ChanBeDu/relevant_section_length · Datasets at Hugging Face

75,668

196,404

21803

Discharge summary

report

Admission Date: [**2125-12-18**] Discharge Date: [**2125-12-31**] Date of Birth: [**2075-1-31**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 348**] Chief Complaint: Fever Major Surgical or Invasive Procedure: - thoracentesis - pleuroscopic tap and biopsy - thoroscopy and pleurodesis History of Present Illness: Mr. [**Known lastname **] is a 50 year old man with a past medical history significant for DM, ESRD on HD, history of Chagas disease and CABG in [**2-15**]. The patient presented to [**Hospital1 18**] on [**12-18**] for scheduled peritoneal catheter placement for dialysis. However, he was noted to be febrile and ill appearing so his procedure was postponed and the decision was made for him to be admitted for monitoring and further work up. . Of note, the patient underwent surgical procedure for attempted right forearm fistula on [**2126-11-28**]. However the procedure was aborted after the vessels were found to be too small. Procedure was with Dr. [**First Name (STitle) **]. Following this he reports having pain but denies redness or swelling. He saw Dr. [**First Name (STitle) **] [**2125-12-13**] but did not undergo evaluation of the ongoing arm pain. . He was otherwise in his usual state of health until 3 days ago (Sunday) when he developed chills, subjective fever, headache, and then nausea with vomiting. The cough was nonproductive and the headache was not associated with nuchal rigidity or photophobia. His appetite has been poor, but he denies any weight loss, diarrhea or changes in his bowel movements. He also denies dysuria, throat or ear pain. He has not had any recent travel. + sick contacts include his wife and grandchildren who have had nonproductive cough and rhinorhea. . He went to his outpt HD unit yesterday ([**2125-12-17**]) where he reportedly was not looking well but was initially afebrile. He spiked a low grade temp of 100.6 and was evaluated by Dr. [**Last Name (STitle) **] who ordered CBC, BMP, LFTs, CBC, and blood cultures. He was given 1 gm Vancomycin and 80 mg Gentamycin. His catheter site was not erythematous and had no drainiage. . Today he presented for the peritoneal dialysis placement but was found to appear ill with a temp of 100.3 so the procedure was aborted and he was admitted to medicine for further work up. VS at time of transfer Vitals: T: 100.3 BP: 135/ HR: 60 RR:16. . On the floor, the patient complained of malaise, fatigue, and fever. He was accompanied by his wife who interpreted for him. Past Medical History: -CKD stage V, on HD, on transplant list, s/p left brachiocephalic AV fistula [**12-16**], s/p angioplasty [**5-17**], s/p thrombectomy in [**8-17**], left upper extremity [**Date Range **] [**11-16**] -CABG x4 [**2123-3-9**]: Left internal mammary artery grafted to the left anterior descending, reverse saphenous vein [**Month/Day/Year **] to the diagonal branch, third marginal branch, and acute marginal branch. -Diabetes Mellitus type II c/b neuropathy -Dyslipidemia -Hypertension -Cardiomyopathy secondary to Chagas -Gastritis, GERD -History of pancreatitis, ? [**1-10**] gallstones, s/p CCY -Obstructive Sleep Apnea, not currently on cpap -Depression -Hyperuricemia Social History: Mr [**Known lastname **] and his wife are originally from [**Name (NI) **] [**Name (NI) 19118**]. He immigrated to the United States 29 years ago and his wife came over 26 years ago. They have five children; his middle son lives with him and his wife. Previously worked in a restaurant. Has been unemployed for the past 5 years due to his medical problems. [**Name (NI) **] frequent travel history to El [**Country 19118**]. Denies etoh, history of tobacco or drug use. Family History: No family history of CAD. Positive family history for diabetes. Physical Exam: ON ADMISSION: Vitals: Temp. 101, BP 160/68 (taken from leg cuff), HR 62, RR 16, 95% on RA. General: Alert, oriented, however looks fatigued, warm to touch HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated to jaw, no LAD Lungs: Dullness to percussion over right base, mild scattered rhales CV: Regular rate and rhythm, mild I/VI murmur at the base Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, [**Male First Name (un) **] edema. right arm with surgical scar over forearm, mildly erythematous with no drainage. Small nodulr felt under skin, tender but not fluctuant. Neuro: CN II -XII intact, 5/5 strength bilat, sensation intact. gait deferred. Pertinent Results: [**2125-12-18**] 08:49AM BLOOD WBC-4.6 RBC-3.09*# Hgb-9.7*# Hct-29.1*# MCV-94 MCH-31.5 MCHC-33.4 RDW-15.1 Plt Ct-132* [**2125-12-19**] 05:50AM BLOOD Neuts-62.5 Lymphs-28.9 Monos-6.8 Eos-1.3 Baso-0.5 [**2125-12-31**] 07:18AM BLOOD WBC-3.7* RBC-2.61* Hgb-8.5* Hct-24.9* MCV-95 MCH-32.5* MCHC-34.1 RDW-17.4* Plt Ct-253 [**2125-12-18**] 08:49AM BLOOD Glucose-125* UreaN-37* Creat-7.0* Na-137 K-4.4 Cl-99 HCO3-26 AnGap-16 [**2125-12-31**] 07:22AM BLOOD Glucose-131* UreaN-61* Creat-7.6*# Na-136 K-5.0 Cl-94* HCO3-27 AnGap-20 [**2125-12-18**] 08:49AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.3 [**2125-12-31**] 07:22AM BLOOD Calcium-8.9 Phos-2.3* [**2125-12-19**] 06:27AM BLOOD LD(LDH)-175 [**2125-12-26**] 06:54AM BLOOD CK(CPK)-67 [**2125-12-26**] 07:29PM BLOOD CK(CPK)-52 [**2125-12-26**] 06:54AM BLOOD CK-MB-1 cTropnT-0.12* [**2125-12-26**] 07:29PM BLOOD CK-MB-2 cTropnT-0.13* [**2125-12-31**] 07:18AM BLOOD WBC-3.7* RBC-2.61* Hgb-8.5* Hct-24.9* MCV-95 MCH-32.5* MCHC-34.1 RDW-17.4* Plt Ct-253 [**2125-12-31**] 07:22AM BLOOD Glucose-131* UreaN-61* Creat-7.6*# Na-136 K-5.0 Cl-94* HCO3-27 AnGap-20 [**2125-12-26**] 06:54AM BLOOD CK-MB-1 cTropnT-0.12* [**2125-12-26**] 07:29PM BLOOD CK-MB-2 cTropnT-0.13* [**2125-12-30**] 05:41AM BLOOD Calcium-8.7 Phos-2.0*# Mg-2.1 Cytology [**12-19**] Pleural Fluid Pleural fluid: NEGATIVE FOR MALIGNANT CELLS [**12-25**] Pleural Biopsy 1. Right pleura, biopsy: - Active pleuritis with reactive mesothelial hyperplasia. - No malignancy identified. 2. Right pleura, biopsy: - Active pleuritis with reactive mesothelial hyperplasia. - No malignancy identified. Microbiology [**2125-12-30**] 12:23 pm SPUTUM Source: Induced. ACID FAST SMEAR (Final [**2125-12-31**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): [**2125-12-28**] 10:08 am BLOOD CULTURE Source: Line-L PICC. Blood Culture, Routine (Pending): [**2125-12-25**] 10:12 am PLEURAL FLUID RIGHT SIDED PLEURAL EFFUSION. GRAM STAIN (Final [**2125-12-25**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2125-12-28**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2125-12-31**]): NO GROWTH. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [**2125-12-26**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2125-12-26**]): NO FUNGAL ELEMENTS SEEN. [**2125-12-25**] 12:15 pm TISSUE PLEURAL BIOPSY. GRAM STAIN (Final [**2125-12-25**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [**2125-12-28**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2125-12-31**]): NO GROWTH. ACID FAST SMEAR (Final [**2125-12-26**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2125-12-26**]): NO FUNGAL ELEMENTS SEEN. [**2125-12-23**] 10:46 am SPUTUM Source: Induced. ACID FAST SMEAR (Final [**2125-12-24**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [**2125-12-22**] 10:55 am SPUTUM GRAM STAIN (Final [**2125-12-22**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2125-12-24**]): SPARSE GROWTH Commensal Respiratory Flora. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [**2125-12-24**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR [**2125-12-22**] 7:45 am SEROLOGY/BLOOD **FINAL REPORT [**2125-12-22**]** CRYPTOCOCCAL ANTIGEN (Final [**2125-12-22**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Performed by latex agglutination. A negative serum does not rule out localized or disseminated cryptococcal infection. Appropriate specimens should be sent for culture. [**2125-12-18**] 2:15 pm Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal aspirate R/O INFLUENZA A AND B. ORDERED BY [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Numeric Identifier 21342**]). **FINAL REPORT [**2125-12-21**]** Respiratory Viral Culture (Final [**2125-12-21**]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [**Telephone/Fax (1) 6182**] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [**2125-12-19**]): Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. Pending Tests: [**2125-12-31**] 09:05AM BLOOD QUANTIFERON-TB GOLD-PND Imaging Studies [**12-18**] CXR FINDINGS: Large persistent right pleural effusion is chronic, slightly larger today than it was in [**Month (only) **]. Also chronic, moderate enlargement of the cardiac silhouette due to cardiomegaly and/or pericardial effusion is stable. Left pleural thickening and scarring or chronic atelectasis in the mid lung are also chronic, though the atelectasis is more pronounced today. There are no findings to suggest acute cardiac decompensation or intrathoracic infection. Supraclavicular dialysis catheter ends in the upper right atrium. No pneumothorax [**12-18**] Ultrasound of Extremity IMPRESSION: Mild right forearm subcutaneous edema without evidence of abscess or thrombophlebitis [**12-22**] CT Chest without Contrast IMPRESSION: Small right pleural effusion and atelectasis with scarring at the right base. Additional area of chronic atelectasis/scarring in the left upper lobe. In correlation with prior radiographs, these findings may be chronic and are in a similar distribution to radiographs dating back to [**2124-10-24**]. [**2125-12-28**] CXR FINDINGS: In comparison with study of earlier in this date, there is little change. Ring of opacification is seen in the outer margins of the right lung. Post-surgical and atelectatic changes are seen at the right base. Some coarse interstitial or fibrotic changes are seen bilaterally. No evidence of acute vascular congestion or definite pneumonia. Brief Hospital Course: Mr. [**Known lastname **] is a 50 year old man with a history of ESRD on HD. He presented for placement of a peritoneal dialysis catheter but was found to be febrile and was admitted for further work up. . # Fever: Prior to admission, Mr [**Known lastname **] had been treated with gentamicin and vancomycin at dialysis. He continued to spike a fever during the admission. Differential diagnosis included TB given Mr [**Known lastname **] history of travel to El [**Country 19118**], as well as viral syndrome, malignancy, infection from failed AV fistula site and HCAP. Work up for source of infection included blood culures, nasopharyngeal cultures, urine analysis, urine culture, influenza swab, sputum culture, AFB, chest x ray and ultrasound of his right failed fistula given the patient complained of pain in that area. Ultrasound of the failed fistula did not show evidence of abscess or fluid collection. Chest x ray showed increase in his pleural effusion compared to his film in [**Month (only) **] [**2124**] and he was covered for healthcare associated pneumonia with vancomycin and Cefepime given the findings and his complaint of cough. His antibiotics were stopped on [**2125-12-23**] as it was determined that his fever had resolved and it was most likely to be due to a viral etiology. # Pleural Effusion: Imaging showed an increase in size of his pleural effusion. There was concern that a malignant or infectious process may be responsible for his presentation. In particular, there was concern from the ID team about TB. Mr [**Known lastname **] underwent a pleuroscopy and pleural fluid drainage with a chest tube inserted. Analysis of pleural fluid showed an exudative effusion with no growth by discharge (acid-fast bacili culture pending). Pleural fluid cytology showed no malignant cells. He underwent thoroscopy and pleurodesis on [**2125-12-25**]. He had a quantiferon gold pending on discharge. He was discharged with a pleurex catheter. Visiting nurses will help him to drain it on Monday, Wednesday, and Friday. On the day of discharge, it drained approximately 10 cc. He has a followup appointment with interventional pulmonology. They will determine how long the catheter should remain in and also if further imaging of the chest should be pursued. . # Bradycardia: On [**12-26**] AM the morning after pleuroscopy he was noted to be in a junctional escape rhythm with sinus node exit block at a rate of approximately 30. He had pressures of ~70-80 systolic, was lightheaded and nauseous. He was transferred to the CCU where dopamine was started. His potassium was elevated at 7.3, which was treated with standard insulin therapy and later with hemodialysis. After treatment for hyperkalemia, his nausea resolved and his native sinus rhythm returned. The dopamine was weaned when he was reliably in sinus (approximately 2 hours after transfer), and he remained in sinus with no further bradycardia throughout his CCU stay. EP was curbsided and felt that this was likely vagal mediated due to a combination of hyperkalemia contributing to nausea and post-pleurodesis pain, as well a possible contribution to nausea from the morphine/dilaudid he received post-procedure. The timecourse of events was indicative of this, as dopamine did not reliably keep him in sinus rhythm, and standard insulin therapy for his hyperkalemia resulted in a reliable sinus rhythm after his nausea stopped (which was not treated with anti-emetics). . # ESRD: The patient underwent HD on [**2125-12-19**] and [**2125-12-24**]. He was continued on his sevelamer and nephrocaps. His renal team will arrange another appointment for placement of a peritoneal dialysis catheter. . # Anemia: Mr [**Known lastname **] anemia was most likely due to his ESRD. Baseline 28-30. Mr [**Known lastname **] was given erythropoietin by the renal team during dialysis. They will determine further dosing as an outpatient. . # Hypertension: The patient was continued on his lisinopril, Isosorbide Mononitrate, and carvedilol. His carvedilol was held during his episode of bradycardia. . # CAD s/p CABG: The patient was continued on his carvedilol, lisinopril, and pravastatin . # Diabetes: On presentation the patient was hyperglycemic to 400+ because he missed his home dose of long acting insulin. He was treated with humalog sliding scale. His Lantus was restarted. Medications on Admission: - Carvedilol 25 mg [**Hospital1 **] - lisinopril 30 mg Q day - isosorbide mononitrate 30 mg ER Q day - pravastatin 10 mg - Fenofibrate 160 mg Q day - Lantus 13 units Q am - Humalog SS - Nephrocaps 1 mg q day - Sensipar 30 mg daily - omeprazole 20 EC Q day - Sevelamer Carbonate 800 mg TID - Aspirin 81 mg Q day Discharge Medications: 1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. pravastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). Disp:*1 bottle* Refills:*1* 8. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. insulin glargine 100 unit/mL Solution Sig: Thirteen (13) UNITS Subcutaneous once a day. 10. fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day. 11. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: Sliding scale insulin. Use as directed. . 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 13. Sensipar 30 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: - Fever most likely due to viral syndrome - Pleural effusion Secondary diagnoses: - ESRD - Hypertension - Anemia - Diabetes - CHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for a fever which was most likely due to a viral syndrome. During your hospitalization, we found an accumulation of fluid in your lungs which was subsequently drained. We performed several tests to make sure that you did not have an infection called tuberculosis (TB). You underwent another procedure called a thoroscopy and pleurodesis to help prevent the re-accumulation of fluid. Following your procedure, you unfortunately had to be transferred to the coronary care unit (CCU) as you developed a slow heart rate (called bradycardia). This was thought to be due to nausea and vomiting causing a reflex response called a vagal episode, which fortunately is benign and completely resolved. Fortunately, your symptoms resolved and you subsequently felt better toward the end of your hospitalization. 1) We recommend that you weigh yourself every morning and call your primary care physician should your weight increase more than 3 lbs. This could indicate a re-accumulation of fluid in your lungs. 2) We have made several follow-up appointments for you listed below. These are all very important to go to. Your doctors [**Name5 (PTitle) **] decide if you should have further imaging of your chest to help find out why the fluid has been accumulating in your lungs. 