PO medications. He continued to make steady progress. On [**2201-7-20**], the patient was noted to have a dark, guiac positive stool. He was changed to [**Hospital1 **] PPI, and his hematocrit was watched closely. On [**2201-7-21**], his hematocrit had fallen from 28 (two days prior) to 25.8. A GI consult was obtained, and they recommended upper and lower endoscopy, which was performed on [**2201-7-23**] after achieving a bowel prep, revealing the aforementioned findings in the "pertinent results" section. Biopsies were taken, which were pending diagnosis at the time of discharge. No active bleeding source was found. The patient is advised to follow up with Dr. [**Last Name (STitle) **] at [**Hospital1 18**] gastroenterology as well as with his PCP for further management of his GI nodules and polyp. For the remainder of his hospitalization, the patient's hematocrit remained fairly stable. It is expected that it may drift slightly and this is to be expected. He was discharged on POD#10 to a rehabilitation facility in stable condition, tolerating a regular diet and with good pain control. He was advised to follow up with Dr. [**Last Name (STitle) 1391**] of vascular surgery, Dr. [**Last Name (STitle) **] of gastroenterology, and his PCP. Medications on Admission: toprolXR37.5', simvastatin 10', albuterol sulfate 90 mcg, fluticasone-salmeterol 100-50", glipizide 2.5", lisinopril 40 (not on HD days), calcium acetate 338 (2TID), gabapentin 100', omeprazole 40', triphrocaps', sucralfate 1gm before meals, hydrocodone Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheeze. 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*120 Tablet(s)* Refills:*1* 8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 9. 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* 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 4 days. Disp:*12 Tablet(s)* Refills:*0* 13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 14. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily). 15. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO ON NON-HD DAYS (). 16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) IV sliding scale per HD protocol Intravenous HD Protocol for 4 days: To be administered during hemodialysis, per protocol, until [**2201-7-27**]. Disp:*4 * Refills:*0* 17. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 18. glipizide 5 mg Tablet Sig: 0.5 Tablet PO twice a day. 19. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO three times a day. 20. sucralfate 1 gram Tablet Sig: One (1) Tablet PO before meals. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Peripheral vascular disease Left lower extremity gangrene Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair; activity per rehabilitation regimen. Discharge Instructions: This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. . ACTIVITY: . There are restrictions on activity. On the side of your amputation you are non weight bearing until cleared by your surgeon. You should keep this amputation site elevated when resting. . You may use the other leg to assist in transferring and pivots. But try not to exert to much pressure on the amputation site when transferring and or pivoting. Please keep knee immobilizer on at all times to help keep the amputation site straight. . No driving until cleared by your surgeon. . Exercise: Follow the recommendations of the rehabilitation facility . Limit strenuous activity for 6 weeks. . Do not drive a car unless cleared by your surgeon. . Try to keep leg elevated when able. . BATHING/SHOWERING: . You may shower. No bathing/soaking. A dressing may cover your amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have staples, which are usually removed in 4 weeks. This will be done by the surgeon on your follow-up appointment. . WOUND CARE: . Sutures / Staples: an appointment will be made for you to return for staple removal. . If sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. . Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. . MEDICATIONS: . Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new [**Location (un) 16615**] for pain medication, which can be taken every three (3) to four (4) hours only if necessary. . Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. . CAUTIONS: . NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. . Avoid pressure to your amputation site. . No strenuous activity for 6 weeks after surgery. . DIET : . There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. . For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. . If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. . If you have diabetes and would like additional guidance, you may request a referral from your doctor. . FOLLOW-UP APPOINTMENT: . Be sure to keep your medical [**Location (un) 4314**]. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! . Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 [**Location (un) 766**] through Friday. . PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE Followup Instructions: Please call Dr[**Name (NI) 26771**] office for a follow-up appointment, [**Telephone/Fax (1) 29415**] Please call Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Hospital1 1170**] Gastroenterology for a follow-up appointment in [**2-13**] weeks. [**Telephone/Fax (1) 13246**] Please call your primary care physician for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] visit in about 1 week. Completed by:[**2201-7-24**]

[ "428.22", "441.4", "428.0", "211.3", "250.00", "V45.11", "458.29", "440.24", "578.9", "585.6", "285.9", "403.91", "556.9", "414.01", "V45.01", "562.10" ]

icd9cm

[ [ [] ] ]

[ "45.16", "39.95", "84.15", "38.93", "38.91", "45.25" ]

icd9pcs

[ [ [] ] ]

9057, 9129

4022, 6663

326, 371

9231, 9231

2671, 3999

14405, 14857

1997, 2080

6967, 9034

9150, 9210

6689, 6944

9444, 10794

2095, 2652

230, 288

10806, 13676

13699, 14382

399, 1045

9246, 9420

1067, 1853

1869, 1981

13,033

154,594

43035

Discharge summary

report

Admission Date: [**2186-8-3**] Discharge Date: [**2186-8-9**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: Hypertensive urgency/ Nausea and Vomiting Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 38 yo male with DM1 complicated by severe gastroparesis, poorly controlled hypertension with severe autonomic dysfunction, ESRD on HD (Tu/Th/Sat), CAD, who is well known to medicine service for multiple admissions secondary to hypertensive emergency and gastroparesis, discharged yesterday, who presented to the ED with elevated BP, nausea/vomiting and back pain. Mild back pain in thorac . On review of systems, the patient denies any chest pain, shortness of breath, fevers, chills, weight loss, night sweats, fatigue, headaches, dizziness, blurred vision, sore throat, nausea, vomiting, abdominal pain, any new rashes, denies dysuria, hematuria, increased urgency, diarrhea, constipation, hematochezia, melena, epistaxis. All other systems were reviewed in detail and were negative except for what has been mentioned above. . He was last admitted on [**5-26**] for question of seizure and elevated cardiac enzymes. Cardiology was consulted and felt that this leak most likely represented subendocardial ischemia in the setting of severe hypertension and tachycardia. He was discharged on a baby aspirin, beta blocker, ace inhibitor, and was continued on his regular coumadin dose. Seizure/altered mental status was attributed to hypertension. . In the ED, was hypertensive to the 250s, was started on labetolol and nitro drip. SBP in 130s. Received dose of toprol prior ot tranfer. ECG with prominent repolarization in the anterior leads. Cardiology did not think it was concerning. Troponins were more elevated than prior, attributed to renal insufficiency. Past Medical History: 1. Diabetes mellitus type I 2. End-stage renal disease on hemodialysis started [**2-/2184**] TuThSa 3. Severe autonomic dysfunction with multiple hospitalizations for hypertensive emergency, gastroparesis, and orthostatic hypotension 5. History of esophageal erosion, [**Doctor First Name **]-[**Doctor Last Name **] tear 6. Coronary artery disease with 1-vessel disease (50% stenosis D1) - Fixed, small, moderate severity perfusion defect involving the LAD (diagonal) territory by MIBI on [**2186-6-7**] 7. History of foot ulcer - 2 months, healing slowly 8. History of clot in AV fistula clot on coumadin - [**Month (only) 958**]/[**Month (only) 205**] of [**2185**] s/p multiple attempts to remove clot 9. History of coagulase negative Staphylococcus bacteremia Social History: Denies alcohol or tobacco use. Endorses occassional marijuana use. Family History: His father died of ESRD and diabetes. His mother is in her 50s and has hypertension. He has two sisters, one with diabetes, and six brothers, one with diabetes. Physical Exam: VS T 98 HR 70s BP 190/100 RR 18 O sats 98% 2 L Gen: Appears well dressed, well nourished, in no acute distress HEENT: NCAT, PERRL, Sclera anicteric, No ulcers, oropharynx otherwise clear, throat with no erythema or exudates, no thrush, no cervical lymphadenopathy, JVP is flat CV: normal S1/S2, RRR, no m/r/g, no tenderness to palpation of precordium, PMI non-displaced Lungs: Clear to auscultation bilaterally, No w/r/rh Abdomen: Soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly, no ascites Ext: No peripheral edema, no clubbing, cyanosis, no calf pain, DP pulses are 2+ bilaterally Neuro: A + O x 3, CN II-XII grossly intact, Motor [**6-17**] both upper and lower extremities, Sensation grossly intact to light touch, DTR 2+ throughout, Toes downgoing Skin: pink, warm, no rashes Pertinent Results: [**2186-8-3**] 08:09PM CK(CPK)-138 [**2186-8-3**] 08:09PM cTropnT-0.90* [**2186-8-3**] 08:09PM CK-MB-7 [**2186-8-3**] 01:30PM GLUCOSE-307* UREA N-56* CREAT-10.2*# SODIUM-135 POTASSIUM-5.3* CHLORIDE-96 TOTAL CO2-21* ANION GAP-23* [**2186-8-3**] 01:30PM ALT(SGPT)-8 AST(SGOT)-14 CK(CPK)-172 ALK PHOS-115 AMYLASE-107* TOT BILI-0.2 [**2186-8-3**] 01:30PM CK-MB-9 cTropnT-0.80* [**2186-8-3**] 01:30PM CALCIUM-10.0 PHOSPHATE-4.9* MAGNESIUM-2.2 [**2186-8-3**] 01:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2186-8-3**] 01:30PM WBC-7.1 RBC-4.84 HGB-12.7* HCT-39.6* MCV-82 MCH-26.3* MCHC-32.2 RDW-19.3* [**2186-8-3**] 01:30PM NEUTS-75.3* LYMPHS-15.7* MONOS-4.5 EOS-3.4 BASOS-1.1 [**2186-8-3**] 01:30PM PLT COUNT-120* [**2186-8-3**] 01:30PM PT-18.0* PTT-34.1 INR(PT)-1.7* [**2186-8-2**] 06:06AM GLUCOSE-344* UREA N-37* CREAT-7.7*# SODIUM-139 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-28 ANION GAP-17 [**2186-8-2**] 06:06AM CK(CPK)-121 [**2186-8-2**] 06:06AM CK-MB-7 cTropnT-0.51* [**2186-8-2**] 06:06AM CALCIUM-9.4 PHOSPHATE-5.9* MAGNESIUM-2.2 [**2186-8-2**] 06:06AM WBC-6.6 RBC-4.65 HGB-11.9* HCT-38.3* MCV-82 MCH-25.6* MCHC-31.0 RDW-19.1* [**2186-8-2**] 06:06AM PLT COUNT-132* CTA CHEST [**2186-8-5**] IMPRESSION: 1. No evidence of aortic dissection, as clinically questioned. 2. Left ventricular hypertrophy, consistent with reported history of hypertension. 3. Diffuse, dense vascular calcifications, including coronary artery calcifications, much greater than expected for patient's age. 4. Extensive collateral venous drainage with associated focal narrowing of the left subclavian vein. CT ABDOMEN-PELVIS [**2186-8-5**] Note is made of bilateral mild gynecomastia. There is a right chest port and a right central venous catheter in place. The liver is normal, without focal lesions. No intra- or extra-hepatic biliary ductal dilatation. The gallbladder, pancreas, adrenal glands and spleen are normal. Note is made of a prominent ampulla projecting into the duodenum (sequence 3A, image 127) that likely is a normal finding. The bowel is unremarkable. The kidneys demonstrate symmetric enhancement without hydronephrosis or focal lesions. No abdominal free fluid or lymphadenopathy. The urinary bladder, rectum, prostate and sigmoid colon are unremarkable. No pelvic free fluid or lymphadenopathy. No suspicious osseous lesions. Brief Hospital Course: # Hypertensive urgency: Pt has a history of widely fluctuating BP [**3-17**] autonomic instability. There is also medication non-adherence. There is no sign of end-organ damage now with the HTN. He occasionally has EKG changes (TWI) as a result of demand ischemia. He was on a nitro drip in the ED and again on the floor. His outpatient medications were re-started and imdur was added to the regimen. It was after the addition of Imdur that the patient??????s BP stabilized at 100s systolic. He at one point became hypotensive and required bolus of 500ccs, with BP meds held. At discharge, he was tolerating well his regimen of meds and was normotensive. . He complained of back pain which is a new complaint in him, and CTA chest was reassuring that there was no aortic dissection. For other findings see report above. . # N/V and abdominal pain: Pt with multiple admissions with similar complaints, etiology [**3-17**] gastroparesis, pain is now resolved. He responds to dilaudis and ativan. He was transitioned from NPO to clears to full to regular, and he was able to tolerate regular at dc. Abdomen-pelvis CT was obtained to rule out other pathologies that might have been masked by gastroparesis. There were none. . =Anticoagulation: 2 days prior to discharge, the patient??????s INR became elevated (6 and above) and his coumadin was dced. Even after the coumadin was dc, his INR increased the next day and subsequently trended down rapidly. .# DMI: - c/w home NPH 3 units [**Hospital1 **], RISS . # ESRD: etiology [**3-17**] DM and HTN, - continued on usual schedule, usual T/Th/Sat, renal following and HD also as needed, such as after contrast for CT scans. - Contact[**Name (NI) **] Transplant team to discuss options for pancreas and kidney transplant. Pt had been relying on former girlfriend to [**Name2 (NI) 92858**] kidney, but that is no longer an option. Transplant team aware of this. . Medications on Admission: Patient not sure Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Metoprolol Succinate 100 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* 9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Three (3) units Subcutaneous twice a day. 10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 11. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Metoprolol Succinate 100 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* 9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Three (3) units Subcutaneous twice a day. 10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 11. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Home Discharge Diagnosis: Hypertensive crisis. Discharge Condition: Fair. Discharge Instructions: Go to dialysis as normally scheduled for tomorrow (Thursday). Take medications as instructed. Followup Instructions: Follow-up with Dr [**Last Name (STitle) 1366**] in [**2-14**] weeks. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "337.1", "536.3", "585.6", "250.61", "414.01", "403.01", "250.41" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

10718, 10724

6306, 8217

354, 362

10789, 10797

3868, 6283

10939, 11141

2854, 3016

8284, 10695

10745, 10768

8243, 8261

10821, 10916

3031, 3849

273, 316

390, 1964

1986, 2753

2769, 2838

400

179,204

15108+56612

Discharge summary

report+addendum

Admission Date: [**2117-8-2**] Discharge Date: Service: This is an 83-year-old male who presents from an outside hospital with multiple episodes of chest pain. He was found to have an elevated troponin. He underwent cardiac catheterization which showed three-vessel disease with an ejection fraction of 25% and was transferred to [**Hospital1 **] for planned CABG. Of note during his stay at the outside hospital, he was found to have a [**12-25**] A-V block and needed ventricular pacing. His Lopressor was stopped and he also had hematuria, which Urology was consulted. His past medical history is significant with chronic anemia, history of PE with an IVC filter in place, chronic venous stasis ulcers and disease, colon cancer status post colectomy in the 70s. MEDICATIONS: He was on aspirin. He was on a Heparin drip. He was on Imdur 30 mg q day, hydroxyzine, and lisinopril. He had no known drug allergies. His lungs were clear to auscultation bilaterally. His heart was regular rate, but bradycardic. His abdomen was soft, nontender, nondistended. Bowel sounds are present. He had a positive colectomy. He had good pulses. He was taken to the operating room on [**2117-8-3**] where a CABG x2 was performed. The patient had a LIMA to left anterior descending artery, a [**Doctor Last Name 4726**]-Tex graft to the right RDA and a left radial to OM. The patient was transferred to the SICU postoperatively. He was slowly weaned from his ventilator and was extubated. He was also started on Plavix for his radiograph as well as for his [**Doctor Last Name 4726**]-Tex graft. He continued to do well. The patient's monitor was slowly turned off, and he was found to be significantly bradycardic and Electrophysiology was consulted. Electrophysiology saw the patient and found that he has had bradycardic heart rate. It was decided at that time for a pacemaker to be placed, and it is scheduled to be done after discharge at a cardiac rehab facility. Physical therapy was also consulted to assess ambulation, and he did well. However, physical therapy agreed with Electrophysiology in requesting patient go to rehabilitation for potential increased physical therapy and range of motion. Patient was transferred to the floor postoperatively and he continued to improve. Foley was removed. He was unable to urinate, therefore Foley was replaced. Patient was not started on beta blockade because for his sinus bradycardia and for antinodal blockade. The patient was continued on the pacemaker at that time and continued on Imdur and Plavix for his graft. His pacer was set for DDI at 60. He continued to improve at that time. On [**2117-8-9**] postoperative day #7, the patient was discharged to rehab facility in stable condition with plan to have a pacer placement at that time. The patient was discharged. Discharge medications include Imdur 30 mg po q day, Plavix 75 mg po q day, captopril 12.5 mg po tid, Percocet 1-2 tablets po q4 hours prn, aspirin 325 mg po q day, Zantac 150 mg po bid, Colace 100 mg po bid, Lasix 20 mg po bid, and [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq po bid. Patient is discharged to rehabilitation in stable condition instructed to followup with primary care physician [**Last Name (NamePattern4) **] [**11-25**] weeks. Also follow up with Cardiology after his pacer as needed and follow up with Dr. [**Last Name (STitle) **] in four weeks. The patient was discharged to rehab in stable condition. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**First Name (STitle) **] MEDQUIST36 D: [**2117-8-9**] 06:27 T: [**2117-8-9**] 06:36 JOB#: [**Job Number **] Name: [**Known lastname **], [**Known firstname 326**] Unit No: [**Numeric Identifier 8045**] Admission Date: [**2117-8-2**] Discharge Date: [**2117-8-11**] Date of Birth: [**2033-12-13**] Sex: M Service: The patient was discharged on [**2117-8-11**]. On [**2117-8-9**], he was not discharged to a rehabilitation facility. He was kept in the hospital and on [**2117-8-10**] a pacemaker was placed here in the hospital. The patient did well postoperatively and was discharged on [**2117-8-11**] to a rehab facility. His medications were unchanged. Patient was instructed to followup as per the original discharge summary. The patient is discharged in stable condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**], M.D. [**MD Number(1) 359**] Dictated By:[**First Name (STitle) 1589**] MEDQUIST36 D: [**2117-8-11**] 11:51 T: [**2117-8-11**] 12:17 JOB#: [**Job Number 8046**]

[ "V10.05", "428.0", "426.13", "998.12", "414.01", "411.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.72", "36.12", "37.83", "36.15" ]

icd9pcs

[ [ [] ] ]

50,261

165,336

50333

Discharge summary

report

Admission Date: [**2124-3-28**] Discharge Date: [**2124-4-1**] Date of Birth: [**2063-4-9**] Sex: M Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 983**] Chief Complaint: mechanical fall Major Surgical or Invasive Procedure: EGD History of Present Illness: 60 yo M with EtOH abuse, MDS, diabetes mellitus, HTN, hyperlipidemia, ?cirrhosis, presents with a fall down 15 stairs. He was intoxicated with EtOH at the time, and also experienced lightheadedness prior to falling. Additionally, the patient complains of black/green vomiting and black stools for the past 3 days. He says that he vomiting 10 times and had [**4-27**] bowel movements before coming to the hospital. . The patient was recently admitted to [**Hospital3 1196**] on [**2124-3-7**] for non-bloody nausea/vomiting, attributed to gastroenteritis. His Hct was 35.9 on admission, which was above his baseline of around 30. He was transfused 2 units PRBC during that admission. His admission was complicated by urinary retention requiring placement of a Foley catheter. . Of note, the patient takes ibuprofen 5-6 tabs/day. he has been doing this for the past 2 months, to control pain from recent zoster infection. He has a history of heavy EtOH use, but denies drinking during the past 1.5 years, except for half a bottle of brandy last night. He denies a history of upper endoscopy but believe that he had a colonoscopy 5-7 years ago. . In the ED, initial vitals were 98.4 84 179/89 16 100% RA. The patient complained of back and shoulder pain. He had a single episode of white emesis. Stool was brown and guaiac-positive. Labs were notable for WBC 2.7, Hct 31.7, Plt 110, INR 1.0, Cr 0.8, ALT 43, EtOH 141, lactate 3.2 (downtrending to 2.9). CT of the head and neck were negative for acute injuries. However, the patient's C-spine could not be cleared due to pain to palpation at C5-6, so he remained in a C-collar. CT abdomen/pelvis showed massive splenomegaly, circumferential bladder wall thickening, pancreatic calcifications, extensive colonic diverticulosis, right renal cyst, no acute process. CXR showed no acute cardiopulmonary process. Left shoulder films were negative for fracture or dislocation. EKG NSR without ischemic changes. . In the ED, 16- and 18-gauge peripheral IVs were placed. The patient was given 3 L NS, ativan 1 mg IV x 3, dilaudid 0.5 mg IV x 1, zofran 4 mg IV x 2. He was bolused with 40 mg of IV protonix, and started on a protonix gtt. NG lavage was not performed. GI was consulted and recommended protonix and octreotide gtt, anesthesia consult for EGD given C-collar. The patient was admitted to the MICU due to concern about CIWA scores as high as 30 ([**Doctor Last Name **] [**1-24**] on transfer). GI also preferred to scope the patient in the ICU due to the present of the C-collar. On transfer, the patient was afebrile with HR 84, RR 20, BP 122/90, Sat 99%/RA. . On arrival to the ICU, the patient's only complaint was left shoulder pain. He says he had some lightheadedness earlier which has improved but is still present. . Review of systems: Denies fever, chills. +cough, sore throat during past 3 days. No chest pain. No abdominal pain. +nausea, vomiting, diarrhea. Denies dysuria. No rashes or skin changes. No focal weakness. Chronic LE tingling/numbness. Denies depression, anxiety, or SI. Past Medical History: Past Medical History: peptic ulcer disease - with GIB 2 years ago per patient report DM2, on insulin, with neuropathy HTN HLD stage 3 fibrosis on liver bx 1-2 years ago per patient report alcohol abuse shingles myelodysplastic disorder bipolar disorder gait instability secondary to alcohol/diabetic neuropathy h/o CVA affecting left side, with full recovery s/p cholecystectomy Social History: Lives alone in a house in [**Location (un) 745**]. Has 3 sisters and 1 brother living. 1 brother is deceased. - Tobacco: Quit 30 years ago. - Alcohol: Heavy drinking until 1.5 years ago. Denies EtOH use during intervening period but drank half a bottle of brandy last night. - Illicits: none Family History: Father had liver cancer. Brother had [**Name2 (NI) 499**] cancer in 40s. Physical Exam: ADMISSION EXAM: . General: Alert, oriented, no acute distress Derm: +spider angioma on chest HEENT: Left subconjunctival hematoma, MMM, oropharynx clear Neck: In C-collar Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, II/VI SEM at LUSB Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, spleen was enlarged to percussion GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema MSK: Shoulders with full ROM bilaterally. Neuro: A+Ox3. CN II-XII intact. Strength 5/5 throughout all extremities. . DISCHARGE EXAM: . VSS GEN: Patient lying comfortably in bed nad a+ox3 HEENT: MMM oropharynx clear NECK: supple no thyromegaly CV: rrr no m/r/g RESP: ctab no w/r/r ABD: soft nt nd bs+ EXTR: no le edema good pedal pulses bilaterally DERM: no rashes, ulcers or petechiae neuro: cn 2-12 grossly intact non-focal PSYCH: normal affect and mood Pertinent Results: ADMISSION LABS: . [**2124-3-28**] 01:00PM BLOOD WBC-2.7* RBC-3.86* Hgb-11.7* Hct-31.7* MCV-82 MCH-30.2 MCHC-36.8* RDW-13.9 Plt Ct-110* [**2124-3-28**] 01:00PM BLOOD Neuts-63.2 Lymphs-29.9 Monos-4.6 Eos-1.5 Baso-0.8 [**2124-3-28**] 01:00PM BLOOD PT-10.7 PTT-31.0 INR(PT)-1.0 [**2124-3-28**] 01:00PM BLOOD Glucose-196* UreaN-8 Creat-0.8 Na-135 K-4.1 Cl-97 HCO3-22 AnGap-20 [**2124-3-28**] 01:00PM BLOOD ALT-43* AST-40 AlkPhos-128 TotBili-1.0 [**2124-3-28**] 01:00PM BLOOD Albumin-4.1 Calcium-8.6 Phos-1.9* Mg-1.6 [**2124-3-28**] 01:00PM BLOOD ASA-NEG Ethanol-141* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2124-3-28**] 01:15PM BLOOD Lactate-3.2* . DISCHARGE LABS: . [**2124-3-31**] 07:45AM BLOOD WBC-1.5* RBC-3.67* Hgb-11.1* Hct-30.8* MCV-84 MCH-30.4 MCHC-36.1* RDW-14.4 Plt Ct-90* [**2124-3-31**] 07:45AM BLOOD Glucose-161* UreaN-9 Creat-1.0 Na-139 K-4.0 Cl-103 HCO3-29 AnGap-11 [**2124-3-30**] 06:35AM BLOOD ALT-38 AST-37 LD(LDH)-182 AlkPhos-113 TotBili-1.9* MICROBIOLOGIC DATA: . [**2124-3-28**] Urine culture - KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. ENTEROBACTER CLOACAE COMPLEX. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA OXYTOCA | ENTEROBACTER CLOACAE COMPLEX | | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 32 S 64 I TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S [**2124-3-28**] Blood culture - ngtd. IMAGING STUDIES: . [**2124-3-28**] CT HEAD W/O CONTRAST - There is no evidence of intracranial hemorrhage, edema, shift of normally midline structures, hydrocephalus, or acute large vascular territorial infarction. Prominence of the ventricles and sulci is suggestive of global volume loss. There is scattered mucosal thickening throughout the bilateral ethmoidal air cells. Minimal mucosal thickening is also seen in the right maxillary sinus. The remainder of the visualized portions of the paranasal sinuses are well aerated. Opacification of scattered posterior right mastoid air cells is noted. The remainder of the mastoid air cells are well aerated bilaterally. No fractures are seen. . [**2124-3-28**] CT ABD & PELVIS WITH CO - No acute process in the abdomen or pelvis. Massive splenomegaly. Extensive colonic diverticulosis, without evidence of diverticulitis. Hyperdense right renal cyst, likely hemorrhagic or proteinaceous however Incompletely characterized. Coarse pancreatic calcifications, possibly the sequelae of chronic pancreatitis. Circumferential bladder wall thickening could relate to chronic outlet Obstruction or cystitis. . [**2124-3-28**] CT C-SPINE W/O CONTRAST - No acute fracture. Minimal anterolisthesis of C4 on C5 is likely degenerative. . [**2124-3-28**] CHEST (SINGLE VIEW) - Single supine portable view of the chest. No prior. Lungs are clear. Cardiomediastinal silhouette is within normal limits. Osseous and soft tissue structures are unremarkable. . [**2124-3-28**] GLENO-HUMERAL SHOULDER - AP, Grashey and scapular Y views of the left shoulder. No prior. There is no visualized fracture. Glenohumeral joint is anatomically aligned. Mild degenerative changes noted at the acromioclavicular joint. Included left lung and ribs are unremarkable. Brief Hospital Course: # GI bleed: The patient presented with report of copious black stools and emesis. History suggestive of upper GIB, particularly in the setting of heavy NSAID use. The differential on admission included gastritis/PUD, variceal bleeding in the setting of possible cirrhosis, [**Doctor First Name **]-[**Doctor Last Name **] tear. His hematocrit has been stable at 28, and probably at patient's baseline, arguing against large bleed. He was maintained NPO, two large bore IV's were placed and a type and cross performed. The patient's hematocrit was serially monitored. He was also maintained on an Octreotide and Protonix infusion. EGD showed esophagitis and possible [**Doctor First Name 329**] [**Doctor Last Name **] tear. He was transitioned to omeprazole [**Hospital1 **]. He will continue on omeprazole on discharge to rehab and should have follow CBC in 2 days [**2124-4-2**]. . # Fall: Patient presented having fallen down 15 steps with a feeling of light-headedness preceeding. The fall was likely due to alcohol intoxication from the [**1-24**] bottle of brandy that patient drank prior to admission, and possibly orthostasis in the setting of GI bleeding and vomiting with diarrhea. He had back pain on presentation and had a CT-neck that showed no fracture, but chronic degenerative changes. On exam, patient had no neurologic deficits and had paraspinal neck tenderness with other tenderness radiating to the left shoulder. He had no tenderness at the midline. He was given a soft collar for comfort for four weeks and discharged to follow-up with spine center in four weeks. Please call [**Telephone/Fax (1) 8603**] to set up a follow up appointment after discharge from rehab. . # Alcohol abuse: Per patient report, no current regular use except the night prior to admission. However, there was concern about alcohol withdrawal in the ED. A CIWA scale was enacated and social work was consulted. No signs of alcohol withdrawl during hospitalization. Patient counseled on importance of absinence from alcohol. . # UTI: pt with no reported urinary symptoms, fevers, but urine culture + klebsiella/enterobacter(sensitive to cipro). He was started on ciprofloxacin and will need a course for 14 days(complicated by foley). The patient passed a voiding trial and the foley was removed. . # DM2: His home insulin (lantus 45 daily lispro 8 tid w/meals) were held as he was npo and a insulin sliding scale was used. His sugars ranged from 120-200 with insulin sliding scale. He will be discharged with a insulin sliding scale and his home regimen can be slowly restarted as his po intake improves. . # HTN: Unclear home regimen. Likely chronically runs high, but BP is significantly elevated now. He was continued on amlodipine and labetolol IV. On discharge his amlodpine was 10mg. If he continues to be hypertensive than po labetolol can be added. . # Hyperlipidemia: stable this admission. . # Bipolar disorder: Patient is on numerous psych medications, but it is unclear who is prescribing them or how regularly he takes them, or if he actually sees a psychiatrist. His last recorded pasychiatry note was a no-show note from [**Month (only) 404**] of [**2123**]. Prozac and wellbutrin were restarted, but his seroquel and abilify were held after discussion with his pcp. . # MDS: Pt leukopenia and thrombocytopenia near baseline(per discussion with PCP). No acute indication for transfusion. He will shedule a follow up appointment with his hematologist at [**Hospital3 **]. TRANSITION OF CARE ISSUES: 1. Patient to follow up with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 97107**],[**First Name8 (NamePattern2) 306**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 74684**] [**4-17**] at 220pm. 2. patient requires follow-up in the spine center in 4 weeks time, in the mean time he is to use the soft collar for comfort. 3. patient to call for follow up with primary hematologist Dr. [**Last Name (STitle) 7173**] at [**Hospital3 **] Medications on Admission: Medications (per recent discharge summary [**2124-3-7**], however discharge summary notes that this list is not accurate): aripiprazole 10 mg daily Wellbutrin SR 150 mg [**Hospital1 **] vitamin B12 1000 mcg daily fluoxetine 80 mg daily folic acid 1 mg daily gabapentin 600 mg TID glargine 45 units SC daily insulin lispro 8 units TID with meals labetalol 100 mg [**Hospital1 **] lidocaine patch to left shoulder multivitamin 1 tab daily quetiapine 100 mg daily tamsulosin 0.4 mg QHS amlodipine 10 mg daily lamotrigine 100 mg daily omeprazole 20 mg daily oxycodone 5 mg daily (discharge summary notes that patient never required this medication during his admission but insisted that it should remain on his medication list) Discharge Medications: 1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 4. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days: Stop date [**4-14**]. 9. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 10. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 12. insulin lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous ASDIR (AS DIRECTED): per sliding scale. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at [**Location (un) 620**] Discharge Diagnosis: Upper GI bleed mechanical fall UTI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a fall and dark color emesis/melena. Imaging showed no acute fractures and EGD was performed showing esophagitis(inflammation of the esophagus). Your blood counts were stable during the hospitalization and no further bleeding episodes occured. You were discharged on protonix to decrease the acid in your stomach. You should also avoid using NSAIDs(ibuprofen, naproxen, aleve, advil, etc) as this could lead to more bleeding. You should also avoid alcohol. A urine culture was also positive indicating a urinary tract infection. You were started on ciprofloxacin and should continue for 14 days. New medications: 1)omeprazole 40mg twice daily 2)ciprofloxacin 500mg every 12 hours x 14 days 3)stop taking abilify and seroquel. Followup Instructions: 1. Patient to follow up with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 97107**],[**First Name8 (NamePattern2) 306**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 74684**] [**4-17**] at 220pm. 2. patient requires follow-up in the spine center in 4 weeks time, in the mean time he is to use the soft collar for comfort. 3. patient to call for follow up with primary hematologist Dr. [**Last Name (STitle) 7173**] at [**Hospital3 **] 4. Please try voiding trial for patient on [**4-3**]. If fails voiding trial will need to follow up with urology clinic after discharge from rehab.

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Discharge summary

report

Admission Date: [**2198-11-18**] Discharge Date: [**2198-11-27**] Date of Birth: [**2144-10-4**] Sex: F Service: CARDIOTHORACIC Allergies: Ativan / Amoxicillin / Bactrim / Codeine / ibuprofen / Lamictal / naproxen / Tetanus Toxoid,Fluid / Cephalexin / Peanuts / Sulfa (Sulfonamide Antibiotics) / golytely / citrate of magnesia / Lithium Attending:[**First Name3 (LF) 5790**] Chief Complaint: Post tracheostomy and tracheostenosis. Major Surgical or Invasive Procedure: 1. Cervical tracheal resection and reconstruction. 2. Flexible bronchoscopy with bronchoalveolar lavage. History of Present Illness: 54F with ESRD [**2-7**] lithium toxicity s/p trach for prolonged respiratory failure (happened [**2198-5-15**]) secondary to hyponatremic seizure (pt was undergoing prep for colonoscopy as part of a renal transplant workup, became hyponatremic and started seizing), complicated by tracheal stenosis requiring tracheostomy. Additionally, she later had a T tube placed at [**Hospital1 18**] which failed 4 days later. She has been at [**Hospital **] Rehab hospital recently where she was receiving ongoing antibiotics in preparation for her upcoming surgery, per report. She was recently transitioned from Peritoneal [**Hospital 2286**] to HD through a R IJ tunneled catheter because of a line infection. Recently completed AB course for VRE UTI. She is now s/p tracheal resection and reconstruction Past Medical History: PMH: tracheostomy [**5-/2198**] for prolonged respiratory failure, hyponatremic seizure following GoLytely prep [**5-/2198**], ESRD for lithium toxicity, on HD, bipolar, GERD, HTN, breast cancer, diverticulosis PSH: parathyroidectomy with reimplantation in left arm, left foot surgery in [**2180**], right knee surgery in [**2191**], lumpectomy for breast cancer (DCIS), status post radiation, repeat mammograms were all negative, history of tonsillectomy in the past. Social History: - Tobacco: Never - Alcohol: Previously occasionally - Illicits: Denies Family History: Mother with ovarian CA Father with CAD Physical Exam: PE on discharge: VS: 98.4, 92, 147/94, 18, 96% RA GEN: NAD, AOx3 CV: RRR, nl s1 and s2 PULM: CTA b/l, no resp distress. Incision on neck c/d/i. No erythema. no crepitus, normal voice and cough ABD: Soft, NT, ND, + BS, dry skin in abd folds, Back: mild erythematous area (2x3 cm) on saccrum EXT: No c/c/e. Pertinent Results: [**2198-11-18**] 04:50PM BLOOD WBC-17.0*# RBC-3.34* Hgb-10.2* Hct-31.9* MCV-96 MCH-30.6 MCHC-31.9 RDW-15.5 Plt Ct-155 [**2198-11-19**] 03:39AM BLOOD WBC-16.3* RBC-3.08* Hgb-9.3* Hct-29.4* MCV-96 MCH-30.3 MCHC-31.7 RDW-15.5 Plt Ct-148* [**2198-11-25**] 11:47AM BLOOD WBC-9.4 RBC-2.41* Hgb-7.4* Hct-22.8* MCV-95 MCH-30.9 MCHC-32.6 RDW-15.5 Plt Ct-232 [**2198-11-18**] 04:50PM BLOOD Glucose-94 UreaN-33* Creat-6.5*# Na-131* K-5.1 Cl-100 HCO3-22 AnGap-14 [**2198-11-19**] 03:39AM BLOOD Glucose-85 UreaN-36* Creat-7.2* Na-131* K-5.4* Cl-100 HCO3-23 AnGap-13 [**2198-11-25**] 11:47AM BLOOD Glucose-84 UreaN-28* Creat-5.6*# Na-131* K-4.7 Cl-94* HCO3-35* AnGap-7* [**2198-11-18**] 04:50PM BLOOD Lithium-1.2 [**2198-11-19**] 06:26PM BLOOD Lithium-1.1 CXR [**2198-11-21**] In comparison with the study of [**11-19**], there is continued substantial enlargement of the cardiac silhouette with double-lumen catheter in place. Continued low lung volumes. Mild engorgement of pulmonary vessels is consistent with overhydration. The left hemidiaphragm is better seen than on the previous study, though there are still some atelectatic changes in the retrocardiac region. Bronchoscopy [**2198-11-26**]: 54 year old female with a history of tracheostomy placement for prolonged respiratory failure secondary to hyponatremic seizure, complicated by tracheal stenosis now s/p cervical tracheal resection/ reconstruction. Flexible bronchoscopy performed to evaluate anastomotic site post-operatively. Patient with hypoxemia during procedure requiring mask ventilation. Subsequently the procedure was well tolerated. The vocal cords appeared normal. The tracheal anastomotic site was visualized and was noted to have fibrinous exudate with mild residual focal tracheomalacia. The distal airways were visualized to the subsegmental level and were patent and normal in appearance. The bronchoscope was subsequently removed. Following the procedure, the suture maintaining neck flexion was removed. Brief Hospital Course: The patient was admitted to the thoracic surgery service on [**2198-11-18**] and had the following procedures: 1. Cervical tracheal resection and reconstruction 2. Flexible bronchoscopy with bronchoalveolar lavage. There were no complications and the patient tolerated the procedures well. She was transferred to the TICU while intubated and sedated. She was extubated later that day. She remained somnolent for a day after and was slowly weaned off her O2 requirements. Foley was removed POD 1. Pureed diet and soft food introduced POD 2 and J tube was removed POD 2. She was transferred to the floor on POD 3. Neuro: Post-operatively, the patient received Dilaudid IV/PCA with good effect and adequate pain control. On POD 2, the patient was transitioned to oral pain medications. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. She was extubated in the ICU the evening after surgery with no complications. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced on POD 2 to thin liquids and purred diet, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD#1. Intake and output were closely monitored. She was closely followed by the HD team while inpatient and underwent several HD treatments while in the hospital to treat her on going renal failure. ID: Post-operatively, the patient's temperature was closely watched for signs of infection. She spiked low grade fevers on POD 2 and 3. A full work up revealed no obvious causes for the temperatures and the pt remained a febrile thereafter. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. 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 5, the patient was doing well, afebrile with stable vital signs, tolerating a regular soft diet, ambulating, voiding without assistance, and pain was well controlled. She went home with VNA and outpatient [**Date Range 2286**] set up. Medications on Admission: ATENOLOL 25', CALCIUM ACETATE 667 3 cap w meals, EPOETIN ALFA 25,000qweek, ERGOCALCIFEROL 20,000qmonth, FLUOXETINE 20', LITHIUM CARBONATE 150" [**Hospital1 **] aim for level of 7, NIFEDIPINE 60 mg 2tab qam 1tab qpm, OLANZAPINE 10', OMEPRAZOLE 20", TOPIRAMATE - 25qhs, VIT B CPLX #11-FA-C-BIOT-ZINC 1mg', DOCUSATE SODIUM - 100", FERROUS SULFATE - 325" Discharge Medications: 1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. topiramate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal DAILY (Daily) as needed for hemorrhoids. 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 8. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for Dry eyes. 9. lithium carbonate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. olanzapine 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 12. nifedipine 30 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO qAM. Disp:*60 Tablet Extended Release(s)* Refills:*0* 13. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO qPM. Disp:*30 Tablet Extended Release(s)* Refills:*0* 14. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: One (1) PO BID (2 times a day). 15. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-7**] Sprays Nasal QID (4 times a day) as needed for NASAL CONGESTION. Disp:*1 Bottle* Refills:*0* 16. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. B complex vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 18. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/head ache. Disp:*30 Tablet(s)* Refills:*2* 19. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 20. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 21. olanzapine 5 mg Tablet Sig: One (1) Tablet PO BEFORE HD PRN () as needed for anxiety. Disp:*15 Tablet(s)* Refills:*0* 22. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for fungal infection: Apply to areas under pannus with rash/irritation. . Disp:*1 Tube* Refills:*0* 23. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Post tracheostomy and tracheostenosis. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the thoracic surgery service for tracheal reconstruction. Please call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or chest pain -neck incision develops drainage -No Driving for 1 month -No lifting greater than 10 pounds -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No lotions, creams, powder or ointment to incision Pain -Acetaminophen 650 mg every 6 hours as needed for pain -Hydromorphone ??? 2 mg every 4-6 hours as needed for pain Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 20 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed -Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30 minutes daily Followup Instructions: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2198-11-28**] 7:30 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2198-12-18**] 9:00 Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2198-12-18**] 10:00 --> Please arrive 30 minutes before appointment with Dr. [**Last Name (STitle) **] to have a chest X-ray. Completed by:[**2198-11-27**]

[ "799.02", "V15.3", "V45.11", "403.91", "E939.8", "519.02", "562.10", "296.7", "285.9", "V10.3", "530.81", "585.6", "E879.8" ]

icd9cm

[ [ [] ] ]

[ "39.95", "33.22", "33.24", "31.79" ]

icd9pcs

[ [ [] ] ]

9564, 9623

4427, 6713

506, 613

9706, 9706

2425, 4404

11424, 11938

2040, 2081

7115, 9541

9644, 9685

6739, 7092

9857, 11401

2096, 2099

2114, 2406

427, 468

641, 1441

9721, 9833

1463, 1935

1951, 2024

26,991

184,578

15387

Discharge summary

report

Admission Date: [**2163-10-8**] Discharge Date: [**2163-10-13**] Date of Birth: [**2112-3-10**] Sex: F Service: MEDICINE Allergies: Carboplatin Attending:[**First Name3 (LF) 398**] Chief Complaint: shortness of breath, fever Major Surgical or Invasive Procedure: None History of Present Illness: 51 yo female with metastatic breast cancer, pt. of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] recently received herceptin/gemzer on [**10-3**] presenting to the ED with shortness of breath and fever to 104 at home. Patient reports that after her chemo on Monday, she became more "wiped out" and her appetite was poor. Her duaghter noticed that she was more sob although pt denies she was sob until today around noon. She had fever to 104 on and off and shaking chills along with diffuse joint pain. Pt denies dizziness, cp, palp, nausea, vomiting, dysuria, diarrhea. Did have loose stools on day of admission. Pt denies CHF symtpoms of PND, orthopnea, LE edema. Past Medical History: 1. Metastatic Breast CA - - diagnosed in [**10-21**] in [**State 4565**] after feeling a lump - biopsy in [**2157**] showed infiltrating ductal CA that was high grade - ER negative, PR positive, HER2/neu positive - liver and lung metastases - s/p [**5-22**] left mastectomy and axillary node dissection - Her disease has been in her left hilar lymph node, right lower lobe pulmonary nodule and a celiac axis lymph node (per Dr. [**Name (NI) 44675**] last note) . - followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], on chemotherapy (Navelbine/herceptin last on [**2162-2-26**]) 2. DVT [**11-23**] 3. HTN 4. Depression . Her ovaries were removed in [**2160-7-20**]. She was postmenopausal since her chemotherapy in [**2159-1-20**]. Social History: Pt orig from [**Country **], lives with daughter. Widowed. [**Name2 (NI) 4084**] worked outside4 the home. 20 pk year tobacco history, quit 3 yrs ago, no etoh or drugs. Family History: Significant for mother who died without cancer at age 70 and a maternal aunt diagnosed with breast cancer at age 45. The patient's sister also was diagnosed with breast cancer at age 53. Her father died at 80 having been diagnosed with prostate cancer at 75. There were two paternal first cousins, one who died of leukemia at age 35 and one who died of colon cancer at a young age. Physical Exam: Vitals: T 104 BP 127/63 HR 109 O2 sat 99% on 100% NRB Pertinent Results: [**2163-10-8**] 04:10PM PLT COUNT-138*# [**2163-10-8**] 04:10PM NEUTS-87.8* LYMPHS-9.2* MONOS-2.7 EOS-0.1 BASOS-0.2 [**2163-10-8**] 04:10PM WBC-9.9# RBC-3.25* HGB-10.4* HCT-28.9* MCV-89 MCH-32.0 MCHC-35.9* RDW-17.7* [**2163-10-8**] 04:10PM CRP-GREATER TH [**2163-10-8**] 04:10PM CORTISOL-33.4* [**2163-10-8**] 04:10PM T4-9.2 [**2163-10-8**] 04:10PM TOT PROT-7.8 ALBUMIN-3.6 GLOBULIN-4.2* CALCIUM-8.6 PHOSPHATE-2.3* MAGNESIUM-2.2 [**2163-10-8**] 04:10PM CK-MB-3 cTropnT-<0.01 [**2163-10-8**] 04:10PM ALT(SGPT)-31 AST(SGOT)-24 CK(CPK)-132 ALK PHOS-73 AMYLASE-49 TOT BILI-0.4 [**2163-10-8**] 04:10PM GLUCOSE-174* UREA N-12 CREAT-1.1 SODIUM-131* POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-23 ANION GAP-16 [**2163-10-8**] 04:16PM LACTATE-2.4* [**2163-10-8**] 06:45PM PT-14.1* PTT-35.9* INR(PT)-1.2* [**2163-10-8**] 08:09PM HGB-9.2* calcHCT-28 [**2163-10-8**] 08:09PM GLUCOSE-119* LACTATE-0.7 K+-3.8 [**2163-10-8**] 11:06PM HGB-9.1* calcHCT-27 O2 SAT-62 [**2163-10-8**] 11:06PM LACTATE-0.9 [**2163-10-13**] 08:24AM BLOOD WBC-7.0 RBC-3.36* Hgb-10.2* Hct-32.2*# MCV-96 MCH-30.3 MCHC-31.5 RDW-16.5* Plt Ct-301# [**2163-10-12**] 04:50AM BLOOD Neuts-56 Bands-2 Lymphs-23 Monos-12* Eos-6* Baso-0 Atyps-1* Metas-0 Myelos-0 [**2163-10-13**] 08:24AM BLOOD PT-13.1 PTT-43.0* INR(PT)-1.1 [**2163-10-13**] 08:24AM BLOOD Glucose-107* UreaN-8 Creat-0.8 Na-140 K-4.3 Cl-101 HCO3-27 AnGap-16 [**2163-10-13**] 08:24AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.2 [**2163-10-12**] 04:50AM BLOOD calTIBC-254* VitB12-598 Folate-15.2 Ferritn-456* TRF-195* [**2163-10-9**] 08:59AM BLOOD Type-ART Temp-37.8 pO2-76* pCO2-36 pH-7.41 calTCO2-24 Base XS-0 [**2163-10-9**] 04:06AM BLOOD Lactate-0.8 [**2163-10-9**] 04:06AM BLOOD Hgb-9.7* calcHCT-29 O2 Sat-92 [**2163-10-9**] 04:06AM BLOOD freeCa-1.04* . Micro: cdiff negative, legionella negative, UCx negative, BCx pending. . Imaging: . CT HEAD W/ & W/O CONTRAST [**2163-10-8**] 6:25 PM IMPRESSION: Unremarkable CT examination without evidence of metastatic disease to the brain. Please note that MRI is more sensitive for detection of such lesions. . CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2163-10-8**] 6:02 PM IMPRESSION: 1. No evidence of aortic dissection or central/segmental pulmonary embolism. Subsegmental branches within lower lobes difficult to evaluate due to suboptimal contrast bolus. 2. Dense right lower lobe pneumonia. A few peripheral new opacities along the right major fissure are also felt to be infection related. Metastatic disease is felt less likely but could be reassessed on the next restaging examination. 3. No interval change to previously identified intrathoracic metastatic disease and mediastinal lymphadenopathy. Probable post-radiation changes involving the left upper lobe. . AP PORTABLE CHEST, [**2163-10-8**] AT 17:15 IMPRESSION: Consolidation involving the right lower lobe highly suspicious for pneumonia. Brief Hospital Course: 51 yo female with metastatic breast cancer presenting with shortness of breath, fever, and hypotension found to have a new infiltrate on CXR c/w pna. . # Sob: She was found to have a pneumonia and initially started on vanc, zosyn, and levo for broad coverage given her history of medical care. Her fever curve decreased over her first days of admission. Legionella was negative. Her SOB resolved and the levo was stopped and she was then covered with vanc and zosyn. She also had a pleural effusion. U/S of her thoracic cavity was done for possible thoracentesis out of concern for empyema. There was not enough effusion to tap. She was given albuterol and atrovent nebulizers. She continued to improve and she was afebrile for more than 48 hours before discharge. Her antibiotics were transitioned to only po levofloxacin 24 hours before discharge. When she remained afebrile and asymptomatic for 24 hours after switching to PO antibiotics, she was discharged with instructions to continue the levofloxacin for a total of 2 weeks of antibiotics. She already had close follow up arranged with her oncologist. . #.) Hypotension: likely from pneumonia. Her lisinopril was held upon admission. She was briefly on pressors, which were d/c'd as her blood pressure stabilized. She was given IVF and remained stable. Her lisinopril was restarted on [**2163-10-11**] and her blood pressure remained stable. . #.) h/o LLE DVT: cont. on Lovenox and discharged on 120mg [**Hospital1 **], her home dose. . #.) Metastatic breast cancer: Pt. of Dr. [**First Name (STitle) **]. Currently receiving weekly treatments of herceptin/gemcitabine. She received no treatments during her stay. She has follow up arranged with Dr. [**First Name (STitle) **] on [**2163-10-24**]. . #.) Depression: cont zoloft . #.) Hyponatremia: resolved on second day . #.) FEN: IVF as above, replete lytes prn, cardiac diet. . #.) PPx: PPi, subq heparin, bowel regimen . #.) Access- piv, LIJ (d/c'd on [**2163-10-10**]), R port . #.) Communication with daughter [**Name (NI) **] at [**Telephone/Fax (1) 44676**]. . #.) Full code- confirmed with patient and daughter Medications on Admission: lisinopril 5 mg daily Calcium 600 mg [**Hospital1 **] MVI QD Ferrous sulfate 325 mg QD Zoloft 50 mg qd Lovenox 120 [**Hospital1 **] Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 8 days: Please take through [**2163-10-21**]. Disp:*8 Tablet(s)* Refills:*0* 7. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*2* 8. Calcium 600 600 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary: pneumonia . Secondary: 1.) Metastatic Breast cancer to lungs and mediastinal lymph nodes 2.) Hypertension 3.) L leg DVT '[**60**] treated with Lovenox Discharge Condition: good, afebrile Discharge Instructions: You were seen at [**Hospital1 18**] for shortness of breath and found to have pneumonia. You were treated with with antibiotics and you improved. You need to continue your antibiotic, levofloxacin, for a full 2 weeks, another 8 days. . The only change to your medication regimen is the levofloxacin. Please continue you home regimen as you were doing before you entered the hospital. . Please keep your appointments with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and Dr. [**First Name (STitle) **], both on [**2163-10-24**] as below. Please call if you need to reschedule. . You should call you primary care provider or return to the ED if you experience worsening shortness of breath, chest pain, fever greater than 101.4 degrees F, or any other symptoms that concern you. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4285**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 22**] Date/Time:[**2163-10-24**] 9:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Date/Time:[**2163-10-24**] 9:00 Provider: [**Name10 (NameIs) 26**] [**Name8 (MD) 28**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-10-24**] 9:30

[ "401.9", "276.1", "V15.82", "486", "458.8", "311", "197.0", "196.8", "787.91", "V10.3", "V58.69", "V12.51" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

8422, 8428

5391, 7533

299, 306

8632, 8649

2485, 5368

9498, 9878

2013, 2396

7715, 8399

8449, 8611

7559, 7692

8673, 9475

2411, 2466

233, 261

334, 1024

1046, 1811

1827, 1997

78,600

102,408

35262+57989

Discharge summary

report+addendum

Admission Date: [**2106-10-6**] Discharge Date: [**2106-11-9**] Date of Birth: [**2065-11-8**] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3645**] Chief Complaint: Back Pain Major Surgical or Invasive Procedure: Pleural biopsy Spine stabilization surgery History of Present Illness: Per Resident Admit note: HPI: 40 F with little PMH, immigrated from [**Country 16465**] 8 years ago, admitted with markedly abnormal T/L spine MRI and low back pain. Patient reports ongoing low back pain for over one year. She thought it may have been related to a fall that occurred around that time. She was also pregnant for a good portion of that time (son is 6 months old) and also thought the pain could be related to her pregnancy. Pain has been gradually worse over the past several weeks. She saw her PCP and was prescribed oxycodone and ibuprofen in the past. She reports outpatient plain films of the L spine with unclear readings and was sent for outpatient MRI yesterday. She was told to go the the ED and presented to OSH, then subsequently transferred to [**Hospital1 18**]. MRI from OSH showing marked abnormality with liquefaction from T12 to L3, L psoas abscess, and cauda equina compression. In the ED she was given a dose of vanco and zosyn and seen by spine. . Denies leg weakness, but does note some vague difficulties when first getting up from a chair, then is okay once she starts to walk. Has also noted bilateral anterior thigh numbness for a couple months, worse when sitting. Limited to anterior thighs, no weakness/numbness elsewhere. No headache or neckpain. NO bladder/bowel incontinence, saddle anesthesia. No fever, chills, night sweats, unintentional weight loss. No chest pain, cough, dyspnea, hemoptysis. No abd pain, diarrhea, constipation. No hoarseness or dysphagia. . Patient from [**Country 16465**], moved 8 years ago. No travel back to [**Country 16465**] since. Able to describe ?negative PPD about 4 years ago. Negative HIV test during her pregnancy ~ one year ago. Sexually active with boyfriend [**Name (NI) **] only. No IV drug use. No contacts with anyone known to have TB, prison inmates, homeless. No known BCG vaccination. Past Medical History: None. Social History: No smoking/etoh/drugs. Sister and boyfriend currently at home with son. no hx of exposure to high risk TB populations. Family History: No breast cancer or other malignancy. Physical Exam: DSICHARGE PHYSICAL: VS: Pertinent Results: [**2106-10-13**] 12:29 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2106-10-13**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2106-10-15**]): NO GROWTH. ACID FAST SMEAR (Final [**2106-10-15**]): REPORTED BY PHONE TO [**Last Name (LF) 16137**],[**First Name3 (LF) **] @ 08:30, [**2106-10-15**]. ACIDFAST BACILLI. 5 seen on concentrated smear. ACID FAST CULTURE (Preliminary): AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW. [**2106-10-22**] 11:16 am SPUTUM Source: Expectorated. ACID FAST SMEAR (Final [**2106-10-25**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACIDFAST BACILLI. MODERATE seen on concentrated smear. REPORTED BY PHONE TO DR.[**Last Name (STitle) **],[**First Name3 (LF) **] AND [**Last Name (LF) 16137**],[**First Name3 (LF) **] @ 13:50, [**2106-10-25**]. [**2106-10-26**] 1:54 pm SPUTUM Source: Induced. ACID FAST SMEAR (Final [**2106-10-27**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. [**2106-10-28**] 10:57 am SPUTUM Source: Induced. ACID FAST SMEAR (Final [**2106-10-29**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. [**2106-10-29**] 8:18 am SPUTUM Source: Induced. ACID FAST SMEAR (Final [**2106-11-1**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACIDFAST BACILLI. 3 seen on concentrated smear. REPORTED BY PHONE TO [**Last Name (LF) **], [**First Name3 (LF) **] AND [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 1;30PM, [**2106-11-1**]. Cytology Report CYTOPATHOLOGY SMEARS, NON-GYN Procedure Date of [**2106-10-17**] REPORT APPROVED DATE: [**2106-10-20**] SPECIMEN RECEIVED: [**2106-10-19**] [**-7/4108**] CYTOPATHOLOGY SMEARS, NON-GYN SPECIMEN DESCRIPTION: Received 1 Hematology slide for review. CLINICAL DATA: None provided. PREVIOUS BIOPSIES: [**2106-10-11**] [**-7/3984**] SPUTUM [**2106-10-7**] [**-7/3959**] SPUTUM REPORT TO: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DIAGNOSIS: Pleural Fluid: NEGATIVE FOR MALIGNANT CELLS. Reactive mesothelial cells, lymphocytes, histiocytes, and neutrophils. DIAGNOSED BY: [**First Name8 (NamePattern2) 5335**] [**Last Name (NamePattern1) 5336**], CT(ASCP) [**Name6 (MD) 8847**] [**Name8 (MD) **], M.D. Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 80443**],[**Known firstname **] [**2065-11-8**] 40 Female [**-7/3980**] [**Numeric Identifier 80444**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] GOODELL/mtd SPECIMEN SUBMITTED: left psoas abcess, CORPECTOMY. Procedure date Tissue received Report Date Diagnosed by [**2106-10-12**] [**2106-10-12**] [**2106-10-15**] DR. [**Last Name (STitle) **]. BROWN/mb???????????? Previous biopsies: [**-7/3979**] (Not on file) [**-7/3938**] RIGHT PLEURAL PARIETAL BIOPSY - RUSH (1 JAR). ************This report contains an addendum*********** DIAGNOSIS: I) Left psoas (A):Fibroadipose tissue and skeletal muscle with chronic inflammation and necrotic debris. II) Soft tissue and bone, T12-L2, corpectomy (B-C): Granulomatous inflammation and necrosis involving bone. Note: Special stains for AFB and fungi are pending. ADDENDUM: A rare AFB is seen on special stain. Special stain for fungi is negative with appropriate positive control. Addendum added by: DR. [**Last Name (STitle) **]. BROWN/lfb Date: [**2106-10-28**] Clinical: Lesion of T12, L1, L2. Gross: The specimen is received fresh in two parts, both labeled with "[**Known lastname **], [**Known firstname 19904**]" and the medical record number. Part 1 is additionally labeled "left psoas abscess". It consists of multiple fragments of pink, tan and yellow soft tissue measuring 3.5 x 1.9 x 0.9 cm in aggregate. The fragments of soft tissue are soft and grossly necrotic. The specimen is represented in cassette A. Part 2 is additionally labeled "corpectomy". It consists of multiple fragments of pink-tan soft tissue and bone measuring 8.9 x 6 x 1.4 cm in aggregate. There are focal areas of hemorrhage but the specimen is otherwise grossly unremarkable. The specimen is represented as follows: B = soft tissue, C = bone for decalcification. [**2106-10-6**] CT of L spine IMPRESSION: 1. Destructive vertebral body changes from T12 through L2 are consistent with tuberculosis infection. These findings are suggestive of spinal instability with posterior propulsion of osseous fragments that causes severe spinal canal stenosis, though evaluation of the spinal canal is limited CT. Recommend correlation with recently performed outside hospital MRI for further evaluation of the spinal canal. 2. Chronic left psoas muscle abscess supports a diagnosis of tuberculosis. 3. Limited evaluation of biapical and right upper and lower lower lobe lung consolidations with hyperdense calcified right pleural thickening and right effusion which is in keeping with TB infection. Dedicated chest CT is recommended for further evaluation. Findings discussed with the infectious disease team. Brief Hospital Course: 40 you F admitted from OSH with low back pain and MRI showing destruction of T12-L3 vertebrae. CT L/T spine showed pleural thickening and calcification in the right lung. High concern for TB/Pott's disease. Pleural biopsy negative for AFB or granulomas. Induced sputum negative. Give marked spinal instability [**1-30**] to vertebral destruction, patient underwent spine stabilization surgery on [**2106-10-13**] & [**2106-10-18**] and tissue biopsies were obtained at that time which showed were positive for AFB. Secondary to acute blood loss due to multiple surgical procedures, pt was transfused two units of blood on [**2106-10-15**] and [**2106-10-19**]. ID consulted, placed on quadruple TB regimen. Thoracics followed for CT and pigtail catheter which were d/c'd w/o difficulty. Subsequent AFBs showed. Worked with physical therapy who cleared patient for home. Plan for d/c to home with follow with infectious disease. Medications on Admission: Ibuprofen 600 mg, average TID Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 7. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours). 9. Pyrazinamide 500 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Tablet(s) 10. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ethambutol 400 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Home With Service Facility: publich health nurse Discharge Diagnosis: TB spine Discharge Condition: stable Discharge Instructions: [**Name8 (MD) **] MD or go to ED if you have fever/drainage from incision site, resume home meds, take TB meds as prescribed, take pain meds as prescribed, activity as tolerated Physical Therapy: activity as toleated Treatments Frequency: change dressing daily, if not drainage, leave open to air staples/sutures to be d/c'd in 14d Followup Instructions: Follow up with Dr. [**Last Name (STitle) 1007**], 2 weeks from time of surgery Completed by:[**2106-11-2**] Name: [**Known lastname 12924**],[**Known firstname 3441**] Unit No: [**Numeric Identifier 12925**] Admission Date: [**2106-10-6**] Discharge Date: [**2106-11-9**] Date of Birth: [**2065-11-8**] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1961**] Addendum: Mrs. [**Known lastname **] did not have three consecutive negative AFB concentrated smears ranging from [**10-26**] till [**10-29**]. She remaind inpatient while further sputum testing was initiated. On dates [**Date range (1) 12926**] three consecutive negative concentrated AFB were obtained. Mrs. [**Known lastname **] was then discharged to home. Pertinent Results: [**2106-11-3**] 10:32 am SPUTUM Source: Expectorated. ACID FAST SMEAR (Final [**2106-11-4**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): [**2106-11-4**] 11:44 am SPUTUM Source: Induced. ACID FAST SMEAR (Final [**2106-11-5**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): [**2106-11-5**] 10:04 am SPUTUM Source: Induced. ACID FAST SMEAR (Final [**2106-11-8**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): [**2106-10-22**] 11:16 am SPUTUM Source: Expectorated. ACID FAST SMEAR (Final [**2106-10-25**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACIDFAST BACILLI. MODERATE seen on concentrated smear. REPORTED BY PHONE TO DR.[**Last Name (STitle) 808**],[**First Name3 (LF) **] AND [**Last Name (LF) 3192**],[**First Name3 (LF) 12927**] @ 13:50, [**2106-10-25**]. ACID FAST CULTURE (Preliminary): REPORTED BY PHONE TO DR. [**Last Name (STitle) 12928**], [**First Name3 (LF) 2397**] AND [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10098**] AT 2:30PM, [**2106-11-8**]. AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Morphine 15 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO every twelve (12) hours. Disp:*100 Tablet Sustained Release(s)* Refills:*0* 7. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*10 Tablet(s)* Refills:*0* 8. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours). Disp:*20 Capsule(s)* Refills:*0* 9. Pyrazinamide 500 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*40 Tablet(s)* Refills:*0* 10. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*10 Tablet(s)* Refills:*0* 11. Ethambutol 400 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*40 Tablet(s)* Refills:*0* 12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*90 Tablet(s)* Refills:*0* 13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Home With Service Facility: publich health nurse [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1962**] MD [**MD Number(2) 1963**] Completed by:[**2106-11-9**]

[ "724.02", "730.88", "737.10", "427.89", "728.82", "015.05", "733.13", "511.9" ]

icd9cm

[ [ [] ] ]

[ "83.32", "34.24", "81.05", "81.04", "77.79", "34.01", "33.22", "34.09", "81.63" ]

icd9pcs

[ [ [] ] ]

14506, 14714

7966, 8907

329, 373

10372, 10381

11638, 11801

10761, 11619

2486, 2526

12992, 14483

10340, 10351

8933, 8965

10405, 10583

2541, 2567

10601, 10622

10644, 10738

12711, 12969

280, 291

401, 2302

2324, 2331

2347, 2470

64,773

111,599

44396+58711+58712+58713

Discharge summary

report+addendum+addendum+addendum

Admission Date: [**2114-8-22**] Discharge Date: [**2114-9-5**] Date of Birth: [**2030-7-13**] Sex: F Service: MEDICINE Allergies: Sulfur / Norvasc Attending:[**First Name3 (LF) 3326**] Chief Complaint: Abd pain, crohns flare Major Surgical or Invasive Procedure: none History of Present Illness: 84 F with PMHx of Renovascular HTN c/b NSTEMI now s/p renal stents, Gout and h/o Crohn's disease who presented to the ED on [**8-21**] with RLQ pain for approx 2 days. She denies any nausea/vomiting/diarrhea or constipation but has not been taking po well and felt dehydrated. . Initial VS on arrival to the ED: T 97.6 BP 116/63 HR 84 RR 20 Sats 97% on RA. Pt was noted to have a leukocytosis with bandemia and underwent a CT abd which showed inflammation in the terminal ileum likely consistent with Crohns flare. She was noted to be guaic negative with normal lactate and was given 2L of IVF prior to admission to the floor. . On arrival to the floor, pt was reporting [**5-5**] RLQ pain, decreased appetite and general lethargy. She denied any fevers, chills, N/V/D/C and had her last BM approx 24hrs ago which was soft but non-bloody. . ROS: Denies CP/SOB/cough/congestion/fevers/rash/dysuria/sick contacts/unusual food exposures but does report 2-3 days of general malaise and poor po intake. Past Medical History: -Crohn's Disease -Accelerated Hypertension -Renal artery stenosis, s/p stents to renal arteries in [**5-31**] -Gout -B12 deficiency . Past surgical history -fibrous tumor requiring abd rescection in [**2075**] -s/p appendectomy at age 9 and tonsillectomy at age 21 Social History: Divorced and lives alone. Pt has many supportive friends and does not smoke cigarettes, denies any EtOH. Daughter is likely her health care proxy, but not officially appointed. Family History: (+) [**Name (NI) 41900**] CAD father died at age 53 of CAD after having Rheumatic fever as a child. Physical Exam: VS: T 96.2 BP 110/58 HR 85 RR 18 Sats 98% RA GEN: NAD, tired appearing but responds appropriately to questions HEENT: NCAT, EOMI, dry MM, no apprec LAD CV: RRR no apprec mr/r/g RESP: CTAB no w/r apprec, no resp distress ABD: soft, NABS, mild distended with TTP over RLQ, no rebound/guarding EXTR: warm, thin, no rash Guaic- negative in ED Pertinent Results: [**2114-8-21**] 05:20PM BLOOD WBC-13.5*# RBC-4.07* Hgb-12.0 Hct-37.1 MCV-91 MCH-29.6 MCHC-32.4 RDW-13.8 Plt Ct-512*# [**2114-8-21**] 05:20PM BLOOD Neuts-58 Bands-22* Lymphs-7* Monos-9 Eos-1 Baso-0 Atyps-1* Metas-2* Myelos-0 [**2114-8-21**] 05:20PM BLOOD PT-18.1* PTT-29.0 INR(PT)-1.6* [**2114-8-21**] 06:13PM BLOOD Glucose-76 UreaN-113* Creat-1.5* Na-142 K-4.5 Cl-110* HCO3-15* AnGap-22* [**2114-8-21**] 06:13PM BLOOD ALT-8 AST-11 LD(LDH)-185 CK(CPK)-19* AlkPhos-45 TotBili-0.3 [**2114-8-21**] 06:13PM BLOOD Lipase-84* [**2114-8-21**] 05:20PM BLOOD cTropnT-0.01 [**2114-8-22**] 12:50AM BLOOD Lactate-0.7 [**2114-8-22**] 12:50AM BLOOD Lactate-0.7 . CT Abd [**2114-8-22**]- prelim read inflammation of the ileum consistent with likely Crohn flare . EKG from [**8-22**]: NSR with LVH but otherwise unchanged from prior tracings with some TW flattening in III. Brief Hospital Course: 84 y/o F with PMHx of Renovascular HTN s/p stenting, Gout and Crohns Dz who presents with RLQ pain and CT findings consistent with crohns flare. Hospital course: Pt slowly improved with bowel rest, IVF, antibiotics (initially ciprofloxacin and flagyl, and ultimately ciprofloxacin, flagyl, and vancomycin). She was evaluated by general surgery who assessed her as a risky surgical candidate. She was intermittantly delerious, however this ultimately resolved. Cultures were negative. During the hospitalization, she experienced atrial fibrillation and flutter with rapid ventricular response. This was rate controlled with metoprolol. Anticoagulation was considered and was not started. She was also noted to have a coagulopathy attributed to malnutrition. This was treated with oral vitamin K supplementation with some improvement. Medications on Admission: Carvedilol 12.5mg [**Hospital1 **] Calcium 500+D Protonix 40mg daily Aspirin 325mg daily Lisinopril 40mg daily Isosorbide Mononitrate 30mg daily Colchicine 0.6mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Mesalamine 250 mg Capsule, Sustained Release Sig: Three (3) Capsule, Sustained Release PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital 789**] Care Center of [**Location (un) 57605**] Discharge Diagnosis: Primary: Crohns Flare Delirium Paroxysmal atrial fibrillation and flutter . Secondary: CRI Renovascular Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. ... Discharge Instructions: You were admitted with a Crohns flare and you were evaluated by our gastroenterologists. You have been treated with antibiotics and ____. You also experienced an abnormal heart rhythm known as atrial fibrillation. This was largely controlled with medication. It does place you at risk for strokes, however, and in order to minimize this risk, anticoagulation with blood thinners was ______________. Dr. [**Last Name (STitle) 19205**] will dictate an addendum with updated discharge instructions. Followup Instructions: Department: Primary Care When: WEDNESDAY, [**8-29**], 9:30AM Name: [**Location (un) 6624**], [**Last Name (un) 16151**] K. MD Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **] Address: [**Location (un) **], [**Apartment Address(1) 6850**], [**Location (un) **],[**Numeric Identifier 3883**] Phone: [**Telephone/Fax (1) 3329**] Department: GASTROENTEROLOGY When: WEDNESDAY [**2114-9-5**] at 9:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18307**], MD [**Telephone/Fax (1) 1983**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2115-1-2**] at 11:00 AM With: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Name: [**Known lastname 15054**],[**Known firstname 1911**] Unit No: [**Numeric Identifier 15055**] Admission Date: [**2114-8-22**] Discharge Date: [**2114-9-5**] Date of Birth: [**2030-7-13**] Sex: F Service: MEDICINE Allergies: Sulfur / Norvasc Attending:[**First Name3 (LF) 310**] Addendum: See below Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 84 F with PMHx of Renovascular HTN c/b NSTEMI now s/p renal stents, Gout and h/o Crohn's disease who presented to the ED on [**8-21**] with RLQ pain for approx 2 days. She denies any nausea/vomiting/diarrhea or constipation but has not been taking po well and felt dehydrated. Initial VS on arrival to the ED: T 97.6 BP 116/63 HR 84 RR 20 Sats 97% on RA. Pt was noted to have a leukocytosis with bandemia and underwent a CT abd which showed inflammation in the terminal ileum likely consistent with Crohns flare. She was noted to be guaic negative with normal lactate and was given 2L of IVF prior to admission to the floor. . On arrival to the floor, pt was reporting [**5-5**] RLQ pain, decreased appetite and general lethargy. She denied any fevers, chills, N/V/D/C and had her last BM approx 24hrs ago which was soft but non-bloody. Past Medical History: -Crohn's Disease -Accelerated Hypertension -Renal artery stenosis, s/p stents to renal arteries in [**5-31**] -Gout -B12 deficiency . Past surgical history -fibrous tumor requiring abd rescection in [**2075**] -s/p appendectomy at age 9 and tonsillectomy at age 21 Social History: Divorced and lives alone. Pt has many supportive friends and does not smoke cigarettes, denies any EtOH. Daughter is likely her health care proxy, but not officially appointed. Family History: (+) [**Name (NI) 15056**] CAD father died at age 53 of CAD after having Rheumatic fever as a child. Physical Exam: VS: 97.0 126/60 80 16 95%RA GEN: Alert and oriented to person, place and situation; no apperent distress HEENT: no trauma, pupils round and reactive to light and accomodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, non-tender, non-distended; no guarding/rebound EXT: no clubbing/cyanosis/edema; 2+ distal pulses; pneumoboots in place DERM: no lesions appreciated Pertinent Results: CT ABDOMEN W/CONTRAST IMPRESSION: 1. Moderate amount of free air within the abdomen of undetermined source, which is a new finding when compared to [**2114-8-26**] study. 2. Bowel wall thickening and wall enhancement of colon and ileum. These findings are consistent with an inflammatory process, namely Crohn's disease flare and/or ischemic enteritis. Diffuse pericolic fat stranding and inflammatory changes are noted within the abdomen and pelvis. 3. Interval increase of fluid collections in the pelvis. Fluid collection with associated pocket of air is seen within the pelvis (3:59), which is concerning for an abscess formation. 4. Interval increase of bilateral pleural effusions and atelectasis. 5. Stable splenic hypodensity, which likely represents a splenic infarct. 6. Moderate hiatal hernia. 7. Stable appearance of bilateral renal cysts and multilobular, septated left renal cyst. Brief Hospital Course: 84 y/o with Crohns disease initially p/w rlq pain for 2 d; CT with terminal ileal inflammation concerning for Crohns flare. Hospital course has been complicated, first by episodes of afib with RVR, Second with pt developing episode of acute GIB, and most recently with pt developing perforated viscous with an acute abdomen. Pt was trasferred to the ICU, but was determined that pt is not a surgical candidate, and that pt would not want surgery anyway. . Morning [**9-1**], pt became hypotensive and very tachycardic to 170's, with evidence of ischemic changes on telemetry. I called and discussed pt's current clinical condition with her HCP [**Name (NI) 582**] [**Name (NI) 15057**] ([**Telephone/Fax (1) 15058**]). Pt was already DNR/DNI based upon decisions in the ICU, and after further repeat discussion with HCP (daughter [**Name (NI) 582**] [**Name (NI) **]) a move with comfort measures oriented therapy was initiated. She was provided morphine IV, which she frequently declined, as she denied discomfort. She denied hunger or thirst. . Palliative care consult was placed, and meds were changed to concentrated morphine solution 5mg q2hr prn, along with oral PPI therapy. A signed DNR/DNI order was signed by HCP and placed in the chart. Discussion with the patient's family undertaken, and family was informed that a time course is unpredictable, though patient's prognosis is grim with high mortality. Patient may continue in current condition for days to weeks. . Diagnoses: # Perforated Viscous # Crohn's flare with terminal ileal inflammation # Acute GI bleed, with Anemia due to acute blood loss # Atrial fibrillation with RVR # Renovascular htn - bp as above Medications on Admission: Carvedilol 12.5mg [**Hospital1 **] Calcium 500+D Protonix 40mg daily Aspirin 325mg daily Lisinopril 40mg daily Isosorbide Mononitrate 30mg daily Colchicine 0.6mg daily Discharge Medications: 1. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 2. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO Q2H (every 2 hours) as needed for pain, labored breathing. Disp:*1 bottle* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital **] Care Center of [**Location (un) 15059**] Discharge Diagnosis: Primary: Crohns Flare Delirium Paroxysmal atrial fibrillation and flutter Perforated viscous with abscess . Secondary: CRI Renovascular Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted with a Crohns flare and you were evaluated by our gastroenterologists. You have been treated with antibiotics. Unfortunately, during your hospitalization, you had a rupture of your intestine. You were evaluated by surgery, but you decided that you did not want surgery for this issue, with the understanding that this will likely be a terminal condition. Comfort oriented care was instituted along with palliative consult visit. Your pain has been well controlled. Your family is also aware of your current condition, and you and they have decided to move you to skilled nursing facility closer to your family, with request for hospice evaluation. Followup Instructions: none [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 314**] MD [**MD Number(2) 315**] Completed by:[**2114-9-5**] Name: [**Known lastname 15054**],[**Known firstname 1911**] Unit No: [**Numeric Identifier 15055**] Admission Date: [**2114-8-22**] Discharge Date: [**2114-9-5**] Date of Birth: [**2030-7-13**] Sex: F Service: MEDICINE Allergies: Sulfur / Norvasc Attending:[**First Name3 (LF) 2097**] Addendum: Discharge Instructions: You were admitted with a Crohns flare and you were evaluated by our gastroenterologists. You have been treated with antibiotics. Unfortunately, during your hospitalization, you had a rupture of your intestine. You were evaluated by surgery, but you decided that you did not want surgery for this issue, with the understanding that this will likely be a terminal condition. Comfort oriented care was instituted along with a palliative consult visit. Your pain has been well controlled. Your family is also aware of your current condition, and you and they have decided to move you to a skilled nursing facility closer to your family, with request for hospice evaluation. You also experienced an abnormal heart rhythm known as atrial fibrillation during your hospitalization. This was controlled with heart rate medications. Although this condition places you at risk for strokes, anticoagulation with blood thinners was not started in the setting of your acute Crohn's flare because of the possibility of sending you for surgery at that time and the potential risk of bleeding that would have resulted from starting an anticoagulant. Discharge Disposition: Extended Care Facility: [**Hospital **] Care Center of [**Location (un) 15059**] Discharge Diagnosis: Primary: Crohns Flare Delirium Paroxysmal atrial fibrillation and flutter Perforated viscous with abscess . Secondary: CRI Renovascular Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: As above Followup Instructions: none [**First Name11 (Name Pattern1) 126**] [**Last Name (NamePattern4) 2098**] MD [**MD Number(1) 2099**] Completed by:[**2114-9-20**] Name: [**Known lastname 15054**],[**Known firstname 1911**] Unit No: [**Numeric Identifier 15055**] Admission Date: [**2114-8-22**] Discharge Date: [**2114-9-5**] Date of Birth: [**2030-7-13**] Sex: F Service: MEDICINE Allergies: Sulfur / Norvasc Attending:[**First Name3 (LF) 2097**] Addendum: Brief Hospital Course: 84 y/o with Crohns disease initially p/w rlq pain for 2 d; CT with terminal ileal inflammation concerning for Crohns flare. Hospital course has been complicated, first by episodes of afib with RVR, Second with pt developing episode of acute GIB, and most recently with pt developing perforated viscous with an acute abdomen. Pt was trasferred to the ICU, but was determined that pt is not a surgical candidate, and that pt would not want surgery anyway. . Morning [**9-1**], pt became hypotensive and very tachycardic to 170's, with evidence of ischemic changes on telemetry. I called and discussed pt's current clinical condition with her HCP [**Name (NI) 582**] [**Name (NI) 15057**] ([**Telephone/Fax (1) 15058**]). Pt was already DNR/DNI based upon decisions in the ICU, and after further repeat discussion with HCP (daughter [**Name (NI) 582**] [**Name (NI) **]) a move with comfort measures oriented therapy was initiated. She was provided morphine IV, which she frequently declined, as she denied discomfort. She denied hunger or thirst. . Palliative care consult was placed, and meds were changed to concentrated morphine solution 5mg q2hr prn, along with oral PPI therapy. A signed DNR/DNI order was signed by HCP and placed in the chart. Discussion with the patient's family undertaken, and family was informed that a time course is unpredictable, though patient's prognosis is grim with high mortality. Patient may continue in current condition for days to weeks. . Diagnoses: # Perforated Viscous # Crohn's flare with terminal ileal inflammation # Acute GI bleed, with Anemia due to acute blood loss # Atrial fibrillation with RVR # Renovascular htn - bp as above Discharge Disposition: Extended Care Facility: [**Hospital **] Care Center of [**Location (un) 15059**] [**First Name11 (Name Pattern1) 126**] [**Last Name (NamePattern4) 2098**] MD [**MD Number(1) 2099**] Completed by:[**2114-9-20**]

[ "555.0", "427.32", "427.31", "276.2", "405.91", "285.1", "578.9", "349.82", "440.1", "287.5", "569.83", "276.0", "412", "585.2", "V66.7", "263.9", "274.01", "286.9", "276.8" ]

icd9cm

[ [ [] ] ]

[ "81.91", "38.93" ]

icd9pcs

[ [ [] ] ]