3) We added a steroid nasal spray to your medications (fluticasone or Flonase). This will help with some of the congestion that you have had. 4) You will be returning home with a "pleurex catheter" to help drain fluid from your lungs. A nurse will visit your home to help empty this. It will be emptied three times a week (Monday, Wednesday, and Friday). Followup Instructions: Please go to your regularly scheduled dialysis sessions. Your kidney doctor is setting up an appointment for you to have a peritoneal catheter placed. They will contact you with this information. The following appointments have been made for you: 1) Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2126-1-4**] 9:00 2) Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2126-3-26**] 3:30 3) Department: WEST PROCEDURAL CENTER When: MONDAY [**2126-1-7**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**Telephone/Fax (1) 7769**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage 4) Department: [**Hospital3 249**] When: THURSDAY [**2126-1-10**] at 2:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2102-11-23**] Discharge Date: [**2102-12-2**] Date of Birth: [**2043-6-18**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 602**] Chief Complaint: Nonproductive cough Major Surgical or Invasive Procedure: Upper endoscopy Colonoscopy History of Present Illness: 59yo F with recent prolonged hospitalization for left arterial embolic clot s/p thrombectomy with course complicated by PCP pneumonia, new diagnosis of HIV/AIDS as well as occipital stroke presenting with worsening nonproductive cough and new oxygen requirement. Patient reports that she developed shortness of breath and a nonproductive cough approximately 3 days ago. She denies associated fever or chills. She reports lightheadedness which is always present, not worse. She denies chest pain. She reports that the cough is different than her raspy, productive cough she had during her recent admission. She has been coughing to the point of dry heaving. Patient was seen for these symptoms by the [**Hospital3 **] physician today who was concerned given her new oxygen requirement of 3-4L from baseline of room air in addition to hypotension. . Patient was hospitalized from [**Date range (1) 91031**], initially admitted with a cool left foot, found to have an arterial embolic clot requiring thrombectomy and fasciotomy. Her hospital course was complicated by hypotension and hypoxia requiring multiple intubations, found to be due to PCP pneumonia for which she completed a 21 day course of bactrim and steroids. She also had a superimposed HCAP treated with vancomycin/zosyn for 8 days. She was discharged on bactrim prophylaxis and a steroid taper which was completed on [**2102-11-20**]. She was diagnosed with HIV with a CD4 count of 11, and started on antiretrovirals prior to discharge. In addition, she was found to have an occipital stroke, thought to be embolic in nature. A TTE did not identify a PFO. She had persistent diarrhea, which, in the setting of CMV viremia, was presumed to be CMV colitis, for which she was treated with IV gancyclovir (currently day 13). . Patient reports that since discharge from the hospital on [**11-15**] to [**Hospital3 **] she has felt fine until three days ago. She has had ongoing diarrhea approximately 3 times a day, not improved with loperamide. She reports that she is barely eating, mostly due to "stubbornness". She denies dysphagia or odynophagia. She is drinking fluids frequently. . In the ED initial vitals were T 98.3 HR 80 BP 83/47 RR 18 O2Sat 97% 3L NC. Patient reported no acute symptoms. Patient was given 2L of IVF and pressures increased to 97/50. She received a dose of vancomycin and zosyn as well as dexamethasone for PCP treatment, however patient did not receive bactrim. Labs were notable for an INR of 11.46 and she was given 1U FFP. Given hypotension, ED was concerned for RP bleed so a CT abd/pelvis was performed which showed no evidence of a bleed. . On arrival to the ICU vital signs were BP 92/5o P 92, RR 24, O2Sat 96% on 2LNC. When oxygen was turned off, patient desat'ed to 91-92%. Past Medical History: # HIV/AIDS: diagnosed during last admission ([**2102-11-2**]), CD4 count 11 - HAART initiated on [**2102-11-13**] (Ritonavir, Darunavir, Emtricitabine-Tenofovir), genotyping compatible with regimen - CMV viremia, treating empirically for CMV colitis given persistent diarrhea with IV ganciclovir x 21 days (day 1= [**11-10**]), then transition to maintenance valgancyclovir - on PCP/toxo prophylaxis with bactrim 1DS daily - on [**Doctor First Name **] prophylaxis with azithromycin # Occipital stroke([**11/2102**]): likely embolic, no evidence of PFO on TTE # Ischemic left foot s/p thrombectomy and fasciotomy d/t acute arterial thrombus([**11/2102**]) # h/o pneumothorax ([**11/2102**]):complication of subclavian line placement # Depression # Anxiety Social History: From [**Location (un) 5028**], MA. She is not married, but has had one partner for the past 26 years who lives in the apartment above her. She lives with a friend. She has been at [**Hospital3 **] for the days in between discharge and this new admission. - Tobacco: h/o 1ppd x 30 years, quit in [**2102-7-3**] - Alcohol: denies - Illicits: denies Family History: No history of lung or heart disease, no history of clotting disorders Physical Exam: Admission exam: Vitals: BP 92/50 P 92, RR 24, O2Sat 96% on 2LNC General: Cachectic, alert female in NAD HEENT: Pupils equal round, but sluggish to light. EOMI. MMM, dentures on upper palate, with evidence of diffuse oral thrush. No erythema or exudate Neck: supple, JVP not elevated, no LAD Lungs: Fine crackles throughout, more pronounced at bilateral bases. No wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: +BS, soft, nontender, nondistended. Well-healed scar in left inguinal region GU: foley in place draining clear urine, mild erythema in vaginal area without skin breakdown Rectal: erythema without skin breakdown Ext: Left foot with dry gangrene of toes extending to MTP of all toes, skin breakdown below areas of gangrene with areas of superficial skin excoriation. No exudate or erythema. Left calf with well healing scars from prior fasciotomy. No erythema or swelling of bilateral legs. 2+ DP/PT pulses on right. Discharge Exam: VS: Tm Afebrile Tc HR 70-80s BP 100s-110s/70s RR 20 SaO2 95-96% RA I/O GENERAL: [x] NAD [] Uncomfortable Eyes: [x] anicteric [] PERRL ENT: [x] MMM [] Oropharynx clear [] Hard of hearing NECK: [] No LAD [] JVP: CVS: [] RRR [] nl s1 s2 [] no MRG [] no edema LUNGS: [x] No rales [x] No wheeze [x] comfortable ABDOMEN: [x] Soft [x]nontender [x]bowel sounds present []No hepatosplenomegaly SKIN: [x]No rashes [x]warm []dry [] decubitus ulcers: Left foot with black necrotic toes and distal foot. No evidence of infection or pus. Incision left leg c/d/i LYMPH: [] No cervical LAD []No axillary LAD [] No inguinal LAD NEURO: [x] Oriented x3 [x] Fluent speech Psych: [x] Alert [x] Calm [x] Mood/Affect: appropriate Pertinent Results: Admission Labs: [**2102-11-23**] 03:20PM BLOOD WBC-7.0# RBC-2.62* Hgb-8.1* Hct-24.3* MCV-93 MCH-30.8 MCHC-33.2 RDW-21.3* Plt Ct-299 [**2102-11-23**] 03:20PM BLOOD Neuts-97.0* Lymphs-2.1* Monos-0.3* Eos-0.6 Baso-0.1 [**2102-11-23**] 03:20PM BLOOD PT-111.5* PTT-56.0* INR(PT)-11.49* [**2102-11-23**] 03:20PM BLOOD Glucose-99 UreaN-19 Creat-0.6 Na-128* K-3.9 Cl-98 HCO3-18* AnGap-16 [**2102-11-23**] 03:20PM BLOOD LD(LDH)-306* [**2102-11-23**] 03:43PM BLOOD Lactate-2.0 [**2102-11-23**] 05:35PM BLOOD Lactate-1.0 Notable studies: Microbiology: [**11-23**] Blood cxs x2: no growth [**11-23**] Urine cx: URINE CULTURE (Final [**2102-11-26**]): YEAST. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 256 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R [**11-26**] C. diff toxin negative [**11-26**] serum Cryptococcal Ag negative [**11-26**] Toxoplasma IgG positive [**11-27**] urine cx: no growth [**11-28**] Stool OandP: Negative including no giardia or cryptosporidium [**11-28**] Stool OandP: Negative including no cyclospora or microsporidium [**11-29**] stool OandP: Negative [**11-29**] HIV VL: 4,800 copies/ml [**11-29**] blood cx: ngtd Studies: [**11-23**] CXR: IMPRESSION: 1. Worsening diffuse parenchymal opacities in the lungs concerning for worsening PCP. [**Name10 (NameIs) **] focal consolidation in the right lung base may represent a secondary pneumonic process. 2. Previously noted small right apical pneumothorax is not visualized on the current exam. [**11-23**] Chest CT: IMPRESSION: 1. Diffuse bibasilar ground-glass opacities with consolidation component in the right lower lobe concerning for worsening of the patient's known PCP. 2. No intraabdominal or retroperitoneal bleeding is seen. [**11-24**] CXR: IMPRESSION: Interval worsening of PCP [**Name Initial (PRE) 1064**]. [**11-26**] Chest CT: IMPRESSION: 1. Extensive right lower lobe consolidation dramatically improved since prior CT [**2102-11-7**]. 2. Widespread PCP alveolitis also demonstrates improvement since CT [**2102-11-7**]. 3. 5 mm right upper lobe nodule. [**12-1**] CXR: IMPRESSION: 1. Left PICC ends in the upper SVC, unchanged in position. 2. Improvement of multifocal opacities when compared to the chest x-ray of [**2102-11-24**]. Discharge Labs: [**2102-12-2**] 05:59AM BLOOD WBC-6.5 RBC-3.76* Hgb-12.2 Hct-36.0 MCV-96 MCH-32.5* MCHC-33.9 RDW-19.2* Plt Ct-494* [**2102-12-2**] 05:59AM BLOOD PT-10.3 PTT-53.1* INR(PT)-0.9 [**2102-11-24**] 01:13AM BLOOD WBC-4.7 Lymph-3* Abs [**Last Name (un) **]-141 CD3%-59 Abs CD3-83* CD4%-20 Abs CD4-28* CD8%-40 Abs CD8-57* CD4/CD8-0.5* [**2102-12-2**] 05:59AM BLOOD Glucose-94 UreaN-20 Creat-0.7 Na-133 K-4.8 Cl-98 HCO3-27 AnGap-13 Studies pending at discharge: [**11-29**] CMV VL: pending [**12-1**] CMV cx: pending [**12-1**] Pathology from EGD biopsies [**12-2**] H. pylori serology Toxoplasma serologies Brief Hospital Course: 59 y/o F with AIDS on HAART, recent PCP pneumonia, CMV viremia with concern for CMV colitis, admitted with hypotension, hypoxia, and cough along with worsening anemia and supratherapeutic INR of 11. Hospital course was notable for MICU admission followed by evaluation for malnutrition and persistent diarrhea in addition to prolonged steroid course for PCP [**Name Initial (PRE) 1064**]. #Hypoxia/PCP [**Name Initial (PRE) 1064**]/bacterial pneumonia/Hypotension: Patient was initially admitted to MICU and initial imaging suggested PCP pneumonia vs. health care associated bacterial pneumonia. Patient was hypotensive and improved with IVF. She was initially treated with Vancomycin/Zosyn as well as started on treatment doses of Bactrim and restarted on steroids after consultation with Infectious Disease for concern of recurrent PCP [**Name Initial (PRE) 1064**]. Testing for adrenal insufficiency was negative. Patient had rapid improvement in symptoms in 3 days and was therefore felt less likely to have true PCP pneumonia or bacterial pneumonia given the quick resolution of pulmonary infiltrates. Antibiotics for HCAP were discontinued and patient did well. It was felt however that pulmonary inflammation/alveolitis may have been due to withdrawal of steroids so patient was placed back on 40mg po of prednisone with plan for slow taper over 4 weeks, dropping dose by 10mg each week. Pt was changed to prophylactic dose Bactrim as well as calcium and vitamin D while on prednisone. #HIV/AIDS: CD 4 count was 28 on [**2102-11-24**]. Patient was continued on MAC prophylaxis with azithromycin and PCP [**Name9 (PRE) **] with 1 SS tab daily Bactrim as above and should continue on PCP prophylaxis until CD4 count stable >200. Pt was continued on Fluconazole prophylaxis as well and continued on ART. VL during hospitalization was 4,800. #CMV colitis: Patient was continued on IV gancyclovir for presumptive treatment of CMV colitis. However, given that the patient's symptoms never truly improved with IV Gancyclovir it is unclear whether she did in fact have CMV colitis or rather AIDS enteropathy. The patient had an EGD and biopsies of the stomach and small bowel were taken. A flex sigmoidoscopy was attempted, but the patient refused the prep and therefore biopsies and adequate visualization could not be accomplished. Patient was discharged to continue IV gancyclovir until her next outpatient ID appointment. #Vancomycin resistant urinary tract infection: She grew VRE in a urine culture from her foley and she received 4 days of therapy for VRE (short course of daptomycin given that she didn't have foley till admission) and her repeat UA/culture improved and her foley was discontinued. #Anemia/Gastritis: Given the drop in hematocrit in the setting of a supratherapeutic INR the patient had an EGD which showed gastritis and recent bleeding. Biopsies were taken and H. pylori serologies were sent and pending at time of discharge. The patient was started on omeprazole for acute gastritis. A colonoscopy was attempted but the patient refused the prep. Therefore, she should have a repeat colonscopy after appropriate prep in the next 4-6 weeks to fully evaluate for potential bleeding sources. H. pylori serologies can be followed up by PCP and treatment initiated if positive. #Diarrhea: She continued to have frequent diarrhea (non-bloody) which was an active issue that was evaluated by GI at her last hospitalization. At that time she had CMV viremia and was emperically started on treatment with IV ganciclovir. She had multiple stool studies negative for both parasites and c. diff by toxin assay. C. diff PCR was negative this admission. Ultimately, it was felt that the diarrhea was more likely to be related to AIDS enteropathy than CMV colitis. Biopsies were taken as above and decision on CMV therapy and course will be determined at next outpatient ID appointment. CMV cx from biopsies were pending at time of discharge. #Arterial Thrombosis/Left foot ischemia/Left foot dry gangrene/Recent occipital stroke: Patient presented with supratherapeutic INR and was noted to be very sensitive to Coumadin on last admit, most probably due to her many medication interactions with Coumadin. Per review of [**Hospital1 **] [**Hospital1 8**] notes patient had INR <2 for a number of days, then one day at 2.4 then a value >3, then >4, then 11 on day of admission, but the exact Coumadin dosing is unclear. In-house this admit, patient was maintained on a heparin drip when INR was <2. She was discharged on heparin drip to Coumadin bridge at 1mg Coumadin/day. The Coumadin should be titrated at rehab to goal INR [**1-5**] and care should be taken to keep INR within range once it starts to approach 2. After discharge from rehab, the patient's Coumadin will be managed by her new primary care doctors [**First Name (Titles) **] [**Hospital6 **] Center (Drs. [**First Name8 (NamePattern2) **] [**Name (STitle) 14740**] and [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **]) who were informed of the patient's admission and discharge plan. Prior to discharge from rehab, communication should take place with the patient's outpatient providers ([**Telephone/Fax (1) 798**]) to confirm that they will be following the INR closely and make adjustments to Coumadin dosing as needed. During hospitalization, Vascular Surgery service examined her ischemic L foot with known dry gangrene and felt it did not look infected. They recommended awaiting further demarcation of the extent of necrosis prior to any elective amputation and the patient will follow up in outpatient Vascular Surgery Clinic. #CODE: FULL #PPX: Heparin gtt bridge to Coumadin as above #Disposition: Pt discharged to rehab to continue heparin bridge to Coumadin with goal INR [**1-5**]. Pt will have outpatient fu with ID and Vascular surgery within one week and will follow up with PCP's at [**Hospital6 **] Center (Drs. [**Last Name (STitle) 14740**] and [**Name5 (PTitle) **]) who will follow up multiple medical issues including titration and monitoring of Coumadin. Medications on Admission: # aripiprazole 1 mg/mL Solution 2mg po daily # sertraline 150 mg PO DAILY # warfarin 1 mg PO Daily, Goal INR [**1-5**]. # miconazole nitrate 2 % Cream [**Hospital1 **] as needed for ITCH/FUNGAL RASH. # lidocaine-prilocaine 2.5-2.5 % Cream [**Hospital1 **] as needed for pain. # emtricitabine-tenofovir 200-300 mg PO DAILY # darunavir 800 mg PO DAILY # ritonavir 80 mg/mL 100mg PO DAILY # sulfamethoxazole-trimethoprim 200-40 mg/5 mL Susp 10mL po daily # azithromycin 1200 mg PO 1X/WEEK (TU) # ganciclovir sodium 300 mg IV Q12H # loperamide 2 mg PO QID as needed for diarrhea. # morphine 2 mg/mL 1-2 mg IV Q4H as needed for pain. # ondansetron HCl (PF) 4 mg/2 mL IV Q8H (every 8 hours) as needed for nausea: give 30 minutes before morning meds. Discharge Medications: 1. warfarin 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 2. sertraline 50 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY (Daily). 3. aripiprazole 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. miconazole nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for itching. 5. emtricitabine-tenofovir 200-300 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. darunavir 400 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 7. ritonavir 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY (Daily). 8. azithromycin 600 mg Tablet [**Hospital1 **]: Two (2) Tablet PO 1X/WEEK (TU). 9. ondansetron 4 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 10. loperamide 2 mg Capsule [**Hospital1 **]: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 11. clonazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day) as needed for anxiety: hold for sedation, RR<10, MAP <55 . 12. insulin regular human 100 unit/mL Solution [**Hospital1 **]: as directed units Injection ASDIR (AS DIRECTED): see printed sliding scale. 13. glucagon (human recombinant) 1 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) neb Inhalation Q4H (every 4 hours) as needed for SOB. 15. sulfamethoxazole-trimethoprim 800-160 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 16. prednisone 10 mg Tablet [**Hospital1 **]: tapered dose as directed Tablet PO once a day for 24 days: Please give 40mg/day for 3 days ([**Date range (1) 90717**]/12), then 30mg/day for 7 days ([**Date range (1) 43505**]/12), then 20mg/day for 7 days (1/11-17/12), then 10mg for 7 days ([**Date range (1) 91032**]) . 17. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Date range (1) **]: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 18. warfarin 1 mg Tablet [**Date range (1) **]: One (1) Tablet PO Once Daily at 4 PM: Please adjust dose as needed to attain goal INR of [**1-5**]. NOTE that patient is very sensitive to Coumadin and has had supratherapeutic INRs in the past with bleeding. 19. cholecalciferol (vitamin D3) 400 unit Tablet [**Date Range **]: Two (2) Tablet PO DAILY (Daily). 20. Calcium 500 500 mg calcium (1,250 mg) Tablet [**Date Range **]: One (1) Tablet PO twice a day: Please do not give with meals or with other prescription medications as Ca can reduce absorption of other medications. 21. Ganciclovir 300 mg IV Q12H 22. Morphine Sulfate 1-2 mg IV Q4H:PRN foot pain 23. 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. 24. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 25. heparin (porcine) 1,000 unit/mL Solution [**Date Range **]: as directed units Injection continuous: Target PTT: 60 - 100 seconds Sliding scale: PTT <40: 2300 units Bolus then Increase infusion rate by 250 units/hr PTT 40 - 59: 1100 units Bolus then Increase infusion rate by 100 units/hr PTT 60 - 100*: PTT 101 - 120: Reduce infusion rate by 100 units/hr PTT >120: Hold 60 mins then Reduce infusion rate by 250 units/hr . 26. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Location (un) **] rehab Discharge Diagnosis: Gastritis with probable gastrointestinal hemorrhage due to supratherapeutic INR (11) Colitis vs enteropathy Resolving PCP pneumonia [**Name9 (PRE) 2325**] foot dry gangrene 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 with low blood pressures, low oxygen levels, low blood counts, and an elevated INR (11). Your symptoms improved with IV fluids and red blood cell transfusions and your blood counts remained stable while on a heparin drip. It is unclear the exact reason for your initial symptoms, but it is likely that you had lung inflammation as a result of your steroids being stopped and a bleed due to an elevated INR level. To evaluate the source of your bleeding, you had an upper endoscopy which showed inflammation of your stomach and you were therefore started on a proton pump inhibitor (omeprazole) to prevent further bleeding. It is possible that you may have also had bleeding from your colon and therefore it is very important that you have a full colonoscopy in the next 4-6 weeks. You were also noted to have malnutrition and diarrhea and were seen by the Gastroenterology and Infectious Disease teams. You were continued on your Gancyclovir as well as your other previous Infectious Disease medications. You were also restarted on your prednisone and this should be reduced slowly over the next 4 weeks (to be reduced by 10mg each week). With regards to your left leg clot, you are being continued on anticoagulation and should follow up with your Surgeon as previously scheduled. Additionally, given that your recent hospitalization was likely related to an elevated INR, your rehab facility should excercise great care in titrating your Coumadin levels to make sure that your INR does not get above 3. You also will need to follow up with your PCP after discharge from rehab to have your INR levels checked and your Coumadin dosing adjusted as needed. Please call your doctor if you experience worsening abdominal pain, fevers, severe worsening of your diarrhea, difficulty breathing, or any other symptoms that concern you. Followup Instructions: 1) Department: INFECTIOUS DISEASE When: TUESDAY [**2102-12-5**] at 10:00 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 2) Department: VASCULAR SURGERY When: THURSDAY [**2102-12-7**] at 2:45 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage 3)Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 14740**] or Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 798**] to arrange a PCP fu appointment 3 days after discharge from rehab. 4) Please call the GI Procedure scheduling to schedule a colonoscopy in the next 4-6 weeks to evaluate for any potential sources of bledding. (Ph: [**Telephone/Fax (1) 2233**]

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icd9cm

[ [ [] ] ]

[ "45.16" ]

icd9pcs

[ [ [] ] ]

19781, 19834

9390, 15483

325, 355

20051, 20051

6167, 6167

22112, 23188

4349, 4421

16278, 19758

19855, 20030

15509, 16255

20234, 22089

8766, 9206

4436, 5411

5427, 6148

9220, 9367

265, 287

383, 3174

6183, 8750

20066, 20210

3196, 3962

3978, 4333

13,745

162,442

18298

Discharge summary

report

Admission Date: [**2178-12-18**] Discharge Date: [**2178-12-29**] Date of Birth: [**2113-3-12**] Sex: F Service: HEPATOBILIARY SURGERY SERVICE HISTORY OF PRESENT ILLNESS: The patient is a 65 year-old female who underwent right colectomy on [**2178-5-12**] for a moderately differentiated adenocarcinoma that extended focally to the serosa. The patient had a follow up CT scan on [**2178-10-30**] and a PET scan on [**11-7**], which demonstrated focal FDG activity on the right lobe of the liver suspicious for metastatic disease. On review of the PET scan lesion appeared to be ______ segment of the right lobe. MRI on [**11-27**] demonstrated 2.5 cm focus of increased signal of the right lobe predominantly ______ abutting superior margin of segment six, suspicious for metastatic disease. Also an additional subcentimeter intrahepatic lesion within segment three difficult to characterize, because of the size. No adrenal mass was seen. She was presenting for an elective hepatic resection. ALLERGIES: Codeine, Percocet, Percodan, Cipro, intravenous contrast and Keflex. CURRENT MEDICATIONS: 1. Hydrochlorothiazide 12.5 mg po q day. 2. Lopressor 75 mg po b.i.d. 3. Propulsid 20 mg po q.i.d. 4. Prilosec 20 mg po b.i.d. SOCIAL HISTORY: The patient denies a history of alcohol use and admitted to a sixty pack year smoking history. Denies the use of other drugs. PAST MEDICAL HISTORY: 1. Colon cancer. 2. Hypertension. PAST SURGICAL HISTORY: Cholecystectomy in [**2137**], bladder suspension [**2168**], two breast nodule excised in [**2169**] and a history of spinal fusion. The patient also has a right hemicolectomy as noted above. PHYSICAL EXAMINATION: The patient was afebrile. Vital signs were stable. Her abdomen had normal bowel sounds, well healed midline abdominal incision. No hepatosplenomegaly, masses or tenderness. HOSPITAL COURSE: The patient underwent a segment seven and segment three resection with an intraoperative ultrasound on [**2178-12-18**]. She tolerated the procedure well. The patient had a postoperative course, which was complicated by respiratory distress, which occurred on [**2178-12-23**]. The patient was transferred to the Intensive Care Unit, aggressively diuresed and ruled out for myocardial infarction and continued to improve returning back to baseline tolerating a regular diet, ambulating well with good O2 saturations. She was transferred back out to the floor on postoperative day number eight and was felt to be ready for discharge on postoperative number eleven with O2 saturations back up to 96% on room air. The patient is afebrile with vital signs stable. Abdomen soft, nontender, nondistended with one JP in place with serosanguinous drainage to be discontinued at an office follow up with Dr. [**First Name (STitle) **]. The patient was discharged to home. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Status post segment three and seven liver resection secondary to metastatic colon cancer. 2. Hypertension. 3. Chronic obstructive pulmonary disease. 4. Aortoiliac occlusive disease. 5. Bilateral foot drop. 6. Colon cancer. DISCHARGE MEDICATIONS: 1. Hydrochlorothiazide 12.5 mg po q day. 2. Lopressor 50 mg po b.i.d. 3. Colace 100 mg po b.i.d. 4. Dilaudid one to two tablets po q 4 hours prn pain. 5. Prilosec 20 mg po b.i.d. 6. Levaquin 500 mg po q day times ten days. FOLLOW UP: The patient will follow up with Dr. [**First Name (STitle) **] on [**2178-12-31**] two days after discharge for possible removal of JP and also for evaluation of wound and progression and also with primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in one to two weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 5915**] MEDQUIST36 D: [**2178-12-31**] 10:10 T: [**2178-12-31**] 10:34 JOB#: [**Job Number 50450**] cc:[**Last Name (NamePattern4) 50451**]

[ "V10.05", "428.0", "682.2", "401.9", "197.7", "441.4", "496", "511.9", "998.59" ]

icd9cm

[ [ [] ] ]

[ "50.22", "38.91", "88.72" ]

icd9pcs

[ [ [] ] ]

2951, 3184

3207, 3437

1898, 2869

1485, 1680

3449, 4055

1703, 1880

1125, 1257

193, 1104

1424, 1461

1274, 1402

2894, 2930

1,259

129,826

19087

Discharge summary

report

Admission Date: [**2191-8-18**] Discharge Date: [**2191-9-3**] Date of Birth: [**2123-9-1**] Sex: F Service: BLUE GENERAL SURGERY HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname 17926**] is a patient with a prior medical history including hypothyroidism, iron-deficiency anemia, osteoporosis, increased cholesterol, peptic ulcer disease, chronic constipation, and status post appendectomy as well as status post hysterectomy and bilateral salpingo-oophorectomy. She was transferred from an outside hospital for evaluation and treatment of adenocarcinoma involving the transverse colon and gallbladder. At the outside hospital the patient had already seemed some workup for a couple weeks duration of bilateral upper quadrant pain which occasionally radiated to her back. She was also complaining of fatigue for two weeks but a good appetite and the patient denied weight loss, melena, or bright red blood per rectum. A CAT scan of the abdomen showed air-fluid levels in the gallbladder. It also showed a thickened gallbladder wall as well as a dilated common bile duct. Incidentally, it also showed diverticulosis. A HIDA scan at the other hospital did not show filling of the gallbladder indicating some sort of cystic duct obstruction. The first imaging study that was done at [**Hospital1 18**] was a MRCP which revealed an enhanced thickened gallbladder wall consistent with chronic cholecystitis. A differential according to the imaging included a fistula with adjacent inflammatory change but also carcinoma or adenomatosis. In addition, also the MRCP showed a mass near the region of the neck of the gallbladder. Of note, at the outside hospital, an endoscopy and colonoscopy were performed. The colonoscopy showed two polyps and also a region in the transverse colon that was biopsied. This biopsy came back as positive for adenocarcinoma. The diagnosis of adenocarcinoma was already established prior to her admission at this hospital. HOSPITAL COURSE: The patient was scheduled for an operative date on [**2191-8-23**] and over the next few days she was given a low-residual diet. She had her belly cleaned with Hibiclens one a day and once an adequate preoperative evaluation was performed, she was given a bowel prep on Monday afternoon and evening in preparation for an exploratory laparotomy on Tuesday, [**2191-8-23**]. On the morning of [**2191-8-23**], the patient was taken to the Operating Room and underwent a cholecystectomy, partial hepatectomy, partial lymph node dissection, a colocolostomy, partial colectomy, and in addition a gastrostomy and a feeding jejunostomy were also put in place. Please refer to the previously dictated operative notes for the details of this surgery. Briefly, the surgery on [**2191-8-23**] revealed a carcinoma of the gallbladder with a cholecystocolonic fistula which crossed into the liver as well as metastatic adenopathy around the portal nodes as well as retroperitoneal nodes around the inferior vena cava and the hepatic artery. In addition to the gastrostomy and feeding jejunostomy tube, two [**Location (un) 1661**]-[**Location (un) 1662**] drains were placed. The patient's pain postoperatively was controlled with an epidural catheter. However, the epidural had the consequence of causing a bit of a hypotension in the patient and the patient was admitted to the Surgical ICU for the first postoperative day. In addition, the patient had low hematocrits which required a transfusion of packed red blood cells. In addition, on postoperative day number two, the patient was transferred out to the floor and she was doing better in terms of pain control on a Dilaudid PCA machine. On postoperative day number two, interestingly, the patient was complaining of sensitivity to light from an unknown etiology. The patient's postoperative course was unremarkable aside from the photophobia. On postoperative day number two, an Oncology consult with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was obtained and follow-up appointments were scheduled with him as an outpatient. Following that, the patient was slowly advanced to clear liquids and to a regular diet once her bowels began working when she began having flatus. Her bowel function was slow to develop and she needed to remain n.p.o. until postoperative day number six. The patient was also given supplemental tube feedings to supplement her calories and caloric intake. On postoperative day number seven, the patient was tolerating her clear liquid diet and her tube feeds. She was started on p.o. medicines and her first [**Location (un) 1661**]-[**Location (un) 1662**] drain was pulled due to scant output. By [**2191-9-3**], the patient was tolerating a full solid diet as well as her tube feeds. Between the two of those, her caloric intake was sufficient for her to sustain herself. She was discharged to home with services including tube feedings for her home care. Therefore, she was discharged on [**2191-9-3**] in good condition. DISCHARGE DIAGNOSIS: 1. Metastatic gallbladder cancer. 2. Status post cholecystectomy. 3. Status post transverse colectomy with anastomosis. 4. G tube placement. 5. Feeding jejunostomy. 6. Hypothyroidism. 7. Blood loss requiring transfusion. DISCHARGE MEDICATIONS: 1. Levothyroxine 100 micrograms orally once a day. 2. Pantoprazole one tablet once a day. 3. Ambien 10 mg orally before bed. 4. Tylenol #3 one tablet every four hours as needed for pain. 5. Reglan 10 mg four times a day before meals and at bedtime. 6. Colace 100 mg twice a day. DISCHARGE INSTRUCTIONS: Follow-up with the Visiting Nurses Association to arrange assistance with her tube feeding and her activities of daily living. The patient is also scheduled for an appointment with Dr. [**Last Name (STitle) 957**] approximately two weeks after her discharge from the hospital. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**] Dictated By:[**Last Name (NamePattern4) 52098**] MEDQUIST36 D: [**2191-9-10**] 01:23 T: [**2191-9-10**] 13:25 JOB#: [**Job Number 52099**]

[ "575.5", "574.10", "196.2", "156.0", "574.00", "244.9", "368.13", "458.2", "285.1" ]

icd9cm

[ [ [] ] ]

[ "45.74", "96.6", "46.39", "40.3", "50.22", "54.4", "51.22", "43.19" ]

icd9pcs

[ [ [] ] ]

5317, 5603

5065, 5294

2002, 5044

5628, 6150

63,053

105,549

5845

Discharge summary

report

Admission Date: [**2146-10-23**] Discharge Date: [**2146-11-15**] Date of Birth: [**2081-11-5**] Sex: M Service: SURGERY Allergies: Demerol / Haloperidol / Ativan / Percocet Attending:[**First Name3 (LF) 668**] Chief Complaint: Fatigue and Fevers, Melena Major Surgical or Invasive Procedure: Liver biopsy [**First Name3 (LF) **] (Endoscopic Retrograde Cholangiopancreatography) repeat [**First Name3 (LF) **] (Endoscopic Retrograde Cholangiopancreatography) [**11-7**] - Exploratory laparotomy, duodenostomy, and oversewing of bleeding location on the ampulla. History of Present Illness: 64-year-old male with a past medical history of hepatitis C cirrhosis and hepatocellular carcinoma who is status post liver transplantation on [**2145-12-7**]. . After his liver transplantation, his course was complicated by recurrent hepatitis C with fibrosing cholestatic hepatitis. He was treated with Infergen and ribavirin, but this was discontinued as the patient developed seizures on this therapy. His recurrent hepatitis C was therefore addressed by changing his immunosuppression from Prograf to rapamycin. The switch to rapamycin was also done due to the fact that he had hepatocellular carcinoma, and evidence has demonstrated reduced recurrence of HCC in patients on rapamycin therapy. . The patient was recently admitted to the hospital in early [**Month (only) **] due to abnormal liver function tests. His liver biopsy demonstrated moderate acute cellular rejection. He was therefore treated with Solu-Medrol 500 mg daily for three days and then discharged on oral prednisone. He currently takes prednisone 20 mg daily. He was readmitted to the hospital on [**2146-10-12**]. This was due to the fact that he had worsening liver function tests, with an ALT of 271 and an AST of 317. His liver biopsy demonstrated no features of acute cellular rejection, but there was evidence of grade 1 inflammation and stage I-II fibrosis. His rapamycin levels at that time were elevated at 27.3, and therefore this medication was held. The patient was discharged on [**10-14**]. Upon discharge, he was told to have his rapamycin levels checked on the 29th and then to restart this medication on the 29th after getting his levels checked. These levels are not available in the [**Hospital1 **] system, but the patient did restart rapamycin. . The patient was seen in [**Hospital **] clinic on [**2146-10-19**] feeling relatively well. A rapamycin level was drawn: 18.2 on [**10-20**] with plan for followup [**2146-10-26**]. . The patient describes being extremely fatigued for one week, but decided to come to the ED when he had fevers to 102.8 last night with chills. He describes having diarrhea [**2-21**] bm per day despite using lomotil. However, he notes that his BM have not changed in frequency or consistency recently- instead he has had diarrhea since starting on an extensive course of liver medications, including bactrim for prophyolaxis while on sirolimus and prednisone taper. He does not that the color of his diarrhea has changed in the past few days from brown to caramel colored. He has some mild abdominal pain that he associates with his diarrhea, but no RUQ pain. He denies chest pain, SOB, dysuria or change in urinary frequency. He also denies confusion or change in skin color or abdominal girth. . In the ED, initial vs were: 57 125/80 16 97%. CT abdomen/pelvis in the ED showing no acute intraabdominal pathology. He was started on PO vanc for presumptive C diff, and was given 1 mg Rapamycin per GI recs. Past Medical History: -Bipolar disorder: Diagnosed in [**2129**], past suicide attempt in the 70s during a manic phase or s/t to drug and alcohol abuse. Had been stable on Wellbutrin and Lithium since [**29**] and 93 respectively, except for during a trial of IFN therapy in [**2138**] where hospitalization was required. - HCV: Genotype unknown. Liver biopsy in [**9-/2144**] showed stage 4 cirrhosis and small well-differentiated hepatocellular carcinoma. Found to have grade 1 esophageal varices on EGD in 4/[**2143**]. Developed hepatic encephalopathy in [**2142**] requiring hospitalization at [**Hospital1 2025**], started on lactulose with good effect. Past treatments include peg interferon and ribavirin in [**2139**]. These meds were discontinued due to suicidal ideation. For recent history please refer to HPI. - HCC: Recently noted 1.4 cm enhancing lesion on liver imaging, proved to be small, well-differentialed HCC on bx in [**9-26**] s/p cadaveric liver transplantation on [**11-28**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]) - Hypothyroidism. On levothyroxine as an outpatient. - [**2145-12-7**] liver [**Month/Day/Year **] - Psych: history of bipolar disorder managed with high dose wellbutrin. prior suicide attempts requiring hospitalization. Social History: He lives [**Location (un) **] w/ wife, who is a nurse and two teenage children. No [**Location (un) 23165**] beverage for 30 years. No tobacco use ever. Family History: Non-contributory. Physical Exam: Gen: NAD HEENT: MMM no lesions CV: RRR no MRG RESP: CTAB no WRR ABD: soft, tender around incision site. No guarding or rebound WOUND: Abdominal incision clean and dry, JP site recently opened with no evidence of active drainage. JP with serous drainage Ext: No LE edema Pertinent Results: Admission Labs: [**2146-10-23**] 09:00AM URINE RBC-0-2 WBC-[**1-21**] BACTERIA-MOD YEAST-NONE EPI-0-2 [**2146-10-23**] 09:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG [**2146-10-23**] 09:00AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.024 [**2146-10-23**] 09:00AM PT-11.7 PTT-29.8 INR(PT)-1.0 [**2146-10-23**] 09:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2146-10-23**] 09:00AM WBC-5.1 RBC-4.02* HGB-11.0* HCT-32.7* MCV-81* MCH-27.4 MCHC-33.6 RDW-14.8 [**2146-10-23**] 09:00AM ALT(SGPT)-252* AST(SGOT)-426* ALK PHOS-392* TOT BILI-3.3* [**2146-10-23**] 09:00AM GLUCOSE-191* UREA N-27* CREAT-1.1 SODIUM-133 POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-21* ANION GAP-16 [**2146-10-23**] 09:12AM LACTATE-1.4 . Imaging: CT Ab/Pelvis [**2146-10-23**]: IMPRESSION: 1. No acute abdominal pathology. 2. Interval decrease in free fluid surrounding the liver with only a small amount remaining. 3. Interval removal of CBD stent without intra- or extra-hepatic biliary ductal dilatation. . CXR [**2146-10-23**]: FINDINGS: In comparison with study of [**5-31**], there is no interval change or evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion, or pleural effusion. . [**Date Range **] report: Successful biliary cannulation with the sphincterotome. A caliber change was noted between the native and transplanted bile ducts. At the anastamosis there was some resistance as an 8.5 mm balloon was pulled through. Otherwise normal post-[**Date Range **] cholngiogram A 11cm by 10FR biliary stent was placed successfully across the anastamosis [stent placement]. Otherwise normal [**Date Range **] to 3rd portion of duodenum. . Recommendations: If the LFTs improve following stent placement, balloon dilation of the anastamosis could be performed in 1 month. If the LFTs fail to improve following stent placement, we will remove the stent in 1 month. Juices when awake and alert, then advance diet as tolerated. Further management as per hepatology service. [**2146-11-9**]: RIGHT UPPER QUADRANT ULTRASOUND WITH DOPPLER: There are no focal or textural abnormalities within the liver. The common bile duct measures 5 mm and is not dilated. The pancreatic body and tail are obscured by overlying bowel gas. However, the remainder of the pancreas appears normal. There is splenomegaly with the spleen measuring 14.7 cm. Incidentally noted is a left renal cyst measuring 5.6 x 5.8 cm in sagittal dimension. A single view of the right kidney shows no hydronephrosis. ABDOMINAL DOPPLER: The left, main, and right portal veins are patent with hepatopetal flow. The hepatic veins are patent with normal directional flow. The main hepatic artery is patent with normal arterial Doppler waveforms. IMPRESSION: 1. Normal hepatic echotexture with no focal lesions. 2. Patent hepatic vasculature without evidence of portal vein thrombosis. 3. Normal caliber common bile duct measuring 5 mm. 4. Splenomegaly. Liver, allograft, core needle biopsy: 1. Moderate portal/periportal, and mild lobular mixed inflammation including lymphocytes, plasma cells, occasional neutrophils, and eosinophils. Occasional apoptotic hepatocytes seen. 2. Prominent bile duct damage with infiltrating lymphocytes are seen. 3. Focal portal endothelialitis [**Doctor Last Name **]. 4. Trichrome stain shows increased portal fibrosis with septa formation and focal minimal sinusoidal fibrosis (stage 2). 5. Iron stain shows minimal iron deposition in hepatocytes. Note: The findings are consistent with recurrent viral hepatitis C. There is also venulitis which is consistent with acute cellular rejection. Brief Hospital Course: 64-year-old male with a past medical history of hepatitis C cirrhosis and hepatocellular carcinoma who is status post liver transplantation on [**2145-12-7**] and presents with fevers at home and diarrhea. . # Fevers (MICU added course, primary team please update): There was concern for C.diff in the ED given diarrhea with fevers; treatment was started with PO Vancomycin. Of note, the patient's WBC is not elevated but he is immunosupressed so this is not sensitive/expected. Of note, another concern in a patient with known liver [**Year (4 digits) **] rejection would be SBP, but the patient does not have ascites on exam or CT and has only mild tenderness to abdominal palpation. Rest of infectious workup negative: U/A negative, CXR negative. During his MICU course, he spiked a fever to 100.6 on [**11-4**]. He was on daptomycin/zosyn at the time. Patient was pan-cultured which grew nothing. . # GI Bleed: While in the hospital, the patient began to pass burgundy colored stools with small blood clots on evening of [**11-1**] and subsequently triggered on the floor for hypotension (85/48). He was subsequently transferred to the MICU for closer hemodynamic monitoring in setting of GI bleeding for which colonoscopy indicated a bleeding at his sphincterotomy with hemostasis acheived. He received 4 units of pRBC total. He did have some maroon stools after the EGD, which may have represented a slow ooze with stable Hgb. His hematocrits were stable until the afternoon of [**11-4**] when he had a Hct drop to 25.9. He was transfused 1 unit, and sent to angio where they could not located the bleeding vessel. He received another unit PRBC that night, continued to have maroon stools and w/ continued low Hct's. Received 10 units as of [**2146-11-6**]. Had positive tagged RBC scan, then went to angio on [**11-6**], but unable to localize on arteriogram so transferred to [**Month/Year (2) **] surgery service in case surgery indicated. . # S/P [**Month/Year (2) 1326**] (Immunosupression): Transplanted [**11-28**]. Had episode of ACR s/p steroids and re-bx confirming no evidence of rejection. patient being immunosuppressed with Rapamycin. Of note, levels have been fluctuating lately. The patient was continued on home med of Rapamune 1 daily and MMF 500 [**Hospital1 **] was started by floor team. There was concern for rejection/HCV given elevated AlkPhos. His levels were followed and re-dose as appropriate . # Direct hyperbilirubinemia (MICU course, primary team to update) Patient had admission bilirubin of 3.3 with subsequent uptrend to 12 mostly direct fraction with obvious jaundice. His recent [**Hospital1 **] showed a patent extrahepatic system. The concern is for an intrahepatic process or infectious etiology such as virus..... . # HCC: The patient is scheduled for a protocol CT scan on [**2146-12-7**], which will be one year post-transplantation. As of yet, he has not had recurrence of HCC. GI following. . # Psychiatric Issues incl. Bipolar Disorder: Continued Modafinil, Seroquel, Keppra, Effexor . # Hypothyroidism: Continued Synthroid The following is a brief summary of the [**Hospital 228**] hospital course while on the [**Hospital 1326**] Surgery Service beginning [**11-7**]: The patient was taken to the operating room for massive melena s/p [**Month/Year (2) **] sphincterotomy on [**2146-11-7**]. See operative report for full details. The patient was transferred to the SICU in good condition. His SICU course was remarkable for post operative delirium, for which a psychiatry consult was obtained. They recommended Zyprexa at night and good sleep hygiene which were followed. The patient's hematocrit stabilized and on POD 2 he was transferred to the floor. His NGT was discontinued on POD3, and the patient was started on a clear liquid diet. Of note, the patient continued to have melanotic bowel movements after his operation. His hematocrit remained stable, and his hemodynamic status never faltered. He was started on Ceftriaxone (later converted to PO Keflex) on POD 3 for erythema around his incision site. His diet was advanced to regulars on POD4. At this time, his bowel movements began to turn more brown in color. On POD5 he was given 1U PRBC's for a Hct of 28.3, down from 31 the day before. He responded appropriately. At this time his course was notable for persistent serous drainage in his JP bulb, close to ~500cc a day. By POD 8 the patient's pain was well controlled with oral medication, and was eating and voiding with no difficulty. His melena had completely resolved. He was ambulating with the assistance of a walker. He was discharged on a 7 day course of keflex for management of his wound incision. His JP drain was left in, and the patient had VNA services arranged to help with it's care and output recording. Lastly, the patient was given a 5 day course of oral lasix to aid with his lower extremity edema. Of note, the liver biopsy performed during his operation was notable for recurrent HCV as well as acute rejection. See pathology report for full details. His rapamycin was transitioned to prograf in the interest of better wound healing, and his levels were aimed at slightly higher values. Due to his history of prior seizures on high dose prograf, his keppra dosing was increased as well. Medications on Admission: Modafinil 100 mg daily. Folic acid 1 mg daily. Daily multivitamin. Seroquel 25 mg. at bedtime. Keppra 500 mg b.i.d. Effexor 37.5 mg b.i.d. Synthroid 100 mcg daily. Hydroxyzine 25 mg p.o. q.i.d. Cholestyramine 4 g p.r.n. for itching. Bactrim 480 mg daily. Omeprazole 20 mg daily. Prednisone 10 mg daily. Valganciclovir 450 mg daily. Mycophenolate (Patient does not know dose; no notes mentioning this) Rapamycin-- patient has been holding for 2 days per GI reccs, was given 1 mg today in ED Discharge Medications: 1. modafinil 100 mg Tablet [**Date Range **]: One (1) Tablet PO qdaily (). 2. folic acid 1 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 3. multivitamin Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 4. venlafaxine 37.5 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a day). 5. levothyroxine 100 mcg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 6. hydroxyzine HCl 25 mg Tablet [**Date Range **]: One (1) Tablet PO Q6H (every 6 hours) as needed for itching. 7. cholestyramine-sucrose 4 gram Packet [**Date Range **]: One (1) Packet PO BID;PRN () as needed for itching. 8. sulfamethoxazole-trimethoprim 400-80 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Date Range **]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. valganciclovir 450 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 11. mycophenolate mofetil 500 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a day). 12. olanzapine 2.5 mg Tablet [**Date Range **]: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 13. levetiracetam 250 mg Tablet [**Date Range **]: Three (3) Tablet PO BID (2 times a day). 14. cephalexin 500 mg Capsule [**Date Range **]: One (1) Capsule PO Q6H (every 6 hours) as needed for wound infxn. Disp:*28 Capsule(s)* Refills:*0* 15. hydromorphone 2 mg Tablet [**Date Range **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 16. prednisone 5 mg Tablet [**Date Range **]: Two (2) Tablet PO DAILY (Daily). 17. tacrolimus 1 mg Capsule [**Date Range **]: Two (2) Capsule PO twice a day. Disp:*120 Capsule(s)* Refills:*1* 18. tacrolimus 0.5 mg Capsule [**Date Range **]: take as directed Capsule PO as directed. Disp:*180 Capsule(s)* Refills:*1* 19. Lasix 20 mg Tablet [**Date Range **]: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Recurrent hepatitis C Acute Kidney Injury GI bleed after sphincterotomy incision cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for fever, fatigue, and increased diarrhea. Because your LFTs were elevated, a liver biopsy was done, which showed infection and recurrent hepatitis C. [**Hospital **] was done and had a stent placed. Fevers continued with elevated liver enzymes, a second [**Hospital **] was done with placement of 2 stents and a procedure called a sphincterotomy was performed. After this procedure you had bleeding. You went to the OR (Dr. [**First Name (STitle) **] to stop the bleeding. Bleeding stopped. The [**First Name (STitle) **] biliary duct stents have migrated down and are making their way through your intestine. Please look at all of your BMs to see if you pass 2 blue stents (tubes). If you do not pass these stents, you will have an abdominal XRAY called a KUB on [**First Name (STitle) 766**] [**11-21**] CareGroup VNA services have been arranged to see you at home for Physical therapy. Empty and record all output from your JP drain. You may shower. No driving while taking pain medication. No straining/heavy lifting/swimming/shoveling You will need to have labs every [**Month/Day (4) 766**] and Thursday starting Thursday [**11-17**] at [**Last Name (NamePattern1) 439**], [**Hospital 86**] [**Hospital 2577**] Medical Office Building Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2146-11-21**] 10:30 Please reschedule your appointment with DERMATOLOGY AND LASER With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2308**], MD [**Telephone/Fax (1) 3965**] Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: RADIOLOGY When: WEDNESDAY [**2146-12-7**] at 10:15 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2146-12-15**] 10:30 Completed by:[**2146-11-23**]