17892, 18135

16184, 17869

7217, 7224

15468, 15468

9228, 10125

15638, 16160

8598, 8699

12049, 12369

15301, 15447

11856, 12026

3356, 4037

15605, 15615

8714, 9209

7163, 7179

7252, 8098

15483, 15581

8120, 8387

8403, 8582

55,186

124,824

20493

Discharge summary

report

Admission Date: [**2121-4-27**] Discharge Date: [**2121-5-30**] Date of Birth: [**2070-3-5**] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 21193**] Chief Complaint: fever, sore throat, double vision, periods of confusion, worsening gait instability Major Surgical or Invasive Procedure: Brain biopsy -- Left cerebellum/mcp History of Present Illness: 51 y/o right handed woman with h/o meningoencephalitis of unknown etiology who now presents with concerns over her blurred vision, and worsening of her left sided weakness. She is a patient well-known to the Neurology service, who was initially followed by Drs [**Last Name (STitle) 1968**] and [**Name5 (PTitle) 1206**] and [**Name5 (PTitle) **] recently has followed with Dr. [**Last Name (STitle) 2340**]. She started to have a sore throat on [**4-20**] afterwhich she was seen by Dr. [**Last Name (STitle) 2340**] in clinic who felt since it was not accompanied by fever or change in neuro exam that it would be ok for her to observe at home. By Wednesday, she developed fever of tmax 100.9. On Thursday, her sister found her more forgetful. She was seen by her PCP on [**Name9 (PRE) 2974**] who did a rapid strep test which was negative and told her it was most likely viral. On Satuday, she began to feel nausea and noticed that she was off balance with standing. She then through the day noticed that her usual weak left side felt weaker and the double vision was worse. Course in the ED: She was given Levaquin x one dose. Neurosurgery and neurology were consulted. Course of Illness: She was first admitted from [**2120-7-5**] - [**2120-7-24**] where she initially presented with fever, somnolence, decreased responsiveness, headache, and nystagmus. LP showed a marked neutrophil-predominant leukocytosis. MRI showed FLAIR hyperintensity and contrast enhancement in the R thalamus, midbrain, corpus callosum splenium, temporal lobe, and cerebellum as well as leptomeningeal enhancement. Extensive neurologic and infectious work-up was negative aside from a mildly elevated adenosine deaminase level. Given borderline positive PPD and known exposure to Tb in her native country of [**Country 4574**], empiric anti-Tb therapy was started with RIPE. She also received a course of high dose steroids for possible inflammatory etiology of her symptoms. Pt was also started on moxifloxacin for Tb and Mycoplasma coverage. During her rehab course, she developed pneumonia and moxifloxacin was changed to levofloxacin. This resolved, but pt had elevated LFT's. Levofloxacin was changed back to moxifloxacin. Her fever resolved one month into treatment. She again returned for another admission [**9-10**] to [**10-10**] for headache and worsening of blurry vision. Initially, her TB medications (RIPE therapy) were continued and a repeat MRI was performed which showed interval progression in and recurrence of the previously seen enhancing lesions in the right thalamus, right mesial temporal lobe, and right cerebellum with further smaller enhancing areas in the right mid brain as well as increased mass effect and 4-mm midline shift to the left. This imaging was thought to be more compatible with a neoplastic process such as CNS lymphoma rather than an infectious process. At that point, ID recommended anti-Tb medications were stopped. There was a thought that this may also be CNS sarcoid however CSF ACE levels were normal. Formal opthamologic exam was negative for evidence of sarcoid. An emergent biopsy of the lesion was performed by Neurosurgery. While the biopsy results were pending, she was started on dexamethasone. Of importance, she was only noted to have minimal clinical improvement on steroids. The biopsy results then returned as active encephalitis (likely bacterial or parasitic), but still no causative organisms were identified. As per ID, she was started on empiric Ampicillin (for Listeria), Rifampin and Moxifloxacin. She actually has since clinically improved while on the antibiotics. Her energy levels and mood have improved, and her cranial nerve palsies (which include a right 6th nerve palsy, left 3rd nerve palsy, and peripheral 7th nerve palsy).the most recent CSF results show improvement while on the antibiotics, including lower WBC and protein counts (please see results section for full comparison of CSF results). Multiple cultures were sent including those for rare parasites and [**Male First Name (un) 2326**] virus which were negative. Upon discharge, she was followed by Neurology and with several unchanged MRI exams, it was decided to discontinue the antibiotics including ampicillin in [**2121-10-21**]. [**Known firstname **] had been receiving physical therapy and her baseline is that she uses a wheelchair for the past 3-4 months. General ROS: Denies chills, weight loss, chest pain, palpitations, abdominal pain, diarrhea, constipation, dysuria, hematuria, easy bruising/bleeding. Neurological ROS: Reports L side weakness that is worse. She feels more unsteady with standing. Denies headache, dysarthria, dysphagia, bowel/bladder incontinence, numbness or tingling. Past Medical History: Hyperlipidemia Anemia (borderline microcytic on CBC) H/o positive PPD Social History: Originally from [**Country 4574**], but has been in US for 16 years. Had been worknig as [**Name8 (MD) **] NP. Married to husband with 1 child. Denies alcohol, tobacco, or recreational drug use. Family History: Father died in accident. Mother and siblings are alive and healthy. Physical Exam: < ON ADMISSION > 98.4 84 140/80 16 99% Gen: WD/WN, comfortable, NAD. HEENT: PERRL, no fluctuance, tenderness or drainage over operative site. Neck: Supple. Lungs: no respiratory distress Cardiac: RRR Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, but will fall back to sleep when not being engaged, cooperative with exam, flat affect. She can relay some of the history. She often requires repetition of questions prior to answers and also translation to her native language by her sister. Orientation: Oriented to person, place, and date. Language: Speech dysarthric with good comprehension and repetition. Naming intact with low and high frequency objects. Praxis normal with burshing her teeth. 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: With left gaze she has difficulty burying her left eye and it exaggerates an upward skew of the left eye. With right eye gaze she has saccadic breakdown and sustained end gaze nystagmus. She has difficulty with upward gaze. She has difficulty tracking an object. She denies any diploplia is all directions. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: not tested [**Doctor First Name 81**]: Sternocleidomastoid and trapezius full XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. Left arm [**2-22**] triceps, [**3-25**] biceps, [**1-25**] wrist extension, [**1-25**] finger extension. Left leg is full strength. Right upper and lower extremity is full strength. Sensation: Equal bilaterally to light touch. DTRs: left toe is upgoing and right toe is downgoing. reflexes normal [**1-24**] throughout with 1/4 in achilles. Pertinent Results: [**2121-4-29**] 02:54PM BLOOD BURKHOLDERIA PSEUDOMALLEI ANTIBODY PANEL, IFA- [**2121-5-1**] 08:52AM BLOOD IgG-1347 IgA-255 IgM-71 [**2121-5-21**] 01:42AM BLOOD Anti-Tg-LESS THAN antiTPO-11 [**2121-4-29**] 02:54AM BLOOD TSH-0.28 [**2121-4-28**] 09:50PM BLOOD Osmolal-276 [**2121-4-30**] 03:34AM BLOOD Osmolal-289 [**2121-4-28**] 09:50PM BLOOD Calcium-8.8 Phos-2.7 Mg-1.9 UricAcd-3.2 [**2121-5-23**] 05:55AM BLOOD Albumin-3.6 Calcium-9.5 Phos-2.9 Mg-2.1 [**2121-5-27**] 05:30AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.2 [**2121-5-28**] 06:09AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.2 [**2121-5-29**] 05:06AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2 [**2121-4-28**] 09:50PM BLOOD ALT-13 AST-14 AlkPhos-56 TotBili-0.4 [**2121-5-9**] 04:12AM BLOOD ALT-11 AST-11 [**2121-5-10**] 05:13AM BLOOD ALT-10 AST-9 [**2121-5-23**] 05:55AM BLOOD ALT-13 AST-13 AlkPhos-54 TotBili-0.1 [**2121-4-27**] 01:30AM BLOOD Glucose-105* UreaN-8 Creat-0.7 Na-137 K-3.9 Cl-102 HCO3-25 AnGap-14 [**2121-4-27**] 03:00PM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-132* K-4.1 Cl-98 HCO3-24 AnGap-14 [**2121-4-28**] 09:50PM BLOOD Glucose-117* UreaN-6 Creat-0.6 Na-132* K-3.6 Cl-99 HCO3-25 AnGap-12 [**2121-5-23**] 05:55AM BLOOD Glucose-118* UreaN-8 Creat-0.5 Na-145 K-4.4 Cl-111* HCO3-26 AnGap-12 [**2121-5-27**] 05:30AM BLOOD Glucose-119* UreaN-8 Creat-0.5 Na-139 K-3.8 Cl-106 HCO3-25 AnGap-12 [**2121-5-28**] 06:09AM BLOOD Glucose-141* UreaN-9 Creat-0.5 Na-143 K-4.3 Cl-105 HCO3-26 AnGap-16 [**2121-5-29**] 05:06AM BLOOD Glucose-93 UreaN-11 Creat-0.5 Na-140 K-4.1 Cl-105 HCO3-26 AnGap-13 [**2121-5-1**] 08:52AM BLOOD CD3%-71.5 CD3Abs-1235 CD5%-72.5 CD5Abs-1253 [**2121-4-27**] 03:00PM BLOOD PT-15.6* PTT-24.9 INR(PT)-1.4* [**2121-5-23**] 05:55AM BLOOD PT-13.5* PTT-24.3 INR(PT)-1.2* [**2121-4-27**] 01:30AM BLOOD Neuts-69.2 Lymphs-24.1 Monos-5.2 Eos-1.3 Baso-0.2 [**2121-4-29**] 02:54AM BLOOD Neuts-83.7* Lymphs-12.0* Monos-2.1 Eos-2.1 Baso-0.1 [**2121-5-1**] 05:00AM BLOOD Neuts-69.5 Lymphs-23.3 Monos-2.8 Eos-4.1* Baso-0.3 [**2121-5-1**] 08:52AM BLOOD Neuts-68.2 Lymphs-23.6 Monos-2.9 Eos-4.7* Baso-0.5 [**2121-5-6**] 12:23PM BLOOD Neuts-75.5* Lymphs-17.2* Monos-3.5 Eos-3.5 Baso-0.2 [**2121-5-9**] 04:12AM BLOOD Neuts-67.0 Lymphs-24.2 Monos-3.4 Eos-4.5* Baso-0.8 [**2121-5-23**] 05:55AM BLOOD Neuts-86.0* Lymphs-9.5* Monos-3.1 Eos-1.0 Baso-0.4 [**2121-5-28**] 06:09AM BLOOD Neuts-70.9* Lymphs-20.8 Monos-4.0 Eos-2.5 Baso-1.8 [**2121-4-27**] 01:30AM BLOOD WBC-9.3 RBC-4.25 Hgb-11.6* Hct-34.0* MCV-80* MCH-27.4# MCHC-34.3# RDW-16.5* Plt Ct-336 [**2121-4-27**] 03:00PM BLOOD WBC-11.4* RBC-4.36 Hgb-11.9* Hct-35.5* MCV-81* MCH-27.2 MCHC-33.4 RDW-16.7* Plt Ct-360 [**2121-4-28**] 03:06AM BLOOD WBC-10.2 RBC-4.32 Hgb-11.7* Hct-35.2* MCV-81* MCH-27.0 MCHC-33.2 RDW-17.0* Plt Ct-346 [**2121-5-23**] 05:55AM BLOOD WBC-9.8 RBC-3.90* Hgb-10.9* Hct-33.5* MCV-86 MCH-28.0 MCHC-32.6 RDW-16.8* Plt Ct-345 [**2121-5-27**] 05:30AM BLOOD WBC-13.7* RBC-3.81* Hgb-10.6* Hct-32.4* MCV-85 MCH-27.8 MCHC-32.6 RDW-16.6* Plt Ct-364 [**2121-5-28**] 06:09AM BLOOD WBC-11.5* RBC-3.75* Hgb-10.6* Hct-32.0* MCV-85 MCH-28.3 MCHC-33.2 RDW-16.8* Plt Ct-400 [**2121-5-29**] 05:06AM BLOOD WBC-11.1* RBC-3.75* Hgb-10.5* Hct-32.1* MCV-86 MCH-28.0 MCHC-32.8 RDW-16.4* Plt Ct-361 [**2121-4-28**] 12:33PM URINE Osmolal-556 [**2121-4-30**] 05:03AM URINE Osmolal-436 [**2121-4-28**] 12:33PM URINE Hours-RANDOM Creat-92 Na-121 K-37 Cl-120 [**2121-4-30**] 05:03AM URINE Hours-RANDOM Na-176 K-9 Cl-180 [**2121-4-28**] 03:38AM URINE RBC-18* WBC-3 Bacteri-NONE Yeast-NONE Epi-<1 [**2121-5-4**] 12:06AM URINE RBC-37* WBC-24* Bacteri-NONE Yeast-NONE Epi-<1 TransE-<1 [**2121-5-27**] 07:45PM URINE RBC-107* WBC-8* Bacteri-MOD Yeast-NONE Epi-1 TransE-<1 [**2121-4-28**] 03:38AM URINE CastHy-1* [**2121-4-28**] 03:38AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-8.0 Leuks-NEG [**2121-5-4**] 12:06AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018 [**2121-4-28**] 06:15PM CEREBROSPINAL FLUID (CSF) WBC-550 RBC-25* Polys-54 Lymphs-41 Monos-5 [**2121-4-28**] 06:15PM CEREBROSPINAL FLUID (CSF) WBC-315 RBC-90* Polys-70 Lymphs-24 Monos-6 [**2121-5-2**] 10:37AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-[**Numeric Identifier 54848**]* Polys-70 Lymphs-20 Monos-10 [**2121-5-2**] 10:37AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-4075* Polys-33 Lymphs-65 Monos-1 Eos-1 [**2121-4-28**] 06:15PM CEREBROSPINAL FLUID (CSF) TotProt-155* Glucose-49 [**2121-5-2**] 10:37AM CEREBROSPINAL FLUID (CSF) TotProt-270* Glucose-52 [**2121-4-28**] 06:15PM CEREBROSPINAL FLUID (CSF) ANGIOTENSIN 1 CONVERTING ENZYME-Test [**2121-4-28**] 06:15PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-Test Reque [**2121-5-27**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2121-5-27**] URINE URINE CULTURE-FINAL INPATIENT [**2121-5-27**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2121-5-23**] SEROLOGY/BLOOD LYME SEROLOGY-FINAL INPATIENT [**2121-5-21**] TISSUE GRAM STAIN-FINAL; TISSUE-FINAL; ANAEROBIC CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; VIRAL CULTURE-PRELIMINARY; CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD)-FINAL INPATIENT [**2121-5-5**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [**2121-5-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2121-5-3**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [**2121-5-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2121-5-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2121-5-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2121-5-2**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; FUNGAL CULTURE-FINAL; ACID FAST CULTURE-PRELIMINARY; VIRAL CULTURE-PRELIMINARY INPATIENT [**2121-4-29**] URINE URINE CULTURE-FINAL INPATIENT [**2121-4-28**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; FUNGAL CULTURE-FINAL; VIRAL CULTURE-FINAL INPATIENT [**2121-4-28**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2121-4-28**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2121-4-28**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2121-4-27**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE, CORYNEBACTERIUM SPECIES (DIPHTHEROIDS), AEROCOCCUS SPECIES}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **] TTE [**4-29**]: Conclusions The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). 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. No masses or vegetations are seen on the aortic valve. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: No vegetations or clinically-significant regurgitant valvular disease seen (adequate-quality study). Normal global and regional biventricular systolic function. Compared with the report of the prior study (images unavailable for review) of [**2120-9-23**], the findings appear similar. TTE [**5-12**]: Conclusions No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. [**4-27**] OSH NCHCT overread: CT HEAD: At an outside institution axial imaging was performed through the brain without IV contrast. Subsequently, IV contrast was administered. Coronal reformats were performed. A second read was requested. COMPARISON: MRI brain [**2121-3-14**], [**2120-10-30**], and CT head [**9-24**], [**2119**]. FINDINGS: No rim-enhancing intracranial lesions are identified to suggest brain abscess. Compared to the most recent CT examination, areas of hypodensity in the posterior fossa, particularly the right cerebellum, the right brainstem, thalamus, and corona radiata are all similar in appearance, and distribution allowing for differences in technique. No new areas of low attenuation are present to suggest the presence of acute infarct. No hemorrhage is identified. The size and configuration of ventricles appears normal and similar to the prior studies. There is a right occipital burr hole. There is a 12 mm fluid collection external to the dura at the site of the burr hole, which does not appear to be present on the prior CT examination and evaluation for this on the MRI is difficult. With the exception of the burr hole osseous structures appear intact. The visualized sinuses are clear apart from a small mucus retention cyst within the left sphenoid sinus. IMPRESSION: 1. No rim-enhancing lesions to suggest the presence of an intracranial abscess. Small probable simple fluid collection at the right occipital burr hole. 2. Stable regions of low attenuation in the right posterior fossa, brainstem, and thalamus similar in distribution to the prior MRI. If clinical concern merits, then MRI with contrast would be more sensitive for intracranial evaluation. [**4-28**] EEG: FINDINGS: ABNORMALITY #1: A mildly slow posterior rhythm with as fast as 7.5 Hz of low to moderate voltage was seen bilaterally in the majority of the waking/resting record. ABNORMALITY #2: Suspicious generalized bifrontally predominant bursts of polymorphic slow theta and delta were seen followed by moderate to moderately high voltage runs of mixed frequency theta lasting anywhere from five to ten seconds without associated sharp or spike forms. BACKGROUND: The anterior-posterior voltage gradient was preserved. No frank epileptiform discharging features were seen. HYPERVENTILATION: Not performed. INTERMITTENT PHOTIC STIMULATION: Not performed. SLEEP: Not obtained. CARDIAC MONITOR: No arrhythmias noted. IMPRESSION: Mildly abnormal EEG with a slowed and disorganized posterior background and superimposed intermittent bursts of theta/delta slowing followed by brief increased runs of mixed frequency theta. The record is indicative of a mild diffuse encephalopathy with some suspicion of increased generalized irritability. No definitive spikes or other evidence of electrographic seizures were seen. [**4-28**] MRI: COMPARISON: Multiple prior MRI studies and CT head studies, including a recent MR head performed at [**2121-3-14**]. TECHNIQUE: Sagittal short TR, TE spin echo images were obtained through the brain. Axial imaging was performed with long TR, long TE, fast spin echo, FLAIR, gradient echo, and diffusion technique. Short TR, short TE spin echo imaging was repeated after intravenous administration of gadolinium contrast. FINDINGS: Multiple FLAIR hyperintense lesions are noted in the white matter tracts along the left corona radiata, posterior limb of the internal capsule, thalamus, mid brain, pons and left cerebellum including the middle cerebellar peduncle. Also seen are two round foci in the left parietal and occipital lobes. All of the above lesions are new since the prior study. These lesions demonstrate patchy enhancement after administration of contrast. Also seen multiple areas of leptomeningeal enhancement, most significant in the left temporal region, suggestive of leptomeningeal disease. There is mild edema surrounding the left sided lesions, with mass effect on the fourth ventricle secondary to the left cerebellar lesion. There is no interval increase in the size of ventricles since the prior study. No shift of midline structures is identified. There is no hemorrhage within the lesions. No diffusion abnormalities are detected. Also seen are stable hyperintensities in the right internal capsule/corona radiata, thalamus, mid brain and cerebellar hemisphere, unchanged since the prior study. Major intracranial arterial flow voids are normal. Burr hole defect is seen in the right occipital region. IMPRESSION: 1. Multiple new areas of T2/FLAIR hyperintensity, associated with patchy enhancement in the region of the left cerebrum, corona radiata, internal capsule, pons, mid brain and left cerebellar hemisphere. The differential diagnosis includes meningoencephalitis, including viral, bacterial, fungal etiologies, ADEM and sarcoidosis. Lymphoma is considered less likely given the new areas of involvement and resolution of previous abnormality. 2. Mild mass effect on the fourth ventricle, without evidence of hydrocephalus. The above findings were discussed with Dr.[**Last Name (STitle) 54849**] at approximately 12:30 p.m on [**2121-4-28**]. [**5-4**] HCT: FINDINGS: Again noted are multiple white matter hypodensities throughout the brain, involving the bilateral centrum semiovale, corona radiata, internal capsules, and thalami, left greater than right; left temporal lobe; midbrain and pons; and left cerebellum and middle cerebellar peduncle. Lesion size and distribution is roughly unchanged, measuring up to 4.4 x 3.4 cm in the left cerebellum, and 4 x 2.7 cm in the left thalamus/temporal lobe. There is associated vasogenic edema, with continued ventricular/sulcal effacement, left greater than right; 4-mm rightward shift of the septum pellucidum; 2 mm rightward shift at the level of the third ventricle; and 5-mm rightward shift of the fourth ventricle. No acute hemorrhage or definite new lesions are identified within the limitations of the study. There is no hydrocephalus. Burr hole defect is noted in the right suboccipital region, with focal encephalomalacia from prior brain biopsy. IMPRESSION: Stable appearance of multiple white matter hypodensities, with continued ventricular/sulcal effacement and mild rightward shift. No definite evidence of increased mass effect. If clinically indicated, MRI can be considered for further evaluation. The nature of the lesions is uncertain from the present study. [**5-5**] EEG: ABNORMALITY #1: A slowed posterior background was seen with the optimal and maximal posterior rhythms in the 7 Hz range. ABNORMALITY #2: Frequent brief and prolonged bursts of polymorphic moderate to moderately high voltage disorganized mixed frequency theta was seen in a generalized distribution with a bifrontal voltage predominance. Some variable projection was seen with, at times, accentuation over the left hemisphere and, at times, over the right without clear laterality. No associated sharp or spike abnormalities were noted. BACKGROUND: The anterior-posterior voltage gradient was relatively preserved. HYPERVENTILATION: Not performed. INTERMITTENT PHOTIC STIMULATION: No activation was seen. The record was noted to have an episode of arm shaking following intermittent photic stimulation but direct observation of the video failed to reveal any evidence of rhythmic arm shaking or any EEG concomitants that would suggest an epileptiform abnormality associated. SLEEP: The patient transitioned briefly into stage I sleep with bursts of somewhat slower theta and faster delta in a generalized distribution. The patient did not achieve stage II sleep. CARDIAC MONITOR: No arrhythmias noted. IMPRESSION: Abnormal EEG due to a mildly slow posterior background rhythm for age with superimposed bursts of mixed frequency theta in a generalized distribution for the most part but with varying laterality at times, all suggestive of a mild diffuse encephalopathy with the superimposed slowing suggesting a possible transition to a more marked encephalopathy. No clear laterality could be seen nor was there any evidence of any discharging abnormalities. [**5-5**] CTA chest: INDICATION: 51-year-old female with meningoencephalitis, unclear etiology, referred to fule out possible mycotic aneurysm. COMPARISON: [**2120-7-12**]. TECHNIQUE: Non-contrast followed by post-contrast CTA imaging of the chest was performed, with administration of 100 mL of Optiray intravenous contrast. Multiplanar reformats are prepared and reviewed. FINDINGS: The lung volumes are low, and there is resultant scattered atelectasis. Evaluation of the parenchyma is also limited by respiratory motion. Within this limitation, there is no focal consolidation to suggest pneumonia, and there are no pulmonary nodules or masses identified. The pleural surfaces are smooth, without effusion or pneumothorax. The heart is unremarkable. There is no pericardial effusion. The aorta is normal in caliber, contour, and configuration, without evidence of acute aortic syndrome, and without evidence of mycotic aneurysm. There is a two-vessel configuration of the arch incidentally noted, with a common origin of the innominate and left common carotid arteries. . The pulmonary arteries are normal in caliber. There is no evidence of pulmonary embolus. The trachea and central airways are patent. There are no endobronchial lesions. There is a small hiatal hernia, but the esophagus is otherwise unremarkable. In the included upper abdomen, there is no acute abnormality identified. Visualized portion of the spleen, liver, and stomach are unremarkable. BONE WINDOWS: There are degenerative changes seen in the visualized thoracic spine, without suspicious lytic or sclerotic osseous lesion. IMPRESSION: Normal caliber and contour of the thoracic aorta, without evidence of mycotic aneurysm. [**5-10**] CT-neck: CLINICAL INFORMATION: Patient with meningoencephalitis and complaining of left incisor pain, question abscess in the neck. TECHNIQUE: Axial images of the neck were obtained from skull base to upper thoracic region with sagittal and coronal reformats. FINDINGS: There is no evidence of a soft tissue mass or an abscess identified in the neck. The nasopharyngeal and oropharyngeal soft tissues are symmetric in appearance. In the region of mandible, although evaluation is limited, no evidence of a periapical abscess identified. In the region of maxillary teeth, evaluation is limited secondary to artifacts. No distinct periapical abscess is identified. There is no evidence of bony destructive process seen. A bony defect is identified in the occipital bone as seen on the previous CT examination. IMPRESSION: No evidence of an abscess identified in the neck. No significant lymphadenopathy is seen in the neck. Limited evaluation of the teeth demonstrate no periapical abscess. Direct oral radiographs would be helpful for further assessment of periapical regions along with dental examination if clinically indicated. [**5-19**] Plain film X-ray of Left shoulder: COMPARISON: [**2120-11-18**]. FOUR VIEWS, LEFT SHOULDER: There is no acute fracture or dislocation. The glenohumeral joint is preserved aside from mild degenerative changes. No amorphous soft tissue calcifications. No fracture is identified. The visualized left hemithorax is clear. [**2121-5-21**] MRI brain: INDICATION: Patient with several lesions on prior studies, receiving antibiotics. Evaluate for interval change. TECHNIQUE: MRI of the brain was performed including sagittal T1 pre- and post-contrast, axial T1 pre- and post-contrast, axial FLAIR, axial T2, axial susceptibility, sagittal MP-RAGE with axial and coronal reformations, and diffusion-weighted sequences. COMPARISON: Multiple prior head MR studies dating back through [**2120-7-5**], including the most recent MR head from [**2121-4-28**]. FINDINGS: Compared to the most recent MR study from [**2121-4-28**], there has been progression of some and regression of other regions of abnormal T2-/FLAIR-hyperintensity. In the left middle cerebellar peduncle, a previously seen focus of T2-/FLAIR-hyperintensity, now appears slightly more confluent, measuring 2.9 x 2.8 cm, compared to 4.1 x 3.2 cm, previously. Enhancement within this area is also now more focal, with a lobular pattern (16:7) rather than the heterogeneous diffuse appearance seen on MR [**First Name (Titles) 767**] [**2121-4-28**]. Blooming artifact along the medial aspect of this lesion is consistent with prior hemorrhage, a finding also seen on MR [**First Name (Titles) 767**] [**10-30**], [**2119**]. This lesion causes unchanged degree of mass effect on the fourth ventricle, without resultant hydrocephalus. A second focus of T2-/FLAIR-hyperintensity, extending from posterior limb of the left internal capsule along the corticospinal tract to the left cerebral peduncle, is decreased in size compared to prior MR, measuring 2.2 x 1.1 cm in the axial plane on today's study, compared to 3.9 x 2.5 cm, previously. There may be interval extension of this lesion across the posterior body of the corpus callosum, into the medial aspect of the right centrum semiovale (6:16-17). Alternatively, the callosal involvement may represent a new, independent lesion. Enhancement of the lesion within the left internal capsule is focal and bipartite, a change compared to [**2121-4-28**], when there was more patchy, heterogeneous enhancement within this region (16:14). A focal round area of enhancement is centered within the callosal lesion (16:16, 19:12). Residuum of previously seen FLAIR-hyperintense lesions in the right middle cerebellar peduncle and right thalamus are noted and now show minimal, if any, enhancement. Additional small T2-/FLAIR-hyperintense lesions in the right corona radiata and right paramedian aspect of the midbrain are not significantly changed. There is no evidence of acute infarction or shift of normally-midline structures. Major intracranial arterial flow-voids are preserved. A burr hole is again seen in the right occipital region, secondary to prior biopsy. The visualized portions of the paranasal sinuses and mastoid air cells are well-aerated, aside from minimal bilateral ethmoidal air cell mucosal thickening. The orbits are grossly unremarkable. IMPRESSION: 1. Very unusual waxing and [**Doctor Last Name 688**] T2-/FLAIR-hyperintense lesions, some of which are centered on foci of intense enhancement, as well as evidence of chronic blood products, presumably related to prior hemorrhage. The differential diagnosis for this process remains extremely broad. Noninfectious demyelinating disease, such as "typical" multiple sclerosis, is thought to be less likely, given the presence of hemorrhagic foci within some of these lesions, although so-called "chronic" ADEM remains a possibility. Along these lines, an unusual form of hemorrhagic leukoencephalopathy, typically, an acute, fulminant rather than a chronic, relapsing illness, should also be considered, particularly given the identification of "microabscesses" on the previous brain biopsy. Other infectious or para-infectious processes such as CNS-variant Whipple's disease, chronic listeriosis or neuroborreliosis (CNS Lyme disease) also remain diagnostic considerations, though may have been ruled-out by the extensive diagnostic testing. Other, more remote considerations include granulomatoses such as Wegener's disease, sarcoidosis or Behcet's disease involving the CNS, though these entities, too, would appear to have been excluded by both biopsy and serologic testing. The same is likely true for the rare entity of so-called "Hashimoto encephalopathy" of thyroid origin. Finally, the intravascular variant of CNS lymphoma, a prime diagnostic consideration, initially, now appears less likely, given both the chronicity of the process, and the apparent "remission" of some of the lesions, in the absence of specific therapy. 2. Unchanged compression of the fourth ventricle secondary to the left middle cerebellar peduncular lesion, with no evidence of hydrocephalus. [**2121-5-21**] PATHOLOGY REPORT FOR BRAIN BIOPSY TISSUE -- <FINAL REPORT IS PENDING> [**5-21**] NCHCT post-op: INDICATION: 51-year-old female status post left cerebellar biopsy. COMPARISON: CT of [**2121-5-21**] at 18:20. TECHNIQUE: Contiguous axial images were obtained through the brain without IV contrast. Coronal and sagittal reformats were displayed. Please note the patient had IV contrast for the most recent scan performed approximately one and a half hours prior. FINDINGS: The patient is status left cerebellar biopsy via left occipital burr hole. There is a small amount of expected postoperative pneumocephalus. In addition, there is minimal hyperdensity layering along the left tentorial leaflet, likely blood products. There is otherwise no large intraparenchymal or extra-axial hemorrhage. The previously noted hyperdense foci in the left internal capsule and corpus callosum are somewhat less conspicuous on this non-contrast-enhanced CT. Ill-defined hypodensity in the right cerebellum is not significantly changed. Mass effect on the fourth ventricle is similar to prior. The remainder of the ventricles and sulci are unchanged in appearance. A right sub-occipital burr hole is again noted. IMPRESSION: Status post left cerebellar biopsy with expected pneumocephalus and a small amount blood products along the left tentorium. Otherwise, little changed from the prior CT and no large intra- or extra-axial hemorrhage. [**5-22**] Left UE doppler U/S to r/o DVT: INDICATION: Undiagnosed brain infection or malignancy. Persistent left arm and shoulder pain. Evaluate for clot in the left upper extremity. LEFT UPPER EXTREMITY VENOUS ULTRASOUND. COMPARISON: PICC line placement, [**2121-5-6**]. FINDINGS: Color and grayscale son[**Name (NI) 1417**] of bilateral subclavian and left-sided internal jugular, cephalic, basilic, and brachial and axillary veins were evaluated. Occlusive thrombus is present within the left cephalic vein. A PICC line is seen within one of the two paired brachial veins. Vessels other than the cephalic vein demonstrated normal flow, and compressibility. Symmetric waveforms were seen within the subclavian veins. IMPRESSION: Occlusive thrombus within the left cephalic vein. However no DVT. [**2121-5-27**] FDG - [**Month/Day/Year **]-CT of brain: RADIOPHARMACEUTICAL DATA: 10.4 mCi F-18 FDG ([**2121-5-27**]); HISTORY: Encephalitis METHODS: Approximately 1 hour after intravenous administration of F-18 fluorodeoxyglucose (FDG), noncontrast CT images were obtained for attenuation correction and for fusion with emission [**Year (4 digits) **] images. [The noncontrast CT images are not used to diagnose disease independently of the [**Year (4 digits) **] images.] A series of overlapping emission [**Year (4 digits) **] images was then obtained. The fasting blood glucose level, measured by glucometer before injection of FDG, was 102 mg/dL. The area imaged spanned the vertex to the base of the skull. Computed tomography (CT) images were co-registered and fused with emission [**Year (4 digits) **] images to assist with the anatomic localization of tracer uptake. The determination of the site of tracer uptake seen on [**Year (4 digits) **] data can have important implications regarding the significance of that uptake. INTERPRETATION: There is asymmetric decrease in FDG avidity in the right thalamus compared to the contralateral side. Otherwise, FDG avidity appears symmetric. There are two osseous occipital defects, presumably related to previous biopsies. IMPRESSION: Asymmetric decreased FDG avidity in the thalamus on the right. [**5-27**] CXR PA/lat:REASON FOR EXAMINATION: Increasing WBC count. AP & lateral radiograph of the chest were reviewed with comparison to [**2121-4-26**]. The left PICC line tip is at the junction of left brachiocephalic vein and SVC. Heart size is normal. Mediastinum is normal. Lungs are clear. There is no pleural effusion or pneumothorax. IMPRESSION: No evidence of acute cardiopulmonary process. [**2121-5-29**] Radiology IN-111 WHITE BLOOD CELL RESULT IS PENDING -- will be followed up by Infectious Diseases Brief Hospital Course: Upon admission, [**Known firstname **] was started on IV Ampicillin at 1gram IV. After one day, she developed higher temperatures of 102.3 and had several episodes of right arm clonic activity. It was thought initially that she was seizing and she was loaded with Dilantin 1500mg IV x one dose; this was not continued. She was later given Keppra (not continued), and then Zonegran (continued briefly, then stopped) for right arm tremor/clonic activity, but this was captured on EEG with no electrographic correlate; there is no plan to continue this. She had an MRI with contrast which showed as per the radiology report: 1. multiple new areas of T2/FLAIR hyperintensity, associated with patchy enhancement in the region of the left cerebrum, corona radiata, internal capsule, pons, mid brain and left cerebellar hemisphere. The differential diagnosis includes meningoencephalitis, including viral, bacterial, fungal etiologies, ADEM and sarcoidosis. Lymphoma is considered less likely given the new areas of involvement and resolution of previous abnormality. 2. Mild mass effect on the fourth ventricle, without evidence of hydrocephalus. On [**4-28**], she became increasingly somnolent despite stable blood pressures and heart rates. Since her MRI showed mass effect on the fourth ventricle, she was transferred to the ICU for closer monitoring over concerns of acute 4th ventricle obstruction. The etiology of her somnolence was thought to be secondary to the Dilantin. An EEG was done which ruled out nonconvulsive status epilepticus although did show encephalopathy. She had a lumbar puncture done which showed WBC 550 RBC 25 with a differential of 54 polys 41 lymphs 5 eosinophils, elevated of protein 155 and normal glucose of 49 which on the second tube cleared to WBC 315 RBC 90. Infectious disease was consulted who recommended that vancomycin and ceftriaxone be started and that Ampicillin be increased to 2gram dosing. [**Known firstname **] did receive two doses of IV steriods afterwhich was discontinued. [**Known firstname **] was transferred back to the floor [**5-1**]. She had a repeat lumbar puncture under fluoroscopy which showed: WBC "0" (in a traumatic tap with 4075 RBC), Protein 270 and glucose 52 With no clear diagnosis, under the guidance of our infectious diseases team, a second brain biopsy was obtained on [**5-21**]. An MRI the morning before the biopsy showed extension of the a Left lesion into and across the splenium of the corpus callosum (see [**5-21**] MRI report, above). Like the MR appearance, initial pathologic information, IHC, gram stain and cultures were unrevealing as to a specific etiology, as before (previous brain Bx in 9/[**2119**]). Final pathology report is pending. The case was discussed with [**Hospital1 112**] pathology. ID sent a sterile sample of the Bx material to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] for 60S ribosomal PCR analysis (sensitive test for any type of bacteria), and the results were verbally relayed to us from UW as negative (per Dr. [**Last Name (STitle) 6137**], ID fellow). A [**Last Name (STitle) **]-CT of the brain did not reveal any evidence of FDG-avid lesion. A tagged WBC scan of the body was obtained on the day of discharge, and ID will follow up the results of this study when they see Mrs. [**Known lastname 54845**] in clinic. ID will follow Ms. [**Known lastname 54845**] in clinic, as will Dr. [**Last Name (STitle) 2340**] of Neuro-Infectious Diseases. ID's discharge plan included the following explicit instructions: OUTPATIENT ANTIBIOTIC REGIMEN AND PROJECTED DURATION: [**Doctor Last Name **] and DOSE: Vancomycin 1g Q8h Ceftriaxone 2g Q12h Start date: [**2121-5-3**] Stop date: [**2121-6-27**] (8 weeks minimum) Followed by a course of oral antibiotics to be determined. REQUIRED LABORATORY MONITORING: * LAB TESTS: CBCdiff, BUN, CREA, LFTs, Vanco trough, ESR, CRP, CK * FREQUENCY: Qweekly All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] TYPE OF INTRAVENOUS ACCESS: 51cm Left BRACHIAL v. PICC All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] or to on [**Name8 (MD) 138**] MD in when clinic is closed Medications on Admission: CITALOPRAM [CELEXA] - 10 mg Tablet - 1 Tablet(s) by mouth once a day RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth twice a day ZOLPIDEM [AMBIEN] - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime as needed for insomnia Medications - OTC ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 1,000 unit Tablet - 1 and half Tablet(s) by mouth once a day Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itchy skin. 6. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for to groin. 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO PRN daily as needed for constipation. 8. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 9. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for mood. 11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 13. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 14. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 15. meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for Vertigo. 16. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 19. Ondansetron 4 mg IV Q8H:PRN nAUSEA/VOMITING 20. CeftriaXONE 2 gm IV Q12H (stop date is [**2121-6-27**], to finish 8wk course, recommended by ID) 21. Vancomycin 1000 mg IV Q 8H meningoencephalitis (stop date is [**2121-6-27**], to finish 8wk course, recommended by ID) Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Primary diagnosis: 1. Meningoencephalitis of undetermined etiology Secondary diagnoses: 1. Depressed Mood 2. Superficial venous thrombosis (Left cephalic vein) 3. Vertigo Discharge Condition: Activity Status: Out of Bed with assistance to chair or wheelchair at least [**Hospital1 **]. Walk with PT. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Neurologic exam notables on day of discharge: - Mental status: A&Ox3. Speech is fluent and not dysarthric; comprehension is intact. Affect flat, mood improved from 1-2wk prior (occasionally smiles). No overt apraxia (brush teeth) or neglect. - CN: Right eye skew up and unable to abduct quite fully; pt denies diplopia, but c/o 'bad vision' in general (with one or both eyes open). Nystagmus has resolved x 2wk+ ago. VFF grossly. Left facial droop as before. - Motor: Left partial hemiparesis stable for several weeks, with +drift of left arm (delt is 4-, tri is [**2-21**], [**Hospital1 **] is 4, WE is [**2-21**], FE [**2-21**], dIOs 3, FEs 4). Left LE is slightly weak (IP 4 to 4+, hams 4+, quad full, TA/[**Last Name (un) 938**] 4+, gastrocs full). Right UE is full but for 4+ delt. Right LE is full. - Sensory - mild subjective decrease to pinprick/cold on the Left UE+/-LE vs. the Right. No neglect/extinction. No substandn a cortical sensory deficit by graphesthesia/stereoagnosia testing. - Coordination: mild dysmetria bilaterally on FNF. No titubation but weakness with sitting / standing (requires substantial support for both). - Gait: hesitatant and requires full support to take small steps with PT. Discharge Instructions: You were admitted to the hospital because of worsening weakness, double vision, sore throat and fever. During this admission, we found that you have recurrence of meningoencephalitis, this time with several lesions on the LEFT side of your brain as compared with before, when you had lesions on the Right side of your brain. We did several tests to try and look for a cause including a CT scan of your head and neck, cardiac echocardiogram, tests for immunodeficiency, blood and urine cultures, lumbar puncture (spinal tap) with cultures, MR [**First Name (Titles) **] [**Last Name (Titles) **] imaging, a tagged-WBC scan, and a second brain biopsy with comprehensive immunohistochemical, culture, and PCR testing for infections and other pathologies. We did not find a source for your infection on cultures, despite the involvement of infectious disease and pathology services here and at collaborating hospitals. The infectious disease service will continue to follow you in clinic as an outpatient. You will finish an eight-week course of antibiotics for empiric treatment. Other issues that arose during your hospital stay here include: you were started on an SSRI medication to improve your mood. You were given a medication (meclizine, a.k.a. Antivert) to help with your dizziness, which is probably due to involvement of your cerebellum in the meningoencephalitis. You had a few episodes of Right arm +/- leg shaking, which did not appear to be a seizure on our examination or on the tests for seizures, your two EEGs (both negative for seizure acitivity, including one test during which the shaking was observed). You were given anti-epileptic medications briefly, but these were stopped because there is no evidence that the shaking was due to seizure activity, and you are not thought to be at significantly increased risk for seizure based on the locations of your brain lesions (mostly beneath the cerebral cortex). You have a history of frozen/uncomfortable shoulder, and had some Left shoulder pain here. We examined the shoulder with doppler-ultrasound imaging to look for a deep venous thrombosis, and found none; you had a stable, supervicial clot in your cephalic vein, which is a different vein from the one with your PICC (the brachial vein), so the PICC was left in place. You recovered well from your brain biopsy, and finished a short course of steroid medication. You worked with our Physical Therapists, and will continue PT in an Acute Rehabilitation Facility. Followup Instructions: 1. FOLLOW UP APPOINTMENTS SCHEDULED: [**2121-6-9**] 10:00a ID,[**Doctor Last Name **] [**Doctor First Name 2482**] LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT ID WEST (SB) 2. Please call to arrange follow-up with Dr. [**Last Name (STitle) 2340**] of Neurology-Infectious Diseases: please call [**Telephone/Fax (1) 2756**] M-F and ask for Neurology / [**Hospital **] clinic. REQUIRED LABORATORY MONITORING: LAB TESTS: CBCdiff, BUN, CREA, LFTs, Vanco trough, ESR, CRP, CK FREQUENCY: Qweekly All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] [**Name6 (MD) 3523**] [**Name8 (MD) 3524**] MD [**MD Number(2) 21196**] Completed by:[**2121-5-30**]

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Discharge summary

report

Admission Date: [**2105-11-2**] Discharge Date: [**2105-11-10**] Date of Birth: [**2034-9-5**] Sex: M Service: CARDIOTHORACIC Allergies: Atenolol / Iodine-Iodine Containing / Ibuprofen / Bactrim / IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest burning/fatigue Major Surgical or Invasive Procedure: s/p Aortic Valve Replacement (#21mm St.[**Male First Name (un) 923**] tissue)/ Coronary artery bypass grafting x 3(Left internal mammary artery grafted to the left anterior descending artery/ saphenous vein grafted to Obtuse Marginal and Posterior descending artery) on [**11-2**] History of Present Illness: This is a 71 year old Spanish speaking male with a history of Burkitt-like Lymphoma/Non Hodgkin's Lymphoma, hypertension, hyperlipidemia and coronary artery diseas s/p multiple PCI/stents. He initially presented with an acute MI and rescue PTCA/stenting of his LAD back in [**11/2090**] and stenting of his OM1 in [**2093-3-11**]. On [**2094-2-26**] he was re-cathed d/t progressive dyspnea and complaints of chest pain. Angiography revealed a 30% stenosis proximal to the LAD stents and partially in the first stent, LCx with no significant disease, OM1 stent widely patent, small OM2 with a 80% stenosis, RCA with a 90% lesion in the proximal portion, mid RCA 80%. EF at that time was noted at 39%. Successful PTCA and stenting of the proximal and mid RCA completed at this time.He underwent a cardiac cath on [**2105-9-3**] which revealed a patent left main stent and LAD stents, 70% diagonal lesion, LCX ostial 90% stenosis in jailed segment, RCA with proximal in-sent restenosis 70-80%. Echo on this day showed moderate aortic stenosis. He was then referred for surgery. Past Medical History: Past Medical History: Coronary artery disease s/p Myocardial infarction s/p Multiple PCI/Stents Hypertension Hyperlipidemia Hypothyroidism Thrombocytopenia Non Hodgkin's Lymphoma/Burkitt-like Lymphoma- Rituxan completed [**2-20**] Peptic ulcer disease GERD Impotence Arthritis/DJD History of atrial fibrillation + PPD with negative chest ray Colon Polyps Chronic sinusitis Sciatica/Back pain Arthritis Past Surgical History: s/p Removal of left-sided indwelling port [**2105-6-23**] s/p Shoulder surgery, left s/p Abdominal hernia repair Social History: Race: Hispanic-Originally from [**Country 7192**] Last Dental Exam: 2 yrs ago Lives with: Wife, daughter, and 2 grandchildren Occupation: Retired, former tailor Cigarettes: Smoked no [] yes [X] last cigarette: quit 25 yrs ago Hx: 1 ppd x 30 yrs ETOH: < 1 drink/week [X] [**2-17**] drinks/week [] >8 drinks/week [] Illicit drug use: - Family History: Family History: No premature coronary artery disease Sister - leukemia Mother - died of PNA in [**2080**] Physical Exam: Admission Pulse: 60 B/P 144/72 Resp: 16 O2 sat: 97% Height: 5'2" Weight: 174 lbs General: Well-developed male in no acute distress Skin: Warm [X] Dry [X] intact [X] HEENT: NCAT [X] PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade [**3-17**] Abdomen: Soft [X] non-distended [X] non-tender [X] +BS [X] Extremities: Warm [X], well-perfused [X] Edema - Varicosities: None [X], spider veins Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit: Right/Left: trans murmur Discahrge VS T 98.7 HR 65 SR BP 110/61 RR 18 O2sat 95% RA Wt 74.8kg Gen: NAD Neuro: A&O x3, nonfocal exam Pulm: CTA [**Last Name (un) **] CV: RRR, sternum stable. Incision CDI Abdm: soft, NT,ND, +BS Ext: warm, well perfused. trace pedal edema bilat. Left EVH site CDI Pertinent Results: Admission Labs: [**2105-11-2**] 08:53PM BLOOD Na-138 K-4.3 Cl-110* [**2105-11-2**] 01:59PM BLOOD UreaN-9 Creat-0.7 Na-140 K-4.0 Cl-112* HCO3-26 AnGap-6* [**2105-11-2**] 07:35AM HGB-12.8* calcHCT-38 [**2105-11-2**] 07:35AM GLUCOSE-98 LACTATE-1.0 NA+-137 K+-3.5 CL--106 [**2105-11-2**] 12:31PM PT-19.0* PTT-38.7* INR(PT)-1.7* [**2105-11-2**] 12:31PM PLT SMR-LOW PLT COUNT-83* [**2105-11-2**] 12:31PM WBC-8.9 RBC-2.42*# HGB-7.9*# HCT-22.2*# MCV-92 MCH-32.7* MCHC-35.6* RDW-14.2 [**2105-11-2**] 01:59PM UREA N-9 CREAT-0.7 SODIUM-140 POTASSIUM-4.0 CHLORIDE-112* TOTAL CO2-26 ANION GAP-6* Discahrge labs: [**2105-11-9**] 04:55AM BLOOD WBC-8.9 RBC-2.88* Hgb-9.3* Hct-26.8* MCV-93 MCH-32.3* MCHC-34.7 RDW-15.9* Plt Ct-183 [**2105-11-9**] 04:55AM BLOOD Plt Ct-183 [**2105-11-9**] 04:55AM BLOOD PT-11.7 INR(PT)-1.1 [**2105-11-9**] 04:55AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-141 K-4.1 Cl-106 HCO3-29 AnGap-10 [**2105-11-6**] 05:44AM BLOOD ALT-15 AST-29 AlkPhos-31* Amylase-67 TotBili-0.7 [**2105-11-9**] 04:55AM BLOOD Mg-2.1 TEE [**2105-11-2**] Findings LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Lipomatous hypertrophy of the interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Normal LV cavity size. Moderate regional LV systolic dysfunction. Moderately depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Focal calcifications in ascending aorta. Simple atheroma in aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Severe AS (area 0.8-1.0cm2). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. No MS. Physiologic MR (within normal limits). LV inflow pattern c/w impaired relaxation. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. Conclusions PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with apical,mid-distal anterior, and mid-distal septal akinesis. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area 0.9 cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The left ventricular inflow pattern suggests impaired relaxation. There is no pericardial effusion. POST-BYPASS: There is normal right ventricular systolic function. The left ventricle continues to display apical and mid to distal anterior and septal akinesis but basilar and mid segments of all the other wall segments show improved function. The left ventricular EF is about 40%. There is a well seated prosthetic valve in the aortic position with no evidence of perivalvular or valvular regurgitation. The peak gradient was 30 mm Hg, with a mean of 14 mm Hg at a cardiac output of 3.8. The effective valve area is about 1.2 cm2. The rest of valvular function is unchanged from the prebypass study. The thoracic aorta is intact after decannulation. Radiology Report CHEST (PA & LAT) Study Date of [**2105-11-6**] 9:33 AM Final Report: PA and lateral views of the chest are obtained. There is some improvement in the left lower lobe atelectasis with one area of linear atelectasis remaining. The cardiomediastinal silhouette is unchanged since prior study and right internal jugular line remains unchanged in position. A right pleural effusion is again seen. CONCLUSION: Improved left lower lobe opacification with some remaining linear atelectasis. Right pleural effusion is again seen. Otherwise, unchanged since the prior study. Brief Hospital Course: On [**2105-11-2**] Mr.[**Known lastname **] was taken to the operating room and underwent Aortic Valve Replacement (#21mm St.[**Male First Name (un) 923**] tissue)/ Coronary artery bypass grafting x 3(Left internal mammary artery grafted to the left anterior descending artery/ saphenous vein grafted to Obtuse Marginal and Posterior descending artery) with Dr.[**Last Name (STitle) **]. Please see operative report for further surgical details. He tolerated the procedure well and was transferred to the CVICU intubated and sedated for further monitoring. He awoke neurologically intact and was weaned to extubation. He weaned off pressor support and Beta-blockers/ Statin/ASA and diuresis were initiated. Chest tubes and pacing wires were discontinued per protocol. POD#1 he was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. POD# 2 he went had intermittent bursts of atrial fibrillation. It resolved with increased Beta-blocker and electrolyte repletion. He complained of constipation and abdominal discomfort and was found to have dilated loops of bowel. Agressive bowel regimen was instated and he was given only clear liquids for one day. He moved his bowels, tolerated a regular diet, and his abdominal symptoms resolved. He continued to progress and was ready for discharge to home on POD8 All follow up appointments were advised. Medications on Admission: AMOXICILLIN-POT CLAVULANATE - amoxicillin-potassium clavulanate 875 mg-125 mg tablet. 1 tablet(s) by mouth twice a day - (Prescribed by Other Provider) CARVEDILOL - carvedilol 12.5 mg tablet. Tablet(s) by mouth twice a day - (Prescribed by Other Provider) ISOSORBIDE MONONITRATE - isosorbide mononitrate ER 30 mg tablet,extended release 24 hr. 1 tablet(s) by mouth once a day - (Dose adjustment - no new Rx) LEVOTHYROXINE - levothyroxine 50 mcg tablet. 1 tablet(s) by mouth once daily - (Prescribed by Other Provider) LISINOPRIL - lisinopril 40 mg tablet. 1 Tablet(s) by mouth once daily NITROGLYCERIN - nitroglycerin 0.4 mg sublingual tablet. 1 (One) tablet(s) sublingually as needed for chest pain - (Prescribed by Other Provider) OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth once a day - (Prescribed by Other Provider) SIMVASTATIN - simvastatin 80 mg tablet. 1 Tablet(s) by mouth once daily - (Prescribed by Other Provider) Medications - OTC ASPIRIN - aspirin 81 mg chewable tablet. 1 Tablet(s) by mouth once a day - (Prescribed by Other Provider) Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Carvedilol 12.5 mg PO BID 3. Levothyroxine Sodium 50 mcg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Simvastatin 80 mg PO DAILY 6. Acetaminophen 650 mg PO Q4H:PRN fever, pain 7. Amiodarone 400 mg PO DAILY 400mg Daily x 7 days then 200mg daily 8. Docusate Sodium 100 mg PO BID 9. Furosemide 20 mg PO DAILY 10. Potassium Chloride 20 mEq PO DAILY 11. Nitroglycerin SL 0.3 mg SL PRN cp Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: primary: Aortic Stenosis/ CAD Coronary artery disease s/p Myocardial infarction s/p Multiple PCI/Stents Hypertension Hyperlipidemia Secondary: Hypothyroidism Thrombocytopenia Non Hodgkin's Lymphoma/Burkitt-like Lymphoma- Rituxan completed [**2-20**] Peptic ulcer disease GERD Impotence Arthritis/DJD History of atrial fibrillation + PPD with negative chest ray Colon Polyps Chronic sinusitis Sciatica/Back pain Arthritis Past Surgical History: s/p Removal of left-sided indwelling port [**2105-6-23**] s/p Shoulder surgery, left s/p Abdominal hernia repair Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol 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 one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] [**2105-12-9**] at 1:00 PM Cardiologist: on [**2105-11-20**] at 2:00 (with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) Wound check in [**Hospital Ward Name **] Office Building on [**2105-11-12**] at 10:45a Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**1-12**] weeks [**Telephone/Fax (1) 14918**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2105-11-10**]

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icd9cm

[ [ [] ] ]

[ "36.12", "35.21", "39.61", "36.15" ]

icd9pcs

[ [ [] ] ]

11825, 11882

8823, 10250

390, 673

12484, 12703

3823, 3823

13506, 14160

2725, 2817

11392, 11802

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2832, 3804

328, 352

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3839, 8800

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2357, 2693

58,792

127,563

16571

Discharge summary

report

Admission Date: [**2159-12-12**] Discharge Date: [**2159-12-18**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 783**] Chief Complaint: fevers, chills Major Surgical or Invasive Procedure: Placement of Percutaneous cholecystostomy tube History of Present Illness: History of Present Illness: 89 y/o male with multiple medical problems from [**Name (NI) **] [**Hospital **] nursing home with hx of CAD s/p 3-vessel CABG, hx CHF (EF 50-55% in [**1-5**]), HTN, COPD (on intermittent home oxygen), hx CKD III (Baseline Cr 1.3) who presents after being discharged from [**Hospital1 **] [**2159-11-27**] when he had ERCP for cholecystitis with sphincterotomy and sphincteroplasty, now p/w 2-3 days of worsening RUQ pain. +nausea today, no vomiting. No diarrhea or subjective fever. No BM in 10 days. . He has significant memory problems and is somewhat of a poor historian, but he states the pain comes on abruptly and then gradually decreases. He does not know what precipitated his pain and he does not know if anything makes it better. He was admitted to [**Hospital1 18**] several weeks ago for cholecystitis at which time he had ERCP with removal of sludge and small stones. He does not remember when he had his most recent bowel movement or whether eating affects his pain. . In the ED, initial VS were: 5, 98.5, 66, 113/45, 16, 95% RA. Labs notable for WBC 16.1, ALT 17, AST 18, AP 100, lipase 24, Tbili 1.1, albumin 3.7, lactate 1.0. Bcx pending. CT abd/pelvis showing, "dilated GB with pericholecystic stranding and gb wall thickening concerning for acute cholecystitis. Air in GB likely secondary to recent ERCP. Urinary bladder wall thickening and enhancement concerning for cystitis. Unchanged right inguinal bowel containing hernia and appendix containing right spigelian hernia." Surgery was called: likely needs perc chole tube, they will call IR. . Pt is being admitted for acute cholecystitis. IR was paged. Pt given IV unasyn and 500 cc IVF prior to transfer. In the MICU, they did percutaneous cholecystostomy in IR, with improvement in his pain, but still mildly tender. Cefepime was added given concern for UTI and resistant E. coli in the past. He was continued on Flagyl for anaerobic coverage. He was given IVF's, and is now +2L for LOS. Past Medical History: CAD s/p CABG in [**2158-3-27**] Coronary bypass grafting x3: Reverse saphenous vein graft from aorta to posterior descending coronary artery; reverse saphenous vein single graft from aorta to second obtuse marginal coronary artery; as well as reverse saphenous vein single graft from aorta to the first diagonal coronary artery. Mild cognitive impairment per OMR notes Congestive heart failure with preserved LVEF (last TTE [**12/2158**]) Hypertension Hypercholesterolemia COPD on intermittent home oxygen PTSD- WWII Veteran Right Facial Nerve Palsy Stage III chronic kidney disease (baseline Cr: ~1.3) History of herpes Zoster Bilateral Cataract Surgery Left Inguinal Hernia Repair Right Inguinal Hernia- Not repaired Benign Prostatic Hypertrophy Anemia Eczema Hard of hearing GERD Malaria over 30 years ago while in [**Country 480**] Social History: Worked in hospital administration. Quit smoking cigarettes over 20 years ago. Quit smoking pipe in his mid 50s. Denies alcohol or drug use. Family History: Brothers/sisters with CAD, no hx of DM, HTN, cancer Physical Exam: PHYSICAL EXAM ON ADMISSION: Vitals: 100.3, 120/55, 94, 24, 94% 2L NC GA: NAD, resting comfortably in bed w/o complaints HEENT: PERRLA. MM dry. no LAD. no JVD. neck supple. Cards: RRR S1/S2 heard though distant heart sounds. no murmurs/gallops/rubs appreciated. Pulm: CTAB no crackles or wheezes though very diminished breath sounds throughout Abd: soft, tenderness over RUQ, +BS. No hepatosplenomegaly. Extremities: wwp, no edema. DPs, PTs 1+. Skin: Dry and intact Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. PHYSICAL EXAM ON DISCHARGE: Pertinent Results: Lab Results on Admission: [**2159-12-12**] 02:00PM BLOOD WBC-16.1*# RBC-4.25* Hgb-13.2* Hct-37.4* MCV-88 MCH-31.1 MCHC-35.4* RDW-13.5 Plt Ct-200# [**2159-12-12**] 02:00PM BLOOD Neuts-89.8* Lymphs-4.8* Monos-5.0 Eos-0.3 Baso-0.1 [**2159-12-12**] 08:08PM BLOOD PT-13.5* PTT-27.0 INR(PT)-1.1 [**2159-12-12**] 02:00PM BLOOD Glucose-210* UreaN-29* Creat-1.1 Na-133 K-4.3 Cl-96 HCO3-27 AnGap-14 [**2159-12-12**] 02:00PM BLOOD ALT-17 AST-18 AlkPhos-100 TotBili-1.1 [**2159-12-12**] 02:00PM BLOOD Lipase-24 [**2159-12-12**] 02:00PM BLOOD Albumin-3.7 Calcium-8.9 Phos-3.3 Mg-2.1 [**2159-12-12**] 02:41PM BLOOD Lactate-1.0 Studies: [**12-12**] ECG's: Sinus tachycardia. The tracing is marred by baseline artifact. There is frequent ventricular ectopy. Right bundle-branch block persists. Repeat tracing of diagnostic quality is suggested. Sinus rhythm. Right bundle-branch block. Non-specific inferior ST-T wave flattening. Compared to the previous tracing of [**2159-11-22**] ventricular ectopy is no longer recorded. The rate has slowed. Otherwise, no diagnostic interim change. [**12-12**] CT Abdomen and Pelvis: IMPRESSION: 1. Findings concerning for acute cholecystitis. 2. Findings concerning for UTI/cystitis. 3. Extensive diverticulosis without diverticulitis. 4. Right Spigelian hernia containing the appendix and small bowel containing right inguinal hernia, no associated bowel obstruction. [**12-12**] Gallbladder Drainage: IMPRESSION: Uncomplicated placement of percutaneous cholecystostomy catheter (8 French [**Last Name (un) 2823**] catheter) via a right subcostal transhepatic approach. Specimen sent for microbiology analysis. [**12-13**] CXR: IMPRESSION: Persistent left basilar scarring. No acute cardiopulmonary process. [**12-13**] Abdominal Xray: IMPRESSION: No evidence of obstruction or ileus. [**Date range (1) 47017**] Blood Cultures: negative [**2159-12-12**] 11:24 pm URINE Source: Catheter. **FINAL REPORT [**2159-12-17**]** URINE CULTURE (Final [**2159-12-17**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ENTEROCOCCUS SP. | | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R <=2 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S <=16 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R VANCOMYCIN------------ 2 S [**2159-12-12**] 11:23 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2159-12-15**]** MRSA SCREEN (Final [**2159-12-15**]): No MRSA isolated. [**2159-12-13**] 12:11 am BILE **FINAL REPORT [**2159-12-17**]** GRAM STAIN (Final [**2159-12-13**]): Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2159-12-13**] AT 0305. 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). FLUID CULTURE (Final [**2159-12-16**]): ESCHERICHIA COLI. MODERATE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. 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--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Final [**2159-12-17**]): NO ANAEROBES ISOLATED. LAB RESULTS ON DISCHARGE: [**2159-12-17**] 04:42AM BLOOD WBC-7.3 RBC-4.05* Hgb-12.6* Hct-36.3* MCV-90 MCH-31.0 MCHC-34.6 RDW-13.3 Plt Ct-182 [**2159-12-13**] 02:58AM BLOOD Neuts-94.0* Lymphs-3.0* Monos-2.9 Eos-0.1 Baso-0 [**2159-12-14**] 04:47AM BLOOD PT-14.3* PTT-31.1 INR(PT)-1.2* [**2159-12-18**] 09:22AM BLOOD Glucose-352* UreaN-23* Creat-1.1 Na-133 K-4.0 Cl-97 HCO3-27 AnGap-13 [**2159-12-14**] 04:47AM BLOOD ALT-15 AST-17 LD(LDH)-144 AlkPhos-77 TotBili-0.4 [**2159-12-18**] 09:22AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.0 Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: Patient is an 89yo male with multiple medical problems including CAD s/p 3-vessel CABG, hx CHF (EF 50-55%), COPD (on intermittent home oxygen), CKD III (Baseline Cr 1.3) who presents after being discharged from [**Hospital1 **] [**2159-11-27**] when he had ERCP for cholecystitis with sphincterotomy and sphincteroplasty, now presented with 2-3 days of worsening RUQ pain and nausea, with radiographic evidence concerning for acute cholecystitis. He underwent percutaneous cholecystostomy resulting in relief of symptoms. . 1. Acute cholecystitis: Patient presented with worsening right upper quadrant abdominal pain and tenderness. He had elevated WBC count with left shift and evidence on CT of gallbladder wall distension, thickening, pericholecystic stranding, all concerning for recurrent cholecystitis. His case was discussed with ERCP team, and there is no evidence for biliary dilation or stone which is visualized on CT abdomen. After discussion with surgery and IR, patient underwent a percutaneous cholecystostomy tube placement as he was not a cadidate for cholecystectomy at this time. After placement patient's abdominal pain decreased. He was placed on a course of Unasyn and flagyl which he completed. Patient remained hemodynamically stable and his diet was advanced. He was discharged with symptomatic relief, hemodynamic stability, and percutaneous cholecystostomy tube in place. . 2. Cystitis: Patient had evidence of cystitis on CT scan. UA was consistent with bacterial infection. Has had previous UTI with resistant E. coli. Patient was covered with IV flagyl and cefepime to cover both UTI as well as intra-abdominal infection. He maintained adequate urine output. He was discharged after completing an antibiotic course, with falling WBC count and no symptoms of dysuria. . CHRONIC CARE: 1. Right inguinal hernia and appendix containing right spigelian hernia: per surgery, while impressive, does not warrant surgical management as he is not obsructing. . 2. CAD s/p CABG x 3: Continued aspirin, metoprolol, simvastatin . 3. CHF with preserved EF: Currently appears euvolemic. Continued home medications . 4. HTN: continued home metoprolol . 5. HLD: Continued statin . 6. COPD: Continued home fluticasone, ipratropium-albuterol . 7. Stage 3 CKD: baseline Cr 1.3 and currently improved from baseline. . 8. GERD: Continued home omeprazole . TRANSITIONS IN CARE: 1. FOLLOW-UP APPOINTMENTS: PCP, [**Name Initial (NameIs) **] 2. MEDICATION CHANGES: 1. START Cefpodoxime 400mg by mouth twice daily for 8 more days 2. START Acetaminophen 500mg by mouth every 6 hours as needed for pain 3. STOP taking diazepam nightly for sleep. You may speak with your PCP about alternative sleep medications or other therapies. You did not require this while you were here and this medication can cause confusion. Medications on Admission: 1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for sob/wheezing. 5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO at bedtime. 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Zyprexa 2.5 mg Tablet Sig: 0.5 Tablet PO twice a day. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 10. diazepam 5 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. 11. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual q5min x3 as needed for chest pain. 12. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray Nasal twice a day as needed for allergy symptoms. Discharge Medications: 1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO HS (at bedtime). 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. olanzapine 2.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 5 minutes for maximum three doses as needed for chest pain: notify your doctor if you take 3 tabs and still have pain. 11. cefpodoxime 100 mg Tablet Sig: Four (4) Tablet PO Q12H (every 12 hours) for 8 days. Disp:*64 Tablet(s)* Refills:*0* 12. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray Nasal twice a day as needed for allergy symptoms. 13. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: do not take more than 4 grams per day of acetaminophen. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Cholecystitis Secondary: Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to the hospital for belly pain and were found to have gallbladder inflammation. We placed a drain into the gallbladder to drain fluid that had built up and relieve the inflammation. After placing the drain your belly pain has improved. We also treated you with antibiotics for a urinary tract infection that we found. You are doing well on antibiotics for this. You will continue to have the drain in until you see the surgeons for follow-up. Please make the following changes to your medications when you are discharged: 1. START Cefpodoxime 400mg by mouth twice daily for 8 more days 2. START Acetaminophen 500mg by mouth every 6 hours as needed for pain 3. STOP taking diazepam nightly for sleep. You may speak with your PCP about alternative sleep medications or other therapies. You did not require this while you were here and this medication can cause confusion. Please take all other medications as prescribed Please keep your follow-up appointments. Physical therapy and VNA will be coming to your home to work with you upon discharge. Followup Instructions: Please follow-up with the following appointments: Department: [**Hospital1 18**] [**Location (un) 2352**] When: WEDNESDAY [**2159-12-26**] at 2:30 PM With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Name: [**Last Name (LF) **], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD Specialty: SURGERY Address: [**Street Address(2) **],STE 1W, [**Location (un) **],[**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 8792**] Appointment: TUESDAY [**1-8**] AT 10:30AM Department: [**Hospital1 18**] [**Location (un) 2352**] When: MONDAY [**2160-2-18**] at 11:30 AM With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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icd9cm

[ [ [] ] ]

[ "51.01" ]

icd9pcs

[ [ [] ] ]

14686, 14743

9156, 11580

267, 316

14845, 14845

4019, 4031

16153, 17337

3370, 3423

13196, 14663

14764, 14824

12045, 13173

15028, 16130

3438, 3452

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4000, 4000

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11664, 12019

213, 229

372, 2337

4046, 8619

14860, 15004

2359, 3196

3212, 3354

8,447

118,819

22887

Discharge summary

report

Admission Date: [**2134-11-10**] Discharge Date: [**2134-11-13**] Date of Birth: [**2084-11-21**] Sex: F Service: SURGERY Allergies: Optiray 320 Attending:[**First Name3 (LF) 668**] Chief Complaint: Left hand numbness, tingling, weakness Major Surgical or Invasive Procedure: ligation L AV graft History of Present Illness: The patient is a 49 y/o female with diabetes mellitus s/p cadaveric renal transplant [**12-7**] who presented for ligation of a left upper extremity graft that had caused her to experience left hand numbness, tingling, and weakness and subsequently became acutely hypoxic in the PACU. In the PACU, her oxygen saturation dropped to 68% on room air, but increased into the 90s with oxygen supplementation via nasal canula and deep breathing. ECG obtained in the PACU showed sinus rhythm with no ST segment changes. Chest x-ray showed congestive heart failure. A VQ scan showed no evidence of PE. The patient denied any lightheadedness, dizziness, shortness of breath, chest pain, or palpitations. The patient currently smokes a pack of cigarettes every 2 days. She also denies fever, chills, nausea, vomiting, abdominal pain, or dysuria. Past Medical History: 1. ESRD s/p cadaveric renal transplant [**12-7**] 2. Diabetes mellitus with diabetic retinopathy 3. Hepatitis virus C 4. osteoporosis 5. h/o left arm AV fistula 6. hysterectomy Social History: Patient smokes half a pack of cigarettes per day. She denies alcohol or recreational drug use. Family History: Mother died of MI at age of 67. Physical Exam: T 98.0 P 85 BP 145/65 R 20 SaO2 98% 6L FM Gen - no acute distress Heent - no scleral icterus, neck supple, mucous membranes moist Lungs - crackles at bases Heart - regular rate and rhythm abd - soft, nontender, nondistended, bowel sounds + Extrem - no lower extremity edema, warm, well-perfused Pertinent Results: [**2134-11-11**] 12:40AM BLOOD WBC-6.6 RBC-4.29 Hgb-12.8 Hct-37.6 MCV-88 MCH-29.8 MCHC-34.0 RDW-16.9* Plt Ct-167 [**2134-11-11**] 12:40AM BLOOD Glucose-157* UreaN-10 Creat-0.8 Na-140 K-4.1 Cl-103 HCO3-29 AnGap-12 [**2134-11-11**] 12:40AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1 [**2134-11-11**] 05:25PM BLOOD CK(CPK)-94 [**2134-11-11**] 05:25PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2134-11-10**] 06:30PM BLOOD Type-ART Temp-36.3 Rates-/16 pO2-34* pCO2-50* pH-7.38 calTCO2-31* Base XS-2 Intubat-NOT INTUBA Brief Hospital Course: The patient was admitted for her hypoxia and monitored. It was unclear why the patient suddenly became hypoxic from her congestive heart failure during the operation or in the interval following her operation as she only received 200cc of crystalloid during the AV fistula ligation and her oxygen saturation was 98% on room air pre-operatively. Cardiac enzymes were negative. The following day, the patient was administered lasix for diuresis and encouraged to perform incentive spirometry, but continued to require supplemental oxygen. A chest CT scan was obtained which showed: 1. Soft tissue mass in the anterior mediastinum, which is highly suspected to be thymoma. Further evaluation with MRI is recommended for better characterization of these findings. 2. There are multiple areas of discoid atelectasis. 3. Cardiomegaly. The findings on the CT scan did not clarify the reason for the patient's gross hypoxia. An transthoracic echocardiogram was performed which showed normal EF. The patient continued to remain hypoxic on room air and was discharged with supplemental oxygen. She will follow up with Pulmonary in regards to her hypoxia. Thoracic surgery consult was obtained for the patient's thymoma and she will follow up with that service as an outpatient. Prograf levels were checked on a daily basis and dosed accordingly. At the time of discharge, the patient was able to ambulate on supplemental oxygen without symptoms and was tolerating a regular, diabetic diet well. Her initial symptoms of left hand numbness, tingling, and weakness had also improved after they surgery. Medications on Admission: 1. Mycophenolate Mofetil 500 mg TID 2. Tacrolimus 2 mg [**Hospital1 **] 3. Ezetimibe 10 mg DAILY 4. Atorvastatin 20 mg DAILY 5. Bactrim SS 1 Tablet DAILY 6. Prilosec 20 mg daily 7. Metoclopramide 10 mg [**Hospital1 **] 8. Alendronate 70 mg PO QWK 9. Calcium Acetate 667 mg Capsule TID W/MEALS 10. Escitalopram 30 mg DAILY 11. iron 325mg [**Hospital1 **] Discharge Medications: 1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QWK (). 10. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Escitalopram 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: Visiting Nurse of Greater [**Location (un) 37361**] Discharge Diagnosis: Left upper extremity steal syndrome due to AV graft Diabetes mellitus Hypoxia Discharge Condition: Stable Discharge Instructions: Please call your doctor if you experience fever, chills, lightheadedness, dizziness, chest pain, palpitations, shortness of breath, numbness/tingling/weakness in left hand, or bleeding or increased redness from surgical site. You may resume all your home medications. Please adhere to diabetic diet. No heavy lifting for 1 week. No swimming or tub baths. It is very important that you do not smoke when using oxygen. Followup Instructions: 1. Please call Dr. [**Last Name (STitle) **] / Thoracic Surgery at [**Telephone/Fax (1) 170**] on [**2134-11-15**] to schedule a follow-up appointment. It is important that you call and follow-up as directed for further care of your mediastinal mass. 2. Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2135-1-4**] 1:00 3. Please follow up in the Pulmonary Clinic regarding your low oxygen saturations. Call [**Telephone/Fax (1) 612**] for appointment. 4. Please follow up with Dr. [**First Name (STitle) **] in [**1-4**] weeks. Call [**Telephone/Fax (1) 673**] for appointment. 5. Please follow up with your PCP regarding your blood glucose control.

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Discharge summary

report+addendum

Admission Date: [**2194-9-14**] Discharge Date: [**2194-9-20**] Date of Birth: [**2158-3-13**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Nicotine Patch Attending:[**First Name3 (LF) 3043**] Chief Complaint: Acetaminophen Overdose. Major Surgical or Invasive Procedure: Endotracheal Intubation History of Present Illness: This is a 30 y.o. F with a history of Bipolar disorder, borderline personality disorder, SI/SA, self harm, admitted for toxic overdose. Per report, she was found to be minimally responsive and dyspneic at her group home. She has a history of asthma, and was therefore given a duoneb thinking that this was an asthma exacerbation. She than became more tachypneic, and was given sub cutaneous epinephrine. and was intubated by EMS. . In the ED, initial VS: HR in the 70's, BP in the 130's, 98% FiO2 100%. Labs were obtained. Urine and serum tox screens were notable for benzodiazepines, opiates, TCAs, and acetaminophen level of 115.5. ABG 7.32 / 48 / 68 / 26. Portable CXR, CTA, Right Foot X-rays, and CT head were completed. She was given albuterol inhaler x 1. She was intubated for airway protection and sedated using Midazolam and Fentanyl. Initially, R mainstem intubation, but ETT pulled back. Given levofloxacin 750 mg IV x 1 for pneumonia and started on the Acetylcysteine protocol for acetaminophen toxicity. . Currently, the patient is sedated and intubated. . ROS: Unable to be obtained due to sedation and intubation. Past Medical History: - History of self harm - SI/SA, last 18 months ago via toxic ingestion - bipolar disorder - borderline personality disorder - ADHD Social History: History of alcohol dependence, sober for 19 months smokes 1ppd no IVDU, illicit drug use. Lives at Dialectic behavioral training group home, on [**Doctor Last Name **] street, [**Location (un) **] MA. [**Telephone/Fax (1) 18755**] single unemployed for past 18 months, used to work at channel 7 as part of film crew. Family History: The patient was adopted and does not know her family hx Physical Exam: Vitals - T: BP:124/72 HR:77 O2 sat 97% CMV 500/16 FiO2 40%, PIP 17, PEEP 5. 700in/350out GENERAL:obese, sedated, intubated. HEENT: No sclericterus, PERRLA CARDIAC: RRR, no m/g/r LUNG: crackles b/l, L>R ABDOMEN: soft, NT, ND, +BS EXT: no peripheral edema. bruise over right second toe. NEURO: sedated DERM: no rash. Pertinent Results: ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2194-9-20**] 06:35AM 260* 96* 243 65 0.5 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2194-9-20**] 06:35AM 3.9 8.6 3.3 2.3 Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2194-9-20**] 06:35AM 6.2 3.81* 11.2* 34.4* 90 29.5 32.7 14.6 220 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2194-9-20**] 06:35AM 220 [**2194-9-20**] 06:35AM 12.4 38.5* 1.0 BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [**2194-9-14**] 08:38PM 428* TRAUMA Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2194-9-20**] 06:35AM 96 7 0.7 143 3.9 107 28 12 [**2194-9-14**] 08:38PM BLOOD WBC-9.1 RBC-4.05* Hgb-11.7* Hct-35.4* MCV-87 MCH-29.0 MCHC-33.2 RDW-14.2 Plt Ct-222 [**2194-9-15**] 01:40AM BLOOD WBC-10.5 RBC-3.80* Hgb-11.1* Hct-33.4* MCV-88 MCH-29.2 MCHC-33.1 RDW-14.1 Plt Ct-207 [**2194-9-15**] 09:02AM BLOOD WBC-13.4* RBC-4.14* Hgb-11.9* Hct-36.5 MCV-88 MCH-28.7 MCHC-32.6 RDW-13.7 Plt Ct-213 [**2194-9-16**] 02:29AM BLOOD WBC-11.8* RBC-3.88* Hgb-11.5* Hct-34.1* MCV-88 MCH-29.6 MCHC-33.6 RDW-14.1 Plt Ct-210 [**2194-9-18**] 05:50AM BLOOD WBC-6.2 RBC-3.51* Hgb-10.2* Hct-30.5* MCV-87 MCH-29.1 MCHC-33.4 RDW-14.4 Plt Ct-178 [**2194-9-18**] 05:15PM BLOOD Hct-32.9* [**2194-9-19**] 09:00AM BLOOD WBC-5.9 RBC-3.76* Hgb-10.9* Hct-33.5* MCV-89 MCH-29.1 MCHC-32.6 RDW-14.4 Plt Ct-189 [**2194-9-15**] 07:52PM BLOOD PT-15.2* PTT-42.0* INR(PT)-1.3* [**2194-9-16**] 02:29AM BLOOD PT-16.7* PTT-50.6* INR(PT)-1.5* [**2194-9-16**] 09:02AM BLOOD PT-17.6* PTT-41.7* INR(PT)-1.6* [**2194-9-17**] 06:55AM BLOOD PT-15.1* PTT-40.6* INR(PT)-1.3* [**2194-9-17**] 12:40PM BLOOD PT-14.0* PTT-42.5* INR(PT)-1.2* [**2194-9-18**] 05:50AM BLOOD PT-13.2 PTT-36.0* INR(PT)-1.1 [**2194-9-19**] 09:00AM BLOOD PT-13.1 PTT-36.2* INR(PT)-1.1 [**2194-9-14**] 08:38PM BLOOD PT-12.8 PTT-36.4* INR(PT)-1.1 [**2194-9-15**] 01:40AM BLOOD PT-14.3* PTT-37.1* INR(PT)-1.2* [**2194-9-15**] 01:40AM BLOOD Plt Ct-207 [**2194-9-15**] 09:02AM BLOOD PT-15.2* PTT-36.7* INR(PT)-1.3* [**2194-9-14**] 08:38PM BLOOD Fibrino-428* [**2194-9-15**] 01:40AM BLOOD Glucose-137* UreaN-9 Creat-0.7 Na-136 K-4.2 Cl-101 HCO3-21* AnGap-18 [**2194-9-15**] 09:02AM BLOOD Glucose-88 UreaN-7 Creat-0.8 Na-140 K-3.6 Cl-105 HCO3-21* AnGap-18 [**2194-9-15**] 07:52PM BLOOD Glucose-113* UreaN-7 Creat-0.9 Na-138 K-3.9 Cl-107 HCO3-19* AnGap-16 [**2194-9-17**] 06:55AM BLOOD Glucose-88 UreaN-8 Creat-0.6 Na-142 K-4.2 Cl-112* HCO3-23 AnGap-11 [**2194-9-18**] 05:50AM BLOOD Glucose-101 UreaN-6 Creat-0.6 Na-139 K-3.6 Cl-106 HCO3-25 AnGap-12 [**2194-9-19**] 09:00AM BLOOD Glucose-107* UreaN-5* Creat-0.6 Na-143 K-3.8 Cl-109* HCO3-25 AnGap-13 [**2194-9-14**] 08:38PM BLOOD ALT-10 AST-12 LD(LDH)-173 AlkPhos-87 [**2194-9-15**] 01:40AM BLOOD ALT-8 AST-9 LD(LDH)-197 AlkPhos-65 TotBili-0.4 [**2194-9-15**] 09:02AM BLOOD ALT-9 AST-10 LD(LDH)-169 AlkPhos-67 TotBili-0.6 [**2194-9-15**] 03:04PM BLOOD ALT-8 AST-12 LD(LDH)-175 AlkPhos-67 TotBili-0.7 [**2194-9-15**] 07:52PM BLOOD ALT-16 AST-47* LD(LDH)-374* AlkPhos-68 TotBili-0.7 [**2194-9-16**] 02:29AM BLOOD ALT-24 AST-47* LD(LDH)-259* AlkPhos-63 TotBili-0.9 [**2194-9-16**] 09:02AM BLOOD ALT-31 AST-47* LD(LDH)-223 AlkPhos-61 TotBili-0.9 [**2194-9-16**] 04:19PM BLOOD ALT-31 AST-45* LD(LDH)-254* AlkPhos-60 TotBili-0.9 [**2194-9-17**] 06:55AM BLOOD ALT-96* AST-114* LD(LDH)-309* AlkPhos-62 TotBili-0.7 [**2194-9-17**] 12:40PM BLOOD ALT-175* AST-203* LD(LDH)-357* AlkPhos-66 TotBili-0.6 [**2194-9-18**] 05:50AM BLOOD ALT-298* AST-249* LD(LDH)-367* AlkPhos-58 TotBili-0.5 [**2194-9-19**] 09:00AM BLOOD ALT-338* AST-171* LD(LDH)-303* CK(CPK)-272* AlkPhos-65 TotBili-0.5 [**2194-9-19**] 12:20PM BLOOD ALT-333* AST-149* AlkPhos-66 [**2194-9-14**] 08:38PM BLOOD Lipase-21 [**2194-9-15**] 01:40AM BLOOD Calcium-8.2* Phos-1.6* Mg-1.9 [**2194-9-15**] 09:02AM BLOOD Albumin-3.7 Calcium-8.0* Phos-3.0 Mg-1.9 [**2194-9-16**] 02:29AM BLOOD Calcium-7.7* Phos-2.6* Mg-2.0 [**2194-9-16**] 04:19PM BLOOD Calcium-7.9* Phos-0.6*# Mg-2.1 [**2194-9-17**] 12:55AM BLOOD Phos-1.1* [**2194-9-17**] 06:55AM BLOOD Albumin-3.5 Calcium-7.7* Phos-1.7* Mg-2.1 [**2194-9-17**] 12:40PM BLOOD Phos-1.8* [**2194-9-17**] 09:00PM BLOOD Phos-1.1* [**2194-9-18**] 05:50AM BLOOD Calcium-7.9* Phos-2.0* Mg-2.0 [**2194-9-19**] 09:00AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.3 [**2194-9-19**] 12:20PM BLOOD Phos-2.5* [**2194-9-15**] 01:40AM BLOOD Osmolal-284 [**2194-9-14**] 08:38PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-115.5* Bnzodzp-NEG Barbitr-NEG Tricycl-POS [**2194-9-15**] 01:40AM BLOOD Acetmnp-69.4* [**2194-9-15**] 03:04PM BLOOD Acetmnp-124.8* [**2194-9-15**] 07:52PM BLOOD Acetmnp-118.9* [**2194-9-16**] 02:29AM BLOOD Acetmnp-37.9* [**2194-9-16**] 09:02AM BLOOD Acetmnp-9.0 [**2194-9-16**] 12:46PM BLOOD Acetmnp-5.5 [**2194-9-16**] 04:19PM BLOOD Acetmnp-NEG [**2194-9-17**] 06:55AM BLOOD Acetmnp-NEG [**2194-9-15**] 01:55AM BLOOD freeCa-1.14 [**2194-9-14**] 08:41PM BLOOD Glucose-124* Lactate-1.5 Na-140 K-4.1 Cl-103 calHCO3-24 [**2194-9-14**] 11:24PM BLOOD Lactate-1.3 [**2194-9-15**] 01:55AM BLOOD Lactate-1.2 [**2194-9-14**] 10:02PM BLOOD Type-ART pO2-68* pCO2-48* pH-7.32* calTCO2-26 Base XS--1 [**2194-9-14**] 11:24PM BLOOD Type-ART pO2-427* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 Intubat-INTUBATED [**2194-9-15**] 01:55AM BLOOD Type-[**Last Name (un) **] Temp-36.7 pO2-84 pCO2-41 pH-7.36 calTCO2-24 Base XS--1 [**2194-9-15**] 09:05PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.050* [**2194-9-14**] 08:59PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.032 [**2194-9-15**] 09:05PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2194-9-14**] 08:59PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2194-9-15**] 09:05PM URINE RBC-23* WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 [**2194-9-14**] 08:59PM URINE RBC-0-2 WBC-0 Bacteri-RARE Yeast-NONE Epi-0-2 [**2194-9-14**] 08:59PM URINE bnzodzp-POS barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG Micro: [**2194-9-16**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2194-9-15**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2194-9-15**] URINE URINE CULTURE-NEGATIVE [**2194-9-15**] MRSA SCREEN MRSA SCREEN-NEGATIVE [**2194-9-14**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2194-9-14**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] Imaging: R foot Xray ([**2194-9-15**]): No localizing history is availale. Allowing for this, no fracture or dislocation is detected. There is dorsal soft tissue swelling. There is hallux valgus with mild degenerative changes of the first MTP joint. There is a moderate-sized inferior calcaneal spur. CXR ([**2194-9-16**]): In comparison with study of [**9-15**], there has been removal of the endotracheal tube and nasogastric tube. Lung volumes are seen. Opacification at the left base could merely reflect atelectasis, though the possibility of supervening aspiration pneumonia must be considered. [**Known lastname **],[**Known firstname **] [**Medical Record Number 47991**] F 36 [**2158-3-13**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2194-9-14**] 8:39 PM [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 47992**] EU [**2194-9-14**] 8:39 PM CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 47993**] Reason: ? bleed or [**Hospital **] [**Hospital 93**] MEDICAL CONDITION: 30 year old woman with ams REASON FOR THIS EXAMINATION: ? bleed or mass CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: JXRl SUN [**2194-9-14**] 9:50 PM no intracranial hemorrhage or edema Final Report INDICATION: 30-year-old woman with altered mental status. COMPARISON: None. TECHNIQUE: Non-contrast head CT was obtained. FINDINGS: There is no intracranial hemorrhage, mass effect, shift of normally midline structures, or edema. The [**Doctor Last Name 352**]-white matter differentiation is preserved. The ventricles, basal cisterns, and sulci are normal in size and configuration. The orbits and soft tissues are within normal limits. There is no fracture. There is mucosal thickening of the maxillary sinuses bilaterally and scattered ethmoid air cells. The mastoid air cells are well aerated. IMPRESSION: 1. No intracranial hemorrhage or edema. 2. Bilateral maxillary sinus mucosal thickening. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**] Approved: MON [**2194-9-15**] 6:14 PM Imaging Lab [**Known lastname **],[**Known firstname **] [**Medical Record Number 47991**] F 36 [**2158-3-13**] Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2194-9-14**] 8:46 PM [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 47992**] EU [**2194-9-14**] 8:46 PM CTA CHEST W&W/O C&RECONS, NON- Clip # [**Clip Number (Radiology) 47994**] Reason: ? pe Field of view: 36 Contrast: OPTIRAY Amt: 100 [**Hospital 93**] MEDICAL CONDITION: 30 year old woman with suden onset resp distress REASON FOR THIS EXAMINATION: ? pe CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: JXRl SUN [**2194-9-14**] 10:19 PM - no PE, no dissection - extensive left lung consolidation/atelectasis - likely aspiration - mild right lung atelectasis, small right effusion Wet Read Audit # 1 JXRl SUN [**2194-9-14**] 9:53 PM - no PE, no dissection - extensive left lung consolidation/atelectasis - 5mm LLL pulmonary nodule. - mild right lung atelectasis Final Report CHEST CT PERFORMED ON [**2194-9-14**]. COMPARISON: None. CLINICAL HISTORY: 30-year-old woman with sudden onset respiratory distress. Evaluate for pulmonary embolism. TECHNIQUE: MDCT was used to obtain contiguous axial images through the chest following the uneventful administration of 100 cc Optiray IV contrast. Multiplanar reformations were provided. FINDINGS: The endotracheal tube is seen with its tip approximately 3.5 cm above the carina. The NG tube courses inferiorly with its tip coiled in the stomach. There is no filling defect within the pulmonary arterial tree to suggest the presence of a pulmonary embolism. The aorta is normal in course and caliber without evidence of aortic dissection. A bovine arch configuration is noted with common origin of the innominate and left common carotid arteries. There is no mediastinal lymphadenopathy. The heart is normal in size and shape. There is no pericardial effusion. Small bilateral pleural effusions are noted. There is consolidation noted in the left upper lobe and left lower lobe posteriorly which is most compatible with aspiration. There is also dependent atelectasis in the right lung. A nodular opacity is noted in the right lower lobe on series 2, image 49 measuring 5 mm. This finding may be inflammatory or infectious. There is no pneumothorax. The upper abdomen is unrevealing. BONE WINDOWS: No suspicious lytic or blastic osseous lesion is seen. IMPRESSION: 1. Bilateral areas of lung consolidation, left greater than right, likely reflect the sequelae of aspiration. 5-mm right lower lobe nodule likely inflammatory. Clinical correlation advised. 2. No evidence of pulmonary embolism. 3. Appropriate position of ET and NG tubes. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**] Approved: MON [**2194-9-15**] 6:15 PM Imaging Lab Brief Hospital Course: # Acetaminophen Toxicity: Patient presented in respiratory distress after ingesting 400 tablets of Tylenol PM. She was intubated emergently in the ED and admitted to the MICU. In the MICU she was started on the NAC protocol for acetaminophen level 115 of unknown time frame, but it was assumed to be at least four hours prior to presentation. Her LFTs and bilirubin remained stable, with only slight increases on the day of transfer out of the MICU. Her INR did increase from baseline of 1.0 to 1.6 initially. In the MICU ABGs were trended, and pH remained above 7.3 signifying that the patient would probably not need a liver transplant. Acetaminophen level peaked at 124.8 on [**9-15**] and it was 0 on [**9-16**] prior to transfer to the medicine floor. Toxicology recommended that NAC be continued until tylenol level undetectable, initially. On [**9-17**] ALT/AST began to rise signifying ongoing liver inflammation and cell destruction. NAC was re-started and continued until [**9-18**], on [**9-19**] her ALT/AST had peaked and began to decrease signifying liver recovery. . # Hypophosphatemia: Patient was found to have severe hypophosphatemia, phosphorus of 0.6 on [**9-16**], upon transfer to the medical floor. This was thought to be due to the patient's lack of nutrition with a component of liver inflammation and cell regeneration. This was aggressively repleted with IV and PO phos. On discharge her level had returned to [**Location 213**]. Please re-check phosphate on [**9-23**] if <2.7 replete with neutraphos 2 pkts. If low would re-check on [**9-25**] and repeat as before. . # Respiratory Distress: Patient was intubated in ED for airway protection. Extensive left lung consolidation/atelectasis after right mainstem intubation was seen potentially from aspiration. She received levaquin in the ED and the ET was repositioned. Consolidation resolved after ET tube was repositioned. She was extubated one day later on [**9-15**]. While in the MICU, held off on further antibiotics, though she did have a temperature of 100.4 on [**2194-9-15**]. She was pancultured at that time, and antibiotics were not started (fever thought to be likely [**1-27**] pneumonitis). She had no white count. While on the medical floor her respiratory status remained stable and she had no more fevers. . # Suicide Attempt: Patient was admitted with toxic ingestion and overdose. Psych was consulted, and recommended adding back lamotrigine first after LFT's stabilized. This was not done as her LFT's began to rise. Later when her LFT's peaked and began to decrease the decision was made not to restart this medications and defer this decision to psych. She was kept on suicide precautions with a 1:1 sitter after extubation. She continued . # Toxic Ingestion: Patient had urine and serum tox positive for benzodiazepines, tricyclic antidepressants, and opiates on admission. Toxicology was consulted. On presentation it was thought that the patient had overdosed on many substances. Upon further investigation and questioning we found out that the patient takes this medications regularly for her psychiatric problems and that was why she tested positive for them. Patient did not require flumazenil or narcan for benzo or opiate toxicity respectively. Medications on Admission: Ritalin LA 30mg PO daily Clonazepam 1mg PO BID Zolpidem 10mg QHS Ferrous Sulfate 325mg PO daily Clonazepam 1mg PO BID PRN Lamotrigine 300mg PO daily Inderal LA 120mg Daily Naltrexone 100mg PO BID Colace Proventil HFA 90mcg 2 puffs q 4-6 hrs Advair [**Hospital1 **] Seasonique daily thorazine 50mg [**Hospital1 **] PRN Pepto bismol milk of magnesia tylenol 500mg PO BID PRN. Discharge Medications: 1. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 2. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Discharge Diagnosis: Primary diagnosis: Tylenol overdose Secondary diagnosis: Bipolar disorder Discharge Condition: medically stable, depressed Discharge Instructions: You were admitted because you overdosed on Tylenol. Upon arrival to the hospital you had to be emergently intubated because your respiratory rate was too slow. You were then transfered to the intensive care unit. In the ICU you were started on a medication that prevents the excess Tylenol from damaging your liver, all your other medications were stopped and your breathing continued to be assisted by the ventilator. On your second day in the ICU you were successfully extubated. You were then transfered to the medical floor. While on the medical floor the tests that measure liver inflammation started to rise. We then re-started the medication that protects your liver and prevented further damage. You developed nausea and low phosphate while on the medical floor. We concluded that your nausea was due to liver inflammation. We treated you with anti-nausea medication an this resolved. We concluded that your low phosphate was due to your lack of nutrition and we repleted this daily. You continued to state that you were depressed, but with no suicidal ideation, throughout your hospitalization. 1. We stopped all of your home medications because many of these could have affected your liver while it was recovering. 2. Do not take any of your medications until instructed by your psychiatrist. 3. Please check phosphate level on Monday [**2193-9-23**] and replete with neutraphos if <2.7. If low would re-check again on Wednesday [**2194-9-25**]. If you at any point develop chest pain, shortness of breath, fevers, chills, nausea, vomiting, suicidal thoughts, severe depression or any other symptom that concerns you please return to the hospital for further evaluation. It was a pleasure to take care of you. Followup Instructions: Please make an appointment to follow up with your PCP after you are discharged from the hospital. Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 8866**] Admission Date: [**2194-9-14**] Discharge Date: [**2194-9-20**] Date of Birth: [**2158-3-13**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Nicotine Patch Attending:[**First Name3 (LF) 8867**] Addendum: Patient did not have aspiration pneumonia, her fever was due to aspiration pneumonitis. Discharge Disposition: Extended Care [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8868**] MD [**MD Number(2) 8869**] Completed by:[**2194-10-10**]

[ "275.3", "285.9", "301.83", "372.72", "493.90", "969.4", "965.4", "314.01", "507.0", "296.50", "573.3", "309.81", "518.0", "518.81", "E950.0" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

21122, 21295

14221, 17480

319, 345

18744, 18774

2419, 9952

20546, 21099

2010, 2068

17905, 18587

11686, 11735

18646, 18646

17506, 17882

18798, 20523

2083, 2400

256, 281

11767, 14198

373, 1504

18704, 18723

18665, 18683

1526, 1659

1675, 1994

25,332

105,052

11771

Discharge summary

report

Admission Date: [**2149-4-28**] Discharge Date: [**2149-5-5**] Date of Birth: [**2110-1-16**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 39 year old male with a past medical history of chronic myelogenous leukemia, status post unrelated allogeneic bone marrow transplant that has been complicated by chronic graft-versus- host disease (hypopigmentation, mild ulceration, and thrombocytopenia). The patient states that he began feeling unwell approximately nine days prior to admission but worsened significantly over the weekend prior to admission, specifically complaining of fever to 101, complicated by myalgias, fatigue and an unproductive cough as well as shortness of breath. He was seen in the [**Hospital 3242**] Clinic on [**4-24**], at which time he had an ANC of 3700 and a chest film that did not reveal any infiltrate. He was seen in clinic today as a follow up with an unchanged chest film but found to be hypoxic to approximately 89 percent on room air. He denies any headache, rhinorrhea, pleuritic chest pain, nausea, vomiting, abdominal pain, changes in bowel or bladder habits. Of note the patient was noted to have a flare of his graft- versus- host disease flare ([**2149-1-6**]). He was seen by pulmonary who felt he had a component of Bronchlitis obliterans and was treated with Prednisone 40 mg which was tapered slowly back down to 5 mg last month. The symptoms appeared to develop approximately one week after having tapered down to 5 mg, in particular the muscle aches, pain, fatigue and low-grade fever. This progressed to a dry cough and worsened fever as above. PAST MEDICAL HISTORY: The patient's past medical history is notable for chronic myelogenous leukemia. It was diagnosed in [**2146-12-8**]. He is status post a match-unrelated allogeneic bone marrow transplant in [**2147-10-8**]. It has been complicated by graft-versus-host disease as mentioned above as well as cytomegalovirus colitis, bronchiolitis obliterans-organizing pneumonia, hemolytic uremic syndrome, and mouth ulcers as well as thrombocytopenia. MEDICATIONS ON ADMISSION: The patient's medications on admission are Prednisone 5 mg q. day and Acyclovir 400 mg p.o. b.i.d., Pentamidine q. month and folic acid q. day. ALLERGIES: His allergies are to Amphotericin and to Ampicillin. SOCIAL HISTORY: The patient is married, works as a computer analyst. He works with his wife and three children. He has no history of tobacco use or intravenous drug use. He does not drink alcohol. FAMILY HISTORY: Notable for the absence of cancer or lung disease. LABORATORY DATA: Laboratory data on admission revealed sodium 141, potassium 3.7, chloride 105, bicarbonate 26, BUN 19, creatinine 1.6, glucose 86. His white count is 7.4 with 46 percent neutrophils and 7 percent bands as well as 99 percent lymphocytes. Hematocrit is 26.1 and platelets are 27. His ALT is 39, AST is 54. His alkaline phosphatase is 101, creatinine 1.0. Chest film does not reveal any evidence of infiltrate or effusion. HOSPITAL COURSE: Pneumonia - A high resolution chest computerized tomography scan did not reveal any acute changes, though the nasal swabs were positive for respiratory syncytial virus. The patient was transferred to the Medical Intensive Care Unit for aerosolized Ribavirin and Synagis treatment. The patient received one dose of Synagis as well as a course of Ribavirin therapy which he tolerated well. The patient received five days of Ribavirin in all. The patient defervesced and had improved oxygenation. A repeat viral culture from a repeat nasopharyngeal aspirate again revealed respiratory syncytial virus. Infectious disease consult was obtained for further assistance. Follow up chest computerized tomography scan was essentially unchanged from the prior admission study. Again, noted were bronchial wall thickening and scarring of the right lower lobe that was unchanged from the prior study with no significant air trapping and no adenopathy. Overall there was no computerized tomography scan evidence for acute infectious process or inflammatory process. However, given the patient's immunocompromised status and out of concern for possible superimposed bronchitis or pneumonia, the patient was treated with a seven day course of Levofloxacin in addition to the treatment for his Ribavirin. The patient's cytomegalovirus viral load was found to be negative. His prednisone dose was also increased to 40mg qd. Thrombocytopenia - The patient has thrombocytopenia which is thought to be secondary to chronic graft-versus-host disease. The patient's platelets on admission were 27. The patient received platelets on [**5-1**], as well as on [**4-29**], one unit. Graft-versus-host disease - The patient has a history of bronchiolitis obliterans-organizing pneumonia. There was concern that his hypoxia in addition to being caused by respiratory syncytial virus infection may also have had an component of graft-versus-host disease as well, in particular given the drop in his platelet count on admission. Therefore Prednisone dose was increased to 40 mg q. day and was tapered slowly. The patient's Prednisone dose is 30 mg at the time of discharge. Anemia - The patient's hematocrit is stable over the course of hospitalization. His hematocrit on admission was 29, the patient received 2 units of packed red blood cells on [**5-1**], and his hematocrit remained stable. Chronic renal insufficiency - The patient had an elevated creatinine on admission of 1.6. It is felt that his baseline creatinine is 1.1 to 1.2. Etiology was unclear for his elevated creatinine on admission. The patient was discharged in stable condition. DISCHARGE DIAGNOSIS: Respiratory syncytial virus. Extensive chronic GVHD. Pneumonia. Status post allogeneic bone marrow transplant with extensive chronic graft-versus-host disease. Anemia. Thrombocytopenia. FOLLOW UP: The patient will follow up with his oncologist following discharge. DISCHARGE MEDICATIONS: 1. Acyclovir 400 mg p.o. q. 12. 2. Folic acid 1 mg q. day. 3. Protonix 40 mg q. day. 4. Levofloxacin 500 mg q. day to complete his seven day course. 5. Prednisone [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 9811**] Dictated By:[**Last Name (NamePattern1) 8188**] MEDQUIST36 D: [**2149-7-1**] 18:43:16 T: [**2149-7-1**] 20:29:17 Job#: [**Job Number 37210**]

[ "584.9", "276.5", "996.85", "287.5", "480.1", "285.9", "593.9", "E878.0", "205.10" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.05" ]

icd9pcs

[ [ [] ] ]

2559, 3056

6033, 6469

5739, 5929

2129, 2340

3074, 5717

5941, 6010

159, 1640

1663, 2102

2357, 2542

19,719

117,378

43335

Discharge summary

report

Admission Date: [**2189-11-29**] Discharge Date: [**2189-11-29**] Date of Birth: Sex: M Service: NEURO ICU HISTORY OF PRESENT ILLNESS: The patient is a 56 year-old man with a history of a recent stroke at the end of [**Month (only) **] causing a left sided weakness due to a right frontal stroke. He also has a history of an old thalamic stroke in [**2179**]. The patient had also been on Coumadin secondary to hip fractures and had been in his nursing home since discharge from the hospital. He was well last night and woke up this morning and initially felt well and then began to call for help with new onset left sided weakness. When the staff arrived they found him leaning to the right with slurred speech. The patient quickly became less alert and was sent immediately to [**Hospital1 69**] via ambulance. On arrival initially he was able to indicate answers to yes or no questions, but soon became completely unresponsive. PAST MEDICAL HISTORY: 1. Right thalamic stroke in [**2179**]. 2. Right frontal stroke several weeks ago. 3. Gunshot wound in [**2155**]. 4. Hip fracture [**9-2**]. 5. Hypertension. 6. Hepatitis C. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Baclofen. 2. Procardia. 3. Elavil. 4. Neurontin. 5. Coumadin 5 mg q day. 6. Percocet prn. SOCIAL HISTORY: Smokes a pack a day. No alcohol or intravenous drug use for years. Lives in a group home. PHYSICAL EXAMINATION ON ADMISSION: He was afebrile. His blood pressure was 200s/100s with a pulse in the 130s. Generally he was a diaphoretic unresponsive to voice. He was quickly intubated. He did not open his eyes to command or to sternal rub. His pupils were 5 mm bilaterally and nonreactive with no response to visual threat. He had no response to oculocephalic or ocular vestibular maneuvers. He had no gag. He had no corneal reflexes. His motor examination although initially he withdrew his left arm from pain and had extensor posturing from the right arm, quickly progressed to no movement to any stimulation in any of his lower extremities with no spontaneous movements. His reflexes were trace to absent throughout. His head CT showed a large left basal ganglia hemorrhage with blood throughout the ventricular system and with significant shift and mass effect as well as some edema. HOSPITAL COURSE: The patient was admitted to the Neurological Intensive Care Unit with a large left basal ganglia bleed. He received fresh frozen platelets to reverse his INR of 3, although no factor 9 complex was available from the pharmacy on admission. Neurosurgery was consulted, but was unable to place a drain with his INR at 3. His blood pressure was controlled with Nipride and Labetalol drips. His family came into the hospital and another head CT was performed with increase in bleeding as well as edema and continued shift. His examination remained without brain stem reflexes and with no evidence of cortical function. After prolonged discussion with his family members the family decided to make the patient CMO and to extubate him. He was extubated around 7:00 on the [**8-30**] and the patient expired soon after. The patient was declared at 9:00 p.m. He had no carotid pulse, no respirations and no heart beat. The cause of death immediately was respiratory failure. The other main cause of death was intracranial hemorrhage. The family was not interested in an autopsy. They were informed of his death. DISCHARGE DIAGNOSIS: Large left basal ganglia hemorrhage with shift in edema. DISCHARGE STATUS: Expired. DR [**Last Name (STitle) **] [**Name (STitle) 4267**] 13.282 Dictated By:[**Last Name (NamePattern1) 1203**] MEDQUIST36 D: [**2189-11-29**] 10:22 T: [**2189-11-30**] 07:12 JOB#: [**Job Number 93316**]

[ "729.89", "401.9", "070.51", "V58.61", "438.89", "518.81", "305.1", "431", "348.5" ]

icd9cm

[ [ [] ] ]

[ "99.05", "38.91", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

3494, 3806

2359, 3473

168, 970

1471, 2341

992, 1325

1342, 1456

6,488

174,500

10378

Discharge summary

report

Admission Date: [**2108-4-10**] Discharge Date: [**2108-4-18**] Date of Birth: [**2033-9-26**] Sex: F Service: MEDICINE Allergies: Penicillins / Caffeine / Quinine / Ampicillin Attending:[**First Name3 (LF) 18369**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 74yo F w/ hx Addison's, HTN, and metastatic spindle cell sarcoma with recent initiation of chemotherapy (gemcitabine, adriamycin, prednisone) 1 weeks PTA. Over the past week, she has been generally feeling "sick" and tired. The night prior to admission, she had one episode of vomiting and had non-bloody watery/mucousy diarrhea and a mild cough. The morning of admission, she had a fever to 101 and came to the ED. She otherwise denied any sore throat, dyspnea, chest pain, abdominal pain, dysuria, new rashes or sick contacts. In the ED, her temp was 101, WBC 0.8, and her SBP was 80. She was given 2L IVF NS and her SBP increased to 110. She was also given a dose of cefepime and hydrocortisone 100mg. She was then transferred to the [**Hospital Unit Name 153**]. Past Medical History: 1. Addison disease diagnosed at 37 years of age. 2. Hypercholesterolemia, on Lipitor in the past. The patient recently stopped the Lipitor, which resulted in improved kidney function, which allowed her to enter the chemotherapy trial. 3. Hypotension. 4. Chronic renal insufficiency. 5. COPD. 6. Peripheral vascular disease with bilateral carotid stenoses status post TIA. In [**8-/2103**], the patient had left upper extremity weakness and slurred speech with complete resolution in less than 24 hours. 7. Coronary artery disease (1 vessel). The first cardiac cath in [**8-/2103**] showed total occlusion of right coronary artery. PCI failed at that time. However, there were significant left-to-right collaterals. Second cardiac cath in [**12/2107**] showed no progression of her coronary artery disease. 60% diag, 40%lad 8. Preserved EF in past--echo [**2103**]-50%, cath showed normal index in [**2107**] and RVG [**2108-3-28**] recently with ef of 72% 9. Osteoporosis, on Fosamax for 2 years and then on Forteo for 2 months, which she stopped at the end of [**Month (only) 359**]. Status post undisplaced pathological fracture of her right pelvis, both inferior and superior rami in 09/[**2107**]. 10. Metastatic sarcomatoid kidney cancer. 11. Right ear deafness. 12. RAD Social History: The patient used to smoke a pack and a half since [**17**] years of age until 65 years of age. She does not drink alcohol. She is a widow. She has 6 children and 18 grandchildren. She currently lives with her son and his family. She used to work as a waitress and then she had an office job. Family History: One brother died at a young age probably secondary to Addison disease. One brother has prostate cancer. One daughter has melanoma. Her father had [**Name2 (NI) 499**] cancer. Two brothers have coronary artery disease. There is no history of osteoporosis in her family. Physical Exam: general: alert, pleasant, interactive and in NAD HEENT: PERRL, EOMI, anicteric, MMM, oropharynx clear, neck: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules lungs: crackles bilaterally chest: kyphosis, tenderness at former port-a-cath site; erythematous, warm and indurated heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated abdomen: nd, +b/s, soft, nt, no masses or HSM extremities: no cyanosis, clubbing or edema neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch Pertinent Results: CXR AP [**4-10**]: 1. Pleural and pulmonary metastatic spread of known renal carcinoma. 2. Bilateral interstitial opacities which may represent congestive heart failure or infectious process. Clinical correlation is suggested. CXR AP [**4-12**]: 1. Prominent interstitial markings. This could be either due to interstitial pulmonary edema or drug reaction. 2. Multiple pulmonary nodules consistent with known metastases from renal cell carcinoma. CXR PA/Lat [**4-16**]: Emphysema and pulmonary metastases as previously demonstrated. No evidence of new pneumonia or pulmonary edema. [**2108-4-10**] 01:00PM BLOOD WBC-0.8*# RBC-3.10* Hgb-9.3* Hct-25.3*# MCV-82 MCH-29.8 MCHC-36.5* RDW-13.3 Plt Ct-100*# [**2108-4-16**] 06:36AM BLOOD WBC-31.3*# RBC-3.20* Hgb-9.1* Hct-27.4* MCV-86 MCH-28.5 MCHC-33.3 RDW-14.0 Plt Ct-73*# [**2108-4-18**] 06:10AM BLOOD WBC-22.5* RBC-3.15* Hgb-9.2* Hct-27.0* MCV-86 MCH-29.2 MCHC-34.1 RDW-14.8 Plt Ct-98* [**2108-4-10**] 01:00PM BLOOD Neuts-4* Bands-0 Lymphs-88* Monos-0 Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2108-4-15**] 06:46AM BLOOD Neuts-62 Bands-12* Lymphs-5* Monos-10 Eos-0 Baso-0 Atyps-0 Metas-9* Myelos-2* [**2108-4-10**] 01:00PM BLOOD Plt Smr-LOW Plt Ct-100*# [**2108-4-14**] 07:00AM BLOOD Plt Ct-34* [**2108-4-11**] 05:52AM BLOOD Gran Ct-40* [**2108-4-13**] 06:35AM BLOOD Gran Ct-1160* [**2108-4-10**] 01:00PM BLOOD Glucose-99 UreaN-32* Creat-1.7* Na-133 K-3.7 Cl-99 HCO3-22 AnGap-16 [**2108-4-18**] 06:10AM BLOOD Glucose-101 UreaN-22* Creat-1.5* Na-140 K-3.7 Cl-102 HCO3-30 AnGap-12 [**2108-4-10**] 01:00PM BLOOD ALT-14 AST-18 AlkPhos-78 Amylase-53 TotBili-0.5 [**2108-4-11**] 05:52AM BLOOD ALT-14 AST-14 LD(LDH)-149 AlkPhos-70 TotBili-0.3 [**2108-4-10**] 01:00PM BLOOD Calcium-10.4* Phos-1.0* Mg-0.9* [**2108-4-18**] 06:10AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.7 [**2108-4-17**] 01:00PM BLOOD PTH-141* [**2108-4-10**] 01:08PM BLOOD Lactate-3.4* [**2108-4-10**] 04:49PM BLOOD Lactate-1.4 Brief Hospital Course: 74yo F w/ recent diagnosis of spindle cell sarcoma s/p 1st cycle of chemotx who presents w/ neutropenic fever, hypotension, vomiting and fatigue. Neutropenic fever: She had no obvious infectious etiology, CXR notable only for intersitial markings c/w pulmonary edema or drug reaction. Changed cefepime to ciprofloxacin when she was afebrile and no longer neutropenic. Neupogen increased from 300 [**Hospital1 **] to 480 [**Hospital1 **]. Hypotension: This was likely due to poor po, relative adrenal insufficiency, sepsis, or cardiomyopathy from adriamycin. Pt responded to IVF boluses and stress dose steroids which support sepsis, adrenal insufficiency and hypovolemia. Hydrocortisone 100 tid was started in ICU given h/o Addison's, and this was tapered as described below. After transfer to the floor, she became more hypertensive, and her home medications were restarted without further episodes of hypotension. Pancytopenia: Likely from bone marrow suppression, and she was continued on neupogen. Metastatic sarcomatoid kidney cancer: s/p 1st cycle chemotx and will continue chemotherapy as an outpatient. Addison's: She had erratic and uncontrolled BP while receiving chemotherapy. Endocrine service was consulted to help manage her steroid dosing. They recommended tapering down hydrocortisone 100 tid to 50 tid for 24hrs, then 25 tid for 24hrs followed by prednisone 10mg daily. Arranged for transfer of her endocrine care to [**Hospital1 18**] physician, [**Name10 (NameIs) **] she will follow up with endocrinologist after discharge. CAD: She continued ASA and plavix; held briefly for port placement. HTN: Could attribute some fluctuation of BP to endocrine issues. Restarted lisinopril, atenolol, isosorbide when BP stabilized. COPD: She was given nebs prn; she had 2L NC O2 requirement w/ ambulation at time of discharge. CRI: Baseline creatinine is 1.5, and she did not have worsening renal function during this admission. PPX: Pt was provided with bowel regimen and heparin SC for prophylaxis. Code: full Medications on Admission: atenolol diovan isosorbide lisinopril prednisone 2.5mg [**Hospital1 **] aspirin 325 magnesium 60 qd calcium 600 [**Hospital1 **] plavix Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: Primary: 1. Neutropenic Fevers 2. Spindle Cell Sarcoma 3. Addison's disease Discharge Condition: Afebrile and no longer neutropenic; still requiring 2L NC for ambulation. Discharge Instructions: Please take all your medications as prescribed. Please restart your aspirin; plavix should be restarted w/ guidance from Dr. [**Last Name (STitle) 7047**]. Please follow up in the hematology/oncology clinic as listed below. Also, an appointment was made for you to see an endocrinologist here at [**Hospital1 18**]. The information is provided below. Please call your doctor or return to the hospital if you develop fevers, chills, nausea, vomiting, unable to tolerate food or have any other concerns. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3972**] [**Last Name (NamePattern1) **] - endocrinologist. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2108-4-20**] 4:00 [**Hospital Ward Name 23**] [**Location (un) 436**]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2108-4-23**] 1:30 Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[**2108-4-23**] 1:30 Completed by:[**2108-7-28**]

[ "197.0", "V58.65", "584.9", "189.0", "585.9", "V12.59", "389.9", "288.0", "272.4", "255.4", "443.9", "284.8", "E933.1", "496", "V26.51", "414.01", "198.5", "275.3", "458.29", "401.9", "276.52" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.99", "86.07" ]

icd9pcs

[ [ [] ] ]

7833, 7884

5607, 7646

319, 326

8004, 8080

3651, 5584

8632, 9162

2761, 3032

7905, 7983

7672, 7810

8104, 8609

3047, 3632

268, 281

354, 1130

1152, 2435

2451, 2745

11,455

118,131

17186

Discharge summary

report

Admission Date: [**2144-3-2**] Discharge Date: [**2144-3-27**] Date of Birth: [**2072-11-16**] Sex: F Service: MEDICINE Allergies: Diflucan / Compazine / Sulfa (Sulfonamides) / Clindamycin Attending:[**First Name3 (LF) 6169**] Chief Complaint: fevers Major Surgical or Invasive Procedure: Port placement History of Present Illness: 71 yo W w/ hx AML s/p chemo x 2 found to have anemia w/ hct down to 23 in clinic and was sent to the [**Hospital Unit Name 153**] for further evaluation. She is s/p 1U PRBC transfusion and was reportedly febrile post-transfusion. . Pt has had decreasing MS over the past few weeks, a 25 lb wt loss, occ DOE, diarrhea and nearsyncope. Currently she reports no CP or SOB, LH or abd pain, no dysuria, no cough. In ED BP 89/Palp w/ SBP's in 60's subsequently up to 100/70's on dopa gtt, s/p 2g cefepime, compazine, 1 bag plts, and 1U PRBC's, 2L IVNS, 1mg ativan, anzemet. She was subsequently weaned off dopa in the ICU and transferred to the BMT floor for further managment. Past Medical History: AML diagnosed [**12/2141**] s/p low dose ara-c w/ remission now w/ recurrence since [**2-/2143**] s/p melphalan and 2 cycles of 5-azacytidine w/out good response on danazol for thrombocytopenia. . diverticulosis hypercholesterolemia Social History: never smoked, occ EtOH, no IVDU/illicit drug use; lives alone at home, ex-husband and nieces, nephews involved Physical Exam: Gen: pale elderly cauc W lying in stretcher in NAD HEENT: anicteric, OP clear, MM dry, pale Heart: flow murmur, no r/g, RRR Lungs: CTBLA, no rales, no wheezes or crakcles Abd: NABS/S/NT/mildly distended, no masses Ext: no edema Derm: no petechiae Rectal per ED guaiac negative. Pertinent Results: [**2144-3-2**] 05:31PM GLUCOSE-137* UREA N-46* CREAT-2.1*# SODIUM-133 POTASSIUM-4.8 CHLORIDE-93* TOTAL CO2-29 ANION GAP-16 [**2144-3-2**] 05:31PM WBC-2.4*# RBC-2.86*# HGB-8.3*# HCT-25.2*# MCV-88 MCH-29.0 MCHC-33.0 RDW-14.3 [**2144-3-2**] 05:31PM NEUTS-21* BANDS-0 LYMPHS-35 MONOS-29* EOS-0 BASOS-0 ATYPS-14* METAS-1* MYELOS-0 Brief Hospital Course: A/P: 71 yo F with h/o AML w/ neutropenia and fever, with hypotension and pancytopenia. . 1. Febrile Neutropenia - In the ED patient was hypotensive and started on dopamine. Patient was off pressors (Dopamine) after transfer from the ICU and blood pressure was stable throughout the stay. Blood cx taken on the bmt service were negative, multiple CXR showed no PNA. Initially, patient's hypotension was thought to be from ativan overdose at home vs. sepsis. Patient was treated emperically with cefepime 2g IV q24h d1 = [**2144-3-2**]. Patient was additionally started on vanco emperically for a fever of 100.4 on [**3-10**]. Subsequently patient was then started on caspo for persistent fevers. MRI of abdomen neg for source of fevers. A source of infection was never found so the initial hypotension and change in mental status were both thought to be from ativan overdose rather than sepsis. 2. Pancytopenia - Most likely [**1-22**] recent chemotherapy. patient is transfused in house 2x and was determined to be transfusion dependent due to her disease. She had a port placed to help with chronic transfusions and blood draws. She remained transfusion dependent. 3. MS changes - Mental status much clearer after first two nights. However, family stated that patient's MS had been deteriorating for past weeks/months. - acute MS changes at admission were most likely due to ativan overdose at home. After transfer from the unit patient became very lucid just short term memory problems. [**Name (NI) 430**] MRI was negative except for sinus disease thought to be chronic. The patient then developed left facial droop and slurring of speech. A head CT was notable for possible new infarct in the right corona radiata. The patients neurological deficits worsened and she was made CMO. . 4. AML - pt is currently recieving azacytidine therapy, which has resulted in her pancytopenia. danazol was d/c'd in house and no further therapy was instituted. . 5. ARF - resolved Cre back to baseline. At admission pt most likely had prerenal azotemia that resolved with fluids. . 6. Code - was DNR/DNI during this hospitalization as discussed w/ Dr. [**First Name (STitle) 1557**]. She was made CMO after her right corona radiata stroke. A morphine gtt was started for respiratory discomfort. She passed away on [**2144-3-27**]. . Medications on Admission: danazol 250mg po tid senokot propranolol 40mg po bid lisinopril 10mg po qhs colace claritin celebrex 100mg po q24h nexium 20mg po q24h centrum silver trazodone 100mg po qhs ativan 10mg po tid Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased

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icd9cm

[ [ [] ] ]

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166,533

14125

Discharge summary

report

Admission Date: [**2133-2-11**] Discharge Date: [**2133-2-27**] Date of Birth: [**2069-2-13**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5893**] Chief Complaint: thrombocytopenia, concern for consumptive process, as well as hematuria/epistaxis/bleeding from new EJ site Major Surgical or Invasive Procedure: [**2-12**] right PICC placement [**2-20**] dialysis cath placement History of Present Illness: 63 year old male with metastatic melanoma (V600E B-Raf mutant) who has been partially response to experimental treatment, now presented with spontaneous bleeding in the setting of new thrombocytopenia. Patient has been treated as part of a phase I clinical trial with chemo using a PI3-Kinase inhibitor and MEK inhibitor with good response. . Patient was on vacation in [**State 108**] and off study drug for 10 days when he reports spitting up bloody sputum and mucus when blowing his nose, starting 7d prior to admission. Pt drove to [**State 108**] from [**Location (un) 86**] directly. Pt was scuba diving to 15m. He noticed very dark urine and reported to a local hospital where he was noted to have a platelet count of 20K (normal bun and creatinine). Pt denied any fevers, chills, SOB or chest pain. He had a mild cough that he attributes to GERD. he also had severe R hip pain, which he attributed to sciatica. By report, the OSH ED performed a CTA chest to evaluate for pulmonary embolism, which was negative. He also had an ultrasound of his right hip and thigh, which did not show any clot. Patient then flew up to [**Location (un) 86**] today and reported directly to the outpatient oncology clinic. There, patient noted continued nose and gum bleeding but now also reports maroon colored urine and mild nausea. His labs were drawn, and given his continued bleeding, Pt was sent to the [**Hospital1 18**] ED for further evaluation and likely inpatient admission. . Per Onc notes, pt was first diagnosed with metastatic melanoma in [**2130**], with excision of primary 1.7mm lesion on left flank in [**2123**] w/ lymph node dissection showing metastasis. Pt underwent several rounds of various chemotherapies that were not successful. Pt developed a new 1.4cm L basilar lung nodule in [**2130**] and underwent VATS resection in [**2130-10-10**]. Pt then had a new lesion in L lower lobe lung nodule in [**2131-7-10**]. Pt started current chemotherapy in [**2132-7-9**], and per [**2133-1-12**], onc clinic note, Pt has been doing well w/ partial remission of disease except for a left lingular nodule that has been getting larger. . In the ED inital vitals were 98.1, 86, 156/86, 18, 95% on RA. Labs were significant for platelet count of 30 and fibrinogen <35, INR 1.8, PTT 43.9, PT 19.2. Hct 34.4 from a baseline of 39-41. WBC 10.9 (74% N, 4% bands), Creatinine 1.1, Uric acid 5.0, LDH 1215, LFTs otherwise normal (Tbili 0.6, Dbili 0.2). Of note, patient's platelets were last 146 on [**2133-1-12**], and his LDH has always been in the 200s. In the ED, patient had L EJ placed, and was given 2units of cryoprecipitate and 1 unit of platelets. Admitted to ICU for concern of thrombocytopenia vs. DIC vs. TTP-HUS. On transfer, VS were 94, 97% RA, 119/76, 10 rr, 99.5%. . On arrival to the ICU, vitals were: 36.7C, HR 93, BP 118/71, RR 12, Sat 94% on RA. Review of systems: (+) bloody mucus and sputum, mild cough, L elbow effusion, R hip pain, maroon urine. Reports mild nausea and constipation x 5 days, which he states is a side effect of his chemo. (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting, diarrhea, abdominal pain. Denies dysuria, frequency, or urgency. Past Medical History: Past Medical History: -Melanoma, V600E BRAF mutant melanoma who has completed 6 cycles of protocol 09-309GERD with partial response. Has growing L lingula nodule. -sleep apnea, not using CPAP -hypercholesterolemia -chronic R hip pain / sciatica Past surgical history: -melanoma resection (left flank) in [**2123**] w/ lymph node dissection showing metastasis. Pt underwent several rounds of various chemotherapies that were not successful. Pt developed a new 1.4cm L basilar lung nodule in [**2130**] and underwent VATS resection in [**2130-10-10**]. Pt then had a new lesion in L lower lobe lung nodule in [**2131-7-10**]. Social History: Pt lives w/ wife in [**Name (NI) 7740**]. No sick contacts. Recently travelled long distance to [**State 108**] from [**Location (un) 86**] by car. - Tobacco: 60 pack year history, quit in [**2098**] - Alcohol: 3 drinks weekly - Illicits: none Family History: both parents had CAD. Father had MI in his late 50's. No cancer or hematologic disorders. Physical Exam: Admission Physical: 36.7C, HR 93, BP 118/71, RR 12, Sat 94% on RA. General: well-appearing man in no acute distress. Alert, oriented x 3. HEENT: PERRL, EOMI, dried blood on R mouth, dried blood in both nostrils, normal oropharynx. Neck: supple, JVP not elevated, no LAD Lungs: CTAB CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur heard best at 4th mid-clavicular line, no gallops Abdomen: soft, non-tender, mildly-distended, bowel sounds present, spleen not palpable GU: no foley Skin: L EJ in place, non-blancing erythematous rash on bilateral forearms. Ext: 2x3cm firm effusion on L elbow with bruise. warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Pain in R hip with external rotation. Straight leg raise negative. Pertinent Results: Admission Labs: [**2133-2-11**] 03:40PM GLUCOSE-104* [**2133-2-11**] 03:40PM UREA N-24* CREAT-1.1 SODIUM-141 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-32 ANION GAP-13 [**2133-2-11**] 03:40PM ALT(SGPT)-16 AST(SGOT)-25 LD(LDH)-1215* CK(CPK)-95 ALK PHOS-80 TOT BILI-0.6 DIR BILI-0.2 INDIR BIL-0.4 [**2133-2-11**] 03:40PM TOT PROT-6.6 ALBUMIN-4.6 GLOBULIN-2.0 CALCIUM-9.5 PHOSPHATE-3.6 MAGNESIUM-2.2 URIC ACID-5.0 [**2133-2-11**] 03:40PM WBC-10.9# RBC-3.76* HGB-11.9* HCT-34.4* MCV-91 MCH-31.5 MCHC-34.5 RDW-12.8 [**2133-2-11**] 03:40PM NEUTS-74* BANDS-4 LYMPHS-14* MONOS-4 EOS-2 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* [**2133-2-11**] 03:40PM I-HOS-AVAILABLE [**2133-2-11**] 03:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2133-2-11**] 03:40PM PT-19.2* PTT-43.9* INR(PT)-1.8* [**2133-2-11**] 03:40PM FIBRINOGE-<35* Discharge labs: [**2133-2-26**] 02:58AM BLOOD WBC-10.9 RBC-2.16* Hgb-6.8* Hct-19.6* MCV-91 MCH-31.5 MCHC-34.9 RDW-15.7* Plt Ct-67* [**2133-2-26**] 02:58AM BLOOD PT-14.3* PTT-27.3 INR(PT)-1.3* [**2133-2-26**] 02:58AM BLOOD Glucose-151* UreaN-125* Creat-6.5* Na-137 K-5.8* Cl-102 HCO3-21* AnGap-20 [**2133-2-26**] 02:58AM BLOOD ALT-60* AST-74* LD(LDH)-3850* AlkPhos-198* TotBili-1.5 [**2133-2-26**] 02:58AM BLOOD Calcium-10.5* Phos-5.5* Mg-2.4 Micro: URINE CULTURE (Final [**2133-2-12**]): NO GROWTH. [**2-15**], [**2-18**]: no growth Blood culture [**2133-2-12**]: negative. [**2-15**]: MSSA [**2134-2-17**] negative [**2039-2-21**], pending Pathology: [**2133-2-20**] bone marrow biopsy (preliminary): extensive metastatic melanoma; no hemosiderin-laden macrophages suggestive of hemophagocytosis Studies: CXR [**2133-2-12**]: IMPRESSION: AP chest read in conjunction with CT scan of the chest, [**2-9**]: Nearly cm rounded opacity in the left mid lung has developed from what was previously a 2-cm wide opacity with surrounding hemorrhage in the lingula on the chest CT performed [**2-9**]. The CT also shows patient has had a wedge biopsy from the left lower lobe and has a small non-serous fluid collection in the left major fissure. Differential diagnosis of the lingular lesion includes abscess or aggressive tumor. Right lung is clear. Heart size is normal. Renal u/s [**2133-2-12**]: IMPRESSION: No definite renal mass lesion identified. No hydronephrosis or calculus. The study and the report were reviewed by the staff radiologist. CXR line placement [**2133-2-12**]: IMPRESSION: AP chest compared to 4:11 a.m.: New right PIC line ends in the mid SVC. Right lung clear. Normal cardiomediastinal silhouette. A roughly 5-cm wide lesion at the lateral periphery of the left mid lung and a smaller lesion just inferior to it developed between [**2131-8-9**] and [**2-12**]. Differential diagnosis is broad and includes pneumonia, malignancy, and infarction. CT scan might be helpful in differentiating among these. Pleural effusion is small on the left, if any. Note is made of at least moderately severe intestinal distention in the upper abdomen. No pneumothorax. MRI Hip [**2133-2-15**]: 1. Diffuse infiltrative bone marrow disease, suspicious for metastases. 2. Intramuscular hematomas of the right iliopsoas and obturator internus muscles. A soft tissue metastatic focus within these muscles is not entirely excluded. [**2133-2-16**] Radiology UNILAT UP EXT VEINS US, right upper extremity No evidence of deep vein thrombosis. [**2133-2-17**] Radiology PORTABLE ABDOMEN XR FINDINGS: Upright views of the abdomen demonstrate multiple dilated air-filled loops of large bowel, compatible with colonic ileus. These loops appear wider in diameter compared with the prior examination. No pneumatosis or pneumoperitoneum. The osseous structures are unremarkable. No radiopaque foreign bodies. IMPRESSION: Worsening colonic ileus. [**2133-2-17**] Radiology RENAL U.S. 1. 5mm non-obstructing right renal calculus. No hydronephrosis. 2. 1.4 cm simple cyst unchanged from the prior examination. [**2133-2-17**] Radiology UNILAT LOWER EXT VEINS - No evidence of DVT in right lower extremity veins. [**2133-2-19**] Radiology CT Chest, ABD & PELVIS W/O CON IMPRESSION: 1. Reidentified is thickening of the right iliacus and right internal obturator muscles, compatible with the patient's known hematoma, no gross change is seen from prior MR examination from [**2133-2-15**]. 2. New left nonhemorrhagic pleural effusion. 3. New ground-glass opacities are seen in the lungs as described. This might be secondary to infectious, given the patient's clinical details intrapulmonary hemorrhage cannot be excluded. 4. Increase in size and number of pulmonary mets. 5. New pericardial effusion. 6. Unchanged presacral tissue density/hematoma. [**2133-2-20**] Cardiovascular ECHO The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The estimated cardiac index is high (>4.0L/min/m2). 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. There is no valvular aortic stenosis or definite vegetation, though a very small (~2-3mm) mobile echodensity on the non-coronary leaflet of the aortic valve is suggested in one view (clip [**Clip Number (Radiology) **], ?74) c/w a possible vegetation vs focal calcification. No aortic stenosis is present. The increased transaortic velocity is likely related to high cardiac output. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Aortic valve sclerosis with trace aortic regurgitation. Possible vegetation on the aortic valve as described above. Normal biventricular cavity sizes with preserved regional and hyperdynamic global biventricular systolic function. If the clinical suspicion for endocarditis is moderate or high, a TEE is suggested. [**2133-2-26**] Radiology CHEST (PORTABLE AP) Right upper lobe consolidation has minimally improved. Left lower lobe opacities are unchanged. Cardiomediastinum is stable. Vascular congestion has improved. Right PICC and right IJ catheter tips are in the SVC. There is no pneumothorax. Brief Hospital Course: Brief Course: Mr. [**Known lastname 1319**] is a 63 year old male with metastatic melanoma (V600E B-Raf mutant) who has been partially responsive to experimental treatment, who presented to the ICU with spontaneous bleeding, hematuria, and DIC. He was admitted to the ICU and required multiple blood product transfusions for support. His course was complicated most notably by renal failure requiring dialysis. In the end, he and his wife decided to not continue to pursue aggressive measures, given the grim prognosis for his metastatic melanoma. He passed away on [**2133-2-27**] at 04:00 with his wife [**Name (NI) 1123**] at his side. Please see below for further details about his hospitalization on a problem-by-problem basis. # DIC: Labs on admission consistent with DIC-- thrombocytopenia, anemia, low fibrinogen, elevated INR/PT, high D-dimer and fibrin degradation products. Smear on admission was negative for schistocytes, no evidence of TTP. Etiology thought to be likely his widely metastatic melanoma, especially now that there are new foci of metastatsis and bone marrow infiltration. No signs of sepsis/infection intially(afebrile, WBC 10.9, no bandemia or left shift, no symptoms of infection). Urine culture was negative, and initial blood culture negative. Did develop transient MSSA bacteremia (likely from infected EJ peripheral IV), however this was placed after initially presentation and therefor unlikely to be precipitant of DIC. He was observed in the ICU and transfused with cryoprecipitate for goal fibrinogen 100, PRBC's for Hct 25, and platelets for goal of 50 given active bleeding. He received a total of 18 units of cryo, mainly in the first 2 days of his hospitalization. He also need 5 transfusions of platelets and 1 unit of FFP. Within the first few days of his stay, his DIC seemed to improve with decreasing transfusion requirements, however he continued to have ongoing anemia requiring frequent blood transfusions. Please see "Anemia" below for more details on that specific problem. # Anemia: Throughout ICU stay, patient required frequent blood transfusions to keep hct >21. Initially, this was attributed to DIC, however DIC abated and his PRBC requirement continued to increase. Etiology seemed to be consistent with blood loss anemia through his GU tract (see "hematuria" below) as well as bleeding/hematomas in his thighs seen on CT and MRI scans. Also question some degree of pulmonary hemorrhage surrounding lung nodule in left lower lobe. Labs were also suggestive of hemolysis with decreasing haptoglobin and elevated LDH. Direct coombs was sent and was negative. Hematology was consulted and felt that hemolysis was unlikely, with his elevated LDH due to his metastatic melanoma and haptoglobin falsely lowered by multiple transfusions. Repeat blood smear showed some nucleated red cells and giant platelets, but few schistocytes. Bone marrow biopsy on [**2-20**] showed extensive melanoma, with no evidence of hemophagocytosis (ferritin 4000). Pt's Hct was more stable over the later part of his hospitialization, as he initially required 3-4 units daily for several days but this eventually decreased to [**2-9**] units daily. Urology was also consulted for continued hematuria (see below). Pt transitioned to comfort care on [**2-26**] and received no further transfusions. . # Hematuria: One of his chief complaints on presentation, likely due to mucosal bleeding from coagulopathy as above. CT scan on admission did not show any reason for bleeding, only small foci of parenchymal hemorrhage in the kidneys. Foley placed and put out frank blood, which eventually began to clot in the tubing. At that point, he was placed on continuous bladder irrigation with 3-way foley. This was complicated by frequent clotting and urinary retention. Urology was consulted and suggested frequent hand irrigation, however he continued to have frequent clots requiring foley changes. At this time he also developed renal failure (see below), so renal US was obtained, and there was no evidence of clot causing obstructive hydronephrosis. Unfortunately, Pt could not be weaned off CBI, and he continued to have significant anemia and hematuria. Pt was offered a cystoscopy and clot evacuation procedure to help reduce the bleeding and clot burden, which was causing significant discomfort for the patient when passed during bladder irrigation. However, he refused on [**2-26**] and transitioned to comfort care. Per urology, CBI would be more comfortable than removing the foley and having potential clots. His manual foley irrigation was reduced to the minimum possible to prevent complete obstruction / clots. . # [**Last Name (un) **]: Cr steadily increasing since [**2-16**] (1.0->6.9 peak on [**2-21**]). While it was difficult to assess urine output due to CBI, he appeared to be anuric. Renal US did not show clot causing obstruction and hydronephrosis. Renal service was consulted and felt this may have been due to pigment-induced acute renal failure due to intravascular hemolysis. Recommended alkalinizing urine, however given anuric status, bicarb was stopped so as to not volume-overload him any further. Nursing reported very little urine output overnight after foley was clamped. Pt had an HD dialysis line placed with IR and initiation of HD on [**2-20**]. His creatinine and BUN continued to increase during his off dialysis days, and renal consult team felt that it would likely be several weeks to months before he would recover any meaningful renal function (if ever). Pt and his wife chose to transition to comfort care on [**2-26**] and did not receive any further HD sessions. No further labs were checked. . # Metastatic Melanoma: Pt has finished cycle 6 of experiment MEK inhibitor therapy and was in-between cycles on admission. As above, given DIC, this chemotherapy was held. Upon imaging, he appeared to have diffuse progressive disease. Pelvic MRI showed diffuse marrow infiltration, new mass in iliacus muscle that may represent another met. Bone marrow biopsy on [**2133-2-20**] showed very extensive infiltration of his bone marrow with melanoma. A colleague of his outpatient oncologist Dr. [**Last Name (STitle) **] (Dr. [**Last Name (STitle) **], who formerly was his onc doctor) followed him throughout his stay. He was willing to try another chemo regimen but believes likelihood of this helping much is low and would not be able to dose regimens without adequate renal function. Dr. [**Last Name (STitle) **] felt his odds of surviving this episode were very low. This information was conveyed to Mr. [**Name13 (STitle) **] and his wife, and given all the recent complications, they ultimately chose to not pursue further treatment. . # Fevers / MSSA bacteremia: Pt was febrile on [**2-15**] and blood cultures later revealed MSSA, thought to be due to infected L EJ IV site which was purulent and also grew MSSA. Pt was started on nafcillin on [**2-17**] for MSSA bacteremia. However, Pt had a CT abdomen, which showed a possible RUL pneumonia, and antibiotics were switched to vancomycin and cefepime. ID was consulted and also recommended TTE for worsening heart murmur. TTE showed a possible 2mm lesion on the aortic valve but no significant regurg or stenosis of any valve and hyperdynamic LV activity. Several surveillance blood and urine cultures were negative afterwards, but the Pt did become mildly febrile on [**2-23**]-18. Pt's antibiotics were discontinued on [**2-26**] when he transitioned to comfort care. # Abdominal pain/distension and R hip pain: Initially though most likely secondary to constipation vs. ileus vs. pain from bleeding into soft tissues. KUB consistent with ileus likely related to opiates. Received 2 doses of methylnaltrexone to help reverse opiate effect on the gut. Pt had minimal bowel movements, and continued to have pain. Small progress was made with enemas and bowel regimen. Given metatstatic disease, MRI pelvis was ordered, which showed diffuse infiltration of the bone marrow with metastatic disease, and enlargement of the right iliacus and the right internal obturator muscles, which appears to be due to bleeding. Also seen was an enhancing nodule in the right iliacus muscle, possibly a met. Abdominal pain possibly related to these findings. Unable to obtain bladder pressure due to 3-way foley. Given persistent and worsening pain, CT abd/pelvis again obtained which showed hematoma of right iliacus muscle, likely contributing to worsened belly and back pain, but no significant enlargement relative to prior. Pt had intermittent abdominal pain that was not related to bowel movement. His pain improved once his medication regimen was liberalized after transition to comfort care. . # Altered mental status: Days into admission, patient was became intermittently altered and somnolent which was attributed to his narcotics. Neuro exam normal, so head CT to r/o bleed deferred. Pt's mental status later waned w/ worsening renal function and was attributed to a combination of his obstructive sleep apnea and worsening uremia. Pt was found to be hypercarbic on VBG. Pt did seem to be more awake and alert when he used his CPAP at night and after dialysis. HD was stopped on [**2-26**] at Pt's request. . # Hypertension: Pt was intermittently hypertensive to 150s, started metoprolol 12.5 mg [**Hospital1 **] with improvement in BPs, but this was later discontinued. Medications on Admission: GDC 0941 (PI3-Kinase inhibitor) GDC 0973 (MEK inhibitor) oxycodone-acetaminophen 10 mg-650 mg Tablet 1-2tabs prn hip pain ranitidine HCl 150 mg Capsule Qday Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Metastatic melanoma Disseminated intravascular coagulation Pancytopenia Acute renal failure Hematuria Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

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icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "99.15", "41.31" ]

icd9pcs

[ [ [] ] ]

21994, 22003

12321, 21079

413, 481

22149, 22158

5672, 5672

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3395, 3863

265, 375

509, 3376

5688, 6557

21095, 21754

3907, 4131

4528, 4776

19,617

127,959

30091

Discharge summary

report

Admission Date: [**2127-4-3**] Discharge Date: [**2127-4-4**] Date of Birth: [**2062-9-5**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2704**] Chief Complaint: Transfer from OSH after cardiac arrest. Major Surgical or Invasive Procedure: None. History of Present Illness: 64 year-old male with history of CAD status post CABG brought to OSH by EMS. The patient is reported to have had chest pain and then syncopized per the family. CPR was initiated by the family. The patient was intubated and shocked x2 by EMS for ventricular fibrillation. At the OSH, the patient was found to be in PEA. The patient was given multiple rounds of epinephrine/atropine --> pacing ---> PEA --- > CPR --- > EPI --- > PEA --- > EPI/lidocaine/dopamine ---> EKG showed IMI ---> PEA ---> CPR ---> EPI ---> junctional/wide complex. Heparin gtt started. Pupils were fixed and dilated. Head CT neg for bleed. TTE with "faint squeeze." The patient was transferred to [**Hospital1 18**] for consideration of cardiac catheterization. . Initial vital signs in the [**Hospital1 18**] ED: 92/44, 136, 90% intubated. The patient was transferred on heparin gtt, however, this was discontinued for coffee-ground emesis. Past Medical History: 1. CAD status post CABG 2. ? Hyperlipidemia 3. ? Depression Social History: Unknown. Family History: Non-contributory. Physical Exam: Vitals: T 93, 107/74 on Dopamine, dobutamine and Lidocaine, HR 126, RR 16 satting 100% on AC/550/16/5/70% Gen: patient intubated and not responsive to sternal rub Neuro: Pupils fixed and dilated, negative corneal reflex, orbital edema CV: tachy, regular, no g/m/r Pulm: bibasilar crackles, coarse breath sounds bilaterally Abdomen: distended, no bowel sounds Ext: UE edema, no LE edema, dopplerable pulses, cool extremities Pertinent Results: Labwork on admission: [**2127-4-3**] 08:50PM WBC-15.5* RBC-4.65 HGB-14.7 HCT-45.4 MCV-98 MCH-31.6 MCHC-32.4 RDW-13.6 [**2127-4-3**] 08:50PM PLT COUNT-364 [**2127-4-3**] 08:54PM GLUCOSE-261* LACTATE-8.7* NA+-140 K+-4.5 CL--106 [**2127-4-3**] 08:50PM UREA N-22* CREAT-1.3* [**2127-4-3**] 08:54PM PO2-44* PCO2-56* PH-7.06* TOTAL CO2-17* BASE XS--16 . ABG after apnea test: [**2127-4-4**] 03:05PM BLOOD Type-ART pO2-68* pCO2-64* pH-7.13* calTCO2-23 Base XS--9 . EKG at OSH demonstrated STE in II, III, aVF, I, aVL, V3-V6 with a rate of 122, RBBB . CHEST (PORTABLE AP) [**2127-4-3**] IMPRESSION: 1. No definite evidence for thoracic injury. 2. Massively dilated stomach, the ET tube appears correctly positioned on this film. This should be confirmed by a clinical examination or a lateral chest film to exclude malpositioning. Findings were discussed with Dr. [**First Name (STitle) **]. . ECHO Study Date of [**2127-4-3**] Conclusions: The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed with global hypokinesis and regional akinesis of a relatively thinned, akinetic infero-septal, inferior and infero-lateral walls. Right ventricular chamber size and free wall motion are normal. Trivial mitral regurgitation is seen. There is an anterior space which most likely represents a fat pad but a loculated pericardial effusion cannot be excluded. Brief Hospital Course: 64 year-old male with CAD status post CABG presenting from OSH after ventricular fibrillation arrest from STEMI. The patient was evaluated by neurology during admission. The patient had no spontaneous breaths during apnea testing. The patient met criteria for brain death and was pronounced dead at [**2127-4-4**] 15:09. The patient was listed as an organ donor and was evaluated by the [**Location (un) 511**] Organ Bank. Medications on Admission: Metoprolol 25 daily Lovastatin 40 daily Paroxetine 20 mg po daily Zetia 10 mg po daily Ecotrin 325 Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Primary: 1. Brain death after VF/PEA arrest 2. ST-elevation myocardial infarction . Secondary: 1. Coronary [**Last Name (un) **] disease status post CABG 2. ? Hyperlipidemia 3. ? Depression Discharge Condition: Expired. Discharge Instructions: Expired. Followup Instructions: None.

[ "311", "348.8", "427.41", "V45.81", "414.00", "458.9", "427.5", "583.9", "410.81" ]

icd9cm

[ [ [] ] ]

[ "55.23", "96.71", "96.07" ]

icd9pcs

[ [ [] ] ]

3939, 3948

3332, 3760

333, 340

4182, 4193

1897, 1905

4250, 4259

1418, 1437

3909, 3916

3969, 4161

3786, 3886

4217, 4227

1452, 1878

254, 295

368, 1293

1919, 3309

1315, 1376

1392, 1402

61,030

103,313

5944

Discharge summary

report

Admission Date: [**2195-2-10**] Discharge Date: [**2195-2-10**] Date of Birth: [**2119-8-13**] Sex: F Service: MEDICINE Allergies: A.C.E Inhibitors / Darvon / Atenolol / Bactrim / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 3556**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 74 year old female with known CAD, diastolic CHF, HTN, DM, dyslipidemia, p/w acute dyspnea on her home BiPap machine, called 911. EMS found her in respiratory distress unable to speak, requiring BVM ventilation, gave her Lasix 80 mg IV, nitro patch. She has been in and out of hospitals for the past year, and has been intubated three times over that period. During a [**Month (only) **] hospitalization she was diagnosed with CHF and reportedly had an EF of 30%, though her last documented Echo is of 55%. She has been out of rehab from that hospitalization for 3 weeks, and since arriving home she was started on BiPap at night, a low-salt diet, and has a home health nurse 4 days/week. Over the past 3 days her nurse tracked a 2-lb weight gain. Past Medical History: 1. Coronary artery disease s/p NSTEMI and Taxus stent to LAD in [**2189**] in [**State 108**] and failed attempt to stent OM1 in [**2187**] 2. Hypertension. 3. Diabetes mellitus type 2 (last A1C 9.0 in [**2192-5-18**]) 4. Hyperlipidemia. 5. Anemia with baseline hematocrit approximately 30.0. 6. Carotid stenosis. 7. Breast cancer, status post lumpectomy and radiation therapy. 8. Chronic Diastolic CHF 9. Status post cholecystectomy. 10. Obstructive Sleep Apnea on CPAP at home 11. Bakere's cyst 12. Osteoarthritis Social History: The patient lives in [**Location 3146**] by herself. She smoked 0.5-1 ppd for 30 years but quit 20 years ago. She does not currently drink alcohol. She denies illicit drug use. Ambulates with walker and needs assistance with ADLs. Family History: Father had stomach cancer and died of a MI at age 62. Her mother had [**Name2 (NI) 499**] cancer and died in her 60s. She had two brothers, one died of an MI at age 39, the other at age 65. She has a sister who had breast cancer. She has three children, one of whom is deceased. The other two children are healthy. She has three healthy grandchildren. Physical Exam: On admission: Vitals: T: 70. BP 158/67. RR 26-30. O2 98% on BiPap. General: Alert, oriented, speaking full sentences HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Crackles in bases CV: S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, no rebound tenderness or guarding GU: Foley Ext: warm, well perfused, 2+ pulses. Nonpitting edema in legs. Pertinent Results: Admission Labs: [**2195-2-10**] 02:25AM WBC-18.3* RBC-3.68* Hgb-10.7* Hct-32.1* MCV-87 MCH-29.0 MCHC-33.3 RDW-15.3 Plt Ct-491* [**2195-2-10**] 02:25AM Neuts-83.8* Lymphs-11.7* Monos-3.0 Eos-1.2 Baso-0.4 [**2195-2-10**] 02:25AM PT-23.5* PTT-30.2 INR(PT)-2.2* [**2195-2-10**] 02:25AM Glucose-178* UreaN-44* Creat-1.7* Na-139 K-4.0 Cl-100 HCO3-29 AnGap-14 [**2195-2-10**] 02:25AM CK(CPK)-77 [**2195-2-10**] 02:25AM cTropnT-0.02* [**2195-2-10**] 03:39AM Type-ART FiO2-80 pO2-106* pCO2-51* pH-7.39 calTCO2-32* Brief Hospital Course: 74 year old female with CAD, diastolic CHF, HTN, DM, dyslipidemia, p/w acute dyspnea. EMS found her in her home with respiratory distress unable to speak, requiring BVM ventilation, gave her Lasix 80 mg IV, nitro patch. When she arrived in the [**Hospital1 18**] ED she was 88% on room air and 100% on Bipap. She was started on a Nitro gtt, given Aspirin 600 mg PR. Labs notable for WBC of 18.9 and so concern for pneumonia she received Ceftriaxone 1 gram and Levaquin 750 mg. It was felt her physical exam, CXR and clinical course c/w CHF exacerbation/acute flash pulmonary edema was felt to be most likely though trigger unknown. Patient was is NSR so arrythmia was not felt likely to be contributing to flash. Patient was therapeutic on Coumadin, and while her left leg is more swollen than her right this is chronic so PE was felt to be unlikely trigger. . When she arrived in the ICU, she arrived on BiPap at FiO2 40% 5/5 had a rate of 30, Vt 600, and on a Nitro gtt 2 mcg/kg/minute. She was able to speak full sentences and no longer appeared to be in acute respiratory distress. She was given 80 IV lasix, nitro gtt was stopped at 2AM and she was weaned to 02 via NC by the morning. Repeat CXR showed improvement of the signs suggesting pulmonary edema. As she had a low grade temperature of 100.1, her antibiotics (azithromycin & ceftriaxone) were continued presumptively for community-acquired pneumonia. Transthoracic echocardiogram was negative for ventricular pathology. Her chest x-ray reportedly showed bilateral extensive focal parenchymal opacities persist, some of which appear mass-like or nodular (notably in the left lung). It was suggested that these nodules may undergo CT evaluation. - sputum cx pending - LENIs ordered but not yet done - PT consult for early mobilization ordered but not yet done . Her other chronic medical problems were managed as below: # A Fib: Patient in NSR, INR therapeutic at 2.2, she was continued on coumadin 6mg po qhs and monitored on telemetry. Of note, her troponin level increased from 0.02 to 0.07, but only non-specific changes were seen on the ECG. This was communicated by telephone to your accepting physician prior to transfer. . # OSA: Continued on CPAP overnight. # HTN: Written for her home Imdur, Metoprolol, Hydralazine # GERD: Home Pantoprazole # DM: Continued on (unable to confirm as patient didn't know her dose) Novolin NPH 20 units QAM, and sliding scale. . # Pulmonary Nodules: CXR read " left more than right, extensive focal parenchymal opacities persist, some of which appear mass-like or nodular (notably in the left lung). As suggested on the previous examination, these lesions could undergo CT evaluation. " -CT not yet ordered or done, will need assessment at [**Hospital1 34**] (where patient is being transferred today). . # Prophylaxis: Subcutaneous heparin, home PPI . # Access: peripherals . # Communication: Patient and son [**Name (NI) 429**] (HCP) [**Telephone/Fax (1) 23433**] Medications on Admission: Nexium 40 mg QD Hydralazine 30 mg TID Novolin NPH 20 units in AM Novolog SS Fluticasone 50 mcg Spray Imdur 120 mg QD Lopressor 100 mg [**Hospital1 **] Lasix 60 mg QD Warfarin 4 mg QD Alb/Atrovent nebs Q4 Ergocalciferol 1,000 unit QD Discharge Medications: 1. Hydralazine 10 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Albuterol Sulfate Inhalation 6. Ipratropium Bromide Inhalation 7. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days: Start on [**2-11**], as [**2-10**] dose already given. Last dose on [**2-14**]. 8. Ceftriaxone 1 gram Recon Soln Sig: One (1) gram Intravenous once a day for 4 days: [**2-10**] dose already given. Last dose will be on [**2-14**]. 9. Insulin Regular Human Injection 10. Warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day: To be adjusted as according to INR levels. 11. Novolin R 100 unit/mL Solution Sig: Twenty (20) Units Injection once a day. 12. Ergocalciferol (Vitamin D2) Oral 13. Fluticasone Nasal Discharge Disposition: Extended Care Discharge Diagnosis: Primary: Acute on chronic diastolic congestive heart failure Fever Secondary: Coronary artery disease Hypertension Hyperlipidemia Diabetes Mellitus, Type 2 Anemia Obstructive Sleep Apnea 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: Ms. [**Known lastname **], You were admitted to [**Hospital1 69**] for respiratory distress. You were given medications to control your blood pressure and to treat any possible pneumonia, and you were given supplemental oxygen. You were given diuretic medications to remove fluid from your body, and your condition improved. An echocardiogram of your heart showed that your heart is still pumping blood effectively. We made the following changes to your medications. Your medication list will be communicated to the hospital you are going to. - Stopped NEXIUM. Instead, you are receiving PANTOPRAZOLE 40 mg by mouth, once daily, to reduce stomach acid. - Your FUROSEMIDE was increased to an 80 mg dose through the IV, to remove fluid from your body. Your new providers will decide how much of this medication to give you, going forward. - AZITHROMYCIN 500 mg today (already given), then 250 mg by mouth once daily, for the next four days. Last dose 2/27 - CEFTRIAXONE 1 g through the IV for a total of 4 days, for the next four days. Last dose 2/27 - Your WARFARIN will be re-dosed as according to your blood tests at the new hospital. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: You are being transferred to a different hospital, for further care [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

[ "V45.82", "412", "427.31", "428.0", "272.4", "327.23", "486", "285.9", "250.00", "V10.3", "401.9", "414.01", "428.33" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7650, 7665

3296, 6274

349, 356

7897, 7897

2762, 2762

9330, 9530

1951, 2310

6558, 7627

7686, 7876

6300, 6535

8077, 9307

2325, 2325

302, 311

384, 1134

2778, 3273

2339, 2743

7912, 8053

1156, 1683

1699, 1935

56,506

122,844

4194

Discharge summary

report

Admission Date: [**2158-11-10**] Discharge Date: [**2158-11-17**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2840**] Chief Complaint: Blood per rectum Major Surgical or Invasive Procedure: EGD History of Present Illness: Pt is a 86 year old with CHF (EF 30%), diastolic CHF, CAD sp MI with DES placed ([**8-/2157**]) on plavix/asa, afib s/p AV ablation s/p pacemaker, prior GI bleed in [**2155**] while INR supratherapeutic without etiology of bleed identified. Patient presents with bright red blood pre rectum. . Over the last three days the patient has become progressively lethargic and short of breath. Her blood pressure was found to be lower than normal when checked at her adult day care - systolics of 90s instead of over 100. The day of presentation the patient was taken to her PCP given increasing lethargy. There she was found to have bright red blood in her rectum. She was sent to [**Hospital1 18**]. . Patient notes no history of abdominal pain, blood per rectum, melena, nausea, vomiting, diarrhea. Besides her lethargy and shortness of breath she has been in her normal state of health. She notes no history of liver disease or alcohol abuse. No NSAIDS at home. Pt is on Plavix and ASA. . Of note the patient reportedly had a prior GI Bleed in [**2155**]. Apparantly an EGD and Colonoscopy were performed and were unrevealing. At that time she was on coumadin for her Afib, INR-5 on presentation, which was discontinued. Since that time she has had no bleeding per rectum. . In the ED, initial vitals 98.3 110 113/57 16 90%. Physical exam with revealed bright red blood per rectum. Two peripheral IVs, 18guage and 20guage placed. NG lavage without any return. Initial HCT found to be 24, HCT [**6-/2158**] was 43.5. Repeat HCT after one unit [**Unit Number **] on green top. Two units pRBCs transfused. EKG with atrial fibrillation with intermittent demand pacing. GI to perform EGD this evening. Pt also recieved lasix 40mg IV x one between blood transfusions, as patient became hypoxic to 86% on room air. This improved Vitals prior to transfer Afebrile, 82, 129/75, 21, 100% RA. . In the MICU patient continue to be hemodynamically stable with initial BP 100's/80's. She had no complaints and appear to be in no distress. She communicates through her daughter as she is cantonese speaking. . Past Medical History: 1. AF, not anticoagulated due to prior GIB 2. AAA, s/p repair in [**2147**] 3. [**Last Name (LF) 9215**], [**First Name3 (LF) **] reported to be 50% 4. prior MI 5. hyperlipidemia 6. HTN 7. DM2, diet controlled 8. CRI, followed by renal at NWH 9. GIB, [**11-15**], source not identified but reported as a "significant" bleed by daughter 10. PUD 11. osteoporosis 12. B12 deficiency Social History: Ms. [**Known lastname **] was born in [**Country 651**]. She and her husband moved to the United States in [**2116**] where she worked as a seamstress. Her husband died in [**2147**]. She has a 4th grade education. She has never smoked and does not drink alcohol. She lives with her son but is generally idenpendant. Family History: The patient has very limited knowledge about illness in her family, but is unaware of premature CAD or other heritable condition. Physical Exam: VS: 97.2 110/64 100 84 18 95% 0.5L O2 Weight on discharge: 52.8kg GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no carotid bruits, no thyromegaly or thyroid nodules. JVP elevated to the level of the jaw. RESP: Bilateral rales, no wheezes CV: Irregularly Irregular, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: +1 lower extremity edema bilateral lower extremity, no cyanosis SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps RECTAL: performed in ED with evidence of bright red blood. . Pertinent Results: On admission: [**2158-11-10**] 10:35AM BLOOD WBC-4.9 RBC-2.62*# Hgb-7.8*# Hct-23.9*# MCV-91 MCH-29.8 MCHC-32.6 RDW-16.6* Plt Ct-109* [**2158-11-10**] 10:35AM BLOOD Neuts-84.6* Lymphs-8.2* Monos-4.7 Eos-1.7 Baso-0.8 [**2158-11-13**] 03:34PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-1+ Polychr-NORMAL [**2158-11-10**] 10:35AM BLOOD PT-13.8* PTT-31.6 INR(PT)-1.2* [**2158-11-10**] 10:35AM BLOOD Ret Aut-3.0 [**2158-11-10**] 10:35AM BLOOD Glucose-107* UreaN-75* Creat-3.2* Na-135 K-5.0 Cl-99 HCO3-21* AnGap-20 [**2158-11-10**] 10:35AM BLOOD LD(LDH)-303* TotBili-0.5 [**2158-11-10**] 10:35AM BLOOD Iron-24* [**2158-11-10**] 10:35AM BLOOD calTIBC-280 Hapto-33 Ferritn-78 TRF-215 [**2158-11-13**] 07:13AM BLOOD VitB12-1717* Folate-GREATER TH [**2158-11-10**] 10:41AM BLOOD Glucose-106* Na-138 K-4.8 Cl-100 calHCO3-25 [**2158-11-10**] 03:12PM BLOOD Hgb-5.9* calcHCT-18 . On discharge: [**2158-11-17**] 05:35AM BLOOD WBC-5.6 RBC-3.75* Hgb-10.5* Hct-33.3* MCV-89 MCH-28.1 MCHC-31.6 RDW-16.6* Plt Ct-88* [**2158-11-17**] 05:35AM BLOOD Glucose-110* UreaN-51* Creat-2.4* Na-135 K-4.0 Cl-99 HCO3-25 AnGap-15 [**2158-11-17**] 05:35AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.2 [**2158-11-16**] 05:30AM BLOOD Osmolal-299 [**2158-11-15**] 05:20AM BLOOD TSH-8.0* [**2158-11-15**] 05:20AM BLOOD T4-6.5 [**2158-11-11**] 05:31AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2158-11-11**] 05:31AM URINE Blood-LG Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2158-11-11**] 05:31AM URINE RBC-[**5-18**]* WBC-0 Bacteri-NONE Yeast-NONE Epi-1 [**2158-11-11**] 05:31AM URINE CastHy-1* [**2158-11-11**] 05:31AM URINE Hours-RANDOM UreaN-550 Creat-46 Na-34 K-39 Cl-28 HELICOBACTER PYLORI ANTIBODY TEST (Final [**2158-11-13**]): NEGATIVE BY EIA. . ECG [**2158-11-10**]: Atrial fibrillation with controlled ventricular response with intermittent ventricular pacing. Delayed R wave transition. Non-specific ST-T wave abnormalities. Compared to the previous tracing of [**2158-3-24**] the underlying rhythm is now atrial fibrillation. Clinical correlation is suggested. . ECG [**2158-11-13**]: Atrial fibrillation with occasional ventricular paced beats. There are Q waves in leads III and aVF. ST-T wave changes in leads I, II, III, aVF and V4-V6. Probable prior inferior wall myocardial infarction. The ST-T wave changes are non-specific but may be due to ischemia. . Portable CXR [**2158-11-14**]: FINDINGS: As compared to the previous radiograph, the pre-existing right-sided pleural effusion has minimally increased in extent. The pre-existing left pleural effusion is unchanged. Both pleural effusions cause basal areas of atelectasis. Moderate cardiomegaly with tortuosity of the thoracic aorta. No newly appeared focal parenchymal opacities. . Left UE ultrasound [**2158-11-16**]: FINDINGS: Grayscale, color and Doppler images were obtained of the left IJ, subclavian, axillary, brachial, basilic and cephalic veins. Occlusive thrombus is seen in one of the two left brachial veins. This vein does not fully compress and does not demonstrate flow on color Doppler imaging or pulse wave Doppler imaging. Normal flow, compression and augmentation is seen in the remainder of the vessels. IMPRESSION: Deep vein thrombosis seen in one of the two left brachial veins. Brief Hospital Course: Pt is a 86 year old with CHF (EF 30%), diastolic CHF, CAD sp MI with DES placed ([**8-/2157**]) on plavix/asa, afib s/p AV ablation s/p pacemaker, prior GI bleed in [**2155**] while INR supratherapeutic without etiology of bleed identified who presents with bright red blood pre rectum. . #BRBPR: Pt presented with BRBPR and was noted to have blood in rectal vault at presentation to ED. Hct on admission was 24 (baseline 40s). She was transfused a total of 3 units with subsequent Hct rise to 37. Transfusion was complicated by mild hypoxia (86%RA) likely due to acute on chronic systolic heart failure. She was evaluated by the gastroenterology team who performed an EGD showing diffuse gastritis, diverticulum in the area of the papilla, small hiatal hernia, and erythema in the gastroesophageal junction, but no source of active GI bleed. H.pylori serologies were negative. She was initially started on a PPI for her gastritis but this was discontinued due to thrombocytopenia. GI advised to postpone colonoscopy until pt was hemodynamically stable given that the prep would like cause fluid shifts that could worsen her CHF. She remained hemodynamically stable with Hct stable in mid 30s. She had three small bowel movements with formed stool tinged with blood that did not appear to be active bleeding throughout hospital course. Given stable Hcts and no evidence of active bleeding, a colonoscopy was ultimately not pursued during this admission. In discussion with GI and pt's family, it was decided to defer this procedure because the risks of colonoscopy would likely be greater than the possible benefits as she most likely had bleeding from diverticulosis or AVM. Per pt's family, even if a colon cancer were to be detected, they owuld likely not pursue treatment. Aspirin and plavix were initially held but aspirin was eventually restarted as Hct was stable. Plavix was discontinued. Per OMR, she had a BMS placed in 09/[**2156**]. The issue of anticoagulation was discussed as pt had atrial fibrillation and had been off coumadin since [**2155**]. She was advised to follow-up with her PCP to further discuss this issue as outpatient after she was stable in terms of her GI bleed. . #Acute on chronic systolic heart failure: Most recent TTE on [**8-/2158**] showed EF 30% and mild AR and MR. After receiving transfusions in the [**Name (NI) **], pt was noted to be hypoxic, satting 86% on room air. She was given 40mg iv lasix with improvement in saturations and kept on oxygen by nasal cannula. Upon resolution of her acute on chronic kidney injury, she was restarted on her home torsemide 40mg daily. However, she appeared volume overloaded clinically with JVP at tragus, [**12-10**]+ pitting edema, and crackles to mid lungs. She was diuresed further with 40mg torsemide [**Hospital1 **] as well as 10mg iv lasix x 1 while on the floor. CXR on [**2158-11-14**] revealed b/l pleural effusions, atelectasis, and moderate cardiomegaly. Her home lisinopril was initially held due to acute on chronic kidney injury as well as low normal BPs in systolic 100s. She was restarted on half her home dose of lisinopril by time of discharge. Her home amlodipine was also held given her low normal blood pressures. She should follow up with her PCP regarding when to restart/increase these BP meds. She continued to require oxygen by nasal cannula by time of discharge because she desatted to 90 on room air while ambulating. By time of discharge she was satting 95% on 0.5L O2. She was discharged to rehab where O2 should be weaned as tolerated . #Acute on Chronic Kidney Injury: Cr on admission was elevated to 3.2 (per OMR, baseline Cr was 2.0 to 2.7 over the last year). Acute on chronic kidney injury was likely [**1-10**] to volume depletion and Cr improved to 2.8 after transfusion of PRBCs. Cr improved to 2.4 by time of discharge. Lisinopril and torsemide were initially held but restarted when kidney injury resolved. She was periodically given double doses of her home torsemide and iv lasix for diuresis as she appeared volume overloaded; Cr remained within her baseline despite further diuresis. Lisinopril was restarted at half her home dose because of low BPs. . #CAD: Aspirin was held initially but restarted when Hct remained stable and pt did not have active bleeding. Plavix was discontinued as she had BMS stent placed in 09/[**2156**]. Beta blocker was also initially held given her GI bleed. She was tachycardic in afib with HR to 100s. Beta blocker was restarted and uptitrated. HR remained wnl by time of discharge. . #Atrial fibrillation: Pt had not been on coumadin since [**2155**] when she had GI bleed. INR on admission 1.2. Discussion was held regarding whether coumadin or dabigitran should be reinitated given her risk of stroke. She should follow-up with her PCP to ensure that she is stable from GI bleed standpoint before starting anticoagulation. . #Hypothyrodism: She was continued on her home dose of levothyroxine. TSH was found to be elevated at 8. However, T4 was wnl at 6.5. Elevated TSH was likely [**1-10**] sick euthyroid syndrome. She should follow-up with her PCP as outpatient. . #Type II DM: Pt had diet-controlled diabetes. She was not on any medications at home . #Hyperlipidemia: No active issues. She was continued on her statin at home dose. . #Left upper arm swelling: Pt was noted to have left upper arm swelling above her IV site on [**2158-11-16**]. An ultrasound was performed that showed a DVT in one of the two left brachial veins. Vascular surgery consult was obtained; stated that pt was not candidate for SVC filter. Ideally, recommendations for upper extremity DVT would be anticoagulation. However, given her recent GI bleed, anticoagulation was not initiated. She should have a repeat left upper extremity ultrasound in 2 weeks to reassess the DVT. . #Thrombocytopenia: [**Date Range 5273**] on admission was 109 and fell to 70s. She had not received heparin during hospital course. PPI was discontinued as this was the only medication that was newly started that may have caused thrombocytopenia. She should follow up her platelet count at rehab and with her PCP. [**Name10 (NameIs) 5273**] on discharge were 88. Medications on Admission: 1. Torsemide 40mg po daily 2. Plavix 75mg po daily 3. Aspirin 81mg po daily 4. Amlodipine 10mg Daily 5. Lipitor 40mg Daily 6. Levothyroxine 37.5mg Daily 7. Lisinopril 5mg Daily 8. Metoprolol 200mg SR 9. Potassium Chloride 20meq Daily 10. Torsemide 40mg Daily Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. levothyroxine 25 mcg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day. 4. metoprolol succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 5. potassium chloride 20 mEq Packet Sig: One (1) PO once a day. 6. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - [**Hospital1 8218**] - [**Location (un) **] Discharge Diagnosis: Primary: Gastrointestinal bleed Secondary: Atrial fibrillation Acute on chronic systolic heart failure Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you in the hospital. You were admitted with bleeding from the rectum. You were transfused with blood products because your blood counts were low. You did not have further episodes of major bleeding in the hospital. Our gastroenterology team was consulted and advised that a colonoscopy not be pursued because your blood counts were stable and because of the risks of a colonoscopy. You should have close follow-up at the gastroenterology clinic and call your doctor immediately if you start to bleed again. You will also need to follow up with your primary care doctor to discuss re-initiation of anticoagulation for your atrial fibrillation to reduce the risk of stroke. You also had an exacerbation of your heart failure after receiving transfusions. You were diuresed with lasix and torsemide for this. You required oxygen by nasal cannula because you had low oxygen saturations from your heart failure. During your hospital stay, you were noted to have swelling in the left arm. An ultrasound showed that you have a blood clot in one of the deep veins in that arm. Our vascular surgeons evaluated you and stated that no surgical intervention was indicated. Ideally, you would be put on blood thinners for this but given your rectal bleeding, you were not started on blood thinners. You should have a follow-up ultrasound of the left arm in 2 weeks. The following changes were made to your medications: 1) Plavix was stopped because of the risk of bleeding 2) Amlodipine was held because your blood pressure was low; you should follow up with your PCP regarding when to restart this medication 3) Lisinopril was decreased to 2.5mg daily because your blood pressure was low 4) Ferrous sulfate 325mg daily was started for low blood counts 5) Docusate sodium 100mg twice daily was started for constipation 6) Senna 8.6mg twice daily as needed for constipation was started Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: You have the following appointments scheduled for you: . Department: GERONTOLOGY When: WEDNESDAY [**2158-11-22**] at 12:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2158-11-29**] at 1 PM With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: CARDIAC SERVICES When: MONDAY [**2159-4-9**] at 8:30 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2159-4-9**] at 9:00 AM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2158-11-19**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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3793

Discharge summary

report

Admission Date: [**2112-2-18**] Discharge Date: [**2112-2-24**] Date of Birth: [**2049-6-28**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 1973**] Chief Complaint: fever, hyptotension Major Surgical or Invasive Procedure: removal of hickman port picc placement History of Present Illness: 62 yo M h/o recent hospitalization for urosepsis, CVA, HTN, DVT p/w fever, hypotension. Pt is non-communicative at baseline and history is limited and largely derived from documentation. Pt is a resident of [**Location **] Manor. On routine exam today, he was found to have T 104.9, 103/59, hr 85, rr?, sat 94% on ? O2. Given fever, EMS contact[**Name (NI) **] and pt transported to [**Hospital1 **]. Of note pt was recently hospitalized at [**Hospital3 3383**] hospital for urosepsis and decub ulcer infection. At [**Name (NI) **] pt was found to have evidence of UTI, cx ? pos for E coli, sacral wound infxn. He was started on a ten day course of azithro/clinda. Upon clinical stabilization, pt transferred to [**Hospital **] [**Hospital **] rehab for further care. He was there [**Date range (3) 17011**]. In addition to completing course of azithro/clinda started at [**Doctor Last Name 1263**] Caritas, he also completed a ten day course of vanc/levofloxacin for further tx of UTI, sacral wound infxn as well as tx of "positive blood cultures," though further data not available. Pt stabilized, discharged from NE [**Hospital1 **] to [**Location (un) **] Manor where he has been residing until he presentation today. . In [**Hospital1 18**] ED, presenting vitals: 104.9, hr 80, bp 80/p, rr 16, 94% ? O2. Pt at neurologic baseline. CXR: ? RLL infiltrate. EKG: nsr@82 bpm, ni/lad, Q in III, avf. U/A 11-20 wbcs, few bact, many yeast. Na 154, bun 65, cr 1.8, wbc 5.9, hct 34.6, lfts/[**Doctor First Name **]/lip nml. Lactate 1.6. INR 1.9. Pt started on levophed gtt given 5 L NS, decadron 10 mg IV, vanc 1 gm X1, levo 500 mg ivX1, flagyl 500 mg x1, tylenol 650 mg pr X2. Transferred to MICU for further management. Past Medical History: lasix 20 mg daily norvasc 10 mg daily paroxetine 20 mg daily valproate liquid 15 ml (750 mg) daily coumadin 7 mg daily vit C 500 mg [**Hospital1 **] Zn 220 mg daily bactrim ds one tab [**Hospital1 **] mvi bisacodyl percs prn tylenol prn Social History: lives at [**Location **] Manor Family History: NC Physical Exam: Temp 99.8 BP 120/80 Pulse 73 Resp 27 O2 sat 100% 4 lnc Gen - non-communicative HEENT - PER sluggishly reactive, anicteric, mucous membranes moist Neck - no JVD, no cervical lymphadenopathy Chest - crackles at bases b/l, R hickman in place CV - Normal S1/S2, RRR, no murmurs appreciated Abd - Soft, nontender, nondistended, hypoactive bowel sounds, PEG and colostomy bag in place Extr - feet in podus boots. 1+ pitting edema to knees b/l, 2+ DP pulses bilaterally Skin - sacral ulcer, R foot ulcer, dressed Pertinent Results: admission labs: [**2112-2-18**] 01:05AM WBC-5.9 RBC-4.28* HGB-11.0* HCT-34.6* MCV-81* MCH-25.7* MCHC-31.8 RDW-17.7* NEUTS-57.9 LYMPHS-37.7 MONOS-3.8 EOS-0.4 BASOS-0.2 VALPROATE-43* ALT(SGPT)-36 AST(SGOT)-36 ALK PHOS-71 AMYLASE-33 TOT BILI-0.3 GLUCOSE-117* UREA N-65* CREAT-1.8* SODIUM-154* POTASSIUM-4.4 CHLORIDE-114* TOTAL CO2-28 ANION GAP-16 . PICC placement report: PROCEDURE AND FINDINGS: The patient was placed supine on the angiography table. A preprocedural timeout was performed to confirm the patient's identity and the type of procedure to be performed. Ultrasound was used to identify the right brachial vein which was patent and compressible. After injection of 5 cc of 1% lidocaine, a 21-gauge needle was advanced under ultrasound guidance into the right brachial vein. Hard copy ultrasound images were obtained before and after venous access documenting patency. A 0.018 guidewire was then advanced through the needle to the brachiocephalic vein where resistance was encountered. Therefore, Optiray contrast material was administered to visualize the area, revealing a near complete occlusion of the upper SVC. The micropuncture sheath was therefore replaced with a vascular access sheath and a Glidewire was able to be advanced into the lower SVC. Subsequently, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] PIC line was advanced with the tip in the lower SVC. The [**Last Name (un) **] PIC line was cut to 45 cm length (41 cm intravascular portion) and the line was StatLocked and heplocked. The patient tolerated the procedure well and there were no immediate post-procedure complications. IMPRESSION: 1. Near complete occlusion of the SVC. 2. Successful placement of a 4-French, 41 cm single lumen [**Last Name (un) **] PICC via the right brachial vein with tip in the lower SVC. The line is ready for use. . ECHO [**2112-2-20**]: Conclusions: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is a probable vegetation on the tricuspid valve. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: This is a 62 yo M h/o recent hospitalization for urosepsis, CVA, HTN, DVT p/w sepsis and was treated in the MICU with pressor and antibiotics. The possible source of his sepsis was thought to be his indwelling Hickman. The Hickman was removed and a PICC line was placed. . 1. Sepsis from Bacterial Line Infection (outside line): Pt was initially found to have a temperature of 104.9F during routine vital signs at his long term care facility ([**Location (un) **] Manor). He was tranferred to [**Hospital1 **] and treated in the Micu for sepsis. However, pt has multiple potential sources for infection inlcude a possible infiltrate on CXR, positive U/A, infxn of sacral decub, and R Hickman. The patient was started on vanco and zosyn. He was on levophed for about 12 hrs for BP augmentation. Pt had blood cultures growing coag neg staph and enterococcus in blood cx. ID is following the patient and recommends treating pulling the Hickman catheter and placing a PICC line for access. This was done by IR. Sensitivities of the enteroccus species showed vancomycin sensitivity. Therefore, zosyn was stopped. After his initial positive blood cx on [**2-18**] remaining surveillance cultures were negative. The Hickman was removed and a PICC line was placed on [**2-23**] by IR (after receiving 3 bags of FFP). Noted by IR was a complete occlusion of the SVC by clot. He was discharged back to [**Location (un) **] manor with 2 weeks of IV Vancomycin and directions for surveillance cultures after treatment. Also, if the pt. was febrile after treatment, ID recommended w/u of possible chronic osteomyelitis. . 3. SVC Deep Venous Thrombosis: as mentioned, this was incidentally noted by IR. He was asymptomatic and without UE swelling. The decision was made to continue his current anticoagulation with 7mg Warfarin daily. . 2. decubitus ulcer: The patient has a chronic ulcers (stage III decubitis ulcers) that did not look infected. Wound care was consulted and directed treatment of wounds. He also had blisters bilaterally on his lower extremities. Multipodus boots were placed to help prevent further ulcerations. . 3. hypernatremia: The patient was hypernatremic upon admission. HE was hydrated with NS given his presumed dehydration. His total water deficit was 4150cc. He was administered free water flushes via his G-tube for gentle correction (250cc NGT Q4). His hypernatremia resolved. . 4. h/o CVA: The patient was continued on valproic acid for sz ppx. . 5. h/o dvt: We were unable to obtain further history of his DVTS. We continued coumadin at his home regimen. . 6. benign Hypertension: Initially all antihypertensive meds were held. Low dose Norvasc 5mg was restarted on [**2-20**]. . 7. acute renal failure: The patient was admitted with Cr 1.8 wich improved to 0.8 s/p volume resuscitation. Therefore, his ARF was attributed to a pre-renal etiology in the setting of fever/insensible losses. On discharge his ARF completely resolved. . FEN: TFs per nutrition . ppx: coumadin, hold all heparin products (HIT+), iv ppi . Full code Discharge Medications: 1. Valproate Sodium 250 mg/5 mL Syrup Sig: Seven [**Age over 90 1230**]y (750) mg PO DAILY (Daily). 2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily) for 2 weeks. 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 2 weeks. 6. Warfarin 3 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 8. Outpatient Lab Work please check surveillance blood cultures after completion of vancomycin therapy. Discharge Disposition: Extended Care Facility: [**Location (un) **] Manor Discharge Diagnosis: sepsis CVA HTN history of urosepsis decubitis ulcers history of deep vein thrombosis Discharge Condition: good. afebrile. Discharge Instructions: You were treated for sepsis. Your hickman port was removed as it was a possible source of infection. A PICC line was placed for further antibiotics. . please take your medications as prescribed. . If you experience fevers, chills or other worrisome symptoms please seek medical attention. Followup Instructions: please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5762**] within 1-2 weeks after discharge. ([**Telephone/Fax (1) 8417**] Completed by:[**2112-3-1**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9824, 9877

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8409

Discharge summary

report

Admission Date: [**2192-5-20**] Discharge Date: [**2192-5-22**] Date of Birth: [**2158-5-12**] Sex: F Service: MEDICINE Allergies: Sulfasalazine / Penicillins / Compazine / acetaminophen / Diphenhydramine Attending:[**First Name3 (LF) 896**] Chief Complaint: Caustic Ingestion Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms. [**Known lastname 20756**] is a 34F with a history of depression, borderline personality disorder and endometriosis s/p TAH/BSO in [**2191**] who presents after "accidental" ingestion of floor cleaner. She states that she was cleaning her bathroom when the spray top on the bottle of cleaning solution malfunctioned and she emptied the remainder of the floor cleaner into a cup. She has difficulty quantifying the volume but on best estimate maybe about ~1 cup of liquid. She had an identical [**Location (un) 2452**] cup of water next to the floor cleaner. She went to watch a movie and became very thirsty; she states that around 1:00 PM (uncertain of exact tmie) she returned to where the cups were and grabbed the wrong cup and gulped down all the liquid before realizing it was the floor cleaner. She denies any intent of self harm. She does have a history of depression for which she is followed by Dr. [**First Name4 (NamePattern1) 6177**] [**Last Name (NamePattern1) 14323**] at [**Hospital1 2025**], though reports that her mood has recently been stable though does note she is under some stress at school (full-time student to become a paralegal). She immediately called EMS when she realized what she had done, and was brought to the ED. She states that almost immediately after ingesting the fluid, her stomach began to hurt. She describes a diffuse pain across the center of her abdomen. Over the course of the afternoon she developed a "sharp" pain in the right upper quadrant, as well as constant pain in the center of her chest. En route to ED, she felt SOB and dizzy, but since laying still in hospital bed these symptoms have improved. . In the ED, initial VS were Pulse: 43, RR: 14, BP: 108/74, Rhythm: Sinus Bradycardia, O2Sat: 100. EKG showed sinus bradycardia. During ED stay HR went as low as 30s, rebounded to 50s. Got 2L IVF. No meds given. Patient brought bottle with her to ED; no ingredients listed but was a CVS generic brand. CVS was [**Name (NI) 653**], could not provide ingredient list. Litmus test notable for pH of 1. CVS headquarters were [**Name (NI) 653**] but closed for [**Name (NI) **] [**Name (NI) 1017**]. At time of transfer to floor, HR close to 60, BP 108/62, RR 15, 98-100% on RA, afebrile. . On arrival to the MICU, patient's VS were HR in 40s-50s, stable BP. Endorses ongoing chest pain (constant center chest, non-radiating), diffuse abdominal pain, "sharp" pain near RUQ. Breathing currently comfortable at rest. No mouth pain but has dry mouth and feels like this makes it hard to swallow. No odynophagia. Endorses nausea, no vomiting. Repeatedly reports ingestion was unintentional; denies SI. . Past Medical History: FYI, patient has not given permission to contact Dr. [**Last Name (STitle) 14323**], who follows her for psychiatric issues. - Depression on Zoloft, has history of prior SI attempts by TCA overdose and wrist cutting - Anxiety on clonazepam - Borderline personality disorder - Migraines on Topamax - Endometriosis s/p exploratory laparoscopy x 4, s/p TAH/BSO in spring [**2191**] (on hormone replacement with Vivelle Dot) . Social History: Lives alone. Full-time student studying to become a paralegal. Smokes a little less than one pack per day. No alcohol. Smokes marijuana about once a month. Denies any other current recreational drug use. Family History: Father died of renal cell carcinoma. Mother has triple-negative breast cancer. No siblings or children. Has grandmother and great aunt with [**Name2 (NI) **]. Physical Exam: ADMISSION EXAM General: Alert, oriented, no acute distress. Tearful when questioned about PMH, pain. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular, bradycardic to ~50, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Soft, non-distended, normal active bowel sounds present, no organomegaly, diffuse tenderness to palpation (not observably worse in RUQ), no rebound or guarding. GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII intact, no sensory deficits to light touch, moves normally, strength not assessed Pertinent Results: ADMISSION LABS [**2192-5-20**] 04:28PM WBC-6.1 RBC-4.12* HGB-12.9 HCT-39.5 MCV-96 MCH-31.2 MCHC-32.5 RDW-13.4 [**2192-5-20**] 04:28PM NEUTS-54.3 LYMPHS-35.4 MONOS-5.0 EOS-4.2* BASOS-1.1 [**2192-5-20**] 04:28PM PLT COUNT-288 [**2192-5-20**] 04:28PM PT-11.0 PTT-31.5 INR(PT)-1.0 [**2192-5-20**] 04:28PM GLUCOSE-95 UREA N-8 CREAT-0.9 SODIUM-138 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-20* ANION GAP-15 [**2192-5-20**] 04:28PM ALT(SGPT)-13 AST(SGOT)-15 ALK PHOS-55 TOT BILI-0.1 [**2192-5-20**] 04:28PM ALBUMIN-4.4 CALCIUM-9.6 PHOSPHATE-4.5# MAGNESIUM-2.1 [**2192-5-20**] 04:28PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2192-5-20**] 05:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2192-5-20**] 04:35PM LACTATE-1.3 EGD Findings: Esophagus: Other single 2mm esophageal erosion Stomach: Other mild antral gastritis Duodenum: Normal duodenum. Impression: Single 2mm esophageal erosion Mild antral gastritis Normal EGD to third part of the duodenum Recommendations: Consider starting ppi or h2 blocker for mild gastritis and her symptoms. No signs of any caustic injury. Ok to start on regular diet. Additional notes: The attending was present for the entire procedure. The patient's home medication list is appended to this report. FINAL DIAGNOSIS are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology. Brief Hospital Course: 34F with history of depression/anxiety with two prior suicide attempts and borderline personality disorder who presents following ingestion of floor cleaner (unknown ingredients/amount). Patient maintains ingestion was accidental. Contents of floor cleaner unknown but litmus test was acidic (pH 1). # INGESTION: Unclear contents of floor cleaner, though appears to have been an acid. After endoscopy it is not clear the ingestion happened at all, given mild erosions and gastritis. LFTs, creatinine, lactate all WNL, no anion gap. Serum and urine tox screens negative. She was started on famotidine per GI recommendations. Toxicology recommended observation. Psychiatry recommended restarting her home zoloft, clonazepam, and topamx. On ther floor she continued to c/o epigastric pain which was out of proportion to her endoscopy, making secondary gain very likely. # BRADYCARDIA: Unclear etiology, most likely causes were ingestion of other substance including possibly clonidine, increased vagal tone from ingestion, anorexia/bulimia, low baseline as she reports previously running 9 miles per day. Per toxicology, most household cleaners would not have components known to cause bradycardia (some nasal sprays or eye drops can have this effect if ingested, though no history of this). Topamax or less commonly Zoloft can cause bradycardia, though these are not new medications. # DEPRESSION/ANXIETY: Patient has a history of depression as well as of prior suicide attempts. However, she denies repeatedly that this was intentional (same story to multiple providers). Did not give consent for psychiatry to contact outpatient provider, [**Name10 (NameIs) **] given story (unclear how this much floor cleaner could be ingested accidentally) a 1:1 sitter ordered per psych recs. # MIGRAINES: Developed a migraine which was treated with imitrex which she said has been effective in past. Aftyer her EGD her topamax was restarted. Medications on Admission: - Zoloft 250 mg PO daily - Clonazepam 1 mg QID (patient states she takes this regularly, tox screen negative) - Topamax 300 mg PO daily - Ambien 10mg QHS - Clonidine 0.1mg [**Hospital1 **] - Oxycontin - Vivelle dot - Aleve/ibuprofen PRN back/hip pain - Clonidine - seroquel 25mg PO qHS Discharge Medications: 1. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for headache. 2. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for Nausea. 3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain. 4. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. topiramate 100 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 8. maalox:lidocaine:benadryl Sig: 15-30 ml every four (4) hours as needed for pain: please mix 1:1:1. 9. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 11. lorazepam 2 mg Tablet Sig: 2-4 Tablets PO Q4H (every 4 hours) as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital1 18**] [**Hospital1 **] 4 Discharge Diagnosis: Toxic Ingestion Suicidal Ideation Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. . Mental Status: Confused - sometimes. Discharge Instructions: You were admitted to the hospital after you ingested floor cleaner. You were monitored and had very limited medical issues related to your ingestion. You were medically cleared, but psychiatry felt that you needed an inpatient stay to help you take care of yourself. . The following changes were made to your medications but are subject to change when you get to your facility. . STOP taking clonidine for anxiety as this may cause an unsafe drop in your blood pressure PLEASE ask someone from your family to bring in your Vivelle DOT STOP taking oxycontin as it may slow your heart rate START taking oxycodone as needed for pain Followup Instructions: as directed by your psych facility Completed by:[**2192-5-23**]

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icd9cm

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2159-11-1**] Discharge Date: [**2159-11-12**] Date of Birth: [**2090-3-4**] Sex: F Service: MEDICINE Allergies: isoniazid Attending:[**First Name3 (LF) 1377**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: central line placement History of Present Illness: 69 yo female history of hepatitis C cirrhosis c/b ascites, encephalopathy and varices presenting with 24 hours of abdominal pain. No fever chills nausea or vomiting change in mental status headache. She had a peritoneal tap on Monday. She does not have any urinary symptoms and her bowel movements have been normal. She was admitted to the SICU for an elevated lactate level to 8 and leukocytosis. This was felt to be concerning for bowel ischemia. An adbominal U/S showed no fluid pockets available for diagnostic paracentesis. She was started on ceftriaxone and unasyn. In the unit she was switched to Vanc/Zosyn for empiric coverage and was fluid resuscitated aggressively with IVF, albumin and PRBCs. Her lactate and WBC have been trending down. She is not experiencing abdominal pain currently. She has not stooled in 2 days. Of note Mrs. [**Known lastname **] was recently discharged from [**Hospital Ward Name 121**] 10 on [**2159-10-24**], admitted for LOC, unclear etiology; had negative EEG for seizure activity, negative CT, and negative infectious work-up, including diagnostic paracentesis. It was felt that her altered mental status was most likely due to hepatic encephalopathy. She was also found to have vaginal bleeding with irregularities seen in the endometrial lining on ultrasound. Her course was also complicated by acute kidney injury and her diurectics were temporarily discontinued. . Review of Systems: -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: Chronic C hepatitis genotype 1 and cirrhosis as above Cirrhosis - complicated by volume overload, grade 1 esophageal varaces, never had encephalopathy or ascites requiring paracentisis. History of positive PPD - evaluated by transplant ID and will undergo INH/B6 therapy post-transplant. Osteopenia - DEXA [**1-/2159**] Hypothyroidism Vitamin D deficiency Social History: She does not smoke. She does not drink. Denies drug use. She is married with five children. She used to works as a nurse, but hasn't been able to work for 3 years. She misses being a nurse and being active. Family History: Non-contributory. Physical Exam: Admission Physical Exam: Vitals:afebrile, HR 85 BP 143/70 RR 24 98%RA General:laying in bed, answering ?s appropriately, NAD HEENT:icteric sclera, poor dentition, no facial asymm noted Neck:IJ line in place Heart:RRR,S1S2, no murmurs,rubs, gallops Lungs:end expiratory wheeze present Abdomen: softly distended, BS+, no TTP, no masses Extremities: no lower extremity edema b/l, no rash Neurological:answering ?s appropriately, no focal deficits noted . Discharge PE: O: Tm 98.58 Tc 97.9 105/55 (105-121/55-66) 80 (78-84) 16 97 RA General: pleasant woman, NAD, laying comfortably in bed, alert and appropriate HEENT:icteric sclera, poor dentition, no facial asymm noted Heart: ?soft SEM loudest at USB, S1, S2 Lungs: clear to auscultation b/l, no wheezes/crackles Abdomen: softly distended, BS+, no TTP, no masses Extremities: 2+ LE edema b/l, no rash Neurological:answering ?s appropriately, no focal deficits noted, no asterixis noted Pertinent Results: Labs on Admission: [**2159-10-31**] 03:35PM BLOOD WBC-7.0 RBC-3.01* Hgb-9.1* Hct-28.4* MCV-95 MCH-30.3 MCHC-32.1 RDW-16.9* Plt Ct-83* [**2159-10-31**] 03:35PM BLOOD Neuts-57.3 Lymphs-26.4 Monos-14.1* Eos-1.6 Baso-0.6 [**2159-10-31**] 03:35PM BLOOD PT-30.3* PTT-49.5* INR(PT)-2.9* [**2159-11-1**] 05:00AM BLOOD Fibrino-104* [**2159-10-31**] 03:35PM BLOOD Glucose-78 UreaN-10 Creat-1.7* Na-134 K-4.2 Cl-110* HCO3-18* AnGap-10 [**2159-10-31**] 03:35PM BLOOD ALT-25 AST-76* AlkPhos-52 TotBili-3.9* DirBili-1.7* IndBili-2.2 [**2159-10-31**] 03:35PM BLOOD Albumin-2.4* [**2159-11-1**] 04:39AM BLOOD Albumin-3.1* Calcium-8.4 Phos-3.5 Mg-1.9 [**2159-10-31**] 03:48PM BLOOD Lactate-3.0* CT Abd/Pelvis: IMPRESSION: 1. Mild wall thickening of the ascending colon, which is collapsed. Fluid around it might be related to the patient's abdominal ascites. Findings are not specific for ischemia, but do not exclude it, and other types of colitis are in the differential diagnosis 2. Distended gallbladder with stones, without wall thickening. Again perihepatic fluid is noted. 3. Cirrhotic liver. A contrast collection adjacent to the left portal vein measures 2.3 x 1.5 cm and probably represents a portal venous aneurysm. 4. Small right pleural effusion. 5. Diffuse anasarca. 6. Uterine enlargement with prominent endometrial thickening for a woman of this age. Recommend further evaluation with pelvic ultrasound and/or endometrial biopsy on a non-emergent basis. Liver Ultrasound: IMPRESSION: 1. Coarse echogenic and shrunken liver, compatible with known history of cirrhosis. 2. Moderate ascites. 3. Patent portal venous system. 4. No intra- or extra-hepatic bile duct dilation. Endometrial biopsy (A-B): Atrophic endometrium with stromal decidualization suggestive of hormone therapy effect. CXR FINDINGS: As compared to the previous radiograph, there is no relevant change. Normal size of the cardiac silhouette. No pleural effusion. Minimal fluid overload but no overt pulmonary edema. No evidence of pneumonia. Mild enlargement of the left atrium. . Discharge labs: [**2159-11-11**] 05:45AM BLOOD WBC-10.3 RBC-3.81* Hgb-11.5* Hct-34.2* MCV-90 MCH-30.2 MCHC-33.7 RDW-18.2* Plt Ct-49* [**2159-11-12**] 06:05AM BLOOD WBC-9.5 RBC-3.85* Hgb-11.6* Hct-34.4* MCV-89 MCH-30.0 MCHC-33.5 RDW-18.4* Plt Ct-56* [**2159-11-11**] 05:45AM BLOOD PT-37.0* INR(PT)-3.6* [**2159-11-12**] 06:05AM BLOOD PT-35.7* INR(PT)-3.5* [**2159-11-10**] 01:57PM BLOOD Glucose-137* UreaN-11 Creat-2.0* Na-141 K-4.0 Cl-107 HCO3-25 AnGap-13 [**2159-11-11**] 05:45AM BLOOD Glucose-59* UreaN-12 Creat-1.9* Na-138 K-3.8 Cl-105 HCO3-26 AnGap-11 [**2159-11-12**] 06:05AM BLOOD Glucose-54* UreaN-12 Creat-1.9* Na-136 K-4.1 Cl-103 HCO3-28 AnGap-9 [**2159-11-9**] 06:02AM BLOOD ALT-23 AST-46* AlkPhos-37 TotBili-7.2* [**2159-11-10**] 01:57PM BLOOD ALT-17 AST-47* AlkPhos-52 TotBili-6.5* [**2159-11-11**] 05:45AM BLOOD ALT-24 AST-53* AlkPhos-59 TotBili-5.6* [**2159-11-12**] 06:05AM BLOOD ALT-26 AST-71* AlkPhos-63 TotBili-5.3* [**2159-11-10**] 01:57PM BLOOD Albumin-2.8* Calcium-9.2 Phos-3.7 Mg-1.9 [**2159-11-11**] 05:45AM BLOOD Albumin-2.6* Calcium-9.2 Phos-4.1 Mg-1.7 [**2159-11-12**] 06:05AM BLOOD Albumin-2.7* Calcium-9.0 Phos-4.1 Mg-2.1 [**2159-11-5**] 09:09AM BLOOD Lactate-1.8 [**2159-11-7**] 04:04PM BLOOD Lactate-2.3* Brief Hospital Course: 69 yo F history of hepatitis C liver failure presenting to the hospital c/o abdominal pain with a rising lactate and leukocytosis . #Bowel [**Name (NI) 2694**] The pt presented with abdominal pain and an elevated lactate to 8 and a leukocytosis. A CT of the abdomen was concerning for ischemia. She was aggressively volume resuscitated and transfused red blood cells in the SICU and started on a course of Zosyn to treat SBP. She was also started on empiric Vancomycin while in the SICU. A paracenteses was not performed due to a lack of an adequate fluid pocket to tap. However, a para done later in her course did, in fact, show SBP, and the patient completed a course of Zosyn. Her lactate and WBC trended down and her abdominal pain resolved. Her diet was slowly advanced and she tolerated it without difficulty. . # SBP: The patient was ultimately found to have SBP, and completed a course of Zosyn. She was on Cipro 250 mg daily for SBP ppx at home. Upon discharge, we increased her Cipro to 500 mg daily. . #UTI- A urine UCx came back with gram postive bacteria speciated to enterococcus. A culture the following day, however, grew out only yeast and no enterococcus. She was initially on Vancomycin, and speciation grew out VRE. The patient was then switched to Linezolid. In total, she completed at three day course of Linezolid, with last dose taken the evening of discharge home. . #Hep C cirrhosis- The pt is currently on the transplant list awaiting transplant. No evidence of encephalopathy was noted on exam. We continued lactulose and rifaximin. After aggressive volume resuscitation in the SICU she notably hypervolemic on exam. We continued both IV and PO diuresis and he lower extremity edema slowly improved. On discharge from the hospital, her lasix was increased from 20 mg to 40 mg daily, and her spironolactone was increased from 50 mg to 100 mg daily. Because the patient's MELD has been greater than 30 during this hospitalization, she will have to have weekly follow up appointments at the liver center. . #CKD- Her kidney function remained at her baseline which is a creatine ranging between 1.6 - 1.8. While in patient, her creat peaked at 2.0. On discharge from the hospital, her creat had started trending down to 1.9, and was stable at 1.9. She will have to get labs checked the week after being discharged. . #Hypothyroidism- The patient was continued on her home Levothyroxine . # enodmetrial thickening- Biopsy was performed which did not show evidence of endometrial cancer. She will need a follow up appointment with OB/GYN following this hospitalization. . Transitional Issues: - The patient's Lasix dose was increased to 20 mg daily to 40 mg daily, and spironlactone was increased from 50 mg to 100 mg. She will have to follow up in liver clinic this coming Wednesday, Decemeber 28th. She can get labs drawn prior to her appointment. The patient must follow up weekly in the liver clinic for now. . - The patient needs to have follow up with GYN as an outpatient. Medications on Admission: 1. calcium carbonate 200 mg calcium (500 mg) Tablet PO BID 2. rifaximin 550 mg Tablet PO BID 3. cholecalciferol (vitamin D3) 400 unit [**Unit Number **] Tablet PO DAILY 4. lactulose 10 gram/15 mL Syrup (30) ML PO TID -titrate to [**1-19**] bowel movements daily. 5. clotrimazole 10 mg Troche Mucous membrane 5X/DAY (5 Times a Day). 6. ciprofloxacin 250 mg Tablet PO Q24H 7. levothyroxine 50 mcg Tablet PO DAILY Discharge Medications: 1. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO once a day. 4. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three times a day: please titrate for [**1-19**] BMs daily. 5. clotrimazole 10 mg Troche Sig: One (1) Mucous membrane four times a day. 6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 9. spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 10. Ensure Plus 0.05-1.5 gram-kcal/mL Liquid Sig: One (1) PO three times a day: please drink one can in between every meal. Disp:*60 cans* Refills:*2* 11. linezolid 600 mg Tablet Sig: One (1) Tablet PO once for 1 doses: please take one pill tonight. Disp:*1 Tablet(s)* Refills:*0* 12. Outpatient Lab Work CBC, Chem 10, LFTs Discharge Disposition: Home With Service Facility: VNA of Brokton Discharge Diagnosis: Gastrointestinal tract ischemia Spontaneous bacterial peritonitis Urinary Tract Infection Hepatitis C Liver Cirrhosis 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 taking care of you at [**Hospital1 **]. You are admitted to the hospital with abdominal pain. We did some blood work and we think that some of this abdominal pain was due to having decreased blood flow to your intestines. You were given a blood transfusion as well as IV fluids to help supply your GI tract with an adequate amount of blood flow. . You were also treated with antibiotics for an infection that you had in your belly fluid. You also had a urinary tract infection while you were here, and we gave you antibiotics for that infection, as well. . It is VERY important that you continue to eat well. Please continue to drink Ensures in addition to what you normally eat during the day. The Ensures should not replace your meals. . Because your MELD score is greater than 30, you will also have to see the liver doctors once [**Name5 (PTitle) **] week in the liver transplant clinic. Please call [**Telephone/Fax (1) 673**] on Tuesday, [**11-13**] to to confirm your appointment for [**11-14**]. You will also have to get blood drawn the morning before your appointment in the lobby of the [**Hospital Unit Name **]. . The following changes have been made your medications: INCREASE Ciprofloxacin from 250 mg to 500 mg by mouth daily INCREASE Lasix from 20 mg to 40 mg by mouth daily INCREASE Spironolactone from 50 mg to 100 mg by mouth daily START drinking an Ensure drink in between meals START Linezolid 600 mg by mouth for one more dose tonight, then stop Please take your other home medications as directed. Followup Instructions: Please call the liver clinic tomorrow at [**Telephone/Fax (1) 673**] to confirm your appointment for Wednesday, [**11-14**]. . Department: TRANSPLANT When: WEDNESDAY [**2159-11-28**] at 9:00 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 . Department: LIVER CENTER When: WEDNESDAY [**2159-11-28**] at 10:00 AM With: [**Name6 (MD) 278**] [**Name8 (MD) **], RN [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: CARDIAC SERVICES When: WEDNESDAY [**2159-11-28**] at 1 PM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**] Completed by:[**2159-11-13**]

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icd9cm

[ [ [] ] ]

[ "68.16", "54.91" ]

icd9pcs

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7015

Discharge summary

report

Admission Date: [**2112-3-15**] Discharge Date: [**2112-3-30**] Date of Birth: [**2052-3-10**] Sex: M Service: MEDICINE Allergies: Amlodipine / Flomax Attending:[**First Name3 (LF) 458**] Chief Complaint: fatigue, weight gain, SOB Major Surgical or Invasive Procedure: CVVH line inserted Central line in RIJ Arterial Line [**Hospital1 **]-Ventricular pacemaker placement History of Present Illness: 60 year old man CAD s/p MI s/p CABG and PCI to LCx, HL, DM, homograph AVR in [**2097**] for aortic stenosis, Afib s/p pacemaker , MS and AS, with a recent admit [**2-8**] at [**Hospital1 18**] for CHF exacerbation. He was diuresed, started on ACEI and discharged home. He comes in today with increasing SOB and leg swelling. He says he has gained abt 12 lbs in last 2 weeks. Also c/o extreme fatigue. Hence he went to see Dr [**Last Name (STitle) 7047**] today. In his office his SBP was in 70s. Hence he was sent to the ER. In the ER his SBP was in 70s. Hence a CVL (Cordis) was placed and subsequently was admitted to the CCU. . 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. . *** Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. Past Medical History: Cardiac Risk Factors: Diabetes (+), Dyslipidemia (+), Hypertension (+) . Cardiac History: CABG: x2 in [**2097**], AVR [**2097**] . Percutaneous coronary intervention, in *** anatomy as follows: . Pacemaker/ICD, in: [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] pacemaker, A sensed - V paced. Yr [**2102**] . Valves: A bioprosthetic AV. 1+ AR, 1+ MR, 3+ TR, MS PAH - 27 mmHg. Small pericardial effusion. Other Past History: -mitral stenosis -Atrial fibrillations s/p pacemaker in [**2102**] and battery change in [**2110**] and s/p cardioversion -RAS s/p renal stents x3, [**2106**] -non-Hodgkin's lymphoma in [**2077**] s/p splenectomy & chemorad Rx to chest/neck/abdomen, - Recurrent right sided effusions, loculated hydropneumothorax s/p right thoracotomy, pleurectomy with decortication -cardiomyopathy secondary to chemo and radiation since [**2077**] -B-cell lymphoma with pulmonary nodules s/p CHOP/CVP'[**03**], -Hypothyroidism, -Upper GI bleed x2 -Renal Insufficiency -gout -s/p L carotid endarteroectomy Social History: Lives with wife, was a silk screen printer for medical devices. In the navy for 20 years. -Tobacco history: Prior 35 pack years -ETOH: occasional Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory Physical Exam: VS - 98.7 90 83/48 28 97/2l 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 JVD midneck CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Bibasilar crackles. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: b/l LE edema No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: Admission labs: [**2112-3-15**] 07:14PM GLUCOSE-115* NA+-136 K+-4.8 CL--94* TCO2-28 [**2112-3-15**] 07:14PM HGB-10.0* calcHCT-30 [**2112-3-15**] 07:00PM GLUCOSE-124* UREA N-75* CREAT-4.6*# SODIUM-136 POTASSIUM-5.1 CHLORIDE-97 TOTAL CO2-26 ANION GAP-18 [**2112-3-15**] 07:00PM CK(CPK)-37* [**2112-3-15**] 07:00PM cTropnT-0.35* [**2112-3-15**] 07:00PM CK-MB-NotDone [**2112-3-15**] 07:00PM CALCIUM-8.4 PHOSPHATE-7.3*# MAGNESIUM-2.3 [**2112-3-15**] 07:00PM WBC-10.8 RBC-4.44* HGB-9.6* HCT-33.9* MCV-76* MCH-21.7* MCHC-28.4* RDW-20.1* [**2112-3-15**] 07:00PM NEUTS-74.9* BANDS-0 LYMPHS-12.6* MONOS-7.8 EOS-4.1* BASOS-0.7 [**2112-3-15**] 07:00PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-OCCASIONAL OVALOCYT-1+ TARGET-OCCASIONAL SCHISTOCY-2+ [**2112-3-15**] 07:00PM PLT SMR-NORMAL PLT COUNT-333 [**2112-3-15**] 07:00PM PT-15.1* PTT-27.2 INR(PT)-1.3* EKG was a paced and v sensed. RENAL ULTRASOUND ([**2112-3-18**]): The right kidney measures 10.7 cm, the left 10.9 cm. There is no hydronephrosis or stone. There is a simple cyst at the lower pole of the left kidney, measuring 1.5 x 1.9 x 1.9cm. There is a left pleural effusion. There has been prior splenectomy with probable splenule in the splenectomy bed. Limited views of the liver are unremarkable. DOPPLERS: There is brisk systolic waveform in the right main as well as the proximal, mid and lower pole renal arteries. However, although the resistive indicex is normal in the main renal artery on the right, resistive indices range from 0.9 to 1 within the intraparenchymal arteries, with absent diastolic flow. On the left, there is a tardus parvus waveform, and absent diastolic flow in the main renal artery, with elevated resistive index. Within the kidney there is not clear diastolic flow. IMPRESSION: Delayed time to peak systole in the LRA suggestive of stenosis on the keft. Bilateral markedly elevated RIs ( 0.9-1.0 ) may indicate diffuse parenchymal disease bilaterally. . ECHO ([**3-25**]): The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. The LV ejection fraction (approximately 40 percent) appears mildly-to-moderately depressed secondaey to inferior posterior hypokinesis (basal segments akinetic). There is no ventricular septal defect. Right ventricular chamber size is normal. with borderline normal free wall function. The aortic valve appears to be a homograft. The prosthetic aortic valve leaflets are thickened. The transaortic gradient is higher than expected for this type of prosthesis. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. Moderate to severe [3+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. The left ventricular pre-ejection delay (110 msec) and the interventricular ejection delay (30-40 msec) are now normal. Compared with the findings of the prior study (images reviewed) of [**2112-2-26**], the left ventricular ejection fraction and stroke volume are increased. The aortic valve effective orifice area may also be increased. All measures of intraventricular left ventricular dyssynchrny are reduced. . Chest X-ray ([**3-25**]): Since [**3-17**], the right axillary pacemaker has been changed or revised. One lead is not connected. New left ventricular lead follows its expected course. Three other leads have not changed in their respective positions since [**3-17**], including one ending in standard position in the right atrium, another in the right ventricle, and a second ending at the origin of the right ventricular outflow tract. Mild pulmonary edema and small right pleural effusion are unchanged since [**3-17**]. Heart size is normal. Right internal jugular sheath ends above the junction with the left brachiocephalic vein. Lower sternal wires are intact. The upper sternal wires are fragmented, as before, and there is suggestion of some widening of the upper aspect of the sternotomy. I doubt that there is any pneumothorax. . Discharge labs: Brief Hospital Course: #. CHF exacerbation/cariogenic shock: Patient was started on dopamine for inotropic support. This transiently increased his UOP (200mL/24hours). He was then started on a lasix gtt to decrease volume overload. He was able to have around 500mL UOP on the lasix gtt but this was not sufficiently diuresing him as he took in more than this in fluids. Therefore, renal was consulted and they started CVVH to help with diuresis. The patient was diuresed with UF quite successfully and was able to stop this treatment after a few days. He maintained his UOP with lasix and maintained a net even fluid status this way. He was discharged with TEDS for LE edema and lasix 40mg day. The patient will need to monitor his weight daily and close follow up with cardiolgy. #. AS: Pt with valve area of 0.7 and mean gradient of 20 on echo a few days prior to admission. With pre-load dependence was very hard to diurese patient and required lasix gtt then CVVH as well as pressors as above. Cardiac surgery, his outpatient cardiologist, and cardiologists here were consulted regarding the best option for him. The patient was felt to have 2 major issues contributing to his symptoms and frequent relapses: 1. severe AS, and 2. poorly functioning ventricles that were not beating effectively. The team opted to place a biventricular placer with the thought that this intervention would improve his cardiac output as well as his symptoms of AS. A pacer was placed on [**2112-3-24**] with substantial improvement in patient's hemodynamics. Pressors were discontinued and the patient's symptoms improved substantially. # ARF: Renal was consulted after patient failed to increase uop sufficiently with lasix gtt. Therefore, a CVVH line was placed and this was initiated both for volume overload and ARF. This was discontinued after a few days because the patient's creatinine and fluid status improved. #. CAD: CAD c/b MI x2 s/p PTCA/stent/CABG. recent cath showed the native 3VD. He was continued on aspirin, plavix, and statin. Beta blockers and ACE inhibitors were held in setting of hypotension. #. Afib: No anticoagulation beecause of hx of upper GIB x2. Contiuned amiodarone. #. DM2: held glyburide and started RISS # Hypothyroidism: continued levothyroxine # GIB: continued omeprazole [**Hospital1 **] #. Code: full Medications on Admission: 1. Allopurinol 100 mg qd 2. Amiodarone 200 mg qd 3. Clopidogrel 75 mg qd 4. Levothyroxine 137 mcg qd 5. Metoprolol Succinate 50 mg qd 6. Omeprazole 20 mg Capsule [**Hospital1 **] 7. Aspirin 325 mg qd 8. Clonazepam 1 mg Tablet qhs 9. Pravastatin 20 mg qd 10. Furosemide 80 mg qd 11. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Lisinopril 2.5 mg qd Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO once a day. 3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. Metoprolol Succinate 25 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* 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime. 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Acute on Chronic Systolic congestive Heart Failure Acute on Chronic Renal Disease Coronary Artery Disease Acute Renal Failure Discharge Condition: stable Discharge Instructions: You had an exacerbation of your congestive heart failure and required diuretics and ultrafiltration to remove fluid from your body. You pacemaker was also changed to a biventricular pacemaker to help both sides of your heart beat together. Despite lingering swelling in your legs, your lungs are clear and your blood pressure is improved. You kedney function was affected by the dontrast given during your catheterization, it has improved back to your baseline renal function. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Please put on TEDS stockings during the day if you notice that your swelling in your legs is increasing. . Adhere to 2 gm sodium diet Fluid Restriction: 1500cc per day or about 6 cups. Medication changes: 1. Your Toprol was decreased to 25mg daily Stop taking these medicines: Lisinopril: this will be restarted when your kidney function improves. . Please call Dr. [**Last Name (STitle) 7047**] if you notice more trouble breathing, increasing leg swelling, shortness of breath with activity, increasing cough, fevers, chest pain or any other unusual symptoms. Followup Instructions: DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2112-4-4**] 3:30 Cardiology: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] Phone: [**Telephone/Fax (1) 8725**] Date/time: Office will call you with an appt Friday Primary Care: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3314**] Phone: [**Telephone/Fax (1) 3183**] Date/time: Tuesday [**4-5**] at 9:00am. Completed by:[**2112-3-30**]