[ "787.91", "296.80", "782.4", "997.4", "E878.0", "573.8", "996.82", "576.1", "790.01", "V10.07", "E879.8", "244.9", "E878.2", "070.54", "998.11", "345.90" ]

icd9cm

[ [ [] ] ]

[ "44.43", "44.49", "51.85", "51.87", "54.11", "38.93", "97.05", "46.39" ]

icd9pcs

[ [ [] ] ]

16988, 17046

9148, 14456

329, 601

17182, 17182

5381, 5381

18625, 19443

5054, 5073

14997, 16965

17067, 17161

14482, 14974

17334, 18602

5088, 5362

263, 291

629, 3566

5397, 9125

17197, 17309

3588, 4866

4882, 5038

17,375

153,942

8228

Discharge summary

report

Admission Date: [**2152-8-30**] Discharge Date: [**2152-9-7**] Date of Birth: [**2093-6-9**] Sex: M Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male with a history of adenocarcinoma of the colon with metastatic disease to the liver. He underwent a colectomy on a previous admission and has subsequently received chemotherapy of oxaliplatin, Avastin and Tarceva. He is now 6 weeks post chemotherapy and presented for resection of liver metastasis. His preoperative workup included multiple radiologic imaging which demonstrated no other malignancies, preoperative assessment which placed him at an acceptable risk for surgery. He presented to the holding area on the day of his operation. PAST MEDICAL HISTORY: Hypertension, gastroesophageal reflux disease. PAST SURGICAL HISTORY: Includes a colectomy in [**2151-7-22**], pre colectomy left ureteral stent. MEDICATIONS ON ADMISSION: Include Celexa 10 mg p.o. daily, lisinopril 10 mg daily and Protonix 40 mg daily. ALLERGIES: Include OXALIPLATIN which caused hives during his chemotherapy course. SOCIAL HISTORY: He quit greater than a year ago, but he use to smoke a pack a day. No EtOH. No IV drug use. PHYSICAL EXAMINATION ON PRESENTATION: His temperature was 98.3, heart rate was 80, blood pressure was 125/100, saturating 98% on room air. He was a well-appearing man in no acute distress. His heart was regular. His lungs were clear. His abdomen was soft and benign. No peripheral edema. LABORATORY DATA: His preoperative labs were unremarkable. RADIOLOGIC AND OTHER STUDIES: His EKG was sinus rhythm. HOSPITAL COURSE: On the day of admission, the patient was taken to the operating room where he underwent a right hepatectomy. He tolerated this procedure well. The details of the operative report are outlined in Dr.[**Name (NI) 670**] operative note elsewhere in the medical record. Due to the length of the case, an extensive dissection, fluid resuscitation the patient was kept in the ICU overnight intubated. His initial postoperative course was significant for relative hypotension. Initially, this was thought to be due to under resuscitation and also an epidural catheter which was placed preoperatively. The epidural catheter was discontinued, and he was fluid resuscitated. His hemodynamics were normal. He required no pressor support, and his issues resolved over the first postoperative day. He was extubated on postoperative day #1, and his postoperative course after that has been unremarkable. On postoperative day #2, he was transferred to the floor. His diet was advanced. He received physical therapy and has been ambulating without assistance. All of his laboratory work has been within normal limits. At the time of discharge his LFTs have trended down to an AST of 116, an ALT of 224, an alkaline phosphatase of 171 and a total bilirubin of 1.7. He had a JP that was placed intraoperatively. This drainage appropriately decreased. Prior to it being removed a JP bilirubin was sent which was 1.8. The patient is now ready for discharge to home. DISCHARGE DIAGNOSES: 1. Metastatic colon adenocarcinoma, status post right hepatectomy. 2. Hypercholesterolemia. 3. Hypertension. 4. Gastroesophageal reflux disease. 5. Blood loss anemia. MEDICATIONS ON DISCHARGE: Include lisinopril 10 mg p.o. daily, Protonix 40 mg p.o. daily, Percocet 1 to 2 q.4h. p.r.n. CONDITION ON DISCHARGE: Good. DISCHARGE FOLLOWUP: The patient will follow up with Dr. [**First Name (STitle) **] in his office in approximately 1 to 2 weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Last Name (NamePattern1) 8958**] MEDQUIST36 D: [**2152-9-7**] 09:42:07 T: [**2152-9-7**] 10:52:14 Job#: [**Job Number 29221**]

[ "285.1", "401.9", "530.81", "197.7", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "99.04", "50.3", "51.22" ]

icd9pcs

[ [ [] ] ]

3128, 3300

3327, 3421

955, 1122

1658, 3107

851, 928

3474, 3848

181, 756

779, 827

1139, 1640

3446, 3453

15,886

168,215

24507

Discharge summary

report

Admission Date: [**2152-5-29**] Discharge Date: [**2152-6-14**] Date of Birth: [**2094-8-21**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: Transfer from OSH s/p PEA arrest Major Surgical or Invasive Procedure: intubation History of Present Illness: 57 yo woman with prior known PMHx significant for COPD (no home O2, no intubations), DM, HTN, CHF who presented to OSH with prodrome of cough/dypnea who initially presented to [**Hospital **] hospital [**5-29**] with dyspnea on exertion and cough for several days. At home, she was found to be 84% O2 sat on RA. EMS was called and she was given lasix 40mg in the ambulance, and another 80mg in the ER. Per report, she coded twice - once in the ED and given ativan and norcuron and intubated, then again in the CCU. Reportedly, at 2:43-2:51 am, she had PEA arrest and SVT requiring epinephrine and dopamine. She then had asystole for 1-2 minutes at [**Hospital1 **] CCU with bp 60/30 requiring atropine and epinephrine. Then at 3:20 am, right pupil noted to be 5 mm and nonreactive. Patient immediately went to head CT for right parietal cortical hypodensity with sulci effacement; however, negative for bleed. . In the [**Hospital1 18**] ED the patient was hypotensive, and agitated. Pressors were running through PIV from OSH. A right IJ was attempted, however, c/b tension PTX. Chest tube was placed emergently. Later a right subclavian was attempted, and ended up in subclavian artery. Vascular surgery evaluated the patient and the line was pulled. Finally a femoral line placed and dopamine was started for BP support. Neurology evaluated the patient for the finding of a fixed dilated pupil. Their impression was that this was due to generalized hypoxic cerebral damage. Within 24 hours of admission, her pupil became reactive. Past Medical History: 1. DM2 c/b microalbumin diagnosed [**2-12**] and started on metformin 2. HTN 3. CHF (diastolic, EF=55%) 4. COPD (bullous- No prior intubations) 5. Hypercholesterolemia 6. Obesity 7. Bilateral Renal Lipomatosis 8. H/o cervical polyps 9. H/o bladder hyperplasia wtih negative biopsy [**2148**] 10. s/p IUD removal [**2152-5-17**] and endocervical polypectomy- benign Social History: She is widowed, lost her husband 4 years ago. Former tobacco. EtoH is not obtainable Family History: NC Physical Exam: (ON TRANSFER FROM ICU TO FLOOR) VS: 96.0 - 91 - 117/51 - 18 - 97% (3L); LOS fluid balance +5653 cc . GEN: comfortable, sitting, speaking in complete sentences, NAD HEENT: PERRL bilaterally (4-->3mm); EOMI bilat; OP clear; MMM NECK: no JVD CV: RRR, normal S1S2, no M/R/G RESP: CTA bilat, no W/R/R appreciated ABD: NABS, soft, NT, ND, no masses EXT: trace pretibial edema bilaterally NEURO: CN II-XII intact bilat; motor tone [**5-11**] bilat; sensory exam intact bilat Pertinent Results: [**2152-5-29**] 09:15AM BLOOD WBC-14.6* RBC-4.74 Hgb-14.9 Hct-43.8 MCV-93 MCH-31.5 MCHC-34.1 RDW-13.4 Plt Ct-219 [**2152-5-29**] 09:15AM BLOOD Neuts-92.3* Bands-0 Lymphs-5.7* Monos-1.7* Eos-0.1 Baso-0.1 [**2152-5-29**] 09:15AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ [**2152-5-29**] 09:15AM BLOOD Plt Ct-219 [**2152-5-29**] 09:15AM BLOOD PT-14.1* PTT-32.4 INR(PT)-1.3 [**2152-5-29**] 09:15AM BLOOD Glucose-300* UreaN-23* Creat-1.7* Na-133 K-5.0 Cl-98 HCO3-23 AnGap-17 [**2152-5-29**] 09:15AM BLOOD ALT-29 AST-26 CK(CPK)-215* AlkPhos-124* Amylase-30 TotBili-0.3 [**2152-5-29**] 09:15AM BLOOD Lipase-25 [**2152-5-29**] 09:15AM BLOOD Albumin-3.7 Calcium-8.6 Phos-6.0* Mg-1.6 . . [**2152-6-5**] 9:46 am BLOOD CULTURE AEROBIC BOTTLE (Final [**2152-6-11**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2152-6-8**]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([**7-/2453**]) immediately if sensitivity to clindamycin is required on this patient's isolate. STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S . . TEE ([**2152-5-31**]) The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm and/or mobile) atheroma in the aortic root. There are complex (>4mm) atheroma in the ascending aorta, atheroma in the aortic arch, and in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. . . TEE ([**2152-6-13**]) The left atrium is normal in size. 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 thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta and aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is a small filamentous strand attached to the aortic valve consistent with a Lambl's excresence (normal variant). Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the tricuspid valve or pulmonic valve. There is no pericardial effusion. Brief Hospital Course: . . During her MICU course, apparently the patient developed significant subcutaneous air from her chest tube site. The chest tube was placed emergently in the ED, and as a result, the entry wound was large. Per report, she became markedly edematous. This later resolved after a second chest tube was placed. The chest tubes were pulled [**6-5**]. She was also initially treated with levo/flagyl for presumed community acquired vs. aspiration pneumonia. She was treated for a total 10 day course. She was also treated with high dose steroids initially for COPD flare, which have been tapered since. During her ICU stay, she also received pressors for continued hypotension. Eventually she became hypertensive and required increased doses of ACE for BP control. On [**6-5**], the patient was found to have MRSA bacteremia when blood cxs drawn were positive. She was started on Vanco with goal levels > 15. The following day, she was also found to have sputum and urine positive for MRSA as well. This was presumed to be VAP. Further surveillance blood cxs since that time have been negative. . The patient was successfully extubated [**2152-6-10**]. At that point, she was no longer hypotensive and was stabilized on vancomycin for ventilator associated MRSA pneumonia and bacteremia. She was transferred to the medicine service for further management. . After transfer to the floor the following issues were addressed: . 1) COPD: The patient was doing well s/p extubation [**6-10**]. She was continued on prednisone 20 mg PO QD, and will need a long taper after discharge (~3 weeks). She was continued on albuterol/atrovent nebs prn. . 2) MRSA PNEUMONIA: This was likely ventilator associated. She was started on vancomycin 1 gm IV Q8H. She should be continued on vancomycin for 14 days with levels maintained > 20. . 3) MRSA BACTEREMIA: Her bacteremia was most likely secondary to the MRSA pneumonia. Follow up surveillance cultures were negative. Prior to discharge, a TEE was performed which did not reveal evidence of endocarditis. As mentioned above, she will be continued on 2 weeks of vancomycin. . 4) DM: The patient was maintained on an insulin sliding scale during this admission. She was on metformin prior to this admission, and this medication should be restarted eventually. . 5) CHF: The patient has diastolic dysfunction with an EF of 55%. She was continued on a metoprolol 50 mg PO TID during her course and then transitioned to Toprol XL prior to discharge. She was also restarted on aspirin and an ACE inhibitor prior to discharge. A lipid panel was sent this admission revealing an LDL of 67, therefore, a statin was not started. . 6) HTN: She was restarted on a betablocker and ACE inhibitor after her hypotension resolved. . 7) Access: A PICC line was placed by radiology prior to discharge for long-term vancomycin therapy. . 8) DISPO: She was discharged to [**Hospital1 **] for long term antibiotic therapy, as well as rehabilitation. Medications on Admission: Meds on Admission: KcL 8mEq TID Zestril 20qd Diltiazem CD 180mg po qd Lasix 40mg po qd Metformin 1gBID Propanolol 80BID Bactrim Combivent inhaler Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: 1) MRSA pneumonia 2) MRSA Bacteremia 3) Hypotension 4) COPD 5) Diabetes 5) CHF Discharge Condition: Stable, improved from the time of admission Discharge Instructions: Please call your doctor or return to the ER if you experience significant fever/chills, nausea/vomiting, chest pain, or difficulty breathing. Take your medications as prescribed and follow up with your PCP after discharge. Followup Instructions: Please follow up with your primary care physician after discharge from rehab.

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icd9cm

[ [ [] ] ]

[ "88.72", "96.04", "96.72", "38.93", "00.17", "96.6", "34.04" ]

icd9pcs

[ [ [] ] ]

9432, 9512

6245, 9235

348, 360

9635, 9680

2954, 6222

9952, 10033

2446, 2450

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1960, 2328

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80,097

135,724

37910

Discharge summary

report

Admission Date: [**2151-6-1**] Discharge Date: [**2151-6-7**] Date of Birth: [**2086-5-13**] Sex: M Service: OME HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 84751**] is a 64-year-old male with metastatic renal cell carcinoma admitted to begin cycle II, week 2 high-dose IL-2 therapy. His oncologic history began in [**2150-3-15**] with hematuria with subsequent workup revealing a right renal mass. He underwent a right nephrectomy on [**2150-5-15**]. Pathology revealed a 10-cm tumor [**Last Name (un) 19076**] grade [**4-15**] with invasion of the adrenal gland. There were no regional lymph nodes, distant mets, extension into the renal artery or vein noted. Subsequent followup imaging revealed a lung nodule. He underwent attempted resection of that nodule on [**2150-8-4**] complicated by V-fib arrest during anesthesia induction which required resuscitation. One week later, he had a left lower lobe wedge resection with pathology consistent with clear cell carcinoma metastatic to the kidney. Followup imaging in [**2150-10-13**] demonstrated multiple small bilateral pulmonary nodules. He was referred here and high-dose IL-2 therapy was discussed. Cardiology cleared him for treatment off Lopressor. Pre IL-2 brain MRI revealed 3 small brain metastases. He underwent CyberKnife to those lesions on [**2150-12-31**] without steroids which he tolerated well. One month post CyberKnife MRI was stable. Repeat torso CT showed increase in pulmonary nodules and he began cycle 1, week 1 high-dose IL-2 therapy on [**2151-2-25**]. He received 13 of 14 doses week 1 and 11 of 14 doses week 2 with course complicated by lethargy and acute renal failure. Followup CT scans revealed disease regression in the lung. Followup brain MRI revealed stability of the right cerebellar lesion, improvement in the occipital lesion and resolution of the frontal lesion. He began cycle II, week 1 high-dose IL-2 therapy on [**2151-5-17**], receiving 12 of 14 doses with course complicated by hypotension requiring Neo-Synephrine, blood pressure support and neurotoxicity. He is now recovered and is ready for week 2 of therapy. PAST MEDICAL HISTORY: Atrial fibrillation; chronic renal insufficiency; BPH; Bell's palsy bilaterally; gout; right inguinal hernia repair in [**2141**]; heel spur; metastatic kidney cancer as above. ALLERGIES: Lipitor causes myalgias. MEDICATIONS: Propafenone 225 mg p.o. t.i.d., Proscar 5 mg at bedtime, colchicine 0.6 mg b.i.d. p.r.n. gout, Toprol XL 25 mg daily (on hold), Vicodin 5/500 1-2 tablets p.r.n. gout pain. PHYSICAL EXAMINATION: GENERAL: Well appearing male in no acute distress. Performance status 1. VITAL SIGNS: 97.1, 97, 20, 150/88, O2 sat 98% on room air. HEENT: Normocephalic, atraumatic. Sclerae anicteric. Moist oral mucosa without lesions. NECK: Supple. LYMPH NODES: No cervical, supraclavicular or bilateral axillary lymphadenopathy. HEART: Regular rate and rhythm, S1-S2. CHEST: Clear. ABDOMEN: Soft, nontender. EXTREMITIES: No lower extremity edema. SKIN: Intact. NEURO EXAM: Nonfocal. ADMISSION LABS: WBC 14.8, hemoglobin 13.8, hematocrit 40.7, platelet count 393,000. INR 1. BUN 31, creatinine 1.6, sodium 139, potassium 5, chloride 108, CO2 23, glucose 99, ALT 25, AST 16, CK 21, total bili 0.5, albumin 4.2. HOSPITAL COURSE: Mr. [**Known lastname 84751**] was admitted and went to Interventional Radiology for central line placement. His admission weight was 92 kg and he received interleukin-2 600,000 international units per kilo equaling 55.5 million units IV q.8 hours x14 potential doses. During this week he received 5 of 14 doses with doses held due to shock and development of rapid atrial fibrillation. On treatment day #1 after his first dose of IL-2 he became unresponsive with a systolic blood pressure in the 60's. He received 3 fluid boluses with systolic blood pressure over 90 and improved mental status. At that time, he was found to be bradycardic in the 30's to 40 which improved to the 50's, normal sinus brady with improved blood pressure. He had no ischemic changes noted on EKG. On treatment day #2 at 4:30 a.m. he developed systolic blood pressure of 80 without improvement with 3 fluid boluses. He was placed on Neo-Synephrine vasopressor support. Shock was attributed to capillary leak syndrome from IL-2 therapy. Continuous blood pressure bedside and central telemetry monitoring were instituted. He was essentially given 1 dose of IL-2 daily with recurrent hypotension after each subsequent dose. On treatment day #5 he received his fifth dose of IL-2 at 8:00 a.m. and later that day developed rapid atrial fibrillation to the 200's with systolic blood pressure of 60 despite Neo-Synephrine blood pressure support. He was given IV digoxin without response. Given continued hypotension and rapid atrial fibrillation, he was transferred to the ICU where he was treated with IV metoprolol and he converted to sinus rhythm in a short time. He was weaned off Neo-Synephrine blood pressure support early the next day. He was transferred back to the floor and was subsequently discharged on [**2151-6-7**]. Other side-effects during this week included nausea, improved with antiemetics; diarrhea, improved with antidiarrheals and bilateral shoulder pain, improved with oxycodone. He was noted to be restless consistent with toxic encephalopathy. Frequent safety checks were instituted per nursing policy. Further IL-2 therapy was on hold due to shock at that time. Mental status improved prior to discharge. During this week he developed acute renal failure with a peak creatinine of 3.7, improved to 3.4 at the time of discharge. He had associated oliguria and metabolic acidosis, improved with bicarbonate replacement intravenously. Electrolytes were monitored and repleted per protocol. Strict I and O and serum chemistries were maintained. IV fluids were continued given evidence of acute renal failure. He had no transaminitis or hyperbilirubinemia noted. He was anemic without the need for packed red blood cell transfusion. He had no coagulopathy, myocarditis or thrombocytopenia noted. By [**2151-6-7**] he had recovered from side-effects to allow for discharge to home. CONDITION ON DISCHARGE: Alert, oriented and ambulatory. DISCHARGE STATUS: To home with his wife. DISCHARGE DIAGNOSIS: Metastatic renal cell carcinoma, status post cycle II, week 2 high-dose IL-2 therapy complicated by shock, acute renal failure, toxic encephalopathy and atrial fibrillation with a rapid ventricular response. DISCHARGE MEDICATIONS: Lasix 20 mg p.o. daily x5 days or until you have reached pretreatment weight, Tylenol 325-650 mg q.i.d. p.r.n. pain, lorazepam 0.5-1 mg q.4 hours p.r.n. nausea/vomiting, Keflex 500 mg p.o. b.i.d. x5 days, Eucerin cream topically, Sarna lotion topically, Benadryl 25-50 mg q.6 hours p.r.n. pruritus, Lomotil 1-2 tablets q.i.d. p.r.n. loose stools, propafenone 225 mg p.o. t.i.d., finasteride 5 mg p.o. at bedtime, Toprol XL 25 mg p.o. daily. FOLLOW-UP PLANS: Mr. [**Known lastname 84751**] will return to the clinic in 4 weeks after CT scan to assess disease response. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 19077**] Dictated By:[**Last Name (NamePattern1) 18853**] MEDQUIST36 D: [**2151-7-6**] 12:44:24 T: [**2151-7-7**] 11:27:06 Job#: [**Job Number 84752**] cc:[**Numeric Identifier 84753**]

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icd9cm

[ [ [] ] ]

[ "38.93", "00.15" ]

icd9pcs

[ [ [] ] ]

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2608, 3099

7065, 7477

163, 2159

3116, 3329

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139,389

44405

Discharge summary

report

Admission Date: [**2197-5-30**] Discharge Date: [**2197-6-7**] Date of Birth: [**2138-6-23**] Sex: F Service: MEDICINE Allergies: Ceclor / Voltaren Attending:[**First Name3 (LF) 5552**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: none History of Present Illness: 58 YO woman with SCLC, history of SIADH, syncope presents with a history of two episodes of syncope. The first episode occured 3 days ago, which was unwitnessed. She was walking outside on her driveway and suddenly fell unconciousness, with no prodrome, or symptoms preceding the event. She was unconscious for approximately 30 minutes by her account, and awoke with no headache, aura, nausea, vomitting, urinary or fecal incontinence. The had an abrasion on her Right shoulder after the fall. The pain is currently [**4-4**]. The second episode occured the next day while walking in her bedroom, it was not related to orthostatic changes, rising from a bed, chair. This episode was witnessed by her husband, who lifted her up and she awoke. Of note, she has had dizziness the past few weeks after receiving her chemotherapy. She denied vertigo, the room did not spin, but rather she felt unsteady on her feet. Also, she was originally planned for a line place last Friday [**5-26**], but was found to be anemic and transfused 1 unit of blood at that time. ROS: Denied Heachache, chest pain, shortness of breath, fever chills, diarrha, + constipation for 3 days, denied dysuria, Pain in right shoulder [**4-4**]. Also c/o inability to fully void x 1 day (no saddle anesthesia, no bowel incont); no neuro deficits. She has previous history of syncope where her glucose was found to be 30. She had 2 other episodes and found to have normal glucose levels. She also is found to have hyponatremia, with the sodium in the 120s. This is likely due to the SIADH effect of the tumor. Past Medical History: Onc Hx: 58 YO woman presented with dyspnea and cough without hemoptysis, [**11-9**] wt loss/2months, and fatigue. On chest CT [**2197-4-22**] was found to have a large left upper lobe mass encasing the pulmonary artery and pulmonary vein, with several lymph nodes, and hepatic metastasis. A fine needle aspirate show SCC. Tx: [**2197-5-15**] D1 [**Doctor Last Name **]-VP16 [**2197-5-17**] D3 VP16 PMHX: Rheumatoid Arthritis req multiple surgeries H/O staph bacteremia (on long term bactrim, recently changed to levofloxacin) Social History: Social History: She lives in [**Location 29789**], [**State 350**] with her husband. She has adopted three children all of whom are in their 20s and 30s. She was previously employed at a large physicians' group as an insurance negotiator. She has smoked tobacco approximately half a pack per day for the last 40 years. She does not drink alcohol significantly. Family History: Non-contributory Physical Exam: O: VS: 98.2 136/86 88 16 97%ra Gen: frail F ib NAD, lying in bed, multiple bone deformities HEENT: NC/AT, PERRL, EOMI, MMM, OP Clear, No JVD CV: S1 S2, RRR, no m/r/g Chest: Course BS, crackles b/l L>R Mid Lung Fields Abd: +BS Soft NT/ND, no organomegaly Ext: L arm in brace s/p elbow replacement and removal of joint, No c/c/e. Skin: Right shoulder abrasion, tender, erythematous, 1.5'' diameter circular Neuro: AAOx3, CNII-CNXII intact, Motor [**3-30**] LE, Upper Right [**3-30**], Upper Left [**2-28**]. Sensory intact to light touch. Pertinent Results: 115 84 7 ----------- 96 3.0 20 0.4 10.4 .5 77 27.1 ANC 100 CT [**2197-5-17**]- Interval progression of neoplastic disease in the mediastinum with worsening mass effect on the trachea and left main stem bronchus. Complete collapse of left upper lobe. 2. New patchy parenchymal opacities in the right lung suggestive of an infectious etiology. Aspiration is an additional consideration. 3. Progression of right-sided mediastinal lymphadenopathy, subcarinal lymphadenopathy and left hilar lymphadenopathy. Brief Hospital Course: Pt is a 58 y/o F with SCLC, history of SIADH, syncope presented s/p two syncopal episodes and Na of 115. 1. Respiratory Failure: Pt was initially admitted to the oncology service. However, she developed worsening respiratory distress during hospitalization. She was evaluated by the ICU team, at which point she expressed her opposition to any prolonged intubation. However, as the etiology of her respiratory distress was unclear, the decision was made to transfer her to the ICU where she could be placed on BiPAP mask and a work-up for reversible causes for her dyspnea pursued. While in the ICU, her respiratory status continued to decline and she was electively intubated. When a repeat CT of the chest showed significant progression of her malignancy, the decision was made to extubate and make the pt [**Name (NI) 3225**] per her previously expressed wishes. She expired shortly thereafter. 2. Syncope: Pt initially admitted for syncope x 2 of unclear etiology. Ddx included orthostasis (anemia vs dehydration) vs hypoglycemia vs hyponatremia. Unlikely vasovagal or [**12-28**] sz, by history. Had head CT neg for bleed or edema. Pt's hyponatremia was treated with fluid restriction as detailed below. 3. HypoNa: Pt previously diagnosed with SIADH. Had Na=115 on admission, urine osm=400. Renal was consulted. Per their recommendations, pt was maintained on fluid restriction of <1.5L / day, with Na goal of 115-120s. 4. SCLC: Dx'ed in [**2197-3-26**], S/P D3 VP16 ([**5-17**]), tolerated well. However, repeat chest CT on [**5-17**] and again on [**6-5**] showed progression of dz in the mediastinum with mass effect on the trachea. 5. Neutropenia: Pt was maintained on neutropenic precautions while neutropenic secondary to chemotherapy. She was subsequently administered G-CSF, which she responded well to. 6. Anemia: Pt was transfused 1U PRBCs during hospitalization. 7. Hypothyroidism: Pt's synthroid was discontinued. 8. Urinary retention: unclear etiology. It was felt by urology consult to be consistent with medication side-effect. An MRI of the spine was obtained which showed multiple bony metastases, but was negative for any intraspinal masses. 9. Proph: Pt was maintained on SQ Heparin for DVT prophylaxis and Protonix for GI prophylaxis. Medications on Admission: Levaquin- began Sat [**5-27**] Protonix 40 mg daily, [**Doctor First Name **] Albuterol Synthroid which she stopped using. Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Respiratory Failure SCLC Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2197-7-24**]

[ "197.7", "198.5", "244.9", "288.0", "253.6", "162.8", "285.9", "788.20", "518.81", "714.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