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icd9cm

[ [ [] ] ]

[ "38.95", "38.93", "38.91", "00.50", "39.95", "89.45" ]

icd9pcs

[ [ [] ] ]

11864, 11870

8095, 10410

305, 409

12040, 12049

3662, 3662

13241, 13679

2766, 2880

10829, 11841

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240, 267

437, 1527

3678, 8054

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2602, 2750

15,143

139,133

51086

Discharge summary

report

Admission Date: [**2193-10-13**] Discharge Date: [**2193-10-15**] Date of Birth: Sex: F Service: ADMISSION DIAGNOSIS: Shortness of breath, congestive heart failure. CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: This is an 89-year-old woman with a history of coronary artery disease status post stent to OM1 in [**7-18**], with congestive heart failure, chronic renal insufficiency at baseline of 1.5 to 1.8, who presents with increased shortness of breath which required intubation secondary to congestive heart failure exacerbation. PAST MEDICAL HISTORY: 1. Coronary artery disease status post an ST wave in [**7-18**], stent to OM1 and left circumflex. 2. Congestive heart failure, last echocardiogram was [**7-18**] showing left ventricular systolic function mildly to moderately impaired, 1+ aortic regurgitation, [**1-17**]+ mitral regurgitation, and mild distal anterior septal and apical akinesis. 3. Chronic renal insufficiency with baseline creatinine of 1.5 to 1.8. 4. Her ejection fraction is 40-45%. 5. Type 2 diabetes. 6. Hypertension since [**2168**]. 7. Hyperlipidemia. 8. History of amaurosis fugax. 9. Peptic ulcer disease. 10. History of ureteral obstruction. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Salicylate 750 b.i.d. 2. Sliding scale insulin. 3. Bisacodyl. 4. Lactulose. 5. Senna. 6. Multivitamin. 7. Colace. 8. Tylenol. 9. Mirtazapine 7.5 q.h.s. 10. Isosorbide dinitrate 30 b.i.d. 11. Captopril 100 q.d. 12. Promethazine. 13. Metoprolol 100 q.d. 14. Glyburide 5 q.d. 15. Plavix 75 q.d. 16. Lipitor 10 q.d. 17. Enteric-coated aspirin 325 mg q.d. 18. Subcutaneous heparin b.i.d. 19. Ipratropium. PHYSICAL EXAMINATION: Vital signs showed her to be afebrile, respiratory rate of 50, blood pressure 91/27, saturating 97% on 40% FIO2 while intubated and sedated, with a tidal volume of 466. Generally she was sedated and intubated. HEENT: Atraumatic, intubated, not responsive while intubated. Neck: Supple, no LAD. Cardiovascular: Regular rate and rhythm, no murmurs, gallops, or rubs. Lungs: Respiratory crackles at bases, otherwise clear to auscultation. Abdomen: Soft, nontender, nondistended, no rebound, no guarding. Extremities: No cyanosis, clubbing or edema. LABORATORY DATA: On admission the white blood count was 6.1, hematocrit 33.4, platelet count 150, sodium 141, potassium 4.3, chloride 109, bicarbonate 18, BUN 38, creatinine 1.9, CK 43, CK MB 0, troponin less than .01. Differential on the WBC was 76.1 neutrophils, 18.7% lymphocytes, 3.6% monocytes, 1.3% eos, and 0.3 basophils. Urinalysis showed specific gravity of 1.020, no blood, no nitrites, no leukocyte esterase, 30 protein, otherwise negative. Urine culture was pending. Arterial blood gases were 7.31 pH, 42 CO2, 212 O2, 100% FIO2. Chest x-ray showed left retrocardiac density, no overt pulmonary edema, prominence of pulmonary vasculature, layering of pleural effusion. An endotracheal tube was placed to 1?????? cm above the carina. Electrocardiogram was a rate of 66 and no significant changes from prior EKG. There was some T wave flattening in V4, T wave in V5 and V6. HOSPITAL COURSE: 1. Congestive heart failure: The patient was admitted for congestive heart failure exacerbation, intubated, with shortness of breath, and admitted to CCU. From a coronary standpoint there was no coronary artery disease status post stenting. He was continued with aspirin and Plavix and was cycled for enzymes which were shown to be negative, ruled out myocardial infarction. Pump: She was afterload reduced with captopril. The captopril was actually increased while she was in the hospital daily, and she was given Lasix for diuresis. She continued on telemetry with no events on telemetry since admission. 2. Pulmonary: She did well and was extubated on day two without any difficulty, did very well and was transferred to the floor without any difficulty. She was weaned off of her O2 and on the day of discharge she was down to two liters, saturating well in the mid-90s. 3. Renal: There was no appreciable acute renal failure. Cardiovascular risk factors was at 1.5 to 1.9. She remained close to that, about 2.0. She was followed daily for her creatinine given that she was on Lasix. 4. Gastrointestinal: She was given prophylactic PPI and her multivitamins. 5. Psychiatry: Her psychiatric medications were continued and she was continued on Regular Insulin sliding scale and good blood sugar control. 6. Prophylaxis: She was on subcutaneous heparin and PPI for prophylaxis. 7. Code status: On the day before discharge per Dr. [**First Name (STitle) **], her code status after discussing with the family was changed to DNR/DNI. The patient was discharged on her home medications with metoprolol and Lasix. Her captopril was maximized on the day of discharge. DISCHARGE DIAGNOSIS: 1. Congestive heart failure. 2. Coronary artery disease. FOLLOW-UP: The patient will follow-up with Dr. [**First Name (STitle) **] and also with the [**Hospital 1902**] clinic. She will follow-up with her PCP in one week for post discharge care. The patient has an appointment for a pulmonary breathing test on [**2193-10-23**]. She also has an appointment with Dr. [**Last Name (STitle) **] on [**2193-10-23**] at 9 AM at the [**Hospital Ward Name 23**] Center, [**Telephone/Fax (1) 5091**]. She also has an appointment with [**Hospital 1902**] clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2193-11-21**] at 9:30 AM at [**Telephone/Fax (1) 2550**], and at the [**Hospital Ward Name 23**] Center Cardiac Services. CONDITION ON DISCHARGE: The patient was discharged in stable condition. DISPOSITION: The patient was discharged to rehabilitation with follow-up per follow-up care. DISCHARGE MEDICATIONS: 1. Mirtazapine 7.5 mg p.o. q.h.s. 2. Plavix 75 mg p.o. q.d. 3. Atorvastatin 10 mg p.o. q.d. 4. Enteric-coated aspirin 325 mg p.o. q.d. 5. Heparin 5,000 units subcutaneous q. 12 hours. 6. Ipratropium bromide nebs. 7. Senna. 8. Bisacodyl p.r.n. 9. Multivitamin 1 q.d. 10. Docusate 100 mg p.o. b.i.d. 11. Captopril 50 mg p.o. t.i.d. 12. Metoprolol 12.5 mg p.o. b.i.d. 13. Furosemide 20 mg p.o. b.i.d. 14. Insulin sliding scale. 15. Lansoprazole 40 mg p.o. q.d. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. [**MD Number(1) 5381**] Dictated By:[**Last Name (STitle) 33907**] MEDQUIST36 D: [**2193-10-15**] 08:01 T: [**2193-10-15**] 08:05 JOB#: [**Job Number 106102**]

[ "518.82", "593.9", "274.0", "428.0", "599.0", "401.9", "250.00", "428.33", "414.8" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

5872, 6612

4918, 5680

3210, 4897

1742, 3192

150, 198

216, 238

267, 591

614, 1719

5705, 5849

21,139

188,803

290

Discharge summary

report

Admission Date: [**2168-12-3**] Discharge Date: [**2168-12-14**] Service: MEDICINE Allergies: Iodine; Iodine Containing / Ampicillin / Phenergan / Zaroxolyn Attending:[**First Name3 (LF) 1711**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **]yo [**Age over 90 595**]-speaking female with CHF, presents with increasing dyspnea, pedal edema x1wk. According to the patient's Grandson, she has had issues with medication and dietary compliance. VNA at home note the patient's dyspnea and edema, was concerned about a CHF exacerbation yesterday. However, the patient refused to come in until today, when her symptoms continued to worsen. Per the patient, at that time her O2 sat was 88% on 5L oxygen via NC at home. In the ED, patient's vitals were 98.2 100 130/93 22 88% 5L NC. Patient reported feeling "lowsy", with shortness of breath and edema. She denied fevers, cough. On 5L nasal cannula, she was comfortable, with a mid-high 90s O2 sat. On physical exam she was noted to have crackles and tachypnea. A CXR showed bilateral pulmonary congestion. A UA was negative for signs of a UTI. Her HCT was at baseline 35. EKG demonstrated afib with around 80. Pt denied CP, but did report some occassional "heart pauses" that were believed to be palpitations, however no changes were observed on telemtry. . Patient is now being admitted to medicine for treatment of a CHF exacerbation. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. All other review of systems are negative. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia 2. CARDIAC HISTORY: -dCHF last echo on [**7-/2168**] EF of 65% -aFIB not anticoagulated due to fall risk -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: -Microvascular disease -Extensive basal ganglia disease -Gait disorder -HTN -Dyslipidemia -Advanced DJD -Meniere's disease -hard of hearing Social History: Patient lives at home by herself at subsidized senior housing with assistance from family. Her Grandson [**Name (NI) 382**] is an interpreter at [**Hospital1 18**] and is very active in her care. Family History: No clear history of CAD. Physical Exam: Admission Exam Vitals: 96.2 140/101 92 20 93%3L, Wt 64Kg Gen: Elderly female, frail, NAD. HEENT: PERRL, EOMI. No scleral icterus. No conjunctival injection. Neck: Supple, JVP to ear lobe. Lungs: diffuse wheezes throughout w rales, no ronchi. Normal respiratory effort CV: Irregularly irregular, no murmurs, rubs, gallops. Abdomen: soft, NT, ND, NABS, no HSM. Extremities: WWP, no cyanosis. 2 + edema to knee Neurological: AOx3, CN II-XII intact. Skin: Paper-thin skin, no rashes or ulcers. GU: foley in place Discharge Exam: Temp Max: 97.5 Temp current: 97.5 HR: 64-92 RR: 24-26 BP: 102-122/56-88 O2 Sat: 95% on 5L Weight 61.5 Kg 24 hour I= 1000 O= 1060++ 8 hour I= 90 O= 300 Physical Exam: Gen: alert, tachypnic HEENT: supple CV: irreg, irreg. no M/R/G RESP: Poor effort, no crackles or wheezes ABD: soft, NT, ND EXTR: trace peripheral edema to knee bilat NEURO: alert, answering questions appropriately, good appetite. Extremeties: Pulses: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Skin: intact Pertinent Results: Blood Counts: [**2168-12-3**] 03:00PM BLOOD WBC-8.1 RBC-3.87* Hgb-12.3 Hct-35.7* MCV-92 MCH-31.8 MCHC-34.6 RDW-16.1* Plt Ct-224 [**2168-12-6**] 05:30AM BLOOD WBC-9.4 RBC-3.91* Hgb-12.1 Hct-37.2 MCV-95 MCH-31.0 MCHC-32.6 RDW-16.1* Plt Ct-245 [**2168-12-8**] 06:00AM BLOOD WBC-6.4 RBC-3.46* Hgb-11.0* Hct-32.0* MCV-92 MCH-31.9 MCHC-34.5 RDW-15.8* Plt Ct-180 Coags: [**2168-12-3**] 03:00PM BLOOD PT-13.4 PTT-26.0 INR(PT)-1.1 Chemistry [**2168-12-3**] 03:00PM BLOOD Glucose-115* UreaN-27* Creat-0.9 Na-139 K-3.4 Cl-97 HCO3-32 AnGap-13 [**2168-12-5**] 06:49AM BLOOD Glucose-104* UreaN-25* Creat-0.9 Na-144 K-3.0* Cl-96 HCO3-36* AnGap-15 [**2168-12-6**] 05:30AM BLOOD Glucose-128* UreaN-26* Creat-0.9 Na-141 K-4.9 Cl-97 HCO3-35* AnGap-14 [**2168-12-8**] 06:00AM BLOOD Glucose-99 UreaN-25* Creat-0.7 Na-140 K-3.8 Cl-98 HCO3-35* AnGap-11 Cardiac: [**2168-12-3**] 03:00PM BLOOD cTropnT-<0.01 proBNP-4693* [**2168-12-4**] 08:10AM BLOOD CK-MB-2 cTropnT-<0.01 Blood Gas: [**2168-12-6**] 09:10PM BLOOD Type-ART pO2-76* pCO2-59* pH-7.41 calTCO2-39* Base XS-9 [**2168-12-6**] 11:32PM BLOOD Type-ART Temp-37.0 O2 Flow-4 pO2-67* pCO2-60* pH-7.43 calTCO2-41* Base XS-12 Intubat-NOT INTUBA [**2168-12-3**] EKG: Atrial fibrillation. Non-specific ST-T wave changes are diffuse. Compared to the previous tracing of [**2168-11-1**] the ST-T wave changes are similar. [**2168-12-3**] CXR: Prominent bronchovascular markings, with bilateral small pleural effusions and bibasilar atelectases, concerning for congestive failure and pulmonary edema. [**2168-12-5**] CXR: Increase in bilateral moderate-sized pleural effusions with associated pulmonary vascular congestion and mild-to-moderate pulmonary edema. On this background assessment for pneumonia is limited and if concern exists, repeat examination should be performed after diuresis. 11.13 CXR: FRONTAL CHEST RADIOGRAPH: Cardiomediastinal silhouette is stable. Pulmonary vasculature indistinctness is improving consistent with resolving pulmonary edema. There are small bilateral pleural effusions as well as retrocardiac and bibasilar atelectasis. Brief Hospital Course: [**Age over 90 **]yo [**Age over 90 595**]-speaking female admitted to general medicine service for likely CHF exacerbation in the setting of poor medication compliance transferred to the CCU secondary to persistent tachypnea. . # Tachpnea/CHF: Pt was admitted for CHF exacerbation likely secondary to med non-compliance and poor rate control of A. fib. CXR revealed pulm edema. Initially cared for on the medical floor, where she was diuresed to 64kg (previous d/c weight was 62kg) with IV Lasix [**Hospital1 **] 120mg. She was trasferred to the CCU for close monitoring after an episode of tachypnea and desaturation. While in the ICU, challenging to balance her blood pressure and fluid status. Pt was given gentle Lasix for diuresis and then transitionted to torsemide PO 100mg [**Hospital1 **]. Went home with torsemide 100mg [**Hospital1 **] and potassium supplementation. Discharge weight was 61.5 kg. Pt with stage IV heart failure. Prognosis discussed with family. Family and patient decided to be DNR/DNI. Strongly encouraged pt to go to rehab but family and pt declined and preferred to go home. Pt has 24 hour support at home. . #Afib: hx afib, CHADS score 3, and only on ASA, since fall risk. Rate controlled with metoprolol 75mg once a day (decreased home dose of 100mg [**Hospital1 **]) and diltiazem was added on this admission. Metoprolol dose was decreased since pt became more hypotensive with higher dose of metoprolol. Pt went home on Diltiazem 240mg daily and metoprolol 75 mg daily. . #Chronic Falls: Continued Phenytoin . #Gallstones: Continued home Ursodiol Medications on Admission: Medications: Phenytoin sodium extended 300 mg 6 DAYS/WEEK (Every day except Sunday) Phenytoin sodium extended 400 mg qSUN Ursodiol 300 mg [**Hospital1 **] Aspirin 325 mg Daily Metoprolol succinate 100 mg [**Hospital1 **] Senna 8.6 mg qHS prn Docusate sodium 100 mg [**Hospital1 **] Furosemide 120mg [**Hospital1 **] 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 once a day as needed for constipation. 3. food supplement, lactose-free Liquid Sig: One (1) bottle PO once a day. 4. multivitamin Tablet Sig: One (1) Tablet PO once a day. 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. phenytoin sodium extended 100 mg Capsule Sig: Four (4) Capsule PO QSUN (every Sunday). 8. phenytoin sodium extended 100 mg Capsule Sig: Three (3) Capsule PO DAYS (MO,TU,WE,TH,FR,SA) (). 9. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. 10. diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 11. torsemide 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 13. Outpatient Lab Work Please check Chem-7 on [**2168-12-16**] with results to [**Last Name (LF) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 142**] Discharge Disposition: Home With Service Facility: surburban Discharge Diagnosis: Acute on Chronic Diastolic Congestive Heart Failure Atrial fibrillation with rapid ventricular response 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 for heart failure. We gave you diuretics to help you urinate some of the extra fluid. This helped your symptoms. It is very important to maintain a low sodium diet, use oxygen at home, and take your medications every day. Please weight yourself every day in the morning and call Dr. [**Last Name (STitle) **] if your weight increases more than 3 pounds in 1 day or 6 pounds in 3 days. It is very important that you do not eat foods high in sodium or it is very likely that you will need to come back to the hospital. We made the following changes to your medications: 1. Start taking potassium every day 2. Decrease Metoprolol to 1.5 tablets of 100mg daily in the am, do not take in the pm. 3. Start Diltiazem 240 mg daily to control your heart rate 4. Stop taking Furosemide, take Torsemide instead twice daily to take off extra fluid. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [**2168-12-19**] at 1:20 PM With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: INTERNAL MEDICINE When: TUESDAY [**2168-12-20**] at 9:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD [**Telephone/Fax (1) 142**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "428.33", "E942.6", "401.9", "799.02", "428.0", "574.20", "458.29", "V15.88", "427.31" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9065, 9105

5742, 7328

279, 285

9253, 9253

3628, 5719

10326, 10935

2559, 2585

7694, 9042

9126, 9232

7354, 7671

9429, 10003

3305, 3609

2003, 2156

3137, 3290

10032, 10303

1502, 1923

232, 241

313, 1483

9268, 9405

2187, 2328

1945, 1983

2344, 2543

26,108

165,071

22454

Discharge summary

report

Admission Date: [**2176-8-5**] Discharge Date: [**2176-8-11**] Date of Birth: [**2130-10-1**] Sex: F Service: PSU HISTORY OF PRESENT ILLNESS: This is a 45-year-old woman who presents for operation of bilateral total mastectomies with immediate breast reconstruction using autologous tissue, in essence free TRAM flap. PAST MEDICAL HISTORY: The patient's past medical history is consistent with intraductal carcinoma diagnosed by open surgical biopsy on [**2176-8-6**]. Patient had a 1.5 cm grade 2 lesion. Patient has an ER/PR positive tumor that was HER- 2/neu negative. There were 0/9 nodes involved. Patient received dose-dense chemotherapy x4. The patient's past medical history is consistent with asthma, 3 Staph. infections. PAST SURGICAL HISTORY: Patient has had bilateral bunion surgery. FAMILY HISTORY: Is consistent with lung cancer. SOCIAL HISTORY: The patient is married. She is a kindergarten teacher. She does not smoke cigarettes. She drinks alcohol rarely. MEDICATIONS: Patient takes Caltrate, albuterol p.r.n. ALLERGIES: Patient is allergic to CT scan dye, possibly latex, and possibly tape. PHYSICAL EXAMINATION: Patient's vitals on admission are 115/78 with a pulse of 88, temperature of 97.8. Patient is 5 foot 1 inches and weighs 128 pounds. General: She is well- nourished, well-developed, and in no acute distress. HEENT: Within normal limits. Her chest was clear to auscultation at both the apices and the bases. Patient's cardiac exam: She is regular rate and rhythm without murmurs, rubs, or gallops. Patient's abdomen is soft, is nontender. There are no masses appreciated. Patient's extremities have full range of motion. There is no clubbing, cyanosis, or edema. Patient does have carcinoma of the right breast. Has a high personal history for breast cancer. HOSPITAL COURSE: Patient will have total mastectomy bilateral and immediate breast reconstruction on [**2176-8-5**]. This is a brief summary of the [**Hospital 228**] hospital course. On [**2176-8-5**], the patient was taken to the OR for bilateral total mastectomies with immediate breast reconstruction with free TRAM flaps. Patient's surgery went well. She had no issues postoperatively. In the PACU postoperatively, the patient's vitals were 98.1, 76, 92/54. She was afebrile with stable vital signs. She was doing well. Both the patient's flaps were checked overnight. They were found to be warm and well perfused with no evidence of ischemic damage or concern. In the morning on postoperative day 1, the patient was comfortable. She was afebrile with stable vital signs. Her abdominal wound was clean, dry, and intact. Patient was doing well. Patient was seen in the PACU on the morning of postoperative day 1 by the plastic surgery attending, who felt that the right flap was fine. It was warm with a normal signal. The attending felt the left flap was cool that had a Dopplerable signal, but it was concerning and swollen. The feeling at the time that the left flap was clearly threatened either from hematoma or more likely venous occlusion. The plan was to urgently return to the OR for exploration. The patient understood the 50% chance of salvage and the possibility of a vein graft in the event that the patient had suffered a venous occlusive problem that might further compromise her flap. So on postoperative day 1 from the original surgery, patient was taken back to the OR for immediate exploration of the left breast. The take-back surgery was successful. Please see the operative note for further detail. On postoperative days 1 and 2, patient was transferred to the surgical intensive care unit where she was monitored very closely. Patient did very well while on the unit. Her hematocrit was monitored very closely along with her other electrolyte labs. The patient's breasts were also monitored very closely with both Doppler exam and clinical examination to determine if there was any further concern for ischemia or venous occlusion. On postoperative day 2 and day 3, the patient did very well. She was afebrile with stable vital signs. Her flaps appeared viable. Her pain was controlled with a PCA and with a Sensorcaine pump. Patient was slightly tachycardic; however, her IV fluids were continued and she settled out. On postoperative day 3 and day 4, the patient continued to do well and continued to progress. She was comfortable. Her pain was well controlled. Her flaps appeared to be very healthy and viable without cause for concern. The left breast specifically was very warm and had an excellent arterial and venous signal. The patient's coagulation labs, specifically the PT and PTT were monitored closely. On postoperative day 3 and day 4, the patient was experiencing some reflux. She was afebrile with stable vital signs. Her urine output began to pickup, and she continued to do very well. The patient also did experience a drop in her hematocrit. This was again very closely monitored and her heparin drip was turned off at this time in order to prevent any further blood loss. The heparin drip had been on to prevent coagulation of the patient's free flaps. However, when the patient sustained a substantial hematocrit drop, the heparin was discontinued. It is important to note that the patient's breast flaps remained viable at all times and at no point was this a cause for concern. On postoperative days 4 and 5, the patient was transferred from the surgical intensive care unit to the regular hospital floor. The patient progressed very well on the regular hospital floor. She was afebrile. Her vital signs were stable. She did not experience any untoward events. Her hematocrit remained stable and did not have any further decrease. Patient did experience some mild temperature elevation. However, her temperature never reached greater than 100.4 degrees. Patient's JP drains remained to bulb suction and they were draining adequately. The plan was to have the patient continue to ambulate and to be up out of bed with physical therapy in order to regain her strength and work on her balance. On postoperative day 6, the patient was doing very well. Her flaps again were warm and well perfused by both clinical exam and Doppler examination. She did have a slight amount of ecchymosis. The plan was to discharge the patient to home on [**2176-8-11**]. DISCHARGE DIAGNOSES: Breast cancer with bilateral total mastectomies and immediate free transverse rectus abdominis myocutaneous reconstruction. DISCHARGE CONDITION: Stable. FOLLOW-UP INSTRUCTIONS: The patient is to followup with Dr. [**First Name (STitle) **] in 1 week. The patient was to call Dr.[**Name (NI) 27221**] office upon discharge from the hospital. Patient is to followup with Dr. [**Last Name (STitle) 11635**] in 3 weeks. Upon discharge from the hospital, the patient is to call Dr.[**Name (NI) 17485**] office in order to followup with her. DISCHARGE MEDICATIONS: Colace 100 mg p.o. b.i.d., aspirin 81 mg p.o. daily, Percocet 5/325 mg 1-2 tablets p.o. q.4-6h. p.r.n. pain, 60 tablets were dispensed, Keflex 500 mg p.o. 4 times a day for 10 days. Patient also was given Sarna lotion which she can apply topically 3 times a day for a small rash that she had on her buttocks. DISCHARGE STATUS: To home. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 24332**] Dictated By:[**Last Name (NamePattern1) 18027**] MEDQUIST36 D: [**2176-9-3**] 08:26:32 T: [**2176-9-3**] 09:16:14 Job#: [**Job Number 58342**]

[ "785.0", "E878.8", "174.8", "996.79", "996.52", "E849.7" ]

icd9cm

[ [ [] ] ]

[ "85.42", "85.7" ]

icd9pcs

[ [ [] ] ]

6505, 6514

840, 873

6358, 6483

6923, 7529

1843, 6336

780, 823

1167, 1825

164, 341

6539, 6899

364, 756

890, 1144

51,918

165,208

37916

Discharge summary

report

Admission Date: [**2196-11-30**] Discharge Date: [**2196-12-13**] Date of Birth: [**2138-6-8**] Sex: M Service: SURGERY Allergies: Clinoril / Indocin Attending:[**First Name3 (LF) 3376**] Chief Complaint: left lower quadrant abdominal pain Major Surgical or Invasive Procedure: Cystoscopy with left ureteral stent placement. L colectomy/completion sigmoidectomy, diverting ileostomy/cystoscopy Take back for hemoperitoneum History of Present Illness: Mr. [**Known lastname 9880**] is a pleasant, cooperative gentleman with a long standing history (20 years) diverticulitis. Over the past year he has been having flares of diverticulitis which were well controlled with cipro and flagyl, intermittently. Over the past two weeks, he was taking PO cipro/flagyl but it was not enough to control his pain, in addition he took oxycodone which he had left over from a previous procedure. This controlled his pain until today, when he went to his PCP who ordered [**Name Initial (PRE) **] CT abdomen/pelvis w/PO contrast, which showed inflammation of the sigmoid colon with diverticuli and thickened bowel wall. Based on the CT findings, his PCP instructed him to come to [**Hospital1 18**]. He states his pain is sharp, [**4-24**], intermittent over the last 2 weeks. The pain is nonradiating, has no provoking factors but is alleviated with narcotics. Over the last 2 weeks, he has had two bouts of emesis, roughly 10 days ago. He has been living mostly on a clear liquid diet over the last two weeks. He reports very rare flatus and rare and small "size of my thumb" bowel movements, which are without mucous, frank blood or black appearance. He reports a 20 lb weight loss over the last 3-4 weeks. Past Medical History: sarcoidosis w/cardiac involvement [**2185**] pacemaker staph infection psoriatic arthritis Social History: He works as a high school history teacher. He is divorced and lives at home with his girlfriend [**Doctor First Name **] and his 75 lb dog. He does not currently and never has used tobacco or illicit drugs. Until 3 weeks ago, he was having [**1-19**] drinks per day. Currently he uses no alcohol at all. Family History: noncontributory, no history of colon cancers or IBD. Physical Exam: A and O x 3 V.S.S LSCTA bilat rrr no m/r/g soft, nt,nd,+bs no c/c/e Pertinent Results: [**2196-12-10**] 04:45AM BLOOD WBC-7.2 Hct-32.0* [**2196-12-9**] 07:20AM BLOOD WBC-10.5 RBC-3.59* Hgb-11.0* Hct-32.0* MCV-89 MCH-30.5 MCHC-34.3 RDW-15.3 Plt Ct-172 [**2196-12-1**] 12:47AM BLOOD WBC-9.7 RBC-4.77 Hgb-14.8 Hct-42.3 MCV-89 MCH-31.1 MCHC-35.1* RDW-12.4 Plt Ct-316 [**2196-12-9**] 07:20AM BLOOD Plt Ct-172 [**2196-12-6**] 07:06PM BLOOD PT-15.1* PTT-38.8* INR(PT)-1.3* [**2196-12-1**] 12:47AM BLOOD PT-16.1* PTT-31.3 INR(PT)-1.4* [**2196-12-6**] 07:06PM BLOOD Fibrino-248# [**2196-12-6**] 05:23PM BLOOD Fibrino-118* [**2196-12-11**] 05:30AM BLOOD Glucose-76 UreaN-13 Creat-0.8 Na-139 K-3.5 Cl-101 HCO3-30 AnGap-12 [**2196-12-6**] 07:06PM BLOOD ALT-19 AST-27 CK(CPK)-197* [**2196-12-6**] 03:15PM BLOOD CK(CPK)-38 [**2196-12-1**] 12:47AM BLOOD ALT-18 AST-35 AlkPhos-70 TotBili-0.7 [**2196-12-11**] 05:30AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.9 [**2196-12-1**] 12:47AM BLOOD Albumin-3.5 Calcium-9.0 Phos-3.3 Mg-2.0 Iron-19* [**2196-12-1**] 12:47AM BLOOD calTIBC-191* TRF-147* [**2196-12-6**] 03:15PM BLOOD TSH-0.51 [**2196-12-1**] 02:19AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.043* [**2196-12-1**] 02:19AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [**2196-12-1**] 02:19AM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 . MRSA SCREEN (Final [**2196-12-9**]): No MRSA isolated. . CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2196-12-5**]): negative . Brief Hospital Course: Mr. [**Known lastname 9880**] was admitted to general surgery secondary to diverticulitis flare. He was maintained as NPO with IVF/ABX. He was pre-op'd and consented for lap possible open colectomy with possible colostomy. He was taken to the OR on HD 6 for a left colectomy and completion sigmoidectomy with diverting ileostomy. In order to assist in visualization and prevention of injury to left ureter, urology was consulted and performed intra-op cystoscopy with left ureteral stent placement. The stent was subsequently removed and patient with resulting hematuria. An immediate post-op HCT was 40.6. Then was transferred to the PACU, where his urine output tapered off to only 10 mL per hour. Patient began to have hypotension and tachycardia and was subsequently started on norepinephrine drip. Surgeons were initially concerned for septic shock given that they had gound left pelvic phlegmon that was unroofed during the operation. HCT was 23.5 after 2 hours in the PACU and a STAT repeat HCT was 17.3, which prompted a trip back to the OR. . In the second trip to the OR, the patient had to be reintubated, which was reported as a difficult intubation due to airway edema. For resuscitation, the patient then received total of 12 L crystalloid prior to going into OR for a second time. Intraop, the patient was transiently on norepi and phenylephrine drips for hypotension. Received 7 unit PRBCs, 5 FFP, 2 packs platelets. In the surgery, the site of bleeding was discovered and hemostasis was obtained. The patient was transferred to the ICU, where he was liberated from pressors and extubated. His Hct remained stable post-op, and he was transferred out of the ICU. . His diet was slowly advanced as tolerated. Foley and CVL were removed without issues. It was noted that he had poor phonation and spoke in a whisper. ENT was consulted and determined he will need further examination and repeat laryngoscopy to evaluate for possible arytenoid dislocation vs. other cause ofTVC immobility. The patient will follow up as soon as possible with Dr. [**First Name (STitle) **] [**Name (STitle) **]. . It was noted that the distal aspect of his wound was warm to touch, and red. 6 staples were removed with ruddy output. This part of the incision was left open and wound care was provided twice a day and as needed. He will have the VNA to assist with wound care and ostomy care. Medications on Admission: prednisone 5mg qd ranitidine 150 mg qd Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks: Do not exceed more than 4000 mg of acetaminophen in 24 hrs. . Disp:*45 Tablet(s)* Refills:*0* 2. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day. 3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 8 days. Disp:*8 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Diversified VNA and hospice Discharge Diagnosis: diverticulitis flare Left pelvic phlegmon. post-op vocal cord injury Post-op hemoperitoneum Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Please take prednisone 10 mg daily until [**2195-12-21**]. On [**2195-12-22**] please take your home dose of 5 mg daily. . Incision Care: -Your staples will be removed at your follow up appointment. -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. . Wound Care: -The VNA will assist with wound care. -Your incisional wound was opened. It was then cleansed using commercial wound cleanser spray and packed with [**Doctor Last Name 12536**] [**12-18**] inch AMD packing strip. The wound measures 6 x 2.5 x 2.5 cm there is a tunnel at 12 o'clock measuring 2 cm and a second tunnel at 6 o'clock measuring 1 cm. the tunnelled areas were wicked with the packing strip and then the packing strip was fluffed into the wound. a cover dressing was placed and secured with paper tape. . Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. -Try to maintain ostomy output between 1000mL to 1500mL per day. -If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours Followup Instructions: 1. Please call Dr.[**Name (NI) 3377**] office, [**Telephone/Fax (1) 160**], to make a follow up appointment in [**12-18**] weeks. 2. Please follow up with ENT as soon as possible, please refer to the card that Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] provided you with. Completed by:[**2196-12-19**]

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icd9cm

[ [ [] ] ]

[ "46.21", "54.12", "59.8", "57.32", "45.75" ]

icd9pcs

[ [ [] ] ]

6702, 6760

3822, 6212

315, 462

6896, 6896

2355, 3799

9547, 9878

2198, 2252

6302, 6679

6781, 6875

6238, 6279

7041, 8306

8321, 8598

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241, 277

8610, 9524

490, 1743

6910, 7017

1765, 1858

1874, 2182

27,925

110,816

42917+58567

Discharge summary

report+addendum

Admission Date: [**2162-7-25**] Discharge Date: [**2162-8-13**] Date of Birth: [**2095-5-11**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 1042**] Chief Complaint: Severe back pain, fever Major Surgical or Invasive Procedure: Sugical Incision and Drainage of the Left Elbow -twice L2-S1 Laminectomy and Washout PICC Line Insertion History of Present Illness: 67 M w/ recent ulnar nerve surgery at OSH p/w severe lower back pain and fever. Of note, patient is a very difficult historian. He states that he has had chronic back pain for several years due to spinal stenosis. Approximately one year ago he had a lumbar laminectomy. He has chronic pain that he reports began to get severe about one week ago. His pain medication regimen is unclear - he states that he only takes what he has with him. His regimen used to include celebrex and colchicine, but has recently run out of these medications and has been taking oxycodone at times and roxicet at times. He denies recent trauma. He states that one time last week he lost control of his bowel and bladder. He denies changes in his sensation. He has difficulty ambulating - uses a cane at home. . He had surgery on his left elbow (for ulnar nerve entrapment) approximately three weeks ago ([**2162-7-8**]) at NEBH by Dr. [**Last Name (STitle) 92623**]. He states that surgery was fine without any complications. He has noted some drainage and redness from the surgical site, but no overt pain. . He has also had fevers, chills, HA, diarrhea over the past few days. . ED course: He presented with fever and otherwise normal vital signs. There was concern for spinal epidural abscess, and an MR L spine was done which revealed his spinal stenosis and no e/o infection. He was given vancomycin for his UE cellulitis. For his pain he was given IV dilaudid and tylenol. . He currently is complaining of lots of back pain. He states that he took 4 of his own Roxicet in the ED without telling anyone. . Review of Systems: He has been nauseous for the past several days with decreased PO intake. He has been a bit more SOB recently. . Past Medical History: Past Medical History: Inferior MI ([**2156**]) w/ stent to RCA and ICU stay at OSH s/p Cardiac arrest (pulseless VTach) Diastolic CHF (EF 60% in [**2156**]) Diverticulitis HTN Hyperlipidemia Depression Esophageal varicies s/p L spine laminectomy / spinal stenosis / chronic LBP Ulnar entrapment Insomnia Asthma BPH . Social History: . Social History: He is a retired registered nurse, has a long smoking history but quit about one year ago. He has not had alcohol in about one year as well. Denies any illicit drugs. He lives alone in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], never been married. . Family History: . Noncontributory . Physical Exam: . PHYSICAL EXAM~ Vs- 101.0 122/64 84 20 94% RA 196 lbs Gen- Uncomfortable, disheveled male lying still in bed, tremulous, but in NAD Heent- MMdry, edentulous, anicteric, pupils 3mm, reactive to light, EOMI no oral lesions Neck- supple, no LAD Cor- RRR, distant heart sounds, no murmur appreciated, no S4 or S3 heard Chest- Poor effort, but clear bilaterally Abd- soft, NT, ND, obese, pos BS, no organomegaly Ext- no c/c/e. Dark discolored toe nail. Neuro- AAO x 3. Poor attention span but easily arousable. [**3-25**] strength in all 4 extremities. Decreased sensation to light touch on LE, but equal bilaterally. 2+ DTR let [**Name2 (NI) 15219**], 3+ DTR right [**Name2 (NI) 15219**]. Atrophy noted (L>R) in intrinsic hand muscles. Skin- Pale, warm. Msk- Left elbow with surgical wound incision draining purulent material that is easily expressible. Limited ROM at the left elbow in full flexion and full extension, both active and passive. Back exam limited by pain. Pain with palpation directly over L4 spinous process. . Pertinent Results: MRI L spine [**2162-7-25**]: No definite pathologic enhancement, though there is extensive postsurgical change in the posterior soft tissues of the lower back, related to lower lumbar laminectomy. . MRI Spine [**2162-8-3**]: 1. Marked short-term interval progression of spinal stenosis at L2-L3, with complete effacement of the CSF space and likely compression of all of the descending nerve roots. 2. Markedly enhancing tissue in the anterior epidural space at the same level. A distinct posterior disc herniation is not well visualized on this study, compared to before, although comparison of the anterior epidural soft tissue is difficult because the timing of contrast enhancement may be different. 3. New bone marrow edema in the L2 vertebral body, and probably increased edema signal within the L2-L3 intervertebral disc with partial enhancement. In addition to the findings above, this appearance raises strong suspicion for infection superimposed on post-operative changes. . TAGGED WBC [**2162-8-5**]: IMPRESSION: 1. No definite evidence of epidural abscess, however, sensitivity of study is decreased as patient has been on antibiotic therapy. 2. Increased tracer activity seen in region of left elbow, consistent with known infection. . MRI SPINE [**2162-8-7**]: 1. Findings at L2-3 disc indicate discitis and osteomyelitis. 2. Anterior epidural phlegmon from L1-2 and L3 level with a small focus of epidural abscess. 3. Phlegmon and enhancement in the left neural foramen and also involving the medial portion of both psoas muscles and also in the posterior soft tissues. 4. Subtle increase of signal indicating fluid in the prevertebral region from C1-C4 level. No evidence of discitis or osteomyelitis in the cervical region. The prevertebral area is not fully evaluated on this study and a followup focused cervical spine MRI is recommended for better evaluation. . TEE ECHO [**2162-7-30**]: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). There are simple atheroma in the aortic arch and descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. There is mild focal thickening of the noncoronary cusp of the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. 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 no pericardial effusion. . LEFT FOOT THREE VIEWS: [**2162-8-10**] 1. Mild soft tissue swelling about the left fifth digit without evidence of osteomyelitis at this time. 2. Mild degenerative changes about the mid foot and small plantar calcaneal enthesophyte. . ABDOMINAL ULTRASOUND [**2162-7-31**] 1. Echogenic liver likely representing fatty metamorphosis. However, more advanced liver diseases including hepatic fibrosis/cirrhosis cannot be excluded in this study. 2. Small right posterior hepatic lobe cyst, unchanged as compared to the prior MR examination dated [**2155-8-21**]. 3. Moderate amount of gallbladder sludge, with no evidence for cholecystitis. 4. No renal calculus or evidence for obstruction. . CXR [**2162-8-2**] COMPARISON: [**2162-7-25**]. Right PICC line has been placed with distal tip of radiodense wire terminating in the proximal right atrium. This finding has been communicated by telephone to the venous access nurse caring for the patient on [**2162-8-2**]. Heart size is normal. Pulmonary vascularity is engorged, and there is new bilateral interstitial pulmonary edema. . CXR [**2162-8-8**]: A single portable image of the chest was obtained and compared to the prior examination dated [**2162-8-6**]. There is no significant interval change. A stable retrocardiac opacity is noted likely reflects underlying small pleural effusion with atelectasis, difficult to exclude pneumonia. There is mild perihilar fullness associated with loss of definition of the pulmonary bronchovasculature as well as vascular redistribution suggesting mild underlying pulmonary venous congestion. No new focal opacities are seen. The cardiomediastinal silhouette is stable. The bony thorax is grossly unremarkable. . ON ADMISSION: [**2162-7-25**] 04:50PM PT-12.6 PTT-29.5 INR(PT)-1.1 [**2162-7-25**] 04:50PM PLT COUNT-327 [**2162-7-25**] 04:50PM NEUTS-94.0* LYMPHS-2.4* MONOS-3.0 EOS-0.1 BASOS-0.5 [**2162-7-25**] 04:50PM WBC-14.1*# RBC-3.89* HGB-12.7* HCT-35.7* MCV-92 MCH-32.5* MCHC-35.5* RDW-14.3 [**2162-7-25**] 04:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-8.3 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2162-7-25**] 04:50PM calTIBC-203* FERRITIN-662* TRF-156* [**2162-7-25**] 04:50PM ALBUMIN-3.8 CALCIUM-9.5 PHOSPHATE-2.4* MAGNESIUM-2.4 IRON-17* [**2162-7-25**] 04:50PM CK-MB-NotDone [**2162-7-25**] 04:50PM cTropnT-<0.01 [**2162-7-25**] 04:50PM ALT(SGPT)-37 AST(SGOT)-31 LD(LDH)-240 CK(CPK)-73 ALK PHOS-132* TOT BILI-1.2 [**2162-7-25**] 04:50PM estGFR-Using this [**2162-7-25**] 04:50PM GLUCOSE-136* UREA N-31* CREAT-1.3* SODIUM-138 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-18* ANION GAP-21* [**2162-7-25**] 05:05PM LACTATE-1.3 . ON DISCHARGE: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2162-8-13**] 07:15AM 4.4 3.05* 9.2* 27.3* 90 30.1 33.6 15.2 400 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2162-8-13**] 07:15AM 72.9* 16.5* 4.1 5.4* 1.1 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr Ovalocy Burr [**2162-8-12**] 07:35AM NORMAL 1+ NORMAL NORMAL NORMAL NORMAL 1+ Source: Line-picc BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2162-8-13**] 07:15AM 400 [**2162-8-13**] 07:15AM 13.9* 33.9 1.2* Brief Hospital Course: 67 male with history of coronary artery disease, lower back pain, hypertension, and recent elbow surgery who presents with bacteremia, elbow joint abscess, and soft tissue infection involving lumbar spine (? cauda equina syndrome). . 1) MSSA bacteremia: On arrival the patient was febrile and rigoring. He was given IVF with stabilization of SBP in 90s-low 100s. He was given Vancomycin IV. Demerol was given for rigoring. He was transferred from the ED to the ICU for hypotension and desaturation. The next AM orthopedics brought the patient to the OR for washout of his elbow. Blood cultures grew MSSA and vancomycin was changed to nafcillin. This bacteremia is likely due to septic arthritis of left elbow causing bacteremia and seeding of lumbar disc space fluid collection based on findings of cauda equina syndrome and enhancement at L2/L3 on MR spine. Blood cultures from 8/5/6/7 all grew MSSA. All blood cultures from 8/8,9,10,15,18,19 are 0/22 with negative cultures. Patient afebrile at discharge. - Continue nafcillin IV 2g Q4H, antibiotic course of 8 weeks ending [**2162-10-2**] - Check weekly labs while on nafcillin (CBC, LFTs, BUN/Cr)to be faxed to Infectious Disease - Follow-up with Infectious Disease - PICC Line Care needed until patient finished antibiotic course. The PICC line will be pulled by infectious disease nursing at [**Hospital1 18**]. Length of PICC: 53cm. . 2) Septic arthritis (L elbow): Patient had two washouts performed on the left elbow [**7-26**] and [**8-5**]. After the first washout patient had a brief ICU stay for hypotension, but was quickly stabilized with fluids and transferred to the floor hemodynamically stable. Patients clinical exam stable with range of motion 70-180 degrees, [**3-30**] pain on active/passive movement, and 4+/5 strength. Erythema, swelling and warmth of elbow resolving with minimal residual swelling. Orthopedics has stated the patient may be discharged from their service. The patient has a wound VAC which was last changed on [**8-12**] and will need change again on [**2081-8-13**]. - Change wound VAC on [**8-14**] or 26, then continue to change wound VAC every three days until a wound VAC is no longer needed, then change to wet to dry dressings. - Orthopedic follow-up at [**Hospital6 2910**] . 3) Soft tissue infection of lumbar spine: Soft tissue infection around lumbar spine consistent with possible cauda equina syndrome with multiple MR [**Name13 (STitle) **] over course of the patient's hospitalization. The most recent on [**8-7**] (performed with intubation for better image quality) showing progressive L2/L3 discitis/osteomyelitis, epidural phlegmon/abscess at L2/L3. Patient had L2-S1 laminectomy with drainage on [**8-7**]. Findings of cauda equina markedly improved since surgery now with 4+/5 hip flexion/extension, improved vibratory sense at L/R hip, unchanged sphincter tone and resolving bowel/bladder incontinence. Patient slowly defervesced after his L2-S1 laminectomy with washout. Patient reports "markedly improved" back pain [**3-30**] at the time of discharge. Patient afebrile on discharge. - Physical and Occupational Therapy in Intensive [**Hospital 1739**] Rehabilitation - Follow-up with Orthopedic Surgery for repeat MRI Lumbar Spine with and without contrast, CRP, ESR and appointment - Staples out [**2162-8-19**] - Wound Care: change dressings daily and as needed if soiled . 4) Paranoia, hallucinations and subtle delirium: In the immediate post-operative period following his laminectomy the patient reported hallucinations, paranoia and was intermittently confused. As soon as able patient was weaned from the Dilaudid PCA which was started post-operatively. Most likely delirium is a drug reaction to hydromorphone as patient has documented reaction of formication to morphine and delirium temporally related to its administration. Infection was considered as a cause, but work-up of lung, urine, wound were negative and patient's fever curve trended downward. Delirium has resolved with in two days on discontinuation of the Dilaudid. Patient currently stabilized on a pain regimen of oxycodone SR (Oxycontin) 60 mg PO Q12H and oxycodone 5mg PO Q4H:PRN. . 5) Hypoxia/Chronic Obstructive Pulmonary Disease: Patient has had intermittent oxygen requirements after his ICU stay and after his surgeries. These have resolved with diuresis for pulmonary edema and treatment of his Chronic Obstructive Pulmonary Disease with albuterol and ipratropium nebulizers. Patient encouraged to use incentive spirometry to improve lung volumes while mostly bed bound. Patient baseline oxygen saturation is 91-92% on room air. - Patient has follow-up with his Primary Care Physician and it is recommended that he have outpatient pulmonary function tests. . 6) Acute Renal Failure: After the patient's episode of hypotension in the ICU and his transition from Vancomycin to Nafcillin the patient developed acute on chronic renal failure. The patient has chronic kidney disease with a baseline Cr 1.1-1.3; however, during this time period the patient's Cr increased to 2. Initial fractional excretion of sodium indicated the patient had prerenal failure. With fluid rehydration the patient's creatinine improved to 1.7. A renal ultrasound was performed that ruled out obstruction. Renal was consulted about the concern for acute interstitial nephritis due to Nafcillin. Over the next two weeks the patient's renal function continued to improve and Renal consult did not feel the acute renal failure was due to acute interstitial nephritis. It is felt that the patient's episode of hypotension due to bacteremia resulted in prerenal renal failure with subsequent damage to the kidney due to this low flow state. As discharge the patient's creatinine has improved to 1.3 which is at the upper limit of his baseline. The patient's medications were renally dosed during this hospitalization. - Weekly BUN/Cr monitoring for Nafcillin renal toxicity - Follow-up with [**Hospital1 18**] Renal for Chronic Kidney Disease . 7) Shock Liver: The patient developed a coagulopathy with elevated transaminases and t. bilirubin after his hypotensive episode. The patient required vitamin K to treat his coagulopathy. Suspect likely due to shock liver; however, poor PO intake and patient's history of Hepatitis B may have contributed to this episode. Patient currently Hepatitis B immune, with a negative Hepatitis B viral load. Patient liver ultrasound concerning for developing fibrosis. Patient's LFTs have normalized and patient INR was 1.2 at the time of discharge. - Follow-up to establish care with [**Hospital1 18**] Liver Center . 8) Multiple loose stools: Likely due to aggressive bowel regimen and patient's spinal infection. Clostridium Difficile was negative. Patient's bowel regimen was changed to as needed. Patient's bowel frequency has decreased and he has two loose bowel movements per day. . 9) Swollen left second toe: Patient has history of gout, although his uric acid was not elevated on this admission. Toe has slowly improved and is currently non-tender with small amount of soft tissue swelling. X-ray of L foot showed no evidence of osteomyelitis with mild degenerative changes about mid foot and small plantar calcaneal enthesophyte. Patient has not been on his colchicine due to his renal failure. - Monitor for resolution - [**Month (only) 116**] restart low dose colchicine as needed . 10) Normocytic Anemia/Declining Hematocrit: Patient's hematocrit has declined over the course of the hospitalization due to hemodilution, losses from JP drain, phlebotomy and surgical losses in setting of anemia of chronic disease per iron studies with inadequate hematopoiesis. Recent hematocrit was 40 at NEBH three weeks ago, 35 on admission. Status post initial elbow washout the hematocrit declined from 35 to 28 and remained stable for three days. Hematocrit decreased from 28 to 25 while patient received multiple blood draws, including blood cultures and fluids. The patient's hematocrit declined further after this second elbow wash out to 22. Patient received 2 units of blood 8/18 during back surgery with repeat hematocrit of 23. Patient has received a total of 4 units of packed red blood cells and 2 units of fresh frozen plasma. Negative stool guiac. Patient hematocrit has stabilized at 25-28 for the past 4 days. - Primary Care Physician should [**Name9 (PRE) 702**] patient hematocrit - Weekly CBC will be checked and faxed to Infectious Disease . 11) Crusted vesicles on left flank - Small 1*2cm region with vesicles which are now resolving. Does not follow clear dermatomal distribution and is non-painful. Skin DFA for VZV testing personally delivered to the laboratory, but the laboratory does not have the sample. No further work-up or treatment is indicated. . 12) Hypertension: Hypotensive episode in ICU led to holding of blood pressure medications. As the patient's pressure have improved her blood pressure medications have been slowly added back on. Patient currently on metoprolol 25 mg PO BID, and lisinopril 10 mg daily. - Please titrate Lisinopril as needed for blood pressure control (patient was previously on 40 mg daily) . 13) Low Back Pain: Patient has chronic low back pain which has been exacerbated by his soft tissue spine infection. In the hospital setting with the patient's renal function both his Celebrex was held. Patient was continued on his narcotics which were increased to provide adequate pain control. - Taper narcotics as patient's acute pain resolves. Anticipate patient will have chronic narcotic requirements. - [**Month (only) 116**] add back Celebrex after consideration of patient's renal function . 14) Gastritis/Food Retention: patient has gastroesophageal reflux disease. He was treated aggressively while in the hospital with proton pump inhibitor twice a day. He will be discharged on a proton pump inhibitor daily. Retained food was found in his esophagus; therefore, he was scheduled for outpatient manometry and gastrointestinal follow-up. - Follow-up with GI and have the manometry study . 15) Coronary Artery Disease: Cardiac enzymes negative. Continue aspirin, Statin, metoprolol and recently added back his ACE-I. . 16) Depression: Continued home Effexor . 17) FEN: pneumatic boots, patient required occasional repletion of potassium, regular cardiac diet . 18) PPx: Pantoprazole 40mg PO daily, bowel regimen prn, incentive spirometry . 19) Code: DNR/DNI, confirmed with patient . 20) Communication: [**Name (NI) 717**] [**Name (NI) 92624**] (sister) [**Telephone/Fax (1) 92625**]. . 21) Disposition: To [**Hospital **] Rehab for intensive rehabilitation. Medications on Admission: Allergies: Morphine (itching) Medications (he brought in a shopping bag with these pills): aspirin 81 daily Atenolol 25 daily Roxicet q4 prn (given by surgeon [**7-9**]) Effexor 150 [**Hospital1 **] (by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**]) Lisinopril 40 daily Oxybutynin 5 daily Lipitor 40 dailiy Terazosin 1mg daily Celebrex 200mg daily (by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 53718**]) Colchicine 0.6 daily (by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 92626**]) Protonix 40 [**Hospital1 **] (by Dr. [**First Name4 (NamePattern1) 22917**] [**Last Name (NamePattern1) 92627**]) Vitamin D 50,000 units q week MVI daily Docusate prn Atrovent Combivent Vitamin C . Prescriptions that were old: Norvasc (not currently taking) (by Dr. [**First Name (STitle) **] [**Name (STitle) **]) Lasix (not currently taking) Discharge Medications: 1. Venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO QDAILY (). 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 10. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours) for 8 weeks: STARTED [**2162-8-7**] STOP [**2162-10-2**]. Disp:*672 grams* Refills:*0* 11. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation three times a day. 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day. 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 18. Outpatient Lab Work Please check weekly liver function tests (AST, ALT, ALK PHOS, T. BILI), BUN, Creatinine, CBC. Please fax the results to ([**Telephone/Fax (1) 10739**] ATTN: [**First Name8 (NamePattern2) 4035**] [**Last Name (NamePattern1) 976**], [**Hospital1 18**] Infectious Disease Clinic START: [**8-16**], END: [**10-2**] 19. Wound Care Please evaluate and treat the patient. The patient has a wound vaccuum on his left elbow that needs to be changed [**Last Name (LF) 1017**], [**8-15**], and then changed every three days thereafter until a wound vaccuum is not longer indicated. At that time please change to wet to dry dressings daily. The patient also has healing wound on his back from his laminectomy which are at risk for skin breakdown, please monitor and treat. 20. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 21. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Methacillin Sensitive Staphlococcus Aureus Bacteremia Septic Arthritis Cauda Equina Syndrome Chronic Obstructive Pulmonary Disease Chronic Kidney Disease Acute Renal Failure Surgical Wound Infection at Site of Previous Back Surgery Shock Liver Anemia Hypoxia Secondary: Coronary Artery Disease Depression Benign Prostatic Hyperplasia Discharge Condition: Afebrile, Vital Signs Stable, Oxygen Saturation at baseline 91-92%. Discharge Instructions: You were admitted for an infection in your elbow joint. This infection had spread to your blood and your back. After antibiotics, back surgery and several elbow surgeries you are much improved and ready to begin your rehabilitation. . Please take your medications as directed. Please complete the full course of your antibiotics. Please make sure to have your blood drawn once a week for laboratory testing. Please keep all of your follow-up appointments. . If you experience any fevers, chills, nausea, vomiting, chest pain/pressure, shortness of breath, diarrhea please report it to your primary care provider or the current physician caring for you at the Extended Care Facility Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 39008**], [**Hospital6 **] Date/Time: [**8-16**] [**2161**] Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2165**] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2162-8-17**] 8:00 Fpr gastroenterology follow-up Provider: [**Name10 (NameIs) 2166**] ROOM GI ROOMS Date/Time:[**2162-8-17**] 8:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7380**],MD MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 457**] Date/Time:[**2162-8-24**] 10:00 For Infectious Disease Follow-up Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 92623**] Orthopedics [**Hospital6 2910**] Date/Time: [**8-26**] 2:10pm Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4090**] [**Hospital1 18**] Renal Date/Time: Thursday [**9-2**] at 1pm [**Hospital Ward Name 23**] [**Location (un) 436**] Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] Date/Time: [**11-3**] 9:20am [**Hospital1 18**] Liver Center. Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Hospital1 18**] West 110 [**Doctor First Name **] 3rd Fl, 3B. Date/Time: [**2162-9-22**]. Name: [**Known lastname 1385**],[**Known firstname 448**] J Unit No: [**Numeric Identifier 14558**] Admission Date: [**2162-7-25**] Discharge Date: [**2162-8-13**] Date of Birth: [**2095-5-11**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 4226**] Addendum: Infectious Disease Follow -Up: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] spoke with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who reported that the patient will follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14559**] from [**Hospital1 8**] Infectious Disease at [**Hospital1 14560**]. Dr.[**Name (NI) 14561**] will follow the patient's laboratory results and monitor his treatment course. The patient will not need to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in Infectious Disease at [**Hospital 8**] Clinic. This appointment has been canceled. Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - MACU [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4228**] Completed by:[**2162-8-13**]

[ "682.3", "530.81", "274.9", "711.02", "585.9", "584.9", "600.00", "493.22", "998.59", "722.93", "414.01", "458.9", "403.90", "344.60", "724.02", "790.7", "428.30", "041.11", "272.4", "570", "285.21", "730.08" ]

icd9cm

[ [ [] ] ]

[ "80.12", "38.93", "03.09", "86.22" ]

icd9pcs

[ [ [] ] ]

27700, 27887

9927, 13266

293, 400

24649, 24719

3922, 8367

25451, 27677

2828, 2849

21536, 24069

24179, 24628

20610, 21513

24743, 25428

2864, 3903

9315, 9904

2050, 2164

230, 255

13278, 20584

428, 2031

8381, 9301

2208, 2504

2538, 2812

14,293

121,576

29065

Discharge summary

report

Admission Date: [**2114-12-22**] Discharge Date: [**2114-12-28**] Date of Birth: [**2094-1-6**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: Hypothermia Major Surgical or Invasive Procedure: None History of Present Illness: 20 yo male who reportedly had an argument with his parents, let his home wearing only shorts and t-shirt and was found unconscious by police. He was taken to an area hospital where he was found to have a core temperature of 89. He [**Last Name (un) 19692**] then transferred to [**Hospital1 18**] for further care. Past Medical History: None Social History: +EtOh and drug use Family History: Noncontributory Pertinent Results: [**2114-12-23**] 12:00AM GLUCOSE-66* UREA N-16 CREAT-0.8 SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-15* ANION GAP-21 [**2114-12-23**] 12:00AM CK(CPK)-[**Numeric Identifier 70008**]* [**2114-12-23**] 12:00AM CALCIUM-6.7* PHOSPHATE-3.7 MAGNESIUM-1.7 [**2114-12-23**] 12:00AM WBC-12.4* RBC-4.79 HGB-14.7 HCT-40.6 MCV-85 MCH-30.7 MCHC-36.2* RDW-13.2 [**2114-12-23**] 12:00AM PLT COUNT-240 [**2114-12-22**] 09:08PM GLUCOSE-69* LACTATE-1.0 [**2114-12-22**] 06:59PM UREA N-20 CREAT-0.7 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2114-12-25**] 5:03 AM CHEST (PORTABLE AP) HISTORY: Hypothermia and rhabdomyolysis. IMPRESSION: AP chest compared to [**12-22**] and 3: Consolidation which developed in both lower lobes on [**12-23**] is still present, probably pneumonia. Heart size normal. No appreciable pleural effusion. No pneumothorax. ECG: Atrial fibrillation. Intraventricular conduction defect. Lateral ST segment elevation - possibily early repolarization or pericarditis. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 86 0 126 [**Telephone/Fax (2) 70009**]6 18 Brief Hospital Course: He was admitted to the Trauma Service. He underwent CT imaging and no intracranial hemorrhage, solid organ or spine injuries were identified. His labs were followed closely. Psychiatry was consulted to rule out any suicidal ideation as cause of him leaving his house under the reported circumstances. No acute psychiatric issues were identified. It was suggested that he have counseling for his substance and alcohol issues. Social work was consulted; he was given information on services to assist with his addictions post hospital discharge. He was discharged to home with his parents. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation: take while on narcotics for pain. 4. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation: take as needed to avoid constipation. Discharge Disposition: Home Discharge Diagnosis: Hypothermia Rhabdomyolysis Discharge Condition: Stable Discharge Instructions: Return to the Emergency room if you develop any fevers, chills, headache, visual disturbances, chest pain, increased shortness of breath, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. You have been provided with information regarding help for your alcohol and drug related issues and have indicated an interest in seeking help. Please contact one of the numbers provided for further assistance and guidance. Followup Instructions: Follow up in Trauma Clinic as needed if there are any concerns. You may call [**Telephone/Fax (1) 6429**] for an appointment. Completed by:[**2115-1-2**]

[ "276.2", "728.88", "991.6", "296.7", "507.0", "E901.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3109, 3115

1966, 2557

327, 334

3186, 3195

794, 1943

3687, 3843

758, 775

2580, 3086

3136, 3165

3219, 3664

276, 289

362, 678

700, 706

722, 742

24,824

194,281

7755+7756

Discharge summary

report+report

Admission Date: [**2120-5-23**] Discharge Date: [**2120-5-30**] Service: VSU CHIEF COMPLAINT: Abdominal aortic aneurysm, symptomatic. HISTORY OF PRESENT ILLNESS: This is an 87-year-old female who had a known abdominal aortic aneurysm since [**2109**] who has been followed on a regular basis. She underwent a CTA scan on [**2120-5-20**], which demonstrated an infrarenal abdominal aortic aneurysm of 5.2 x 5.0 cm. She has noted over the last 5 weeks back pain, but it has become more progressive over the last 4 days to the point that it radiates from the mid lower back to the lateral anterior abdominal wall bilaterally and is present the majority of the time. This seems to increase with attempt to stand or ambulate or sit in chair. The patient denies chest pain, palpitations, PND, orthopnea or edema. She denies diarrhea, dysuria, hematuria, frequency, urgency. She denies stroke, TIA or syncope. She does admit to a change in color of her stools with black-colored stools in the last week. She admits to fevers and chills, and because of her history of fluid retention, her Lasix has been increased by her physician. She was evaluated at an outside hospital and transferred here with the presumptive diagnosis of symptomatic abdominal aortic aneurysm. ALLERGIES: She is allergic to penicillin which causes hives. MEDICATIONS: Levothyroxine 0.25 mg daily, Lipitor 10 mg daily, Cozaar 50 mg daily, Norvasc 2.5 mg daily, nitro patch 0.2 mg/hr daily, Plavix 75 mg daily, verapamil 240 mg daily. PAST MEDICAL HISTORY: Coronary artery disease with myocardial infarction in [**2112**] and [**2114**], status post triple bypass with LIMA to the LAD, saphenous vein graft to the PDA and obtuse marginal 1 in [**2115-2-28**]. He has a history of hypertension, controlled. History of hypercholesteremia on statin. Abdominal aortic aneurysm. Hypothyroidism, supplemented. Left ventricular aneurysm by echocardiogram. Diverticulosis of the colon by CT scan. History of congestive heart failure, recurrent, last episodes [**2116-7-30**]. History of GERD. History of GI bleed in [**2113**]. PAST SURGICAL HISTORY: Appendectomy, bladder suspension, hemorrhoidectomy, urine polypectomy, ovarian cystectomy, coronary artery bypass graft. The patient's cardiologist is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27082**], M.D., in [**Location (un) **], [**State **] hospital number is [**Telephone/Fax (3) 28121**]. SOCIAL HISTORY: She lives with a friend. She is a former smoker. She has not smoked since [**2112**]. She has a 60 pack-year history of smoking. She denies alcohol use. PHYSICAL EXAMINATION: Vital signs: Temperature 102.6, pulse 79, respirations 23, blood pressure 134/54, oxygen saturation 95% on 2 L, 90% on room air. General: Alert white female in no acute distress. Oriented times 3. HEENT: No JVD. Carotids were palpable. There was bilateral murmur versus bruits. Thyroid was not enlarged. Lungs: Basilar crackles, left greater than right, cleared with coughing. Heart: Regular rate and rhythm with a 2/6 systolic ejection murmur at the base. Abdomen: Soft. It was noted that there was a right renal bruit, right iliac bruit and bilateral femoral bruits. The abdomen demonstrated an enlarged abdominal aorta with right lower quadrant tenderness along the edge of the aneurysm. Rectal: Minimal amount of stool but guaiac positive. Extremities: Without edema, ulcerations or erythema. Pulse exam: Palpable radials and femorals bilaterally, 2+. Popliteals were absent bilaterally. Dorsalis pedis pulses were palpable, 2+. Posterior tibial pulses were 1+ and palpable. Neurologic: Examination was nonfocal. HOSPITAL COURSE: The patient's admitting white count was 19.8, hematocrit 32.8, platelet count 1121; BUN 18, creatinine 1.0; albumin 157, ALT 46, AST 20, albumin 4.4. Blood and urine cultures and chest x-ray were obtained. Two out of 2 blood cultures grew gram negative rods which were identified as Bacteroides rugalis, Beta Lactamase positive. With 2 out of 2 blood cultures, a third set of blood cultures were obtained on [**2120-5-25**], which were no growth but not finalized. An urine culture was contaminated specimen. A repeat urine culture was sent on [**2120-5-29**], which showed no growth. Initial urinalysis showed leukocytes, trace, with 6-10 WBCs, moderate bacteria, 0-3 epithelial and moderate mucus. The patient was continued on levofloxacin and Flagyl. The surgery was deferred secondary to the patient's abdominal pain and positive blood cultures. Surgery was consulted. The patient was initiated on levofloxacin on [**5-23**] for a UTI, which was discovered at the outside hospital. The patient was transferred to the ICU secondary to her sepsis. She had a subclavian line placed for hemodynamic monitoring. Her white count peaked at 34.1, and surgery was consulted. After arrival to the ICU, the patient required intubation for respiratory distress. At the time, they felt that they would treat the patient conservatively and would defer abdominal exploration, giving the patient's co-morbidities. They did not feel her symptoms were related to ischemic bowel but were related to her urinary tract. While in the ICU, the patient went to paroxysmal atrial fibrillation with a V-rate of 120-140. She required electrocardioversion secondary to hypotension with singular 200 joules. The patient converted to sinus rhythm. She was started on an amiodarone drip, and this was eventually tapered to p.o. On ICU day 2, the patient was placed on pressure support. The patient was extubated on [**2119-5-27**]. She continued to show clinical improvement. She was transferred to the VICU for continued monitoring and care. Vancomycin was discontinued on [**2120-5-27**]. She was continued on levofloxacin and Flagyl. Her abdominal exam continued to show significant improvement. Her diet was advanced to clears on hospital day #5 and then advanced as tolerated. There was some question of regarding aspiration while eating. Speech and swallow evaluation was obtained. The patient's bed side evaluation was negative for aspiration. Recommendations were to continue her diet and advance. Physical therapy evaluated the patient on [**2120-5-27**]. It was felt that she would benefit with continued therapy prior to being discharged to home. Rehab screening process was in place. On hospital day 7, the patient required continued diuresis. The patient will be transferred to rehab once medically stable and a bed is available. DISCHARGE MEDICATIONS: Acetaminophen 325 mg tablets 2 q.4-6 hours p.r.n. pain, albuterol 90 mcg actuation aerosol 1-2 puffs q.4 hours p.r.n., Protonix 40 mg daily, levothyroxine 25 mg daily, atorvastatin 10 mg daily, amiodarone 400 mg b.i.d. for a total of 1 week and then the patient is to go to amiodarone 200 mg b.i.d. for 1 week and then amiodarone 200 mg daily for a total of 2 weeks, her verapamil should be continued at 240 mg daily, amlodipine 2.5 mg daily, levofloxacin 500 mg tablets daily for a total of 14 days post discharge, Flagyl 500 mg t.i.d. for a total of 14 days post discharge. DISCHARGE INSTRUCTIONS: The patient should followup in 2 weeks with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 14135**], for a CBC and consideration of CT of abdomen with contrast, resolving gram-negative, presumptive source, colonic, and clearance for endovascular abdominal aortic repair. While the patient is on antibiotics, CBC should monitored weekly, and it should be called to the primary care physician's office. They should call Dr.[**Name (NI) 1392**] office if the patient has increasing abdominal or back pain or any circulatory lower extremity changes. The patient should also call for an appointment with Dr. [**Last Name (STitle) 1391**] in 2 weeks at [**Telephone/Fax (1) 1393**] for followup prior to scheduling her endovascular repair for abdominal aortic aneurysm. DISCHARGE DIAGNOSIS: 1. Gram-negative rod bacteremia, treated. 2. Abdominal aortic aneurysm, 5.2 x 5.0 cm. 3. History of coronary artery disease status post myocardial infarction, status post CABG with LIMA to the LAD, saphenous vein graft to the PDA and obtuse marginal 1 in [**2115-2-28**]. 4. History of hypothyroidism, supplemented. 5. Left ventricular aneurysm noted on echocardiogram and intraoperatively with her CABG. 6. History of recurrent congestive heart failure, last episode in [**2116-7-30**]. 7. History of gastroesophageal reflux disease. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2120-5-29**] 13:40:33 T: [**2120-5-29**] 15:07:41 Job#: [**Job Number 28122**] Admission Date: [**2120-5-23**] Discharge Date: [**2120-5-31**] Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 4748**] Chief Complaint: abdominal aortic aneurysm Major Surgical or Invasive Procedure: central venous line placement swan ganz placement arterial line placement electrical cardioversion endotracheal intubation History of Present Illness: Pleasant 87F who presented [**5-23**] for an elective endovascular AAA repair, but was noted to be febrile to 103, with chills and associated abdominal pain x 4 days. Past Medical History: CAD s/p MI HTN ^chol hypothyroid L ventricular aneurysm diverticulosis CHF GERD h/o UGI bleed s/p CABG x3 ([**2114**]) s/p appy s/p bladder suspension s/p hermorrhoidectomy s/p uterine polypectomy s/p ovarian cystectomy Social History: noncontrib Family History: noncontrib Physical Exam: 102.6 79 134/54 23 95% AOx3 2+ carotid pulses RRR 2/6 SEM bibasilar crackles L>R Soft RLQ TTP, guaiac+ Pulses 2+ fem/DP bilat; 1+ PT bilat Pertinent Results: [**2120-5-24**] 04:50AM BLOOD WBC-34.1*# RBC-3.14* Hgb-9.3* Hct-28.9* MCV-92 MCH-29.5 MCHC-32.1 RDW-22.3* Plt Ct-868* [**2120-5-24**] 12:30PM BLOOD Neuts-84* Bands-12* Lymphs-1* Monos-2 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 NRBC-1* [**2120-5-23**] 4:00 pm BLOOD CULTURE AEROBIC BOTTLE (Preliminary): GRAM NEGATIVE ROD(S). BEING ISOLATED. FOR FURTHER IDENTIFICATION. ANAEROBIC BOTTLE (Final [**2120-5-28**]): REPORTED BY PHONE TO [**First Name9 (NamePattern2) 28123**] [**Location (un) 394**] @ FA6B [**Numeric Identifier 28124**] @ 1550 ON [**2120-5-24**]. BACTEROIDES FRAGILIS GROUP. BETA LACTAMASE POSITIVE. [**2120-5-31**] 03:57AM BLOOD WBC-17.0* RBC-3.27* Hgb-9.5* Hct-29.7* MCV-91 MCH-29.0 MCHC-32.0 RDW-21.8* Plt Ct-729* [**2120-5-31**] 03:57AM BLOOD Glucose-97 UreaN-19 Creat-0.7 Na-139 K-3.9 Cl-103 HCO3-28 AnGap-12 [**5-23**] echo: Conclusions: LVEF 60% The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%); however, the apex appears focally aneurysmal and dyskinetic. An apical left ventricular mass/thrombus cannot be excluded. Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. There is no pericardial effusion. Brief Hospital Course: [**5-23**]: Admitted for elective endovascular AAA repair but noted to be septic from abdominal source. Ruptured AAA ruled out by nonocontrast CT, and patient transferred to ICU for pressor to maintain BP. [**5-24**]: Patient's BP improved with triple antibiotics, IV fluids & levophed. However, patient's respiratory status worsened & she was intubated for airway protection. She developed rapid atrial fibrillation & was electrically cardioverted. A swan ganz catheter was placed for fluid management. [**5-25**]: blood cultures grew out anaerobic gram negative rods. antibiotics weaned to levo/flagyl. pressors weaned. [**5-26**]: extubated. swan changed to TLC CVL [**5-27**]: transferred to VICU. ? of aspiration on PO intake [**5-28**]: negative bedside swallow evaluation for aspiration. Diet started & tolerated. [**5-29**]: PT recommended rehab. diuresis begun. [**5-31**]: accepted at [**Location (un) **]. discharged in good condition Medications on Admission: synthroid, lipitor, cozaar, norvasc, plavix, verapamil, protonix Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 3 days: doses for [**Date range (1) 28125**]. Disp:*6 Tablet(s)* Refills:*0* 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks: doses for [**Date range (1) 28126**]. Disp:*14 Tablet(s)* Refills:*0* 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks: from [**6-10**] to [**6-23**]. Disp:*14 Tablet(s)* Refills:*0* 9. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 10. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. 12. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 2 weeks. 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 14. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once a day for 1 weeks. Disp:*7 doses* Refills:*0* 15. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: sepsis ischemic colitis GNR bacteremia, treated atrial fibrillation AAA 5.2cmx5.0 cm CAD s/p MI s/p cabg's:lima-lad,svg-pda,omi [**2-28**] hypothyroid HTN left ventricular aneurysm history of recurrent CHF, last episode [**7-31**] GERD diverticulosis history of GI bleed [**2113**] s/p uterine polypectomy s/p bladder suspension Discharge Condition: stable Discharge Instructions: Diet as tolerated. You may resume all activities. Contact your MD if you develop fevers>101, increasing abdominal pain, inability to tolerate PO's, or if you have any questions Followup Instructions: Contact Dr.[**Name (NI) 1392**] office at [**Telephone/Fax (1) 1393**] to schedule a follow up appointment after your GI evaluation. Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27542**], to arrange outpatient GI work-up for your colitis. Completed by:[**2120-5-31**]

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icd9cm

[ [ [] ] ]

[ "38.91", "96.04", "89.64", "38.93", "96.71", "99.60" ]

icd9pcs

[ [ [] ] ]

14238, 14324

11614, 12575

9029, 9154

14697, 14706

9827, 11591

14933, 15239

9637, 9649

12690, 14215

14345, 14676

12601, 12667

3679, 6507

14730, 14910

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9664, 9808

2643, 3661

8964, 8991

9182, 9350

9372, 9593

9609, 9621

8,168

127,724

9029

Discharge summary

report

Admission Date: [**2185-11-17**] Discharge Date: [**2185-11-21**] Date of Birth: [**2123-5-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9554**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization with stenting History of Present Illness: 64 yo M with severe CAD (s/p 4v CABG '[**75**], 6 stents '[**83**]), DM, hyperchol, HTN with baseline stable angina treated by NTG SL has been having CP at rest. At baseline pt needs to take NTG with mod activity (>1 flight of stairs) or sex. His symptoms have been getting worse over the past 2 weeks. The night of admission he began to have pain while walking short distances and after an argument. He then began to have pain, diaphoresis, and palpitations while sitting during a play and called an ambulance. Found to have BP 300/150 in field and brought to [**Hospital1 18**] ED. Here found to have BP 229/87 and given O2, morphine, nitropaste, metoprolol, ASA, ativan, and heparin gtt. Denied SOB, F/C, abd pain, leg swelling, pnd, orthopnea, HA, VA changes. Of note, the pt had been on ASA and plavix since his stents in '[**83**] but had stopped since [**8-20**] when he had a prostate procedure. Past Medical History: 1) CAD - as above in PMH (most recent cath and stenting was [**2-16**] and done at [**Hospital1 18**]) 2) Prostate Ca - s/p seed implants [**8-20**] 3) HTN 4) High Cholesterol 5) DM x 5 years 6) Gout 7) Pagets - dx on bone scan for prostate ca work up, no symptoms or further treatment 8)GERD 9) Tongue Cancer - '[**72**] s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],XRT, chemo Social History: No tobacco use 1 scotch per day lives with wife and [**Name2 (NI) **] retired consultant Family History: Cancer Physical Exam: T 97.3 BP 229/87 -> 148/79 P 97 R 15 O2 100 on 2L NC Wt 210 lbs Gen - A+O x 3 NAD HEENT - EOMI, pupils (L 4->3 mm, R 3->2mm) ERRL, OP clear Neck - supple, no JVD, scar from tongue ca [**Doctor First Name **] on R Cor - RRR no murmur Chest - CTA b Abd - S/NT/ND +BS, GUIAC - per ED Ext - no c/c/e, Bruit over R femoral artery Pertinent Results: [**2185-11-17**] 04:34AM GLUCOSE-101 UREA N-22* CREAT-1.4* SODIUM-141 POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-23 ANION GAP-14 [**2185-11-17**] 04:34AM CK(CPK)-129 [**2185-11-17**] 04:34AM CK-MB-4 cTropnT-0.04* [**2185-11-17**] 04:34AM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-1.9 [**2185-11-17**] 04:34AM WBC-6.9 RBC-4.48* HGB-13.6* HCT-40.7 MCV-91 MCH-30.3 MCHC-33.3 RDW-13.7 [**2185-11-17**] 04:34AM PLT COUNT-229 [**2185-11-16**] 10:30PM CK(CPK)-150 [**2185-11-16**] 10:30PM cTropnT-0.03* EKG - sinus tach, nl axis, nl int Q in III, aVF Cardiac Cath [**2185-11-17**] 1. Three vessel coronary artery disease. 2. Successful stenting of the distal and the proximal LAD with two Drug ELuting Stents. 3. Unsuccessful attempt for PCI of the OM/Ramus due to inability to cross the lesion despite using several wires. Echo [**2185-11-18**] 1. The left atrium is moderately dilated. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. 3. The aortic valve leaflets (3) are mildly thickened. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Brief Hospital Course: 64 yo M with severe CAD (s/p 4v CABG '[**75**], 6 stents '[**83**]), DM, hyperchol, HTN with baseline stable angina treated by NTG SL has been having CP at rest. 1) CAD/HTN - Pt was taken to cath and found to have lesions in the OM/ramus and LAD. The LAD was stented however the OM could not be stented. In the lab he became hypertensive to the 190's which was controlled with labetalol and nitro drips. He was transferred to the CCU. Stable BP since however had 1 episode of CP when taken off of the nitro gtt. This resolved upon restarting his imdur. Echo revealed normal EF, mild dys dysfunction, and mod LA enlargement. ACE held b/c pt was having increasing Cr in setting of dye load. Since then restarted on his oral anti hypertensives and has been stable. CK/MB has been trending down since cath. Trop has been increasing however this is likely due to his CRF. He was sent out on an increased dose of metoprolol (50mg [**Hospital1 **]). He was instructed to watch for s/s of low BP. 2) CRF - The pt came in at his baseline Cr of 1.3. With the cath dye load he increased to 1.7 but has remained stable at 1.6. ACE has been held throughout his admission due to this rise. Sent out without ACE. Will f/u with outpt cardiologist. If Cr improves then can consider restarting ace. 3) DM - Pt's glucose well controled on oral agents with an insulin sliding scale. (Oral agents were stopped when he was NPO) Medications on Admission: Metoprolol 25mg [**Hospital1 **] Isosorbide 60mg qam/30mg qpm Glucatrol XL 10mg [**Hospital1 **] Avandia 4mg qday Allopurinol 50mg qday Lisinopril 40mg qday Lipitor 20mg qday Flomax 0.4mg qday ASA/Plavix stopped [**8-20**] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QAM (once a day (in the morning)). 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QPM (once a day (in the evening)). 6. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 7. Allopurinol 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Glipizide 10 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO BID (2 times a day). 9. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Unstable Angina Severe CAD Prostate Cancer HTN Hypercholesterolemia Diabetes Type II Gout GERD Discharge Condition: Stable Discharge Instructions: Please take all of your medications as indicated on the discharge paper work. If you have chest pain at rest (especially if it does not respond to nitroglycerine) please call your physician or go to the emergency room. Also if you experience shortness of breath, fevers, chills, or dizziness call your physician. Also we have increased your metoprolol to 50mg twice a day. Please call your cardialogist if you have any dizziness or fainting. Please watch your cath site(Right groin) if a lump develops or there is redness and warmth please inform your physician. Followup Instructions: Please follow up with your cardiologist in 1 week (Dr. [**Last Name (STitle) 31241**]). Have your Creatinine rechecked. If stable or decreasing, should restart lisinopril. [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]

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icd9cm

[ [ [] ] ]

[ "36.01", "36.07", "37.22", "99.20", "88.56" ]

icd9pcs

[ [ [] ] ]

6222, 6228

3453, 4885

327, 367

6366, 6374

2224, 3430

6989, 7291

1854, 1862

5158, 6199

6249, 6345

4911, 5135

6398, 6966

1877, 2205

277, 289

395, 1311

1333, 1732

1748, 1838

58,828

115,410

42511

Discharge summary

report

Admission Date: [**2156-1-21**] Discharge Date: [**2156-2-5**] Date of Birth: [**2113-7-10**] Sex: M Service: MEDICINE Allergies: Amoxicillin / Paxil / Sulfa(Sulfonamide Antibiotics) / Penicillins Attending:[**First Name3 (LF) 425**] Chief Complaint: line infection and bradycardia Major Surgical or Invasive Procedure: Removal of pacemaker and wires Placement of PICC line History of Present Illness: Patient is a 42yo male with PMH of Down's Syndrome, sick sinus syndrome, and hypothyroidism who presented to OSH because of increased drainage from a shoulder wound associated with recent manipulation of his pacemaker. . Patient received the dual-chamber [**Company 1543**] Sigma, serial number PJD [**Numeric Identifier 91991**], placed initially in [**2146-10-17**], insertion of a new [**Company 1543**] atrial lead because of fractured wire was done on [**2153-1-10**]. In [**2155-12-14**], the tie down sleeve of the atrial lead was noted to be visible at the site of the right clavicle. There had previously been granulation tissue/eschar there since [**Month (only) 116**] the previous year. He reportedly is always picking at the site. He presented to his PCP and was treated with a 10-day course of Keflex 500mg PO QID for 10 days. Wound culture was negative before that treatment. He presented to his electophysiologist on [**2156-1-9**] where he was noted to have an obviously exposed pacemaker lead. A lead extraction was planned on [**2156-1-22**]. However, patient noted increased drainage from the wound site prior to the scheduled date and presented to OSH on [**2156-1-15**] for evaluation. At that time he had no fevers/chills, no abdominal pain, no nausea and vomiting, and no other pain. He was placed on mupirocin ointment and IV cephazolin. He was transferred to [**Hospital1 18**] for lead removal. . On arrival to the floor, patient is accompanied by two people who work for his home aid/group home services. His vitals on arrival are T98.1, BP123/77, HR59, RR20, O2sat 98%RA. He reports diffuse pain symptoms but staff that know him and report that his expression of "pain" is in fact an obsessive/compulsive discomfort with the sticky leads on his body. He reportedly will point and react with grimace when is feeling pain. He knows not to pick at the leads. . ROS: difficult to assess, but staff reports he has not had pain, shortness of breath, or fever. Past Medical History: Down's Syndrome Hypothyroidism Sinus Node dysfunction s/p pacemaker with lead revision Social History: lives in a group home no tobacco no alcohol Family History: Father had leukemia, mother has multiple cardiac stents, no FH of pacemaker Physical Exam: PHYSICAL EXAM ON ADMISSION: VITALS: T98.1, BP123/77, HR59, RR20, O2sat 98%RA GENERAL: NAD, resting comfortably in chair HEENT: prominant facial features stereotypic of Down's Syndrome, large, semi-protuberant tongue, atraumatic skull, PERRL, EOMI, MMM NECK: no JVD, no LAD CHEST WALL: dime to quarter-sized area of exposed granulation tissue over the right anterior chest wall HEART: RRR, no M/R/G LUNGS: CTAB ABDOMEN: soft, nontender, nondistended, NABS, no organomegaly EXTREMITIES: no peripheral edema, no [**Last Name (un) **] lesions or splinter hemorrhages. PHYSICAL EXAM ON DISCHARGE VITALS: T:97.7, BP:99/59, HR68, RR18, O2sat:100%RA CHEST WALL: steristrips covering a wound that appears clean, dry, intact with no surrounding erythema EXTREMITIES: venous catheter in place on left arm Pertinent Results: Labs on Admission: [**2156-1-21**] 06:10PM BLOOD WBC-5.3 RBC-3.87* Hgb-13.9* Hct-43.7 MCV-113* MCH-35.9* MCHC-31.8 RDW-14.5 Plt Ct-194 [**2156-1-22**] 07:55PM BLOOD PT-11.6 PTT-33.2 INR(PT)-1.1 [**2156-1-21**] 06:10PM BLOOD Glucose-115* UreaN-19 Creat-1.0 Na-143 K-4.0 Cl-109* HCO3-28 AnGap-10 [**2156-1-21**] 06:10PM BLOOD Calcium-8.7 Phos-2.8 Mg-2.2 TTE [**1-22**]: 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%). 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. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Visualization of the pacemaker leads throughout their course is incomplete, but no large pacer vegetations are seen. IMPRESSION: No vegetations seen. Normal global and regional biventricular systolic function. Mild functional tricuspid regurgitation. TEE [**1-22**]: The left atrium is normal in size. A probable thrombus is seen in the wall of the right atrium. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a probable thrombus or vegetation on the tricuspid valve. There is a very small pericardial effusion. Micro: [**2156-1-22**] 4:00 pm SWAB RIGHT SHOULDER. **FINAL REPORT [**2156-1-24**]** GRAM STAIN (Final [**2156-1-22**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2156-1-24**]): NO GROWTH. [**1-21**], [**1-22**], [**1-27**] BC: no growth 2/14UC: negative [**1-28**] stool C. diff: negative [**2156-1-28**] 10:46 [**Location (un) **]-LIKE VIRUS (NLV) ANTIGEN, EIA Test Name In Range Out of Range Reference Range --------- -------- ------------ --------------- Norovirus, EIA (Stool) Norovirus Antigen Positive LAB RESULTS ON DISCHARGE: Radiology Report CHEST PORT. LINE PLACEMENT Study Date of [**2156-1-26**] 12:04 PM IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: Tip of the right PIC line ends near the superior cavoatrial junction, would need to be withdrawn 2 cm to competently re-position it in the low third of the SVC. Lungs clear. Heart size normal. No pneumothorax. Radiology Report CHEST (PORTABLE AP) Study Date of [**2156-1-27**] 7:30 PM IMPRESSION: AP chest compared to [**1-26**]: Previous left long line catheter or lead has been removed. Normal heart, lungs, hila, mediastinum, and pleural surfaces. Radiology Report PORTABLE ABDOMEN Study Date of [**2156-1-28**] 9:47 AM IMPRESSION: Focally dilated loops of small bowel and colon within the mid abdomen with otherwise gasless abdomen raises concern for obstruction. CT is recommended for further delineation of etiology as clinically indicated. Radiology Report CT ABD & PELVIS WITH CONTRAST Study Date of [**2156-1-28**] 6:04 PM IMPRESSION: 1. No small-bowel obstruction. 2. Abnormal location of the small bowel suggestive of an internal hernia; however, this is uncomplicated. There is no evidence of strangulation or obstruction and is probably congenital in origin. 3. Small fat-containing umbilical hernia. 4. Air within the bladder may relate to recent catheterization. [**2-5**] CXR: Read over the phone, Tip of PICC is at upper SVC, showing that the line is CENTRAL Lab results on Discharge: [**2156-2-1**] 02:59AM BLOOD WBC-3.1* RBC-3.02* Hgb-11.0* Hct-34.0* MCV-113* MCH-36.4* MCHC-32.3 RDW-14.8 Plt Ct-215 [**2156-2-1**] 02:59AM BLOOD Plt Ct-215 [**2156-2-1**] 02:59AM BLOOD Glucose-75 UreaN-12 Creat-0.9 Na-142 K-3.8 Cl-114* HCO3-24 AnGap-8 [**2156-2-1**] 02:59AM BLOOD CK(CPK)-26* [**2156-2-1**] 02:59AM BLOOD Albumin-3.2* Calcium-7.9* Phos-3.4 Mg-2.1 [**2156-1-27**] 06:40AM BLOOD VitB12-801 Folate-GREATER TH Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: Mr. [**Known lastname 91992**] is a 42yo male with PMH of Down's Syndrome, sick sinus syndrome and hypothyroidism who presented for extraction of exposed and infected pacer wires. The leads were extracted and though patient remains bradycardic, he is asymptomatic and has not experienced any episodes of light-headedness or fainting. He is afebrile and on abx and shows no signs of systemic disease. . ACUTE CARE: 1. INFECTED PACEMAKER LEADS: Patient has a long-standing implanted pacemaker because he previously had experienced syncopal episodes related to sick-sinus syndrome. He had begun to pick at an area where the pacer wires were close to the skin and developed a complicated infection with exposed pace wires. There was granulation tissue over the site of patient's previous intervention and a previous wound culture grew MSSA for which he had undergone a course of Keflex. This is in addition to multiple antibiotic treatment course in sequence beginning in spring of [**2154**]. Because of inability to eliminate infection and continued exposure of the pacer wires, a scheduled explant of the pacemaker was planned. Because patient had increased purulent drainage from the site, he presented to [**Hospital3 3583**] where he was started on vanc and cefazolin. Upon transfer to [**Hospital1 **], a TEE was performed that showed a potential vegetation on the tricuspid valve vs. fibrous tissue from exposure to pacemaker leads. His pacemaker was explanted on [**1-22**], procedure complicated by hematoma at right groin site which self-resolved with some inital pressure and asymptomatic bradycardia to 30s-40s. [**Hospital3 **] microbiology records show that blood cultures drawn prior to the initation of antibiotics were all No Growth Final. Blood cultures drawn here are NGTD. IV cefazolin and topical mupirocin was continued, and patient was switched to IV daptomycin. He remained afebrile and with no signs of systemic infection. He is to receive a total of 6 weeks of IV daptomycin for treatment of potential endocarditis given the finding of vegetation vs. fibrous tissue on the tricuspid valve. Chest X-ray on [**2156-2-5**] confirmed that the tip of the PICC is in a central location. 2. Sick Sinus Syndrome: Patient is s/p pacer explantation on [**1-22**]. Intra-operatively, his HR was noted to be in 30s-40s, but he was asymptomatic. He was sent to the CCU for closer bradycardia monitoring overnight after the procedure, and HR remained in the 50s with no arrhythmic events. On the medical floors, he remained with bradycardia to the 50's and sometimes 40's without symptoms. Telemetry was discontinued because patient was assymptomatic for days with this bradycardia. Patient should be considered for reimplantation of PM once infection is cleared. 3. Norovirus: Patient contracted norovirus during his hospital stay. He experienced fever to 104F, vomiting, abdominal pain, and diarrhea that all resolved in 24 hours time. His last symptom was diarrhea on the morning of [**2156-1-29**] and has been asymptomayic since. CHRONIC CARE: 1. Mental Disability: Patient has downs syndrome, and at baseline is able to respond to many questions and communicates needs well with provider. [**Name10 (NameIs) 91993**] caregivers from his group home are often with him and understands his needs. Per his mother, he has mood disturbances secondary to Down's and takes mood stabilizers; he has been stabilized on this regimen. He was continued on lithium and topomax per home regimen. He was written for oral ativan prn agitation which he rarely required as he responded to redirection very well when having episodes of agitation. . 2. Hypothyroidism: Patient was continued on home levothyroxine. . 3. Skin Care: Patient has chronic problems with skin dryness likely related to obsessive cleaning behaviors and picking at his skin. Per group home, patient's skin becomes red/irritated, and this is his baseline. He was continued on antifungal and moisurizing agents per home regimen. . TRANSITIONS IN CARE: 1. CODE STATUS: FULL CODE (mother is still thinking about this issue and will get back to us if things change) 2. CONTACTS: [**Name (NI) **] [**Name (NI) 91992**], mother and legal guardian [**Telephone/Fax (1) 91994**] (cell) [**First Name5 (NamePattern1) 4457**] [**Last Name (NamePattern1) 91995**] Nursing Supervisor at patient's group home [**Telephone/Fax (1) 91996**] 3. MEDICATION CHANGES: 1. START Daptomycin 400mg iv daily until [**2156-3-4**]. 4. FOLLOW-UP: Department: CARDIAC SERVICES When: TUESDAY [**2156-3-9**] at 12:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2156-2-10**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: MONDAY [**2156-3-1**] at 10:30 AM With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: TUESDAY [**2156-3-9**] at 12:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You should have the rehab schedule a follow-up appointment with your PCP on discharge. 5. OUTSTANDING CLINICAL ISSUES: -Patient expected to stay at rehab for less than 30 days. -Monitoring of CBC, CMP, and CPK weekly while on daptomycin -follow-up with infectious disease and cardiology Medications on Admission: Lithobid 600 mg q.h.s Buspirone 10 mg twice a day Topamax 100 mg in the morning and 50 mg in the evening Levoxyl/Synthroid 75 mg daily Metamucil two tablets daily Colace 100 multivitamins potassium 20 mEq b.i.d. folic acid 1 mg daily ferrous gluconate 325 Lamisil cream hydrocortisone ointment ketoconazole cream, Lactaid acetaminophen Eucerin cream Denorex shampoo. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - [**Location (un) 3320**] Discharge Diagnosis: Vegetative endocarditis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 91992**], It was a pleasure taking part in your care. You were admitted to the hospital because there was an infection around your pacemaker wires that extended to your heart. This type of infection requires removal of the pacemaker and wires to allow healing. The pacemaker was removed and you will need to complete a course of IV antibiotics to completely treat the remaining infection on the heart. Please make the following changes to your medications: 1. START Daptomycin 400mg iv daily until [**2156-3-4**]. Please take all other medications as previously prescribed. You will need lab work done at the outside facility and have the results faxed to the number provided. Please keep all follow-up appointments. Followup Instructions: Please have the rehab facility schedule a primary care follow-up for you on discharge. Department: CARDIAC SERVICES When: TUESDAY [**2156-3-9**] at 12:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2156-2-10**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: MONDAY [**2156-3-1**] at 10:30 AM With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: TUESDAY [**2156-3-9**] at 12:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "37.87", "37.76" ]

icd9pcs

[ [ [] ] ]

14825, 14907

8307, 12756

356, 412

14975, 14975

3522, 3527

15900, 17274

2615, 2692

14928, 14954

14433, 14802

15126, 15583

2707, 2721

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12779, 14407

286, 318

440, 2426

3541, 6379

14990, 15102

2448, 2537

2553, 2599

54,663

181,726

39775

Discharge summary

report

Admission Date: [**2116-8-28**] Discharge Date: [**2116-9-6**] Date of Birth: [**2083-6-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 603**] Chief Complaint: worsening R [**Known lastname **] weakness and foot drop for past few months w/ associated L1 spinal stenosis Major Surgical or Invasive Procedure: Posterior lumbar decompresion and fusion T12 - L2 with instrumentation History of Present Illness: REASON FOR CONSULT: pre-op clearance, HTN urgency . CC: progressive [**Known lastname **] weakness . HPI: Mr. [**Known lastname **] is a 33 yoM with right [**Known lastname **] weakness that has progressed over the last few months. He presented to the ED on [**2116-8-28**] with worsening of his symptoms over this week. It is felt to be due to L1 cona stenosis, possibly congenital. He denies bladder or bowel incontinence. In the ED, BP was 210's systolic, which was thought to be from anxiety. He has no history of HTN. He initially received PO labetalol in the ED with improvement to 170's-180's systolic. He required doses of IV hydralazine overnight with minimal effect on his BP. He was scheduled for the OR today, but his blood pressure was too elevated and the surgery was deferred until BP could be better controlled. HR has been in the 100's to 120's. This evening, after the patient triggered for systolic BP's running in the 190's to low 200's conistently throughout the day. Patient has been asymptomatic, denying headache, chest pain, shortness of breath, or hematuria. After being triggered, patient received 5mg IV metoprolol and was started on metoprolol 50mg PO BID. He also remains on IV hydralazine Q6 hours standing. When he was seen around 10pm, his blood pressure was 165/112. Prior to this, his blood pressure range for the past 24 hours has been 170/96-200/100, and his HR ranging 103-126. . Patient notes he has been quite anxious since coming into the hospital. He is extremely nervous about the surgery and has a great deal of anxiety with regard to needles and other hospital procedures. He was also quite upset about the rescheduling of his surgery earlier today. His primary team feels that at least some component of his HTN is related to his anxiety. Following the trigger, he also received IVF and has been drinking PO's. His pain is under good control with PO percocets as per the patient. Patient smokes cigarettes, but states that he doesn't think he is having nicotine withdrawal- just that he would like a cigarette because of the stress he is experiencing at present. . Mr. [**Known lastname **] notes that he has been told he has HTN in the past. He states the highest he can remember his SBP ever being is in the 150's, and that it is usually "borderline". His outpatient physician informed him that did not need to start on any medications for his blood pressure, and that they would just watch it. . ROS: Negative for CP/SOB/N/V/abdominal pain/fevers/chills/rash. Pt notes some pins and needles sensation in [**Known lastname **]. Past Medical History: -Hospitalized for severe hypokalemia 8 years ago. Pt states he has had his potassium checked intermittently and it has been normal. -Hypothyroidism (now euthyroid) -- took supplementation for 2 months -Gout -Hypertension (no medications ever prescribed) Social History: Works as a tax accountant. Smokes 15 cigarettes per day. No ETOH in one month, previously drinking "couple" drinks 3 times a week. No binge drinking since college. Smokes occasional marijuana. No other illicits Family History: Mother with hypothyroidism. No other endocrinological problems. [**Name (NI) **] family history of HTN. Father with diabetes. Grandfather died of stomach cancer, grandmother died of unknown cancer. Physical Exam: PHYSICAL EXAM: VS: T 98.6, BP 165/112, HR 91, RR 18, O2 sat 97RA GEN: NAD, mild anxiety throughout exam. Obese. HEENT: PERRLA, EOMI, MM slightly dry, OP clear, No cervical or supraclavicular lymphadenopathy. CV: Tachycardic rate, normal S1/S2, no murmurs RESP: CTA b/l ABD: +BS, soft, NTND EXT: 2+ DP and PT pulses b/l, no edema b/l, RLE w/ 4-/5 strength on straight leg, LLE w/ 4+/5 strength on straight leg. Decreased sensation to fine touch in [**Known lastname **] b/l, worse on right. SKIN: No striae. Pertinent Results: Labs on admission: [**2116-8-28**] 08:10PM BLOOD WBC-13.6* RBC-5.36 Hgb-16.1 Hct-46.6 MCV-87 MCH-30.1 MCHC-34.6 RDW-14.7 Plt Ct-204 [**2116-8-28**] 08:10PM BLOOD Neuts-70.9* Lymphs-22.3 Monos-4.4 Eos-1.3 Baso-1.1 [**2116-8-28**] 08:10PM BLOOD PT-12.8 PTT-23.8 INR(PT)-1.1 [**2116-8-29**] 08:30AM BLOOD ESR-2 [**2116-8-28**] 08:10PM BLOOD Glucose-120* UreaN-21* Creat-1.2 Na-145 K-2.9* Cl-101 HCO3-30 AnGap-17 [**2116-9-2**] 03:22AM BLOOD ALT-25 AST-17 AlkPhos-51 Amylase-31 TotBili-0.4 [**2116-8-30**] 12:49PM BLOOD CK-MB-8 cTropnT-0.03* [**2116-8-30**] 08:45PM BLOOD CK-MB-16* MB Indx-3.3 cTropnT-0.57* [**2116-8-31**] 03:19AM BLOOD CK-MB-13* MB Indx-3.0 cTropnT-0.54* [**2116-8-31**] 02:24PM BLOOD CK-MB-7 cTropnT-0.30* [**2116-8-31**] 08:59PM BLOOD CK-MB-5 cTropnT-0.25* [**2116-9-1**] 03:21AM BLOOD CK-MB-4 cTropnT-0.25* [**2116-8-30**] 08:00AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.1 [**2116-9-2**] 03:22AM BLOOD Triglyc-1 HDL-32 CHOL/HD-3.5 LDLcalc-79 [**2116-9-1**] 03:21AM BLOOD TSH-0.86 [**2116-9-4**] 07:20AM BLOOD Cortsol-7.5 [**2116-9-5**] 04:50PM BLOOD ALDOSTERONE-PND [**2116-9-5**] 04:50PM BLOOD RENIN-PND Labs on discharge: [**2116-9-3**] 10:52PM URINE METANEPHRINES, FRACTIONATED, 24HR URINE-PND [**2116-9-6**] 05:22AM BLOOD WBC-10.9 RBC-3.69* Hgb-10.9* Hct-33.2* MCV-90 MCH-29.4 MCHC-32.8 RDW-14.8 Plt Ct-326 [**2116-9-6**] 05:22AM BLOOD Glucose-113* UreaN-24* Creat-0.9 Na-141 K-4.0 Cl-107 HCO3-28 AnGap-10 [**2116-9-6**] 05:22AM BLOOD Calcium-8.7 Phos-4.6* Mg-2.1 Radiology: Renal U/S: TECHNIQUE: Renal ultrasound. FINDINGS: The right kidney measures 12.3 cm. The left kidney measures 11.3 cm. There is no evidence of hydronephrosis or perinephric fluid collection. The morphology is normal. The resistive indices range from 0.49 to 0.60. The waveforme in the main renal arteries demonstrate brisk upstroke and normal morphology. IMPRESSION: No evidence of hydronephrosis or perinephric fluid collection. Resistive indices range from 0.49 to 0.60 with brisk upstroke and normal waveforms identified. [**9-1**]: Echo: Conclusions The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is normal (LVEF>55%). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion [**8-28**] MR [**Name13 (STitle) 1093**]: IMPRESSION: Extensive degenerative changes involving T12-L1 and L1-2 levels with moderate stenosis at T12-L1 due to a disc herniation and severe stenosis at L1-2 due to diffuse disc bulging and posterior ridging. These findings are not significantly changed since the recent outside MRI. Brief Hospital Course: Assessment: 33 yoM with h/o worsening R [**Known lastname **] weakness and foot drop for past few months w/ associated L1 spinal stenosis, borderline HTN, resolved hypothyroidism, and 1 episode of hypokalemia in [**2108**] who presented to [**Hospital1 18**] for posterior lumbar fusion; course complicated by hypertension and hypokalemia #S/p Lumbar Fusion: Pt was referred for surgery after a long course of conservative treatment when he had worsening R [**Known lastname **] weakness and foot drop. His surgery was initially postponed due to hypertensive urgency with BP 200/110's. His blood pressure was treated with IV medications and the patient underwent T12/L1 bilateral laminectomy and lumbar fusion on [**8-30**]. Post-operatively, the patient again had hypertension and some ST changes on EKG. Troponins peaked at 0.57 on [**8-30**]. The patient's post-operative pain was controlled with narcotics and Tylenol. He was discharged with prescriptions for narcotics as well as physical therapy support at home. #Hypertensive Urgency: The patient reported that he had a history of borderline hypertension but that he never required medications for this. On presentation to [**Hospital1 18**], his BP was in the 200s/110s. He was treated with IV medications and post-operatively required a nitroprusside drip. The patient was discharged on a regimen of Amlodipine 10 mg qd, Labetalol 200 mg TID, Lisinopril 20 mg qd. Due to the acuity of the patient's presentation, there is concern for secondary causes of hypertension. Renal U/S showed no renal artery stenosis. Plasma levels of renin and aldosterone were pending at the time of discharge as were urine metanephrines. Serum metanephrines, however, were elevated. He was seen by endocrinology, who will follow him as an outpatient. #NSTEMI: The patient's telemetry showed ST wave changes in the PACU. EKG showed changes concerning for ischemia. Troponins returned elevated and peaked at 0.57. The patient was started on aspirin 325 mg qd, lisinopril 20 mg qd, labetalol, and simvastatin 20 mg qd. He was followed by cardiology, who wanted to do medical management. He may benefit from an outpatient stress test. #Hypokalemia: The patient reported 1 episode of hypokalemia 8 years prior that required hospitalization. The patient was admitted with K+ of 2.9 His potassium was repleted with IV and PO formulations and normalized. Renin and aldosterone levels were sent as mentioned above. #The patient received subQ heparin for DVT prophylaxis. He remained full code throughout this admission. Medications on Admission: Percocet Baclofen Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) 17g dose PO DAILY (Daily) as needed for constipation. Disp:*1 bottle* Refills:*0* 8. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:*42 Tablet Sustained Release 12 hr(s)* Refills:*0* 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for breakthrough pain. Disp:*90 Tablet(s)* Refills:*0* 10. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary: Lumbar stenosis Hypertensive Urgency Hypokalemia Secondary: Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Last Name (Titles) **], It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted for back surgery and were found to have very high blood pressure on admission. Your surgery was delayed and you were given strong IV anti-hypertensive medications. After your posterior lumbar fusion surgery, you again became very hypertensive in the recovery room and actually had a very small heart attack. This was treated with medications and you will need close follow-up with your primary care doctor who can help to manage these new medications as well as your heart disease. There are studies still pending to help us determine whether your high blood pressure is "typical" hypertension or if there is a secondary cause. Your primary care doctor will help to follow-up these results. You were also found to have very low potassium levels on admission. Your potassium level was repleted. The low level may be related to your high blood pressure, and your primary care doctor will continue to monitor this value. We made the following changes to your medication regimen: We STOPPED Percocet We STARTED Amlodipine 10 mg once per day for hypertension We STARTED Labetalol 200 mg three times per day for hypertension We STARTED Lisinopril 20 mg once per day for hypertension We STARTED Simvastatin 20 mg once per day for heart disease We STARTED Aspirin 325 mg once per day for heart disease (you can buy this medication over-the-counter) We STARTED Oxycodone SR 20 mg every 12 hours for back pain We STARTED Oxycodone 5 mg every 4-6 hours only as needed for back pain *These are high doses of narcotics and you should only take as much medication as you need to control your pain and allow you to recover* We STARTED you on Docusate Sodium 100 mg twice per day for constipation that is associated with narcotics We STARTED you on Senna 8.6 mg twice per day for constipation associated with narcotics We STARTED you on Miralax, 1 17g dose per day for constipation; you can also buy this medication over-the-counter. We also arranged for you to have help with physical therapy at home. You are allowed to use your elliptical trainer, but do not force your progress if you have pain. No bending more than 90 degress, no twisting. The information for you to make your follow-up appointments is listed below. Followup Instructions: You need to schedule 2 follow-up appointments - 1 with your primary care doctor to help manage your new blood pressure medications and 1 with Dr. [**Last Name (STitle) 1352**] who performed your back surgery. Their contact information is below. Finally, an appointment will be made for you with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in Endocrinology. If you don't hear about this appointment, you should call the [**Hospital 18**] [**Hospital 6091**] Clinic at [**Telephone/Fax (1) 1803**]. Name: [**Last Name (LF) **],[**First Name3 (LF) **] M. Location: [**Hospital1 **] HEALTHCARE - [**Hospital1 **] Address: ONE PEARL ST, [**Apartment Address(1) 12836**], [**Hospital1 **],[**Numeric Identifier 9647**] Phone: [**Telephone/Fax (1) 64296**] Appt: Dr [**Last Name (STitle) 24862**] office is closed until [**9-14**] for vacation. Please call on [**9-14**] to book a follow up appt for post hospitalization. Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] Location: Spine Center; [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **] (Adjacent to Outpatient Rehab Services) Campus: [**Hospital Ward Name 516**] Phone: [**Telephone/Fax (1) 3736**] Appointment: You should call the number above and make a post-operative appointment within the next 2-3 weeks.

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icd9cm

[ [ [] ] ]

[ "81.05", "81.62", "77.79" ]

icd9pcs

[ [ [] ] ]

11135, 11206

7374, 9930

423, 496

11325, 11325

4367, 4372

13833, 15163

3625, 3824

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11227, 11304

9956, 9975

11476, 13810

3854, 4348

274, 385

5504, 7351

524, 3103

4387, 5484

11340, 11452

3125, 3381

3397, 3609

29,806

159,709

33951

Discharge summary

report

Admission Date: [**2133-6-29**] Discharge Date: [**2133-7-3**] Date of Birth: [**2079-12-28**] Sex: F Service: PLASTIC Allergies: Sulfasalazine / Codeine / Latex Gloves Attending:[**First Name3 (LF) 16920**] Chief Complaint: Left breast cancer. Bilateral acquired absence of breast s/p mastectomy. Major Surgical or Invasive Procedure: 1. Bilateral immediate deep inferior epigastric perforator ([**Last Name (un) 5884**]) flap breast reconstruction. 2. Bilateral harvest of the deep inferior epigastric artery and vein for donor pedicle formation. 3. Bilateral fat grafting of the microvascular pedicle. History of Present Illness: Ms. [**Known lastname 78429**] is a 53-year-old woman who has a left-sided breast cancer. She also have a finding on her mammogram on the right that requires further imaging. She desired bilateral mastecomies with immediate [**Last Name (un) 5884**] flap reconstruction. Pertinent Results: [**2133-6-30**] 03:54AM BLOOD WBC-14.7* RBC-3.57* Hgb-10.4* Hct-31.4* MCV-88 MCH-29.1 MCHC-33.1 RDW-13.4 Plt Ct-222 [**2133-6-30**] 04:18AM BLOOD Glucose-154* UreaN-11 Creat-0.7 Na-140 K-4.2 Cl-109* HCO3-26 AnGap-9 [**2133-6-30**] 04:18AM BLOOD CK(CPK)-585* [**2133-6-30**] 04:18AM BLOOD Calcium-8.1* Phos-1.6* Mg-1.5* [**2133-6-30**] 04:18AM BLOOD TSH-<0.02* Brief Hospital Course: Pt is a 53 y.o. female diagnosed with bilateral breast cancer. She was admitted to [**Hospital1 18**] on [**2133-6-29**] for planned b/l mastectomy and breast reconstruction with [**Last Name (un) 5884**] flap. She tolerated the procedure well and, as planned, remained in the PACU for 24 hours post-operatively where she underwent continuous Vioptix monitoring and Q1 hour doppler checks of her right [**Female First Name (un) 899**] pulse. After 24 hours, she was admitted to the Plastic Surgery service. On POD 1, she was tolerating a regular diet and getting out of bed to chair. Her Foley catheter was removed and she voided appropriately. IVF were discontinued as she had adequate PO intake. She began ambulating on POD 2. She was also continued on Cefazolin and 121.5 mg daily of ASA per the [**Last Name (un) 5884**] pathway. Througout her course, her breasts had good color and tone, with strong doppler signals and adequate Vioptix monitoring througout her hospital course. Her abdominal incision remained C/D/I throughout. Pain: Her pain was managed initially with a PCA and then with PO Percocet She was discharged home with VNA services for social work on POD 4. Medications on Admission: listed in OMR. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO DAILY (Daily). Disp:*45 Tablet, Chewable(s)* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day for 10 days. Disp:*20 Capsule(s)* Refills:*1* Discharge Disposition: Home With Service Facility: Centrus Home Care Discharge Diagnosis: 1. Left breast cancer. 2. Bilateral acquired absence of the breast. Discharge Condition: Good. Discharge Instructions: Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If 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. Other: * 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. *No strenuous activity *No pressure on your chest or abdomen *Okay to shower, but no baths until after directed by your surgeon Followup Instructions: Please follow up with Dr. [**First Name (STitle) 3228**] on Tuesday, [**7-7**]. Call to make an appointment at ([**Telephone/Fax (1) 2868**]. Completed by:[**2133-7-4**]

[ "233.0", "174.8", "V10.83" ]

icd9cm

[ [ [] ] ]

[ "85.7", "40.23", "85.36" ]

icd9pcs

[ [ [] ] ]

3100, 3148

1356, 2538

372, 651

3260, 3268

972, 1333

4111, 4283

2603, 3077

3169, 3239

2564, 2580

3292, 4088

260, 334

679, 953

8,451

190,646

49492

Discharge summary

report

Admission Date: [**2146-10-15**] Discharge Date: [**2146-10-24**] Date of Birth: [**2095-11-26**] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: Fifty-year-old gentleman with past medical history significant for end-stage liver failure due to hepatitis C cirrhosis admitted complaining of progressive shortness of breath, ascites, and hypoxia. Patient has a history of hepatitis C cirrhosis with complications including encephalopathy, history of SBP, and multiple admissions for ascites and effusions. He was recently taken off the transplant list due to lack of social support. He most recently was admitted in [**2146-8-16**] for ascites and dyspnea, which resolved following a paracentesis. Currently, patient notes increasing shortness of breath over the previous few weeks. He also notes an increase in his ascites and mild abdominal pain. On the date of admission, he was noted to be hypoxic to 84%, shortness of breath, and was transferred to the ED from his nursing home for evaluations. In the ED, his oxygenation improved to 90-91% on 4 liters of O2. He was also orthostatic and tachycardic. His chest x-ray showed bilateral pleural effusions. He was admitted to the Medicine service for management of these symptoms. PAST MEDICAL HISTORY: 1. Hepatitis C cirrhosis. 2. History of SBP. 3. History of hepatic encephalopathy. 4. Diabetes. 5. Chronic hyponatremia. 6. Grade 1 varices. 7. Depression. 8. Psoriasis. HOME MEDICATIONS: 1. Paxil 20 q.d. 2. Lasix 40 q.d. 3. Cipro 250 q.d. 4. Aldactone 100 q.d. 5. Protonix 40 q.d. 6. Trazodone 25 q.h.s. 7. Lactulose 30 q.i.d. 8. NPH insulin 6 units b.i.d. 9. Sliding scale regular insulin. ALLERGIES: Codeine. PHYSICAL EXAM ON ADMISSION: Vital signs: Temperature 99.1, blood pressure 118/65, pulse 112, and O2 saturation 91% on 4 liters. General: Unpleasant, cachectic, middle age man in no acute distress. HEENT: Oropharynx clear. Scleral icterus, dry mucous membranes. Neck is supple. Cardiovascular: Regular rate, distant heart sounds. Lungs: Decreased breath sounds bibasilarly. Scattered crackles. Abdomen: Distended, no guarding or rebound tenderness. Dull to percussion, palpable liver and spleen tip. Neurologic: Positive asterixis. Extremities are warm and dry, no edema. Skin: Psoriatic lesions throughout body. SIGNIFICANT LABORATORIES: White count 6.3, hematocrit 33.3, platelets 29. PT 23.9, PTT 50.7, INR 3.8. Sodium 122, BUN 10, creatinine 0.3. Chest x-ray: Bilateral effusions increased in interval since last exam. HOSPITAL COURSE: 1. Respiratory failure: Patient admitted with bilateral pleural effusions, which showed an interval increase from his last x-ray. This is thought to be related to his end-stage liver disease. Patient is hypoxic on admission and was placed on oxygen. His hypoxia worsened throughout his hospitalization with an increased oxygen requirement, which correlated with an increase in his pleural effusions on chest x-ray. Patient underwent thoracentesis with drainage of approximately 1300 cc. Was sent for analysis and was consistent with a pleural effusion with no evidence of superinfection. Patient was placed on BiPAP, but continued to have significant respiratory distress. Despite the thoracentesis, he subsequently required intubation. Patient initially did not tolerate intubation and had paradoxical respirations despite sedation and trials of multiple modes of ventilation. Paralytics were to be the next step-- however the patient's family decided to withdraw care consistent with the patient's previously expressed wishes prior to initiation. 2. Hepatic failure: Patient with hepatitis C cirrhosis with end-stage liver disease. He was recently taken off the transplant list due to lack of social support. He has had progressive worsening of his hepatic function over the previous few months with multiple admissions for worsening ascites, effusions, hyponatremia, and coagulopathies. Patient was treated supportively throughout his hospital stay including therapeutic paracentesis and thoracenteses. He also received FFP and platelet infusions to support his unclotting function. His hyponatremia was also managed. Unfortunately, patient's hepatic status continued to decline and he developed multiorgan failure. He also developed hypoglycemia. Hepatology team continued to follow him throughout his hospitalization. Given his progressive hepatic function decline along with multiple organ failure, patient was felt to be in shock with end-stage liver disease and to have no further therapeutic options. Hepatology team recommended continued supportive care. 3. ID: Patient afebrile with no leukocytosis on admission. Given his significant ascites, he was placed on Levaquin and Flagyl for SBP prophylaxis. He was continued on these antibiotics throughout his hospital stay. Later in his admission, patient did develop thick yellow bilious secretions and it was thought to have aspirated in the setting of his BiPAP. Patient was continued on Levaquin and Zosyn was added for increased coverage. For his coagulopathy, his INR progressively worsened throughout his hospital stay. He received multiple units of FFP and platelets in preparation for various procedures, thought to be due to his hepatic failure. The patient was also anemic and received 1 unit of PRBC. He was not thought to be actively bleeding, and this was instead thought to be stress in the hospital setting. 4. Diabetes: Patient with type 2 diabetes on insulin as an outpatient. During the hospitalization, he was initially placed on NPH and sliding scale insulin per his outpatient regimen, however, his blood sugars progressively decreased and he had multiple hypoglycemic episodes following admission to the MICU. His insulin was held and he also received IV dextrose. His hypoglycemia was thought to be due to his hepatic failure. 5. Fluids, electrolytes, and nutrition: Patient with multiple electrolyte abnormalities due to his hepatic failure. He had decreased p.o. intake throughout his hospitalization and decreased appetite. Following his admission to the MICU and intubation, he was started on tube feeds for hydration. 6. Disposition: Patient progressively declined throughout his hospitalization and was eventually admitted to the MICU. He was intubated secondary to worsening respiratory failure. Following intubation, he became hypotensive, and was started on pressors. Patient's blood pressure continued to decline despite being on two pressors. Discussion was undertaken with the family, who felt that given the patient's poor prognosis and and lack of a reversible factor to be treated that the patient would not want continued therapy. Therefore, they requested that care be withdrawn. Pressors were withdrawn and the patient rapidly became hypotensive and then had cardiorespiratory arrest . His healthcare proxy was aware and involved throughout. Autopsy was declined. DISCHARGE STATUS: Deceased. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**] Dictated By:[**Last Name (NamePattern1) 5212**] MEDQUIST36 D: [**2147-1-16**] 14:52 T: [**2147-1-17**] 06:36 JOB#: [**Job Number 103556**]

[ "572.8", "518.84", "507.0", "286.7", "789.5", "572.4", "276.1", "070.44", "570" ]

icd9cm

[ [ [] ] ]

[ "93.90", "54.91", "34.91", "96.71", "38.91" ]

icd9pcs

[ [ [] ] ]

2559, 7305

1470, 1711

165, 1259

1726, 2542

1281, 1452

81,719

182,771

7033

Discharge summary

report

Admission Date: [**2102-6-17**] Discharge Date: [**2102-6-30**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2817**] Chief Complaint: Abd pain Major Surgical or Invasive Procedure: Hemodialysis catheter Continuous Venous Venous hemodialysis Arterial line triple lumen catheter Nasogastric tube PICC Foley Catheter History of Present Illness: 88-year-old man, with diabetes, CAD, status post MI over a decade ago, hypertension, hyperlipidemia, peripheral vascular disease p/w abdominal tightness. It started around 730 pm when the pt was sitting watching TV. It resolved by itself within 5 mins. However it reappeared when the pt was in the ER and this time lasted abt 10 minutes. No SOB/dizzy/palps. In the emergency department, initial vitals:98.2 66 132/80 18 100/ra. In the ED he recd ASA 325, SL NTG x 1, zofran x 1. Dropped SBP to 80s after SL NTG. Recd 2L IVF and SBP back to 110s. First set of enzymes was neg. CXR was WNL. On the general medicine floor this am, he was found to have SBP 78/palp, felt nausea, vomited 400cc dark brown mixed w/ food. Gastoccult positive, guiac positive w. rectal exam of dark brown stool. Started PPI bolus and gtt. AM labs returned with HCT of 31.7 down from 33.7 after IVF, INR 3.1. GI aware. He also received 10mg po Vit K. VS at time of transfer BP 80-100 systolic, HR 70, afebrile, 98% on Ra. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: CAD, status post MI over a decade ago hypertension hyperlipidemia peripheral vascular disease with bilateral carotid endarterectomies BCC Systolic HF, EF 25-30% in 04 w/ severe AK/HK (on coumadin) Social History: He is a retired fireman, lives in [**Location (un) 538**] with his wife. Married 55 years. Grown children. No smoking. No alcohol consumption. Family History: NC Physical Exam: Vitals: T: 98.6 BP:108/57 P:87 R: 20 O2: 97% on 2L NC General: Alert, mentating well, does not appear acutely ill, appears younger than stated age HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: JVP not elevated 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: [**2102-6-17**] 08:50PM GLUCOSE-161* UREA N-48* CREAT-2.4* SODIUM-139 POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15 [**2102-6-17**] 08:50PM CK(CPK)-50 [**2102-6-17**] 08:50PM cTropnT-<0.01 [**2102-6-17**] 08:50PM CK-MB-3 [**2102-6-17**] 08:50PM WBC-6.2 RBC-3.88* HGB-11.2* HCT-33.1* MCV-85 MCH-29.0 MCHC-33.9 RDW-14.2 [**2102-6-17**] 08:50PM NEUTS-60.5 LYMPHS-27.2 MONOS-7.5 EOS-4.3* BASOS-0.5 [**2102-6-17**] 08:50PM PLT COUNT-243 [**2102-6-17**] 08:50PM PT-26.2* PTT-27.9 INR(PT)-2.5* . [**2102-6-17**] ECG: Sinus rhythm. Left bundle-branch block. Compared to the previous tracing of [**2098-6-3**] no diagnostic change. . [**2102-6-21**] ECG: Sinus rhythm with atrial ectopic activity versus atrial fibrillation with rapid ventricular response. Left bundle branch block Possible inferior infarct - age undetermined. Lateral ST elevation, CONSIDER ACUTE INFARCT. Since previous tracing of [**2102-6-20**], the heart rate is faster, irregular rhythm, atrial ectopic activity or atrial fibrillation now present. Clinical correlation is suggested. . [**2102-6-22**] ECG: Sinus rhythm. Left bundle-branch block. Compared to the previous tracing of [**2102-6-22**] the rhythm is now sinus. . [**2102-6-17**] CXR: No acute pulmonary process. . [**2102-6-19**] CXR: Bilateral infrahilar opacification, left greater than right, which has worsened since [**6-17**] is stable since [**6-18**], probably atelectasis, conceivably aspiration. Upper lungs clear. Heart size normal. No pulmonary edema. No appreciable pleural effusion or pneumothorax. Left jugular line tip projects over the junction of the brachiocephalic veins. Nasogastric tube ends in the upper stomach. Heart size top normal. . [**2102-6-22**] CXR: Lung volumes are lower. Cardiomediastinal silhouette is unchanged. Bilateral bibasal opacities greater on the left side have increased on the left probably due to atelectasis and or aspiration. There is no pneumothorax. The left IJ catheter remains in place. NG tube has been removed. . [**2102-6-22**] CXR: Right PICC terminates in the mid SVC. Minimally increased right upper lung opacity may represent evolving infectious process or increasing atelectasis. Otherwise little change since [**05**] hours prior. . [**2102-6-19**] TTE: The left atrium is mildly dilated. The interatrial septum is aneurysmal. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe regional left ventricular systolic dysfunction with near akinesis of the distal 2/3rds of the ventricle (LVEF 25%). No aneurysm or thrombus is seen. Right ventricular chamber size and free wall motion are normal. 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. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left vevntricular cavity size with extensive regional systolic dysfunction c/w multivessel CAD. Moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Compared with the report of the prior study (images unavailable for review) of [**2097-1-7**], the severity of mitral regurgitation and the estimated pulmonary artery systolic pressure have increased. Left ventricular systolic function is similar. . [**2102-6-18**] Liver/Gallbladder U/S: 1. Gallbladder filled with sludge and stones with moderate wall thickening. The findings are equivocal for acute cholecystitis and if there is continued concern, consider HIDA scan for further evaluation. 2. Echogenic liver consistent with fatty infiltration. However, other forms of liver disease and more advanced liver disease (ie hepatic fibrosis/cirrhosis) are not excluded. . [**2102-6-20**] Liver/Gallbladder U/S: 1. Mildly improved appearance of the gallbladder, containing sludge, with mild wall thickening. No specific sign of cholecystitis or biliary dilatation. 2. Increased hepatic echogenicity as previously seen. 3. Right pleural effusion. . LFT TREND: Brief Hospital Course: This is a 88 yo M admitted for abdominal pain and hypotension, transferred to the unit for evaluation of new UGI bleed in setting of anticoagulation. # Hypotension/Shock. Felt initially to be hypovolemia in setting of GIB and poor po intake. He received IVF and blood (4 units total) and hcts remained stable. Patient also with poor CO (EF 25%) and some concern for cardiogenic shock so IVF given conservatively after initial boluses in ED. Patient then developed rapid AF and had MAPs in 40s. He was started on neosynephrine with good result. Digoxin was started as below and when patient remained in NSR BPs were in 110s/60s and the neo was turned off. In the setting of the hypotension he did develop ARF and ALF as noted below. After initiation of CVVH, hypotension continued and mental status deteriorated. Goals of care were transitioned to comfort measures after discussion with his family and he died less than 24 hours after CVVH was discontinued. Family and PCP were notified. Family declined autopsy. # Coffee ground emesis - Thought likely upper GI source in setting of therapeutic INR, ddx included PUD, ASA-induced gastritis, malignancy. Gi was consulted and wanted to perform EGD when INR< 2. He was given FFP and INR decreased however Hct remained stable after 2units pRBCs and he did not have further emesis so scope was deferred. Hct continued to remain stable and GI eventually decided to have EGD as o/p. He was on PPI gtt X 72 hours then transitioned to IV and later PO BID. His diet was advanced slowly. Coumadin and ASA were held. # Afib with RVR: Patient developed AF with RVR after a few days of hospitalization. With this arrhythmia he developed hypotension. Given his ARF and ALF medication options were limited. His cardiologist was consulted and recommended a digoxin load with close follow up of digoxin levels. He was started on digoxin with good effect and remained mostly in NSR. Eventually metoprolol was introduced and titrated up to help control rate. The AFib again became difficult to treat after patient initiated CVVH. # Shock Liver: Patient noted to have supratherapeutic INR on admission. LFTs rose steadily. RUQ U/S showed patent vessels. Patient was treated for hypotension as above. Liver team was consulted and felt it was consistent with shock liver. Hepatitis serologies were negative. He devleoped ~1 day of encephalopathy treated with lactulose. This resolved. His LFTs began to trend down, however the t-bili continue to rise throughout his stay. # Acute Renal Failure: Baseline Cr around 2.0 however rose steadily to 4.8 in setting of hypotension. Renal felt likely [**2-6**] hypoperfusion. IVF did not improve the creatinine. Renal discussed with son the potential need for hemodialysis and given his rising BUN to 155 on [**6-26**], the decision was made to intiate CVVH. On CVVH he required vasopressors and his mental status continued to deteriorate. As above, decision was made to transition to comfort measures and CVVH was discontinued. # Heart Failure: most recent EF 25% with severe hypokinesis. Has been anticoagulated with coumadin to prevent intra-ventricular thrombus formation. Coumadin was held on admission given GIB and supratherapeutic INR. Cardiology was consulted for AF with RVR and suggested starting dig and metoprolol for this. TTE showed stable EF with slightly worse MR and PAH. He tolerated modest amounts of IV fluids. #DM: Held home glyburide and was kept on ISS while hospitalized. Medications on Admission: At home EZETIMIBE [ZETIA] - 10 mg qd GLYBURIDE 5 mg one Tablet(s) by mouth qam, 0.5 tab po qpm HYDROCHLOROTHIAZIDE - 12.5 mg qd ISOSORBIDE MONONITRATE - 30 mg Sustained Release qd METOPROLOL SUCCINATE [TOPROL XL] - 50 mg qd PRAVASTATIN [PRAVACHOL] - 40 mg qd QUINAPRIL - 40 mg qd WARFARIN [COUMADIN] - 5 mg Tablet - 1/2-1 Tablet(s) by mouth daily take one tab 4 days a week and [**1-6**] taab on Tue, Th and Sat ASPIRIN - (OTC) - 81 mg qd ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - Dosage uncertain On transfer: Ezetimibe 10 mg PO DAILY Insulin SC (per Insulin Flowsheet) Sliding Scale Ondansetron 4 mg IV ONCE Pantoprazole 80 mg IV BOLUS plus 8 mg/hr IV DRIP Phytonadione 10 mg PO ONCE Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Pravastatin 40 mg PO DAILY Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Systolic Heart Failure Gastrointestinal Bleed Acute hemorrhagic shock Cardiogenic shock renal failure shock liver atrial fibrillation with rapid ventricular rate Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "39.95", "99.07", "38.93", "99.04", "38.95", "38.91" ]

icd9pcs

[ [ [] ] ]

11335, 11344

6986, 10462

271, 406

11550, 11561

2809, 6963

11614, 11622

2228, 2232

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11365, 11529

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1452, 1831

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434, 1433

1853, 2051

2067, 2212

28,221

190,351

9063

Discharge summary

report

Admission Date: [**2180-1-17**] Discharge Date: [**2180-1-21**] Date of Birth: [**2117-3-6**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[**First Name3 (LF) 1505**] Chief Complaint: Exertional chest pain and shortness of breath Major Surgical or Invasive Procedure: [**2180-1-17**] - CABGx3 (left internal mammary artery->left anterior descending artery, Saphenous vein graft->Diagonal artery and Saphenous vein graft->Right coronary artery). History of Present Illness: Mr. [**Known lastname **] is a 62-year-old gentleman with a history of coronary artery disease following ST elevation myocardial infarction in [**2179-6-6**]. He underwent PCI stenting to his left anterior descending artery and diagonal. In [**Month (only) **] of the same year he underwent repeat cardiac catheterization for recurrent complaints of chest pain. This catheterization revealed an 80% in-[**Month (only) **] re-stenosis of the bare metal [**Month (only) **] in his pyramidal [**Month (only) **] in his mid LAD. He underwent restenting with a drug-eluding [**Month (only) **] which was placed inside his bare metal [**Month (only) **]. Despite PCI standing and medical therapy, he continued to complain of exertional angina and he was then referred for surgical revascularization. Past Medical History: Hypertension Hyperlipidemia STEMI in [**2179-6-10**] s/p diagonal PTCA and LAD stenting Gout s/p surgical removal of foot deposits Psoriasis History of sciatica from damaged disc Spontaneous PTX as a teenager Social History: Social history is significant for the the absence of current tobacco use (the patient quit 30 years ago). There is no history of alcohol abuse (patient drinks 1 glass of red wine a night). Works as a market communications manager at a tech firm in [**Location (un) **]. Divorced, lives alone in [**Location (un) 31315**] and works in [**Location (un) **]. has 2 grown children. Family History: There is a family history of premature coronary artery disease or sudden death (father had an MI in his 50s and brother had sudden death while mowing the lawn in his early 60s.) Physical Exam: Admission VS BP 135/84 HR 77 RR 16 O2sat 100% on RA Gen: WDWN middle aged male in NAD. Oriented x3. AOx3 HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with no significant JVP. No carotid bruits. CV: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. LUNGS: CLear Abd: Soft, NTND. No HSM or tenderness. No guarding or RT. Ext: Trace lower extremity edema. DPs, PTs 2 + BL. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Discharge VS T 99 BP 116/76 HR 88 SR RR 20 O2sat 96%-RA Gen NAD Neuro A&Ox3, nonfocal exam Pulm CTA bilat CV RRR, sternum stable. Incision CDI Abdm soft, NT/+BS Ext warm, well perfused. Trace edema bilat Pertinent Results: [**2180-1-17**] 11:14AM HGB-13.0* calcHCT-39 [**2180-1-17**] 11:14AM GLUCOSE-112* LACTATE-1.4 NA+-140 K+-4.0 CL--108 [**2180-1-17**] 02:28PM FIBRINOGE-137* [**2180-1-17**] 02:28PM PT-15.0* PTT-25.4 INR(PT)-1.3* [**2180-1-17**] 02:28PM PLT COUNT-129* [**2180-1-17**] 02:28PM WBC-10.4# RBC-2.38*# HGB-8.6*# HCT-23.3*# MCV-98 MCH-36.0* MCHC-36.8* RDW-13.5 [**2180-1-17**] 04:16PM UREA N-15 CREAT-0.9 CHLORIDE-113* TOTAL CO2-26 [**2180-1-21**] 06:04AM BLOOD WBC-8.0 RBC-2.58* Hgb-9.2* Hct-25.2* MCV-98 MCH-35.7* MCHC-36.5* RDW-15.8* Plt Ct-188 [**2180-1-21**] 06:04AM BLOOD Plt Ct-188 [**2180-1-17**] 04:16PM BLOOD PT-14.0* PTT-30.6 INR(PT)-1.2* [**2180-1-21**] 06:04AM BLOOD UreaN-21* Creat-1.2 Na-141 K-3.9 ========================================================= [**2180-1-17**] ECHO Pre Bypass: The left atrium is normal in size. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) 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 Bypass: Preserved biventricular function. LVEF >55%. MR remains 1+. Aortic contours intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. ============================================================= [**Known lastname 259**],[**Known firstname 7167**] M [**Medical Record Number 31316**] M 62 [**2117-3-6**] Radiology Report CHEST (PA & LAT) Study Date of [**2180-1-21**] 12:56 PM [**Hospital 93**] MEDICAL CONDITION: 62 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pneumothorax No pneumothorax. Stable appearance of the chest. Final Report REASON FOR EXAMINATION: Followup of a patient after CABG. PA and lateral upright chest radiograph was compared to prior study obtained the same day earlier at 09:58 a.m. The right internal jugular line tip is in the mid low SVC. The post-sternotomy wires are stable. The cardiomediastinal silhouette is unchanged. There is no interval change in the small left pleural effusion and right middle lobe atelectasis. There is no evidence of pneumothorax. There is no evidence of failure. DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**] Approved: [**First Name9 (NamePattern2) **] [**2180-1-21**] 3:11 PM = ================================================================ Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2180-1-17**] for surgical management of his coronary artery disease. He was taken directly to the operating room where he underwent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Within 4-5 hours, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was extubated. On postoperative day one, Mr. [**Known lastname **] was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Mr. [**Known lastname **] developed rapid atrial fibrillation which was treated with amiodarone and an increase in his beta blockade, he converted back to sinus rhythm. The remainder of his post-operative course was uneventful. On POD 4 he was discharged home with visiting nurses. Medications on Admission: Toprol 100mg daily Pravachol 80mg daily Allopurinol 100mg daily Lisinopril 10mg daily Norvasc 5mg daily Enbrel weekly Plavix 75mg daily Aspirin 325mg daily Discharge Medications: 1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:*50 Tablet(s)* Refills:*0* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x5 days then 400mg QD x5 days then 200mg QD. Disp:*60 Tablet(s)* Refills:*1* 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 12. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Discharge Disposition: Home With Service Facility: Diversified VNA and hospice Discharge Diagnosis: CAD s/p CABGx3 h/o STEMI h/o Angioplasty and stenting HTN Hyperlipidemia Gout Psoriasis Sciatica Spontaneous pneumothorax in past Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: [**Hospital 409**] clinic in 2 weeks Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) **] on [**2180-2-1**] at 11:20AM. [**Telephone/Fax (1) 62**] Please follow-up with Dr. [**Last Name (STitle) **] in [**2-9**] weeks. [**Telephone/Fax (1) 30445**] Call all providers for appointments. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2180-2-1**] 11:20 Completed by:[**2180-1-21**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8650, 8708

5881, 6915

319, 498

8882, 8889

3045, 4977

9666, 10249

1966, 2145

7121, 8627

5017, 5042

8729, 8861

6941, 7098

8913, 9643

2160, 3026

234, 281

5074, 5858

527, 1322

1344, 1554

1570, 1950

6,760

169,418

49598

Discharge summary

report

Admission Date: [**2101-7-29**] Discharge Date: [**2101-8-10**] Date of Birth: [**2046-12-1**] Sex: M Service: NMED HISTORY OF PRESENT ILLNESS: This is a 54 year-old gentelman with new onset of gait unsteadiness and symptoms of bumping into things on the left. The patient had a lot of pain in the neck and the left shoulder thought to be due to a left C6-7 radiculopathy. Surgery had been planned. On the day prior to admission he had some shoulder pain and then taken a Percocet. A little later while talking on the phone a friend noted that his speech was slurred. Before going to bed he found himself missing some keys while typing. The following morning as he was getting out of bed he found himself unsteady on his feet and kept bumping into things on the left side. These symptoms brought him to the Emergency Room. PAST MEDICAL HISTORY: Significant for hypertension and recurrent deep venous thrombosis initially in [**2097**] both of which were treated temporarily with Coumadin. There was also a history of an irregular heart rate (? Paroxysmal atrial fibrillation) following knee surgery some years ago. PRESENT MEDICATIONS: Mavic, baby aspirin, Percocet and Celebrex. ALLERGIES: Penicillin unknown reaction. SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] denies the use of tobacco and drinks an occasional alcohol. PHYSICAL EXAMINATION: Blood pressure 170/80. Heart rate 80s. Temperature 98.6. Respiratory rate 16. HEENT normocephalic, atraumatic. Sclera white. Oropharynx clear without lesions. Mucous membranes are moist. Neck was supple. No jugulovenous distention or bruits. Lungs were clear to auscultation bilaterally. Cardiovascular examination he had a regular rate and rhythm. He had a 2 out of 6 systolic ejection murmur that was heard at the left upper sternal border without radiation and no gallops or rubs. Abdomen was normal bowel sounds, soft, nontender, nondistended. No hepatosplenomegaly. Extremities showed no clubbing, cyanosis or edema. Neurological examination he was awake, alert, oriented and attentive. There was no anomias. Speech was fluent. He follows commands and could repeat and do a normal clock and cue. Pupils were symmetrical and reactive and there was no RAPD. Pursuit was full and without diplopia or nystagmus, saccadic velocity was slow toward left and saccadic to the left were hypermetric. There was no visual field defect even with testing with a small red object. There was no visual extinction. Facial sensation was intact. Face was strong. Tongue and palette moved normally. Muscle bulk was normal and there was no pronator drift. There was a subtle left hemiparesis with mild weakness on shoulder abduction, elbow extension, finger extension, hip flexion and knee flexion on the left. There was also mild ataxia on the left that seemed disproportionate to the degree of weakness. Reflexes were all present and symmetrical and plantars were both flexed and sensation was normal. LABORATORY TESTING: Normal CBCs, coags, chem 7, liver enzymes and urinalysis. MRI in the Emergency Room showed two areas of abnormal signal within the right occipital and right temporal lobe. There was also substantial susceptibility effect within the center of these lesions. There was also marked surrounding edema. On the susceptibility images there was also very dark signal at the confluence of the sinuses. HOSPITAL COURSE: This is a 54 year-old gentleman who presented with gait unsteadiness and difficulty seeing objects out of his left visual field. His examination demonstrated left sided upper motor neuron weakness and ataxia. The nature and etiology of these lesions were initially unclear. The neurology team first considered metastatic deposits versus venous infarcts. An MRV and CT of the chest, abdomen and pelvis were normal aside from some evidence of some chronic pancreatitis. A repeat MRI of the brain with contrast revealed ring enhancement of his lesions with edema suggesting neoplasm versus abscesses. Within 24 hours his left arm and leg weakness had worsened and he was placed on Decadron. Neurosurgery was consulted and they resected the large occipital lesion, which proved on gross inspection to be an abscess. The other lesion was too deep for resection. He was placed on Vancomycin, Levaquin and Flagyl. Streptococci milleri and anaerobic gram negative rods grew from the microbiological specimens. Penicillin is the first line of choice for this streptococci he had a documented allergy to this antibiotic. An allergy consult was obtained and he had no observed reaction to Penicillin skin testing. However, the patient was ultimately changed to Ceftriaxone and maintained on Flagyl. They attempted to determine a possible infectious source. A transesophageal echocardiogram did not find a vegetation or ASD. A urine culture and numerous blood cultures were negative. He remained afebrile. After returning from surgery he was maintained on Decadron and his strength in his left arm and leg gradually improved to the point where he had 4+ strength in the triceps and biceps, 5 in the wrist extensors and 5 in the left leg. He did not have a visual field cut, but he did extinguish to double simultaneous stimulation on the left. He also had one episode where he complained about abnormal movements of his left arm reminiscent of alien hand. The abnormal movement was a transient event and did not suggest seizure activity. While in house he also passed a less then 5 mm kidney stone originally visualized on the right ureterovesicular junction. The patient stated that he had gout and his uric acid was 7.1 (upper end of normal). His specimen was sent to the pathology laboratory. He was aggressively hydrated and given pain medication. A urology consult did not suggest any further workup. His creatinine was 1.0 on the day of discharge. He will follow up in the [**Hospital 878**] Clinic ([**Doctor Last Name **] and [**Doctor Last Name **]) and also in the Infectious Disease Clinic. He is to complete a six week course of antibiotics and he will be discharged to [**Hospital3 7**]. DISCHARGE MEDICATIONS: Ceftriaxone 2 grams intravenous q 12 times six weeks, Flagyl 500 mg intravenous q 8 times six weeks, Toradol 10 mg po q 4 to 6 hours prn for pain. Protonix 40 mg po q day. Mavic 2 mg po q day. Decadron 6 mg po q 6. The patient should be tapered off of his Decadron according to recommendations by neurosurgery. DISCHARGE DIAGNOSIS: Brain abscesses. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. [**MD Number(1) 11772**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2101-8-10**] 10:31 T: [**2101-8-10**] 12:54 JOB#: [**Job Number 10642**]

[ "592.0", "530.81", "274.9", "401.9", "577.1", "324.0" ]

icd9cm

[ [ [] ] ]

[ "88.72", "01.31" ]

icd9pcs

[ [ [] ] ]

6202, 6517

6538, 6834

3459, 6178

1405, 3441

162, 849

872, 1253

1270, 1382

19,731

157,854

7660+7661

Discharge summary

report+report

Admission Date: [**2145-1-27**] Discharge Date: [**2145-2-5**] Date of Birth: [**2089-9-20**] Sex: M Service: ICU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 55-year-old gentleman with a history of coronary artery disease, hypertension, hypothyroidism and chronic back pain who was found unconscious on [**2145-1-25**] by his roommate. EMT was called and the patient was admitted to [**Hospital6 10443**]. It was thought that a syncope was secondary to narcotic overuse and subsequent rhabdo and renal failure. He soon developed hypotension, hypoxia, bilateral infiltrates and Staph aureus bacteremia. The patient was started on dopamine, intubated and then transferred to [**Hospital1 346**] in [**Location (un) 86**]. As per patient's son and wife, he had several falls at home in [**Month (only) **]. Since discharged from rehab in [**2144-11-4**], the patient has been weak at home. On [**1-18**] of this year, he developed severe back pain and right leg pain. He self increased his doses of methadone and became lethargic and confused. PAST MEDICAL HISTORY: 1. His past medical history is significant for coronary artery disease status post cath on [**2144-9-9**], complicated by a right groin hematoma. LAD stent was 95%, mid-LAD lesion. 2. Chronic back pain. 3. Hypothyroidism. 4. Hypertension. 5. Non-Hodgkin's lymphoma status post chemo and XRT. 6. Prostate CA status post prostatectomy. 7. Nephrolithiasis. 8. Right salivary gland excision. 9. Peyronie's disease. 10. Dupuytren's contracture. ALLERGIES: The patient has no known drug allergies. MEDS PRIOR TO ADMISSION: Hydrocodone, Vioxx, methadone, Neurontin, Motrin, Protonix, Restoril, Plavix, Mavik, Lasix, Lipitor, meclizine, Levoxyl, Detrol, Ditropan, DDAVP, amitriptyline and Robitussin. MEDS ON TRANSFER: Ceftriaxone, vancomycin, Ativan, morphine. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Thirty pack a year of tobacco, quit in [**2134**]. Lives with roommate, separated from wife, but was not divorced, on good terms. Has a son. PHYSICAL EXAM: T-max 99, pulse 105, blood pressure 112/63, respiratory rate 20, satting 100% on FIO2 of 0.6. CVP at 12, his dopamine was discontinued, ........... off. He was on a Versed and fentanyl drip at the time of arrival. Physical exam is significant for no JVP, intubated, enlarged thyroid, pupils equal round and reactive to light. S1-S2: No murmurs, rubs or gallops. Lungs showed diffuse bronchi bilaterally. Abdomen was obese, soft, nontender, decreased bowel sounds. Extremities showed anasarca, 2+ dorsalis pedis pulses and left hip ecchymoses. LABS ON TRANSFER: White count 14.0, hematocrit 30.7, platelets 158. Coags: INR 2.6, PTT 34.2. Chem 7 normal. BUN, creatinine 70 and 2.1. ALT 83, AST 183. CK 2286, had been in the 6000s. Chest x-ray showed bilateral pulmonary infiltrates. EKG showed sinus tachycardia at 100 beats per minute. Left axis, right bundle-branch block incomplete as per outside hospital. Had CT negative and abdominal and pelvic CT negative. Blood and cultures in the outside hospital showed 2/2 bottles positive for Staphylococcus aureus. HOSPITAL COURSE BY SYSTEMS: 1. The patient was admitted to the [**Doctor Last Name **] ICU for presumed staph pneumonia, staph sepsis, staph bacteremia. He was covered with vancomycin. Impaired Gram-negative coverage with levofloxacin was continued. Sputum cultures on [**2145-1-28**] grew out MRSA as did those from [**2145-2-2**]. At the time of discharge from the intensive care unit, the patient had no positive blood cultures. CT of the chest, abdomen and pelvis revealed no evidence of epidural or abscess or spinal osteo. Evaluation in the lower lumbar spine was limited by beam hardening from the metallic plate and screws. Also, significant for multi-focal pneumonia, diffuse fatty infiltration of the liver. He had an echocardiogram on [**2145-1-29**] revealing normal systolic function and no evidence of vegetation on transthoracic. The patient was extubated on [**2145-2-4**]. 2. Renal: Creatinine was 2.1 on arrival. The patient was given adequate hydration and with improved hemodynamics, creatinine was 0.4 at the time of discharge from the unit. 3. Pain medications given as chronic narcotics and pain syndrome as an outpatient: He required a great deal of narcotics to keep him comfortable in the ICU. However, upon weaning of his sedation, he woke up easily and was extubated without difficulty. The patient was sent to the floor on [**2145-2-5**] in good condition. DISCHARGE DIAGNOSES: 1. Staph pneumonia. 2. Staph bacteremia. 3. Chronic pain. MEDICATIONS ON TRANSFER: Vancomycin, Reglan, Senna, Thiamine, , aspirin, levothyroxine, Plavix, heparin, Lansoprazole, fentanyl patch, Lopressor and Tylenol. ADDENDUM: 1. The patient was noted to have positive troponins during this admission that were trending down at the time of discharge, felt to be due to demand ischemia setting of hypertension and pressors. 2. Swallow study: The patient had a bedside swallow study which he did not pass. He was felt to be safe to eat pills and custard only. He was therefore made NPO except for medication at the time of discharge from the floor. He remained full code. He was transfused two units in the ICU. [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**] Dictated By:[**Last Name (NamePattern1) 2396**] MEDQUIST36 D: [**2145-2-6**] 00:17 T: [**2145-2-7**] 04:11 JOB#: [**Job Number 27870**] Admission Date: [**2145-1-27**] Discharge Date: [**2145-2-18**] Date of Birth: [**2089-9-20**] Sex: M Service: ACOVE Medicine HISTORY OF PRESENT ILLNESS AND SUMMARY OF HOSPITAL COURSE IN THE INTENSIVE CARE UNIT: Patient is a 55-year-old man with history of coronary artery disease status post catheterization with left anterior descending stents, chronic back pain status post multiple surgeries, hypothyroidism, hypertension, non-Hodgkin's lymphoma status post chemotherapy and radiation, prostate cancer status post prostatectomy, and nephrolithiasis, transferred to [**Hospital1 18**] on [**1-28**] from outside hospital, where he was intubated for respiratory distress after being found to have multilobar pneumonia, acute renal failure, rhabdomyolysis, methicillin-sensitive Staph aureus bacteremia. Patient initially was brought to the outside hospital after being found on the floor of his apartment bathroom, and he had been on the floor for an unknown period of time, but not more than seven hours. Cause of the patient being on the floor was thought to be either accidental drug overdose as the patient was on chronic narcotics for lower back pain or sepsis. Upon admission to the Intensive Care Unit at [**Hospital1 18**] on [**2145-1-27**], the patient was febrile, hypotensive, and hypoxic requiring pressors and ventilatory support. His white blood count was elevated and he was also in acute renal failure, but his creatinine was already trending down from 4.1 at the outside hospital to 2.1 upon admission here. Patient was initially on Vancomycin and levofloxacin for broad coverage given his persistent fevers. Workup for the source of his bacteremia was undertaken with CAT scan of the torso without evidence of abscess or osteomyelitis, although lumbar spine imaging was suboptimal due to the patient's metallic hardware. The CAT scan did show multilobar pneumonia and bilateral pleural effusions. Echocardiogram on [**1-30**] showed no evidence of vegetations, left ventricular ejection fraction of 59% and no focal wall motion abnormalities. The patient's antibiotic regimen was switched numerous times in the Intensive Care Unit, but eventually changed to just Vancomycin after a negative workup and after the patient's sputum grew methicillin-resistant Staphylococcus aureus. Patient's acute renal failure resolved with aggressive hydration. Patient was extubated on [**2-4**] and transferred to the Medicine floor on [**2-5**]. PAST MEDICAL HISTORY: 1. Coronary artery disease status post catheterization and stent to the left anterior descending artery in [**2144-2-5**]. 2. Chronic back pain status post multiple surgeries. 3. Hypothyroidism. 4. Hypertension. 5. Non-Hodgkin's lymphoma status post chemotherapy and radiation 10 years ago. 6. Prostate cancer status post prostatectomy. 7. Nephrolithiasis. 8. Right salivary gland excision. SOCIAL HISTORY: Patient lives with his partner, who is also married, but separated. Patient has a grandchild. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: 1. Vioxx 25 once a day. 2. Methadone 10 b.i.d. 3. Neurontin 300 q.d. 4. Motrin 800 t.i.d. 5. Protonix 40 q.d. 6. Restoril 1-2 tablets q.h.s. 7. Plavix 75 q.d. 8. Mavik 2 q.d. 9. Lasix 40 q.d. 10. Meclizine 12.5 t.i.d. 11. Levoxyl 0.225 q.d. 12. Detrol LA 4 mg q.h.s. 13. Ditropan XL. 14. DDAVP 2 mg q.h.s. 15. Amitriptyline. 16. Robitussin prn. PHYSICAL EXAM ON ADMISSION TO THE [**Hospital1 18**] INTENSIVE CARE UNIT: Temperature 99.0, heart rate 105, blood pressure 112/63, satting 100% on ventilator. General: Patient was intubated, sedated, middle-aged male. Skin: Left hip ecchymosis. HEENT: Pupils are equal, round, and reactive to light. Oropharynx clear. Moist mucous membranes, no lymphadenopathy, supple neck, thyromegaly. Heart: S1, S2 with no murmurs. Lungs: Diffuse rhonchi bilaterally. Abdomen is soft, nontender, nondistended, decreased bowel sounds. Extremities: 2+ pulses, anasarca with 3+ pitting edema in all extremities. Neuropsych: Sedated, unable to fully assess. PERTINENT DIAGNOSTICS ON ADMISSION TO THE [**Hospital1 18**] INTENSIVE CARE UNIT: White blood cell count 14, hematocrit 30.7, platelets 158. INR of 2.6. PT 19.6, PTT 34.2. Chemistries within normal limits except BUN and creatinine of 70/2.1. ALT 83, AST 182, CK 2286. CONCISE SUMMARY OF HOSPITAL COURSE ON THE MEDICINE FLOOR: See history of present illness above for details of the course in the Intensive Care Unit. 1. Infectious disease/pulmonary: Upon transfer to the medicine floor, the patient was afebrile without significant respiratory symptoms for the remainder of his hospital stay. As described in the history of present illness above, the patient was extubated on [**2145-2-4**], and was satting well on nasal cannula and then on room air by [**2-8**]. Patient with sputum that was methicillin-resistant Staphylococcus aureus positive. CAT scan in the ICU showed multilobar pneumonia. Patient also reported with methicillin-sensitive Staph aureus bacteremia at the outside hospital. Patient's white blood count trended down and was within normal limits by the time he was transferred out of the Intensive Care Unit. Infectious Disease was consulted and followed the patient throughout his hospital stay. Infectious Disease workup in the Intensive Care Unit was done as outlined in the history of present illness including CAT scan of the torso, echocardiogram, and blood cultures. On the medicine floor, MRI of the spine with and without contrast showed no evidence of abscess or osteomyelitis, but the study is limited by metallic lumbar spine hardware. MRI of the head with and without contrast showed bilateral subdural hematomas without enhancing lesions or acute hemorrhage. Surveillance blood cultures did not grow bacteria. The subclavian catheter tip was sent for culture and did not grow any bacteria either. A transesophageal echocardiogram was completed on [**2145-2-16**] to evaluate for endocarditis and showed no evidence of valvular vegetations, left ventricular ejection fraction greater than 55%, normal wall motion, normal cavity sizes. Patient was continued on Vancomycin, which was restarted on [**2-1**], which he tolerated well. Vancomycin peak and trough serum levels were tested and were at target, so the patient was continued on his current dosing. Per Infectious Disease recommendations, plan to continue the Vancomycin for at least a six week course. Patient has an appointment with Infectious Disease Clinic at [**Hospital1 18**] on [**2145-3-9**] at which time they are decide on whether to discontinue antibiotics after six weeks or if longer course is necessary. Patient's central line was removed. A PICC line was placed for IV antibiotic administration. 2. Rhabdomyolysis: Creatine kinases reported in the 6,000s at the outside hospital, but had decreased to 2,286 upon transfer to [**Hospital1 18**] after hydration. Patient's CKs trended down to within normal limits by the time of transfer to the Medicine floor from the ICU, and the patient denied muscular pain at that time. 3. Acute renal failure: Patient's acute renal failure resolved with hydration in the Intensive Care Unit and BUN and creatinine remained within normal limits the remainder of his hospital stay. An ACE inhibitor was restarted on the Medicine floor, and was tolerated well. Patient also received nonsteroidal anti-inflammatory drugs for costochondritis which he tolerated well without GI symptoms or changes in BUN or creatinine. 4. Neurology: The patient was observed to have a generalized tonic-clonic seizure on [**2-7**], but had no further episodes throughout his hospital stay. Patient was noted to have short periods of aphasia and staring 2-3 days following the generalized seizure. Patient has no history of seizures, however, and the etiology is likely toxic metabolic. Patient is loaded with Dilantin and then maintained on a stable dose. Patient did not have any evidence of seizure activity throughout the remainder of his hospital stay. Workup for the cause of his seizures were negative. MRI of the head without contrast on [**2-7**] showed no evidence of stroke, or mass, or mass effect. EEG on [**2-7**] showed encephalopathy, but no evidence of seizure activity. Lumbar puncture with pleural guidance by Interventional Radiology on [**2-8**] revealed cerebrospinal fluid within normal limits. Vitamin B12, folate, and RPR were within normal limits. HIV test was negative. Thyroid stimulating hormone and free T4 levels were also within normal limits. A 24 hour bedside push button EEG was performed and was also within normal limits without changes during aphasic periods. Neurology service was consulted and followed the patient throughout his hospital stay. Per their recommendations, patient was continued on Dilantin at a dose of 400 q.d. based on his albumin adjusted serum levels. Patient is to followup in [**Hospital 878**] Clinic on [**2145-4-13**] to consider discontinue Dilantin if he remains stable. 5. Mental status: Patient initially confused and delirious after transfer from the Intensive Care Unit to the floor. This is likely due to ICU psychosis and exacerbated by high dose narcotics. Patient's narcotics were titrated down as outlined below. Patient's mental status improved dramatically, and by the time of discharge was very stable and lucid. Psychiatry was consulted and agreed that the patient's delirium was likely related to his intubations, sedation, and ICU stay, as well as exacerbated by high dosed narcotics. Patient was started on Celexa 20 q.d. per psych recommendations. Patient had been on a SSRI prior to admission as well. Plan outpatient psychiatric followup. Patient should continue on the lowest tolerated dose of narcotics to avoid mental status affects. 6. Cardiovascular: Patient with history of coronary artery disease and hypertension. Patient's hypotension requiring use of pressors which resolved in the Intensive Care Unit as described above, and he was slowly restarted on his antihypertensives for his hypertension. Patient's blood pressures remained very well controlled on the Medicine floor with metoprolol 100 b.i.d. which was changed to atenolol 100 q.d. and then with captopril 50 t.i.d. which was changed to lisinopril 20 q.d. Patient was also continued on his aspirin, Plavix, and Lipitor. 7. Pain: History of chronic back pain on methadone at home. Patient also developed rib pain consistent with costochondritis on the Medicine floor, which was due to his approximate 10 days of intubation. Patient's costochondritis and rib pain improved entirely after two days of standing Naprosyn 500 b.i.d. Upon transfer from the ICU to the floor, the patient was initially on Fentanyl patch 250 for pain control. On [**2-10**], this was changed to methadone 30 t.i.d. and titrated up to 40 t.i.d. for chronic pain control. Patient also received Morphine 15 mg p.o. prn breakthrough pain. Patient also restarted on his Neurontin, which he was on as an outpatient with a starting dose of 200 b.i.d. for neuropathic pain. Planned to titrate the patient's pain regimen as needed as an outpatient. 8. Anemia: The patient received 3 units of red blood cells from [**1-30**] and 27th for anemia. Patient's hematocrit remained stable between 28 and 30 throughout the remainder of his hospital stay. Vitamin B12 and folate were within normal limits. Iron studies were most consistent with anemia of chronic disease. 9. Fluids, electrolytes, and nutrition: Patient was cleared by bedside swallow study to tolerate fluids and fluid by mouth on [**2-8**], and he tolerated his cardiac diet very well on the Medicine floor. Patient's potassium and magnesium were repleted as needed during his hospital stay. Patient was also given artificial saliva as needed. 10. Prophylaxis: Patient maintained on subcutaneous Heparin initially and then on Lovenox for DVT prophylaxis. Patient also maintained on Protonix as well as Colace prn and senna prn. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation facility. DISCHARGE DIAGNOSES: 1. Septicemia, Staphylococcus aureus. 2. Hypertension, benign. 3. Coronary artery disease. 4. Mental status, altered/delirium. 5. Pneumonia, Staphylococcus. 6. Seizure grand mal. DISCHARGE MEDICATIONS: 1. Plavix 75 q.d. 2. Lansoprazole 30 q.d. 3. Artificial saliva solution prn. 4. Lovenox 60 subQ q.d. for DVT prophylaxis. 5. Ambien [**6-14**] q.h.s. prn. 6. Aspirin 81 once a day. 7. Synthroid 225 mcg once a day. 8. Senna one tablet b.i.d. prn. 9. Atenolol 100 q.d. 10. Lipitor 10 q.d. 11. Naprosyn 500 mg q.12h. prn. 12. Vancomycin 1 gram IV q.12h., last dose on [**2145-3-13**] unless otherwise instructed by Infectious Disease Clinic. 13. Vioxx 12.5 mg q.d. 14. Methadone 40 mg t.i.d. 15. Morphine sulfate immediate release 15 mg q.4h. prn breakthrough pain. 16. Thiamine 100 once a day. 17. Colace 100 twice a day prn. 18. Lisinopril 20 once a day. 19. Phenytoin 400 q.d. 20. Neurontin 200 b.i.d. 21. Celexa 20 q.d. FOLLOW-UP PLANS: Patient has an appointment with Infectious Disease Clinic with Dr. [**Name (NI) 27871**] early [**2145-3-7**]. Patient has an appointment with [**Hospital 878**] Clinic with Dr. [**Last Name (STitle) **] in early [**Month (only) 958**]. Patient is to followup with primary care physician within one month. Patient is to followup with a psychiatrist as referred from his primary care physician. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**] Dictated By:[**Name8 (MD) 6906**] MEDQUIST36 D: [**2145-2-21**] 19:48 T: [**2145-2-22**] 06:09 JOB#: [**Job Number 27872**]

[ "733.6", "728.88", "482.41", "038.11", "584.9", "780.39", "304.00", "518.82", "414.8" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "96.72", "38.91", "88.72", "03.31", "99.04" ]

icd9pcs

[ [ [] ] ]

1903, 1921

17739, 17919

17942, 18664

3204, 4582

8635, 14639

2097, 3176

18682, 19374

160, 1083

14655, 17636

4691, 8049

8071, 8463

8480, 8614

17661, 17718

1842, 1886

42,310

153,382

38913

Discharge summary

report

Admission Date: [**2181-8-6**] Discharge Date: [**2181-8-10**] Date of Birth: [**2111-7-27**] Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Lisinopril / Nifedipine / Procardia / Lipitor / Zocor / Pravachol / Avandia Attending:[**First Name3 (LF) 2901**] Chief Complaint: NSTEMI Major Surgical or Invasive Procedure: Left carotid endarectomy cardiac catheterization with drug eluting stent to the Left anterior descending artery History of Present Illness: 70F with a PMH CAD-CABG ([**2181-3-19**] LIMA LAD), DES of mid LCx on [**4-18**], critical AS s/p St. [**Male First Name (un) 923**] bioprosthetic AVR [**2181-3-19**], DM, s/p L CEA [**8-6**] for asymptomatic 80-99% stenosis, POD#1, who presents to CCU from cath lab (originally on vascular surgery service). . Pt underwent CEA on [**8-6**] for asymptomatic 80-99% carotid stenosis, and per report tolerated the procedure well, and had no significant symptoms other than a little epigastric dyscomfort and nausea immediately post-op. The following day she had more nausea and vomited, given her cardiac history, biomarkers were checked (trop 0.02-->0.34, CK 3-->9) and returned elevated. ECG showed new ST depressions in V4-V6. The patient denied any chest pain, shortness of breath or other symptoms since the surgery. She had previously had DOE and mild chest dyscomfort prior to the PCI in [**4-18**], which had dramatically improved since (NYHA III symptoms to NYHA I/II). Following the procedure, she had ambulated without difficulty, with no angina or DOE, and reported that she felt well. Cardiology was consulted because of elevated biomarkers and recommended cardiac cath, which demonstrated patent LIMA to LAD, patent DES to mid LCx, occluded RCA wtih L-to-R collaterals, and successful drug-eluting stent to the native LAD (via LIMA) with stent. . On cardiac review of symptoms, the patient denies any chest pain or anginal equivalent, shortness of breath, dysnpea on exertion, orthopnea, PND, palpitations, syncope or presyncope, or claudication-type symptoms. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Coronary artery disease s/p CABG [**2181-3-19**] (LIMA-LAD), PCI--> LCX [**4-18**] (2.5x23mm Promus drug eluting stent in the mid LCX) - Critical aortic stenosis s/p St. [**Male First Name (un) 923**] bioprosthetic AVR [**2181-3-19**] - Post-operation atrial fibrillation [**2181-3-19**] (on amiodarone) - Chronic renal failure - Hypertension - Diabetes Mellitus Type II - Hyperlipidemia - Peripheral vascular disease - Left carotid stenosis - LLE strep infection [**2175**] - h/o VRE UTI - Left rotator cuff repair - tonsillectomy . Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension Social History: Lives with: husband Occupation: retired nurse Tobacco: 30 pack years, quit ~15yrs. ago ETOH: None Family History: There is no family history of premature coronary artery disease or sudden death. Her mother died of a stroke at age 72. Her daughter has a conduction defect (not sure what type). Her father had a history of [**Name (NI) 39299**] during stress tests. Physical Exam: Gen: A/O, NAD HEENT: supple, no JVD CV: RRR, no M/R/G RESP: CTAB post, no crackles or wheezes ABD: soft, NT EXTR: right groin with extensive bruising and mod hematoma, decreased in size from outlined area and appears to be resolving. No bruit. Mild tenderness with palpation. NEURO: A/O, no focal defects. Right: DP 1+ PT 1+ Left: DP 2+ PT 1+ Skin: as above, no open areas Pertinent Results: [**2181-8-10**] 07:25AM BLOOD WBC-7.3 RBC-3.01* Hgb-9.2* Hct-27.2* MCV-90 MCH-30.5 MCHC-33.8 RDW-14.2 Plt Ct-183# [**2181-8-10**] 07:25AM BLOOD Plt Ct-183# [**2181-8-10**] 07:25AM BLOOD PT-12.8 PTT-27.7 INR(PT)-1.1 [**2181-8-10**] 07:25AM BLOOD Glucose-168* UreaN-41* Creat-1.8* Na-131* K-4.3 Cl-98 HCO3-24 AnGap-13 [**2181-8-10**] 07:25AM BLOOD CK(CPK)-77 [**2181-8-8**] 05:55AM BLOOD CK(CPK)-171 [**2181-8-7**] 06:04PM BLOOD CK(CPK)-165 [**2181-8-7**] 10:16AM BLOOD CK(CPK)-112 [**2181-8-7**] 02:10AM BLOOD CK(CPK)-80 [**2181-8-10**] 07:25AM BLOOD CK-MB-3 cTropnT-0.55* [**2181-8-9**] 03:53AM BLOOD CK-MB-4 cTropnT-0.35* [**2181-8-8**] 05:55AM BLOOD CK-MB-7 cTropnT-0.34* [**2181-8-10**] 07:25AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.2 . [**2181-8-8**] Cardiac catheterization: COMMENTS: 1. Coronary angiography in this right-dominant system demonstrated native two-vessel disease. The LMCA had no angigoraphically apparent disease. The LAD had an 80% mid-vessel stenosis and a an 80% stenosis distal to the LIMA-LAD anastamosis. The LCx stent was widely patent. The RCA was totally occluded and filled via left-to-right collaterals. 2. Arterial conduit angiography demonstrated a patent LIMA-LAD with an 80% stenosis in the LAD distal to the anastamosis. 3. Limited resting hemodynamics revealed moderate systemic arterial hypertension, with an SBP of 178 mm Hg. 4. Successful PCI of mid LAD with a 2.5x18mm Promus drug eluting stent postdilated to 2.5mm. Final angiography revealed no residual stenosis, angiographically apparent dissection and TIMI 3 flow. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Patent LIMA-LAD with stenosis distal to the anastamosis. 3. Moderate hypertension. 4. Successful PCI of mid LAD. . ECHO [**8-8**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with basal to mid inferior hypokinesis to akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal. RV with borderline normal/mildly depressed free wall function. There is abnormal septal motion/position. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**2-10**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2181-3-15**], the LV systolic function has slightly improved and there is now a bioprosthetic AVR (with normal function). Brief Hospital Course: # NSTEMI: Pt had elevated biomarkers and new ST depressions on ECG after an episode of vomiting, post-op left CEA. She was taken to cath lab and LAD stented with a drug eluting stent. No chest pain after procedures. CK's were not > 200 but pos troponin, high of 0.55. ECHo showed EF of 45% with 1-2+ MR and 2+ TR with basal/mid inferior hypokinesis, akinesis. Pt was cont on aspirin, home dose of metoprolol and home dose of Plavix 75 mg daily. The importance of Plavix daily for at least one year was stressed with pt. The patient declined the inititiation of ACEi and ARBs given her previous allergic reaction. She also states she has a hx of pos CK's on statins. The possibility of starting Crestor should be explored as an outpatient. . # Aortic stenosis: s/p AVR [**2181-3-19**], no symptoms currently. Aortic valve function normal on last ECHO although she does have a mild murmur. Her home dose of Lasix was held because of increasing creatinine. She had some mild peripheral edema at discharge and was instructed to elevate her legs. . # A fib: History of prior atrial fibrillation post op [**2181-3-19**]. Now in sinus rhythm. . # Acute on chronic Kidney Disease: Pt had a rising creatinine at discharge, increased to 1.8 from 1.2, consistant with [**Last Name (un) **] from contrast during catheterization. She was asked to stay in the hospital for further monitoring but refused and a plan was devised that she would have the VNA draw her blood at home with results to Dr. [**Last Name (STitle) **]. She has close follow up with her PCP [**Last Name (NamePattern4) **] [**8-22**]. . # HTN: Cont home metoprolol tartrate 50mg PO BID. . # Diabetes Mellitus Type II: PO anti-glycemics were restarted at discharge. . # Peripheral vascular disease/Left Carotid Stenosis: S/p CEA. Extensive bruising on the left neck site around the suture area with some tracking of ecchymosis to the left shoulder area. This is stable per vascular surgery and she has close follow up. . # UTI: E. coli growing in culture. Finished 3 day course of Cipro - cont cipro for total 3 day course. . Medications on Admission: HOME MEDICATIONS: - plavix 75', ecASA 325', lopressor 50'', lasix 20', famotidine 20', glipizide 5'', januvia 50', Fe 50', fish oil Discharge Medications: 1. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day. 3. Ferrous Sulfate 47.5 mg (Iron) Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Outpatient Lab Work Please check Chem-7 on Saturday [**8-11**] with results to Dr. [**Last Name (STitle) **]: [**Telephone/Fax (1) 86332**] (cell). Alternate phone: [**Telephone/Fax (1) 62**]. 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Non ST elevation Myocardial Infarction Carotid Endarectomy Diabetes Mellitus Acute on Chronic Kidney Disease Bioprosthetic AVR Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Right groin with resolving hematoma, not extending beyond circled area. No bruit or bleeding. Area is soft and appears to be resolving. Left neck area with extensive bruising but again appears to be resolving. Hct is low but stable. Discharge Instructions: You had a left cardotid endarectomy and was found to have positive troponins after the operation and ECG changes. You were brought to the lab where they found a blockage in your LAD (your LIMA was patent) You received a drug eluting stent to the left anterior descending artery. You also have a total occlusion with collaterals to your RCA and and a patent DES to your left circumflex. Your ECHO showed an EF of 45%. You had no evidence of CHF while you were here. You also had e-coli in your urine and had 3 days of cipro for this. Medication changes: 1. Stop your Lasix until your creatinine improves. Keep your legs elevated to help with the edema. 2. continue all of your other medicines as before. 3. Start oxycodone for pain as needed. . You will need to check your Lytes tomorrow [**8-11**]. Results will go to to Dr. [**Last Name (STitle) **] who can follow them over the weekend. We have been in touch wtih Dr. [**Last Name (STitle) 86333**] as well. Please talk to Dr. [**Last Name (STitle) 86333**] about trying Crestor. Followup Instructions: Department: VASCULAR SURGERY When: TUESDAY [**2181-9-11**] at 1:45 PM With: VASCULAR LAB [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: VASCULAR SURGERY When: TUESDAY [**2181-9-11**] at 2:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Primary care: Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] When: Wednesday [**2181-8-22**] at 9 AM Location: FAMILY MEDICINE ASSOCIATES Address: [**Street Address(2) **], [**Apartment Address(1) 86334**], [**Hospital1 **],[**Numeric Identifier 66038**] Phone: [**Telephone/Fax (1) 72506**] . Department: Cardiology Name: Dr. [**Last Name (STitle) **] [**Name (STitle) 4922**] When: 16-30 days after your hospital discharge Location: ASSOCIATES IN CARDIOVASCULAR MEDICINE Address: [**Location (un) 85348**], [**Location **],[**Numeric Identifier 21918**] Phone: [**Telephone/Fax (1) 84020**] You will be contact[**Name (NI) **] by the office for your appointment. If you have not heard from the office in 2 business days please call the office to discuss your appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2181-8-14**]

[ "V45.82", "443.9", "414.01", "427.31", "997.1", "585.9", "410.71", "599.0", "V45.81", "584.9", "V45.89", "433.10", "272.4", "041.4", "E878.8", "403.90", "V43.3", "250.00" ]

icd9cm

[ [ [] ] ]

[ "00.40", "37.22", "88.56", "00.66", "38.12", "36.07", "00.45" ]

icd9pcs

[ [ [] ] ]

10342, 10348

7154, 9237

359, 473

10539, 10539

4022, 5580

11979, 13492

3361, 3612

9421, 10319

10369, 10518

9263, 9263

5597, 7131

10923, 11456

3627, 4003

9281, 9398

11476, 11956

313, 321

501, 2609

10554, 10899

2632, 3229

3245, 3345

42,447

116,455

36752

Discharge summary

report

Admission Date: [**2108-2-13**] Discharge Date: [**2108-2-15**] Date of Birth: [**2042-10-15**] Sex: M Service: MEDICINE Allergies: Codeine / Amoxicillin Attending:[**First Name3 (LF) 2891**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2108-2-14**] left heart catheterization with bare metal stent placed in left circumflex History of Present Illness: 65 year old male w/ PmHx of HTN and longstanding GERD (s/p Nissen procedure) who presented to OSH with chest pain and found to have elevated troponin without EKG changes, diagnosed with NSTEMI and transfered to [**Hospital1 18**] for further evaluation. Mr. [**Known lastname 73466**] reports that around 10am in the morning he developed a pressure-like sensation around his sternum. He has prominent GERD symptoms chronically and takes [**Hospital1 **] omeprazole, but this felt different than his GERD symptoms and didn't feel like anything he's ever had before. He devleoped diaphoresis, SOB, and nausea with dry heaving shortly after the chest discomfort started. He went to [**Hospital3 **] around 2pm. Initial EKG showed no ischemic changes but troponin I there was elevated at 3.54. He was given 325mg ASA, 75mg clopidogrel, 2SL nitro, nitro past, 4mg IV morphine, and 40mg simvastatin. Cardiology at [**Hospital1 2436**] recommended transfer to [**Hospital1 18**]. On arrival to the [**Hospital1 18**] ED, inital VS: 97.4 67 147/107 18 100% 2L. EKG showed no ischemic changes. Guiac negative and started on heparin gtt for troponin of 0.47 with CK 144 and CKMB 16. Since chest pain was still present, was given 5mg IV morphine. He was chest pain free at transfer to [**Hospital Ward Name 121**] 2 with Vs at transfer 97.8, 71, 162/90, 16, 99%RA. Currently, symptom free. Only other thing that has been going on recently is severe lower back/Left SI pain with radiation down the left leg which got much worse over weekend. Started having issues with this after hurting his back lifting furniture a few months back. Has received steroid injections in his back in the past. Over weekend got so bad his feet became a bit numb and that he couldn't walk much, but this has resolved. Is in process of being evaluated by a spinal surgeon for this issue. Also reports intermittent diarrhea with food for many months. REVIEW OF SYSTEMS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Hiatal hernia, Nissen fundoplication [**2105-7-16**] GERD s/p ACL repair in [**2099**] HTN Depression Peroneal nerve entrapemnt s/p surgical decompression in [**2102**] B/l inguinal hernia repair in [**2102**] Anemia R should rotator cuff tear and biceps tendon tear in [**1-28**] Social History: Wroked as a painter, physically active. Divorced, in a monogamous relationship with girlfriend. [**Name (NI) 1139**] - greater than 30 pack years, quit in [**2088**], began smoking at age 12. Alcohol - 1-2 drinks beer daily, almost never binge drinks. No illicit/IV drug use. Family History: Father died of MI at age 70, mother and siblings are healthy Physical Exam: ADMISSION PHYSICAL EXAM: VS - Temp 98.0F, BP 166/99, HR 77, R 18, O2-sat 100% RA GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - Supple, no JVD HEART - PMI non-displaced, RRR, nl S1-S2, no MRG LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - awake, A&Ox3, no focal deficits, intact sensation in both LE without areas of numbness or paresthesias BACK: mild pain to palpation over lower back and left SI joint . DISCHARGE PHYSICAL EXAM VS Tmax 99.5, BP 110-140s/68-96, HR 60s, RR18, sats 100% RA unchanged Pertinent Results: ADMISSION LABS [**2108-2-13**] 09:50PM BLOOD WBC-6.8 RBC-3.85* Hgb-11.9* Hct-38.6* MCV-100* MCH-31.1 MCHC-30.9* RDW-11.8 Plt Ct-415 [**2108-2-13**] 09:50PM BLOOD Neuts-87.9* Lymphs-8.8* Monos-2.6 Eos-0.7 Baso-0 [**2108-2-13**] 09:50PM BLOOD PT-10.9 PTT-31.4 INR(PT)-1.0 [**2108-2-13**] 09:50PM BLOOD Glucose-132* UreaN-21* Creat-1.0 Na-132* K-4.7 Cl-99 HCO3-21* AnGap-17 [**2108-2-14**] 07:20AM BLOOD Calcium-8.9 Phos-2.1* Mg-2.0 . CARDIAC ENZYMES [**2108-2-13**] 09:50PM BLOOD CK-MB-16* MB Indx-11.1* [**2108-2-13**] 09:50PM BLOOD cTropnT-0.47* [**2108-2-14**] 07:20AM BLOOD CK-MB-11* MB Indx-9.7* cTropnT-0.49* . DISCHARGE LABS [**2108-2-14**] 07:20AM BLOOD WBC-7.1 RBC-3.53* Hgb-11.3* Hct-34.4* MCV-98 MCH-32.0 MCHC-32.8 RDW-12.1 Plt Ct-322 [**2108-2-15**] 06:30AM BLOOD UreaN-8 Creat-0.9 Na-136 K-4.3 Cl-100 [**2108-2-15**] 06:30AM BLOOD ALT-42* AST-65* AlkPhos-47 TotBili-0.9 [**2108-2-15**] 06:30AM BLOOD Triglyc-241* HDL-70 CHOL/HD-2.7 LDLcalc-71 . IMAGES [**2108-2-14**] CARDIAC CATH: COMMENTS: 1) Selective coronary angiography of this right-dominant system demonstrated two-vessel coronary artery disease. The LMCA and LAD had no angiographically-apparent flow-limiting stenoses. The large OM branch of the LCx had a 70% stenosis at the bifurcation. The proximal RCA had a 50-60% stenoses. 2) 3) Limited resting hemodynamics revealed systemic arterial normotension, with a central aortic pressure of 127/78 mmHg. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Successful BMS to LCx. 3. Aspirin 81 mg daily indefinitely and clopidogrel 75 mg daily for 1 month minimum, longer if no bleeding. . 3/38/12 TTE: RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). Doppler parameters are indeterminate for LV diastolic function. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Doppler parameters are indeterminate for left ventricular diastolic function. 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 aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. . Brief Hospital Course: Mr. [**Known lastname 73466**] is a 65 year old male w/ hypertension (HTN) and difficult to control GERD (s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1358**]) who presented to OSH with chest pain different from his baseline GERD and found to have elevated troponin without EKG changes ruling in for NSTEMI and transfered to [**Hospital1 18**]. . # Non-ST elevation myocardial infarction (NSTEMI): His chest pain syndrome was very different from his baseline GERD with a substernal location, pressure-like pain, and associated diaphoresis and nausea. Eventually, he became chest pain free and without shortness of breath, but took hours to achieve this with morphine and nitro. No heart failure on symptoms or exam. No prior history of coronary disease nor stable anginal syndrome and no prior caths but has smoking history and hypertension. He recieved aspirin 325 mg, clopidogrel loaded 600 mg, heparin gtt, atorvastatin 80 mg daily, metoprolol tartrate 25 mg [**Hospital1 **], and his lisinopril was increased to 40 mg daily. He underwent a cath with placement of a bare metal stent to his left circumflex artery. After this, his plavix was changed to prasugrel 10 mg daily because this does not interact with his fluoxetine or omeprazole. His transthoracic ECHO showed no wall motion abnormalities, slight mitral regurgitation. He was discharged on: aspirin 81 mg, prasugrel 10 mg daily, atorvastatin 80 mg daily, metoprolol succinate 50 mg [**Hospital1 **], and lisinopril 40 mg daily. . # HTN: His systolic pressure on admisson was 169 and so his lisinopril was increased to 40 mg daily in light of NSTEMI as would prefer to reduce afterload to reduce myocardial oxygen demand. . # Gastroesophageal reflux disease (GERD): This is chronic and poorly controlled despite past [**Last Name (un) 1358**]. Has been on 40mg omeprazole [**Hospital1 **] for some time. Because PPI interacts with clopidogrel, placed BMS so that anticoagulation time is minimized. Also, discharged him on prasugrel as 2nd antiplatelet [**Doctor Last Name 360**] so that omeprazole can be continued. . # Depression: Symptoms stable. Has been on high dose fluoxetine. Fluoxetine also interacts with plavix so again favored prasugrel in [**Hospital 4820**] medical management of NSTEMI. . # Siatica: Again long-standing and difficult to control. His PCP has reported that he trusts him to have narcotics on a short-term basis if needed for pain while in house. He is getting set-up with the spine center for possible surgical intervention. Was given oxycodone for pain control but this caused nightmares so he asked to not have this continued. Avoided NSAIDS because don't want to irritate known gastritis in the setting of new antiplatelet agents as above. . # CONTACT: [**Name (NI) 8214**] [**Name (NI) 83084**] (friend-[**Telephone/Fax (1) 83085**](h) / [**Telephone/Fax (1) 83086**](w) . TRANSITIONAL ISSUES: - Please discontinue prasugrel after a month if concerns for GI bleeding - His AST and ALT were slightly elevated and he was started on a statin. These should be rechecked Medications on Admission: Lisinopril 20mg PO daily Omeprazole 40mg PO BID Fluoxetine 40mg PO daily ASA 81mg PO daily Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS non-ST elevation myocardial infarction (NSTEMI) . SECONDARY DIAGNOSIS hypertension gastroesophageal reflux disease (GERD) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 73466**], . You were admitted to the hospital because you had chest pain which was concerning for a heart attack. Your blood work showed that you had a small heart attack and you underwent a procedure (called cardiac catheterization) where they placed a stent in one of your blood vessels to open it up again. We also started some new medications to control your blood pressure and cholesterol. Finally, there are some new medications to thin your blood so that new blood clots are less likely to form in your heart. However, these medications do increase your risk of bleeding in your stomach slightly so you should monitor yourself for symptoms such as black stools. . The following changes were made to your medications: - START taking prasugrel 10 mg daily - START taking metoprolol succinate 50 mg a day - START atorvastatin 80 mg daily - INCREASE lisinopril to 40 mg daily . You should keep all of the follow-up appointments listed below. . It was a pleasure taking care of you in the hospital! Followup Instructions: Department: [**Location (un) **] PRIMARY CARE When: TUESDAY [**2108-2-28**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 79306**], MD [**Telephone/Fax (1) 3736**] Building: [**Street Address(2) 82764**] ([**Location 15289**], MA) [**Location (un) 859**] Campus: OFF CAMPUS Best Parking: Parking on Site Department: [**Hospital3 249**] When: MONDAY [**2108-2-27**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD. [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. Department: CARDIAC SERVICES When: WEDNESDAY [**2108-3-21**] at 1:20 PM With: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 18267**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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3969, 5396

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3136, 3198

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11404, 11546

10491, 10583

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10291, 10465

2352, 2522

244, 256

415, 2333

11582, 11694

2544, 2826

2842, 3120

9,396

106,469

12467

Discharge summary

report

Admission Date: [**2109-2-16**] Discharge Date: [**2109-2-22**] Service: HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old male with an unwitnessed fall face forward, no loss of consciousness. He fell about 3:15 p.m. on the day of admission, face forward, no loss of consciousness. He was transferred to [**Hospital6 1597**]. He had a head CT, which showed a large right chronic subdural hematoma with small bilateral areas of acute hemorrhage with mass effect and midline shift. The patient was transferred to [**Hospital1 346**] for further management. PAST MEDICAL HISTORY: 1. Paget disease. 2. Depression. 3. Benign prostatic hypertrophy. 4. Dementia. 5. Hypertension. ALLERGIES: The patient has no known allergies. MEDICATIONS ON ADMISSION: 1. Atenolol. 2. Aspirin. 3. Colace. 4. Celexa. 5. Albuterol. PHYSICAL EXAMINATION: On examination, the patient was alert, not oriented, talking clearly, large purple swelling over the left eye. Pupils left 5 down to 3, right 4 down to 2, face symmetrical. EOMI full on the right side, unable to assess on the left because of swelling. Neck in C collar. CHEST: Bronchial breath sounds. CARDIAC: Irregular. ABDOMEN: Soft, positive bowel sounds, moving all four extremities, no pronator drift. LABORATORY DATA: Labs on admission revealed the white count of 9.2, hematocrit 43.4, platelet count 185,000, sodium 141, potassium of 4.4, chloride 103, CO2 19, BUN and creatinine 26.9 and glucose 97. HOSPITAL COURSE: The patient was admitted to the Surgical Intensive Care Unit. The patient had subdural drainage at the bedside without complications. Subdural drain was in place for two days. The patient had a repeat head CT, which showed evacuation of the chronic component of the subdural hematoma. The patient was awake and alert, following commands, pupils equal, round, and reactive to light. The spine films were clear. Collar was removed. He was transferred to the regular floor, where he was seen by physical therapy and occupational therapy and found to be safe for discharge back to his rehabilitation. Vital signs remained stable. He has been afebrile. MEDICATIONS ON DISCHARGE: 1. Atenolol 25 mg p.o.q.d. 2. Celexa 20 mg p.o.q.d. 3. Zantac 150 mg p.o.b.i.d. CONDITION ON TRANSFER: The patient in stable condition at the time of transfer. The patient will followup with Dr. [**Last Name (STitle) 1132**] in three to four weeks time. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2109-2-22**] 09:45 T: [**2109-2-22**] 10:02 JOB#: [**Job Number **]

[ "852.21", "E888.9", "294.8", "731.0", "401.9", "921.0", "600.0" ]

icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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621, 772