6484, 6493

4012, 6283

285, 291

6561, 6570

3461, 3989

6622, 6656

2863, 2881

6456, 6461

6514, 6540

6309, 6433

6594, 6599

2896, 3442

238, 247

319, 1909

1931, 2468

2500, 2847

42,437

173,199

45624

Discharge summary

report

Admission Date: [**2192-10-16**] Discharge Date: [**2192-11-12**] Date of Birth: [**2115-10-30**] Sex: F Service: MEDICINE Allergies: Paxil / Haldol Attending:[**First Name3 (LF) 4891**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 76 year old woman with history of HTN, COPD and psychiatric illness presenting with increased left breast size and worsening dyspnea on exertion. Symptoms started approximately 5 days ago and have progressed to where her left breast is 4-6 times larger than her right breast. The dyspnea on exertion began ~2 days ago (patient is unable to really recall at this point) and has worsened, now including some symptoms even with just talking (previously had some dyspnea with exertion). Reports some cough across past few days, unclear if productive. She denies any chest pain, fevers, nipple discharge or specific breast pain. No trauma. . On arrival in the ED her initial VS were 97.5 119/71 72 20 98/4L. Left breast noted to be enlarged and mildly erythematous. She was started on vancomycin with concern for cellulitis. CXR was felt to be concerning for a LLL infiltrate and she was started on levoquin for CAP. An EKG showed slow atrial fibrilation. A bedside echocardiogram was performed which showed a pericardial effusion. . Denies any chest pain, fevers, chills, night sweats, nausea, vomiting, diarrhea, dizziness, light-headedness. Past Medical History: bipolar disorder HTN COPD h/o EtOH abuse h/o thiaside abuse (?) h/o CVA h/o endometrial Ca w/p TAH-BSO h/o falls degenerative disc disease of lumbar spine atrial fibrillation Social History: Widowed in [**2175**]. Has three children. Significant smoking history: 1 pack per day x 40 years. Former alcohol abuse. Family History: Grandmother positive breast cancer. Mother positive hypertension. No family history of colon cancer. The patient does not know father's side. Physical Exam: On admission VS: 96.1 122/65 hr 107 rr 20 93%/3L pulsus: 8 mm Hg (with doppler) General: ill-appearing elderly woman in mild distress Lungs: diffuse rhonci, minor wheeze Heart: RRR, no R/G/M Chest: Left breast larger than right with diffuse errythema, mild warmth, no significant TTP, nipple WNL, no discharge, no palpable masses Extremities: 2+ LE edema, palpable distal pulses Neuro: CNII-XII intact, alert, oriented to self, place and year . On discharge General: Alert, oriented x 3, lethargic but arousable, no acute distress, answers questions but can only provide "yes, no" answers HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP flat on U/S sitting and upright, no LAD Lungs: Crackles to lower [**2-5**] bilaterally in lateral fields, scant wheezes in upper [**2-5**]. R crackles>L crackles CV: Irreg, irreg; normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding GU: foley in place Ext: LE's edematous and diffusely tender to touch, UE's edematous. Extremities wrapped with ACE bandages. R hand ecchymotic; well perfused, pulses difficult to palpate, but ext warm bilaterally Neuro: CN II-XII intact, moving all four extremities spontaneously, strength difficult to assess due to lack of cooperation and pain Pertinent Results: CBC [**2192-11-12**] 06:55AM BLOOD WBC-8.1 RBC-2.74* Hgb-9.2* Hct-29.6* MCV-108* MCH-33.4* MCHC-30.9* RDW-22.6* Plt Ct-364 [**2192-11-11**] 06:40AM BLOOD WBC-8.7 RBC-2.89* Hgb-9.4* Hct-31.0* MCV-108* MCH-32.5* MCHC-30.2* RDW-22.5* Plt Ct-404 [**2192-11-10**] 06:20AM BLOOD WBC-7.3 RBC-2.83* Hgb-9.3* Hct-30.5* MCV-108* MCH-32.8* MCHC-30.4* RDW-22.3* Plt Ct-444* Chemistry [**2192-11-12**] 06:55AM BLOOD Glucose-109* UreaN-25* Creat-0.9 Na-143 K-4.9 Cl-114* HCO3-22 AnGap-12 [**2192-11-11**] 06:40AM BLOOD Glucose-99 UreaN-28* Creat-1.0 Na-143 K-5.1 Cl-114* HCO3-23 AnGap-11 [**2192-11-10**] 06:20AM BLOOD Glucose-104* UreaN-31* Creat-1.0 Na-144 K-5.2* Cl-116* HCO3-23 AnGap-10 Troponins [**2192-10-16**] 11:45PM BLOOD CK-MB-2 cTropnT-<0.01 [**2192-10-16**] 03:50PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-8869* TSH [**2192-10-19**] 06:45AM BLOOD TSH-1.5 HIT antibodies [**2192-10-19**] 12:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES-negative Miscellaneous: [**2192-10-25**] 05:50AM BLOOD Ret Aut-1.1* [**2192-10-25**] 05:50AM BLOOD ACA IgG-10.0 ACA IgM-6.2 [**2192-10-25**] 05:50AM BLOOD Lupus-POS [**2192-10-31**] 05:38AM BLOOD ALT-7 AST-15 CK(CPK)-19* [**2192-10-25**] 03:57PM BLOOD Lipase-12 [**2192-11-12**] 06:55AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1 [**2192-10-31**] 05:38AM BLOOD VitB12-1502* [**2192-10-24**] 10:23AM BLOOD D-Dimer-892* [**2192-10-18**] 06:50AM BLOOD calTIBC-251* Ferritn-107 TRF-193* Urine: [**2192-11-8**] 12:19PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.026 [**2192-11-8**] 12:19PM URINE Blood-LG Nitrite-NEG Protein-75 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2192-11-8**] 12:19PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-RARE Epi-0 [**2192-11-7**] 07:59PM URINE CastHy-[**7-12**]* [**2192-10-26**] 04:48AM URINE Hours-RANDOM UreaN-636 Creat-94 Na-11 K-60 Cl-LESS THAN [**2192-10-17**] 05:37AM URINE Osmolal-321 URINE CULTURE (Final [**2192-11-9**]): NO GROWTH. URINE CULTURE (Final [**2192-11-7**]): YEAST. ~6OOO/ML Microbiology: CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2192-10-24**]): FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. Blood Culture, Routine (Final [**2192-10-31**]): NO GROWTH. TTE ([**2192-10-17**]) The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are moderately 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. Mild (1+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. Compared with the report of the prior study (images unavailable for review) of [**2185-9-5**], the right ventricular cavity is now dilated and severe pulmonary artery systolic hypertension is now present. The severity of tricuspid regurgitation is also increased and a small circumferential pericardial effusion is now present. Mammogram ([**2192-10-18**]) IMPRESSION: 1. Diffuse left breast skin and trabecular thickening with associated diffuse edema of the left breast tissue. No evidence of pathologically enlarged left axillary nodes. Differential considerations would include fluid overload related to congestive heart failure (unilateral in this patient who states that she preferentially sleeps with her left side down), mastitis, or a diffuse infiltrative process such that can be seen with inflammatory breast cancers or lymphoma. Clinical correlation is advised and any decision to biopsy at this time should be based on the clinical assessment. CT Chest w/o contrast ([**2192-10-26**]) FINDINGS: The thyroid gland is unremarkable. There is extensive atherosclerotic calcification involving the arch of the aorta and coronary arteries. There is moderate-to-severe cardiomegaly with a small pericardial effusion. Numerous mediastinal lymph nodes measure up to 8 mm in short axis diameter are present. No axillary or hilar lymphadenopathy. In the tracheobronchial tree, there is moderate narrowing of the trachea and more severe narrowing of the bronchial tree, particularly on the left, due to bronchomalacia, compounded by extensive mucous plugging progressively increasing distal to the left main stem bronchus, occluding the left lower lobe bronchus, resulting in left lower lobe collapse. The left upper lobe and lingular bronchi are clear. There is a trace left pleural effusion. Bilateral coarse reticulation occuring predominantly in the subpleural region, with areas of honeycombing particularly along the right major fissure, is consistent with moderately severe chronic interstitial lung disease, partially fibrotic. Diffusely increased density of the right lung when compared to the left, and thickening of its interlobular septa is likely asymmetric pulmonary edema. No evidence of pneumonia. There is no pneumothorax. The thoracic aorta is of normal caliber, however, there is area of fusiform dilatation within the abdominal aorta measuring up to 3.4 cm (400B, 29). Area of linear calcification which appears medially displaced from the left lateral wall in the aorta at this level may represent sequelae of a penetrating ulcer or pseudointimal calcification of mural thrombus. Evaluation is limited due to lack of IV contrast. Limited views of the upper abdomen demonstrate bilateral renal cysts which are partially imaged. BONE WINDOWS: There are no suspicious osseous lesions. Multilevel degenerative changes of the thoracic spine are present. IMPRESSION: 1. Tracheobronchomalacia, worse on the left, probably predisposes to extensive mucous plugging of the left lower lobe bronchus and lower lobe collapse. 2. Chronic, moderately severe fibrosing, interstitial lung disease. Asymmetric pulmonary edema. 3. Moderate-to-severe cardiomegaly, small pericardial effusion. 4. Mild aneurysmal dilatation of the abdominal aorta measuring up to 3.4 cm. Ultrasound abdomen ([**2192-10-29**]) IMPRESSION: 1. Patent hepatic vasculature with no portal vein thrombosis identified. 2. Trace of ascites. 3. Multiple bilateral simple renal cysts. CXR ([**2192-11-4**]) FINDINGS: As compared to the previous examination, there is no relevant change. The left PICC line ends in the left brachiocephalic vein, as on the previous study. No other changes. Moderate cardiomegaly, minimal increase in lung density at the bases of the right upper lobe, no evidence of pleural effusions. Brief Hospital Course: 76 yo female with history of HTN and COPD who initially presented from her senior living center with left mastitis, but developed SOB and hypoxia on arrival to the medicine floor felt to be from CHF exacerbation. Hospitalization complicated by pneumonia, Afib with RVR, Clostridium difficile colitis, low urine output, severe anasarca, low nutrition status, delirium, and risk of aspiration. #. Mastitis: Patient initially presented with swelling of left breast. Mammogram showed left breast edema c/w CHF vs. mastitis vs. inflammatory breast cancers or lymphoma. Rash and edema resolved with bactrim and cefazolin. No pathologically enlarged left axillary nodes were seen on mammogram. Patient asked to continue to discuss further outpatient repeat imaging and screening schedule with primary care #. Hypoxia/Aspiration/Hospital Aquired Pneumonia: The patient had marked clinical concern upon arrival to the medical floor because she had hypoxia to 80% on 2L nasal cannula. This desaturation and shortness of breath was felt to be due to aspiration event. Patient was transferred to the MICU for several days of close monitoring. CXR showed LLL opacity. Bronchoscopy was performed and significant for mucus plugging, plugging was relieved with improvement of her hypoxia. She was also treated for hospital aquired pneumonia, and completed a 7 day course of IV vancomycin and a IV ceftazidime. Her respiratory status has improved to the point where she saturates in the mid to high 90's on room air, but is more stable in the mid-90s on 2L NC continuously. She may drop to high 80s without nasal cannula. Also, with any administration of aggressive IV fluids, she tends to third spaces/accumulate additional fluid into her lungs and can desaturate. #. Clostridium difficile colitis: Patient developed diarrhea soon after getting several antibiotics for her left mastitis/cellulitis. Stool studies were positive for Clostridium difficile. She was treated initially with PO vancomycin and IV metronidazole with improvement of her symptoms. Antibiotics were later narrowed to include just PO vancomycin liquid at 125mg q6hrs . She will need to complete another 3 days of PO vancomycin which is to be completed on [**2192-11-15**]. PLEASE reassess if still having diarrhea after completing antibiotics. #. Thrombocytopenia: During her hospital course the patient was also noted to be thrombocytopenic and she was evaluated by heme/oncology service. Several ongoing studies and clinical trend revealed that she was not thrombocytopenia due to DIC/TTP/HUS. PF4 antibodies were negative for HIT. Thrombocytopenia was ultimately attributed to Bactrim. Platelet count recovered following discontinuation of Bactrim and has remained within normal limits. #. Atrial fibrillation: Inpatient team spoke with PCP who reports that the patient is in chronic A fib, although she has never required rate control in the past and had not been on anticoagulation. HR prior to hospitalization had been in the 70-80s. On this admission, patient was very difficult to diurese, each time an attempt was made at diursing her, she would have A fib with RVR, likely a reflection of being so intravascularly depleted despite looking grossly anasarcic. Patient was started on PO diltiazem with good control of her rate which remains in the 70-80s range predominantly. Patient had never been on warfarin anticoagulation for a history of falls. #. CHF/Anasarca: She has a history of CHF, although unclear what her EF was prior to this admission. TTE on this admission showed preserved EF of >55%. Patient was grossly anasarcic on this admission, likely due to both CHF as well as low albumin (near 2.0). Attempts were made to diurese her but it would trigger Afibrillation with RVR. In order to help mobilize her third spaced fluids, PO nutrition was encouraged, and ACE wraps were utilized to help in encouraging fluids to return to intravascular space. On discharge, the edema in her arms and legs are much improved, but she would likely benefit from further use of ACE wraps to provide compression to her arms and legs. She was also started on additional triamcinlone cream to try to help with some stasis skin changes/pain associated with severe anasarca and poor circulation issues. #. Pain: Unclear what the exact etiology of her pain is, but she describes a vague pain in both her legs as well as her arms at times. Likely due to the edematous state that they are in given her very extreme anasarca. She was initially given morphine for the pain but transitioned to low dose oxycodone by discharge. As above, she was also started on triamcinalone cream to help with stasis skin changes/severe anasarca discomfort. She has done very well and requires only minimal amounts of oxycodone for pain control. #. COPD: Longstanding history of COPD on admission. She was put on ipratropium and albuterol nebs. Her desaturations (see above) were attributed more to her pulmonary edema/pneumonia rather than to her COPD history. On discharge her respiratory status is stable, doing well on 2L nasal cannula with saturations above >95% range. She will plan to continue albuterol nebs PRN at rehab, daily Advair and will also continue her daily nicotine patch as well. Please continue to wean oxygen further if she tolerates. #. Nutritional status: Patient with low albumin of 2.0, which likely exacerbated her edema/anasarca. Per family, patient does not eat much at baseline. Speech and swallow evaluated the patient and found her to aspirate on thin liquids. During this hospitalization she was maintained on a ground solid and nectar thickened diet, but took very limited amounts of food PO. She needs someone to actively encourage her to eat. Two attempts were made in the ICU to place a dobhoff but patient was unable to tolerate placement of a feeding tube. Given her anasarca, our hope was to give her more nutrition to increase her albumin to help in mobilizing third spaced fluids, however both patient and family did not want a feeding tube or PEG tube to be placed. Nutrition being supplemented with thiamine, MVI, and Vitamin B12. #. Goals of care: In the week prior to her discharge, a family meeting was called. With the help of social worker, patient named her sons as her HCPs. She was made DNR/DNI. It was established by the patient and family that they did not want to have any escalation of care. The decision was also made that they would not pursue a feeding tube for nutrition should her nutritional status deteriorate further. #. Delirium/Bipolar Disorder: Intermittently delirious on this admission likely from pain vs. polypharmacy issues at times. Once pain was under control, patient was much more lucid and could hold short conversations. She also has a history of bipolar disorder for which psychiatry was consulted. Since all her home meds had been held during her ICU stay, psychiatry thought it prudent to give her medications back slowly given her delirium. Divalproex was restarted (sprinkles form at 250mg at each meal for 750mg daily dose) and most recent level within normal limits. Risperdal was recommended to be used prn for agitation but she did not require any risperdal during her hospital course. Patient may need to be restarted on her usual pre-admission psychiatric medications that include 15mg mirtazapine qhs and 50mg trazodone qhs. If possible, please discuss with psychiatrist while at rehabilitation. #. Acute renal failure/Oliguria: Despite being anasarcic, patient was overwhelmingly intravascularly dry. JVP is flat. She had very poor urine output while in the ICU. Renal labs showed that she was incredibly prerenal. Her BUN and creatinine would improve with administration of IVF, however given her poor nutritional status, it would also cause for her to have more pulmonary edema and extremity edema. On call out to the floor, IVF's were very cautiously given during brief periods of hypernatremia (Na peaked at 148-->143 by discharge), but otherwise PO intake was encouraged. An albumin challenge was also tried, but with only marginal increase in her urinary output. Her urine output has gradually improved over the course of her stay on the medicine floors, averaging 300-500 cc/day. U/A consistently showed dirty urine with leuks, WBCs, and few bacteria. Urine culture at one point showed scant amount of yeast but otherwise showed no growth. Dirty UA was attributed to the fact that her urine was so concentrated and she was not treated for UTI given no new leukocytosis, fevers or other clinical complaints of suprapubic pain, dysuria or urgency. Medications on Admission: -atenolol 100mg daily -divalproex 750mg daily -doxazosin 2mg daily -lasix 20mg PO daily -lisinopril 30mg daily -mirtazapine 15mg QHS -nifedipine ER 90mg daily -ranitidine 150mg [**Hospital1 **] -detrol 4mg QHS -simvastatin 40mg daily -trazadone 50mg qhs -acetamenophen 500-1000mg Q6h prn Discharge Medications: 1. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for dermatitis changes/leg pains. 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal every twenty-four(24) hours as needed for request. 9. therapeutic multivitamin Liquid Sig: One (1) Tablet PO DAILY (Daily). 10. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule, Sprinkle PO TID (3 times a day). 12. vancomycin 125 mg Capsule Sig: One (1) LIQUID 125mg PO Q6H (every 6 hours) for 3 days: ORAL LIQUID FORM PLEASE . 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for sob, wheeze. 14. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 15. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 16. white petrolatum-mineral oil Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 17. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): aplly to sacral area . 18. oxycodone 5 mg Capsule Sig: 0.5 Capsule PO AS DIRECTED : give [**2-4**] tablet x 1 pre-transport or when moving patient . 19. Anasarca Ace Wraps -Daily ACE wraps over full length of both upper and lower extremities for severe anasarca Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary: Left breast mastitis Hospital acquired pneumonia C.diff colitis Acute renal failure Aspiration risk Secondary: Atrial fibrillation COPD Bipolar disease HTN Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taking care of you in the hospital. You were initially admitted with concern for a skin infection on the left breast called mastitis/cellulitis in addition to shortness of breath and a cough which was felt to be from a flare up of your known congestive heart failure. You were given medications called diuretics and your heart failure symptoms slowly resolved. You were also treated with antibiotics and your breast infection improved. However, in the setting of multiple antibiotics you developed a diarrhea infection called C.difficile colitis. You were put on antibiotics for this infection and will finish the course at the [**Hospital3 2558**]. You also developed pneumonia while you were with us and were treated with antibiotics for this as well. Also during your stay, you had difficulty swallowing and would aspirate. You were put on a pureed nectar-thickened diet for this. Your nutritional status remained poor because you ate very little during your hospital course. Your low level of proteins made the swelling in your arms and legs difficult to get rid of. The nutrition team saw you in the hospital and you have been placed on several vitamin supplements and nutritional shakes to enhance your caloric intake. You will be going to a rehab facility where doctors, nurses, and physical therapists will be able to help you with all these issues. Please see your complete medication list and instructions below. MEDICATION INSTRUCTIONS /CHANGES: The following medications that you were taking prior to admission have been DISCONTINUED: atenolol, doxazosin, lasix, lisinopril, nifedipine, detrol, mirtazapine and trazodone. Please CONTINUE taking the following medications you were taking prior to admission: -Depakote 750mg daily (now in sprinkle forms with meals*, 250mg per meal*) -Ranatidine 150mg tablet twice daily -Simvastatin 40mg tablet once daily -Tylenol 650mg tablet q6 hours as needed The following NEW MEDICATIONS have been started while you were in the hospital: -triamcinalone cream applied to extremities twice daily -Hydrocerin/mineral oil cream applied twice daily to extremities -fluticasone-salmeterol 250/50mcg inhaler twice daily -albuterol nebulizers q4 hours as needed -thiamine 100mg tablet daily -multivitamin tablet daily -oxycodone 5mg q6 hours as needed for pain (also: 2.5mg x 1 dose as needed when moving or transporting the patient) -heparin SC three times daily for DVT prevention -vitamin b12 50mcg daily ([**2-4**] 100mcg tablet) -Vancomycin 125mg liquid q6 hours for 3 more days (discontinue [**2192-11-15**]) -2% miconazole powder -apply twice daily to sacral area -Senna/Colace as needed for any constipation Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] after you are discharged from rehab, at the [**2192**] office. [**Telephone/Fax (1) 30837**]. *Please discuss the need for additional breast cancer screening (mammography) with your primary care physician as sometimes surface skin changes on the breast can be a warning sign for early breast cancers.

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Discharge summary

report

Admission Date: [**2108-6-25**] Discharge Date: [**2108-6-29**] Date of Birth: [**2036-12-14**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 613**] Chief Complaint: Melena Major Surgical or Invasive Procedure: Esophogastricduodenoscopy - [**2108-6-26**] Colonoscopy - [**2108-6-27**] History of Present Illness: Mr. [**Known lastname 54467**] is a 71yo M with history of CML on Gleevac, diverticulitis s/p partial colectomy and IBS who presents with melena. Patient saw his PCP where he was found to have systolics in the 90s with guaiac positive black stool. He has taken NSAIDs for chronic joint pain and felt weak for the past 1-2 weeks. Patient has been constipated for the past 5 days and took MOM yesterday. Today, he had a few episodes of melena. He denies N/V, heartburn, dysphagia, abdominal pain or bloating. He has had mild dizziness and lightheadedness with dyspnea on exertion the past few weeks as well. . In the ED, initial vs were: T 98.7 P 65 BP 115/47 R 18 O2 sat 100%. His hematocrit was 17, and he had guaiac positive black stool. NG lavage was negative and produced clear fluid. Patient was seen by GI with plan for transfusion and EGD in AM unless unstable. He was started on PPI drip and started receiving blood. . In the MICU, he reports feeling better than he did this morning. No current dizziness or lightheadedness. The NG tube is irritating him but otherwise he feels ok. Patient has had black stools in the past intermittently (on iron) but none that have looked like this. . Review of systems: (+) Per HPI (-) Denies fever, chills, headache. Denies cough, shortness of breath at rest, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - CML on Gleevac - Diverticulosis c/b perforated diverticulum, s/p partial colectomy with temporary colostomy and reversal - Colonic Polyps - Hearing Loss Sensorineural - Psoriasis - Anxiety - s/p Vasectomy - s/p Rotator Cuff Repair - s/p Appendectomy Social History: He is married and has two sons. - [**Name2 (NI) 1139**]: smoked 2 PPD for 20 years, quit [**2069**] - Alcohol: drinks a cocktail and beer daily - Illicits: none Family History: Father Deceased at 90 COPD Mother Deceased at 89 DEMENTIA and Hypertension Paternal Grandmother Diabetes Physical Exam: ADMISSION Vitals: T: 96.3 BP: 144/73 P: 71 R: 18 O2: 100% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE VS: 96.3 116/57 68 18 97%RA GEN: Comfortable, NAD HEENT: Sclera anicteric, MMM, OP clear Neck: Supple, no JVP, no LAD Lungs: CTA b/l, no wheezes, rales, rhonchi CV: RRR, no mrg, nlS1S2 ABD: soft, NT/ND, naBS, no rebound/guarding Ext: WWP, 2+DP/PT/radial, no clubbing, cyanosis or edema Pertinent Results: Blood Count [**2108-6-25**] 03:50PM BLOOD WBC-3.0* RBC-1.65*# Hgb-6.2*# Hct-17.7*# MCV-107*# MCH-37.7*# MCHC-35.2* RDW-14.9 Plt Ct-202 [**2108-6-26**] 04:22PM BLOOD WBC-3.6* RBC-2.65* Hgb-9.1* Hct-26.7* MCV-101* MCH-34.5* MCHC-34.3 RDW-19.2* Plt Ct-192 [**2108-6-27**] 10:40AM BLOOD WBC-2.6* RBC-3.08*# Hgb-10.4* Hct-30.3* MCV-98 MCH-33.9* MCHC-34.4 RDW-18.6* Plt Ct-189 [**2108-6-29**] 06:51AM BLOOD WBC-4.2 RBC-2.48* Hgb-8.7* Hct-24.6* MCV-99* MCH-35.1* MCHC-35.5* RDW-17.9* Plt Ct-225 [**2108-6-29**] 01:15PM BLOOD WBC-4.7 RBC-2.60* Hgb-9.2* Hct-26.1* MCV-100* MCH-35.5* MCHC-35.4* RDW-17.4* Plt Ct-254 . Chemistry [**2108-6-25**] 03:50PM BLOOD Glucose-92 UreaN-32* Creat-1.5* Na-140 K-4.3 Cl-106 HCO3-29 AnGap-9 [**2108-6-29**] 01:15PM BLOOD Glucose-116* UreaN-27* Creat-1.3* Na-138 K-4.1 Cl-106 HCO3-27 AnGap-9 . REPORTS Endoscopy [**2108-6-26**] Antral gastritis (biopsy), bulbar duodenitis, otherwise normal EGD to third part of the duodenum . Colonoscopy [**2108-6-27**] Diverticulosis of the whole colon. Grade 1 internal hemorrhoids. Old blood in the whole colon. Recently bleeding lesion could not be identified. The cecum was deformed, however, overlying mucosa was normal. Semi-solid and liquid stool was noted scattered in the whole colon. This was copiously irrigated and the patient was re-positioned to improve mucosal visualization. Despite these measures, small size pathology may have been missed. Otherwise normal colonoscopy to cecum and terminal ileum Brief Hospital Course: HOSPITAL COURSE This is a 71-year old M admitted to the MICU with melena and a Hct of 17, who received 4 units pRBCs w/o focal source of bleeding identified on EGD and [**Last Name (un) **], with Hct stabilizing at 25, undergoing capsule endoscopy, discharged with plan for outpatient follow-up for results. . ACTIVE #. GI Bleed, Uncertain Source: Patient was admitted with melena and Hct 17, requiring MICU stay and 4 units pRBCs. He underwent EGD and [**Last Name (un) **] w/o identification of a source of the bleeding. Capsule endoscopy was performed. Hct stabilized at 25 and, as patient's Hct was stable and he was tolerating a regular diet without further melena, the patient was discharged with plan for outpatient telephone follow-up for discussion of results of capsule endoscopy. Patient was discharged on protonix, with home propanolol and iron held. . INACTIVE # CML: Gleevac held in setting of acute illness. Outpatient thereapy deferred to outpatient oncologist. . # Anxiety/Insomnia: Continued on trazodone and mirtazapine . TRANSITIONAL 1. Code - Patient remained full code for the duration of this hospitalization 2. Pending - At discharge results of capsule endoscopy were pending. GI c/s service Dr [**Last Name (STitle) **] and Dr [**Last Name (STitle) 3708**] agreed to follow-up via telephone w patient to discuss results. 3. Transition of Care - Patient was scheduled for outpatient PCP and GI followup. Medications on Admission: FERROUS SULFATE ORAL 1 by mouth once daily Mirtazapine (REMERON) 15 mg Oral Tablet take 1 tablet AT BEDTIME Propranolol 40 mg Oral Tablet TAKE 1 TABLET FOUR TIMES A DAY Trazodone (DESYREL) 100 mg Oral Tablet 3 po qhs GLEEVEC TABLET 400MG PO (IMATINIB MESYLATE) 1 by mouth once daily MULTIVITAMIN CAPSULE PO (MULTIVITAMINS) 1 by mouth once daily VITAMIN B COMPLEX CAPSULE PO Discharge Medications: 1. ferrous sulfate Oral 2. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO once a day. 3. trazodone Oral 4. Gleevec 400 mg Tablet Sig: One (1) Tablet PO once a day. 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PRIMARY Gastrointestinal Bleed of Uncertain Origin acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with bloody stools and a fall in your hematocrit (a measurement of your red blood cell level). You received blood transfusions and underwent scoping via endoscopy and colonoscopy. Neither process was able to identify a clear origin of your bleeding. You underwent capsule endopscopy--a test where you swallow a small camera which takes pictures of your gastrointestinal tract looking for signs of bleeding. The results of this test are still pending. Your blood levels remained stable and you are ready for discharge. During your hospitalization the following changes were made to your medications: -STOPPED propranolol (please follow up with your primary care doctor to discuss restarting) -STOPPED iron (can interfere with testing of your stool for blood) -STARTED protonix (a medication to help prevent bleeding from your stomach) Please see below for your scheduled follow-up visit Followup Instructions: Name: [**Last Name (LF) 54468**],[**First Name3 (LF) 54469**] B. Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 3530**] Appointment: Friday [**2108-7-6**] 10:30am We are working on a follow up appointment in Gastroenterology at [**Location (un) 2274**]-[**Location (un) **] within 1 month. The office will contact you at home with an appointment. If you have not heard within 2 business days or have any questions please call [**Telephone/Fax (1) 2296**]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "45.16", "45.23", "45.19" ]

icd9pcs

[ [ [] ] ]