7,900

155,630

7859+7860+7869

Discharge summary

report+report+report

Admission Date: [**2199-1-20**] Discharge Date: Date of Birth: [**2140-12-29**] Sex: M Service: Medicine HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 28322**] is a 58 year old male with longstanding insulin dependent diabetes mellitus, chronic renal insufficiency, hyperlipidemia and recently diagnosed pulmonary fibrosis and atrial flutter. He was admitted on [**1-20**] with light headedness, weakness, hypotension and acute renal failure. The patient was at [**Hospital6 1129**] on [**11-27**] to [**2198-12-23**]. Per [**Hospital1 2025**] discharge summary, he presented with right sided pleuritic chest pain and abnormal chest x-ray at the PCP's office. CT angiogram was done which was negative for pulmonary embolism but had a mass at the right base with pleural plaques and mediastinal and hilar lymphadenopathy. Bronchoscopy with brushings was done, complicated by significant bleeding requiring epinephrine injection. CT scan was negative for malignancy. Mediastinoscopy was done with lymph node biopsy and pleural biopsy. Chest tube was placed. Final pathology was negative for malignancy but with "fibrous pleural lesions." The patient was diuresed with improvement in shortness of breath. Obstructive sleep apnea was diagnosed as well and bi-pap was initiated with increased oxygen saturations at night. Other issues at [**Hospital6 1129**] included acute renal failure, post CT angiogram; creatinine up to high 2's; renal function improved with aggressive intravenous fluids. He also had knee pain, consistent with gout, treated with intra- articular steroids. He developed a flutter with right ventricular rhythm and was treated with Coumadin and Verapamil. He also had balanitis with penile edema and purulent discharge. Foley was discontinued and he was treated with Diflucan times one and topical Bacitracin. The patient was discharged on [**2198-12-23**] from [**Hospital6 1130**] to [**Hospital3 **] for physical therapy and bilateral heel ulcers. He was discharged from rehabilitation on [**1-18**]. While at rehabilitation, he developed petechia/purpura rash on bilateral lower extremities. Coumadin was stopped on [**1-18**] and Plavix was started on [**1-18**]. On [**1-19**], the patient had shortness of breath, decreased urine output and light headedness. He was also noted to be confused by family. He was taken to the Emergency Room by EMS on [**1-19**]. In the Emergency Room, he was found to be hypotensive to the 70's over 30's. Nasogastric lavage was negative. Blood pressure increased to 90's over 40's with three liters of intravenous fluids. Laboratory studies were significant for BUN over creatinine of 51 over 3.1, from 37 over 1.9 on [**1-17**] at rehabilitation. Electrocardiogram revealed atrial fibrillation at 67, no acute changes. Chest x-ray with volume loss on right; pleural thickening. CT of the abdomen and pelvis revealed no hydronephrosis or acute intra-abdominal process. Abdominal ultrasound was negative. No evidence of cholecystitis with thickened gallbladder wall. The patient was given empiric Ceptaz, Flagyl, Levaquin and stress dose steroids. Required Dopamine transiently. He was admitted to the medical Intensive Care Unit early a.m. on [**1-20**]. HOSPITAL COURSE: In the medical Intensive Care Unit, by system: 1.) Renal. FENA 1.13%. Renal was consulted. Etiology of acute renal failure was unclear. Urine sediment was 90; red blood cells greater than 50; granular casts; zero to two white blood cells, treated with intravenous fluids, with minimal improvement in creatinine, 3.1 to 3.0 to 3.4 to 3.1 to 2.9. Multiple studies ordered including ANCA, C3, C4, [**Doctor First Name **]. 2.) Hypotension. Etiology sepsis versus volume depletion. Only transiently on pressors in the Emergency Room. Blood pressure improved with intravenous fluids. Empiric antibiotics were given in the Emergency Room, Ceftriaxone and continued in the medical Intensive Care Unit. Decreased stress dose steroids. Cortisol pending. All cultures revealed no growth to date. 3.) Rash/purpura/petechiae on extremities, etiology unclear. Awaiting dermatology biopsy. Dermatology suspects hypersensitivity vasculitis in response to verapamil. 4.) Fluids, electrolytes and nutrition. Hyperkalemia to 6.8; treated with [**Doctor First Name 233**]-Exalate times two; calcium, bicarbonate and insulin with decrease to 4.7 with n.p.o. for nausea and vomiting initially but now on clears. 5.) Hematology. Coagulation studies high with INR to 4.6. Etiology was unclear. Coumadin was discontinued on [**1-18**]. 6.) Gastrointestinal. Guaiac positive bowel movements, with stable hematocrit. 7.) Cardiovascular. He had episodes of chest pain on admission. CK's negative times two. Troponin negative times two. No further chest pain. He was called out to medicine on [**2199-1-21**]. PAST MEDICAL HISTORY: Insulin dependent diabetes mellitus, complicated by retinopathy, neuropathy, proteinuria, Charcot joints, peripheral vascular disease. Hyperlipidemia. Obesity. Obstructive sleep apnea. Atrial fibrillation. Gout, right knee. Pleural fibrosis. Chronic renal insufficiency, baseline around 1.9. Depression. MEDICATIONS ON ADMISSION: NPH 15 twice a day. Coumadin 5 mg q. day, discontinued on [**1-18**]. Colchicine 0.6 twice a day. Plavix 75 q. day, started on [**1-18**]. Zantac 150 mg twice a day. Zocor 10 q. day. Celexa 20 mg q. day. Colace 100 mg twice a day. MVI. Verapamil SR 240 mg q. day. Aspirin 325 mg q. day. Regular insulin, sliding scale, per renal. Had been taking Motrin 800 mg one to four tablets per day times one year. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He lives alone. He works in the ceramic industry. Positive asbestos exposure. Positive tobacco, one pack per day, times 30 years; quit seven years ago. Positive alcohol, quit two months ago. FAMILY HISTORY: Brother and father with coronary artery disease. Two brothers with asbestosis. Brother with breast cancer. No renal failure, no vasculitis in the family. REVIEW OF SYSTEMS: No fevers, chills, positive nausea and vomiting in ED after drinking barium. No sore throat. Occasional cough. Of note, shortness of breath is worse than baseline, improved since admission. Positive dyspnea on exertion. Lives alone in house. Ten steps results in severe dyspnea on exertion. No dysuria, no urinary symptoms, no diarrhea, constipation. No headaches. PHYSICAL EXAMINATION: Temperature current 96.9; temperature maximum 98.0; pulse 80 to 103; blood pressure 134/77. Respiratory rate 16 to 28. Oxygen saturations in the 90 to 94%. General: Obese, white male, breathing comfortably, appearing greater than stated age. No acute distress. HEAD, EYES, EARS, NOSE AND THROAT: Right pupil surgical. Left equal, round, reactive to light and accommodation. Conjunctiva pale. Oropharynx with two one cm soft palate ulcers, beige colored, three cm nodule at right pharyngeal arch. Neck: Obese, supple, no lymphadenopathy, no obvious jugular venous distention. Cardiovascular: Distant. Heart sounds tachycardia. Chest clear to auscultation bilaterally, decreased breath sounds at bases with crackles at bases. Abdomen: Obese, nontender, nondistended, normal active bowel sounds. Back no tenderness. Extremities: Bilateral heel necrotic ulcers, 1+ edema bilaterally; no clubbing. Dermatology: Palpable purpura bilaterally, lower extremities, greater than upper extremities. LABORATORY DATA: Per history of present illness. HOSPITAL COURSE: 1.) Acute renal failure, initially resolved, believed due to tubular necrosis from hypotension. He also has a history of multiple episodes of acute renal failure at [**Hospital6 1129**] after receiving intravenous dye. His creatinine increased again after receiving an NSAID and being started on Captopril, so both were discontinued and his creatinine returned to baseline. He received Mucomyst for catheterization given history of ARF from dye loads. Because he was severely volume overloaded, he was not started on intravenous fluids. 2.) Cardiovascular system. He presented with hypotension of unclear cause. Echo on [**1-22**] showed an ejection fraction of 50 to 20% with severe dilated cardiomyopathy. Congestive heart failure service was consulted. He was started on Ace inhibitor and beta blocker, Carvedilol. ACE-I was discontinued, as noted above. The etiology of cardiomyopathy, diabetes mellitus versus alcohol versus ischemia vs. tachycardia, is unclear. The patient was eventually transferred to the cardiac floor for Natrecor, with successful diuresis of multiple kilograms. On [**2-1**], he had a cardiac catheterization which revealed a wedge of 30; later that evening at 6:30, he was started on the Natricor drip and, after receiving the bolus, his systolic blood pressure decreased from 180 to 80. The patient had headache and dizziness so the Natrecor drip was stopped at that time. His hypotension resolved with the medication held. 3.) Coronary artery disease. He has multiple coronary risk factors; diabetes mellitus, tobacco, family history, obesity, hypercholesterolemia, hypertension. Catheterization on [**2-1**] showed 90% left circumflex lesion and 80% non dominant right coronary artery. The left circumflex stent was placed. He was started on Integrolin times 18 hours, to be transitioned back to heparin drip. Regular rate and rhythm. Once hitting the floor, he had persistent tachycardia in the in one- teens. At [**Hospital6 **], he had atrial fibrillation/flutter and was treated with Verapamil which was stopped because of vasculitis. On [**1-31**], he had a nine beat run of non sustained ventricular tachycardia. Electrophysiology service was consulted and the plan is to perform an EPS study on Monday, [**2199-2-4**]. 4.) Probable purpura. Dermatology was consulted and felt that it was most likely hypersensitivity vasculitis from Verapamil which was stopped. The palpable purpura resolved; however, initial dermatology biopsy revealed only hemangioma so a repeat biopsy was obtained which again showed hemangioma. 4.) Gastrointestinal/liver. On [**1-22**], AST and ALT markedly elevated in the 300's from 30's from [**1-20**]. This was believed most likely due to ceftriaxone which was stopped, and liver enzymes are trending down. On [**1-25**], total bilirubin was increased after receiving a blood transfusion. Right upper ultrasound was unchanged, and total bilirubin returned to [**Location 213**]. 5.) Hematology. He received two units of packed red blood cells on [**1-24**], given his anemia and coronary artery disease. 6.) Pulmonary. Obstructive sleep apnea, on bi-pap at night. Pleural fibrosis was worked up at [**Hospital6 **]. He underwent aggressive diuresies for his CHF, as noted previously. 7.) Endocrine. He was continued on a diabetic diet and started on NPH 15 twice a day with regular insulin sliding scale. 8.) Rheumatology. History of gout, and complained of left knee pain. Treated with Oxycodone and became somnolent requiring Naloxone. He then received and NSAID and colchicine, with increasing creatinine, so these were discontinued. Rheumatology was consulted and performed steroid injection on [**1-28**] with resolution of the pain. 9.) Bilateral heel ulcers. PVR revealed bilateral occlusive tibial disease. Vascular surgery recommends an angiogram, tentatively planned for [**2199-2-8**]. 10.) Oncology. Chest x-ray concerning for mesothelioma per radiology. This has not been further investigated as the patient had work-up at [**Hospital6 **] and his cardiac issues are more pressing at the moment. Also, on physical examination, he has a nodule on his right oropharynx concerning for carcinoma. This should be followed up as an outpatient. This completes the hospital course up until [**2199-2-2**]. The rest of the hospital course will be dictated by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAD Dictated By:[**Last Name (NamePattern1) 2918**] MEDQUIST36 D: [**2199-2-3**] 07:50 T: [**2199-2-4**] 04:39 JOB#: [**Job Number 28323**] Admission Date: [**2199-1-20**] Discharge Date: [**2199-2-13**] Date of Birth: [**2140-12-29**] Sex: M Service: ADDENDUM The patient will follow-up in the Device Clinic with Dr. [**Last Name (STitle) **] on Tuesday, [**2208-4-17**]:30 p.m. The [**Month (only) 956**] appointment with Dr. [**Last Name (STitle) **] has been changed to [**4-16**]. The patient will follow-up with Dr. [**Last Name (STitle) **] in the Vascular Surgery Clinic on [**2-27**] at 12:15 p.m. The clinic is located at [**Hospital Unit Name 22682**]. The patient's stool was guaiac negative. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Doctor First Name 28324**] MEDQUIST36 D: [**2199-2-13**] 13:02 T: [**2199-2-13**] 13:01 JOB#: [**Job Number 28325**] Admission Date: [**2199-1-20**] Discharge Date: [**2199-2-13**] Date of Birth: [**2140-12-29**] Sex: M Service: Medicine ADDENDUM: This Discharge Summary will cover the [**Hospital 228**] hospital course from [**2199-2-2**] until [**2199-2-13**]. The hospital course will be reviewed by systems. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. CARDIOVASCULAR SYSTEM: (a) Pump: The patient continued to be followed by the Heart Failure Service. He continued on carvedilol and Lasix 40 mg intravenously b.i.d. The patient was placed back on a Natrecor drip for further diuresis. He was continued on a low-sodium diet. On [**2199-2-4**], the Natrecor was discontinued. (b) Rhythm: Due to the patient's atrial tachycardia, he underwent an electrophysiology study on [**2199-2-4**]. A transesophageal echocardiogram did not disclose evidence of atrial thrombus. The patient was noted to have an atrial tachycardia and underwent ablation. He subsequently became bradycardic with a low blood pressure. He underwent placement of an implantable cardioverter- defibrillator. A chest x-ray the following day confirmed lead placement. The patient was loaded with amiodarone 400 mg p.o. b.i.d. times five days. He is currently taking amiodarone 200 mg p.o. b.i.d. times one month. (c) Ischemia: The patient continued to aspirin and Plavix since he had a stent placed in the left circumflex artery on [**2199-2-1**]. The patient was to continue Plavix until [**2199-3-4**]. (d) Anticoagulation: Due the patient's atrial arrhythmia, he was anticoagulated with heparin intravenously. He was started back on Coumadin on [**2199-2-9**]. He will continue to be anticoagulated for four weeks. 2. RENAL SYSTEM: The patient's medications were renally dosed. His ACE inhibitor was held and restarted on [**2199-2-12**]. Prior to angiogram, the patient was administered Mucomyst and hydration. 3. GASTROINTESTINAL SYSTEM: The patient was continued on a bowel regimen during his hospital stay. 4. ENDOCRINE SYSTEM: The patient was continued on NPH 15 units subcutaneously q.a.m. and 15 units subcutaneously q.p.m. as well as a regular insulin sliding-scale. He was maintained on a diabetic diet. 5. PULMONARY SYSTEM: The patient has obstructive sleep apnea; on BiPAP at night. Pulmonary function tests were checked upon initiation of amiodarone. 6. VASCULAR SYSTEM: The patient underwent angiogram and vein mapping for further evaluation of his bilateral lower extremity ulcers. The angiogram disclosed bilateral diffuse disease. The patient was to under bypass for both lower extremities; left-sided operation was to occur in three to four weeks. Podiatry has been following the patient and has been providing recommendations for dressing changes. 7. HEMATOLOGIC ISSUES: On [**2-6**], the patient was noted to have a hematocrit of 26.3. Hemolysis laboratories were negative. He was transfused one unit of packed red blood cells on [**2-6**] and a second unit of packed red blood cells on [**2-7**]. On [**2-12**], his hematocrit was noted to be 29; so he was transfused an additional one unit of packed red blood cells. 9. PSYCHIATRIC ISSUES: The patient has a history of depression. He continued to take his Celexa. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: Discharge status was to a rehabilitation facility. DISCHARGE DIAGNOSES: 1. Insulin-dependent diabetes mellitus. 2. Chronic renal insufficiency. 3. Hyperlipidemia. 4. Pulmonary fibrosis. 5. Atrial tachycardia. 6. Obstructive sleep apnea. 7. Obesity. 8. Gout. 9. Depression. 10. Coronary artery disease. 11. Bilateral heel ulcers. MEDICATIONS ON DISCHARGE: 1. Warfarin 5 mg p.o. q.d. 2. Amiodarone 200 mg p.o. b.i.d. times one month; then amiodarone 200 mg p.o. q.d. 3. NPH 15 units subcutaneously q.a.m. and 15 units subcutaneously q.p.m. 4. Plavix 75 mg p.o. q.d. (until [**2199-3-4**]). 5. Simvastatin 20 mg p.o. q.d. 6. Carvedilol 50 mg p.o. b.i.d. 7. Colace 100 mg p.o. b.i.d. 8. Captopril 6.25 mg p.o. t.i.d. 9. Lasix 40 mg p.o. q.d. 10. Celexa 10 mg p.o. q.d. 11. Enteric-coated aspirin 325 mg p.o. q.d. 12. Ambien 5 mg p.o. q.h.s. as needed. 13. Regular insulin sliding-scale (to be administered in rehabilitation). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. [**First Name (STitle) **] in the Heart Failure Clinic on [**2199-3-4**] at 11 a.m. 2. The patient was to follow up with Dr. [**Last Name (STitle) **] in the Electrophysiology Clinic on [**2199-2-26**] at 3:30 p.m. 3. The number for both clinics is [**Telephone/Fax (1) 2207**]. 4. The patient was to follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] (telephone number [**Telephone/Fax (1) 28339**]). 5. The patient was to undergo bypass to the left extremity in three to four weeks [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Last Name (NamePattern1) 5092**] MEDQUIST36 D: [**2199-2-12**] 16:24 T: [**2199-2-12**] 16:27 JOB#: [**Job Number 28340**]

[ "428.0", "458.9", "707.14", "274.0", "515", "584.5", "427.32", "427.31", "250.40" ]

icd9cm

[ [ [] ] ]

[ "39.64", "37.94", "37.34", "86.11", "88.56", "88.48", "36.06", "99.23", "37.26", "37.23", "99.20", "36.01", "00.13", "93.90" ]

icd9pcs

[ [ [] ] ]

5920, 6078

16520, 16797

16824, 17413

5248, 5691

7570, 13425

17446, 18345

13458, 16378

6494, 7552

16393, 16498

6098, 6471

148, 3259

4911, 5222

5708, 5903

5,496

122,347

13592

Discharge summary

report

Admission Date: [**2136-10-8**] Discharge Date: [**2136-10-12**] Date of Birth: [**2097-10-17**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old female with a history of diabetes and chronic renal insufficiency who presents with three days of nausea and bilious vomiting and decreased oral intake. The patient denies any fevers, chills, chest pain, abdominal pain, shortness of breath, or polyuria. The patient has noted decreased urine output for the past several days. The patient states she has been taking her insulin throughout the past three days except for the morning of admission. She has chronic renal insufficiency, but is not yet undergoing hemodialysis. PAST MEDICAL HISTORY: 1. Type 2 diabetes for approximately 20 years. 2. Chronic renal insufficiency with a baseline creatinine of 5.8. 3. Hypertension. 4. Glaucoma. 5. Hydradenitis suppurativa. 6. Nephrolithiasis. 7. Status post incision and drainage of a perirectal abscess. 8. Cesarean section. MEDICATIONS ON ADMISSION: Renagel, labetalol, Diovan, Norvasc, doxazosin, Niferex, Lasix, Epogen, insulin 20 units subcutaneous q.a.m. and 20 units subcutaneous q.p.m. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Vitals showed a temperature of 95.1, pulse of 86, blood pressure of 102/49, respiratory rate of 26, oxygen saturation of 98%. In general, the patient was a tired-appearing middle-aged female. She was oriented to voice. She appeared somnolent. Head, eyes, ears, nose, and throat showed pupils were equal, round, and reactive to light. The extraocular movements were intact. The oropharynx was dry with no lesions. The conjunctivae were pale. There were dry mucous membranes. Her neck was supple. There was full range of motion. The lungs were clear to auscultation bilaterally. The heart had a tachycardic rate and regular rhythm. There was normal first heart sound and second heart sound. The abdomen was soft, obese, and nontender. The extremities showed trace edema. Neurologic examination showed the patient to be alert and oriented times two. Cranial nerves II through XII were intact. Strength was [**6-16**] throughout and symmetric. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission revealed a white blood cell count of 13.1, hematocrit of 30, platelets of 345. Differential showed 96% neutrophils, 2% lymphocytes. PT of 15.2, PTT of 29.6, INR of 1.5. Urinalysis was significant for a moderate amount of blood, greater than 1000 glucose, 300 protein, and 15 ketones. Sodium was 114, potassium of 8.6, chloride of 76, bicarbonate of less than 5, blood urea nitrogen of 140, creatinine of 6.9, glucose of 1271. The anion gap was 33. Calcium of 9.1, magnesium of 2.9, phosphorous of 14.2. Urine sodium was less than 10, urine creatinine was 41, urine osmolalities were 382. Arterial blood gas showed a pH of 7, PCO2 of 19, and a PO2 of 121. Free calcium of 1.24. RADIOLOGY/IMAGING: Chest x-ray showed a question of a retrocardiac opacity. Electrocardiogram showed normal sinus rhythm at 75 with normal axis. Intervals were P-R of 162, Q-T of 434, QRS of 110. 1 mm to [**Street Address(2) 1766**] elevations in leads V1 through V3. T waves were peaked throughout. HOSPITAL COURSE: The patient was admitted to Medical Intensive Care Unit for treatment of diabetic ketoacidosis and severe acidemia with acute-on-chronic renal failure. The Renal Service was immediately consulted for urgent hemodialysis for her elevated hyperkalemia and her metabolic acidosis. They placed a temporary hemodialysis catheter and dialyzed the patient on the evening of the first hospital day. Sources of why the patient's slipped into diabetic ketoacidosis were sought. She was pancultured. Her enzymes were cycled to rule out possible myocardial infarction. Liver function tests showed the patient to have elevated amylase and lipase consistent with pancreatitis which was thought to be a possible cause of her diabetic ketoacidosis. She was made n.p.o. An nasogastric tube was placed. An insulin drip was started. On the evening of admission, the patient spiked a temperature to 102. Upon closer physical examination, the patient was found to have a right breast abscess which was most likely the cause of her having slipped into diabetic ketoacidosis. She was started on broad spectrum antibiotics, and Surgery was consulted for a possible incision and drainage of the abscess. She was dialyzed for a second time on the second hospital day as she was still showing symptoms of uremia with asterixis on examination. She had a CT scan on the second hospital day to look for possible retroperitoneal bleed given a 10-point hematocrit drop overnight, as well as to image the pancreas given her elevated amylase and lipase. The pancreas only showed some mild stranding, most notably around the pancreatic head, and it was postulated that the patient may have had some gallstone pancreatitis. She received 2 units of packed red blood cells on the second hospital day for her 10-point hematocrit drop, and her hematocrit stabilized. There was no evidence of retroperitoneal bleed on CT. On the third hospital day, the patient had incision and drainage of the right breast abscess by Surgery. Her antibiotics were changed to oxacillin and ciprofloxacin. The drainage was sent for Gram stain and culture. On the fourth hospital day, the patient was improving with regard to her blood sugars, but she was still on an insulin drip as she was not taking p.o. at this time. At the recommendation of the [**Last Name (un) **] attending she was kept on the drip until she was taking p.o.; at that time she would be switched to subcutaneous insulin. The Gram stain from her abscess showed only gram-positive cocci. Therefore, ciprofloxacin was discontinued as there was no evidence of Pseudomonas. The oxacillin was switched to dicloxacillin as the patient began to tolerate p.o. The insulin drip was weaned off, and she was switched to subcutaneous NPH, as per the [**Last Name (un) **] recommendations. She was transferred to the floor on the fourth hospital day in good condition. She stayed there one final night to stabilize on her insulin as well as to monitor her tolerance to p.o. She did well and was discharged on the fifth hospital day. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] (her primary care physician) in approximately one month after discharge. She was also to follow up with Dr. [**First Name (STitle) 1313**] (her nephrologist) in approximately two weeks after discharge. She also was to follow up with her outpatient dermatologist for recommendations regarding her hydradenitis suppurativa. She had [**Hospital6 407**] after discharge for help with dressing changes of the right breast abscess. MEDICATIONS ON DISCHARGE: 1. Regular insulin sliding-scale. 2. NPH insulin 20 units subcutaneous q.a.m. and 20 units subcutaneous q.p.m. 3. Labetalol 300 mg p.o. q.d. 4. Cardura 2 mg p.o. b.i.d. 5. Norvasc 5 mg p.o. q.d. 6. Valsartan 80 mg p.o. q.p.m. 7. Diovan HCTZ 150/12.5 mg p.o. q.a.m. 8. Renagel 400 mg p.o. t.i.d. with meals. 9. Dicloxacillin 500 mg p.o. q.6h. for 10 days after discharge (to complete a 14-day total course). 10. Epogen. DISCHARGE DIAGNOSES: 1. Diabetic ketoacidosis. 2. Acute-on-chronic renal failure. 3. Hypertension. 4. Hyperkalemia. 5. Metabolic acidosis. 6. Right breast abscess, status post incision and drainage. 7. Pancreatitis. 8. Anemia. [**Name6 (MD) 1730**] [**Name8 (MD) **], M.D. [**MD Number(1) 19985**] Dictated By:[**Last Name (NamePattern1) 6859**] MEDQUIST36 D: [**2137-5-14**] 15:10 T: [**2137-5-14**] 20:02 JOB#: [**Job Number 41029**]

[ "250.11", "584.9", "365.9", "611.0", "577.0", "276.7", "585" ]

icd9cm

[ [ [] ] ]

[ "39.95", "85.0", "38.95" ]

icd9pcs

[ [ [] ] ]

7471, 7933

7012, 7450

1047, 3286

3305, 6376

6391, 6427

6448, 6985

158, 714

736, 1020

17,339

191,167

50811

Discharge summary

report

Admission Date: [**2127-12-3**] Discharge Date: [**2127-12-24**] Date of Birth: [**2058-12-19**] Sex: M Service: CARDIOTHORACIC Allergies: Latex Attending:[**First Name3 (LF) 2969**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Radiation Ablation Intubated Chest tubes x3 PICC line A-line Central line placement Tracheostomy PEG tube placement History of Present Illness: Pt had a radio-frequency tumor ablation of left lung for new LLL small cell lung cancer, as he was an extremely poor surgical risk. A small PTX was noted in the left lung after the procedure and a pigtail catheter was placed. A RUL collapse was also noted thought to be secondary to mucus plugging or aspiration. A CXR showed a new lower lobe infilitrate and small effusion on right. The Pt dropped his pressure soon after the procedure and was given 1L of LR and placed on norepinephrine. MICU was then consulted. . Upon arrival the patient was noted to still be intubated and ventilated from the procedure with a RR=14 and Vt=700. An ABG taken at that time was 7.14/73/187. Labs were as follows: WBC=12.8, Hct=30.6, Plts=248, PTT=43.8, INR=1.4, Na=140, K=4.8, Cl-104, CO2=23, BUN=27, Cr=1.2, GLUC=292, MG=2.0, Ca=8.9, lactate=6.7, albumin=2.8, troponin=0.02. The Pts respiratory rate was increased to 22 and 2L of LR was run wide-open with the result of his ABG= 7.31/37/317. However, his BP continued to drop despite maximal dose of norepinephrine and continual IVF. Given bedside TEE findings that showed a decreased CO and a mixed venous O2 in the high 50s, a cardiogenic component to his shock was entertained and dobutamine was added. This resulted in transient increase in BP, but it then dropped markedly to SBPs=40s and epinephrine 1 mg had to be pushed and an epinephrine gtt was started. The Pts BP responded well to the epinephrine, but continual epinephrine boluses had to be administered to maintain MAPs = 60s. Thus vasopressin was added. A swan was floated and showed his PAP and wedge pressure to be wnl. A follow-up Hct was 23, thus 2 units of PRBCs were given and Hct bumped to 29. Given the Pts documented adrenal insufficiency, he was administered 4 mg dexamethasone empirically. A follow-up CXR showed the evolution of a large left sided pleural effusion. . Upon being transferred to the MICU the Pt had been given 10.5 L of LR and was on norepinephrine, epinephrine, dobutamine and vasopressin. After coming to the MICU the Pt was able to be weaned off norepinephrine and dobutamine, maintaining his MAP=70s. He received an additional 3L of LR. Two additional chest tubes were placed that drained 1.5L of blood out of the left pleural space. Past Medical History: PMHx: 1. CAD w/ MI [**2-5**] 2 prox and 1 mid LAD + PTCA of diag 2. CHF with preserved EF of about 57% 3. SSS s/p [**Month/Year (2) 4448**] implantation in [**3-/2122**] 2. Hypertension 3. Seizure disorder after head trauma 4. COPD and a history of prior ARDS 5. AAA, status post repair and complicated by graft infection. 6. History of pseudomonas sepsis 7. History of DVTs and RLL PE in [**1-/2125**] 8. Depression 9. Reflex sympathetic dystrophy of the right lower extremity. 10. History of GI bleeding. 11. History of C. difficile colitis. 12. Obstructive sleep apnea. 13. Gout. 14. tracheomalacia w/ main stem bronchus stents, removed [**2125**] 15. osteomyelitis foot 16. adrenal insufficiency on prednisone 20 mg QD Social History: SOCIAL HISTORY: Lives with wife and four children. Went to Korean War and received blood transfusions. Denies alcohol. Has a history of three-and-a-half-pack-per-year smoking, stopped in [**2121**]. Denies intravenous drug use. Was an arbitration lawyer. [**Name (NI) **]. Family History: non contributory Physical Exam: T=afebrile BP=90s/40s HR=110s RR=14 O2sat= 100% intubated Vt=700, FiO2=100% GEN= intubated, lying in bed, moridly obese male HEENT= MMM dry, PERRL, no elevated JVP, no lad CV= distant heart sounds, rrr, nl s1/s2 PULMO= no breath sounds in upper right or lower left, coarse breath sounds in lower right and uppper left ABD= obese, no masses palpated, midline surgical scar at umbilicus EXT= cool, clammy, edematous, palp pulses, bandage around right ankle Pertinent Results: Most Recent Blood Work [**2127-12-24**] 04:45AM BLOOD WBC-15.2* RBC-3.26* Hgb-10.0* Hct-29.6* MCV-91 MCH-30.6 MCHC-33.6 RDW-15.1 Plt Ct-580* PT-15.3* PTT-59.2* INR(PT)-1.6 Glucose-136* UreaN-39* Creat-1.1 Na-141 K-3.8 Cl-101 HCO3-28 AnGap-16 Albumin-2.8* Calcium-8.5* Phos-4.6 Mg-1.9 . [**2127-12-22**] 03:30AM BLOOD Phenyto-7.3* . [**2127-12-4**] 05:13AM BLOOD CK-MB-50* MB Indx-13.7* cTropnT-1.93* [**2127-12-4**] 05:30PM BLOOD CK-MB-22* MB Indx-7.2* cTropnT-1.21* [**2127-12-5**] 04:11AM BLOOD CK-MB-8 cTropnT-0.74* . Admission Labs [**2127-12-3**] 05:00PM BLOOD WBC-12.8* RBC-3.06*# Hgb-9.9*# Hct-30.6* MCV-100* MCH-32.4* MCHC-32.5 RDW-14.2 Plt Ct-248 PT-14.5* PTT-43.8* INR(PT)-1.4 Glucose-292* UreaN-27* Creat-1.2 Na-140 K-4.8 Cl-104 HCO3-23 AnGap-18 Albumin-2.8* Calcium-8.9 Phos-7.1*# Mg-2.0 [**2127-12-3**] 05:45PM Cortsol-11.0 11:17PM Cortsol-20.5* 02:13AM Cortsol-22.6* . Imaging [**2127-12-3**] CT Chest- Radiation Ablation IMPRESSION: 1. Successful RF ablation of lesion in the left lower lobe. 2. Small left pneumothorax managed with chest tube. 3. Collapse of right upper lobe (plugging Vs aspiration). . [**2127-12-5**] CT Chest IMPRESSION: 1. Large left hemopneumothorax with three left-sided chest tubes in place. 2. Bibasilar atelectasis and small right pleural effusion. Stable appearance of large right-sided bulla. 3. The known left-sided lung nodule is not visualized due to atelectasis. . [**2127-12-17**] CT Chest IMPRESSION: 1. Decreased size of left complex effusion with hemothorax component and resolved right pleural effusion. 2. Improved aeration with decreased parenchymal opacities, likely due to resolving congestive heart failure. 3. Abnormal orientation and position of the tracheostomy tube as discussed above, with focal collection of air outside the tracheal lumen around the tube. 4. Left renal cystic lesions, not fully characterized on this study. Further workup may be obtained by ultrasound if clinically indicated. . [**2127-12-22**] CXR Lung volumes are lower. Interval improvement in the diffuse interstitial pulmonary abnormality over the last three days represents remission of a component of pulmonary edema though whether there is interstitial lung disease at the lung bases is radiographically indeterminate. Tip of a left PIC catheter projects over the SVC. Right ventricular transvenous pacer lead projects over the floor of the right ventricle. No definite pneumothorax is present. A large bulla in the right middle lobe displaces the anterior junction to the left. . Bilateral Upper Extremity Ultrasound RIGHT SIDE. Jugular vein and subclavian vein are widely patent. They demonstrate normal compressibility and augmentation were appropriate and normal respiratory phasicity. There is an acute thrombus involving the right axillary vein and extending distally to the level of the brachial vein. This thrombus is relatively anechoic and is producing expansion of the vessel. The right basilic and cephalic vessels appear patent. LEFT SIDE: There is normal compressibility, augmentation, and respiratory variation in the deep vessels of the left upper extremity were appropriate. The PICC line is identified in good position. . EKG: normal sinus rhythm @ 83 bpm, normal PR/QRS/QT intervals, normal T waves, no ST segment elevations or depressions. Brief Hospital Course: 1. Respitory Status: Patient developed a small right pneumothorax and large left hemothorax after IR radio-ablation procedure for a NSCLC mass in the left lower lobe. Because of the hemothorax he had 3 chest tubes placed on the left side by thoracic surgery. These drained well after placement and were removed as the output decreased. The last chest tube was removed on the day of discharge. He had been intubated during the procedure and remained so on transfer to the MICU. On hospital day 3 his sputum grew out MRSA and he was treated with vancomycin for a 7 day course. His respiratory status on the vent waxed and waned and after fluid resuscitation for hypotension was noted to have significant pulmonary edema. He required diuresis later in hospital stay which help to improve his respiratory status. After his course of vanco he continued to spike fevers and then sputum from [**12-13**] grew out Klebsiella that was sensitive to meropenem/gent/imipenem/pip-tazo. He was started on meropenem with plans for 15 day course. Meropenem will need to be continued until [**2127-12-31**]. Since the meropenem was started his sputum samples have been contaminated so no new data is available. His fevers have drifted down, but continues to have low grade fevers at times which is felt to be secondary to his cancer. He had a trach and PEG tube placed on [**12-16**]. After his trach procedure it was noted that the trach was abutted against the posterior wall. A bronch was performed the day after trach and was noted to collapse when patient was placed on 0/0 vent support. The trach was then advanced forward 2 cm. After this he continued to have some difficulties with the trach so we attempted to deflate the cuff on the trach and allow patient to breath through both trach and mouth. He tolerated this well going 10 hours a day on trach mask. At night he was placed on CPAP/PS 8/5 FiO2 40% for rest. He will need further weaning at rehab. When patient on trach mask his cuff must be deflated in his trach. . 2. Fever Pt was persistently febrile throughout his stay. He has MRSA and Klebsiella pna and C. diff. colitis as noted. His fever did not change with antibiotic therapy. Etilogy felt most likely [**3-5**] cancer; other etiology included residual hemothorax v. empyema, however these were considered less likely given the patient continued to improve. He had serial blood and urine cultures, all of which were negative. All catheter tip cultures were also negative. . 3. CAD - s/p LAD stents ~3wk pta On asa, plavix, bb, gemofibrozil; added ACE-I and titrated to lisinopril 10mg. No evidence of ischemia throughotu his stay. . 4. Afib w/ RVR Initially complicated by hypotension. Was loaded with IV and PO amiodarone (400mg [**Hospital1 **] x7d, then 400mg qd x7d), completed [**12-23**]. Beta-blocker titrated and has had stable HR and BP over last week. Initially not on anticoagulation given hemothorax. However started heparin ~1 week ago and coumadin [**12-23**]. Goal PTT 50-70, goal INR [**3-6**]. Has PM for SSS. . 5. Seizure disorder On dilantin, required several IV loads. Has had stable therapeutic levels on current dose of 300mg tid. . 6. NSCLC Found on biopsy of left lower lung lesion. Underwent RF ablation given he was a poor surgical candidate. Further treatment options unclear at this point. If his condition improves, this will need to be re-addressed. . 7. Adrenal insufficiency Currently on prednisone at home dose of 20mg. Per d/w PCP, [**Name10 (NameIs) **] has been on variable doses of 5-20mg but has not tolerated discontinuation entirely. His dose was not weened during his ICU stay. . 8. C.diff- Patient found to be cdiff positive on [**12-13**]. Started on flagyl. Plan to continue for 10 days after meropenem is finished. . 9. Right [**Name (NI) **] [**Name (NI) 91691**] Pt found tohave right basilic-axillary clot on ultrasound. Started on heparin with goal PTT 50-70. Coumadin started [**12-23**]. Goal INR [**3-6**]. Will need to stop heparin 2 days after INR is therapeutic. . 11. Thrush- Started on 7 day course of fluconazole for thrush that was not resopnsive to nystatin. Continue till [**12-29**]. . 11. Access - Left double lumen PICC placed [**12-15**]. . 12. CODE: FULL Medications on Admission: 1. Allopurinol 100 mg daily 2. Calcium Carbonate 500 mg TID 3. Ferrous Sulfate 325 (65) mg [**Hospital1 **] 4. Imipramine HCl 75 HS 5. Gemfibrozil 600 mg [**Hospital1 **] 6. Zolpidem 5 mg HS 7. Nitroglycerin 0.3 mg prn 8. Clopidogrel 75 mg daily 9. Docusate Sodium 100 mg [**Hospital1 **] 10. Senna 8.6 mg [**Hospital1 **] 11. Aspirin 325 mg daily 12. Guaifenesin 600 mg Q12h 13. Gabapentin 1200 mg [**Hospital1 **] 14. Bisacodyl 10 mg daily prn 15. Magnesium Hydroxide 400 mg/5 mL 30 ml q6h prn 16. Methyl Salicylate-Menthol 15-15 % Ointment TID 17. Camphor-Menthol 0.5-0.5 % QID. 18. Oxycodone-Acetaminophen 1-2 Tablets Q4-6H prn 19. Fluconazole 100 mg Q24h 20. Phenytoin Sodium Extended 200 mg in am and 300 mg in pm 21. Prednisone 20 mg daily 22. OxyContin 80 mg TID 23. Combivent [**Hospital1 **] 24. Spiriva daily 25. Metoprolol XL 25 [**Hospital1 **] 26. Nexium 20 mg daily 27. Lasix 40 mg [**Hospital1 **] 28. imipramine 75 mg HS 29. serzone 100 mg [**Hospital1 **] 30. zanaflex 12 mg [**Hospital1 **] Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily): via NG. 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): to continue for 10days after Meropenem is completed. 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Albuterol 90 mcg/Actuation Aerosol Sig: Ten (10) Puff Inhalation Q4H (every 4 hours). 12. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation QID (4 times a day). 13. Phenytoin 100 mg/4 mL Suspension Sig: Three Hundred (300) mg PO Q8H (every 8 hours). mg 14. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 15. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 17. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q4H (every 4 hours). 18. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days: last day = [**12-29**]. 19. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): 1st dose 11/22. Goal INR [**3-6**]. 23. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 24. Meropenem 1 g Recon Soln Sig: One (1) gram Intravenous every eight (8) hours for 10 days: last day 11/31. 25. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: [**2072**] ([**2072**]) unit/hr Intravenous ASDIR (AS DIRECTED): Goal PTT 50-70. Continue for 2 days after INR therapeutic. 26. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Non-small cell lung cancer Hemothorax Ventilator associated pneumonia C. diff. colitis Congestive heart failure Chronic obstructive pulmonary disease Atrial fibrillation Coronary artery disease Deep vein thrombosis Seizure disorder Adrenal insufficiency Discharge Condition: Stable with trach mask. Tolerating trach mask for several hours at a time. Hemodynamically stable. Low grade fevers. Discharge Instructions: Fluid Restriction: 1500cc Followup Instructions: Please contact patient's primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5717**] [**Telephone/Fax (1) **], with any questions regarding his long-term care.

[ "V09.0", "E849.7", "041.85", "512.1", "162.8", "428.0", "458.29", "414.01", "112.0", "507.0", "008.45", "511.8", "274.9", "518.81", "482.0", "780.39", "276.2", "424.1", "255.4", "E878.8", "428.30", "337.22", "427.31", "453.8", "V45.01", "482.41", "425.4", "276.52", "311" ]

icd9cm

[ [ [] ] ]

[ "33.21", "33.23", "89.64", "96.72", "99.10", "32.29", "88.72", "38.93", "34.04", "34.91", "96.04", "43.11", "38.91", "31.1", "99.04" ]

icd9pcs

[ [ [] ] ]

15386, 15465

7621, 11892

286, 403

15763, 15884

4294, 7598

15958, 16148

3785, 3803

12952, 15363

15486, 15742

11918, 12929

15908, 15935

3818, 4275

235, 248

431, 2716

2738, 3473

3506, 3769

21,372

199,697

30958

Discharge summary

report

Admission Date: [**2195-6-20**] Discharge Date: [**2195-6-26**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: rigors, coffee ground emesis Major Surgical or Invasive Procedure: None History of Present Illness: 88 yo M p/w rigors, coffee ground emesis being admitted to MICU for management of urosepsis and UGIB. . The patient was initially sent to [**Hospital 4199**] Hospital from Rehab where he was being treated for cellulitis. At the OSH he was reported to have a Hct 31, leukocytosis, elevated cardiac enzymes and coffee ground emesis (30 cc, Guaiac +). He remained hemodynamically stable, was given Ceftraxone and 1L NS and sent to [**Hospital1 18**] for further management. . In the ED, initial vitals: 99.0, 82, 182/59, 16, 100% on 4L. Pt was initially HD stable, but ultimately became tachycardic to 110s, SBPs down to 70s. WBC 20.7, Hct 36 initially, then 28 (post IVF, 4L NS), plt 345. Lactate was initially 1.5, but rose to 3.2. Tpn 0.18, CK 2265, CK-MB 33. U/A with > 50 wbcs, many bacteria. Blood and urine cxs sent. CXR: no infiltrate. EKG: NSR, no ST changes/TWI. Cardiology called: no indication for emergent cardiac cath, but trend CEs. GI called: possibly EGD in AM, NPO o/n. Pt given vanc X one gram, levofloxacin 750 mgX1, 3L NS. Transferred to MICU for further management. Past Medical History: RLE cellulitis dementia HTN PVD chronic ulcers gait disturbance Social History: prior heavy smoker and heavy drinker per pt's report, WWII veteran Family History: Not obtained Physical Exam: Temp 100.6 (rectal) BP 79/46 (54) Pulse 95 Resp 20 O2 sat 100% 4L NC Gen - Cachectic elderly male, alert, no acute distress, confused HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes dry Neck - no JVD, no cervical lymphadenopathy Chest - Clear to auscultation anteriorly CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds Back - Sacral decub, no costovertebral angle tendernes Extr - No clubbing, cyanosis, or edema. L AKA. Neuro - Alert and oriented x to person, "hospital", birthday, but not year, poor recall, cranial nerves [**3-23**] intact, moving all four extremities, sensation grossly intact Skin - large ulcerated lesion over R knee, clean, dry; R ankle ulcer w/ surrounding erythema rectal: guaiac + in the ED Pertinent Results: [**2195-6-20**] 04:25PM BLOOD WBC-20.7* RBC-4.07* Hgb-12.2* Hct-36.6* MCV-90 MCH-30.1 MCHC-33.5 RDW-14.8 Plt Ct-345 [**2195-6-20**] 04:25PM BLOOD Neuts-91.8* Lymphs-5.2* Monos-2.9 Eos-0 Baso-0.1 [**2195-6-20**] 04:25PM BLOOD PT-10.9 PTT-29.4 INR(PT)-0.9 [**2195-6-20**] 04:25PM BLOOD Glucose-126* UreaN-63* Creat-1.4* Na-138 K-4.7 Cl-103 HCO3-23 AnGap-17 [**2195-6-20**] 04:25PM BLOOD ALT-23 AST-85* CK(CPK)-2265* AlkPhos-85 Amylase-56 TotBili-0.4 [**2195-6-21**] 01:00AM BLOOD ALT-18 AST-67* LD(LDH)-201 CK(CPK)-1883* AlkPhos-63 TotBili-1.0 [**2195-6-21**] 12:00PM BLOOD CK(CPK)-2719* [**2195-6-22**] 05:42AM BLOOD CK(CPK)-1214* [**2195-6-20**] 04:25PM BLOOD CK-MB-33* MB Indx-1.5 [**2195-6-20**] 04:25PM BLOOD cTropnT-0.18* [**2195-6-21**] 01:00AM BLOOD CK-MB-35* MB Indx-1.9 cTropnT-0.47* [**2195-6-21**] 12:00PM BLOOD CK-MB-42* MB Indx-1.5 cTropnT-0.37* [**2195-6-22**] 05:42AM BLOOD CK-MB-23* MB Indx-1.9 cTropnT-0.30* [**2195-6-20**] 04:25PM BLOOD Albumin-3.4 Calcium-9.3 Phos-4.2 Mg-2.8* [**2195-6-21**] 06:22PM BLOOD Type-ART Temp-38.2 Rates-/24 pO2-124* pCO2-22* pH-7.41 calTCO2-14* Base XS--7 Intubat-NOT INTUBA [**2195-6-20**] 04:41PM BLOOD Lactate-1.5 . CXR: No focal consolidation to suggest pneumonia. Hyperinflation is suggestive of small vessel obstructive disease or COPD. . EKG: NSR, NA, NI, PACs/PVCs, no ST changes, no TWI, no Q waves Brief Hospital Course: A/P: 88 yo M with urosepsis and UGIB, now s/p afib w/ RVR . # Sepsis: Resolving. Potential sources include pseudomonas UTI, given grossly positive U/A vs. LE cellulitis. Pt met SIRS criteria: elevated wbc, borderline temp (max in ED 100.4), tachycardic in ED. Went to ICU on sepsis protocol, did not require pressors, though, as hypotension was fluid responsive. Was on antibiotics for Pseudomonas in urine and also vancomycin for cellulitis, however, family recognized that antibiotics for these infections were not likely to change his overall prognosis, so antibiotics were stopped after family meeting with palliative care team. . # Afib w/ RVR: Apparently a new diagnosis. Now back in sinus rhythm after load with amio. Likely [**3-13**] lung dz vs the stress of infection. Not anticoagulated because overall prognosis precludes benefit from anticoagulation and anticoagulation could cause catastrophic recurrence of recent GI bleeding. . # blood loss anemia of upper GI source: Pt with evidence of UGIB: coffee ground emesis by report and bloody lavage in [**Hospital1 18**] ED. Also had Guaiac positive stool. No additional emesis. Hct stable and no further overt bleeding, so GI consult recommended against EGD because of his overall prognosis. Protonix to prevent recurrence. . # NSTEMI: ddx includes ACS vs. demand ischemia in setting of infection. Doubt renal failure as contributor, given concommitantly elevated CK-MB/trop without significantly elevated cr. No known coronary dz, though at risk given pvd. EKG without changes concerning for ischemia. Enzymes trended down. Hold on heparin/plavix for now given GIB. . # Elevated Transaminases on presentation: elevated AST in absence of elevation of other LFTs. Abd exam unremarkable. No Etoh at rehab. DDx: cardiac source of enzyme leak vs. acute injury (? ischemia), though LFTs drawn when pt was normotensive. . # PVD with cellulitis: Patient is s/p L AKA and R TMA; now with non-healing RLE ulcers/cellulitis. Vasc surgery recommended R amputation, but patient and family declined surgery; additionally, antibiotics were not likely to change overall prognosis and would require restraining patient to secure IV access for administration, which the family felt was inhumane, and so changed to comfort care only. Pain control with morphine prn for ulcers. . # HTN: Pt has been normotensive to hypotensive. . # Dementia: ativan prn for agitation or anxiety. . # FEN: heart-healthy, soft/dysphagia diet. . # COMMUNICATION: Wife, [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 73176**] . # DNR/DNI: discussed at length in family meeting with palliative care before leaving ICU, clarified comfort measures only with family on [**6-24**]. . # Dispo: to [**Hospital1 1501**] with hospice Medications on Admission: aricept 5 mg qhs plavix 75 mg daily lisinopril 20 mg daily mvi asa 81 mg daily vicodin prn pain 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 Q12H (every 12 hours). 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for agitation. 4. Morphine 10 mg/5 mL Solution Sig: [**6-18**] mL PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital **] - [**Location (un) **] Discharge Diagnosis: primary: blood loss anemia from upper gastrointestinal source secondary: non-ST segment elevation myocardial infarction right lower extremity cellulitis dementia hypertension peripheral vascular disease with chronic ulcers gait disturbance Discharge Condition: fair Discharge Instructions: You were diagnosed with multiple problems including cellulitis, a small heart attack, and gastrointestinal bleeding. The goals of care as discussed with your family are to focus on keeping you comfortable. Followup Instructions: With Dr [**Last Name (STitle) **] [**Name (STitle) 33652**]. Call [**Telephone/Fax (1) 33653**] for an appointment as needed. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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Discharge summary

report

Admission Date: [**2180-9-19**] Discharge Date: [**2180-10-12**] Date of Birth: [**2123-8-4**] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 8388**] Chief Complaint: Fatigue and Malaise Major Surgical or Invasive Procedure: Therapeutic paracentesis History of Present Illness: Patient is a 57 year old male with history of hepatitis C cirrhosis (acquired via blood transfusion) c/b grade I-II esophageal varices, episodes of SBP and hepatic encephalopathy who presents with fatigue and malaise. Patient had scheduled therapeutic paracentesis earlier today, but felt to weak to travel. [**Name (NI) **] wife called [**Hospital1 18**] hepatology division, with suggestion to proceed to [**Hospital1 18**] ED for evaluation. Patient endorses increasing fatigue over past few days. Associated diffuse abdominal pain. Denies fevers/chills. He also denies n/v/melena/BRBPR. His appetite has been okay. He also notes increased weight gain over past few days. He initially was evaluated OSH, and transferred to [**Hospital1 18**] ED for further management. . In the ED, initial vs were: T 102.4 P 83 BP 102/57 R 18 O2 sat 100% 2 liters n/c. RUQ u/s showed patent portal vein. Diagnostic para showed WBC > 4000. blood cultures were obtained, and patient was given a dose of vancomycin and pip-tazo. He was admitted to the ICU given concern for his initial work of breathing. . Upon arrival to the ICU, patient was complaining of LUQ and lower abdominal discomfort. He also noted some neck tenderness on the right, and was asking for another pillow. He was otherwise asymptomatic. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: (PER OMR) 1. Cirrhosis: - Secondary to hepatitis C (from blood txn) - Listed for liver transplant - AFP 2.3 ([**1-18**]) - 3 cords of grade II and 1 cord of grade 1 non-bleeding varices ([**1-17**]) - ascites requiring paracenteses q2-4 weeks previously but well controlled now - h/o hepatic encephalopathy - h/o SBP on cipro prophylaxis 2. Hepatitis C: - Genotype 1, Viral load 412,000 IU/mL ([**10-17**]) - failed interferon tx (thrombocytopenia) 3. History of CVA, [**2175**] w/ mild residual R sided weakness 4. Heterozygous for H63D for hemochromatosis 5. Hypertension 6. Osteoporosis 7. h/o PTX [**9-18**] with pleural effusion thought to be transudative by Pulm in clinic 8. progressive LE weakness thought to be [**3-14**] parkinsonism or manganism [**3-14**] chronic liver disease by Neuro in [**11-18**] 9. s/p R ankle fx in [**12-19**] Social History: (PER OMR) Married and lives with his wife. Formerly worked as a custodian. History of smoking but quit 10 years ago. Smoked 1ppd x [**8-17**] years. Denies alcohol or drug use. Family History: (PER OMR) Significant for Alzheimer disease in mother and an unspecified cancer in father and brother. Physical Exam: On admission: Vitals: T: afebrile BP: 90s/60s P: 70s R: 16 O2: 100% 2 liters n/c General: Alert, oriented, no acute distress HEENT: Sclera mildly icteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi, slightly decreased at right base CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, distended, tender in LUQ and lower quadrants without rebound or guarding, bowel sounds present, no rebound tenderness or guarding GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs II-XII intact, RUE and RLE 4/5 strength at baseline, no asterixis, sensation intact . Pertinent Results: [**2180-9-19**] 12:00PM BLOOD Neuts-74* Bands-9* Lymphs-5* Monos-9 Eos-0 Baso-0 Atyps-2* Metas-1* Myelos-0 [**2180-10-9**] 08:55AM BLOOD WBC-2.4* RBC-2.34* Hgb-8.1* Hct-23.5* MCV-101* MCH-34.7* MCHC-34.4 RDW-17.9* Plt Ct-30* [**2180-10-8**] 05:45AM BLOOD WBC-2.1* RBC-2.29* Hgb-7.9* Hct-23.5* MCV-102* MCH-34.4* MCHC-33.6 RDW-17.5* Plt Ct-40* [**2180-9-21**] 08:50PM BLOOD WBC-3.7* RBC-2.76* Hgb-9.6* Hct-28.6* MCV-104* MCH-34.8* MCHC-33.5 RDW-19.0* Plt Ct-21* [**2180-9-21**] 06:43AM BLOOD WBC-3.4* RBC-2.88* Hgb-9.9* Hct-29.1* MCV-101* MCH-34.4* MCHC-34.0 RDW-19.1* Plt Ct-29* [**2180-10-6**] 09:02AM BLOOD Neuts-85.7* Lymphs-5.7* Monos-5.2 Eos-2.8 Baso-0.6 [**2180-10-5**] 08:00AM BLOOD Neuts-78.7* Lymphs-6.9* Monos-10.6 Eos-3.3 Baso-0.5 [**2180-10-4**] 04:40AM BLOOD Neuts-70.4* Lymphs-13.5* Monos-10.7 Eos-4.8* Baso-0.6 [**2180-10-9**] 08:55AM BLOOD Plt Ct-30* [**2180-10-9**] 08:55AM BLOOD PT-22.9* PTT-49.9* INR(PT)-2.2* [**2180-10-8**] 05:45AM BLOOD Plt Smr-LOW Plt Ct-40* [**2180-10-8**] 05:45AM BLOOD PT-22.8* PTT-41.7* INR(PT)-2.2* [**2180-10-7**] 05:55AM BLOOD Plt Ct-36* [**2180-9-21**] 06:43AM BLOOD Fibrino-154 [**2180-9-21**] 12:21AM BLOOD Fibrino-153 [**2180-10-9**] 08:55AM BLOOD Glucose-122* UreaN-33* Creat-1.8* Na-138 K-3.9 Cl-101 HCO3-28 AnGap-13 [**2180-10-8**] 05:45AM BLOOD Glucose-120* UreaN-27* Creat-1.9* Na-138 K-4.0 Cl-101 HCO3-28 AnGap-13 [**2180-10-7**] 05:55AM BLOOD Glucose-130* UreaN-23* Creat-2.0* Na-138 K-3.7 Cl-101 HCO3-28 AnGap-13 [**2180-10-6**] 03:45PM BLOOD Creat-2.0* [**2180-10-2**] 05:06AM BLOOD Glucose-105* UreaN-16 Creat-1.6* Na-132* K-3.7 Cl-101 HCO3-21* AnGap-14 [**2180-10-1**] 12:43PM BLOOD Glucose-95 UreaN-15 Creat-1.5* Na-133 K-3.6 Cl-101 HCO3-26 AnGap-10 [**2180-9-29**] 05:00AM BLOOD Glucose-103* UreaN-15 Creat-1.5* Na-135 K-3.2* Cl-102 HCO3-25 AnGap-11 [**2180-9-28**] 07:20PM BLOOD UreaN-12 Creat-1.7* [**2180-9-28**] 08:58AM BLOOD Glucose-105* UreaN-13 Creat-1.5* Na-135 K-3.6 Cl-100 HCO3-27 AnGap-12 [**2180-9-26**] 11:56PM BLOOD Glucose-125* UreaN-11 Creat-1.2 Na-132* K-3.6 Cl-103 HCO3-23 AnGap-10 [**2180-9-26**] 04:51AM BLOOD Glucose-105* UreaN-11 Creat-0.9 Na-137 K-3.7 Cl-106 HCO3-23 AnGap-12 [**2180-9-25**] 06:14AM BLOOD Glucose-103* UreaN-12 Creat-0.8 Na-138 K-3.2* Cl-107 HCO3-25 AnGap-9 [**2180-10-9**] 08:55AM BLOOD ALT-5 AST-21 LD(LDH)-126 AlkPhos-47 TotBili-1.7* [**2180-10-8**] 05:45AM BLOOD ALT-5 AST-20 LD(LDH)-134 AlkPhos-49 TotBili-1.9* [**2180-10-7**] 05:55AM BLOOD ALT-5 AST-18 LD(LDH)-123 AlkPhos-43 TotBili-2.6* [**2180-10-6**] 09:02AM BLOOD ALT-10 AST-18 LD(LDH)-125 AlkPhos-44 TotBili-4.0* DirBili-0.9* IndBili-3.1 [**2180-9-21**] 06:43AM BLOOD ALT-14 AST-19 AlkPhos-47 TotBili-10.0* [**2180-9-19**] 12:00PM BLOOD ALT-27 AST-58* CK(CPK)-50 AlkPhos-115 TotBili-5.0* [**2180-10-6**] 09:02AM BLOOD GGT-10 [**2180-9-19**] 12:00PM BLOOD Lipase-40 [**2180-10-9**] 08:55AM BLOOD Albumin-4.7 Calcium-9.1 Phos-1.8* Mg-1.9 [**2180-10-8**] 05:45AM BLOOD Albumin-4.7 Calcium-9.4 Phos-1.8* Mg-2.0 [**2180-10-7**] 05:55AM BLOOD Albumin-4.6 Calcium-9.1 Phos-2.4* Mg-2.0 [**2180-9-18**] 02:25PM BLOOD PEP-POLYCLONAL IgG-2563* IgA-485* IgM-212 [**2180-10-1**] 05:37AM BLOOD Vanco-13.8 [**2180-9-30**] 06:16AM BLOOD Vanco-24.0* [**2180-9-29**] 05:00AM BLOOD Vanco-14.8 [**2180-10-7**] 09:43PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.020 [**2180-10-7**] 09:43PM URINE Blood-LG Nitrite-NEG Protein-25 Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2180-10-2**] 05:50PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2180-9-19**] 12:20PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG [**2180-10-5**] 09:46AM ASCITES WBC-60* RBC-380* Polys-5* Lymphs-63* Monos-26* Mesothe-2* Macroph-4* [**2180-10-3**] 06:02PM ASCITES WBC-150* RBC-390* Polys-5* Lymphs-35* Monos-22* Eos-1* Mesothe-1* Macroph-36* [**2180-9-22**] 04:02PM ASCITES WBC-625* RBC-2250* Polys-53* Lymphs-6* Monos-22* Macroph-19* [**2180-9-20**] 07:52PM ASCITES WBC-1850* RBC-5150* Polys-86* Lymphs-4* Monos-4* Macroph-6* . CT Abd/Pelvis IMPRESSION: 1. Little interval change to small bowel containing right inguinal hernia with dilated loops of mid and distal small bowel, upstream to this location and decompressed distal ileum distal to this location. Air and stool is noted within the large bowel, suggesting that this is likely a partial obstruction but can correlate with serial abdominal radiographs for contrast progression into the large bowel. 2. Slight interval redistribution of bilateral pleural effusions, now moderate-sized on the left and small on right. One-year stability to right middle lobe pulmonary nodule which is sub 4 mm in size suggesting benignity. 3. Unchanged atherosclerotic disease, infrarenal aortic aneurysm and cholelithiasis. 4. Known sequelae of underlying cirrhosis including splenomegaly and intra-abdominal collateral vessels consistent with underlying portal hypertension. 5. Large right hydrocele. Micro Blood cx [**9-21**]: SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 1 R RIFAMPIN-------------- =>32 R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S Blood cx [**9-19**]: Blood Culture, Routine (Final [**2180-9-25**]): 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 CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Peritoneal fluid [**9-19**]: 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 CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 57yo man with HCV cirrhosis c/b esophageal varices (grade 1), ascites, SBP, PSE, on transplant list, found to have SBP, and bacteremia. He completed the necessary course of ABx, and now with suspected hepatorenal syndrome. Also, new fevers with an unknown course. Being covered with ceftriaxone. . #. SBP - Diagnostic paracentesis (+) with 1850 WBCs upon admission, initially received Vancomycin + Zosyn, changed to Ceftriaxone on admission to MICU. Finished his course of CTX and subsequent paracenteses were negative for SBP. He was started on Cefpodoxime for PPX which was discontinued when he was reinitiated on ceftriaxone for new fevers (because of instrumentation w/ paracentesis on the day of his second large volume tap). He received an additional 6 days of ceftriaxone, and fevers resolved. He was afebrile for >36 hours after ceftriaxone was discontinued, and had no abdominal pain. He was started on cefpodoxime for SBP prophylaxis because the organism in peritoneal fluid was quinolone resistant and he has a bactrim allergy. . # Coagulase negative staph: He was also found to be bacteremic with pan sensitive coag negative staph. He was treated with vancomycin for a 14 day course. Surveillance cultures were negative. . #. HRS - His creatinine had worsened early in his course and returned to baseline with albumin treatment and eradication of his infection. His creatinine then bumped again to 1.2, and he had a large volume paracentesis. His creatinine bumped to 1.5 and 1.7. He was placed on octreotide, midodrine, and albumin. His creatinine remained 1.7-1.8. Octreotide and albumin both stopped and creatinine remained stable. He had minimal improvement to 1.6 on discharge. Diuretics were held on discharge. He was discharged on midodrine with plan for repeat labs on [**2180-10-16**] if able to be checked by VNA versus [**2180-10-17**] if this is not possible b/c of labor day holiday. . # Small bowel obstruction: He has a reducible inguinal hernia that has caused a partial SBO during admission. He is not a surgical candidate. Pt was asymptomatic. It seems to occur when he has accumulated a large volume of ascites. During paracenteses he needs it to be reduced to avoid strangulation and incarcerated hernia. His PO lactulose was being held for the partial SBO so we were giving PR. Once he was having bowel movements and tolerating PO intake, lactulose PO was restarted and was continued on discharge. Of note, all of his paracenteses were perforemd by IR, and he did have 4 L tapped prior to discharge on [**2180-10-12**]. . # Hyponatremia: He was hyponatremic at times during admission. It was likely hypervolemic hyponatremia, and it resolved during admission with paracentesis and holding diuretics. . #. Hepatitis C cirrhosis. Currently back on the liver transplant list. He was being worked up for [**State 108**], however, he became to ill, and remained in [**Location (un) 86**]. He did endorse a great deal of frustration, and did threaten to remove NGT placed for tube feeds b/c he felt, "what's the point if I won't get a liver?" These feelings seemed to resolve/improve on discharge, but patient's citalopram was increased from 10mg to 20mg. . # Varices: Nadolol was held given renal dysfunction and relative hypotension with SBPs in 90s and HR in 70's. If tolerated, may consider restarting as an outpatient. . # Osteopenia: Contact[**Name (NI) **] Dr. [**Last Name (STitle) 65808**] about starting once yearly bisphosphonate infusions, but now that patient's renal function is borderline, he would like to hold off. These medications require CrCl of 35 or greater, which Mr. [**Known lastname 13144**] is barely above. Furthermore, his alendronate was held on discharge b/c of new renal failure and also because of known esophageal varices. He will f/u with Dr. [**Last Name (STitle) 65808**] as an outpatient. Medications on Admission: spironolactone 200 mg QAM, 100 mg QPM androgel 50mg/5grams daily caltrate plus 600-400mg TID ciprofloxacin 250 mg daily citalopram 10 mg daily colace 100 mg [**Hospital1 **] compazine 10 mg [**Hospital1 **] PRN nausea folic acid 1 mg daily furosemide 80 mg daily lactulose 30-60 mg Q6H PRN nadolol 20 mg daily omeprazole 20 mg daily rifaximin 600 mg [**Hospital1 **] senna MVI Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO every six (6) hours. 3. Midodrine 10 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Caltrate 600+D Plus Minerals 600 mg (1,500 mg)-400 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 6. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO twice a day. 8. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO twice a day as needed for nausea. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a day. 12. Outpatient Lab Work Please have complete metabolic panel PROCESSED STAT, checked on the morning of Tuesday, [**2180-10-17**] and reported to [**First Name8 (NamePattern2) 6177**] [**Last Name (NamePattern1) **]/Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] PHONE: ([**Telephone/Fax (1) 3618**] FAX:([**Telephone/Fax (1) 8396**] 13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 14. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Primary diagnoses: Spontaneous Bacterial Peritonitis Hepatorenal syndrome Small bowel obstruction Coagulase-negative Staphylococcus bacteremia . Secondary diagnosis: Hepatitis C cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were initially admitted for increasing lethargy, increasing abdominal distension, and a high fever. You were seen at [**Hospital 7912**] and then transferred to us at [**Hospital1 18**]. When we removed fluid from your abdomen, it was found to be infected and you were started on antibiotics. You were also found to have an obstruction in your small bowel due to a hernia that seemed to resolve over time. Further blood testing showed that you had a blood infection and another set of antibiotics was prescribed to treat this. Your kidney function was decreased during the admission, likely due in part to your liver disease, and you were given albumin treatments to help this. Upon discharge, your kidney function did not improve to your previous baseline level, but was stable. The following changes have been made to your medications: 1. STOP spironolactone (because of your kidney function) 2. STOP furosemide (because of your kidney function) 3. STOP ciprofloxacin (because you are going to switch to a different antibiotic) 4. STOP nadolol (because of your kidney function and your blood pressure is low) 5. STOP alendronate (because of your kidney function, and your esophageal varices) 6. INCREASE citalopram 10mg daily to 20mg daily 7. START cefpodoxime 100mg daily to prevent infection in your abdomen. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 673**] Date/Time: Wednesday [**2180-10-18**] at 2:20 pm. (Transplant hepatology clinic) Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2181-9-18**] 8:00 Your visiting nurse will try to do your labwork on Monday. If it cannot be done on Monday, please have your labwork done first thing Tuesday morning and sent to [**First Name8 (NamePattern2) 6177**] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) 497**] at the transplant center. You are being provided with a prescription for this.

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icd9cm

[ [ [] ] ]

[ "54.91", "38.93", "97.49" ]

icd9pcs

[ [ [] ] ]

16574, 16633

10780, 14642

288, 314

16865, 16865

3933, 10757

18366, 19039

3074, 3178

15070, 16551

16654, 16799

14668, 15047

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229, 250

1656, 1990

342, 1638

16820, 16844

3207, 3914

16880, 16992

2012, 2862

2878, 3058

66,859

147,380

36698

Discharge summary

report

Admission Date: [**2153-6-14**] Discharge Date: [**2153-6-20**] Date of Birth: [**2069-10-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 458**] Chief Complaint: Symptomatic pauses, fractured RV lead of BiV pacer/ICD Major Surgical or Invasive Procedure: Temporary pacemaker placement RV lead extracted/replaced + new pacemaker placed History of Present Illness: 83 yo M with history of non-ischemic cardiomyopathy s/p dual chamber pacemaker placement in [**2143**] with upgrade to a dual chamber BiV in [**2149**]. He has had three syncopal episodes within the last week (two on [**6-10**] and one on day prior to admission), with most significant one the day prior to admission when he fell and hit his head on the plaster board. He was unable to be aroused for approximately 2 minutes according to his wife. [**Name (NI) **] [**Name2 (NI) 82999**] was able to be aroused, though was groggy. . At OSH ([**Hospital3 **] Hospital), he underwent head CT and was found to have a small subarachnoid hemorrhage. Cervical and lumbar spine CT were also performed prior to transfer with no evidence of fracture. He was seen in cardiology consultation and had his device interrogated. It was hypothesized at that time that his Fidelis RV lead had fractured, which was inhibiting V-pacing resulting in periods of asystole. The timing of these events coincides with his syncopal episodes. Attempts to program RV sensing off were unsuccessful. He was transferred to [**Hospital1 18**] have an extraction of the Fedelis lead and a new lead implantation. Of note, he was anticoagulated with warfarin for his atrial fibrillation and after INR was noted to be 2.6 at OSH, he was given Vitamin K 5 mg and then 2 units of FFP. . Upon arrival to the floor here the patient reports he had been having episodes of "wooziness" for approximately 2 weeks, noting "hundreds" of episodes where he has to sit down or slow his pace for fear of passing out. It was not until [**6-10**] that he actually passed out. . REVIEW OF SYSTEMS: (+)ve: presyncope, syncope, neck pain, constipation (-)ve: chest pain, dyspnea, orthopnea, PND, diarrhea, fever, chills, cough, loss of appetite, loss of bowel or bladder function, dysuria Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: None - PACING/ICD: s/p PCM [**2143**] upgraded to biV ICD for 3rd degree block - Atrial fibrillation - Non-ischemic cardiomyopathy - Complete LBBB vs. ?tachy-brady 3. OTHER PAST MEDICAL HISTORY: - CRI (Cr 1.7 at OSH) - Gout - Esophagitis - Temporal arteritis - s/p AAA repair - s/p aortic dissection with repair in [**2136**] Social History: Lives with wife and another couple in a single family home within [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Community. Patient and his wife have five children (3 daughters and 2 sons). -[**Name2 (NI) 1139**] history: denies. -ETOH: rare. -Illicit drugs: denies. Family History: Mother died from lung cancer and father died from colon cancer. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: GENERAL: WA elderly man in NAD. Oriented x3. Mood, affect appropriate. HEENT: Contusion of left posterior scalp with ecchymosis extending from site of injury down left posterior neck, became nontender by HD#6. PERRL/EOMI. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Wearing soft collar on admission --> later removed. No JVD, hepatic reflux. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1-S2. +III/VI SEM @ LUSB. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: NABS, soft/NT/ND. No HSM or tenderness. Abd aorta not enlarged by palpation. EXTREMITIES: WWP, no c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. +Large non-tender ecchymotic area over left posterior scapula. Mild ecchymosis of left buttocks. NEURO: A&Ox3, CNs II-XII intact, strength 5/5 throughout, sensation grossly intact to light touch throughout PULSES: Right: Radial 2+ DP 1+ PT 1+ Left: Radial 2+ DP 1+ PT 1+ Pertinent Results: [**2153-6-14**] 141 102 45 107 AGap=14 3.7 29 1.7 estGFR: 39/47 (click for details) Mg: 2.4 102 8.2 11.2 152 33.5 PT: 19.2 PTT: 29.8 INR: 1.8 [**2153-6-14**] Head CT non-con 1. Bilateral subacute hemispheric subdural hematoma measuring 6 mm. 2. Hyperdense material noted within the basal cisterns is reminiscent of prior subarachnoid hemorrhage. 3. Hyperdense focus located adjacent to the left lateral ventricle may represent a focus of intraparenchymal hemorrhage or cavernous malformation or developmental venous anomaly. For further evaluation of the latter MR with contrast can be obtained. 4. Small amount of left occipital subgaleal hematoma. [**2153-6-20**] Head CT non-con (prior to discharge) PFI: No acute intracranial process. Bifrontal subdural hematomas are decreased in attenuation, consistent with evolution of blood products. Minimal subarachnoid blood is also again noted. There is no mass effect, midline shift, hydrocephalus, or evidence of acute ischemia. TTE [**6-16**] The left atrium is moderately dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate global left ventricular hypokinesis (LVEF = 30-35%). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension (may be underestimated secondary to high right atrial pressure). There is no pericardial effusion. IMPRESSION: Moderate global left ventricular systolic dysfunction. Dilated right ventricle with mild global systolic dysfunction. Mild aortic regurgitation. Moderate mitral regurgitation. Severe tricupsid regurgitation, mostly around the multiple pacemaker/defibrillator leads. At least moderate pulmonary hypertension. [**2153-6-19**] EKG Ventricular paced rhythm. Compared to the previous tracing of [**2153-6-16**] no change. Brief Hospital Course: 83-yo man with HTN, Afib on coumadin, non-ischemic CMP, ?h/o tachy-brady versus complete heart block, s/p dual chamber pacemaker in [**2143**] with upgrade to dual chamber BiV [**2149**], who presents with presyncope/syncope, falls, and SDH/SAH on NCHCT, found to have a likely fractured RV lead resulting in episodes of syncope, now s/p temporary pacing wire placement in right IJ by EP and awaiting lead revision. . #. RHYTHM: 83-yo man with hypertension, atrial fibrillation, non-ischemic cardiomyopathy, and ? h/o tachy-brady versus complete heart block, s/p dual chamber pacemaker placement in [**2143**] with upgrade to dual chamber BiV in [**2149**]. In recent weeks he has been having frequent episodes of dizziness and feeling faint, as well as three syncopal episodes in the last week, most recently one day prior to admission when he fell and hit his head and was unarousable for approx 2 minutes. At [**Hospital3 **] Hospital, he underwent a NCHCT that revealed a small SAH. C-spine and L-spine CTs did not show any evidence of fracture. Cardiology was consulted and his device was interrogated, and he was found to be having episodes of asystole that were felt to coincide with these events. It is hypothesized that his Fidelis RV lead is fractured which is inhibiting V-pacing and resulting in these episodes of asystole, and attempts to program RV sensing off were unsuccessful, so he was transferred to [**Hospital1 18**] for extraction of the Fidelis lead and implantation of a new lead. He is anticoagulated with an INR of 2.6, so received 5mg PO Vitamin K and 2units FFP prior to transfer. . On transfer to [**Hospital1 18**], he was continued on his home BB and amiodarone, but he continued to have symptomatic pauses as long as 6-7 seconds overnight, with an episode of syncope that correlated with a pause on telemetry. He was seen by EP, who attempted to adjust his pacemaker settings, but he was ultimately taken to the EP lab for placement of a temporary pacing wire [**6-15**]. He was transferred to the CCU for continued monitoring and remained stable. Pt remained stable over the weekend and did not become bradycardic or hypotensive. Pt went for pacemaker revision on [**6-18**]. Pt did well and was transfered back to the floor. Pt did not develop any complications from the procedure. . #. SDH/SAH: Post-traumatic in setting of syncope/fall while therapeutic on coumadin with INR 2.8. At [**Hospital3 **] Hospital, he underwent a NCHCT that revealed a small SAH. C-spine and L-spine CTs did not show any evidence of fracture. At [**Hospital1 18**] he was also seen by Neurosurgery and underwent urgent NCHCT, which revealed bilateral subacute-chronic hemispheric SDH, acute post-traumatic SAH, a small subgaleal hematoma, and cavernous malformation versus parenchymal hemorrhagic contusion. This was not felt to be significantly different from the serial NCHCTs he received at OSH prior to transfer. He was placed in a soft collar for comfort and received an additional 2mg PO Vitamin K and 2units FFP for INR 1.8, with unremarkable neuro checks overnight. He received a total of Vitamin K 7mg PO and 4units FFP w/ INR 1.4. Neurologically intact without concerning neuro checks and SDH/SAH stable per NSG. His C-spine was clinically cleared on [**6-16**]. Pt had repeat CT heads without signficant interval change. Pt is to have a repeat CT head on [**6-21**] and follow up with Neurosurgery with Dr. [**Last Name (STitle) **] in 1 mo. Pt also received 3d of Vancomycin prior to procedure. Vancomycin was d/c'd on [**2153-6-19**] and switched to 7 day course of Levofloxacin. # PUMP: ECHO: EF 30-35% Moderate global left ventricular systolic dysfunction. Severe tricupsid regurgitation, mostly around the multiple pacemaker/defibrillator leads. Pt was hypervolemic and pt was diuresed while in the CCU with torsemide 60 daily, spironolactone 25 daily, and was negative 1L prior to procedure, but still had bilateral rales and received another lasix 40mg IV x1 prior to procedure. Pt stable for discharge on [**6-19**] per EP and CCU but desaturated to 88% on NC when wean attempted. CXR suggested fluid overload so pt diuresed and was able to wean on [**6-20**]. Pt sent home w/ VNA services (Physical Therapy) and cardiology/neurosurgery followup instructions Medications on Admission: - spironolactone 25mg PO daily - colchicine 0.6mg weekly on Sundays - omeprazole 20mg PO daily - metoprolol 50mg PO BID - amiodarone 200mg PO daily - torsemide 60mg PO daily - warfarin 2.5mg PO daily - allopurinol 200mg PO daily - centrum silver MVI PO daily - potassium daily Discharge Medications: Torsemide 60mg PO daily after 2 days Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: Primary: Right ventricle lead fracture Secondary: Syncope, Subdural Hematoma, Hypertension Non-ischemic cardiomyopathy, atrial fibrillation, complete left bundle branch block vs. tachy-brady syndrome, chronic renal insufficiency (creatinine 1.7) Discharge Condition: Stable, good. Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were transferred to [**Hospital1 18**] for revision of your pacer lead. You had been feeling dizzy and light-headed as well as fallen multiple times. It was thought that your pacemaker was not working properly. You had a temporary pacemaker placed intially and then you underwent lead revision. > We made the following changes to your meds: Increase your Torsemide dose to 80 mg, TID for the next two days. Resume regular dose of 60 mg, TID afterwards Started an antibiotic, Levofloxacin, to be taken daily until [**2153-6-26**] Started Aspirin 325 mg daily Stopped your Warfarin; please do not restart until you have been seen by Dr. [**Last Name (STitle) **] > If you develop any symptoms of pain/swelling over pacemaker site, experience dizziness/new falls or fainting, come back in to the [**Hospital1 18**] Emergency Room. Also contact medical personnel for fevers/chills/chest pain or with any questions or concerns. You were also found to have a bleed in your head. You were seen by neurosurgery and no intervetion was performed. You had a head CT-scan that showed that your bleed was stable. Please follow the medications prescribed below. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: Please follow-up with your cardiologist, Dr. [**First Name (STitle) 2405**], (or his Device Clinic nurse) this [**Last Name (LF) 2974**], [**6-22**] @ 8:45AM. Please follow-up w/ Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] with Neurosurgery. Please call his office at [**Telephone/Fax (1) 2731**] for an appointment within the month. Please follow-up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 83000**]

[ "E888.9", "852.21", "996.04", "427.31", "425.4", "852.01", "585.9", "403.90" ]

icd9cm

[ [ [] ] ]

[ "37.79", "37.75", "37.78" ]

icd9pcs

[ [ [] ] ]

11419, 11480

6731, 11030

370, 452

11770, 11786

4463, 6708

13277, 13815

3123, 3302

11358, 11396

11501, 11749

11056, 11335

11810, 13254

3317, 4444

2426, 2642

2125, 2316

276, 332

480, 2106

2673, 2806

2338, 2406

2822, 3107

52,064

108,577

35432

Discharge summary

report

Admission Date: [**2138-2-6**] Discharge Date: [**2138-2-18**] Date of Birth: [**2061-10-8**] Sex: F Service: SURGERY Allergies: Codeine / Ibuprofen Attending:[**First Name3 (LF) 695**] Chief Complaint: Biliary hilar stricture c/w concern for cholangiocarcinoma Major Surgical or Invasive Procedure: [**2138-2-13**]: ERCP [**2138-2-17**]: Bilateral Wallstent placement History of Present Illness: 76 y.o. F with multiple CV problems transferred from [**Name (NI) **] for concern of cholangiocarcinoma. Over 2 weeks, patient had increased pruritus. U/S of liver showed ductal dilatation with bilirubin elevation. GI at [**Hospital1 **] performed ERCT [**2138-2-5**] with sphincterotomy with stent (8.5Fr 12 cm). ERCP findings concerning for cholangiocarcinoma with hilar stricture c/w cholangiocarcinoma on right side Past Medical History: CAD s/p pacemaker, s/p cath [**2133**]: 70% stenosis, HTN, DM, h/o DVT/PE, pancreatitis PSH: s/p TKA [**2135**], SBR ? diverticulitis Social History: widowed with children denied etoh/smoking/illicit drugs independent at senior living Brief Hospital Course: On [**2138-2-7**], a cholangiogram was performed to evaluate the bile duct anatomy. This demonstrated severely dilated left-sided hepatic ducts with high- grade stricture approximately 2 cm in lenght extending from the confluence of the common hepatic and left hepatic ducts to just central to the confluence of the segment II and segment III left hepatic ducts. Mildly dilated right anterior ducts were noted with a stricture in the central right anterior ducts as well as a markedly dilated gallbladder were also noted. The patient's post ERCP plastic stent was noted within the common duct with extension superiorly into the superior common hepatic duct. The right posterior ducts were not visualized likely due to high grade stricture or obstruction of central right posterior ducts. An 8 French internal/external biliary drain was placed via the left biliary system after cholangioplasty of strictured region to 5 mm. On [**2-9**] she spiked a temperature to 102.5 with chills. Blood and urine cultures were done. All were negative. On [**2-10**], bile was sent for culture growing Klebsiella pneumoniae. Unasyn had been started prior to the Cholangiogram and this was continued for 5 days until bile cultures revealed that Klebsiella sensitivity to Unasyn was indeterminate. It was otherwise pansensitive. Unasyn was switched to Cipro on [**2-12**] after 5 days of Unasyn. Fever resolved. Overall, LFTs trended down. On [**2-9**], a triple phase CT was done showing a large Klatskin-type hilar mass with imaging characteristics compatible with a cholangiocarcinoma. There was intrahepatic bile duct dilatation in all segments except for segment III, where there was an internal-external biliary drain and a biliary stent. The left portal vein was completely encased by tumor and minimal enhancing portal vein is seen. There were numerous enlarged porta hepatis lymph nodes. A small anterior pelvic wall hernia and small pleural effusions were noted. A cardiac workup was started with TTE noting LVEF of 45-50%, mild to moderate MR, mild pulmonary systolic HTN. Of note, on [**2-12**], she had an episode of L chest pain when transferring from chair to bed. O 2 2 liters and NTG 0.4 sl was given with relief. EKG was unchanged, cardiac enzymes were negative. She had no further episodes of chest pain. It was noted that her hct was 26 and she was given 2 units of PRBC. Hct increased to 33. On [**2-13**], an ERCP was performed to remove the previously placed stent at OSH. She did have a questionable run of V tach after the procedure. She then underwent placement of left and right wall stents with placement of PTCs thru the wall stents. Findings were notable for a Klatskin type biliary stricture at confluence of central right and left ducts extending to upper common hepatic duct (obstructive on right), this was balloon dilated. Metallic biliary stenting with two 8mm Wallstents deployed side by side and extended into the right and left hepatic ducts crossing the stricture at the confluence of the right hepatic ducts. Ursodiol was started. The next day, IR removed the right and left PTCs that were thru the wall stents as stents were in satisfactory position. LFTs trended down post procedure. Post procedure, she was hypertensive requiring iv hydralazine. She was transferred to the SICU overnight for management. She was extubated and then transferred back to the med-[**Doctor First Name **] unit. Her case was presented at the Tumor Board and she was found to be unresectable. After discussing findings with the patient and her family, an Oncology Consult was obtained. Dr. [**Last Name (STitle) **] met with her and discusses possible options. A chest CT was recommended to evaluate for any possible metastatic lesions for staging. This showed a few scattered peripheral lung nodules as described, with the largest measuring 5 mm in the right upper lobe. Small bilateral pleural effusions and mild intralobular septal thickening at the lung bases was noted. A density in the subcarinal station may represent fluid in a pericardial recess versus an enlarged lymph node. Calcified granuloma in the lung and several in the spleen were consistent with prior granulomatous exposure. A follow up outpatient appointment with Oncology was set up to discuss options. PT declared her safe for discharge to home. VNA services were arranged. She was discharged with stable vital signs. Medications on Admission: asa 81', labetalol 200'', lasix 20', simvastatin 400', metformin 1000', glyburide 2.5' Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day for 21 days. Disp:*21 Tablet(s)* Refills:*0* 3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 5. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Increased dose. Disp:*90 Tablet(s)* Refills:*2* 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Unresectable cholangiocarcinoma Discharge Condition: Stable Discharge Instructions: Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] if you develop fever, chills, abdominal pain, increased yellowing of eyes or skin, [**Male First Name (un) 1658**] colored stools or other concerning symptoms. You will be following up with Dr [**Last Name (STitle) **] as an outpatient for further evaluation of treatment options Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2138-3-5**] 9:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12766**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2138-3-5**] 9:30 [**Hospital Ward Name 23**] Building [**Location (un) 24**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2138-2-20**]

[ "996.01", "577.1", "416.8", "401.9", "424.0", "V43.65", "414.01", "E879.8", "155.1", "V45.01", "576.2", "E849.8", "428.0", "553.20", "250.00", "427.1" ]

icd9cm

[ [ [] ] ]

[ "51.10", "51.98", "87.51", "89.45", "97.05" ]

icd9pcs

[ [ [] ] ]

6312, 6361

1138, 5545

336, 407

6437, 6446

6858, 7354

5682, 6289

6382, 6416

5571, 5659

6470, 6835

238, 298

435, 856

878, 1013

1029, 1115

5,727

160,367

51961

Discharge summary

report

Admission Date: [**2158-3-10**] Discharge Date: [**2158-3-15**] Date of Birth: [**2096-11-3**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 678**] Chief Complaint: Fever Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: 61 y/o M with hx of ESRD, DM, CAD, afib, hyperlipidemia who presents to the hospital today with 24 hours of fevers, chills, cough and chest pain. He had been in his usual state of health until today when these symptoms started. His cough is productive of white phlegm. Of note, he had rescheduled his [**First Name3 (LF) 2286**] (which is usually T/T/Sat) for today, but didn't go because he wasn't feeling well. Also, yesterday he had a fall and lost consciousness after he hit his head on a beam while doing some work. He has no bruises or headaches today. No confusion. . In the ED, his initial vitals were T 101.9, P 100, BP 184/108, R 20 and 99% 15L NRB. He received 2 SLNG for chest pain. He received vanco and unasyn in the ED for a RLL pneumonia. Renal was called and patient is to be urgently dialyzed tonight for fluid overload. Of note, he admitted to using crack cocaine yesterday. Past Medical History: 1. ESRD on HD T/Th/Sa at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] [**Last Name (NamePattern1) **], [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**], [**Telephone/Fax (1) 69669**] 2. Type 2 diabetes mellitus c/b peripheral neuropathy 3. CAD: On review of records, he had demand ischemia in [**9-/2155**] with no flow-limiting stenoses on cardiac cath. MIBI in [**11/2152**] showed reversible defects inferior/lateral. Baseline troponin 0.2-0.4. Cath in [**2155**] - normal coronaries. 4.Chronic systolic CHF with EF 30% ([**10/2156**] TTE) 5. Atrial fibrillation/AFlutter s/p ablation [**2153**]; h/o atrial tachycardia s/p EPS [**9-21**] and ablation x 2. not on coumadin due to history of GIBs. 6.Hypertension 7. Dyslipidemia: [**9-/2155**] TC 101, LDL 54, HDL 29, TG 112 8. History of GI bleeds: Duodenal, jejunal, and gastric AVMs s/p thermal therapy; diverticulosis throughout colon 9. Chronic pancreatitis 10. Possible Hepatitis C infection, HCV Ab + [**10/2150**], but neg [**2154**] - GERD - Gout - s/p arthroscopy with medial meniscectomy [**5-/2149**] - Depression with multiple hospitalizations due to SI - Polysubstance abuse: crack cocaine, EtOH, tobacco - frequent bouts of chest pain following crack/cocaine use - Erectile dysfunction s/p inflatable penile prosthesis [**5-/2148**] - H/o C diff in [**2156-8-14**] Social History: Per previous notes, patient reports a 42 pack-year smoking history. He currently smokes [**2-16**] cigarettes per day. He has a history of alcohol abuse, with DTs and detoxification, with last drink reportedly > 1 year ago. Pt has used crack cocaine for years, approx 2-3x/wk. Lives with his girlfriend. Family History: Mother had ESRD on HD, died from MI at the age of 58. 4 Brothers and 2 sisters, nearly all with DM2. Physical Exam: ICU: Vitals: 99.1, 152/78, 99, 20, 100% on NRB Transfer to floor: VS: Tc 98.5, Tm 103.4, BP: 116/62, P: 101, RR: 20, 93% on 2L NC GA: AOx3, NAD HEENT: presbycusis, PERRLA. MMM. no LAD. no JVD. neck supple. Chest: multiple open/closed comedomes over anterior chest, No RVH. RRR S1/S2 heard. [**2-19**] holosystolic murmur over LUSB Pulm: CTAB at anterior, middle lungs, crackles over bilateral bases along with rhonchi over R base Abd: soft, mildly TTP in epigastrium, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. Extremities: wwp, no edema. DPs, PTs 2+. Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. sensation intact to LT. +asterixis Discharge: 97.7 (tmax 98.3) 144/91 (132-144/70-91) 95 20 95% 2L GA: AOx3, NAD HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. Chest: RRR S1/S2 heard. [**3-19**] holosystolic murmur over LUSB Pulm: crackles at bases bilaterally, +diffuse expiratory wheeze Abd: soft, mildly TTP in epigastrium, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. Extremities: wwp, no edema. DPs, PTs 2+. Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. sensation intact to LT. +asterixis Pertinent Results: Admission Labs: CBC: WBC-7.3 RBC-4.09* Hgb-12.4* Hct-36.3* MCV-89 MCH-30.2 MCHC-34.0 RDW-14.5 Plt Ct-156 Diff: Neuts-84.6* Lymphs-8.8* Monos-3.6 Eos-2.2 Baso-0.8 Chemistries: Glucose-171* UreaN-63* Creat-10.2*# Na-133 K-7.0* Cl-95* HCO3-20* Calcium-9.5 Phos-4.8* Mg-3.1*Cardiac Biomarkers: cTropnT-0.26* proBNP-[**Numeric Identifier 18816**]* CXR [**3-11**]: Pulmonary edema, small right pleural effusion, stable cardiomegaly. Repeat CXR [**3-15**]: Substantial improvement in pulmonary edema with residual small effusions. Right lower lobe opacity most likely reflect residual edema, and/or atelectasis. Infection is not totally excluded Brief Hospital Course: 61 y/o M with hx of ESRD, HTN, HL, CAD, Afib, GI bleeds, and substance abuse who presents with fevers, chills and SOB, due to healthcare associated PNA. # Fevers / Pneumonia: On arrival to the ICU he was treated with vancomycin, cefepime and azithomycin as above. Nasal swab was negative for influenza. Azithromycin continued for 5 day course, vancomycin and cefepime total 8 day course. Pt was afebrile for >48 hrs prior to discharge. After discharge, he should receive two more doses of vancomycin (to be dosed with [**Month/Day (2) 2286**]) and cefepime 500 mg IV q24H on Thursday [**3-16**] and Saturday [**3-18**]. . # Hypoxemia: Likely secondary to PNA and fluid overload. Patient was taken urgently to hemodialysis where 4.5L of fluid were removed. He was treated with vancomycin, cefepime and azithomycin for suspected pneumonia. His oxygen requirement decreased to 2L NC after [**Month/Day (1) 2286**]. Continued to be hypoxic after transfer to floor, and had rales on exam. After two more [**Month/Day (1) 2286**] sessions, patient was taken off oxygen and O2 sats were mid 90s on room air. . # ESRD: HD was performed urgently on admission and 4.5L of fluid was removed. Given the dramatic improvement in his respiratory status, repeat session was delayed. Received 2 more sessions of HD while inpatient. . # Atrial fibrillation/atrial tachycardia: Patient was continued on home doses of amiodarone and diltiazem. He had two episodes of afib with RVR with rates in the 170s and was given diltiazem 10mg IV with excellent rate control. Metoprolol was avoided in the setting of his cocaine use. He remained in sinus with rates of ~100. He was not anticoagulated given h/o GI bleed. Initially, was on diltiazem 120 mg QID for frequent episodes in ICU, however was decreased to home dose of 360 mg ER daily prior to discharge. Multiple episodes of 2:1 AV block were noted in pt overnight, however this had been noted in the past so diltiazem was continued. He has a follow up appointment scheduled with his cardiologist. . # Hyperkalemia: K was elevated at 5.4 on admission with no EKG changes. He was given kayexalate with improvement of his K. Was no longer hyperkalemic. . # HTN: Patient was kept on diltiazem. Lisinopril initlaly held for increased Cr, but restarted after [**Month/Day (1) 2286**] at lower dose of 10 mg daily. . # Hyperlipidemia: Patient was continued on his home statin. . # DM: continued on home insulin sliding scale Medications on Admission: Albuterol MDI Amiodarone 200 mg daily Atorvastatin 20 mg daily Diltiazem ER 360 mg daily Gabapentin 100 mg [**Month/Day (1) 5910**] Lantus 14 u [**Month/Day (1) 5910**] with Humalog SS Lisinopril 40 mg daily Percocet 5-325 mg daily PRN prior to HD Protonix 40 mg daily Senna/Docusate PRN Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze, shortness of breath. 2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). 5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO at bedtime. 6. insulin glargine 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous at bedtime. 7. insulin lispro 100 unit/mL Cartridge Sig: 2-10 units Subcutaneous four times a day: per sliding scale. 8. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual q5minutes as needed for chest pain: do not take more than 3 doses, call doctor if taking. 10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours as needed for pain: before and after [**Month/Day (1) 2286**], as needed for pain. 12. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. vancomycin 1,000 mg Recon Soln Sig: HD dosing Intravenous once a day for 2 doses: to be dosed with HD on [**3-16**] and [**3-18**]. 16. cefepime 1 gram Recon Soln Sig: Five Hundred (500) mg Injection Q24H (every 24 hours) for 2 doses: to be given at HD on [**3-16**] and [**3-18**]. 17. sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO three times a day: take with meals. Disp:*180 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Pneumonia End-stage renal disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen in the hospital for cough which was most likely due to pneumonia. For this, you were treated with IV antibiotics and improved. You will continue to get antibiotics while at [**Month/Day (1) 2286**] on Thursday [**3-16**] and Saturday [**3-18**]. For your heart failure, weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Changes to your medications: DECREASE lisinopril to 20 mg daily (you can take half of a 40 mg pill) INCREASE sevelamer to 1600 mg three times a day with meals START taking vancomycin IV at [**Name8 (MD) 2286**] for two more doses START taking cefepime IV at [**Name8 (MD) 2286**] for two more doses Followup Instructions: Department: [**Hospital3 249**] When: WEDNESDAY [**2158-3-22**] at 10:10 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2158-3-27**] at 1:30 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DERMATOLOGY When: WEDNESDAY [**2158-4-5**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16424**], MD [**Telephone/Fax (1) 1971**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PODIATRY When: WEDNESDAY [**2158-4-26**] at 10:30 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: ORTHOPEDICS When: WEDNESDAY [**2158-4-26**] at 11:50 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: WEDNESDAY [**2158-4-26**] at 12:10 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 17785**],MD [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**] Completed by:[**2158-3-16**]

[ "250.60", "428.0", "272.4", "428.22", "276.7", "486", "V45.11", "427.31", "585.6", "403.91", "357.2", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

9612, 9618

4922, 7390

274, 289

9696, 9696

4254, 4254

10548, 12501

2950, 3052

7729, 9589

9639, 9675

7416, 7706

9847, 10224

3067, 4235

10253, 10525

229, 236

317, 1213

4270, 4899

9711, 9823

1235, 2612

2628, 2934

77,502

151,200

45943

Discharge summary

report

Admission Date: [**2183-3-14**] Discharge Date: [**2183-3-21**] Date of Birth: [**2120-12-7**] Sex: F Service: MEDICINE Allergies: Captopril / Aspirin / Tetracycline / Erythromycin Base / Penicillins / Motrin / Wellbutrin Attending:[**First Name3 (LF) 2763**] Chief Complaint: SOB w/ exertion Major Surgical or Invasive Procedure: ... History of Present Illness: 62F with h/o COPD on 3L home O2, sCHF s/p ICD/Ppm, HTN, DM2 presents from [**Hospital3 2558**] with worsening SOB with exertion x 2 days. . Of note, the patient was recently admitted to [**Hospital1 112**] from [**2-21**] to [**2-27**] for a facial burn sustained when she tried to smoke a cigarette while on oxygen via nasal cannula. She was initially on BiPap in the ED, was given high-dose steroids. Bronchoscopy showed no airway edema or soot. On [**2-22**], she had flash pulmonary edema and was treated with 40 mg IV Lasix. She was discharged on her home meds and Prednisone taper. . She notes that yesterday she tried to be more active and was getting up and moving around more and noticed that she felt more short of breath doing activities - felt she couldn't catch her breath. She was on her usual 3L nc at that time and didn't try to increase the rate. She took a Duoneb inhaler yesterday, which helped her SOB. Then this morning, she noticed that she again had trouble catching her breath with activity. Duoneb inhaler was given without improvement. She was given 40 mg Prednisone (takes 20 mg chronically) and was brought to the ED. . In the ED, initial vitals 97.0 128 (sinus) 144/93 20 100% on 2L (home requirement is 3L). Exam was notable for absence of wheezing, absence of significant crackles, and no LE edema. Labs revealed Cr 0.5, WBC 17.1, Hct 27.5. CT-A was performed and showed no PE; did reveal emphysema and a 7 mm LLL pulmonary nodule. CXR showed COPD, dual-chamber Ppm/AICD, flat diaphragms, and large cardiac silhouette - no infiltrate or edema. She was given 1L NS, Solumedrol 125 mg, 5 mg Oxycodone for face/hand pain, and Levaquin 750 mg IV. She was then transferred to the floor. . Currently, VS are 115 159/83 18 99% on 3L. The patient generally appears to be breathing comfortably and is in no apparent distress. She speaks in full sentences. She denies recent cough. Denies fevers/chills, no chest pain, no n/v, dysuria, no recent illness. She did have her flu vaccine this year. ROS is positive for diarrhea for a few days that resolved one week ago, recent PND - was been waking up more often feeling SOB, orthopnea - 1 pillow chronically, has gained [**4-11**] pounds over 1.5 months. Past Medical History: COPD on 3L home O2 with multiple hospitalizations; was in ICU for COPD exacerbation in [**1-17**] - FEV1 27% in [**12/2171**] systolic CHF with dual chamber pacemaker and AICD -placed [**12/2171**] -dilated cardiomyopathy with EF = 20-25% from ?year TB - treated in [**2168**], had RUL wedge resection paroxysmal Afib? GERD Anxiety HL OA GI bleed [**3-12**] duodenal/gastric ulcer Osteoporosis Vtach Gastric ulcer DM - type 2 HTN Macrocytic anemia Chronic leukocytosis s/p myomectomy in [**2166**] s/p C-section Social History: Retired LPN - worked at [**Hospital3 **], LT care, substance abuse facility. Before going to [**Hospital3 **], lived at home with daughter [**Name (NI) 97832**]. Ambulates with a walker. Occasionally needs help with dressing, feeding. + tob - 60 pack-year history, states she quit after recent burn History of heavy EtOH, none since [**5-18**] No drugs Family History: HTN, Dementia Physical Exam: On admission: VS - AF 115 159/83 18 99% on 3L GENERAL - elderly AAF appears older than state age, breathing comfortably in NAD, pleasant, a&ox3 HEENT - face with obvious burn on upper lip and tip of nose, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - poor air movement throughout, few bibasilar crackles, no wheezing, no accessory muscle use HEART - RRR, no MRG, nl S1-S2, ?additional heart sound vs. split S1 ABDOMEN - C-section scar, soft/NT/ND, NABS, no masses or HSM, no rebound/guarding EXTREMITIES - thin, WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-13**] throughout but equal bilaterally, sensation grossly intact throughout, gait deferred Pertinent Results: On admission: 137 92 14 ------------< 121 4.8 35 0.5 . 17.1>---< 299 27.5 Diff: 79N, 14L, 4M, 3E . proBNP 4125 . PT 11.8 PTT 25 . U/A neg . [**3-14**] Urine and blood cultures: pending . CT-A: (wet read) -no PE -emphysema - 7 mm LLL pulmonary nodule . Admit CXR: (wet read) - COPD, ?lung reduction surgery, dual chamber Ppm and AICD, flat diaphragms, enlarged cardiac silhouette . EKG: Sinus tach, rate 121; LAD, ?LA enlargement, < 2mm STE in V2, V3, lead V4-V6 difficult to interpret [**3-12**] baseline artifact . Brief Hospital Course: 62F with h/o COPD on 3L home O2, sCHF s/p ICD/Ppm, HTN, DM2 presents from [**Hospital3 2558**] with worsening SOB with exertion x 2 days . # SOB: On presentation to the ED, the patient appeared to be breathing comfortably; she was satting 99% on her home O2 requirement of 3L. CXR showed no infiltrate or evidence of edema. CT-A was negative for PE. Exam revealed no wheezing or significant crackles. She had been given 40 mg Prednisone at [**Hospital3 2558**]. She received an additional 125 mg of Solumedrol in ED and a dose of 750 mg IV Levaquin. On the floor, she appeared comfortable. Antibiotics were discontinued. Nebulizers were administered prn. On [**3-15**] AM, the patient became acutely SOB after getting up to go to the bathroom. O2 sats were 95% on 2L. CXR showed acutely worsened vascular congestion. She was given 80 mg IV Lasix with some improvement but still appeared to be in significant respiratory distress. She was transferred to the ICU. In the MICU, she diuresed approximately 1.5 L from one dose of Lasix 80 mg IV. She was noted to be tachypneic with minimal movements but did not desaturate, so she was eventually transferred back to the floor on [**2183-3-16**]. Please see COPD section for remainder hospital course. . # COPD: FEV1 listed as 27% in 11/[**2171**]. States that she hasn't seen pulmonologist in a while but thinks she needs to see one given multiple recent admits to [**Hospital1 112**]. 125 mg IV Solumedrol was given initially in the ED. Bactrim DS 1 tab M/W/F was continued. Home inhalers - Advair, Spiriva were continued. On transfer to the ICU, patient started on Levofloxacin daily for COPD exacerbation, as patient has significant allergies to PCNs and macrolides. Continued Prednisone 60 mg PO daily with a 2-week taper. Attempted to use BiPAP but patient did not tolerate well due to facial burns. She was noted to be tachypneic with minimal movements but did not desaturate, so she was eventually transferred back to the floor on [**2183-3-16**]. On the floor, she developed increased work of breathing and tachycardia. Her O2 saturation at this time was noted to be 100% on 3L. She had an ABG on this O2 saturation, which demonstrated pH 7.32, pCO2 of 71, and pO2 of 132. Given that her hypercarbia was felt secondary to high O2 administration in the setting of COPD, her oxygen was titrated down to 1 L, with resulting desaturation to 85 %; she was then tried on CPAP, which she failed to tolerate, and she was then restarted on 3 L NC with improvement back up to 100%. As she was thought to be dry on physical exam, she was given 250 cc NS. Her EKG was unchanged. She was given Morphine 2 mg IV and was transferred back to the MICU on [**2183-3-17**] for increasing nursing demand. Over the next several days in the ICU, her ABGs continued to improve. Her Advair was increased to 500/50. Her respiratory improved to the point that she was called out to the floor for several days but a bed was not available. Anxiety and pain were thought to be a large contribution to her dyspnea; her symptoms much improved with Ativan and Morphine as needed. She worked with physical therapy daily to help maintain her strength. On [**2183-3-21**], a bed became available at the [**Hospital3 2558**] so she was discharged directly from the MICU. . She will need repeat CT chest in 6 months for pulm nodule and outpatient pulmonologist follow up for repeat PFTs. . # Chronic sCHF with dilated CM (EF 20-25%) from ?year. On initial presentation, did not appear overloaded on exam. She was given gentle IVF in the ED and on the floor our of concern for history of recent diarrhea and sinus tachycardia. As above, on [**3-15**], the patient had a likely episode of flash PE when getting up to go to the bathroom. In the MICU, she diuresed approximately 1.5 L from one dose of Lasix 80 mg IV. Her home Torsemide was restarted and she diuresed appropriately. Baseline BPs were 80-90s systolic while maintaining normal mental status and making good urine. . # Chest pain: The patient states that she has [**6-17**] substernal chest pain, which started earlier this afternoon. EKG showed TWIs in V4-V6, which appear to be changed from her EKGs on [**2183-3-14**]. Her chest pain is relieved with Morphine 2 mg IV. She was monitored on telemetry; serial cardiac enzymes remained flat and no new EKG changes over several days. Thought to be most likely anxiety is setting of respiratory distress. Resolved. . # Tachycardia: Sinus tachycardia on admission. Was intially given gentle IVF, which were stopped after the flash PE event. After improvement of COPD exacerbation, patient's tachycardia resolved. . # Facial burn: - Bacitracin/Neosporin/Polymixin ointment . # HTN: Monitor closely given h/o flash PE. 159/83 currently. - cont. Toprol 100 mg qday . # Osteoporosis: - cont Ca and Vit D . # GERD: - cont. Omeprazole 40 mg [**Hospital1 **] . # Anemia: MCV = 93. Hct = 25.9 in [**7-18**].7 on [**2183-3-7**]. Appears to be at baseline. - cont. to trend . # DM: - diabetic diet - ISS . # Leukocytosis: Likely [**3-12**] chronic steroids. Listed as chronic medical issue in OSH records. . # LLL nodule: - repeat CT scan in [**4-13**] months . # Anxiety: Ativan 0.5 mg q8h prn as per home regimen . ## CODE STATUS: Full code # CONTACT: [**Name (NI) 97832**] [**Known lastname **] ([**Telephone/Fax (1) 97833**] Medications on Admission: Toprol XL 100 mg qday Multivitamin 1 tab qday Oxycodone 5 mg q4h prn Ultram 25 mg q6h prn Tylenol 650 mg TID prn Calcium Carbonate 1 tab [**Hospital1 **] Colace Ferrous Sulfate 325 mg qday Potassium Chloride 20 Meq qday Omeprazole 40 mg [**Hospital1 **] Prednisone 20 mg qday (chronic home dose) Lactulose 30 mg QID prn constipation Senna 8.6 mg [**Hospital1 **] prn Bactrim DS - 1 tab M,W,F Insulin sliding scale Duoneb q6h prn Spiriva 18 mcg qday Torsemide 20 mg [**Hospital1 **] Albuterol neb prn Bacitracin/Neosporin/Polymixin ointment Advair 250/50 [**Hospital1 **] Caltrate 600/400 [**Hospital1 **] Lorazepam 0.5 mg q8h prn Vit D3 400 U qday Discharge Medications: 1. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. bacitracin-polymyxin B Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for upper lip burn. 8. torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, anxiety. 11. potassium chloride 20 mEq Packet Sig: One (1) PO once a day. 12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 14. Ultram 50 mg Tablet Sig: 0.5 Tablet PO every six (6) hours as needed for pain. 15. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 16. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 4 days: Started [**2183-3-20**]. total course 5 days. Last dose [**2183-3-24**]. . 17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 18. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 19. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day: hold for SBP <90. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 20. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 21. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: COPD exacerbation Systolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital for your shortness of breath and were treated for a COPD exacerbation. You were given steroids and antibiotics to help improve your lung function. THE FOLLOWING CHANGES WERE MADE TO YOUR MEDICATIONS: . Advair was increased to 500/50 . Prednisone 40mg daily for next 4 days, then continue your normal 20mg daily dose . OxycoDONE (Immediate Release) 5 mg by mouth every 4 hours as needed for pain Followup Instructions: Please follow up with Pulmonology for a repeat CT chest in 6 months and for repeat pulmonary function tests. Dr [**First Name (STitle) **] should be able to help you set this up. You have a follow up appointment with your PCP Dr [**First Name (STitle) **] on Thursday [**2184-3-26**]:20. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13258, 13328