7079, 7085

4882, 6316

311, 386

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2419, 2526

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110,938

11210

Discharge summary

report

Admission Date:[**2162-10-29**] DISCHARGE DATE [**2162-11-16**] Date of Birth: [**2101-10-15**] Sex: F Service: MED ICU HISTORY: Ms. [**Known lastname **] is a 61-year-old woman with a past medical history significant for nonHodgkin lymphoma of the stomach diagnosed in [**2156**], status post resection chemotherapy and XRT. She initially presented to [**Hospital3 417**] Hospital on [**10-8**] of this year with the chief complaint of two to three weeks of cough with yellow-sputum production. She also complained of progressive dyspnea, sore throat, and headache. At the time of admission to [**Hospital3 417**] she was hypoxic and afebrile with a white cell count of 17,000 including 52% bands and extensive bilateral infiltrates on chest x-ray. She was admitted to the Intensive Care Unit at [**Hospital3 417**] Hospital and started on IV Levaquin and Ceftriaxone. She was intubated on [**10-10**]. Bronchoscopy was performed on [**10-11**] and [**10-15**]. She was begun on IV Solu-Medrol 25 mg q.6h. on [**10-16**] for presumptive BOOP (bronchiolitis obliterans-organizing pneumonia). She underwent wedge resection of the right lower lobe on [**10-18**]. Pathology confirmed by [**Hospital6 1129**] as "organizing fibrinous pneumonia, (question infectious). The patient had improvement in respiratory status, while at [**Hospital 36047**] Hospital with progressively decreasing FIO2 requirements. Hospital course at [**Hospital3 417**] was completed by infection with [**Female First Name (un) 564**] and Pseudomonas in the sputum and the development of a 6-cm area septation and cavitation in the left upper lobe. She was started on Ceftazidime, Amikacin, and Diflucan after receiving a 17-day course of Ceftriaxone and Levaquin. She also had a prolonged need for mechanical ventilation at [**Hospital3 417**] and arrived at [**Hospital3 **] status post tracheostomy and peg-tube placement on [**10-27**]. She also had some liver-function test abnormalities and some question of cardiac function. She reportedly ruled out for a MI at [**Hospital3 418**]. The Swan-Ganz catheterization during the hospital course at [**Hospital3 417**] revealed a pulmonary capillary wedge pressure of 12 and transthoracic echocardiogram showed normal biventricular function with 1 to 2+ tricuspid regurgitation. She was transferred to the [**Hospital1 188**] for further management. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. Pernicious anemia. 4. NonHodgkin gastric lymphoma (large and cleaved follicular-cell type). Status post trans-abdominal resection of stomach and distal esophagus in [**2136**], status post chemotherapy and radiation therapy. Bone marrow biopsy was negative for malignancy. 5. Status post left shoulder prosthesis placement. 6. Echocardiogram in [**2156**] reportedly showed left ventricular hypertrophy with right ventricular hypertrophy and mitral regurgitation. MEDICATIONS ON TRANSFER: 1. Univasc 7.5 mg q.d. 2. Prevacid 30 mg q.d. 3. Lopressor 25 mg b.i.d. 4. Reglan 10 mg t.i.d. 5. Potassium 40 mEq q.d. 6. Heparin 5000 units subcutaneously b.i.d. 7. Solu-Medrol 80 mg q.8h. 8. Tube feeds. 9. Ceftazidime 2 g IV q.8h. 10. Amikacin 750 mg IV q.24h. 11. Diflucan 400 mg IV q.24h. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient is married, born in [**Country 2784**]. She drinks alcohol socially. She has a 45-year-history of tobacco use. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 81 kg. Temperature 98.9 degrees Fahrenheit. Heart rate 59. Blood pressure 179/76. Respiratory rate 16. Oxygen saturation 95%. Arterial blood gas 7.56/41/68 on mechanical ventilation settings of SIMV at a rate of 6 with tidal volume of 800. Pressure support 10. PEEP of 5. FIO2 45%. GENERAL: She was an obese intubated woman on a ventilator in no apparent distress. She opened her mouth on command. HEENT: Normocephalic, atraumatic. There were several crusted erythematous lesions near the right angle of the mouth. The mucous membranes were moist. Neck was supple. There was a tracheostomy tube in placed. A right IJ triple-lumen catheter was also placed. HEART: The heart was regular without evidence of murmur. LUNGS: Auscultation of the lungs revealed rhonchorous transmitted upper airway sounds, anteriorly, with expiratory wheezes bilaterally. ABDOMEN: Abdomen was soft, nontender, and nondistended with normoactive bowel sounds and no palpable masses. A G-tube was in place. EXTREMITIES: Extremities showed no evidence of clubbing, cyanosis or edema. There was a right radial arterial line in place. SKIN: Examination of the skin was notable for the crusted-erythematous lesions at the angle of the right mouth. LABORATORY DATA: Data revealed the white cell count of 19.3; hematocrit 30.6; platelets 234,000; sodium 137; potassium 3.7; chloride 96; bicarbonate 35; BUN 22 and creatinine 0.2; glucose 164; ALT 70; AST 35; alkaline phosphatase 171; total bilirubin 0.4; albumin 1.8; calcium 7.5; magnesium 1.4; phosphate 3. Microbiology tests done at [**Hospital **] Hospital revealed the following: negative tests for hepatitic C antibody, hepatitis A, IgM hepatitis B surface antigen, and hepatitis B core IgM. There was a positive Legionella urinary antigen test. Bronchoscopy washing from [**10-11**], showed Aspergillus fumigatus. Fungal culture of the right lower lung tissue showed no growth to date at the time of admission to [**Hospital3 **]. Numerous sputum cultures from [**Hospital3 417**] Hospital were positive for [**Female First Name (un) 564**] albicans. Chest CT, without contrast, perform on [**10-28**], showed a 6-cm area of cavitation in the anterior left upper lung likely secondary to fungal infection with septations and air, but no fluid levels. There was also bilateral air-space disease with some sparing of the left lung base in the right upper and middle lobes. There was small-to-moderate effusion on the left side, without evidence of pneumothorax. There was some subcutaneous emphysema on the right chest wall. Lower extremity Dopplers were performed on [**10-9**] and showed no evidence of DVT. Right upper quadrant ultrasound performed on [**10-9**] showed no acute pathology. HOSPITAL COURSE: 1. Pulmonary: Ms. [**Known lastname **] remained on mechanical ventilation throughout the duration of her hospital course. The indication for mechanical ventilation was hypoxic respiratory failure. This was mainly due to thick, copious secretions from her left upper lobe cavitary lesion. At the time of admission to [**Hospital3 **], the question was raised of the diagnosis of BOOP, for which she had been started on high-dose intravenous corticosteroids at [**Hospital3 417**] Hospital. Review of the pathology slides from her wedge resection at [**Hospital3 417**] Hospital showed no evidence of BOOP. As a result, the intravenous corticosteroids were gradually tapered and she is now off steroids. She remained on Ceftazidime, Amikacin, and Diflucan for several days after admission cultures at that point ruled Klebsiella pneumonia and Pseudomonas aeruginosa. At that time, her antibiotic regimen was changed to Imipenem and Zosyn. After several days on the combination of Imipenem and Zosyn, the decision was made to change the antibiotic regimen to Zosyn and Bactrim. A day later the antibiotic regimen was changed to Trinamm and Bactrim because of a possible drug reaction to Zosyn. The patient became acutely tachycardiac and depressed with a drug-like rash on her torso. She was started on Bactrim on [**11-9**], and Triamm on [**11-10**]. Skin scrapings of the erythematous lesion around her mouth, sone at the time of admission were positive for HSV-1. She received a course of Acyclovir per the dermatology recommendations. She received treatment with appropriate antibiotics. She required less and less of a need for mechanical ventilation. She was gradually weaned to pressure-support ventilation, and on [**11-14**], she successfully tolerated a four-hour, tracheostomy-collar trial. At the same time she began tolerating trials with a Passy-Muir valve, which she now remains on for most of the day. In the last week, prior to discharge, the number of secretions gradually declined and her lung examination dramatically improved. Neuromuscular: The patient was profoundly weak at the time of admission and remains profoundly weak at the time of discharge, most likely due to critical-care myopathy with the possible contribution of steroid-induced myopathy. She began receiving physical therapy in the Intensive Care Unit and will need [**Hospital 4820**] rehabilitation to improve her muscle strength. Endocrine: The patient had some trouble with glycemic control at the time of admission, most likely secondary to supplemental corticosteroid doses. Steroids were tapered down. Her glycemic control improved. Sugars had been fine off supplemental corticosteroids. The corticosteroids were also thought to be the cause of her metabolic alkalosis at the time of admission. The metabolic alkalosis has gradually resolved as the corticosteroids had been tapered off. Hematology: The patient received several transfusions of red blood cells for dropping hematocrit. There was no evidence of active bleeding. She does have a history of pernicious anemia for which she received vitamin 12 shots (100 mcg every month). CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Ms. [**Known lastname **] will be discharged to a rehabilitation facility for [**Hospital 4820**] rehabilitation and long-term intravenous antibiotics. Per the recommendations of the Infectious Disease Consult Service, she should receive six-week course of Trinamm and IV Bactrim. She began receiving the Trinamm on [**11-10**] and began receiving Bactrim on [**11-9**]. Followup chest CT in two to three weeks will be worthwhile to check for improvement in the left upper lung cavitary lesion. If there is no improvement, a surgical opinion regarding hospital resection would be indicated. DISCHARGE DIAGNOSIS: 1. Left upper lobe pneumonia secondary to Klebsiella pneumonia and Pseudomonas aeruginosa. 2. Hypertension. 3. Hyperlipidemia. 4. Pernicious anemia. 5. Critical care myopathy + or - steroid-induced myopathy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7512**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2162-11-15**] 15:03 T: [**2162-11-15**] 15:09 JOB#: [**Job Number 36048**] cc:[**State 36049**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10125, 10622

6293, 9456

3497, 6276

2974, 3332

2437, 2949

3349, 3474

9481, 10104

67,323

108,836

20946

Discharge summary

report

Admission Date: [**2187-5-31**] Discharge Date: [**2187-6-4**] Date of Birth: [**2118-2-22**] Sex: F Service: MEDICINE Allergies: Aspirin / Motrin / Advil / Penicillins / Amoxicillin Attending:[**First Name3 (LF) 30**] Chief Complaint: Coffee ground emesis. Major Surgical or Invasive Procedure: [**2187-6-1**] Paracentesis [**2187-6-1**] EGD History of Present Illness: Ms. [**Known lastname **] is a pleasant 69 year old female with past medical history of cirrhosis and scleroderma who presents with coffee ground emesis. On 6/23PM, she vomited 500cc dark brown material with several clots on a car ride from [**Location (un) 86**]. She denies wrenching and bright red blood. . Prior to this event, she denies any recent history of nausea/vomiting, dysphagia or GERD. She denies NSAID use and other anticoagulation medications. She does report melanotic stools the past week and occasional BRBPR which she attributes to her external hemorrhoids. She denies any episodes of syncope or dizziness. She has felt weak the last few weeks, but attributed this to her worsening scleroderma and cirrhosis (unknown etiology). . Of note, her symptoms of ascites began in [**2187-2-5**]. Since [**2187-3-8**], she has had two paracentesis since for removal of fluid. Per her report, neither have demonstrated evidence of infection. Her most recent paracentesis was roughly two weeks ago, at which time her daughter reports 5 liters were removed. She reports worsening lower extremity edema. She was seen in liver clinic [**5-30**] by Dr. [**Last Name (STitle) **]. . She presented to [**Hospital3 **] Hospital, where she was initiated on octreotide and pantoprazole drips. During her time there, reported to be hypotensive (unknown how low BP was), for which she received 2 liters of IVF. She was then transferred to [**Hospital1 18**] for further management. . In the [**Hospital1 18**] ED, initial vtial signs were: temperature of 97.6, blood pressure 111/86, heart rate 10, respiratory rate of 16, and oxygen saturation of 100%. NG lavage was completed and notable for dark coffee ground material that did not clear; there was no bright red blood. Pantoprazole and octreotide drips were continued. . She was transfered to the MICU where she received 2U pRBC (Hct 22.9-currently stable at 35.1) and started on ciprofloxacin. She was evaluated for upper GI bleed via NGL and EGD. On EGD showed no signs of active bleeding, 2 cords of non-bleeding grade I varices, gastritis, and severe esophagitis. She was started on sucralafate. RUQ ultrasound showed evidence of cholelithiasis with no evidence of cholecystitis, but no portal vein thrombosis. She was note to have a leukocytosis to 23 which was attributed to steriods, stress response, and possible infection. CXR showed no consolidations and diagnostic paracentesis showed no signs of infection. . On the floor, she appears comfortable, although complains of sharp lower extremity and lower back pain. Of note, her bed sheets are soaked around her abdomen which could be due to recent paracentesis. She denies any recent episodes of vomiting, diarrhea, (has been NPO), dysuria. . Review of systems: (+) Per HPI. + Abdominal distension, + lower extremity and back pain (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies constipation, abdominal pain, dysphagia. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Scleroderma - Cirrhosis of unknown etiology: Status-post two paracentesis, last one several weeks ago, with 5L fluid withdrawal. No episodes of SBP, encephalopathy, or bleeding. She saw Dr. [**Last Name (STitle) **] [**5-30**] for the first time. Liver biopsy has not been completed. History of positive [**Doctor First Name **] 1:640 - Hypothyroidism - Anemia of chronic disease - Coagulopathy - Cellulitis (multiple infections in lower extremities) - Sinus tachycardia - Mitral regurgitation (patient unaware) - External hemorrhoids - 'Heart burn' but no diagnosis of GERD . Social History: Retired, lives with 84 yo husband in [**Name (NI) **] [**Hospital3 **]. Husband disabled with dementia. VNA and PT visits 1-2 times per week. Daughter and son provide additional care. Feels safe at home, but overwhelmed by husband's health and own health problems. - [**Name2 (NI) 1139**]: Never - Alcohol: Very rarely, none in the last few years. - Illicits: Denies Family History: No family history of liver disease, auto-immune disease. Lung cancer history related to smoking, grandmother with type two diabetes mellitus. Physical Exam: General: Alert, oriented, pleasant, no acute distress, cachectic. HEENT: Sclera anicteric, PERRL, EOMI. MMM and oropharnyx clear, Neck: Flat neck veins. No lymphadenopathy. Lungs: scant bibasilar inspiratory crackles, no wheeze. CV: Tachycardic. RR. Normal S1 + S2. No murmurs, rubs, or gallops, Abdomen: Soft, distended, no fluid wave. tympanic to percussion in LLQ, non-tender w/o rebound or guarding. Ext: Warm, well perfused, 2+ pulses. 2+ pitting edema to upper shin. NEURO: CN II-XII intact. Upper and lower extremity sensation intact bilaterally SKIN: Per nurses report, patient has two 1-2cm lesions on gluteus Pertinent Results: [**5-31**] Dupp Abd/Pelvis IMPRESSION: 1. Massive ascites, with the largest collection marked in the right lower quadrant. 2. Shrunken cirrhotic liver. 3. 4 mm hypoechoic hepatic lesion within segment VI. In the absence of any available comparison studies at [**Hospital1 18**], a three month followup is recommended. 4. Cholelithiasis with no evidence of cholecystitis. 5. Patent portal veins, hepatic veins, and hepatic arteries, with appropriate flow directions and waveforms. [**5-31**] US IMPRESSION: 1. Massive ascites, with the largest collection marked in the right lower quadrant. 2. Shrunken cirrhotic liver. 3. 4 mm hypoechoic hepatic lesion within segment VI. In the absence of any available comparison studies at [**Hospital1 18**], a three month followup is recommended. 4. Cholelithiasis with no evidence of cholecystitis. 5. Patent portal veins, hepatic veins, and hepatic arteries, with appropriate flow directions and waveforms. [**6-1**] Therapeutic/diagnostic paracentesis: GRAM STAIN (Final [**2187-6-1**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2187-6-4**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Micro: Blood cultures ([**5-31**]): pending [**2187-5-31**] 08:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG [**2187-5-31**] 10:15PM HCT-22.9*# [**2187-5-31**] 08:00AM HGB-10.0* calcHCT-30 [**2187-5-31**] 07:51AM WBC-23.3*# RBC-3.08* HGB-9.8* HCT-31.6* MCV-103* MCH-31.9 MCHC-31.1 RDW-17.4* [**2187-5-31**] 06:54AM ALT(SGPT)-31 AST(SGOT)-46* ALK PHOS-181* TOT BILI-0.5 [**2187-5-30**] 04:55PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE HAV Ab-NEGATIVE [**2187-5-30**] 04:55PM AMA-NEGATIVE [**2187-5-30**] 04:55PM IgG-1429 IgA-1180* IgM-258* [**2187-5-30**] 04:55PM HCV Ab-NEGATIVE At time of discharge HCT: 33.7 WBC13.8 Brief Hospital Course: MICU [**2102-5-31**]: Patient is a 69yo female with past medical history of cirrhosis and scleroderma who presents with coffee ground emesis -Hematemesis: Coffee ground emesis secondary to likely upper GI bleed. Upper endoscopy performed on day of admission notable for old blood in stomach/small intestine, but no active bleeding; non-bleeding grade I varices were seen. Severe esophagitis and gastritis were observed. Sucralafate and PPI were started. Pt had stable H/H. Liver team provided further recommendations, including investigating possible hepatic process, however, this was ruled out by abdominal US which demonstrated patent portal veins, hepatic veins, and hepatic arteries, with appropriate flow directions and waveforms. . -Cirrhosis: Per report, unknown etiology. Unlikely alcohol related given history. No clear offending medications on initial review of her home list, though per yesterday's liver note, prior use of minocycline (for scleroderma) is a consideration. Ciprofloxacin was started as prophylaxis in setting of acute ascites with plan for 5days of treatment. Diagnostic and therapeutic IR-guided paracentesis (3L) revealed no SBP, and patient was given 25g albumin. GRAM STAIN (Final [**2187-6-1**])NO POLYMORPHONUCLEAR LEUKOCYTES SEEN, NO MICROORGANISMS SEEN. Fluid culture with no growth. The paracentisis site continued to drain ascitic fluid. Ostomy care was provided. Liver Team saw patient prior to discharge and reported that bag could be left in place to drain ascitic fluid at time of discharge. Spironolactone was continued to aid in diuresis. Lasix was discontinued secondary to side effect of persistent diarrhea. . -Hypoechoic lesion in liver: Seen on [**5-31**] RUQ US, and may represent HCC vs other process. AFP was 3.0. Plan to follow-up lesion as out-patient. . -Leukocytosis: Marked increase at admission that was normalizing without intervention. Possible stress response secondary to bleed as no obvious source of infection. No localizing symptoms. No vital sign instability. However, blood and urine cx ordered with results pending; paracentesis did not reveal source of infection. . -Scleroderma: Followed by Dr. [**Last Name (STitle) 6426**] in rheumatology, but not currently on tx. Minocycline was discontinued while in house and at time of discharge due to concern that it may have contributed to cirrhosis. . -Hypothyroidism: Continued home dose of levothyroxine Medications on Admission: - Calcium with vitamin D - Nyastatin swish and swallow [**Hospital1 **] (currently not taking) - Acetaminophen 500 mg [**Hospital1 **] - Calan SR 60 mg daily (Verapamil) - Levothyroxine 50 mcg daily - Fluconazole 200 mg Q72 hr (currently not taking) - Acidophilus 500 million cell [**Hospital1 **] - Millipred 10 mg daily (prednisolone)- Stopped [**5-30**] - Hydrocodone 1 tab q6-8 hours - Lactulose -- prescribed [**5-30**] - Spironolactone 50 mg -- prescribed [**5-30**] - Furosemide -- prescribed [**5-30**] Discharge Medications: 1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. Verapamil 40 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours). 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: Hold for sedation, RR<12, SBP<95. Do not take when driving or when operating heavy machinery. 11. Lactulose 10 gram/15 mL Solution Sig: Three (3) ML PO TID (3 times a day) as needed for prn for confusion: Take if patient becomes confused, unsteady. Discharge Disposition: Extended Care Facility: Eagle [**Hospital **] Rehabilitation Center - [**Location 23723**] Discharge Diagnosis: Primary diagnosis: Gastritis Esophagitis Blood loss anemia secondary to upper GI bleed Malnutrition Cryptogenic cirrhosis . Secondary diagnosis: Scleroderma Tachycardia 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 presented to the hospital after vomiting blood. You were admitted to the intensive care unit (ICU) and monitored overnight and received two units of blood. You underwent endoscopy which revealed inflammation of your esophagus and stomach. This inflammation was likely due to your underlying scleroderma and your recent use of steroids. Your steroids were discontinued and you were started on medications to help protect your stomach. You had been collected fluid in your belly and a procedure was performed to both help your symptoms as well as test the fluid for any sign of infection. You were started on antibiotics to cover for any intra-abdominal infections. Your bleeding resolved and were transferred to the medicine floor. On the medicine floor your blood counts remained stable. Physical Therapy saw you and thought it would be beneficial to discharge to a rehabiliation facility prior to returning home. . The following changes were made to your home medications: STOP minocycline STOP prednisone START Ciprofloxicin 500mg taken by mouth once in the morning, once at night - to be taken through [**6-6**]. START Pantoprazole 40mg taken by mouth once in the morning, once at night START Sucralfate 1gm taken by mouth four times a day. START Oxycodone 2.5mg every four hours as needed for pain management. Do not take this medication if driving or operating heavy machinery as it has the potential for sedation. START Lactulose 30ml as needed three times a day for increasing confusion, unsteadiness. Followup Instructions: Department: LIVER CENTER When: WEDNESDAY [**2187-6-27**] at 3:30 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2187-6-6**]