4955, 10324

367, 372

13413, 13413

4404, 4404

14051, 14436

3556, 3572

11023, 13235

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312, 329

400, 2633

4418, 4932

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2655, 3169

3185, 3540

31,348

140,818

46023

Discharge summary

report

Admission Date: [**2123-6-22**] Discharge Date: [**2123-6-28**] Date of Birth: [**2084-7-2**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Arterial line placement, L radial artery History of Present Illness: 38 year old female with history of HTN, CHF, Etoh abuse, CKD [**12-25**] htn presents with 3 days of worsening shortness of breath. At baseline, patient has shortness of breath and 4 pillow orthopnea. 3 days ago she noticed gradual onset of worsening shortness of breath. She reports PND and worsened orthopnea that she had to sleep upright in a chair at night. Of note, patient has a history of severe hypertension and ran out of all of her medications excluding lisinopril 20 mg 3 weeks ago. Over the past 3 days she reports visual changes but no headache. She also reports palpitations and occasional episodes of sweating. Furthermore, she has also experienced non-radiating chest pain lasting from seconds to minutes, feels like "pinching" over her L chest and L epigastrum; this pain is unchanged and chronic lasting from [**2115**] until now. . At the ED her vitals were 98.6, BP 200's / 120-150's (max systolic 247, max diastolic 153), hr 122, rr 18, sat 97% on RA. She was started on a nitroprusside drip, given lasix 40 mg, lisinopril 20mg, amlodipine 4 mg, and trasferred to the CCU for further management. Past Medical History: HTN CHF - [**Last Name (un) 5487**] systolic or diastolic dysfunction Etoh Abuse Medical non-adherance s/p section 12 inpatient psych admission [**3-29**] CRI, secondary to HTN, baseline ~ 2.3 Anemia - patient reports having had 1 transfution for "thalassemia" within the past year Social History: Etoh - reports last drink [**2123-3-23**]; in past has had problems w/ excessive drinking Drugs - denies IVDA, reports prior marijuana Tobacco - reports positive history . Lives at home w/ 4 children and mother Family History: Mother - CVA at 49, and several since, HTN Father - HTN Sister - no HTN Denies history of cancer or diabetes Physical Exam: VS: hr 112 rr 25 bp 166/111 (map 124) 99% on 2L NC GEN: friendly woman laying on stretcher with cold rag on her neck HEENT: perrla, eomi; mmm, no [**First Name9 (NamePattern2) 97965**] [**Doctor First Name **]; JVP at 8 cm; retinoscopic exam, no venous pulsations, no hemorrhages in tightly limited field within retina COR: nl s1s2, + S4 gallop, no rubs, no murmurs PUL: CTA bilaterally ABD: quiet bowel sounds, soft, NT, ND, no masses EXTREM: warm, strong 2+ pulses bilaterally; 2+ pitting edema at ankles, up to mid calf; no cyanosis, clubbing Pertinent Results: results obtained from [**Hospital 1263**] Hospital [**Doctor First Name **] + 1:160 speckled pattern c-ANCA negative p-ANCA negative anti Scl-70 1.1 (ref<20) C3 104 (ref 75-179) C4 31 (ref 14-40) CH50 63 . [**2123-6-22**] 01:50PM BLOOD WBC-14.6* RBC-3.88*# Hgb-9.5*# Hct-29.2* MCV-75* MCH-24.4* MCHC-32.4 RDW-17.9* Plt Ct-320 [**2123-6-22**] 01:50PM BLOOD Neuts-80.8* Bands-0 Lymphs-14.1* Monos-2.5 Eos-1.8 Baso-0.7 [**2123-6-22**] 01:50PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-1+ Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+ [**2123-6-22**] 01:50PM BLOOD Glucose-103 UreaN-33* Creat-2.6* Na-142 K-3.9 Cl-114* HCO3-17* AnGap-15 [**2123-6-28**] 07:05AM BLOOD Glucose-141* UreaN-39* Creat-2.8* Na-139 K-4.3 Cl-105 HCO3-23 AnGap-15 [**2123-6-22**] 01:50PM BLOOD CK-MB-6 proBNP-[**Numeric Identifier 97966**]* [**2123-6-23**] 03:37AM BLOOD CK-MB-5 cTropnT-0.04* [**2123-6-22**] 09:35PM BLOOD calTIBC-261 Ferritn-73 TRF-201 [**2123-6-23**] 03:37AM BLOOD Triglyc-100 HDL-24 CHOL/HD-5.3 LDLcalc-84 [**2123-6-22**] 01:50PM BLOOD TSH-2.6 . MRI abdomen (to eval for masses, renal artery stenosis) IMPRESSION: 1. The study is limited due to lack of intravenous contrast and patient's inability to hold her breath during the scan. Mild narrowing of the mid right renal artery without evidence of significant stenosis. 2. Normal adrenal glands. . Echocardiogram Conclusions: The left atrium is elongated. The estimated right atrial pressure is 11-15mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is moderately depressed (LVEF= 30-35 %) with global hypokinesis (slightly more prominent in the inferior wall). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. There is no ventricular septal defect. Right ventricular chamber size is normal. There is mild global right ventricular free wall hypokinesis. 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. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Moderate LVH. Biventricular systolic dysfunction (consider infiltrative vs hypertensive cardiomyopathy). . [**2123-6-23**] 07:22PM URINE VANILLYLMANDELIC ACID-PND [**2123-6-23**] 07:22PM URINE METANEPHRINES-PND [**2123-6-23**] 07:22PM URINE CATECHOLAMINES-PND [**2123-6-22**] 08:10PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Brief Hospital Course: 38 year old female with essential HTN, CKD w/ baseline creatinine 2.3, systolic dysfunction with EF 30% presents with hypertensive emergency and congestive heart failure in setting of medical non-adherance. . #HTN Patient presented without visual changes, confusion, mental status changes, hematuria, however did present with symptomatic moderate to severe congestive heart failure. The diagnosis of hypertensive emergency / urgency was made and the patient was started on a nitroprusside IV drip to lower BP from 200's / 100's (up to 150) by approximately 25% to goal SBP 140-150's. She was then started on labetalol, lisinopril, and lasix for diuresis. After her BP stablized, she was maintained on amlodipine (10 mg daily), and carvedilol (50 mg [**Hospital1 **]), and lasix 20 mg PO daily. Her ace inhibitor was briefly held due to a bump in her creatinine, and subsequently restarted with lisonopril 40 mg daily. Patient refused trial of labetalol PO instead of carvedilol. On discharge, a clonidine patch 2 was added to optimize her bp control. She was provided 0.2mg [**Hospital1 **] clinidine PO x 4 days to bridge her until her follow up appointment with her PCP at [**Name9 (PRE) **] health center on [**2123-7-2**] at 11:30AM. . Likely has essential htn. Secondary causes were evaluated. MRI did not show renal artery stenosis. Urine metanephrines were evaluated for pheochromocytoma but were pending on discharge. No intra-abdominal or adrenal masses were discovered on MRI of the abdomen. . #Heart Failure, systolic dysfunction, diastolic dysfunction Patient has an EF of approximately 30%. Presentation was consistent with CHF exacerbation in setting of uncontrolled and elevated blood pressure. Diuresis and control of BP was successful in normalization of hemodynamics to baseline. She requires 20 mg lasix PO daily. She is currently able to walk the hospital floors without desaturation or shortness of breath. Patient was instructed that without weight loss, a stable and effective exercise program, a low sodium / low fat diet, smoking cessation, and tight blood pressure control that she faces likely worsening of her heart function, kidney function and probable failure, and likely cardiac / cardiovascular / neurologic event (stroke) in the next 5 to 10 years. She was instructed to weigh herself daily and report > 3 lb weight gain to her doctor. Visiting nursing assistant was set up to visit her home and evaluate her blood pressure / manage medications. It was recommended that the patient purchase a blood pressure machine for the home and keep a journal of pressure and medications. She is scheduled to follow up with her PCP [**Last Name (NamePattern4) **] [**7-2**]. . #Chronic renal insufficiency Her baseline creatinine was 2.3 late [**2121**]. Over the hospital stay, her creatinine has fluctuated between 2.6 and 2.9. This was believed to be roughly her baseline and natural decrease of GFR over time. Creatinine trend was stable on discharge. . #Anemia She has a microcytic (mcv=75) anemia, with a baseline hematocrit of 33. During her hospital stay, her hematocrit has been stable between 25-27. Her TIBC=261, ferritin=73, and haptoglobin=173 were within normal range. She reports a history of requiring transfusions for thalasemmia. Thus, her anemia is most likely due to thalasemmia. Anemia of chronic disease cannot be excluded. . #Abdominal pain She has had intermittent crampy abdominal pain over her hospital course. The pain is of a a similar nature to what she has experienced chronically at home. She has had bloody bowel movements after being constipated. She states that she had hemrrhoids. The abdominal pain can be evaluated further as an outpatient. Hematocrit was stable during admission. . #TO FOLLOW UP Urine studies for pheochromocytoma / hypercortisolism. Blood pressure management; consider PO labetalol since IV labetalol worked well. Patient was resistant to trying labetalol PO. . Patient remained afebrile during hospitalization. Blood pressure was moderately controlled during hospitalization, but lowered dramatically from presentation pressure. She will follow up with her PCP on [**Name9 (PRE) 2974**]. Clonidine 0.2 mg PO BID will be continued as well as the clonidine 2 patch and home BP meds (amlodipine 10mg daily, lisinopril 40 mg daily, carvedilol 50 mg [**Hospital1 **]). Whether to continue clonidine PO or not will be determined by Dr. [**Last Name (STitle) 724**] on [**7-2**]. Medications on Admission: lisinopril 20 QD Lasix 20 QD Coreg 50 mg [**Hospital1 **] Norvasc 10 mg QD Celexa - 20 daily Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. Disp:*8 Tablet(s)* Refills:*0* 4. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSUN (every Sunday). Disp:*4 Patch Weekly(s)* Refills:*2* 5. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*2* 6. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: - hypertension, essential - congestive heart failure, systolic dysfunction - chronic kidney disease, likely htn induced Secondary: - tobacco abuse - etoh abuse history Discharge Condition: stable Discharge Instructions: You were admitted to the hospital with very high blood pressure and congestive heart failure. You must continue to take your medications every day without missing a dose. You should also stop smoking, lose weight, and eat a healthy diet high in fruits / vegetables and low in saturated fats. You should refrain from drinking alcohol. . Continue to take clonidine orally 0.2 mg twice daily as well as the patch. On Friday [**2123-7-2**] you will meet with Dr. [**Last Name (STitle) 724**] who will address whether to change this medication or continue it. Followup Instructions: ****You have an appt with Dr. [**Last Name (STitle) 724**], [**First Name3 (LF) **] at the [**Hospital1 **] Health center on Friday [**7-2**] at 11:30am. . You have an appointment with Dr. [**Last Name (STitle) 14049**] on [**2123-7-5**] at 9:30 for a blood pressure check. . You have an appointment scheduled with Dr. [**First Name (STitle) **] on [**2123-7-21**] at 11:15.

[ "403.90", "789.00", "428.0", "282.49", "585.9", "455.0" ]

icd9cm

[ [ [] ] ]

[ "38.91" ]

icd9pcs

[ [ [] ] ]

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5805, 10283

334, 377

11417, 11426

2772, 5782

12032, 12410

2079, 2189

10427, 11116

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10309, 10404

11450, 12009

2204, 2753

275, 296

405, 1530

1552, 1835

1851, 2063

63,987

125,485

35357

Discharge summary

report

Admission Date: [**2165-9-23**] Discharge Date: [**2165-10-5**] Date of Birth: [**2104-6-30**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 5569**] Chief Complaint: End stage liver disease for orthotopic liver transplantation Major Surgical or Invasive Procedure: Orthotopic liver transplant [**2165-9-23**] s/p hepatojej and hepatic artery to splenic a conduit for ha anastomosis [**9-25**] History of Present Illness: [**Known firstname **] [**Known lastname 80598**] is a 61-year-old man with hepatocellular carcinoma and liver cirrhosis who is being admitted for orthotopic liver transplant. He was well until about three or four years ago when an ultrasound demonstrated liver cirrhosis. This was presumably due to fatty liver disease in association with a markedly elevated triglycerdes of 25 years. Patient was referred to [**Hospital1 18**] in [**2165-3-20**] for work-up of bleeding esophageal varices which were banded in [**2165-1-20**] at an outside hospital. In [**2165-3-20**], a RUQ ultrasound was obtained which showed a 2-cm lesion in left lobe of liver. MRI demonstrated two highly suspicious liver masses that could represent hepatocellular. On [**2165-5-29**] Mr. [**Known lastname 80598**] [**Last Name (Titles) 1834**] radiofrequency ablation and biopsy of two left liver lobe lesions. He was added to the waiting list [**2165-6-27**] with a calculated MELD score of 8; an additional 14 points were awarded due to the presence of hepatocellular carcinoma, for a total MELD score of 22. Subsequent, post-ablative CT scans have shown no recurrence of cancer. Patient is Hepatitis B negative. Of note, several EGDs have been performed with the most recent on [**2165-9-5**] which demonstrated: Three cords Grade I varices at the lower third of the esophagus Ulcerated polyps in the antrum (biopsy) Thick gastric folds Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum Past Medical History: Cirrhosis likely from fatty liver Esophageal varices Diverticulosis renal stones gastroesophageal reflux disease (GERD) type 2 diabetes perianal cyst hyperlipidemia hypertension skull fracture at age 6 anemia Social History: Radiochemist in a nuclear power station. Lives with his family in [**Location (un) 3320**], MA. History of 1 ETOH drink/day until [**2163**] when he stopped. Ex-smoker who quit x 25 years. No IVDA. Family History: His dad died of some sort of liver disease but no liver cancer. He is unsure of any details of this. His mom had a myocardial infarction and stroke at question of age 59, and otherwise his family is healthy. Physical Exam: VS: 98.7 91 148/82 20 98RA FS: 141 Gen: AAOx3, NAD, pleasant, anicteric HEENT: EOMI, NCAT, PERRL Pulm: CTA Bilaterally, no wheezes or crackles Cards: RRR, normal S1/S2, no M/R/G Abd: Soft/Nontender/Nondistended, liver was nonpalpable, spleen non palpalpable, no abnormal masses GU: no CVA tenderness Extremities: move extremities spontaneously, no LE edema, warm, well perfused Neuro: grossly intact Pertinent Results: [**2165-9-23**] 09:56AM BLOOD WBC-5.2 RBC-3.80* Hgb-11.6* Hct-33.8* MCV-89 MCH-30.5 MCHC-34.2 RDW-14.3 Plt Ct-108* [**2165-9-23**] 09:56AM BLOOD PT-14.3* PTT-29.5 INR(PT)-1.2* [**2165-9-23**] 09:56AM BLOOD Glucose-145* UreaN-9 Creat-0.7 Na-144 K-3.5 Cl-110* HCO3-20* AnGap-18 [**2165-9-23**] 09:56AM BLOOD ALT-49* AST-57* AlkPhos-108 TotBili-1.3 Brief Hospital Course: Mr.[**Known lastname 80598**] had an Orthotopic livet transplant. First post operative day his duplex did not show good flow in the hepatic artery . It was repeated the following day and the Duplex failed to demonstrate intrahepatic arterial flow in the left and right lobes, nor any flow in the porta with only a partial signal seen well away from the liver hilum, suggesting severe stenosis or oclusion. Portal and hepatic venous flow was normal . He was taken back to the operating room Procedure done: 1. Exploratory laparotomy. 2. Revision of hepatic artery anastomosis. 3. Roux-en-Y hepaticojejunostomy. 4. Liver biopsy. 5. Intraoperative ultrasound. Post op he was on a heparin gtt. He did well. Was extubated with [**Last Name **] problem and transferred to the floor. Events on the floor were 1) Heparin gtt was transitioned to Coumadin 2) Slowly drifting down of Hct so he was transfused a couple of units PRBC after much discussion it was decided to stop the anticoagulation as the hepatic artery anastomosis was revised 3) He had a hepatico jejunostomy so he was NPO for 3-4 days after which his diet was slowly advanced 4) He received HBIG vaccines in addition to monitoring Hep B Ab titers 5) His immunosuppresive medication was managed per protocol. 6) He had some loose bowel movement but CDiff was negative. Medications on Admission: Meds: metformin, iron, glyburide, multivitamin, lactulose, rifaximin, propranolol, and omeprazole. Discharge Medications: 1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 12. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours) for 2 doses: Dosage dtermined by levels. 13. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous every six (6) hours: Humalog sliding scale. Disp:*5 * Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA Discharge Diagnosis: 61M with HCC and cirrhosis s/p OLT [**9-23**]; s/p hepatojej and hepatic artery to splenic a conduit for ha anastomosis [**9-25**] Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Continue to ambulate several times per day. . Incision Care: -Staples will be taken out during your follow up visit. -You may shower, and wash surgical incisions. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2165-10-10**] 1:40 Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2165-10-17**] 1:50 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2165-10-24**] 11:30 Completed by:[**2165-10-14**]

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icd9cm

[ [ [] ] ]

[ "53.49", "38.93", "50.69", "50.59", "00.93", "50.12", "88.74", "39.49" ]

icd9pcs

[ [ [] ] ]

6293, 6344

3492, 4823

332, 462

6519, 6526

3122, 3469

7864, 8319

2464, 2673

4973, 6270

6365, 6498

4849, 4950

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2688, 3103

232, 294

490, 1999

2021, 2232

2248, 2448

32,137

113,013

34767+57945

Discharge summary

report+addendum

Admission Date: [**2138-8-25**] Discharge Date: [**2138-8-27**] Date of Birth: [**2113-9-25**] Sex: F Service: OTOLARYNGOLOGY Allergies: Bactrim / Amoxicillin Attending:[**First Name3 (LF) 7729**] Chief Complaint: bleeding from left tonsillar fossa 2.5 weeks s/p tonsillectomy Major Surgical or Invasive Procedure: Left lingual artery neuroembolization History of Present Illness: 24 F s/p tonsillectomy 2.5 weeks ago (Dr. [**Last Name (STitle) **], MEEI), was well until 12:30 AM of [**2138-8-25**] when she awoke with profuse oral bleeding. Presented to OSH ED where ENT (Dr. [**Last Name (STitle) 28434**] diagnosed Left tonsillar fossa bleed. Tranfusion started given massive bleed, and patient taken to OR. In OR no active bleeding seen after suspension, R fossa cauterized, no source from L fossa seen. Total blood loss from ED and OR estimated at 3 L. Patient kept intubated with vaginal pack in oropharynx and transfered to [**Hospital1 18**] for further care, including neurointervential radiology embolization of her left lingual artery. Past Medical History: Patient takes OCP for menstrual bleeding Childhood h/o epistaxis Surgery for wisdom teeth Social History: Patient denies tobacco use, infrequent alcohol use, no recreational/street drug use. She works for the state [**Doctor Last Name **]. Family History: Family history of heart disease and colon cancer Mother had a mild anemia, which improved with iron; a paternal uncle had frequent nosebleeds requiring cauterization, and a paternal grandmother was diagnosed with colon cancer in her 50s. There are two maternal great uncles with cancer, one with mouth cancer and another with lung cancer. Physical Exam: VS: stable OC/OP: b/l tonsilar fossa with cautery scab, no signs of bleeding, swelling, hematoma of d/c CV: RRR, no m/g/r appreciated Pulm: CTA b/l Neuro: CN2-12 grossly intact Pertinent Results: [**2138-8-26**] 02:00AM BLOOD WBC-12.4* RBC-4.17* Hgb-12.4 Hct-35.0* MCV-84 MCH-29.7 MCHC-35.3* RDW-13.7 Plt Ct-193 [**2138-8-25**] 02:17PM BLOOD WBC-16.7* RBC-4.77 Hgb-13.7 Hct-40.0 MCV-84 MCH-28.8 MCHC-34.3 RDW-13.5 Plt Ct-237 [**2138-8-25**] 02:17PM BLOOD Neuts-93.3* Bands-0 Lymphs-4.5* Monos-0.5* Eos-0.5 Baso-1.3 [**2138-8-25**] 02:17PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2138-8-26**] 02:00AM BLOOD Plt Ct-193 [**2138-8-26**] 02:00AM BLOOD PT-13.6* PTT-26.8 INR(PT)-1.2* [**2138-8-25**] 02:17PM BLOOD PT-13.4 PTT-26.4 INR(PT)-1.1 [**2138-8-25**] 02:17PM BLOOD Plt Smr-NORMAL Plt Ct-237 [**2138-8-26**] 02:00AM BLOOD Glucose-141* UreaN-7 Creat-0.6 Na-138 K-4.0 Cl-108 HCO3-24 AnGap-10 [**2138-8-25**] 02:17PM BLOOD Glucose-119* UreaN-9 Creat-0.6 Na-141 K-3.7 Cl-108 HCO3-24 AnGap-13 [**2138-8-25**] 02:17PM BLOOD ALT-15 AST-20 AlkPhos-70 TotBili-0.6 [**2138-8-26**] 02:00AM BLOOD Calcium-9.1 Phos-4.2 Mg-1.8 [**2138-8-25**] 02:17PM BLOOD Albumin-3.9 Calcium-9.0 Phos-2.8 Mg-1.7 Brief Hospital Course: The patient initially presented to an ODH ED and was transferred to [**Hospital1 18**] for profuse tonsillar bleeding. She was taken to the OR and intubated by anesthesia. The tonsillar fossa bleeding was controlled with suction cautery bilaterally. Total ED and OR was about 3000cc. Between the OSH ED and the operation at [**Hospital1 18**], she received 4 units of pRBCs. She was transferred to the MICU intubated and awake. Interventional radiology neuroembolized her left lingual artery (3 coils). The patient was transferred to the TICU and extubated. Hematology was consulted to evaluate for bleeding disorders - initial labs (vWF, Factor VIII) were within normal limits; she will follow up with hematology clinic. The remainder of her hospital course was uneventful - there was no sign of bleeding, pain was well controlled with dilaudid IV and later PO, and she was advanced from clear liquids to full liquids then a soft diet as tolerated. Patient is being discharged on HD3: afebrile, tolerating regular diet without nausea/vomiting, pain well controlled on oral medication, voiding, and ambulating well. Patient will follow-up in [**8-21**] days. Medications on Admission: OCP MVI Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: do not drive, operate heavy machinery, or drink alcohol while taking narcotics. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: left tonsillar fossa bleeding 2.5 weeks s/p tonsillectomy, now s/p left lingual artery neuroembolization (3 coils) Discharge Condition: stable Discharge Instructions: Resume all home medications. Seek immediate medical attention for fever >101.5, chills, swelling, bleeding or discharge from tonsillar surgical site, chest pain, shortness of breath, difficulty breathing, severe headache, new neurological deficit, or anything else that is troubling you. No strenuous exercise or heavy lifting until follow up appointment, at least. Do not drive or drink alcohol while taking narcotic pain medications. Call your surgeon to make follow up appointment. Resume all home medications. Seek immediate medical attention for fever >101.5, chills, swelling, bleeding or discharge from tonsillar surgical site, chest pain, shortness of breath, difficulty breathing, severe headache, new neurological deficit, or anything else that is troubling you. No strenuous exercise or heavy lifting until follow up appointment, at least. Do not drive or drink alcohol while taking narcotic pain medications. Call your surgeon to make follow up appointment. Followup Instructions: Please call Dr.[**Name (NI) 20390**] clinic to set up an appointment for within 1-2 weeks of discharge. Please call the hematology clinic for a follow up appointment: [**Telephone/Fax (1) 42668**], within 1-2 weeks of discharge from hospital Completed by:[**2138-8-27**] Name: [**Known lastname 12797**],[**Known firstname **] [**Last Name (NamePattern1) 12798**] Unit No: [**Numeric Identifier 12799**] Admission Date: [**2138-8-25**] Discharge Date: [**2138-8-27**] Date of Birth: [**2113-9-25**] Sex: F Service: OTOLARYNGOLOGY Allergies: Bactrim / Amoxicillin Attending:[**First Name3 (LF) 1065**] Addendum: Please f/u up with Dr. [**Last Name (STitle) **] at the [**State 12800**] clinic, rather than with Dr. [**Last Name (STitle) **] (within 1-2 weeks). Discharge Disposition: Home [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1067**] MD [**MD Number(1) 1068**] Completed by:[**2138-8-27**]

[ "E878.6", "998.11" ]

icd9cm

[ [ [] ] ]

[ "99.29" ]

icd9pcs

[ [ [] ] ]

6476, 6641

2998, 4158

351, 391

4607, 4616

1928, 2975

5636, 6453

1370, 1713

4216, 4419

4469, 4586

4184, 4193

4640, 5613

1728, 1909

249, 313

419, 1090

1112, 1203

1219, 1354

17,339

197,601

50809

Discharge summary

report

Admission Date: [**2127-2-6**] Discharge Date: [**2127-3-3**] Date of Birth: [**2058-12-19**] Sex: M Service: MEDICINE Allergies: Latex Attending:[**First Name3 (LF) 2880**] Chief Complaint: sob and chest pain Major Surgical or Invasive Procedure: cardiac cath ([**2127-2-7**]) History of Present Illness: 68 yo male with extensive PMH includes diastolic CHF, probable CAD, s/p pacer for CHB, PE ([**2125**]), htn, dyslipidemia, tracheal stenosis s/p multiple T-tubes, dilations, stents, COPD, OSA, h/o pneumothorax, AAA s/p repair and s/p graft infection, axillary DVT, h/o seizure disorder, adrenal insufficiency on prednisone, h/o pseudomonas sepsis, h/o ARDS, h/o MRSA bronchitis, h/o c.diff, GIB, gout, balanitis, reflex sympathetic dystrophy, and depression. Last seen by Dr.[**Last Name (STitle) **] [**2126-12-2**], who felt CAD is progressing but subsequently pt did not have his recommended nuclear stress test. In the interim, Mr.[**Known lastname 105663**] SOB has progressed to occuring with minimal exertion and occasionally at rest. His CP also increased with a particularly severe episode 7 days ago (several hours of tightness radiating to both arms with dyspnea without relief with ntg). Mr.[**Name14 (STitle) 105664**] also notes increased LE edema and LE pain. Seen by Dr.[**Last Name (STitle) 5717**] in clinic today who sent the pt via ambulance to ED. Past Medical History: PMHx: 1. Presumed Coronary artery disease with last evaluation [**2-3**] (negative P-MIBI) 2. CHF with preserved EF of about 57% 3. CHB s/p [**Month/Year (2) 4448**] implantation in [**2122-3-3**] with CPI Discovery SR. 2. Hypertension. 3. Seizure disorder after head trauma. 4. COPD and a history of prior ARDS. 5. Abdominal aortic aneurysm, status post repair andcomplicated by graft infection. 6. History of pseudomonas sepsis. 7. History of DVTs and right lower lobe pulmonary embolism in [**2125-1-31**]. 8. Depression. 9. Reflex sympathetic dystrophy of the right lower extremity. 10. History of GI bleeding. 11. History of C. difficile colitis. 12. Obstructive sleep apnea. 13. Gout. Social History: SOCIAL HISTORY: Lives with wife and four children. Went to Korean War and received blood transfusions. Denies alcohol. Has a history of three-and-a-half-pack-per-year smoking;stopped in [**2121**]. Denies intravenous drug use. Was an arbitration lawyer. [**Name (NI) **] is Catholic. Family History: non contributory Physical Exam: PE: 98.1 80 20 150/70 Gen: dyspneic, fatigued-appearing obese older man Heent: EOMI, PERRL, MMM, poor dentition Neck: JVD to angle of jaw Heart: RRR normal S1 and S2. No m/r/g Lungs: Diffuse crackles [**2-3**] way up Abd: Obese. Soft, nt/nd. +BS Ext: 2+ edema to knees bilaterally. Pertinent Results: CBC: [**2127-2-6**] WBC-9.5 RBC-4.42* HGB-13.6* HCT-42.2 MCV-96 PLT COUNT-257 NEUTS-77.5* LYMPHS-17.4* MONOS-4.1 EOS-0.8 BASOS-0.3, MACROCYT-1+, [**2127-2-28**]: WBC-8.3 HGB-11.0* HCT-31.5* MCV-94 PLT-372 HEMATOLOGIC: Iron 65, TIBC-195*, B12-946*, Folate-16.5, Haptoglobin-185, Ferritin-529*, TRF-150* ELECTROLYTES: [**2127-2-6**]: UREA N-34* CREAT-1.1 SODIUM-143 POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-31* GLUCOSE-117* [**2127-2-28**]: GLUCOSE-82 BUN-23* CREAT-0.9 SODIUM-142 POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-29 COAGS: [**2127-2-6**] 03:00PM PT-12.7 PTT-23.3 INR(PT)-1.0 [**2127-2-6**] 11:55AM PSA-2.5 URINE: [**2127-2-6**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG, RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 LFTs: [**2127-2-6**] 03:00PM ALT(SGPT)-28 AST(SGOT)-33 CK(CPK)-83 ALK PHOS-71 AMYLASE-64 TOT BILI-0.3, ALBUMIN-4.3 CARDIAC ENZYMES: [**2127-2-6**] 03:00PM CK-MB-4 [**2127-2-6**] 03:00PM cTropnT-0.12* [**2127-2-6**] 11:30PM CK-MB-NotDone [**2127-2-6**] 11:30PM cTropnT-0.12* [**2127-2-6**] 11:30PM CK(CPK)-78 IMMUNOLOGY: ANCA-NEGATIVE [**Doctor First Name **]-NEGATIVE ESR-117 [**2127-2-17**] PHENYTOIN 10.3 [**2127-2-6**] EKG: No change from previous. NSR. LAD. Poor RWP. No Q's. Normal [**Doctor Last Name 1754**] and intervals. [**2127-2-6**] RLE u/s: No evidence of DVT in the right lower extremity. RIGHT FOOT, THREE VIEWS: There is a hallux valgus deformity of the first toe. There is diffuse osteopenia. There are no obvious fractures, given the patient's positioning. Soft tissue swelling dorsally. Erosion of the first distal tarsal bone. No definite fracture. [**2-6**] CXR: There is pulmonary vascular congestion and interstitial edema. [**2-7**] ECHO: 1. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is difficult to assess but may be normal. 2. The aortic root is moderately dilated. The ascending aorta is moderately dilated. 3.The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. 4.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 5. Compared with the findings of the prior study (tape reviewed) of [**2126-11-13**], there has been no significant change. [**2-11**] CATH: HEMODYNAMICS: RIGHT ATRIUM {a/v/m} 16/15/14 RIGHT VENTRICLE {s/ed} 44/17 PULMONARY ARTERY {s/d/m} 44/10 PULMONARY WEDGE {a/v/m} 25/21/19 LEFT VENTRICLE {s/ed} 100/28 AORTA {s/d/m} 100/58/78 CARDIAC OP/IND FICK {l/mn/m2} 8.9/3.7 SYSTEMIC VASC. RESISTANCE 575 1. 2VD, right dominant ciruclation. LMCA without angiographically apparent flow limiting disease. The LAD had diffuse disease up to 90% in the proximal-mid vessel with extensive calcifications. A large D1 was occluded chronically. The LCX had mild disease throughtout its course to the AV groove. The OM1 was a large caliber vessel without flow limiting disease. The RCA had a 50% stenosis in the proximal vessel and an occluded posterolateral branch that was occluded. 2. Resting hemodynamics from right and left heart catheterization demonstrated elevated right and left sided filling pressures (RVEDP=17mmHg and LVEDP=28mmHg). Pulmonary arterial hypertension was noted (41/10mmHg). The superior vena cava oxygen saturation was elevated suggesting the possibility of partial anomalous pulmonary venous return, of unknown significance. 3. Successful placement of two overlapping Cypher drug-eluting stents in the proximal (3.0 x 23 mm) and mid-LAD (2.5 x 28 mm) after successful rotational atherectomy using a 1.5 mm burr. 4. Successful balloon angioplasty of chronically, totally occluded diagonal with a 2.5 mm balloon. Final angiography demonstrated a 40% residual stenosis, no angiographically apparent dissection, and normal flow. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Elevated right and left sided filling pressures. 3. Preserved cardiac output/index on dopamine. 4. Successful placement of drug-eluting stents in proximal-mid LAD. 5. Successful balloon angioplasty of diagonal branch. CT ABD/PELVIS [**2-14**]: No evidence of retroperitoneal hemorrhage. Stable appearance of large lung bleb in the right lower lobe. Vicarious excretion of contrast through the gallbladder. Multiple small exophytic left renal cysts. [**2-14**] CXR: The pulmonary vasculature bilaterally appears prominent. A circular opacity surrounding the right middle lobe is again seen and corresponds with the right middle lobe emboli identified on a CT on the chest recently on [**2126-11-12**]. There is diffuse opacification of bilateral lungs, which is stable since the prior exam, and is consistent with pulmonary congestion. An underlying infiltrate consolidation cannot be excluded. [**2-16**] CXR: Severe degree of bilateral pulmonary infiltration is noted diffusely throughout both lungs. [**2-19**] CXR: The appearance of bilateral lungs with diffuse bilateral alveolar opacities is largely unchanged. The above findings remain consistent with the diagnosis of congestive heart failure. [**2-23**] CXR: There has been interval improvement in the degree of perihilar haziness. There is a small right pleural effusion present. There is improved aeration in the left retrocardiac region. [**2-25**] CXR: There has been near interval resolution of the patchy bilateral opacities consistent. There remains diffuse pulmonary edema bilaterally, with persistent left lower lobe collapse consolidation. Radiopaque opacities again identified overlying the left heart border. This is in unchanged position dating back to [**2124**]. The right lower lung cyst is again noted. Brief Hospital Course: 1. CAD: Pt was admitted with stuttering chest pain and troponin leak, worrisome for progression of his presumed CAD, given his last stress was 2 years ago. The pt was found to have 2VD with elevated right and left filling pressures. His prox and mid LAD were stented with DES and PTCA of chronically occluded diag. Integrillin was used for 18 hours and he was plavix loaded. His peak CK 479 after the cath likely [**3-5**] the intervention. He remained chest pain free subequently. Mr.[**Known lastname 105524**] was maintained on aspirin, plavix, statin (low dose [**3-5**] medication interactions), and beta-blockade. His ACE inhibitor was stopped [**3-5**] hypotension (see below) and will not be re-started (he may actually not require an ACE based on the reversal trial). 2. Hypotension: Mr.[**Known lastname 105524**] has preserved ventricular function with diastolic dysfunction. He was volume overloaded on admission and was diuresed with IV lasix. Unfortunately, the patient is quite volume sensitive, and dropped his SBP to the 50's transiently but responded to IVF's. On the day of the pt's cath, he again became hypotensive with SBP's to the 60's. He required dopamine gtt and was admitted to the CCU after the cath, then transitioned to neosynephrine. He required a vasopressor for 4 days. PA catheter revealed distributive physiology but also a high wedge. The etiology of his hypotension is unclear, but likely related to a combination of hypersensitivity to ACE-inhibitors, adrenal insufficiency and perhaps sepsis. He was also treated with stress dose steroids and emperic antibiotics (vancomycin and zosyn given history of MRSA and pseudomonas). During his second CCU transfer (transferred twice to the CCU during this admission), he was aggressively diuresed, and dropped his blood pressure acutely after a 5L diuresis over two days with the addition of captopril. He required dopamine for only a few hours. Diuresis was halted and he was kept negative, with return of his blood pressure. Currently, his BP has been stable at 120's/70's. He does have have a history of reflex sympathetic dystrophy which may be complicating his picture. It is felt that he is still total body fluid overloaded, and will need another 3-4 L diuresis, however this should be done over the course of the next week or two to avoid rapid fluid shifts. He should have daily weights in an attempt to ascertain his appropriate dry weight. 3. Pump: Diastolic dysfunction with preserved EF. Volume overloaded on admission and IV lasix used to diurese. He responded and dropped pressure (as above). Subsequently, he was continued to be diuresed with a lasix drip while in the CCU, titrating to PCWP (were in the low 20's with a cardiac output/index 9.9/3.6). A component of his diastolic dysfunction was likely hibernating myocardium, and his symptoms improved after revascularization. His heart failure regimen will include anti-ischemic meds, in addition to beta-blockade and standing PO lasix. No ACE or [**Last Name (un) **] given history of hypotension. 4. Rhythm: Mr.[**Known lastname 105524**] has complete heart block and is ventricularly paced. 5. ID: Pt was admitted with LE cellulitis for which he was treated with IV oxacillin. He remained afebrile and without leukocytosis, until he went to the CCU, where he developed ventilator-associated pneumonia for which he was broadly covered with vanc/zosyn for a two week course. 6. Diffuse alveolar hemorrhage: The day after transfer out of his first CCU admission, Mr. [**Known lastname 105524**] developed blood streaked sputum on the floors, as well as guaiac positive stools. He had a hct drop (24) and had melanotic stool, though NG lavage was negative. CT abd/pelvis did not reveal a retroperitoneal bleed. The next day he was transfused 1 U PRBC. 12 hours later he developed acute hypoxic respiratory failure requring intubation, at which point he was transferred back to the CCU. At the time of intubation, copious blood was found in the endotracheal tube. A CXR revealed severe diffuse bilateral pulmonary infiltrates that were new. The patient underwent bronchoscopy on [**2-16**] which demonstrated clear aways but the L lingular washings were bloody and the wash was terminated early secondary to desaturation. All BAL studies were negative. It was unclear whether or not pulmonary edema was a component of his diffuse infiltrates, as his fluid balance is difficult to assess on physical exam secondary to obesity, therefore a swan ganz catheter was inserted which demonstrated an elevated wedge pressure. Aggressive diuresis was begun with a lasix drip. The pulmonary team was following, and felt that his hypoxic respiratory failure was likely secondary to a combination of diffuse alveolar hemorrhage, as well as pulmonary edema. Unfortunately, the alveolar hemorrhage remained of unclear etiology ([**Doctor First Name **], ANCA, and anti-GBM antibody all negative). He was treated with ARDS protocol (low lung volumes and oxygenation sparingly) and aggressive diuresis. Subsequent CXRs revealed improvement of the infiltrates, and the patient had no further hemoptysis. He was able to be extubated after 9 days on the ventilator, and subsequently had oxygen saturations > 95% on 4 L via nasal cannula. 7. Adrenal Insufficiency: Mr. [**Known lastname 105524**] normally takes 20 mg Prednisone daily for a history of adrenal insufficiency. While in the CCU the patient was given stress dose steroids while on the ventilator, however post-extubation was weaned back down to his maintenance dose of 20 mg. 8. Guaiac positive stools/Anemia: He was found to have guaiac positive stools during the admission, and a stable anemia, with one hematocrit drop on the day before the second transfer to the CCU at which time he received a PRBC transfusion. Iron studies revealed an anemia of chronic disease, and despite the macrocytosis, his B12 and folate were within normal limits. It is suggested that he have a colonoscopy as an outpatient. 9. Pain: Mr. [**Known lastname 105524**] suffers from chronic pain for which he reports taking 80 mg oxycontin TID, as well as nefazodone. He was noted to become quite lethargic, with slurred speech following his oxycontin doses. While in the CCU on the ventilator he was not given any opiates, and after extubation he was given only 20 mg of Oxycontin TID. He repeatedly denied pain when asked, and did not complain of pain until he was told that he was doing well on only 20 mg doses. It is suggested that he not recieve the extraordinarily high doses of opiates that he requests, both secondary to extreme lethargy with potential contribution to hypotension, as well as the fact that 20 mg kept him pain free. 10. Rehab. At time of discharge, Mr. [**Known lastname 105524**] [**Last Name (Titles) 105665**] to go to rehab. We have set up VNA services for him. Medications on Admission: All: Latex Meds: 1. Ambien 10 q. day. 2. Oxycodone/acetaminophen one to two tabs p.o. q. four to six tabs p.r.n. 3. Allopurinol 100 mg q. day. 4. Calcium carbonate 500 mg b.i.d. 5. Phenytoin 700 mg q. day. 6. Ferrous Sulfate 325 mg q. day. 7. Imipramine 75 mg q. day. 8. Furosemide 80 mg q. day. 9. Gabapentin 400 mg t.i.d. 10. Fluconazole 100 mg q. day. 11. Nefazodone 150 mg b.i.d. 12. Tizanidine 12 mg b.i.d. 13. Guaifenesin 5 to 10 mg q. six hours p.r.n. 14. Prednisone 20 mg q. day. 15. Triamcinolone 0.1% applied to area t.i.d. 16 Lipitor 20 mg po QD 17. Oxycodone Sustained Release 80 mg t.i.d. 18. Metoprolol 25 mg b.i.d. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). Disp:*30 * Refills:*2* 4. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*60 Capsule(s)* Refills:*2* 5. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours). Disp:*qs * Refills:*2* 8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*qs * Refills:*2* 9. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 10. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* 11. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q8H (every 8 hours). Disp:*30 Tablet Sustained Release 12HR(s)* Refills:*2* 14. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 16. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: chf htn cellulitis nstemi others: Presumed Coronary artery disease with last evaluation [**2-3**] (negative P-MIBI) CHB s/p [**Month/Year (2) 4448**] implantation in [**2122-3-3**] with CPI Discovery SR. Seizure disorder after head trauma. COPD and a history of prior ARDS. Abdominal aortic aneurysm, status post repair andcomplicated by graft infection. History of pseudomonas sepsis. History of DVTs and right lower lobe pulmonary embolism in [**2125-1-31**]. Depression. Reflex sympathetic dystrophy of the right lower extremity. History of GI bleeding. History of C. difficile colitis. Obstructive sleep apnea. Gout. Discharge Condition: Good Discharge Instructions: Call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5717**], or go to the ED if develop recurrent chest pain, shortness of breath, fevers, progression of redness on lower extremities, or any concerning symptoms. We have recommended a stay at rehab but you have refused. We have set up home serices for you to monitor your weights and breathing. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19547**], RNP Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2127-3-3**] 11:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2127-3-31**] 3:00 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 542**] Where: PA [**Location (un) 5259**] BUILDING ([**Hospital Ward Name **] COMPLEX) Date/Time:[**2127-4-16**] 1:20 [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]

[ "285.29", "578.1", "V45.01", "486", "428.30", "414.01", "519.1", "733.90", "041.19", "735.0", "516.9", "511.9", "278.01", "V02.59", "682.7", "410.71", "V09.0", "272.0", "799.0", "458.9", "458.8", "786.3", "518.81", "707.15", "428.0", "274.9", "337.29", "780.79", "401.9", "496", "780.39", "E935.2", "682.6" ]

icd9cm

[ [ [] ] ]

[ "37.23", "38.93", "99.60", "89.64", "31.42", "33.24", "99.04", "99.20", "88.56", "96.04", "42.92", "96.72", "36.07", "36.05" ]

icd9pcs

[ [ [] ] ]

18103, 18161

8623, 15551

284, 315

18828, 18834

2828, 3749

19245, 19952

2467, 2485

16243, 18080

18182, 18807

15577, 16220

6768, 8600

18858, 19222

2500, 2809

3766, 6751

226, 246

343, 1418

1440, 2144

2177, 2451

10,907

185,528

20457

Discharge summary

report

Admission Date: [**2173-3-9**] Discharge Date: Service: [**Hospital Unit Name 196**] HISTORY OF THE PRESENT ILLNESS: This patient is an 83-year-old male with no past medical history who has not seen a regular physician in [**Name Initial (PRE) **] number of years who presents with reports of some fleeting left-sided chest pressure occurring over the past several weeks. The patient described this as a fleeting chest pain that would resolve on its own. On the day prior to admission, the patient states that he just did not feel right, although he was unable to be more specific and he denied having any further chest pain, any shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**] dizziness, any nausea or vomiting, nor any fevers or chills. The patient states that he had a drink of water, sat down, and then he felt better. However, his son called EMS and they found the patient on a monitor in a rapid rate and brought to the Emergency Department. In the ED for this rapid rate, he was given 15 of IV Diltiazem after which the rate slowed to normal sinus rhythm. The previous rhythm had been narrow complex was interpreted initially as atrial fibrillation. On admission to [**Hospital Unit Name 196**], the patient was symptom-free. PAST MEDICAL HISTORY: None. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: None. SOCIAL HISTORY: No tobacco. No alcohol except for an occasional glass of wine. The patient is a retired construction worker and is married. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 99.4, blood pressure 137/78, heart rate 82, respirations 17, 02 saturation 100% on 2 liters nasal cannula. General: The patient was a well appearing elderly male in no acute distress. Neck: There was no jugular venous distention. No carotid bruits bilaterally. Heart: Regular rate and rhythm at approximately 80 beats per minute with no murmurs, rubs, or gallops noted. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended. Extremities: The lower extremities had no edema. His pulses were 2+ bilaterally in the upper and lower extremities. LABORATORY/RADIOLOGIC DATA: The patient's initial white blood cell count was 10.6, hematocrit 35.7, platelets 347,000. Sodium 140, potassium 4.8, chloride 104, bicarbonate 25, BUN 21, creatinine 1.4, glucose 128. His initial CK and troponin, first two sets CK of 47, troponin less than 0.1, second set at 47 and troponin of less than 0.01. A chest x-ray demonstrated a small right pleural effusion and cardiomegaly. A urinalysis was done which was negative for any evidence of UTI. An EKG was obtained which demonstrated the patient with a regular rate at approximately 140 beats per minute without any visible P waves. It was notable for pseudo S waves in multiple leads, most prominent in lead aVF, V3, V4, V5, and V6. Per discussion with the attending cardiologist, Dr. [**Last Name (STitle) 1911**], this was likely to represent AVNRT. HOSPITAL COURSE: Initially, this gentleman presented with a rapid rhythm appearing to be AVNRT which responded initially to 15 mg of IV Diltiazem given in the Emergency Department which slowed the rate enough that it reverted to normal sinus rhythm. With concern for what had caused this irregular rhythm, the patient had an echocardiogram done which demonstrated a 1-2 cm circumferential effusion with normal left ventricular ejection fraction, mild left atrial dilation, and no signs of tamponade including a right ventricular, right atrial diastolic collapse. Therefore, on admission, this patient had two remarkable problems. 1) The patient's rate and rhythm which on initial EKG appeared to be atrioventricular nodal reentrant tachycardia (AVNRT). The patient was started initially on Diltiazem p.o. and then changed to metoprolol at a low dose given p.o. just for some moderate rate control. The patient remained in sinus rhythm for the first few days of his hospital stay reverting into the AVNRT several times for a few minutes each time. On hospital day number two, the patient, while in AVNRT, had a left carotid sinus massage done by the attending cardiologist, which reverted the rhythm into sinus rhythm. The AVNRT rhythm ended in a P wave giving further evidence or support to the belief that this rhythm was in fact AVNRT. the overall plan for treatment of this rhythm was to take the patient for ablation which was successfully performed in the Electrophysiology Laboratory on hospital day number four. The second significant issue for this patient was the pericardial effusion of unknown origin. There were no significant EKG changes to suggest any evidence of pericarditis in this patient and his history was remarkably negative for any other symptoms which might suggest a connective tissue disorder or malignancy. This patient did have a CAT scan of his torso to undergo a malignancy workup. The CAT scan demonstrated a right pleural effusion as well as multiple mediastinal lymphadenopathy, the largest being 1.2 cm. It also demonstrated a large homogenous pericardial effusion without evidence of nodularity. No primary malignancy was demonstrated on the CT of the chest or abdomen. In definitive workup of the pericardial effusion, it was decided that the patient should have a pericardiocentesis. This decision was supported by the fact that the patient seemed to be developing some signs of compromise during the hospital stay. It was noted that his initial rhythm was sinus tachycardia but he also appeared to have elevated jugular venous distention as well as a pulsus paradoxus measured at approximately 14. However, the patient never experienced any dyspnea, chest pain, or hypotension throughout his hospital course. Therefore, the pericardiocentesis was performed in a nonurgent manner on hospital day number four. During the pericardiocentesis, approximately 800 cc of hemorrhagic fluid was removed from the pericardium. The patient had a cardiac catheterization done during this to evaluate for cardiac pressures. The catheterization demonstrated signs of early pericardial tamponade which improved following the pericardiocentesis. This fluid was sent then for cytology, culture, cell count, and chemistries. The pericardial drain was left in following the procedure, at which point the patient went to the CCU with the plan to have him go back to the [**Hospital Unit Name 196**] Service after the drain was removed on hospital day number five. Also, on hospital day number three, also in trying to evaluate the origin of the pericardial effusion, a Rheumatology Consult was obtained. They agreed with the plan for pericardiocentesis at that time and also recommended sending [**First Name8 (NamePattern2) **] [**Doctor First Name **], C3 and C4 for possible autoimmune causes. They also recommended that if the workup was negative that the patient may benefit from pleural pericardial or lymph node biopsy for diagnosis. Therefore, at the time of this dictation, the plan as far as working up the pericardial effusion was dependent on the findings on the cytology culture, cell count, and chemistries from the pericardial effusion. Therefore, at the time of this dictation, the patient was status post ablation of his AVNRT and was in the CCU for monitoring of the pericardial drain output as well as for signs or recurrent pericardial effusion/signs of tamponade. The patient will have a repeat echocardiogram in the morning and barring any complications will return to the [**Hospital Unit Name 196**] Service. The remainder of this discharge dictation will be completed upon completion of this [**Hospital 228**] hospital course. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 13389**] MEDQUIST36 D: [**2173-3-12**] 07:21 T: [**2173-3-12**] 20:55 JOB#: [**Job Number 54789**]

[ "285.9", "426.89", "423.0", "584.9" ]

icd9cm

[ [ [] ] ]

[ "37.0", "37.34", "37.26", "38.93", "37.21", "37.27" ]

icd9pcs

[ [ [] ] ]

1374, 1381

3036, 7982

1561, 3018

1294, 1356

1398, 1546

50,471

122,088

39752

Discharge summary

report

Admission Date: [**2105-10-5**] Discharge Date: [**2105-10-10**] Date of Birth: [**2064-8-23**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2105-10-6**] - Coronary artery bypass grafting to four vessels (left internal mammary artery grafted left anterior descending->Saphenous vein->Obtuse Marginal1/Obtuse Marginal2/Posterior descending artery). History of Present Illness: Two weeks ago Mr. [**Known lastname 87555**] felt left chest pressure after eating and again waking him up from sleep. He took NTG and pain resolved. He presented to OSH for evaluation. Cardiac cath revealed multivessel coronary disease. He was transferred to [**Hospital1 18**] for surgical revascularization. Past Medical History: Hyperlipidemia Social History: Lives with:wife, 6&12 yo children Occupation:auto mechanic-owns garage. Has been working 16-18 hr days lately. Tobacco:never ETOH:occ. Family History: father with CAD in 40s, s/p CABG Physical Exam: Admission PE Pulse: Resp: O2 sat: B/P Right:130/70 Left:132/70 Height: 67" Weight:205# General: Skin: Dry [] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [] Heart: RRR [] Irregular [] Murmur 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 Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [**Name (NI) 167**]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit Right:n Left:n Pertinent Results: [**2105-10-5**] 09:40PM PT-13.2 PTT-28.5 INR(PT)-1.1 [**2105-10-10**] 05:00AM BLOOD WBC-8.3 RBC-4.37* Hgb-13.0* Hct-37.1* MCV-85 MCH-29.8 MCHC-35.1* RDW-12.8 Plt Ct-252# [**2105-10-8**] 04:55AM BLOOD PT-13.7* INR(PT)-1.2* [**2105-10-5**] 09:40PM BLOOD PT-13.2 PTT-28.5 INR(PT)-1.1 [**2105-10-10**] 05:00AM BLOOD Glucose-137* UreaN-11 Creat-1.0 Na-140 K-4.1 Cl-99 HCO3-32 AnGap-13 [**2105-10-5**] 09:40PM BLOOD Glucose-87 UreaN-12 Creat-0.9 Na-141 K-3.7 Cl-104 HCO3-27 AnGap-14 [**2105-10-5**] 09:40PM BLOOD ALT-13 AST-18 LD(LDH)-185 CK(CPK)-90 AlkPhos-79 TotBili-1.7* [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 87556**] (Complete) Done [**2105-10-6**] at 4:05:40 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2064-8-23**] Age (years): 41 M Hgt (in): 67 BP (mm Hg): 134/67 Wgt (lb): 205 HR (bpm): 67 BSA (m2): 2.05 m2 Indication: Chest pain. Coronary artery disease. Shortness of breath. Intraoperative TEE for CABG procedure. ICD-9 Codes: 786.05, 786.51, 424.0 Test Information Date/Time: [**2105-10-6**] at 16:05 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW2-: Machine: siemens AW2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *5.7 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.9 cm Left Ventricle - Fractional Shortening: 0.32 >= 0.29 Left Ventricle - Ejection Fraction: 55% >= 55% Left Ventricle - Stroke Volume: 98 ml/beat Left Ventricle - Cardiac Output: 6.58 L/min Left Ventricle - Cardiac Index: 3.21 >= 2.0 L/min/M2 Aorta - Sinus Level: *4.1 cm <= 3.6 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Aorta - Arch: 2.8 cm <= 3.0 cm Aortic Valve - Peak Velocity: 0.9 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 4 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 3 mm Hg Aortic Valve - LVOT pk vel: 0.84 m/sec Aortic Valve - LVOT VTI: 20 Aortic Valve - LVOT diam: 2.5 cm Aortic Valve - Valve Area: 4.2 cm2 >= 3.0 cm2 Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.4 m/sec Mitral Valve - E/A ratio: 2.00 Findings LEFT ATRIUM: No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No spontaneous echo contrast is seen in the LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: The MR vena contracta is <0.3cm. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions Pre CPB: No mass/thrombus is seen in the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results. Post CPB: Patient is in sinus rhythm and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. Aorta is 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) **] [**2105-10-9**] 15:56 ?????? [**2098**] CareGroup IS. All rights reserved. Brief Hospital Course: Mr. [**Known lastname 87555**] was admitted to the [**Hospital1 18**] on [**2105-10-5**] via transfer from [**Hospital6 1109**] for surgical management of his coronary artery disease. He was worked-up in the usual preoperative manner. On [**2105-10-6**], he was taken to the operating room where he underwent coronary artery bypass grafting to four vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated without difficulty. He was weaned off drips and started on Beta-blocker/Statin/Aspirin, and diuresis. All lines and drains were discontinued in a timely fashion. On postoperative day one, he was transferred to the step down unit for further recovery. Physical therapy was consulted for evaluation of strength and mobility. The remainder of his postoperative course was essentially uneventful. By post-operative day #4 he was cleared for discharge to home with VNA. All follow-up appointments were advised. Medications on Admission: Zetia 10mg daily,Lipitor 80mg daily, ASA 81mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Ranitidine HCl 150 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) 1110**] VNA Discharge Diagnosis: Coronary artery disease Hyperlipidemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/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: [**Doctor Last Name **] [**Hospital1 **] on [**10-29**] at 9am Cardiologist: Dr. [**Last Name (STitle) 8051**] [**11-3**] at 11:15pm([**Telephone/Fax (1) 80078**] Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 8051**] in [**4-27**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2105-10-10**]

[ "272.4", "997.91", "411.1", "E878.2", "414.01", "E849.7", "780.60" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9143, 9202

6969, 8025

333, 545

9285, 9518

1767, 6486

10358, 10889

1093, 1127

8127, 9120

9223, 9264

8051, 8104

9542, 10335

1142, 1748

283, 295

573, 886

908, 924

940, 1077

6497, 6946

28,231

156,008

34011

Discharge summary

report

Admission Date: [**2148-5-24**] Discharge Date: [**2148-5-29**] Date of Birth: [**2074-5-31**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: right hemiparesis Major Surgical or Invasive Procedure: Intubation History of Present Illness: 72yo woman with PMH possibly notable for HTN presents as a transfer from [**Hospital3 **] with ICH. Per [**Location (un) **] transfer report, she was fine on awakening at 6am and at the breakfast table had slurred speech and slumped over. Per the patient's daughter, who spoke to the patient's husband, who was at the table with the patient but has advanced Parkinson's disease, the patient may have awoken with right hemiparesis. EMS was called and the patient was brought to [**Hospital3 **]. FS in the field was 105. At the OSH, she was noted to be hypertensive to 191/92, and as high as 240/134. NIHSS was 14-15 for LOC (1), LOC questions (2), visual fields (2), motor RUE (3), motor RLE (4), language (?1), and neglect (1). She had a head CT showing the left frontal ICH. She was intubated and given lidocaine 75mg, etomidate 15mg, succinylcholine 80mg, versed 3mg, and [**Last Name (un) 78520**] 20ml/hr (stopped after 5 minutes for BP 154/90). She was medflighted to [**Hospital1 18**]. En route, she was given fentanyl 100mcg x 2 and dilantin 1gm (over 15 minutes). BP dropped to 90/56 during the flight and she was given NS 200cc. On arrival to the [**Hospital1 18**] ED, BP was 82/54. She was found to have nitropaste on, which was wiped off. Her BP further dropped to 76/40s and dopamine gtt was started. Neurology consult was called. She was given an additional 1mg versed. Past Medical History: HTN anxiety Social History: Lives with husband, who has advanced PD, and acts as his caregiver. [**First Name (Titles) **] [**Last Name (Titles) 11807**] at home for his care, but independent in all her ADLs. No tobacco or alcohol per her daughter. Daughter is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 78521**] cell). Family History: not elicited Physical Exam: VS: T 98.2pr, HR 82/54, HR 53, RR 8, SaO2 100%/vent Genl: intubated, sedated HEENT: NCAT, ETT in place Neck: no bruits appreciated CV: RRR, nl S1, S2, no m/r/g Chest: vented BS Abd: soft, NTND, BS+ Ext: warm and dry MS: grimaces to noxious, no eye opening, does not follow commands CN: pupils 2->1.5mm b/l, slightly exotropic eyes, +dolls eyes b/l, +corneals, unable to assess facial droop due to ETT, +gag/cough Motor: withdraws RUE, moves LUE spontaneously, triple-flexes RLE, moves RLE spontaneously Sensory: responds to noxious in all extremities DTRs: [**Name2 (NI) 19912**] throughout, R toe upgoing, L downgoing Pertinent Results: [**2148-5-24**] 11:33AM TYPE-ART TEMP-36.8 PO2-194* PCO2-37 PH-7.40 TOTAL CO2-24 BASE XS-0 INTUBATED-INTUBATED [**2148-5-24**] 08:29AM GLUCOSE-116* LACTATE-1.4 NA+-139 K+-3.9 CL--104 TCO2-26 [**2148-5-24**] 08:20AM UREA N-29* CREAT-1.0 [**2148-5-24**] 08:20AM ALT(SGPT)-17 AST(SGOT)-20 CK(CPK)-110 ALK PHOS-55 AMYLASE-91 TOT BILI-0.4 [**2148-5-24**] 08:20AM cTropnT-<0.01 [**2148-5-24**] 08:20AM CK-MB-6 [**2148-5-24**] 08:20AM ALBUMIN-3.3* CALCIUM-8.6 PHOSPHATE-2.3* MAGNESIUM-1.8 [**2148-5-24**] 08:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2148-5-24**] 08:20AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2148-5-24**] 08:20AM WBC-6.4 RBC-3.82* HGB-11.7* HCT-35.2* MCV-92 MCH-30.7 MCHC-33.3 RDW-13.2 [**2148-5-24**] 08:20AM PLT COUNT-218 [**2148-5-24**] 08:20AM PT-11.3 PTT-26.6 INR(PT)-0.9* [**2148-5-24**] 08:20AM FIBRINOGE-261 [**2148-5-24**] 08:20AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2148-5-24**] 08:20AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2148-5-24**] 08:20AM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0-2 [**2148-5-24**] 08:20AM URINE MUCOUS-MOD [**2148-5-28**] 07:20AM BLOOD %HbA1c-5.7 [**2148-5-27**] 07:10AM BLOOD Triglyc-133 HDL-50 CHOL/HD-3.3 LDLcalc-87 Urine culture [**2148-5-27**] negative Blood cultures x 2 ([**5-27**] and [**2148-5-28**]) nothing to date, pending Non-contrast CT head, [**2148-5-24**]: IMPRESSION: 1. Left frontal intraparenchymal hemorrhage, with blood layering in the ventricle and minimal subarachnoid blood. The subarachnoid hemorrhage is better seen than on prior study. Not significantly changed. 2. New air seen adjacent to the bilateral zygomatic arches, some of which is in a tubular pattern, which suggests it may be venous. However this raises the concern for a traumatic intubation and tracheal injury versus venous air cannot be clearly delineated. CT neck may be helpful to look for venous air. CT neck, [**2148-5-24**]: IMPRESSION: 1. Resolution of soft tissue gas of the bifrontotemporal region seen on the prior non-contrast head CT of [**2148-5-24**]. Findings on the prior study are doubtful to represent intravenous gas and there is no evidence of this on the current study. 2. Suboptimal evaluation of known intraventricular and left frontal intraparenchymal hemorrhage, but these are not grossly changed compared to the recent head CT. 3. 4-mm nodule of the left upper lobe is nonspecific. In a patient with no risk factors for malignancy, no followup is necessary. In a high-risk patient, 12-month CT followup is recommended. MRI/MRA head [**2148-5-25**]: MRI of the head: IMPRESSION: Left parietal intracerebral hematoma with mass effect and surrounding edema. Although minimal marginal enhancement is seen in the anterior lateral aspect of the hematoma. It is not clear whether this is due to an underlying lesion or mild enhancement at the margin of hematoma due to loss of blood brain barrier. Further followup after evolution of hematoma is recommended for assessment. No abnormal flow voids are seen in this region. The hematoma extends to the ventricular system with fluid-fluid levels seen in both lateral ventricles posteriorly. No acute infarct. MRA OF THE HEAD: Head MRA demonstrates normal flow signal within the arteries of anterior and posterior circulation. No evidence of vascular occlusion or stenosis seen. IMPRESSION: Normal MRA. Non-contrast CT head, [**2148-5-26**]: IMPRESSION: No significant interval change in left frontal intraparenchymal hemorrhage with associated edema. Scattered foci of probable subarachnoid hemorrhage. Mild interval increase in density and minimal increase in the amount of intraventricular and subarachnoid blood without evidence of hydrocephalus. Non-contrast CT head, [**2148-5-28**]: IMPRESSION: 1. No new hemorrhage. 2. No change in left frontal hemorrhage. 3. Decrease in degree of intraventricular hemorrhage and possible previous subarachnoid hemorrhage. Chest x-rays: [**2148-5-24**]: IMPRESSION: 1. Retrocardiac opacity, likely atelectasis, but cannot exclude aspiration or early pneumonia. Suggest close follow-up. 2. Tubes in standard position. 3. Air in the left side of the neck without pneumothorax, raises concern for traumatic intubation as d/w Dr [**Last Name (STitle) 78522**] on the morning of the study. [**2148-5-27**]: The patient is scoliotic. The lungs are clear. There is no consolidation. The heart size is normal. There is no pleural effusion. IMPRESSION: 1. Negative examination for aspiration pneumonia. Brief Hospital Course: The patient was admitted to the inpatient neurology ICU for further evaluation and management. The bleeding on the initial scan at the outside hospital appeared similar to that seen here on arrival. Initial imaging by CXR was also concerning for air in the left side of the neck, though further imaging by CT of the neck showed that the finding had resolved. The patient remained stable clinically, and was extubated successfully on [**2148-5-25**], the day after arrival. On examination, she was initially sleepy, and somewhat confused, with a right hemiparesis. MRI/MRA of the head was performed and revealed a stable hemorrhage with no clear lesion lying underneath. Although minimal marginal enhancement was seen in the anterior lateral aspect of the hematoma, it was not clear whether this was due to an underlying lesion or mild enhancement at the margin of hematoma due to loss of blood brain barrier. Further followup after evolution of hematoma was recommended for assessment. It was thought that the hematoma could be due to amyloid angiopathy, though there were no clear microbleeds on imaging. The patient was stable for transfer to the neurologic stepdown unit, where her mental status improved, albeit with some periods of somnolence. This was attributed to increased activity and an intermittent low-grade fever. The fever was evaluated with urinalysis, urine and blood cultures, and chest x-ray, none of which revealed an underlying source. There was no leukocytosis and no antibiotics were started. She had defervesced at time of discharge. Repeat CTs of the head showed a stable hematoma, starting to resolve. Overall, by discharge, she was generally more alert and oriented to person, sometimes place and time. Her right hemiparesis had improved a bit, and was gaining some mild strength anti-gravity and even against resistance. She was risk stratified, with a normal A1C and excellent fasting lipid profile (LDL 87/HDL 50). After hospital evaluation by speech/swallow, physical, and occupational therapy services, she was stable for discharge for further rehabilitation on [**2148-5-24**]. Please note that a 4-mm nodule of the left upper lobe of the lung was seen on CT neck, and is nonspecific. Per radiology, "In a patient with no risk factors for malignancy, no followup is necessary. In a high-risk patient, 12-month CT followup is recommended." Medications on Admission: evista 60mg daily protonix 40mg daily atenolol 25mg daily amoxicillin 500mg tid ativan 0.25mg daily prn Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Pepcid 20 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Evista 60 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: Left frontal intracranial hemorrhage Discharge Condition: Stable. Alert, oriented to person, sometimes place and time. Improving right-sided hemiparesis with 3-4 strength throughout. Left side spontaneous. Discharge Instructions: Please administer medications and follow up appointments as scheduled. If the patient should have any new, worsening, or concerning symptoms, such as increasing confusion/somnolence, vision loss, and worsening weakness, please call your neurologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at ([**Telephone/Fax (1) 15319**] or immediately head to the nearest emergency room. Followup Instructions: Neurology Follow-Up: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2148-7-30**] 1:30 [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

[ "401.9", "733.00", "342.90", "300.00", "530.81", "518.81", "276.3", "431", "458.9", "277.39", "781.94", "459.9" ]

icd9cm

[ [ [] ] ]

[ "38.91", "96.71" ]

icd9pcs

[ [ [] ] ]

10793, 10905

7551, 9942

334, 346

10986, 11137

2841, 6189

11580, 11882

2170, 2185

10097, 10770

10926, 10965

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11161, 11557

2200, 2822

277, 296

374, 1764

6207, 7528

1786, 1799

1815, 2154

948

125,857

3331

Discharge summary

report

Admission Date: [**2117-12-20**] Discharge Date: [**2117-12-23**] Date of Birth: [**2078-11-9**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5037**] Chief Complaint: diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: 39 year old female with past medical history of renal transplant x 2 and hypertension who was in usual state of health until 3 weeks ago. Her husband and her went to [**Country 13622**] republic for a wedding where they both had crampy abdominal pain which resolved with BM and diarrhea. Her husband's symptoms resolved after one week while her symptoms worsened after one week to more frequent diarreha. Her appetite has been normal throughout but her po intake decreased due to fear of causing diarrhea. She does not report nausea/vomiting. She waited till today as she was hosting [**Holiday 944**] dinner and her daughter was home for [**Holiday 944**]. . She reports chills but no cough, pleuritic chest pain, shortness of breath, abdominal pain, nausea, vomiting or dysuria. . In the ED, initial VS were: 97.1 80 89/40 16 100%. Labs notable for lipase of 5180, [**Last Name (un) **] with creatinine of 7.0, HCO3 < 5, anion gap of > 25, lactate of of 0.7, Mg of 1.1, phos of 14.9. CXR showed no acute cardiopulmonary process. She was given 3LNS for fluid resuscitation along with stress dose steroids and then started on HCO3 gtt. She was given IV zosyn for empiric coverage. Renal US showed mild increase in resistive indices which would not completely explain her acute kidney injury. She was admitted to MICU for further evaluation and management. . On arrival to the MICU, she reports no other complaints. Past Medical History: 1. Uretral Reflux: cause of her renal failure at a young age Renal transplant: #1 [**2097**] failed due to preeclampsia with patient's pregnancy, # 2 [**2106**] with signs of chronic kidney disease baseline Cr 1.4-2.0 2. Hypertension 3. Primary HSV hepatic and pulmonary infection [**2114**] 4. Renal osteodystrophy Social History: Married, lives in [**Location 13011**],MA. Has one daughter. Was recently vacationing on [**Location (un) **]. She denies any tobacco use, or illicits. She drinks occasional alcohol. Currently sexually active. - Tobacco: None - Alcohol: Social. Last drink half a glass of wine on Xmas day - Illicits: None Family History: NC Physical Exam: Vitals: HR: 82 BP: 111/66 RR: 18 100% on RA, Afebrile General: Tan, NAD HEENT: moist mucous membranes, anicteric sclera Neck: supple, soft Heart: regular, 2-3/6 SEM Lungs: CTA B Abdomen: Soft, NT, NABS Extremities: No lower extremity Edema Neurological: AOX3, CN II-XII intact Discharge: Vitals: HR: 61 BP: 127/87 RR: 18 96% on RA, Afebrile General: Tan, NAD HEENT: moist mucous membranes, anicteric sclera Neck: supple, soft, non-tender, no [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3495**]: regular, 2-3/6 SEM Lungs: CTA B, moving air well and symmetrically Abdomen: Soft, NT, NABS Extremities: No lower extremity Edema Neurological: AOX3, CN II-XII intact Pertinent Results: Admission labs: [**2117-12-20**] 02:30PM BLOOD WBC-8.6 RBC-2.88* Hgb-9.1* Hct-26.3* MCV-91# MCH-31.7 MCHC-34.7 RDW-14.8 Plt Ct-371 [**2117-12-20**] 02:30PM BLOOD PT-10.9 PTT-31.4 INR(PT)-1.0 [**2117-12-21**] 06:00AM BLOOD Ret Aut-1.3 [**2117-12-20**] 02:30PM BLOOD Glucose-100 UreaN-124* Creat-7.0*# Na-134 K-4.4 Cl-104 HCO3-<5* [**2117-12-20**] 02:30PM BLOOD ALT-37 AST-35 LD(LDH)-445* CK(CPK)-86 AlkPhos-65 TotBili-0.1 [**2117-12-20**] 02:30PM BLOOD TotProt-7.0 Albumin-4.3 Globuln-2.7 Calcium-7.3* Phos-14.9*# Mg-1.1* UricAcd-12.4* [**2117-12-21**] 06:00AM BLOOD calTIBC-202* VitB12-765 Folate-GREATER TH Hapto-239* Ferritn-247* TRF-155* [**2117-12-20**] 02:30PM BLOOD TSH-1.4 [**2117-12-20**] 02:30PM BLOOD Cortsol-23.9* [**2117-12-21**] 06:00AM BLOOD IgA-50* [**2117-12-21**] 04:33AM BLOOD rapmycn-2.6* [**2117-12-20**] 11:56PM BLOOD Type-[**Last Name (un) **] pO2-39* pCO2-22* pH-7.26* calTCO2-10* Base XS--16 [**2117-12-20**] 02:44PM BLOOD Lactate-0.7 K-3.3 Discharge Labs: [**2117-12-23**] 05:47AM BLOOD WBC-4.5 RBC-2.60* Hgb-8.1* Hct-23.0* MCV-88 MCH-30.9 MCHC-35.0 RDW-16.0* Plt Ct-255 [**2117-12-23**] 05:47AM BLOOD Glucose-83 UreaN-33* Creat-1.5* Na-142 K-4.0 Cl-113* HCO3-22 AnGap-11 [**2117-12-23**] 05:47AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.6 [**2117-12-23**] 05:47AM BLOOD rapmycn-4.4* . Imaging: . CXR (portable AP) [**2117-12-20**]: No acute cardiopulmonary process. . Renal transplant ultrasound [**2117-12-20**]: The renal transplant in the left lower quadrant measures 11.7 cm, previously 10.7 cm (likely due to technical differences). The renal pyramids appear more son[**Name (NI) 15487**]. [**Name2 (NI) **] hydronephrosis, stones, perinephric fluid collections or masses are seen. Doppler and spectral analysis of the main renal artery and segmental arteries of the upper, mid, and lower poles were performed. The renal arteries have a sharp systolic upstroke, with mildly elevated resistive indices ranging from 0.83 to 0.93 (previously 0.61-0.65). The main renal vein has normal flow. IMPRESSION: Elevated resistive indices in the renal transplant, concerning for rejection. . CT abdomen/pelvis [**2117-12-20**]: 1. No definite findings related to pancreatitis. No complications of pancreatitis are evident. It should be noted that changes of early or mild/noncomplicated pancreatitis may not be evident on CT examination. 2. Transplant kidney seen in the left iliac fossa without evidence of hydronephrosis or complication based on the non-contrast examination. 3. No other explanation for the symptoms is identified. 4. Small hiatal hernia. Brief Hospital Course: Ms. [**Known lastname 15467**] is 39F s/p renal transplant x2 in [**2106**] on sirolimus, MMF, and prednisone, h/o HTN who is presenting with diarrhea x3 weeks, initially transferred to MICU for persistent hypotension, [**Last Name (un) **] with metabolic acidosis. With fluids [**Last Name (un) **] has resolved and revealed worsened anemia. . # Diarrhea: Likely infectious given recent travel. Given immunocompromised could certainly consider cryptosporidium. Giardia/Ova/Parasites is also a consideration though less likely to cause such a severe presentation. C. Diff negative. The patient was treated empirically with cipro/flagyl and improved greatly. Stool studies were sent and are pending. Hypovolemia treated as below. . # Acute kidney Injury: The patient presented with creatinine 7.0. She was treated with agressive hydration with normal saline and sodium bicarbonate, with rapid improvement of her creatinine to 1.5. . #. Normocytic Anemia: The patient's hematocrit was 26 on admission and fell to 16 with rehydration. Retic was inappropriately low for degree of anemia. Iron studies were notable for low TIBC and high ferritin. She was transfused 2 units PRBC, with appropriate increase in hematocrit. HCT remained stable and on discharge was 23.0 . #. s/p Renal Transplant: Rapamycin was continued. Steroids were initially stress dosed, and tapered back to home dose of 5mg daily. MMF held due to GI symptoms, but restarted prior to discharge. . #. HTN: Antihypertensives held due to hypovolemia and hypotension. Restarted home diltiazem on transfer to floor. Patient should be restarted on home metoprolol and lisinopril as well. . CHRONIC ISSUES #. HLD: Continued pravastatin . #. HSV prophylaxis: Renally dose valtrex to 1000 mg po qdaily. . TRANSITIONAL ISSUES -Bilateral adnexal cysts noted on renal US. The one the left measuring 6.9 cm. The patient has not had a menstrual period for five months. Pelvic ultrasound is recommended for further workup. - Patient should have labs drawn Q2weeks while an outpatient Medications on Admission: Bactrim SS 3xweek Diltiazem 120 mg daily Lisinopril 5 mg po daily Metoprolol 25 mg po BID MMF 1000 mg po BID Pravastatin 10 mg daily Prednisone 5 mg daily Sirolimus 3 mg daily Valtrex 1000 mg daily Discharge Medications: 1. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO three times per week. 2. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 5. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 8. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 8 days. Disp:*24 Tablet(s)* Refills:*0* 11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days. Disp:*16 Tablet(s)* Refills:*0* 12. Outpatient Lab Work ORDER TO BE OBTAINED BY [**2116-12-30**] Please get a CBC, complete metabolic panel including calcium, magnesium, and phosphurus, and sirolimus level. Please fax results to PCP and Nephrologist. PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone# [**Telephone/Fax (1) 10508**] Nephrologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone #[**Telephone/Fax (1) 673**] Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Diarrhea, likely infectious Acute Renal Failure Chronic: s/p renal transplant Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 15467**], . You were admitted to the hospital because you were having diarrhea. We suspected and infectious cause and treated you with antibiotics. However, all your tests came back negative and a cause was not discovered. As you have improved on antibiotics, you should continue the antibiotics for a total of 10 days. You were also found to have acute renal failure (aka kidney damage). This was most likely do to losing lots of fluid with your diarrhea. Your kidney function improved to baseline with intravenous fluids. . The following changes have been made to your medications: - START taking ciprofloxacin 500 mg twice daily until [**2117-12-30**] - START taking metronidazole 500 mg three times a day until [**2117-12-30**]. You should not drink alcohol while you are taking this medication as it can cause a severe reaction including rash, abdominal pain, nausea, and vomiting. Additionally, avoid using mouthwash while on this medication or any oral products containing alcohol. - We have decreased your Myophenolate Mofetil to 500 mg two times a day from 1000 mg two times a day. - We have decreased your Sirolimus from 3 mg a day to 2 mg a day. - No other changes were made, please continue taking the rest of your home medications as previously prescribed . It is also very important that you keep all of the follow-up appointments listed below. . It was a pleasure taking care of you in the hospital! Followup Instructions: You have the following follow up appointments: . Name:[**Name6 (MD) **] [**Name8 (MD) **],MD Specialty: Primary Care Location: THE MEDICAL GROUP Address: [**Last Name (un) 15488**], STE#101, [**Hospital1 420**],[**Numeric Identifier 15489**] Phone: [**Telephone/Fax (1) 10508**] When: [**Last Name (LF) 2974**], [**12-31**] at 11:00am . Department: TRANSPLANT CENTER When: WEDNESDAY [**2118-1-5**] at 11:30 AM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]

[ "585.9", "584.9", "285.29", "V42.0", "620.8", "276.52", "V58.65", "272.4", "009.2", "276.2", "403.90", "458.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9449, 9455

5758, 7792

315, 321

9609, 9609

3163, 3163

11234, 11257

2444, 2448

8040, 9426

9476, 9588

7818, 8017

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2463, 3144

267, 277

11281, 11981

349, 1765

3179, 4129

9624, 9736

1787, 2105

2121, 2428

5,865

111,718

45240

Discharge summary

report

Admission Date: [**2187-5-27**] Discharge Date: [**2187-5-31**] Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is an 83 year old man with a history of coronary artery disease and a long history of duodenal arteriovenous malformations followed closely with the primary care physician with periodic hematocrit to monitor her blood loss. The patient's hematocrit recently dropped from 42 to 35. The patient presented to the Emergency Department with several days of melena. Hematocrit on admission was 30. The patient denies pain, non-steroidal anti-inflammatory drugs use or Aspirin use. PAST MEDICAL HISTORY: Coronary artery disease, multiple duodenal intestinal arteriovenous malformations, status post esophagogastroduodenoscopy on [**2184-6-29**] with cautery of duodenal arteriovenous malformations, status post jejunal arteriovenous malformations, diverticulosis, history of colon cancer Duke's A, status post partial resection, aortic stenosis, myocardial infarction in the past times two, status post hernia repair, status post prostatectomy, gastroesophageal reflux disease. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Atenolol 100 mg q.d.; Isordil 10 mg b.i.d.; Prevacid 30 mg q.d.; Celexa 20 mg q.d.; Hydrochlorothiazide 12.5 mg q.d.; Lipitor 10 mg q.d. SOCIAL HISTORY: Married, retired. Tobacco 5 pack years, quit 35 years ago. Denies alcohol. FAMILY HISTORY: Mother died of a stroke at 67, Father died of lung cancer at age 87. PHYSICAL EXAMINATION: Temperature 98.9, pulse 60, blood pressure 96/36, respiratory rate 14, sating 99% on 4 liters nasal cannula. Elderly man in no acute distress. Pupils equal, round and reactive to light. Extraocular movements intact. Sclera nonicteric. Oropharynx clear. Moist mucous membranes, no jugulovenous distension. Lungs clear to auscultation bilaterally. Regular rate and rhythm, S1 and S2, III/VI systolic murmur at the left upper sternal border. Abdomen soft, nontender, nondistended, positive bowel sounds. No edema. Alert and oriented times three. Moves all extremities. LABORATORY DATA: In the Emergency Department esophagogastroduodenoscopy was performed with Glucagon. Excellent view of duodenum down past second portion was achieved. No ulcers, arteriovenous malformations or active bleeding was noted. Fresh bile was found in the duodenum. Stomach had patchy gastritis in the prepyloric area and one small patch in the fundus but no active bleeding and not significant enough to account for his bleeding. Laboratory data on admission revealed white count 13.9, hematocrit 30, down from 34.7 on [**5-25**]. Platelets were 221. Sodium 136, potassium 3.6, chloride 97, bicarbonate 25, BUN 28, creatinine 1.2, glucose 112. PT 12.5, PTT 22.6, INR 1.0. Electrocardiogram was normal sinus rhythm at 68 beats/minute, left ventricular hypertrophy, normal axis, QRS 152, right bundle branch block, poor R wave progression, .[**Street Address(2) 34274**] depressions in V5 through V6. Iron 25, TIBC 393. HOSPITAL COURSE: The patient was admitted to the Medicine Intensive Care Unit where the patient was transfused a total of 4 units of packed red blood cells. Two large bore intravenous lines were placed. The patient was started on b.i.d. Protonix. The patient had a tag red blood cell scan performed which was negative. The patient was ruled out for an myocardial infarction with serial creatinine kinase. Aspirin was held. The patient was continued on beta blocker and Lipitor. The patient also had his Atenolol and Hydrochlorothiazide held secondary to his bleeding. The patient's hematocrit remained relatively stable. He had b.i.d. hematocrits checked. He was felt stable enough to transfer back to the Medicine Floor. The patient was transferred. He had esophagogastroduodenoscopy and colonoscopy performed on [**5-30**]. The colonoscopy revealed diverticulosis of the sigmoid colon and distal descending colon, intact ileocolonic anastomotic site, otherwise normal colonoscopy to the ileum. Endoscopy revealed normal esophagus, patchy discontinuous erythema and granularity of the mucosa with no bleeding noted in the antrum and stomach body. These findings were compatible with gastritis. In the duodenum a single sessile 2 mm nonbleeding polyp of benign appearance was found in the jejunum. A single nonbleeding arteriovenous malformation was found in the jejunum also. The patient was switched from intravenous b.i.d. Protonix back to once a day p.o. proton pump inhibitors. His diet was advanced. His hematocrit remained stable. The patient was felt stable for discharge the next day. The patient was restarted on all cardiac medications. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Gastrointestinal bleed, status post multiple esophagogastroduodenoscopies and colonoscopy which revealed gastritis, nonbleeding arteriovenous malformation in the jejunum and nonbleeding jejunal polyp. 2. Coronary artery disease 3. Aortic stenosis 4. Gastroesophageal reflux disease DISCHARGE MEDICATIONS 1. Celexa 20 mg q.d. 2. Lipitor 10 mg q.d. 3. Prevacid 30 mg q.d. 4. Isordil 10 mg b.i.d. 5. Hydrochlorothiazide 12.5 mg q.d. 6. Atenolol 100 mg q.d. The patient has been scheduled for a capsule endoscopy for [**6-5**]. He was instructed to be NPO the night of [**6-4**], after midnight and to report to the [**Hospital Ward Name 516**] Lobby at 8 AM on [**2187-6-5**]. The patient will also follow up with Dr. [**First Name (STitle) 2405**] and Dr. [**Last Name (STitle) 120**]. The patient is instructed to follow up with his primary care physician in one to two weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Name8 (MD) 23326**] MEDQUIST36 D: [**2187-5-31**] 16:20 T: [**2187-5-31**] 17:04 JOB#: [**Job Number 96687**]

[ "412", "535.50", "285.1", "424.1", "414.01", "562.10", "V10.05", "530.81", "569.85" ]

icd9cm

[ [ [] ] ]

[ "45.23", "45.13" ]

icd9pcs

[ [ [] ] ]

1428, 1499

4760, 5920

1178, 1316

3053, 4705

1522, 3035

123, 615

638, 1151

1333, 1411

4730, 4739

68,089

112,007

7305

Discharge summary

report

Admission Date: [**2115-9-19**] Discharge Date: [**2115-9-20**] Date of Birth: [**2052-12-23**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 594**] Chief Complaint: Sent in by cardiologist for hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 62 yo male with advanced esophageal ca s/p palliative chemo/XRT, recurrent pl effusions s/p L pleurex, CAD s/p POBA/PCI [**2101**] who presents from cardiology clinic with tachypnea and hypotension. The patient had 450cc drained from his pleurx yesterday ([**9-19**]) as usual. This morning he awoke with a [**Month/Year (2) **] and states he developed some chest pain after a coughing spell "like a pulled muscle, not cardiac" after coughing. He also notes feeling short of breath, but not much more than he has in the past. Pt attributes SOB to pain during inspiration. He went for a routine clinic visit today to follow-up for his known pericardial effusion. He was reportedly hypotensive to the 80's, tachypnic, and complaining of pain. An echocardiogram performed earlier today showed a moderate effusion without evidence of tamponade. In clinic, his pulsus paradoxus was reportedly normal. Pt he felt dizzy earlier in the week but currently denies any dizziness or lightheadedness. In the ED, initial VS were: 98.3 128 97/56 26 89%. Cardiology was consulted and believed pt's symptoms were not secondary tamponade physiology based on pt's echo and pulsus <3. Pt was given 1L NS with improvement in sbp to 105. An ECG sinus tachycardia, old inf TW flattening. CXR was notable for stable L pleural effusion with pleurx in place and R pleural effusion, unchanged from [**9-18**]. The patient was given iv dilaudid and tachypnea improved. On arrival to the MICU, the patient in laying comfortably, saturating 97% on room air with HR 106, BP 110/69. Past Medical History: ONCOLOGIC HISTORY: Mr. [**Known lastname 26973**] presented with a sensation of food getting stuck in his chest in the fall of [**2112**]. Barium swallow demonstrated a stricture in the distal esophagus. ECG demonstrated circumferential narrowing and thickening at the GE junction (40 cm), and extended proximally to 35 cm. Biopsies were performed and pathology demonstrated adenocarcinoma, mucin-producing with few signet ring cells, moderately differentiated. He underwent PET/CT scan [**2113-12-31**], which showed FDG uptake in the GE junction but no evidence of regional or distant metastases. He was referred for EUS staging, performed on [**2114-1-5**], which demonstrated a mass at the distal esophagus/GEJ consistent with known adenocarcinoma, maximum depth 1 cm, with extension beyond the muscularis propria. There were no concerning lymph nodes identified. By EUS, the tumor was staged as T3N0Mx, Stage IIB esophageal adenocarcinoma. . He began concurrent chemoradiation with cisplatin/5-FU on [**2114-1-23**]. He had a J-tube placed prior to treatment. His last radiation treatment was on [**2114-3-1**], total dose 5040 cGy. His last cycle of chemotherapy (C2D1) was [**2114-2-19**]. He underwent [**Month/Day/Year 12351**]-[**Doctor Last Name **] esophagectomy [**2114-4-25**] which demonstrated residual disease, including a positive proximal margin. Surveillance endoscopy demonstrated friable and nodular distal esophagus and biopsy demonstrated adenocarcinoma. . [**2114-9-3**] C1D1 Epirubicin, Oxaliplatin, 5-fluorouracil (5-FU given by continuous infusion pump Mon-Fri x96 hours given his difficulty swallowing pills) [**2114-9-24**] C2D1 Epirubicin, Oxaliplatin, 5-fluorouracil . PAST MEDICAL HISTORY: -Myocardial infarction in [**2101**] treated with plain old balloon angioplasty to one vessel and a stent in another vessel. -Choleocystectomy -Kidney stones -Osteoarthritis: mainly neck and right knee -Low back injury -GERD Social History: Married to his wife of 40 years. two children, & two grandchildren. He works in software and customer teaching for an electronic access device maker. Smoked half a pack to pack a day for approximately 30 years, but quit in [**2101**] with his heart attack. He does not drink alcohol regularly. Family History: Parents both died of heart attack. He has a sister who has had breast cancer twice and a brother with diabetes. Family members with emphysema Physical Exam: Admission: 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, no murmurs, 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, finger-to-nose intact Discharge: 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, no murmurs, 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, finger-to-nose intact Pertinent Results: Labs [**2115-9-20**] 04:16AM BLOOD WBC-8.4 RBC-4.07* Hgb-11.5* Hct-35.6* MCV-88 MCH- 28.2 MCHC-32.2 RDW-16.6* Plt Ct-255 [**2115-9-20**] 04:16AM BLOOD Glucose-94 UreaN-14 Creat-0.5 Na-137 K-4.1 Cl-108 HCO3-23 AnGap-10 ECHO [**9-19**] The left atrium is normal in size. Overall left ventricular systolic function cannot be reliably assessed due to the technically suboptimal nature of this study. However, the inferior and posterior walls appear dyskinetic, and the overall left ventricular ejection fraction is depressed (? 35%). Other segmental wall motion abnormalities cannot be excluded with certainty. The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with borderline normal free wall function. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is a moderate sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. No right atrial or right ventricular diastolic collapse is seen. Compared with the findings of the prior study (images reviewed) of [**2115-7-18**], the overall left ventricular ejection fraction appears lower secondary to increased dyskinesis of the inferior and posterior walls CXR: IMPRESSION: Stable appearance of esophageal stent, bilateral pleural effusions, right greater than left, and bibasilar opacities, possibly reflecting atelectasis MICRO: None Brief Hospital Course: 62 yo male with advanced esophageal ca s/p palliative chemo/XRT, recurrent pl effusions s/p L pleurex, CAD s/p POBA/PCI [**2101**] who was sent in from cardiology clinic for hypotension and tachypnea. #Respiratory distress: Pt found to be tachypnic in ED and was started on nasal canula. Most likely secondary to poor tidal volumes in setting of chest wall strain from coughing yesterday. Pt notes acute onset of pain after coughing last night and physical exam notable for reproducable pain. ECG unchanged from baseline and echo unremarkable for new wall abnormalities this morning. While pleural effusion may be contributing to dyspnea, CXR is largley unchanged from yesterday with stable R effusion and drained L effusion with pleurex in place. No signs of pneumothorax on CXR. His tachypnea improved with dilaudid and he had no need for supplemental oxygen following admission. He was discharged with a prescription of dilaudid for breakthrough pain. His pleurx catheter was also drained prior to discharge. #Hypotension: Most likely secondary to poor po intake. No signs of tamponade or MI on cardio workup. No signs of pneumothorax on CXR. Pt does promote poor po intake over recent weeks with 25lbs weight loss. He has need admission previously for IV hydration. Pt's hypotension has resolved thus far with hydration. -Continued with hydration with bolus target sbp >105, UOP>50cc/hr -Continued to monitor for signs of PP #Pericardial effusion: Chronic and followed by cards as an outpt. Echo this am does not show tamponade physiology and pt has no PP on exam. Furthermore, hypotension resolved with fluids and no appreciable JVP on PE. -Considered elective pericardial drainage -Montitored for PP #Esophageal Ca: Advanced now focusing on palliative chemo and radiation. Followed by Dr. [**Last Name (STitle) 26981**] as an out pt. -Continued with home megace -Sent email to Dr. [**Last Name (STitle) 26981**] Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ascorbic Acid 250 mg PO BID 2. Aspirin 325 mg PO DAILY 3. Fentanyl Patch 25 mcg/h TP Q72H 4. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 5. Lorazepam 0.5 mg PO 4-6H:PRN nausea/insomnia 6. Megestrol Acetate 400 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Ondansetron 8 mg PO Q12:PRN nausea/vomitting 9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain Please monitor and hold for sedation, RR<12 or AMS 10. Senna 1 TAB PO BID:PRN constipation 11. Docusate Sodium 100 mg PO BID:PRN constipation 12. Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Ondansetron 8 mg PO Q12:PRN nausea/vomitting 2. Ascorbic Acid 250 mg PO BID 3. Aspirin 325 mg PO DAILY 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Fentanyl Patch 25 mcg/h TP Q72H 6. Lansoprazole Oral Disintegrating Tab 30 mg PO BID 7. Lorazepam 0.5 mg PO 4-6H:PRN nausea/insomnia 8. Megestrol Acetate 400 mg PO DAILY 9. Vitamin D 800 UNIT PO DAILY 10. Senna 1 TAB PO BID:PRN constipation 11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain Please monitor and hold for sedation, RR<12 or AMS 12. Multivitamins 1 TAB PO DAILY 13. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain take 1-2 tablets as needed for pain not controlled by oxycodone. Do not take if drowsy or driving. Call your oncologist if requiring more than 2 tablets in 24 hours RX *hydromorphone [Dilaudid] 2 mg [**12-3**] tablet(s) by mouth up to once every 6 hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary: hypotension, chest pain Secondary: Pleural effusion, pericardial effusion, esophageal cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Last Name (Titles) 26982**], It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted with shortness of breath and low blood pressure. We gave you fluids and treated your pain, which helped you feel more comfortable and improved your breathing. We also drained your pleurx catheter. Please followup with your oncologist, see below. Please call your cardiologist to schedule a followup appointment to check the status of the [**Hospital1 **] collection around your heart in the next week. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. We made the following changes to your medications: -STARTED Dilaudid for pain control. Please continue taking your other medications as usual. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2115-10-1**] at 9:00 AM With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2115-10-1**] at 9:30 AM With: [**First Name8 (NamePattern2) 4617**] [**Last Name (NamePattern1) 26978**], RN [**Telephone/Fax (1) 9644**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please call your cardiologist Dr. [**Last Name (STitle) **] to schedule a followup appointment to check the status of the [**Last Name (STitle) **] collection around your heart in the next week.

[ "715.80", "786.06", "530.81", "412", "511.9", "786.50", "721.0", "423.9", "458.9", "150.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10766, 10817

7294, 9218

314, 321

10963, 10963

5603, 7271

11901, 12723

4214, 4359

9868, 10743

10838, 10942

9244, 9845

11114, 11755

4374, 5584

11784, 11878

235, 276

349, 1905

10978, 11090

3659, 3885

3901, 4198

16,112

154,582

50607

Discharge summary

report

Admission Date: [**2172-1-12**] Discharge Date: [**2172-1-24**] Date of Birth: [**2093-12-30**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors / Heparin Agents / Fragmin Attending:[**Known firstname 2181**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Hemodialysis. Mechanical ventilation Central line placement History of Present Illness: This is a 78 year-old male nursing home resident with coronary artery disease, ischemic cardiomyopathy leading to CHF (EF 20%), type II diabetes with neuropathy and nephropathy, end stage renal disease status post failed transplant on hemodialysis and recent amputation of left foot for gangrene presents with altered mental status. He was most recently admitted to [**Hospital1 18**] between [**2171-5-22**] to [**2171-5-25**] with fevers thought to be due to line sepsis from his hemodialysis line verse pneumonia. At that time, he was treated with vancomycin and ceftriaxone. He also has a known transudative, left sided pleural effusion thought to be due to his CHF. As per the daughter, he has been feeling illness for the past two weeks and was given a diagnsosis of pneumonia. During this time, he was feeling lethergic and fatigued. He subseqeuently completed a 10-day course of levofloxacin for a community acquired pneumonia. He was without significant complaints until yesterday when he developed fever to 101. He felt ill, "sick as a dog", with respiratory distress. He was subsequently given a neb/cool mist mask but he appeared confused (he reported being locked up in the jail at [**Location (un) 669**]) and appeared more ill by the daughter. During previous episodes of infection, he had also become equally confused. He was started on erythromycin 333mg [**Hospital1 **] for a 10-day course for presumed pneumonia at the time. This morning, he developed altered mental status in addition to fever. At baseline, he is alert and oriented. At his nursing home however, he was lethargic and confused. In addition, he was found to be diaphoretic, and tachypneic with some respiratory distress. He was referred to the [**Hospital1 18**] [**Location (un) 620**] ED, where he had an episode of apnea in the resuscitation bay. He was intubated, and given Levofloxacin, zosyn, vancomycin as well as decadron. He had an episode of hypotension and started on Dopamine. Physical examination was significant for surgical wound of left foot and scrotal erythema. Urinalysis was positive and chest x-ray was without any obvious infiltrate and head CT was without evidence of a bleed. A left IJ was placed and he was trasnferred to [**Hospital1 18**]. Past Medical History: 1. Insulin dependent diabetes with neuropathy and neprhopathy 2. 3 vessel CAD s/p cath [**4-23**] and [**12-26**]: PTCA LAD and LCX, course complicated by ischemic CM with EF 20% 3. s/p Right Femoral-popliteal bypass 4. CHF: [**1-23**] ischemic cardiomyopathy w/ EF <20% 5. ESRD s/p failed transplant on HD (Mon, Wed, Fri) [**1-23**] diabetic nephropathy, baseline CR 2.2-2.4 6. Anemia of chronic disease, baseline HCT 30 7. h/o VF arrest [**4-/2170**] 8. Hypertension 9. stroke: Left posterior deep white matter CVA [**7-24**], right sided weakness, resolved aphasia 10. Seizures in the setting of sepsis: [**4-23**] on dilantin 11. Urinary retention 12. Left pleural effusion 13. s/p OS catract, s/p OD catract [**2166**] 14. s/p thoroscopic, parietal decrotication for hemothorax [**4-23**] 15. s/p tracheostomy [**4-23**] 16. s/p EGD with percutaneous gastrostomy [**4-23**] 17. s/p cholecystectomy [**7-24**] 18. s/p appendectomy 19. Bell's Palsy 20. h/o MRSA bacteremia 21. h/o lower extremity dvt, [**9-/2170**], [**12/2170**] on coumadin 22. h/o heel ulcer colonized with MRSA 23. h/o left foot osteo with VRE Social History: Patient is married. He has been between hospital, [**Hospital1 **] and [**Hospital1 11851**] since [**4-23**]. He is a retired court officer and state representative. Denies any history of tobacco, alcohol, or illicit drug use. At baseline, he is able to feed himself (thickened liquid diet), he does not dress himself and he wears a diaper at baseline. Family History: Mother: died at 92, diabetes and breast cancer Sisters ages 70 and 80 - one has CAD and had MI, other with MR, thyroid problems Brother died at 52 of cancer of unknown type Physical Exam: VS: BP: 105/42, HR: 88, RR: 14, SaO2: 100% AC: 500x14. GEN: intubated, sedated elderly, caucasian male in NAD. breathing comfortably. spontaneously moving all four extremities. withdraws from painful stimuli. grimaces to pain. HEENT: 2mm pupils on L, 3mm pupils on R, neither is reactive, anicteric CV: distant heart sounds, rrr, s1, s2, no m/r/g CHEST: coarse vented bs with crackles ABD: obese, soft, NT, ND, BS+ EXT: BKA on left, open stage III decubitus ulcer on right heel with minimal granulation tissue, no erythema or discharge from site. Back: stage III decubitus ulcer on sacrum Pertinent Results: Hematology: WBC-11.3 HGB-11.8 HCT-36.6 PLT COUNT-127 NEUTS-62 BANDS-25 LYMPHS-7 MONOS-5 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 . Chemistries: GLUCOSE-137 UREA N-30 CREAT-1.9 SODIUM-142 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-28 ALBUMIN-2.0 CALCIUM-7.0 MAGNESIUM-1.9 . LFTs: ALT(SGPT)-29 AST(SGOT)-25 CK(CPK)-21 ALK PHOS-84 AMYLASE-71 TOT BILI-0.3 . Cardiac: CK-MB-NotDone cTropnT-0.10 . CXR [**2172-1-12**]: Layering left pleural effusion which has increased since [**2170**], left IJ in place, no PTX . ECG [**2172-1-12**]: NSR at 90, nml axis, wide P, wide QRS with downward deflection of V1, v2, TWI in V4-v6 (old). Brief Hospital Course: This is 78 year-old male nursing home resident admitted with altered mental status, hypotension, and fevers. . 1. Hypotension/Fevers: The likely source of his fevers and hypotension was urosepsis given his positive urinalysis. Other infectious work-up was negative. His cortisol stimulation test was within normal limits. He also received 7 days of stress dose steroids. He completed a course of vancomycin, zosyn, and tobramycin empirically for urinary tract infection. He had a repeat urinalysis that had elevated white cells. He was treated empirically with a 10 day course of ciprofloxacin. He will complete the course as an outpatient. All of his urine cultures were only positive for yeast. . 2. Altered Mental Status: His lethargy and increased confusion where attributed to his underlying infection. He had a head CT that was negative for mass effect or stroke. His mental status cleared as his fevers and hypotension resolved. . 3. Ventilatory support: He was intubated for apnea at the outside hospital. As his sepsis and mental status improved, he was easily weaned from the ventilator and extubated without difficulty. . 4. End stage renal disease: He has a history of chronic renal disease likely secondary to diabetes with a baseline creatinine of 2.0-2.4. During this admission, he was maintained on Tuesday, Thursday, Saturday dialysis. He was also maintained on nephrocaps, doxecalceferol, and epoeitin with dialysis. . 5. History of seizure: He has a history of seizure in the setting of sepsis in the past. On admission, his dilantin level was subtherapeutic (0.6). He was maintained on dilantin throughout the admission. He was given 2 days of 300 mf dilantin [**Hospital1 **] with increase in his dilantin level. Also, his tube feeds were held before and after dilantin doses to prevent binding of the dilantin by the tube feeds. On discharge his corrected dilantin level was about 7. . 6.Coronary artery disease: He had no evidence of active ischemia. He was maintained on aspirin and statin. His beta-blocker and [**Last Name (un) **] were restarted once he was no longer hypotensive. . 7. Congestive heart failure: He had some evidence of volume overload as evidence by respiratory distress. He received an extra round of dialysis with good effect. he was maintained on his regular cardiac medications. . 8. History of DVT: He had a history of 2 prior DVTs. His coumadin was initially held given procedures performed in the ICU. At that time, he was anticoagulated with argatoban. When the coumadin was restarted, he was bridged with 4 days of overlapping argatroban. . 9. Diabetes: He has known insulin dependent diabetes. He was maintained on an insulin drip in the ICU for good glycemic control. He was then transitioned to his outpatient insulin regimen with good control. . 10. Erythematous Scrotum: This is most likely due to a yeast infection from appearance. He was maintained on topical antifungal powders. . 11. Anemia: He has a known anemia, most likely from anemia of chronic disease/CRI. He continued to receive epoeitin with dialysis. . 12. FEN: Once he was extubated, he was maintained on a mechanical soft with nectar thick liquids with supplemental tube feeds. He was maintained on supplements including the following: MVA, nephrocaps 1 caps daily, B Complex-Vitamin C-Folic Acid 1 mg once daily, and Zinc Sulfate 220 mg once daily. . 13. Access: He had a left IJ catheter placed and this was removed prior to discharge. He also had a right dialysis catheter. . 14. Code Status: Full code, confirmed by daughter. . 15. Dispo: He was discharged back to his nursing home. Medications on Admission: 1. Warfarin 2mg PO HS. 2. Metoprolol Tartrate 25mg PO BID 3. Irbesartan 37.5mg PO DAILY. 4. Aspirin 81 mg PO DAILY. 5. Simvastatin 40 mg PO DAILY. 6. Insulin Regular Sliding Scale Injection four times a day. 7. Insulin Glargine Twenty-two units Subcutaneous qAM. 8. Phenytoin 100mg [**Hospital1 **] 9. Erythromycin 333mg [**Hospital1 **] x 10days ([**2172-1-11**] ->). 10. Zyprexa 2.5mg QHS 11. Nephrocaps one caps daily 12. Acetaminophen 325 mg PO qhs 13. Protonix 14. Zinc Sulfate 15. Calcium 500mg daily 16. MVA 17. Folate 18. Erythromycin eye ointment TID x7days. 19. Robitussin with codeine PRN 20. Duonebs Q4hours while awake Discharge Medications: 1. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Irbesartan 150 mg Tablet Sig: 0.25 Tablet PO qd (). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous once a day. 7. Insulin Regular Human 100 unit/mL Cartridge Sig: asdir Injection four times a day: Sliding scale 150-199: 2 units 200-249: 4 units 250-299: 6 units 300-349: 8 units 350-400: 10 units. 8. Phenytoin 100 mg/4 mL Suspension Sig: One (1) PO BID (2 times a day). 9. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for pain. 12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 14. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day. 15. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. 16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 18. Doxercalciferol 0.5 mcg Capsule Sig: Two (2) Capsule PO 3X/WEEK (TU,TH,SA). 19. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours) as needed. 20. Ascorbic Acid 90 mg/mL Drops Sig: One (1) PO BID (2 times a day). 21. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 22. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Healthcare - [**Location (un) 620**] Discharge Diagnosis: Urinary tract infection End stage renal disease Coronary artery disease Congestive heart failure Diabetes DVTs Discharge Condition: Stable. His respiratory status and mental status have returned to baseline. Discharge Instructions: Take all medications as prescribed. . Seek medical attention if you have shortness of breath, fevers, chills, nausea, vomiting, or anything else that you find worrisome. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Please make an appointment to see Dr. [**Last Name (STitle) **] as soon as possible Completed by:[**2172-1-24**]

[ "V17.3", "995.92", "403.91", "425.4", "V12.51", "707.03", "707.07", "250.60", "038.8", "250.40", "V45.1", "V45.82", "518.81", "V58.61", "V18.0", "V43.4", "996.81", "285.29", "583.81", "112.2", "585.6", "785.52", "V45.61", "428.0", "599.0", "357.2", "V49.75", "V58.67", "414.01", "438.89", "780.39", "V02.59" ]

icd9cm

[ [ [] ] ]

[ "38.94", "96.71", "39.95", "96.6" ]

icd9pcs

[ [ [] ] ]

11876, 11960

5656, 6374

324, 386

12115, 12194

5016, 5633

12515, 12630

4215, 4391

9980, 11853

11981, 12094

9323, 9957

12218, 12492

4406, 4997

263, 286

414, 2684

6389, 9297

2706, 3828

3844, 4199

73,312

155,874

37896

Discharge summary

report

Admission Date: [**2136-9-26**] Discharge Date: [**2136-10-1**] Date of Birth: [**2068-9-7**] Sex: M Service: CARDIOTHORACIC Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 1505**] Chief Complaint: Fatigue/Shortness of breath Major Surgical or Invasive Procedure: [**2136-9-26**] - MV Repair ([**Company 1543**] CG 34mm Ring) History of Present Illness: 68 year old male who has been complaining of worsening fatigue as well as mild exertional dyspnea. In addition he was four pillow orthopnea and occasional PND. He has been followed for mitral regurgitation and most recent echo revealed severe mitral regurgitation with prolapse of posterior mitral valve leaflet likely due to chordal rupture. He is now referred for surgical evaluation. Past Medical History: Mitral Regurgitation/Mitral valve prolapse Congestive heart failure Pulmonary hypertension Hyperlipidemia Asbestos exposure Past Surgical History: Tonsillectomy Assaulted/Stabbed in the back age 20 s/p exploratory lap Social History: Occupation: Retired locksmith and inventor Last Dental Exam:edentulous Lives with wife [**Name (NI) **]: Caucasian Tobacco: Non-smoker ETOH: 6 beers/week Family History: no premature, father had coronary artery disease at age 70 Physical Exam: VS: T 98.7 HR 50-60 Afib BP: 109/71 Sats: 94% RA Wt: 79.8 preop 73.4 General: 68 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple Card: irregular no murmur/gallop or rub Resp: decrease breath sounds otherwise clear GI: benign Extre: warm trace edema Incision: sternotomy clean dry intact no erythema Neuro: non-focal Pertinent Results: [**2136-9-26**] ECHO: PRE-BYPASS: The left atrium is markedly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. There is moderate/severe mitral valve prolapse. The mitral regurgitation vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**Known lastname 36066**], W at 09:45 before CPB. Post_Bypass: Normal RV systolic function. LVEF 45%. There is a ring in the mitral postion with no residual regurgitation. There is no [**Male First Name (un) **]. Thoracic aorta is intact. Trivial TR. [**2136-9-30**] CXR: As compared to the previous examination, the extent of the pre-existing right pneumothorax has not substantially changed. There are no signs of tension. Unchanged aspect of the cardiac silhouette and of the remaining lung parenchyma. No newly occurred focal parenchymal opacity suggesting pneumonia. [**2136-9-26**] 12:30PM BLOOD WBC-14.5*# RBC-3.08*# Hgb-9.1*# Hct-26.5*# MCV-86 MCH-29.7 MCHC-34.6 RDW-13.4 Plt Ct-137* [**2136-9-30**] 06:50AM BLOOD WBC-6.1 RBC-3.16* Hgb-9.2* Hct-27.5* MCV-87 MCH-29.0 MCHC-33.4 RDW-13.4 Plt Ct-125* [**2136-9-26**] 12:30PM BLOOD PT-17.0* PTT-29.5 INR(PT)-1.5* [**2136-10-1**] 06:10AM BLOOD PT-14.4* INR(PT)-1.2* [**2136-9-26**] 01:54PM BLOOD UreaN-16 Creat-0.7 Cl-116* HCO3-22 [**2136-10-1**] 06:10AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-138 K-4.9 Cl-104 HCO3-29 AnGap-10 [**2136-10-1**] 06:10AM BLOOD Mg-2.2 Brief Hospital Course: Mr. [**Known lastname 36066**] was admitted to the [**Hospital1 18**] on [**2136-9-26**] for surgical management of his mitral valve disease. He was taken to the operating room where he underwent a mitral valve repair. Please see operative note for details. Postoperatively he was taken to the intensive care unit for invasive monitoring in stable condition. Over the next 4 hours, he awoke neurologically intact and was extubated. He had some ventricular and atrial ectopy which was treated with amiodarone. On postoperative day one, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. He had atrial fibrillation in the 50-60's with slowing to the 40's. Electrophysiology was consulted and they recommended stopping amiodarone and beta-blockers and start anticoagulation. He was started on Warfarin. Chest tubes were removed on post-op day two. A follow-up chest film showed small apical pneumothorax and bilateral effusion. Epicardial pacing wires were removed on post-op day three. He was seen by physical therapy for strength and mobility who eventually cleared him for discharge home. His pain was well controlled on oral pain medication. He made steady progress and was discharged to home with VNA services on post-op day six. He will follow-up as an outpatient and with his cardiologist for further Coumadin management. Medications on Admission: Aspirin 81mg qd, Lasix 40mg qd, Zocor 20mg qd, Tylenol prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*1* 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 10 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day: Adjust dose per Dr. [**Last Name (STitle) **] for atrial fibrillation. INR Goal of 2.0-3.0. Disp:*60 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Mitral Regurgitation/Mitral valve prolapse s/p MV repair Congestive heart failure Pulmonary hypertension Hyperlipidemia Asbestos exposure Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. 8) Please take Coumadin and adjust dose per Dr. [**Last Name (STitle) **]. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) **] for Coumadin follow-up Please follow-up with Dr. [**First Name (STitle) 10940**] in [**12-27**] weeks. Please call all providers for appointments. Completed by:[**2136-10-1**]

[ "512.1", "E878.2", "428.0", "511.9", "V58.61", "427.31", "424.0", "V15.84", "287.5", "997.1", "416.8", "429.5" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.12" ]

icd9pcs

[ [ [] ] ]

6489, 6547

3871, 5268

308, 371

6728, 6734

1676, 3848

7603, 7926

1215, 1275

5377, 6466

6568, 6707

5294, 5354

6758, 7580

956, 1028

1290, 1657

241, 270

399, 787

809, 933

1044, 1199

32,690

119,837

34537

Discharge summary

report

Admission Date: [**2119-8-20**] Discharge Date: [**2119-8-24**] Date of Birth: [**2090-6-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1**] Chief Complaint: Sigmoid volvulus Major Surgical or Invasive Procedure: Sigmoid colectomy History of Present Illness: Mr. [**Known lastname 79331**] a 29yo male with no medical history who presented to ED with abdominal and [**Doctor Last Name **] back pain. He underwent CT scan which revealed a sigmoid volvulus. He was admitted for managment. Past Medical History: none Social History: He is a non-smoker. Drinks occasional ETOH. Supportive girlfriend Family History: Mother & sister have IBS Physical Exam: At Discharge: Vitals:_________________________ GEN: A/Ox3 CV: RRR RESP: CTAB ABD: +BS, soft, ND, appropriately TTP, +BM Incision: abdominal, midline OTA with staples Extrem: no c/c/e Pertinent Results: [**2119-8-22**] 07:40AM BLOOD WBC-5.5 RBC-4.10* Hgb-14.0 Hct-37.7* MCV-92 MCH-34.2* MCHC-37.2* RDW-12.5 Plt Ct-121* [**2119-8-21**] 05:35AM BLOOD WBC-7.6 RBC-4.01* Hgb-13.4* Hct-36.6* MCV-91 MCH-33.4* MCHC-36.6* RDW-13.6 Plt Ct-147* [**2119-8-22**] 07:40AM BLOOD PT-14.2* PTT-28.5 INR(PT)-1.2* [**2119-8-22**] 07:40AM BLOOD Glucose-52* UreaN-12 Creat-0.7 Na-140 K-3.8 Cl-105 HCO3-20* AnGap-19 [**2119-8-20**] 12:00PM BLOOD ALT-21 AST-26 AlkPhos-45 TotBili-1.6* DirBili-0.4* IndBili-1.2 [**2119-8-22**] 07:40AM BLOOD Calcium-8.2* Phos-3.0 Mg-1.7 . CT Scan [**2119-8-20**]--IMPRESSION: Sigmoid volvulus with massively distended sigmoid colon and transverse and proximal descending colon. The distal transition point is located deep within the pelvis. . Pathology [**2119-8-22**]-Not finalized Brief Hospital Course: Mr. [**Known lastname **] was found to have sigmoid volvulous vis CT scan which was decompressed for 2 days in the SICU. He underwent a colonoscopy with GI on [**2119-8-21**] which confirmed anatomy of volvulous within sigmoid. General Surgery was consulted for management options. It was decided to perform a semi-elective operation to prevent future recurrence of volvulous. The patient underwent necessary pre-op labwork, and consent was obtained. . He underwent a colectomy, tolerated procedure well. He was transferred to 12 [**Hospital Ward Name 1827**] after routine observation in the PACU. . POD1: He was started on sips, tolerated well. He became hypoglycemic (50-60) post-op, but was asymptomatic. Blood sugar increased appropriately with 1/2D50 IV. Blood sugars remained stable thereafter. Pain well controlled with PCA. Abdominal dsg CDI, incision intact. Foley in place. Urine output decreased-bolused with LR-1500cc with incease in urine output. Foley removed overnight. Patient failed to urinate. Foley re-inserted. Ambulating independently. . POD2: Diet advanced to FULL liquids, tolerated well. Medications transitioned to PO, pain well controlled with Vicodin. Foley removed once again. Voided adequate amounts. Reported flatus and loose BM. Diet advanced to regular food. . Medications on Admission: none Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed for pain for 2 weeks: Take with food. Disp:*35 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: sigmoid volvulous Post-op hypoglycemia Post-op urinary retention Discharge Condition: Stable Tolerating a regular diet Adequate pain control with oral medication 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. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your staples will be removed at your follow-up appointment -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: 1. Please make a follow-up appointment with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 9**] in 2 weeks for staple removal. 2. Follow-up with your Primary care provider [**Last Name (NamePattern4) **] 1 week and as needed.

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Discharge summary

report

Admission Date: [**2191-4-28**] Discharge Date: [**2191-5-4**] Date of Birth: [**2122-6-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2610**] Chief Complaint: nausea/vomiting, dizziness, fevers Major Surgical or Invasive Procedure: lumbar puncture History of Present Illness: Mr. [**Known lastname **] is a 68-year-old male with a past medical history of coronary artery disease s/p MI with DES to LAD, type 2 diabetes, history of CVA with residual left hemiparesis, hypercholesterolemia, hypertension, and recent I&D of posterior right chest wall abscess who presents for back pain, LE weakness, and fever. The patient is status post I&D for right upper posterior abscess on [**2191-4-20**] with drainage of substantial purulent, caseous material and was started on a 10-day course Augmentin and Bactrim for antibiotic treatment. He was given Percocet, but not currently taking, only on Tylenol for pain. About a week ago, he developed pain over his back at the site of the abscess. Dizziness started on Saturday and described it as a lightheadedness not vertigo. He does not have any complaints of hearing loss. He subsequently developed nausea and vomiting and has been unable to tolerate much food for the past few days. He has some baseline LLE weakness but noted increasing BLE weakness with difficulty ambulating. His bactrim was stopped on [**2191-4-27**] per a note by her geriatrician on that date due to concerns for hypoglycemia although per pt, he has been off both bactrim and augmentin for several days. Yesterday, he developed subjective fevers so came to the ED today for evaluation. . In ED, he was noted to have Temp 101.1, HR 134, BP 144/73, RR 20, O2 SAT 98%. There was a question of L midline spine tenderness and proximal > distal weakness on initial exam which was not noted on subsequent exam. Pt had nl rectal tone and no saddle anesthesia. His posterior chest wall abscess appeared indurated without gross fluctuance. He did have a macular rash diffusely. Blood cx were drawn. CXR and U/A were unremarkable, blood and urine cultures sent. Pt was started on vanc 1gm IV and ceftriaxone 2gm IV for cellulitis v. possible epidural abscess given his LE weakness although the wet read of his MRI spine did not note epidural abscess. He subsequently spiked a fever to 103.9, was tachycardic to the 120s and appeared ill. He did not respond to tylenol but was given motrin with defervescence and improvement in his clinical appearance. His abscess site was reexamined with ultrasound and appeared to have a fluid pocket but this was opened up and nothing was aspirated except some to squeeze out some fibrinous material. On transfer, VS were: T 95, BP 117/68, RR 21, O2sat 96% RA. . On floor, pt currently without complaints. He states that his LE weakness and back pain seems to have resolved in the ED. . ROS: Denies headaches, recent weight loss or gain. Denies chest pain or tightness, palpitations. Denies diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias. Other systems otherwise negative. Past Medical History: 1. Coronary artery disease status post PTCA and stenting x3 in [**2183**], mid-LAD stent in [**2185**]. 2. Type 2 diabetes. 3. History of CVA with left hemiparesis in [**2174**]. 4. Hypercholesterolemia. 5. Hypertension. 6. Vitamin B12 deficiency. 7. Iron deficiency anemia. Social History: Originally from [**Country **]. Retired, used to work in the Laundry department at [**Hospital1 18**]. He denies any alcohol use. He quit smoking in [**2180**]. No illicit drug use. Family History: Father had DM, died at 75. Physical Exam: VS: T 96.9, BP 126/81, P 90, RR 20, O2sat 99RA. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD Back: No focal spine or CVA tenderness. Bandage over 1cm incision on right-mid posterior chest with packed area about 6x3 cm, surrounding hyperpigmentation v. erythema, mild tenderness, no purulent drainage visualized. 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. [**Last Name (un) 5813**] sign neg. Neuro: AAO x3, CN II-XII intact, strength 5/5 b/l, sensation to LT intact, cerebellar fxn intact, no pronator drift, patellar reflexes symmetric, toes downgoing on Babinski, gait not assessed. Skin: Diffuse macular rash across abdomen and back, nonpruritic. Pertinent Results: Admission labs: GLUCOSE-131* UREA N-19 CREAT-1.3* SODIUM-132* POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-21* ANION GAP-18 ALT(SGPT)-39 AST(SGOT)-25 CK(CPK)-66 ALK PHOS-93 TOT BILI-0.7 CK-MB-NotDone cTropnT-<0.01 ALBUMIN-4.4 WBC-15.6* RBC-4.87 HGB-14.6 HCT-43.0 MCV-88 MCH-29.9 MCHC-33.8 RDW-13.2 NEUTS-84.5* LYMPHS-9.6* MONOS-5.3 EOS-0.3 BASOS-0.3 PLT COUNT-298 PT-14.2* PTT-27.1 INR(PT)-1.2* LACTATE-2.5* URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.025 URINE BLOOD-NEG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG URINE RBC-0-2 WBC-[**4-8**] BACTERIA-NONE YEAST-NONE EPI-[**4-8**] . Discharge Labs: [**2191-5-4**] WBC-10.2 RBC-4.02* Hgb-11.8* Hct-36.0* MCV-89 MCH-29.4 MCHC-32.8 RDW-13.6 Plt Ct-295 Glucose-212* UreaN-15 Creat-0.8 Na-136 K-4.2 Cl-104 HCO3-23 AnGap-13 Calcium-8.8 Phos-2.4* Mg-1.8 . Micro: Blood cx x9: no growth to date, 2 of which are final Urine cx: no growth CSF gram stain and culture: no organisms Sputum: contaminated Stool: negative for campylobacter, shigella, salmonella and Cdiff RPR: non reactive Lyme serologies: negative HIV: negative PPD: negative . Imaging: [**2191-5-2**] Echo: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild (non-obstructive) focal hypertrophy of the basal septum. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal to distal inferior and inferolateral walls.. The remaining segments contract normally (LVEF = 45-50%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. Trace 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 (1+) mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No endocarditis, abscess. Mild mitral regurgitation. Normal regional and global biventricular systolic function. . [**2191-5-1**] CT chest/abd/pelvis: 1. Cholelithiasis, without evidence of acute cholecystitis. 2. Diverticulosis, without evidence of acute inflammation. 3. Focus of gas within the bladder. Correlate with history of Foley placement; if this has not occurred recently, this could be indicative of infection. 4. Prominent elongated peripancreatic lymph node. In the absence of other adenopathy, this is likely not of significance. . [**2191-4-28**] MRI Spine: Minimal degenerative changes of the lumbar spine. Otherwise unremarkable MRI of the thoracic and lumbar spine, without evidence of an epidural abscess, abnormal enhancement, or spinal cord/neural foraminal compromise. . [**2191-4-28**] Back U/S: 2.5 x 0.7 cm complex collection in the region of concern in the right posterior chest wall, 5 mm below the skin surface, suspicious for recurrent abscess. The skin directly overlying the lesion was marked. Brief Hospital Course: 68-year-old male with a past medical history of coronary artery disease s/p MI with DES to LAD, type 2 diabetes, history of CVA with left hemiparesis, hypercholesterolemia, hypertension, and recent I&D of right axilla abscess presented with complaints of dizziness, fever, nausea and vomiting. . # Fever/leukocytosis: Initially there was question of cellulitis or invading abscess with a specific concern for extension of his right back abscess into epidural space given presenting complaints of LE weakness and back pain. An ultrasound was done and surgery felt that the fluid collection was too small to drain further and no intervention was necessary. Surgery did not feel that it was the cause of fevers. There were no signs of abscess or cord compression on the spinal MRI. He was initially on vanco, metronidazole and ceftriaxone 2gm Q12hrs for treatment of suspected epidural abscess while awaiting MRI results, with metronidazole stopped after the negative MRI results. CXR and UA were clean, and the patient had no diarrhea or abdominal pain. The morning after admission he was complaining of neck stiffness without headache or confusion in the setting of fevers to 103.9. He was started empirically on ampicillin, but an LP showed no signs of infection. Two days after admission he looked very ill in the setting of repeated fevers, and was started on Zosyn. A maculopapular rash was seen to be spreading on his torso, and the possibility of drug reaction was raised, as no definitive infectious source had been found. All antibiotics were stopped and the patient symptoms and fevers trended down. ID was consulted this admission and felt that his rash was consistent with drug fever. The patient was HIV negative. Lyme serologies and RPR was negative. PPD was negative. . # Back abscess: Patient had right back superficial skin abscess that was initial drained [**4-20**], followed by 7 days of augmentin and bactrim. Did not appear infected on arrival to the floor. U/S showed small, deep fluid pocket. Seen by general surgery who did not think the fluid pocket should be drained, and thought that it was unlikely to be causing the fevers. . # Back pain: MRI of thoracic and lumbar spine was done and showed no acute pathology. Patient had an LP and later complained of back pain. CT imaging showed no pathology. Patient's pain would improve with pain medications and PT cleared patient for home. Patient has LLE weakness and difficulty ambulating at baseline. Case reviewed with radiology who did not feel any further imaging was waranted given that pain was stable and fevers resolving. Feel pain is most likly [**3-8**] degenerative changes and should improve with pain medications and physical therapy at home. . # Acute renal failure: Had mild renal failure on arrival, likely due to hypovolemia and/or bactrim use. Resolved with hydration. . # CAD s/p PTCA and stenting x3 in [**2183**]. CP free. Continued ASA 325mg, plavix 75mg, metoprolol 12.5mg , statin 10mg . # Type 2 diabetes: Coverage with ISS while in house, but patient was discharged on his home oral agents. . Medications on Admission: AMOXICILLIN-POT CLAVULANATE (500/125) [**Hospital1 **] for 10 days (has not taken for several days per pt) CLOPIDOGREL [PLAVIX] 75 mg by mouth daily GLYBURIDE 5mg Tablet(s) QAM and QHS METFORMIN 1,000 mg Tablet twice a day METOPROLOL TARTRATE 12.5 mg QHS SIMVASTATIN 10 mg daily ACETAMINOPHEN - 650 mg Tablet Sustained Release - 2 Tablet(s) by mouth every 8 hours ASPIRIN - 325 mg Tablet - 1 Tablet(s) by mouth daily CYANOCOBALAMIN 1,000 mcg - 1 Tablet(s) by mouth daily DOCUSATE SODIUM - 100 mg Capsule twice a day FERROUS SULFATE - 325 mg (65 mg Elemental Iron) daily BLOOD-GLUCOSE METER [ONE TOUCH] directed 1-2 times per day ONE TOUCH COMBO - Combo Pack - use as directed 1-2 times per day SENNOSIDES [**2-5**] Tablet(s) QHS Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 8. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). Disp:*30 Tablet(s)* Refills:*0* 10. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: do not drive or drink alcohol on this medication. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: Drug Rash w fever h/o right upper back abscess . Secondary Diagnosis: 1. Coronary artery disease status post PTCA and stenting x3 in [**2183**], mid-LAD stent in [**2185**]. 2. Type 2 diabetes. 3. History of CVA with left hemiparesis in [**2174**]. 4. Hypercholesterolemia. 5. Hypertension. 6. Vitamin B12 deficiency. 7. Iron deficiency anemia. Discharge Condition: stable, satting well on room air, ambulates with assistance Discharge Instructions: You were admitted to the hospital with back pain, fever, and rash. Imaging showed no current infection in your back or chest or abdomen. You complained of neck stiffness so you had a lumbar puncture that also did not show infection. We also tested you for HIV and placed a PPD and both tests were negative. We feel that all of your symptoms were related to an allergic reaction to previously perscribed antibiotics. We stopped all antibiotics and you improved. It is unclear which antibiotic caused this reaction. Therefore, you should discuss future antibiotic use with your PCP. . We feel that your back pain is related to degenerative changes in your back. We think it should improve with pain medications and physical therapy. A physical therapist will work with you in your home. . In terms of your previous abscess, your wound looks to be healing well. Please clean with wound cleanser once a day. Then place a dry sterile dressing. Change this daily and keep the wound clean and dry. The home nursing services will help you with this. Your PCP will give you further instructions if needed. . While in the hospital we repleated your phosphorus. When at home, please eat a diet [**Doctor First Name **] in protein to get enough phosphorus in your diet. . We have made the following changes to your medication: 1. Tylenol 1000mg by mouth three times a day 2. Oxycodone 5mg by mouth every 6 hours as needed for pain. Do not drive or drink alcohol while on this medication. 3. Senna 8.6mg by mouth twice a day as needed for constipation 4. Colace 100mg by mouth twice a day as needed for constipation Followup Instructions: Appointment #1 MD: Dr. [**First Name (STitle) **] [**Name (STitle) **] Specialty: Gerontology Date/ Time: [**2191-5-9**] 10:30am Location: [**Last Name (NamePattern1) 439**] [**Hospital Unit Name **] [**Location (un) **], [**Location (un) 86**] MA Phone number: [**Telephone/Fax (1) 719**] Special instructions for patient: Completed by:[**2191-5-4**]

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icd9cm

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10812

Discharge summary

report

Admission Date: [**2176-7-19**] Discharge Date: [**2176-7-23**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old man with a history of hypertension, catheterization ten years ago complicated by intracranial bleed, and a 120 pack-year smoking history, who developed the acute onset of substernal chest pain with shortness of breath, nausea, and diaphoresis on the day of admission. He was taken to [**Hospital3 3583**] where he was found to have ST elevations in electrocardiogram leads V2-V6, I, II, and AVF. He was brought via [**Last Name (un) **]-Flight to [**Hospital6 256**] for primary angioplasty. On catheterization, he had elevated filling pressures with pulmonary artery systolic of 37, diastolic of 21, and mean of 29. He was found to have right dominance. His left main was normal. Proximal LAD had a 30% stenosis. Mid LAD had 100% stenosis. Left circumflex had no disease. Proximal right coronary artery had 30% stenosis. Mid right coronary artery had 60% stenosis. The mid LAD lesion was stented with mild impingement of D1 at the origin. He received Lasix 20 mg in the lab. Integrilin was deferred secondary to history of hemorrhagic cerebrovascular accident. He was then admitted to the CCU in stable condition for continued management. PHYSICAL EXAMINATION: Vital signs: On admission temperature was 97.9??????, blood pressure 112/54, pulse 89, respirations 19, oxygen saturation 96% on 4 L nasal cannula. General: He was alert and oriented times three. He was in no acute distress. He was pain free. HEENT: There was no jugular venous distention present. No bruits. There were 2+ carotid pulses bilaterally. Lungs: Clear to auscultation bilaterally. Heart: Regular, rate and rhythm. S1 and S2. There was a 1 out of 6 systolic ejection murmur. Abdomen: Soft, nontender, nondistended. Active bowel sounds. Extremities: Right pressure dressing intact. No discomfort or hematoma in groin. Distal pulses 2+ bilaterally. No edema present. LABORATORY DATA: On admission white count was 13.7, hematocrit 28.1; CHEM7 within normal limits; coags with an INR of 1.3, PTT 95.1; CK initially 219, peaked to 3611, the second cycle of CKs with a MB fraction of 518, troponin 8.0-12.4, and the rest of the admission laboratories were not of noted. Electrocardiogram on admission revealed normal sinus rhythm at 88 beats per minute, normal axis and intervals, marked ST elevation in the anterior precordium, V2-V6, lead I, II, and AVF. After stenting, there was partially normalizing of the ST elevations, new Q-waves and loss of R-wave in V2 and V3. HOSPITAL COURSE: The patient was admitted and ruled in for myocardial infarction by enzymes and by electrocardiogram. The enzymes peaked at 3611 on the 10th and continued to decrease on that day until the day of discharge. The patient diuresed well on Lasix. Captopril was added for afterload reduction and to decrease mortality. Plavix and Aspirin were added status post myocardial infarction, as well as because of the stent placement. Lopressor was added because of beta-blocker favorable affects on mortality. The patient was also given subcue Heparin and Zantac for prophylaxis. The patient developed hemoptysis with brown sputum, slightly blood tinged on day #2 of admission. This continued but decreased throughout the rest of his hospital stay. The patient was covered with Levaquin initially for community acquired pneumonia. The patient's temperature spiked to 104.2?????? on this regimen, and was switched to Ceftriaxone and Azithromycin; however, the patient spiked a temperature to 103.2??????. At that point, the patient was switched to Levaquin, Flagyl and received one dose of Vancomycin, at which point the patient defervesced. An abdominal CT scan was also done which was negative for intra-abdominal abscess; however, it did reveal right middle lobe pneumonia which had also been seen on earlier chest x-rays. Also urinalysis revealed probably urinary tract infection which was felt to be treated on the Levaquin, and an electrocardiogram revealed possible V5 ST elevation, which would have been a new finding compared with previous electrocardiograms. However, because of a lack of increase in the CK or the CKMB fraction, this was felt to be noncontributory. The patient's remaining course was insignificant. DISPOSITION: Stable for discharge. DISCHARGE PLAN: He is to be discharged to home with VNA nursing, possibly home Physical Therapy. He will most likely have home oxygen. He is to have cardiac rehabilitation in [**3-15**] weeks. DISCHARGE MEDICATIONS: Levaquin 500 mg p.o. q.d. to finish off a 10-day course, Flagyl 500 mg p.o. t.i.d. to finish a 10-day course, Plavix 75 mg p.o. q.d. to finish a 30-day course, Aspirin 325 mg p.o. q.d., Lopressor will be switched to Atenolol, Captopril will be switched to Univasc, Phenobarbitol 60 mg p.o. t.i.d., Lipitor 10 mg p.o. q.h.s. The patient will not receive any antibiotics as an outpatient. FOLLOW-UP: He will follow-up with his primary care physician, [**Name10 (NameIs) 3**] well as his cardiologist. DR.[**Last Name (STitle) 12203**],[**First Name3 (LF) **] 12-465 Dictated By:[**Name8 (MD) 6069**] MEDQUIST36 D: [**2176-7-22**] 14:27 T: [**2176-7-22**] 15:25 JOB#: [**Job Number 35284**] [**Country **] FACILITY FOR HOME OXYGEN VNA FOR HOME NURSING CARE(cclist)

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icd9cm

[ [ [] ] ]

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47835

Discharge summary

report

Admission Date: [**2190-9-1**] Discharge Date: [**2190-9-15**] Date of Birth: [**2125-5-16**] Sex: M Service: SURGERY Allergies: Cephalosporins / Metoclopramide / Infed Attending:[**First Name3 (LF) 5569**] Chief Complaint: Scrotal abscess Major Surgical or Invasive Procedure: [**2190-9-1**] Incision and drainage of scrotal abscess, skin debridgement [**2190-9-2**] Further debridement of scrotal tissue History of Present Illness: This is a 65 M c/ pmh of hepatitis C/cirrhosis, ESRD, DM, PVD, who presented to the [**Hospital1 1474**] ED on [**2190-8-31**] complaining of scrotal swelling and tenderness. The patient states that the tenderness presented last Thursday ([**8-26**]). He was seen by hepatology on [**8-27**] with no testicular/scrotal swelling. Over the weekend, the patient noticed increased scrotal swelling and tenderness. At [**Hospital 1474**] Hospital, the patient was initially on Levophed for hypotension which was weaned off with fluids. He as given Vanc PO, Linezolid, Clindamycin, Cipro, and Zosyn. CT ABD consistent with diffuse scrotal edema with large fluid collection in the right wall of the scrotum. The patient was transferred to the [**Hospital1 18**] SICU hemodynamically stable for definitive treatment. Past Medical History: PMH: CKD V from diabetic nephropathy (HD since [**5-/2183**]), DM2 (20 yrs, on insulin), Hepatitis C genotype 4, Cirrhosis (portal hypertensive gastropathy, grade I varices on EGD), h/o ischemic colitis with GIB (approx [**2180**]), small bowel AVMs, HTN, h/o TB (age 15, Rx with PAS/INH x 2 yrs), Hep B core Ab positive (negative viral load in [**2185**]), h/o IV drug use (heroin, methadone since [**2159**]), AV fistula infection , VRE and MRSA, Chronic anemia, MSSA HD line infection, prior ESBL Klebsiella wound infections, recent osteomyelitis of left finger, new pancreatic head mass (CT [**2190-8-6**]) PSH: S/p bilat BKA ([**2179**], [**2183**]) for polymicrobial chronic osteomyelitis; wears prostheses and uses walker, s/p penectomy for necrosis [**1-26**] arterial insufficiency, past AV fistulas/grafts Social History: Retired computer worker. Smokes [**12-26**] PPD cigarettes x 10+ years; denies alcohol or current polysubstance use; former IVDU. Came to [**Hospital1 18**] from [**Hospital1 1501**] the Embassy House rehab in [**Hospital1 1474**]. Family History: Several siblings with diabetes Physical Exam: VS: T 96 HR 72 BP 130/46 RR 16 96% 4L NC GEN: NAD, AAOx3 HEENT: dry mucous membranes, no scleral icterus CHEST: CTA B/L, R. tunnelled HD line HEART: RRR, S1/S2 ABD: soft, ND, NT, BS present Groin: significant scrotal swelling, diffusely tender, 5x6 cm area of necrotic skin over right scrotum, active ? purulent drainage from bottom, left scrotum EXT: B/L BKA, no edema Pertinent Results: [**2190-9-15**] 11:15AM BLOOD WBC-7.2 RBC-3.16* Hgb-9.0* Hct-29.1* MCV-92 MCH-28.4 MCHC-30.9* RDW-19.7* Plt Ct-183 [**2190-9-7**] 05:08AM BLOOD PT-15.8* PTT-39.5* INR(PT)-1.4* [**2190-9-14**] 08:00AM BLOOD Glucose-144* UreaN-26* Creat-3.4* Na-132* K-4.7 Cl-94* HCO3-33* AnGap-10 [**2190-9-7**] 05:08AM BLOOD ALT-16 AST-33 AlkPhos-101 TotBili-0.6 [**2190-9-14**] 08:00AM BLOOD Calcium-7.2* Phos-3.7 Mg-2.4 [**2190-9-14**] 08:00AM BLOOD Vanco-19.9 Brief Hospital Course: The patient was transferred to the [**Hospital1 18**] SICU from [**Hospital 1474**] Hospital with a significant right scrotal abscess. He was hemondynamically stable on transfer and was taken to the OR soon after for debridement of his scrotal abscess, which was concerning for Fournier's gangrene. The patient had an incision and drainage of the scrotal abscess, in addition to debridement of necrotic skin on his right scrotum. He was transferred back to the SICU intubated, but hemodynamically stable. On the POD1, the patient returned to the OR for further debridement. He was extubated on POD2/1 and continued to remain hemodynamically stable. With regards to organ systems: Neuro: The patient was started on IV methadone, [**12-26**] his PO dose. He received IV morphine prn for pain. Once extubated, he was restarted on his home PO dose of methadone with prn iv morphine. CV: Hemodynamically stable. Pulm: The patient remained intubated on POD0 with intention of returning to the OR. He was extubated on POD2/1 after having his Dobhoff tube placed by IR. GI/FEN: While intubated, the patient was given minimal fluids due to this ESRD and HD requirement. On POD2/1, a post-pyloric Dobhoff was placed by IR due to coiling of the Dobhoff when placed in SICU. He was started on Nutren 2.0 with 21g Beneprotein. Formula was later changed to Novasource Renal at 35ml/hour. The tube was pulled out once and replaced with tip post pyloric by xray on [**9-13**]. He experienced diarrhea. Stools were negative for C.diff x3. Lomotil and immodium (home doses) were resumed for chronic diarrhea. Oral vancomycin was resumed as well for suppression of c.diff while on antibiotics. A Flexiceal was in place most of the hospital course for diarrhea. GU: The patient requires HD. HD was continued on Tues-Thursday-Sat scheduled treatments. Last dialysis treatment was [**9-14**]. IV Vanco was administered during dialysis sessions. Heme: The patient had a coagulopathy on admission. However, he did not experience any issues with bleeding. ID: Due to the concern for Fournier's gangrene, infectious diseases were immediately consulted. They recommended starting the patient IV Vanc/Clinda/Zosyn. He was also started on PO Vanco for C. Diff prophylaxis (prior history of C. Diff). Since he received Vanco without HD, his levels were initially high. Gram stain of the scrotal fluid and swab were GPC, GPR, GNR. Culture isolated staph coag negative and enterococcus (low numbers). Zosyn was stopped on [**9-15**]. IV Vancomycin was continued given prior MRSA infection of hand in [**8-3**]. Vanco started [**8-1**] with 6 week course recommended. He will continue on Vancomycin until f/u with ID on [**9-21**]. ENDO: The patient has DM2 and is being covered initially by an insulin drip then he was converted to glargine and humalog sliding scale with glucoses ranging between 75-140. Skin: Scrotal abscess was vac'd using white sponge on testes and black sponge on the scrotum. Last vac change demonstrated granulation on [**9-13**]. Suction was set at 75mmHg. He does have h/o of prior penectomy for necrosis [**1-26**] arterial insufficiency. He also had a stage 2 sacral decubitus that was treated with Mepilex with some improvement. PT: recommended rehab. See PT notes. Dispo: A bed became available at [**Hospital 100**] Rehab and he was transferred there on [**9-15**] in stable condition. Medications on Admission: CINACALCET 30 qdaily, LOMOTIL, DOXEPIN 10 mg qHS, FOLIC ACID 1 mg qdaily, GABAPENTIN 300 mg qod, INSULIN GLARGINE [LANTUS] INSULIN LISPRO [HUMALOG], METHADONE 20 mg QID, OMEPRAZOLE, RENAGEL 2400 mg TID, SUCRALFATE 1 gram QID, VANCOMYCIN 1 gram IV qHD per HD protocol, VICADIN, B COMPLEX VITAMINS one Capsule(s) by mouth daily, CYANOCOBALAMIN (VITAMIN B-12) 500 mcg daily, FERROUS SULFATE 325 mg (65 mg iron) daily, FERROUS SULFATE, IMODIUM A-D Discharge Medications: 1. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection [**Hospital1 **] (2 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: Three [**Age over 90 **]y Five (325) mg PO DAILY (Daily). 7. Cyanocobalamin (Vitamin B-12) 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Methadone 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 12. Doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 13. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): empiric. 14. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day) as needed for diarrhea. 15. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 16. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 17. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for diarrhea. 18. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 19. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol): administer at hemodialysis sessions thru [**9-21**]. started [**2190-8-1**] for MRSA L hand. 20. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous at bedtime. 21. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale orders Subcutaneous four times a day. 22. Tunnelled hemodialysis line care per protocol Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: ESRD DM Scrotal abscess Malnutrition HCV cirrhosis MRSA hand infection Sacral decubitus 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 will be transferring to [**Hospital 100**] Rehab today Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office [**Telephone/Fax (1) 673**] if you develop any of the listed warning signs Penile/scrotal wound vac dressing will continue Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2190-9-21**] 11:10 Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2190-9-24**] 1:40 Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2191-1-31**] 11:00 Completed by:[**2190-9-15**]

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icd9cm

[ [ [] ] ]

[ "96.6", "39.95", "61.0", "61.3" ]

icd9pcs

[ [ [] ] ]

9226, 9292

3302, 6704

314, 443

9423, 9423

2832, 3279

9895, 10403

2389, 2421

7199, 9203

9313, 9402

6730, 7176

9599, 9872

2436, 2813

259, 276

471, 1284

9438, 9575

1306, 2124

2140, 2373

79,126

104,534

53337

Discharge summary

report

Admission Date: [**2135-3-8**] Discharge Date: [**2135-3-12**] Date of Birth: [**2066-2-16**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Initiation of Milrinone Major Surgical or Invasive Procedure: Right heart catheterization History of Present Illness: 69 yo M history of idiopathic dilated cardiomyopathy with moderately dilated left ventricle (last EF 10%) now with 4+ MR, 3+ TR and resultant pulmonary hypertension, NYHA class III heart failure presenting for milrinone initiation. . Per Dr.[**Name (NI) 3536**] last clinic note dated [**2135-3-7**], the patient has had progressive and marked reduction in his functional capacity over the last few months. Over this period of time, the patient has developed pulmonary hypertension. His most recent ECHO in [**7-23**] demonstrated tricuspid regurgitation pressure gradient of 50 mmHg indicating a pulmonary artery systolic pressure of 60 mmHg to 70 mmHg. Currently, he is unable to walk more than a few yeards or a few stairs without dyspnea. He also complains of orthopnea, paroxysmal nocturnal dyspnea and occasional lightheadedness. His symptoms were thought to be representative of NYHA class III symptoms. . Weight in clinic on [**2135-3-7**] was 241 pounds, which is not far from what has been considered in the past to be his dry weight. . It was felt that the patient was doing poorly at this time now with orthopnea, paroxysmal nocturnal dyspnea and dyspnea during ordinary activities of daily living. ECHO was performed in clinic showing left ventricle is more dilated and there has been a substantial further reduction of ejection fraction (LVEF 10 %). In addition his mitral regurgitation is markedly increased. Lasix apparently made him lightheaded and it was discontinued recently. . Patient underwent right heart cath before admission. Results: Baseline PCWP 28 Mean PA 57 Mixed Veinous p02 42 CO 3.11 CI 1.4 [**Doctor Last Name **] unit [**Unit Number **].333 (Transpulmonary gradient/CO 57-28 = 29/3.11 L) Post-Milrinone 0.5 mcg/kg/min (with large amount of ectopy) PCWP 15 Mean PA 34 Mixed Veinous p02 60 CO 4.75 CI 2.15 [**Doctor Last Name **] unit [**Unit Number **].6 Post-Milrinone 0.375 mcg/kg/min PCWP 14 Mean PA 33 Mixed Veinous p02 60 CO 5.21 CI 2.35 [**Doctor Last Name **] unit [**Unit Number **].7 # gastric bypass 25 years ago # cholecystectomy # non-ischemic cardiomyopathy, EF 10% # [**Company 1543**] dual chamber ICD placement for primary prevention of sudden cardiac death in the setting of nonsustained VT and class III heart failure # hypertension # gout # Obstructive sleep apnea Last seen by Dr. [**Last Name (STitle) **] on [**2135-3-7**] for OSA follow-up. He utilizes an Adapt SV machine. His pressure was change to expiratory pressure of 9 and pressure support 3 and 10. # Diabetes # CKD - evaluated by renal, baseline creatinine ~1.2-1.4 # Hyperlipidemia Past Medical History: # gastric bypass 25 years ago # cholecystectomy # non-ischemic cardiomyopathy, EF 10% # [**Company 1543**] dual chamber ICD placement for primary prevention of sudden cardiac death in the setting of nonsustained VT and class III heart failure # hypertension # gout # Obstructive sleep apnea Last seen by Dr. [**Last Name (STitle) **] on [**2135-3-7**] for OSA follow-up. He utilizes an Adapt SV machine. His pressure was change to expiratory pressure of 9 and pressure support 3 and 10. # Diabetes # CKD - evaluated by renal, baseline creatinine ~1.2-1.4 # Hyperlipidemia Social History: Married and retired police officer. He cares for his 19 and 12 year old grandchildren. He denies tobacco or illicit drug use. History of extensive EtOH use, however he has cut back. Last alcoholic drink 1 month ago. Family History: Grandmother with CAD but no premature CAD in family. Mother with cancer, sister with DM Physical Exam: Admission weight 109 kg VS: 97.6 97 146/87 14 93% RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: moist mucus membranes NECK: Supple with flat JVP. CARDIAC: RRR with normal S1/S2, occasional PVCs. No murmurs rubs gallops LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [**2135-3-9**] ECHO Left ventricular cavity size is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20 %). Overall left ventricular systolic function is severely depressed (LVEF= 15-20 %). The right ventricular cavity is mildly dilated with normal free wall contractility. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**12-13**]+) mitral regurgitation is seen. Compared with the prior study (images reviewed) of [**2135-3-7**], right ventricular function is more vigorous. The severity of mitral and tricuspid regurgitation is reduced. Left ventricular ejection fraction appears slightly improved and cavity size is smaller. [**2135-3-7**] ECHO The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe global left ventricular hypokinesis (LVEF = 10 %). The estimated cardiac index is depressed (<2.0L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with borderline normal free wall function. 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. An eccentric, posteriorly directed jet of at least moderate to severe (3+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. Moderate [2+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2134-7-21**], the left ventricle is more dilated and there has been a substantial further reduction of ejection fraction. Mitral regurgitation is markedly increased. [**2135-3-12**] 05:42AM BLOOD WBC-3.6* RBC-4.19* Hgb-11.1* Hct-35.7* MCV-85 MCH-26.5* MCHC-31.1 RDW-16.2* Plt Ct-170 [**2135-3-12**] 05:42AM BLOOD Glucose-141* UreaN-22* Creat-1.5* Na-140 K-3.9 Cl-107 HCO3-24 AnGap-13 [**2135-3-9**] 03:46AM BLOOD CK-MB-2 cTropnT-<0.01 [**2135-3-12**] 05:42AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.9 Brief Hospital Course: 69 yo M history of idiopathic dilated cardiomyopathy with moderately dilated left ventricle (last EF 10%) now with 4+ MR, 3+ TR and resultant pulmonary hypertension, NYHA class III heart failure presenting for milrinone initiation. Started on milrinone in cath lab with excellent response. . # Milrinone Initiation He has had significantly worsening functional status and LVEF to 10% over the last few months. He underwent right heart cath, showing elevated wedge and PA pressures. He was started on milrinone during right heart catheterization, with impressive response. Wedge and PA pressures both dropped by almost half. Cardiac index doubled. Milrinone was decreased from 0.5mcg/kg/min to 0.375 mcg/kg/min due to ectopy. He was admitted to the CCU to monitor infusion. He continued to have some ectopy and tachycardia. Carvedilol was restarted at an increased dose of 25mg [**Hospital1 **] (he was on Coreg 20mg daily at home). This helped to control his heart rate and ectopy. A repeat echo the following day showed increased RV and LV squeeze. The swan catheter was pulled and his milrinone was continued via PICC line. He was transferred to the floor. He had occasional episodes of hypotension to the 70s and 80s intermittently throughout his hospital stay. The carvedilol was switched to metoprolol to avoid the hypotension. He was also felt to be dry, so the torsemide was stopped. His valsartan was also decreased to 120mg daily. He continued to have occasional dizziness, and was advised to avoid standing up too quickly. . # CHF/HTN LVEF of 10% as above. This improved to about 20% with repeat echo. His anti-hypertensives were titrated as above. He was discharged home on metoprolol succ 200mg daily, valsartan 120mg daily, aspirin 81mg, rosuvastatin 40mg daily and eplerenone 25mg daily. He was provided a prescription for torsemide to take if he had weight gain. . # OSA Uses a CPAP machine at home. His O2 sats were monitored in house. . # DM - Continued glipizide 2.5mg daily. . # Gout - continued allopurinol 100mg daily . # BPH - continued finasteride and tamsulosin daily TRANSITIONAL ISSUES - Patient is being discharged off diuretics, with a prescription for PRN torsemide. If at follow-up, he appears volume overloaded, then restart torsemide 10mg daily. Medications on Admission: Allopurinol 100mg tablet daily Calcitriol 0.25 mcg weekly Carvedilol (Coreg CR) 20mg daily Eplerenone 25mg daily Finasteride 5mg daily Folic acid 1mg daily Furosemide 40mg daily Glipizide 5mg [**12-13**] tablet daily Omeprazole 20mg [**Hospital1 **] Rosuvastatin (Crestor) 40mg daily Tamsulosin (Flomax) 0.4mg daily Valsartan (Diovan) 320mg [**12-13**] tablet daily Aspirin 81mg daily Calcium Carbonate - Vitamin D3 - 600mg (1500mg) - 400 unit Cholecalciferol (Vitamin D3) 1000unit daily Cyanocobalamin (Vitamin B12) 500mcg daily MVI Discharge Medications: 1. milrinone in D5W 200 mcg/mL Piggyback Sig: 0.375 mcg/kg/min Intravenous INFUSION (continuous infusion). Disp:*1 bag* Refills:*10* 2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a week. 4. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 11. valsartan 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*2* 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 16. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 17. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for weight gain. Disp:*30 Tablet(s)* Refills:*0* 18. metoprolol succinate 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Acute on Chronic Systolic congestive heart failure Hypotension Acute on Chronic Kidney Injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had trouble breathing and an echocardiogram showed that your heart function was very poor. You were admitted to start a medicine called milrinone that you will have infused continuously into your IV. Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] if weight goes up more than 3 pounds in 1 day or 5 pounds in 3 days. . We made the following changes to your medicines: 1. START milrinone to help your heart pump better 2. DECREASE valsartan to 120 mg daily 3. STOP taking furosemide, take torsemide if you notice your weight is increasing 4. STOP taking carvedilol, take metoprolol instead to lower your heart rate and help your heart pump better. Followup Instructions: Name: [**Last Name (LF) 7726**],[**First Name3 (LF) 177**] A. Address: [**Street Address(2) 7727**],2ND FL, [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 7728**] Appointment: Wednesday [**2135-3-16**] 3:00pm Department: CARDIAC SERVICES When: MONDAY [**2135-4-4**] at 10:00 AM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: Nutrition Phone: [**Telephone/Fax (1) 3681**]. A message was left for an outpatient nutritionist to schedule an appt with you in the next few weeks. They should be contacting you at home. Please call the number next week if you do not hear from them. Department: WEST [**Hospital 2002**] CLINIC When: WEDNESDAY [**2135-4-6**] at 10:00 AM With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

[ "403.90", "458.9", "416.8", "585.9", "425.4", "584.9", "V45.02", "600.00", "272.4", "428.23", "274.9", "250.00", "327.23", "428.0", "V45.86" ]

icd9cm

[ [ [] ] ]

[ "99.29", "38.97", "37.21", "89.64" ]

icd9pcs

[ [ [] ] ]

11809, 11861

7180, 9463

335, 364

11999, 11999

4420, 7157

12845, 14025

3844, 3934

10047, 11786

11882, 11978

9489, 10024

12149, 12822

3949, 4401

272, 297

392, 2997

12014, 12125

3019, 3595

3611, 3828

74,174

195,853

37551

Discharge summary

report

Admission Date: [**2173-12-5**] Discharge Date: [**2173-12-11**] Date of Birth: [**2122-3-26**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2173-12-6**] Coronary artery bypass grafting times three (LIMA to LAD, SVG to Diag, SVG to PDA) History of Present Illness: 51 yo male with admission for new onset congestive heart failure and pulmonary embolisms in [**8-18**]. A cardiac catheterization showed 3 vessel disease so he was evaluated for a coronary artery bypass grafting. Past Medical History: LV apical thrombus [**8-18**] on coumadin CVA [**10-17**] -residual word finding difficulty systolic and diastolic heart failure PEs MI cardiomyopathy (EF 10-15%) PVD bipolar disease mediastinal lymphadenopathy ETOH abuse Social History: Occupation: disabled Lives with mother [**Name (NI) 1139**]: smoked 1ppd x30 yrs-last smoked 3 days prior to admit ETOH: 6 drinks per month? Family History: Family History: (parents/children/siblings CAD < 55 y/o) Physical Exam: Pulse: 86 Resp: 20 O2 sat: B/P Right: 104/75 Left: Height: 68" Weight: 90.6 kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs diffuse expiratory wheezes Heart: RRR [x] Irregular [] Murmur 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 Pulses: Femoral Right:2+ Left: 2+ DP Right: +1 Left: +1 PT [**Name (NI) 167**]: +1 Left: +1 Radial Right: +2 Left: +2 Carotid Bruit None Right:+2 Left: +2 (well healed scar on left neck) Pertinent Results: Intra-operative echo PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is severe regional left ventricular systolic dysfunction with severe hypokinesis in the entire LAD, RCA distribution.Overall left ventricular systolic function is severely depressed (LVEF=20 %). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. There is mild TR and the Tricuspid annulus measures 4.0cm Dr. [**Last Name (STitle) **] was notified in person of the results on Mr [**Name13 (STitle) 84314**] before surgical incision. POST-BYPASS: On epinephrine and levophed, Overall LVEF 20%. RV mild global systolic dysfunction. Intact thoracic aorta. Valves similar to prebypass. [**2173-12-9**] 07:04AM BLOOD WBC-11.5* RBC-3.40* Hgb-10.4* Hct-31.8* MCV-93 MCH-30.5 MCHC-32.7 RDW-15.1 Plt Ct-130* [**2173-12-9**] 07:04AM BLOOD PT-14.1* PTT-25.1 INR(PT)-1.2* [**2173-12-9**] 07:04AM BLOOD Glucose-115* UreaN-15 Creat-0.8 Na-137 K-4.1 Cl-97 HCO3-31 AnGap-13 Brief Hospital Course: On [**2173-12-6**] Mr. [**Known lastname 84315**] [**Last Name (Titles) 1834**] a coronary artery bypass grafting times three (LIMA to LAD, SVG to Diag, SVG to PDA). This procedure was performed by Dr. [**First Name (STitle) **] [**Name (STitle) **]. Please see the operative note for details. He tolerated this procedure well and was transferred in critical but stable condition to the surgical intensive care unit. He was extubated and weaned from his drips. His chest tubes and epicardial wires were removed. He was transferred to the surgical step down floor. Coumadin was restarted for his left ventricular apical thrombus. He was seen in consultation by the physical therapy service. He experienced some asymptomatic hypotension and but tolerated minimal doses of beta blockade and ACE inhibitor. By post-operative day five he was cleared for discharge to home by Dr. [**Last Name (STitle) 914**] on Dr.[**Name (NI) 5572**] behalf. All follow-up appointments were advised. Medications on Admission: **coumadin daily - 5mg/alter 7.5. Last dose [**2173-12-1**] carvedilol 25 mg [**Hospital1 **] lisinopril 10 mg daily pravastatin 20 mg daily ASA 81 mg daily lasix 40 mg daily seroquel 300mg qhs Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Quetiapine 100 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: take 5 mg alternating with 7.5 mg daily. Disp:*30 Tablet(s)* Refills:*0* 7. Outpatient Lab Work INR to be drawn on 12/****. Results to be sent to the [**Hospital1 **] coumadin clinic ([**Telephone/Fax (2) 84316**]. 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 9. Captopril 12.5 mg Tablet Sig: 0.25 Tablet PO TID (3 times a day). Disp:*30 Tablet(s)* Refills:*2* 10. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: coronary artery disease Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37063**] in [**12-11**] weeks [**Telephone/Fax (1) 37064**] Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4610**] in [**12-11**] weeks [**Telephone/Fax (1) 54722**] Wound check appointment - at [**Hospital **] Hospital - call ([**Telephone/Fax (1) 26917**] to schedule. Coumadin will be followed by the coumadin clinic at the Heart Center of [**Hospital **] Hospital ([**Telephone/Fax (2) 84316**]. Plan confirmed with [**Doctor First Name **] on [**2173-12-9**]. Completed by:[**2173-12-11**]

[ "296.80", "412", "V58.61", "425.4", "428.0", "305.01", "V12.51", "428.43", "443.9", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6106, 6165

3391, 4383

342, 443

6233, 6240

1804, 3368

6865, 7588

1125, 1168

4628, 6083

6186, 6212

4409, 4605

6264, 6842

1183, 1785

283, 304

471, 685

707, 932

948, 1093

18,681

115,106

47457

Discharge summary

report

Admission Date: [**2196-2-5**] Discharge Date: [**2196-2-9**] Date of Birth: [**2164-10-29**] Sex: M Service: [**Location (un) **] Medicine HISTORY OF PRESENT ILLNESS: This is a 31-year-old gentleman with HIV with recently undetectable viral load and CD4 greater than 200, which is complicated by HIV nephropathy and HIV cardiomyopathy and a remote [**Doctor First Name **] infection as well as the [**November 2195**] admission for lactic acidosis and fulminant hepatic failure secondary to Stavudine, who was well following his discharge until [**2196-2-2**], when he noted productive cough with yellow sputum. Cough improved, but then worsened again the day prior to admission. Patient also noted feeling warm in the morning of admission, temperature to 102, rechecked later in the evening with a temperature to 103, and came into the Emergency Room at [**Hospital1 18**]. He had no dyspnea at rest only with a significant exertion. He is able to cook and clean without dyspnea. He has been compliant with his HAART and Bactrim therapy without missing any doses. In the Emergency Room received 2 liters of IV fluids, levofloxacin 500 mg p.o., Combivent nebulizer, and acetaminophen. PAST MEDICAL HISTORY: 1. HIV with undetectable viral load, CD4 greater than 200, diagnosed in [**2194-3-31**] complicated by nephropathy, collapsed focal segmental glomerulonephritis on biopsy with end-stage renal disease on hemodialysis 3x a week, also complicated by HIV cardiomyopathy with a last ejection fraction of 20-25% in [**2195-12-29**]. 2. History of [**Doctor First Name **] infection. 3. Hepatitis C carrier. 4. Anemia of chronic disease. 5. History of G-6-P-D deficiency. 6. Left upper extremity A-V fistula placed [**2194-5-31**], revised in [**2195-4-30**]. 7. HAART-induced hepatic failure and lactic acidosis in [**2195-11-30**]. 8. Acute renal failure with hypocalcemia. 9. Uremic coagulopathy. 10. Inflammatory arthritis of the left knee. ALLERGIES: Stavudine to which he has lactic acidosis. MEDICATIONS ON ADMISSION: 1. Cyanocobalamin 100 mg q.d. 2. Bactrim single strength one p.o. q.d. 3. Lisinopril 10 mg p.o. q.d. 4. Metoprolol 12.5 mg p.o. b.i.d. 5. Sevelamer. 6. Pantoprazole. 7. Tenofovir. 8. Efavirenz. 9. Lamivudine. SOCIAL HISTORY: He lives with his mother and three nephews. [**Name (NI) **] smokes about one pack per week x10 years. Alcohol every 1-2 weeks, no illicit drugs. FAMILY HISTORY: Hypertension. PHYSICAL EXAMINATION: Vitals on admission: Temperature 101.8, pulse of 119, blood pressure 159/90, respiratory rate of 16, and sats of 89% on room air with 97% on 2 liters. In general, he is very pleasant and nontoxic appearing. HEENT: No sinus tenderness. Pupils are equal, round, and reactive to light. Oropharynx and conjunctivae are clear. Moist mucous membranes. Neck was soft, supple, no lymphadenopathy. No JVD. Cardiovascular is tachycardic, normal S1, S2, [**2-5**] holosystolic murmur throughout. Pulmonary: Diffuse rhonchi, scattered wheezes expiratory greater than inspiratory, right bibasilar crackles, no egophony, no fremitus. Abdomen is soft, nontender, nondistended, positive bowel sounds. No hepatosplenomegaly. Back: No CVA or paraspinal tenderness. Extremities: 2+ dorsalis pedis pulses bilaterally. Trace bipedal edema. Skin: No rashes or lesions. Neurologic is nonfocal, alert and appropriate. LABORATORIES ON ADMISSION: White count 5.8 with 65% neutrophils, 25% lymphocytes, hematocrit 35, platelets of 233. Chem-7 with a sodium of 135, potassium of 5.9, which is hemolyzed, chloride 92, bicarb 29, BUN 21, creatinine 8.4, glucose 89, lactate of 2.7, ALT of 18, AST 72 hemolyzed. Alkaline phosphatase 75, total bilirubin 0.9, amylase 209 hemolyzed, LDH 584 hemolyzed corrected to 241 nonhemolyzed. Blood cultures sent x2. Chest x-ray with enlarged cardiac silhouette consistent with a bibasilar infiltrative process. Urinalysis with small blood, 100 protein, 100 glucose. HOSPITAL COURSE: This is a 31-year-old gentleman with HIV admitted with pneumonia. 1. Pneumonia: Patient had chest x-ray and history which were consistent with community acquired pneumonia initially started on levofloxacin. Initially not concerned for PCP as had been compliant with his medicines and stable CD4 count, and on prophylaxis, although on single strength Bactrim, G-6-P-D deficiency, and nonelevated LDH. Patient was admitted initially for his pneumonia because of hypoxemia. Was eventually treated with levofloxacin to complete a two week course. However, was also hydrated in the Emergency Room secondary to presumed insensible loss with a fever, and was transferred to the floor, where he completed his fluids, and had stable gas of 7.48, 58, 72 on the floor on room air, which was stable. However, patient was then taken to hemodialysis day of admission for his scheduled dialysis and went into acute respiratory distress. Patient had a blood gas taken at that time, which showed gas of pH of 7.36, CO2 of 42, and pO2 of 61. Chest x-ray at that time showed asymmetric right sided pulmonary edema. Patient also at that time was noted to be tachycardic into the 140s, had a blood pressure up to 202/128 and was concerned for flash pulmonary edema. Was eventually ultrafiltrated via dialysis and then was transferred to the MICU for further observation. Patient also received one dose of prednisone for concern for acute PCP, [**Name10 (NameIs) **], as patient was improving with diuresis via ultrafiltration, the patient was not continued on treatment doses for PCP, [**Name10 (NameIs) **] was back to his home regimen of prophylaxis. Over the course of his MICU stay, the patient had 6 kg of weight ultrafiltrated, and otherwise remained stable throughout the rest of his stay. His oxygenation improved after some nebulizer treatments and was nonrebreather and essentially weaned back down to room air. By the time of discharge, had been ambulating and not requiring oxygen for 36 hours prior to discharge without any desaturations. Patient also had two induced sputums sent for PCP, [**Name10 (NameIs) 6643**] were negative, and patient was continued on his levofloxacin to complete a two week course and this was stable. 2. End-stage renal disease with HIV nephropathy: This was stable and patient after his MICU stay continued on his [**Name10 (NameIs) 766**], Wednesday, Friday regimen, and will follow up with his renal nephrologist, Dr. [**Last Name (STitle) 1860**] as an outpatient. 3. For patient's CHF, known ejection fraction of 20-25% secondary to his HIV. Was continued on his ACE inhibitor and beta blocker, which were tolerated well and no further signs of overload throughout the rest of his stay, and will follow up with the CHF team as an outpatient. 4. HIV: Stable with a CD4 count greater than 200 and undetectable viral load. Will continue HAART and continue Bactrim prophylaxis. Continue to monitor for concerns for toxicity from HAART with history of MICU admission for lactic acidosis and hepatic failure on Stavudine. This will be continued to be followed by patient's nephrologist and PCP. 5. Anemia: This is secondary to his renal disease. No evidence of hemolysis. Reticulocytes normal. Patient was continued on his Procrit at hemodialysis. 6. GERD: Patient's abdominal symptoms were stable over the course of his stay, and was continued on his proton-pump inhibitor. 7. Nutrition: Patient was continued on renal diet, and continued to follow electrolytes. He did have evidence of hyperkalemia on day of flash edema, which improved with dialysis of 0 K dialysis. This was determined to be secondary to acid-base changes. 8. Prophylaxis: Patient was ambulating throughout his stay and continued on his proton-pump inhibitor. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Pulmonary edema. 3. End-stage renal disease. 4. Congestive heart failure with ejection fraction of 20-25%. 5. Human immunodeficiency virus. DISCHARGE MEDICATIONS: 1. Levofloxacin 250 mg p.o. q.48h. for four more doses. 2. Lamivudine 10 mg p.o. q.d. 3. Efavirenz 600 mg p.o. q.d. 4. Tenofovir 300 mg p.o. q Friday. 5. Metoprolol XL 12.5 mg p.o. q.d. 6. Lisinopril 10 mg p.o. q.d. 7. Cyanocobalamin 100 mcg p.o. q.d. 8. Pantoprazole 40 mg p.o. q.d. 9. Sevelamer 400 mg p.o. t.i.d. 10. Dextromethorphan [**5-9**] mL p.o. q.6h. as needed for cough. 11. Nephrocaps 1 mg p.o. q.d. 12. Bactrim SS one p.o. q.d. 13. Albuterol 1-2 puffs inhaled q.i.d. as needed for shortness of breath or wheezing. FOLLOW-UP PLANS: Patient is to followup with his PCP on [**2-18**] at [**Hospital1 778**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Patient is to call [**Hospital 1902**] Clinic and setup a repeat evaluation with Dr. [**First Name (STitle) 2031**]. Patient is to keep his follow-up appointment with Dr. [**First Name (STitle) **] in [**Month (only) 958**]. DISCHARGE CONDITION: Good. Patient is ambulating without difficulty. Not requiring oxygen and otherwise stable. DISCHARGE STATUS: Discharged to home. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2667**], M.D. [**MD Number(1) 2668**] Dictated By:[**Name8 (MD) 264**] MEDQUIST36 D: [**2196-2-10**] 10:07 T: [**2196-2-10**] 10:17 JOB#: [**Job Number 100378**]

[ "428.0", "285.21", "425.4", "585", "271.0", "486", "042", "276.7", "581.9" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

8931, 9328

2445, 2460

7809, 7967

7990, 8518

2053, 2263

3999, 7788

2483, 2490

8536, 8909

186, 1210

3425, 3981

1232, 2027

2280, 2428

24,537

161,245

14344

Discharge summary

report

Admission Date: [**2195-6-3**] Discharge Date: [**2195-6-25**] Date of Birth: [**2138-10-13**] Sex: F Service: Surgery, Gold Team CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old woman with a history of hypertension and alcohol use who was transferred from an outside hospital with a diagnosis of pancreatitis and pancreatic pseudocyst. The patient's initial symptoms began on [**2195-5-19**] when she presented to her clinic with several days of intermittent nausea and vomiting and upper abdominal pain. There was no fever, diarrhea, or changes in bowel habits. She was evaluated, and on laboratories was found to have an elevation of her liver function tests. She was admitted to the [**Hospital 8**] Hospital where she was treated with conservative therapy for pancreatitis. She was made n.p.o. She was hydrated and placed on total parenteral nutrition. She began to stabilize at the outside hospital until one week after admission when she developed increasing abdominal pain and found to have an increasing white blood cell count to 15,000 and an increased pancreatic enzyme level. She obtained an abdominal CT which showed possible pancreatic pseudocyst, and she was then transferred to [**Hospital1 1444**] for consultation and evaluation by Dr. [**Last Name (STitle) 1305**] in the Gold Surgery Service. PAST MEDICAL HISTORY: Past Medical History significant for hypertension. PAST SURGICAL HISTORY: Past surgical history significant for status post total abdominal hysterectomy, status post cholecystectomy, status post colonoscopy (where she was found to have a small polyp which was removed). MEDICATIONS ON ADMISSION: None. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient works as aide in a courthouse. She has smoked half a pack per day times 40 years and reports drinking one to two drinks per week, and sometimes five to six on the weekends per night. PHYSICAL EXAMINATION ON PRESENTATION: Examination on admission revealed temperature was 100.2, heart rate was 80, blood pressure was 138/70, respiratory rate was 20, 98% on room air. The patient was in no acute distress. Pupils were equal, round, and reactive to light. There was no lymphadenopathy. The neck was supple. The chest was clear to auscultation bilaterally. The heart was regular in rate and rhythm with no murmurs, rubs or gallops. The abdomen was soft, obese, and nondistended. She was tender in the epigastric region with no rebound and no guarding. She had no spider angiomas. There was no clubbing, cyanosis or edema of the extremities. PERTINENT LABORATORY DATA ON PRESENTATION: Her laboratories on admission included a white blood cell count of 13.1, hematocrit of 29.7, and platelets of 612. PT of 14.7, PTT of 30.7, INR of 1.9. Sodium of 137, potassium of 4.1, chloride of 103, bicarbonate of 22, blood urea nitrogen of 12, creatinine of 0.6, blood glucose of 164. ALT was 17, AST was 24, alkaline phosphatase was 121, total bilirubin was 0.3, amylase was 252, lipase was 594. Calcium was 9, magnesium was 1.7, phosphorous was 4.3. HOSPITAL COURSE: The patient was admitted to the Gold Surgical Service. She was kept n.p.o. A peripherally inserted central catheter line was placed. She was continued on total parenteral nutrition. Her initial hospital course was uneventful. She remained afebrile. Her abdominal pain continued to resolve, and she was continued on total parenteral nutrition. Once stabilized, the patient was started on a clear diet. She initially tolerated this, but after one day the patient began to develop worsening abdominal pain. She had a temperature spike to 102.1. Laboratories were sent, and she was found to have an amylase of 277, and a lipase of 816, and her fingerstick blood sugar levels were difficult to control with an insulin sliding-scale and ranged anywhere from 250 to 350. The patient continued to remain hemodynamically stable, but in light of what appeared to be a worsening of her pancreatitis secondary to increasing oral intake the patient was again made n.p.o. She was continued on total parenteral nutrition, and she was transferred to the Surgical Intensive Care Unit for close monitoring for her pancreatitis. She also underwent a CT-guided drainage of fluid found around the pancreas. There was dye-load peripancreatic fluid collection inferior to the pancreas. This was sampled under CT-guidance. The fluid was sent for culture which was negative. The patient was carefully monitored in the Intensive Care Unit and began to improve. She was started on imipenem antibiotics and continued to have increasing white blood cell count and temperature and abdominal pain. After several days in the Intensive Care Unit, the pain began to improve and the patient began to stabilize and was transferred back to the floor for the remainder of her recovery. On the floor, the patient continued to be n.p.o. The initial peripherally inserted central catheter that was placed became clotted, and the patient's peripherally inserted central catheter line was changed over wire. The patient had a temperature spike on hospital day seven to 103.3. Cultures were sent, and the patient was found to have a urinary tract infection that grew enterococcus sensitive to vancomycin. The patient was started on a 10-day course of vancomycin. The patient's temperatures began to subside, and the patient's white blood cell count normalized to 9. The patient's pain continued to improve, and physical examination showed markedly decreased tenderness in the epigastric region. The patient was continued on total parenteral nutrition, and on hospital day 20 (once she had remained afebrile for several days and was stable) she was restarted on a clear diet which she tolerated. This was advanced to low-fat diet which she tolerated. She was weaned off her total parenteral nutrition, and she continued to be pain free and afebrile, and the patient was stable and ready for discharge to home. The patient was to follow up with Dr. [**Last Name (STitle) 1305**] in his office approximately one week to 10 days after discharge. DISCHARGE DIAGNOSES: 1. Pancreatitis. 2. Pancreatic pseudocyst. 3. Hypertension. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Dilaudid 4 mg p.o. q.4h. p.r.n. 2. Colace 100 mg p.o. b.i.d. 3. Protonix 40 mg p.o. q.d. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [**Last Name (STitle) 1305**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1306**], M.D. [**MD Number(1) 1307**] Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2195-6-24**] 22:02 T: [**2195-6-25**] 12:50 JOB#: [**Job Number 42540**]

[ "041.00", "790.6", "599.0", "577.0", "V11.3", "577.2" ]

icd9cm

[ [ [] ] ]

[ "99.15", "52.19", "38.93" ]

icd9pcs

[ [ [] ] ]

6217, 6281

6308, 6447

1706, 1767

3169, 6196

1482, 1679

6462, 6498

165, 182

6519, 6867

211, 1383

1406, 1458

1784, 3151

28,038

168,739

33167

Discharge summary

report

Admission Date: [**2194-2-22**] Discharge Date: [**2194-3-2**] Date of Birth: [**2151-2-25**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin / Metronidazole Attending:[**First Name3 (LF) 1162**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Diagnostic Cholangiogram [**2194-2-23**] EUS with pancreatic biopsy US guided liver biopsy History of Present Illness: Mr. [**Known lastname 18252**] is a 42 yo man with no significant PMH who initially presented [**2-12**] with ~6 weeks of decreased appetite, 10-pound weight loss and about a week of painless jaundice. He underwent ERCP, which revealed an infiltrating mass causing obstruction. They were unable to cannulate the CBD, and a percutaneous cholecystostomy tube was placed by interventional radiology. . He was discharged on a 10-day course of ciprofloxacin and metronidazole, but developed a rash after only 3 days. In spite of that, he continued the antibiotics for nearly their entire course. . For the past 2 days, he has had worsening abdominal pain. He also reports mild fevers (as high as 100.8 at home), as well as constipation (no BM for ~2 days). He reports that the pain comes in waves, and was not controlled with long- or short-acting oxycodone. . In the ED, his initial VSs were 98.0, 93, 135/80, 95% RA. He was given 1L NS, ampicillin-sulbactam, antiemetics and hydromorphone and transferred to the [**Hospital Unit Name 153**] for further management. Past Medical History: Pancreatic head mass with presumed metastatic liver lesions Social History: lives with wife in [**Name (NI) 12415**], MA. Works as a lawyer. Denies tobacco. 1 drink of ETOH/day Family History: no family history of medical problems Physical Exam: Vitals: T: 96.7 BP: 134/70 P: 77 R: 10 SaO2: 94% on RA General: Vomiting during exam, awake, alert, oriented X3, cooperative HEENT: NCAT, PERRL 3->2, EOMI, + scleral icterus, MM dry Neck: no significant JVD Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: tender throughout, most significantly in RLQ, + guarding, mild rebound tenderness, hypoactive bowel sounds Extremities: No edema, 2+ radial, DP pulses b/l Skin: diffuse macular erythematous rash Pertinent Results: [**2194-2-22**] 10:21PM PT-14.1* PTT-30.4 INR(PT)-1.2* [**2194-2-22**] 05:50PM GLUCOSE-137* UREA N-11 CREAT-0.8 SODIUM-132* POTASSIUM-4.2 CHLORIDE-92* TOTAL CO2-27 ANION GAP-17 [**2194-2-22**] 05:50PM ALT(SGPT)-98* AST(SGOT)-36 ALK PHOS-572* AMYLASE-26 TOT BILI-5.0* [**2194-2-22**] 05:50PM LIPASE-37 [**2194-2-22**] 05:50PM WBC-20.1*# RBC-4.53* HGB-13.5* HCT-38.9* MCV-86 MCH-29.8 MCHC-34.8 RDW-14.6 [**2194-2-22**] 05:50PM NEUTS-92.1* LYMPHS-2.7* MONOS-4.6 EOS-0.3 BASOS-0.2 [**2194-2-22**] 05:50PM PLT COUNT-403 [**2194-2-22**] 05:49PM LACTATE-1.3 Blood Culture, Routine (Final [**2194-3-1**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [**2194-2-24**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 2120 ON [**2-24**].. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. CT OF THE ABDOMEN WITH IV CONTRAST: Predominantly dependent patchy opacity at the bases of the lower lobes is presumed related to atelectasis. Again demonstrated is the mass of the head of the pancreas, which has not appreciably changed over the short interval from [**2194-2-13**], again measuring approximately 4.4 x 3.6 cm. There has been interval placement of a percutaneous transhepatic biliary catheter with pigtail termination in the duodenum, in good position. There has been some improvement in biliary ductal dilatation, particularly centrally, compared to the prior study; however, the left-sided ducts remain dilated . Numerous relatively hypodense lesions scattered throughout the liver with relatively ill-defined margins are redemonstrated, concerning for hepatic metastases. Moderate distension of the gallbladder is unchanged. There is no evidence of gallstones, pericholecystic fluid, or appreciable gallbladder wall thickening. The spleen, adrenal glands, and kidneys are unremarkable. A large portion of the administered oral contrast remains in the stomach, although some has passed into the proximal small bowel. There are no dilated loops of small bowel or evidence of inflammatory change. There is a moderate amount of retained stool distributed throughout the colon mixed with gas. The colon is mildly distended with gas. The appendix fills with gas throughout its course. There is a small amount of intraperitoneal fluid which layers into the pelvis. CT OF THE PELVIS WITH IV CONTRAST: The ureters are normal in caliber. The bladder and rectosigmoid are unremarkable. There is a small amount of free pelvic fluid. A right inguinal hernia is noted with pelvic fluid extending into the processus vaginalis. There is no evidence of herniation of bowel loops or incarceration. BONE WINDOWS: No concerning lytic or sclerotic osseous lesions are identified. Brief Hospital Course: Mr. [**Known lastname 18252**] is a 42 yo man with an obstructive pancreatic head mass of unknown etiology who presents with abdominal pain, fever. 1. Abdominal pain, fever: The patient's initial presentation was concerning for ascending cholangitis, although his perc drain was in place and extending through the duodenum. There was persistant elevation in bilirubin concerning for obstructed drainage. External biliary drain was uncapped by interventional radiology on [**2-23**] and left draining externally. Persistant mild to moderate intra and extra hepatic biliary duct dilation was also seen. The proximal sideport of the drain was withdrawn for better drainage of intrahepatic ducts and the patients LFTs and obstructive picture improved over the course of the hospitalization. There was significant leukocytosis on admission and given his prior reaction to cipro and flagyl the patient was initially managed on IV Unasyn. This was transitioned to Augmentin with good tolerance. The patient had low grade temperatures to 99 during the course of his stay however on [**2-28**] the patient became febrile to 101.5 while on po abx. He was pan-cultured and a PICC line was placed for transition to Zosyn for a 10 day course to be completed as an outpatient. The patient's pain was felt to be secondary to the external drain as well as the pancreatic mass and liver lesions. He was adequately managed on MS Contin with oxycodone for breakthrough. Tylenol was avoided during his stay given his hepatic involvement and NSAIDs were minimized secondary to frequent planned interventions. A bowel regimen was given while on narcotics. 2. Pancreatic head mass: The EUS FNA biopsy was consistent with carcinoma with neuroendocrine features. The official read of pathology is pending as of this dictation. A liver biopsy was obtained via CT guidance to evaluate for metastatic disease. Those results are pending as well. The patient will follow up with Dr. [**Last Name (STitle) **] next week. Of note, both the CEA and CA [**05**]-9 were reported as WNL. Medications on Admission: Oxycodone 5 mg 1-3 Tablets PO q3h prn Discharge Medications: 1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 3. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release(s)* Refills:*0* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: 4.5 grams Intravenous Q8H (every 8 hours) for 9 days. Disp:*qs qs* Refills:*0* 8. Line care Line care and flushes per critical care protocol. 9. heparin 10 ml of normal saline followed by 2 ml of 100u/ml of heparin. 200u heparin in PICC daily. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: ascending cholangitis pancreatic tumor Discharge Condition: stable, tolerating po, afebrile Discharge Instructions: You were admitted with abdominal pain and were treated for ascending cholangitis. Your preliminary pancreas biopsy results are consistent with carcinoma. You should return to the ER if you develop fevers, chills, worsening abdominal pain, nause or vomiting. Followup Instructions: Please call Dr.[**Name (NI) 8949**] office for a follow up appointment on Tuesday AM.

[ "576.2", "518.0", "197.7", "576.1", "276.52", "157.0" ]

icd9cm

[ [ [] ] ]

[ "50.11", "87.54", "52.11", "99.07", "38.93" ]

icd9pcs

[ [ [] ] ]

8432, 8484

5175, 7250

304, 397

8567, 8601

2318, 5152

8909, 8998

1707, 1746

7338, 8409

8505, 8546

7276, 7315

8625, 8886

1761, 2299

250, 266

425, 1489

1511, 1572

1588, 1691

14,413

196,922

14055

Discharge summary

report

Admission Date: [**2181-5-22**] Discharge Date: [**2181-5-27**] Date of Birth: [**2131-1-21**] Sex: F Service: NOTE: The following history and physical is as noted by [**Male First Name (un) 1573**] assistant resident in the Medical Intensive Care Unit, Dr. [**First Name8 (NamePattern2) 2398**] [**Last Name (NamePattern1) **]. CHIEF COMPLAINT: Dyspnea HISTORY OF PRESENT ILLNESS: This is a 50-year-old female who was transferred today from [**Hospital3 3834**] [**Hospital3 **], presenting there on the [**7-21**] with shortness of breath. The patient's recent history includes one month of cough, dysphagia, and some shortness of breath. Was treated initially with Protonix and, five days prior to presentation there, complained of shortness of breath and decreased breath sounds on the right. She underwent thoracentesis in the Emergency Room there, with 1300 cc of an exudative fluid aspirated. CT scan done at that time revealed mediastinal lymphadenopathy, narrowing of the right lower lobe bronchi, and bilateral pulmonary nodules. There were also liver nodules noted, with numerous episodes of supraventricular tachycardia. An echocardiogram revealed a pericardial effusion with some tamponade physiology. At this time, the patient was transferred to [**Hospital1 346**], where her pleural effusions were tapped, and she had a drain placed in her pericardium. PHYSICAL EXAMINATION: Vital signs: Temperature 99.4, heart rate 110, blood pressure 116/50, oxygen saturation 100% on a non-rebreather. Head and neck: Normocephalic, atraumatic, extraocular movements intact, pupils equal, round and reactive to light, anicteric, oropharynx moist and pink. The neck has a palpable lymphadenopathy, and there is a left anterior cervical lymphadenopathy with an SCL lymphadenopathy. Lungs: Clear to auscultation bilaterally, with occasional rhonchi. Cardiovascular: Regular rate and rhythm, S1, S2, no murmurs, gallops or rubs. Abdomen: Positive bowel sounds, soft, nontender, no hepatosplenomegaly. Extremities: No edema. Neurologic: Awake, alert and oriented x 3. Strength 5/5. Deep tendon reflexes 2+. Cranial nerves intact. LABORATORY DATA: From the outside hospital on [**2181-5-22**], white count 12, hematocrit 30.8 down from 36.6 the day prior, MCV 87.8. Pleural fluid: Cloudy, yellow, pH 7.43, glucose 142, total protein 3.9, LDH 216, white blood cells [**Pager number **], red blood cells [**Pager number **], differential on that is 34 neutrophils, 31 lymphs, 10 monos. GGT of 772, LDH of 276, ALT of 149, AST of 61, alkaline phosphatase of 525, total bilirubin of less than 0.5, albumin of 1.6. Sodium 130, potassium 4.6, chloride 95, bicarbonate 29, BUN 11, creatinine 0.8, glucose 125. INR 1.1, PT 12.2, PTT 23.3. On admission to [**Hospital1 346**], pericardial fluid revealed 425 white blood cells, 2525 red blood cells, total protein 2.8, glucose 62, LDH 278, amylase 5, albumin 1.8, pH 7.43. Pericardial Gram stain and cultures were sent. White count 12.3, hematocrit 31, platelets 529. ALT 99, AST 34, LDH 315, total bilirubin 0.4, alkaline phosphatase 464, calcium 8.3, magnesium 1.8, phos 3.5, albumin 2.2. Sodium 134, potassium 4.2, chloride 100, bicarbonate 24, BUN 8, creatinine 0.5, glucose 90. HOSPITAL COURSE: The following hospital course is as noted by [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) **], M.D., Ph.D. Mrs.[**Last Name (un) 41934**] course was very rapid and took an unfortunate turn, leading to her eventual demise. Given the rapidity of the patient's signs and symptoms and early evidence of metastatic cancer, we admitted the patient to the Medical Intensive Care Unit for close monitoring. We consulted Surgery for biopsy, which revealed poorly-differentiated cells, consistent with some adenocarcinomatous process. Hematology/Oncology was consulted at this time and, after significant discussion with the family, it was felt that there was no treatment option available, and recommended no further treatment. The understanding is that the patient's clinical course will deteriorate very rapidly, leading to her eventual demise. The patient and her husband were aware of the implications, and wished not to have aggressive measures taken on her behalf. However, with regard to symptomatic relief, we note that the patient's shortness of breath had progressed during the hospitalization, and she underwent rigid bronchoscopy with stenting of the bronchi for symptomatic relief. Two days prior to her demise, she was made comfort measures, and a morphine drip was started, titrated for her comfort. On [**2181-5-27**], she passed away comfortably, with her husband at her side. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was called to evaluate an unresponsive Mrs. [**Known lastname 2520**]. Dr. [**Last Name (STitle) **] noted in her final note that the patient was asystolic and there were no spontaneous respirations, no heart sounds. Pupils were fixed and dilated. The time of death was set at 11:50 A.M. on [**2181-5-27**]. The patient's husband was at her bedside, and consented to a post-mortem analysis to further understand the etiology of Mrs.[**Known lastname 41934**] unfortunate and untimely demise. Subsequent to the hospital course as noted above, gross pathology and post-mortem analysis revealed that the patient had primary lung cancer, widely metastatic to multiple organ systems. This information was relayed to the patient's husband and primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1159**] and Dr. [**Last Name (STitle) 41935**]. Thank you for the opportunity to care for this very kind and unfortunate woman. Our thoughts are with her family. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2181-6-30**] 15:37 T: [**2181-7-1**] 00:35 JOB#: [**Job Number 23256**]

[ "196.3", "197.2", "162.9", "427.31", "423.9", "427.1", "519.1", "573.8", "196.0" ]

icd9cm

[ [ [] ] ]

[ "34.04", "96.05", "97.41", "33.91", "93.90", "33.22", "40.11" ]

icd9pcs

[ [ [] ] ]

3300, 6052

1425, 3281

369, 378

408, 1403