[ "261", "456.21", "244.9", "288.60", "571.5", "710.1", "535.51", "789.59", "285.1", "530.19", "530.82" ]

icd9cm

[ [ [] ] ]

[ "54.91", "45.13" ]

icd9pcs

[ [ [] ] ]

11630, 11723

7527, 9960

332, 381

11936, 11936

5445, 6747

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409, 3165

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11951, 12095

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29,502

170,034

44787

Discharge summary

report

Admission Date: [**2175-7-2**] Discharge Date: [**2175-7-8**] Date of Birth: [**2119-1-1**] Sex: M Service: MEDICINE Allergies: Penicillins / Lithium Attending:[**First Name3 (LF) 613**] Chief Complaint: suicide attempt Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a 56-yo man w/ Bipolar disorder and h/o EtOH abuse who was picked up from a park bench tonight with an empty bottle of Listerine nearby. The pt has been wanting to die for the last couple weeks, and has been drinking "a quart to half-gallon" of whiskey daily. Last drink 3 days ago, after which he started drinking Listerine, which he "did not know had alcohol in it". He continues to say that he would rather die now. On arrival to the ED, VS - Temp 98.6F, HR 136, BP 150/104, R 30, O2-sat 95% RA. EtOH level on arrival was 290. ECG showed sinus tachycardia. He received a banana bag and a total of Valium 25mg PO and Ativan 1mg IV, and was admitted to the MICU for further management of EtOH withdrawal and suicidal ideation. VS prior to transfer - BP 138/35, HR 118, R 16, O2-sat 95% 2L. On arrival to the ICU, the pt was visibly very tremulous and anxious. He received an additional 10mg IV Valium. Review of Systems at the time revealed that the pt had chest pain earlier in the day, in the setting of palpitations, as well as diarrhea for the last week, increased from baseline. Past Medical History: - Bipolar disorder, h/o SI, treated at [**Hospital3 **] in [**Location (un) 5583**], s/p multiple ECT treatments - EtOH abuse, h/o EtOH withdrawals / DTs / Social History: Homeless from [**Location (un) 260**] MA, formerly employed by [**Company 25186**] / [**Company 25187**] until 2 years ago when the Bipolar disorder worsened. +EtOH, denies smoking or other drug use incl IVDU Family History: Non-contributory / unknown Physical Exam: VS - Temp 96.4F, BP 125/85, HR 115, R 20, O2-sat 100% 2L NC GENERAL - ill-appearing man smelling of Listerine, tremulous, flushed, diaphoretic, anxious, with eyes closed HEENT - PERRL, EOMI, sclerae anicteric, very dry MM NECK - supple, no JVD LUNGS - CTA bilat, no r/rh/wh HEART - RRR, nl S1-S2, no MRG ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs); +left arm w/ cutting marks NEURO - awake, A&Ox1, CNs II-XII grossly intact, muscle strength [**3-20**] throughout, sensation grossly intact throughout Brief Hospital Course: 56-M w/ bipolar disorder and EtOH abuse, admitted with EtOH withdrawal and SI. EtOH level 290 on arrival. On admission Pt reported vivid halucinations of seeing frightening faces. Also reported hearing voices. Unclear what portion of this is part of his baseline mental status. Was maintained on a CIWA scale with diazepam. . #. EtOH withdrawal - Pt a/w EtOH intoxication (level 290 on admit) and withdrawal w/ HR elevated to 130s on admit. It was initially difficult to adequately treat withdrawal symptoms. Increased to 20 mg of Valium q 1hr prn CIWA. Total requirement 100 mg in the first 36 hours. Has not required diazepam more than 12 hours at time of transfer out of the MICU. Pt also received a "banana bag" and electrolyte repletion. He is now taking PO MVI / thiamine / folate. . #. Bipolar disorder - Pt treated at [**Hospital3 **] for Bipolar disorder, recently on Celexa, Trileptal, and Seroquel. Psych meds have been per orders from psych consult. Pt requires 1:1 sitter given SI. Antidepressants and neuroleptics were held in the setting of acute withdrawal and will be reinitiated at inpatient pschyiatric facility . #Cellulitis - patient noted to have erythema, edema and pain of left anterior forearm with associated central fluctuant pustule and satellite pustules concerning for community acquired MRSA. Started on vancomycin with rapid clinical improvement in 24 hours and changed to oral antibiotic regimen with Bactrim DS [**Hospital1 **] for 5 more days after discharge. . #. Chest pain- resolved - Pt c/o chest pain on the day of admission, in the setting of palpitations. Likely related to tachycardia. No bump in troponins. . #. Diarrhea ?????? resolved- Pt c/o diarrhea over last week, increased from baseline of loose stools. Likely related to EtOH and poor nutritional status. . #. FEN ?????? Regular diet, needs a safety tray. Can consider maintanence fluids, but pt is taking po. Continue PO MVI/Thiamine/Folate. Medications on Admission: - Celexa 40 daily - Trileptal 300 [**Hospital1 **] - Seroquel 100 daily Discharge Medications: 1. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Bactrim DS 160-800 mg Tablet Sig: Two (2) Tablet PO twice a day for 6 days. Discharge Disposition: Extended Care Discharge Diagnosis: Alcohol withdrawal Alcohol intoxication Alcohol abuse Cellulitis Suicidal ideation Bipolar disorder Alcoholic hepatitis Discharge Condition: Good. Hemodynamically stable and afebrile. Discharge Instructions: You were admitted to the ICU for suicidal thoughts and alcohol withdrawal. You completed a detoxification program for alcohol withdrawal. You will be admitted to a pscyhiatric unit for further treatment of suicidal ideation and bipolar disorder. You were also noted to have fevers and a skin infection. An antibiotic was started and should be continued. The following changes were made to your medications: 1) Added thiamine 100mg daily 2) Added folate 1mg daily 3) Added multivitamin 1 tablet daily 4) Added bactrim DS 2 tablets twice daily for 7 days Followup Instructions: Please follow up with outpatient appointments as directed when discharged from inpatient psychiatric facility. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "786.59", "571.1", "303.01", "V60.0", "291.0", "296.80", "787.91", "682.3", "V62.84" ]

icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

4887, 4902

2502, 4450

294, 301

5066, 5111

5714, 5949

1847, 1875

4573, 4864

4923, 5045

4476, 4550

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239, 256

329, 1425

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1621, 1831

16,504

163,895

19579

Discharge summary

report

Admission Date: [**2191-10-23**] Discharge Date: [**2191-11-11**] Date of Birth: [**2117-12-9**] Sex: F Service: CARDIOTHORACIC Allergies: Vancomycin / Penicillins / Gentamicin / Clindamycin / Cefotaxime Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2191-11-2**] Redo Sternotomy. Single Vessel Coronary Artery Bypass Grafting utilizing free left internal mammary artery to left anterior descending artery. Aortic Valve Replacement utilizing a 19mm St. [**Male First Name (un) 923**] Mechanical Valve. [**2191-10-26**] EGD and Colonoscopy [**2191-10-28**] Capsule study History of Present Illness: This is a 73 year old female with rheumatic heart disease and history of coronary artery disease. She underwent closed mitral commisurotomy in [**2149**]. She subsequently underwent single vessel coronary artery bypass grafting and mechanical mitral valve replacement in [**2158**]. Since that time, she has undergone PCI of the right coronary artery with placement of DES in [**2188**] for recurrent angina. Recently in [**2191-9-11**], she presented to outside hospital with chest pain and ruled in for a small NSTEMI. Echocardiogram at that time was notable for aortic stenosis. While on Integrillin and Heparin, she developed melena followed by a 17 unit GI bleed. Once her bleeding issues resolved, she underwent cardiac catheterization. Left Ventriculograhpy showed an LVEF of 50% without mitral regurgitation through the mechanical MVR. Coronary angiography showed total occlusion of LAD, 60% lesion in the distal circumflex and patent stents in the RCA. The vein graft to the LAD was known to be occluded. Right and left heart catheterization demonstrated critical aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.5cm2 and mean gradient of 37mmHg. The mean PA pressure was 30mmHg and cardiac output was 3.2l/min very consistent with congestive heart failure. Based on the above results, she was transferred to the [**Hospital1 18**] for cardiac surgical intervention. Past Medical History: Congestive Heart Failure, Aortic Stenosis, Atrial Fibrillation, Coronary Artery Disease with recent history of myocardial infarction - s/p PCI/stenting to RCA in [**2188**], Hypertension, Hypercholesterolemia, Chronic Obstructive Lung Disease, Interstitial Lung Disease, Obesity, History of Rheumatic Heart Disease - s/p mitral valve commisurotomy in [**2149**], s/p Mitral Valve Replacement(Bjork Shiley) and Single Vessel Coronary Artery Bypass Grafting(vein graft to left anterior descending) in [**2158**], History of GI Bleed(secondary to AV Malformations) - s/p Cautery, Cerebrovascular Disease - history of CVA in [**2178**], Chronic Renal Insufficiency, Type II Diabetes Mellitus, History of Gout, History of Gastritis/GERD, History of Pulmonary Embolus, Recent Deep Vein Thrombosis - s/p IVC Filter in [**2191-10-12**], Anemia Social History: Lives with husband. Denies use of tobacco, ETOH, or illicit drugs. Family History: Non-contributory. Physical Exam: Admission Vitals: T 98.1, BP 118/80, HR 66 AF, RR , SAT 98% on 2L NC General: obese female in no acute distress HEENT: oropharynx benign, PERRL, sclera anicteric Neck: supple, no JVD, bilateral carotid bruits(versus transmitted murmur) Heart: irregular rate, normal s1s2, 3/6 systolic murmur Lungs: clear bilaterally Abdomen: obese, soft, nontender, normoactive bowel sounds Ext: warm, no edema, bilateral varicosities Pulses: 1+ distally Neuro: alert and oriented, nonfocal Discharge Vitals 98.7, 86 AF 88/50, 18 2L NC Neuro alert and oriented nonfocal pulmonary lungs clear bilaterally Cardiac Irregular Sternal incision: healing no drainage no erythema, sternum stable Abdomen soft nontender, nondistended, + bowel sounds Ext warm, no edema Pertinent Results: [**2191-11-11**] 05:28AM BLOOD WBC-15.6* RBC-2.88* Hgb-8.8* Hct-25.1* MCV-87 MCH-30.4 MCHC-34.9 RDW-17.2* Plt Ct-246 [**2191-11-4**] 01:12AM BLOOD WBC-21.9* RBC-3.26* Hgb-10.0* Hct-28.4* MCV-87 MCH-30.6 MCHC-35.2* RDW-16.2* Plt Ct-155 [**2191-10-23**] 10:40PM BLOOD WBC-10.2 RBC-3.77* Hgb-11.6* Hct-33.0* MCV-88 MCH-30.8 MCHC-35.2* RDW-17.6* Plt Ct-150 [**2191-11-11**] 05:28AM BLOOD Plt Ct-246 [**2191-11-11**] 05:28AM BLOOD PT-25.0* PTT-80.6* INR(PT)-2.5* [**2191-11-10**] 08:17PM BLOOD PT-22.4* PTT-72.5* INR(PT)-2.2* [**2191-11-9**] 06:29AM BLOOD PT-17.6* PTT-60.2* INR(PT)-1.6* [**2191-10-23**] 10:40PM BLOOD PT-13.3* PTT-47.9* INR(PT)-1.2* [**2191-10-23**] 10:40PM BLOOD Plt Ct-150 [**2191-11-11**] 05:28AM BLOOD Glucose-107* UreaN-30* Creat-0.8 Na-135 K-3.9 Cl-97 HCO3-31 AnGap-11 [**2191-10-23**] 10:40PM BLOOD Glucose-92 UreaN-10 Creat-0.9 Na-135 K-4.7 Cl-101 HCO3-26 AnGap-13 [**2191-10-23**] 10:40PM BLOOD ALT-22 AST-23 LD(LDH)-244 AlkPhos-102 TotBili-0.6 [**2191-11-9**] 09:22PM BLOOD Calcium-8.5 Phos-4.4 Mg-1.9 [**2191-10-23**] 10:40PM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0 CHEST (PA & LAT) [**2191-11-10**] 11:02 AM CHEST (PA & LAT) Reason: evaluate left lower lobe opacity [**Hospital 93**] MEDICAL CONDITION: 73 year old woman s/p redo sternotomy/AVR/Cabgx1 REASON FOR THIS EXAMINATION: evaluate left lower lobe opacity REASON FOR EXAMINATION: Followup of a patient after sternotomy, aortic valve replacement and CABG. Portable AP chest radiograph compared to [**2191-11-9**]. The pulmonary edema has been improved being now mild. The bilateral pleural effusions and left lower lobe retrocardiac atelectasis are unchanged. The replaced aortic valve is in unchanged position. IMPRESSION: Improvement in pulmonary edema, now being of mild degree. Otherwise unchanged. Atrial fibrillation with a controlled ventricular response. Slight T wave inversions in leads I, aVL and V4-V6 suggest possible anterolateral ischemia. Compared to the previous tracing of [**2191-11-6**] the anterolateral T wave inversions are new. Clinical correlation is suggested. Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **] Intervals Axes Rate PR QRS QT/QTc P QRS T 80 0 98 390/425.71 0 85 128 Conclusions: PRE-BYPASS: The left atrium is dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No mass/thrombus is seen in the left atrium or left atrial appendage. Mild spontaneous echo contrast is present in the left atrial appendage. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. No left ventricular aneurysm is seen. Overall left ventricular systolic function is moderately depressed. There is mild global right ventricular free wall hypokinesis. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (area 0.8-1.19cm2) Mild to moderate ([**12-13**]+) aortic regurgitation is seen. [Due to acoustic shadowing, the severity of aortic regurgitation may be significantly UNDERestimated.] Asingle tilting disk mitral valve prosthesis is present. The motion of the mitral valve prosthetic leaflets appears normal. The transmitral gradient is normal for this prosthesis. There is no pericardial effusion. POST-BYPASS (on milrinone): Mild LV global dysfunction. Overall LVEF 45%. Aortic contour is maintained. Mitral valve prosthesis appears similar to prebypass. A bileaflet aortic prosthesis visualized,well seated and no periprosthetic leaks seen. The images are poor due to acoustic shadowing . Normal RV systolic function. Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD on [**2191-11-2**] 15:46. [**Location (un) **] PHYSICIAN: Brief Hospital Course: Ms. [**Known lastname **] was admitted to the cardiac surgical service. She remained on Heparin with no clinical signs of active GI bleed. She was started on Ciprofloxacin for a urinary tract infection. Given her recent history of massive GI bleed and known AV malformations, the GI service was consulted to evaluate for any potential sources of bleeding prior to heparinization with cardiopulmonary bypass. Capsule study was performed along with EUS, EGD and colonoscopy. EGD found two polypoid lesions in the stomach adjacent to the GE junction. Colonoscopy revealed a few non-bleeding diverticula. The diverticulosis appeared mild in severity. She was eventually cleared by the GI service to proceed with cardiac surgical intervention. (There are no official results of the EUS and capsule study at the time of this dictation.) The rest of her hospital course was unremarkable. On [**11-2**], Dr. [**Last Name (STitle) 1290**] performed redo sternotomy with single vessel CABG and aortic valve replacement. For further surgical details, please see seperate dictated operative note. Following the operation, she was brought to the CSRU for invasive monitoring. She was slow to wake but eventually extubated on postoperative day three. She gradually weaned from Neosynephrine and Milrinone. She maintained stable hemodynamics and remained in a rate controlled atrial fibrillation. Heparin was resumed for a subtherapeutic prothrombin time while Warfarin anticoagulation was restarted. She was pan-cultured for a leukocytosis, white count peaked to 25K on postoperative day three. She did not experience fevers. Sputum and blood cultures were negative while urine culture grew out yeast. White count gradually improved and no additional antibiotics were given. A bedside swallow examination was performed on postoperative five for a coughing episode following thin liquids. Evaluation showed no overt signs of aspiration but silent aspiration could not be ruled out. A thin liquid/soft solid diet was recommended along with close supervision. Her CSRU course was otherwise uneventful and she transferred to the SDU on postoperative day six. She continued to progress and was ready for discharge to rehab on POD 9 with plan for INR to be checked [**11-13**] goal INR 3-3.5 Medications on Admission: Aspirin 81 qd, Lipitor 80 qd, Aldactone 25 qd, Lasix 80 [**Hospital1 **], Toprol XL 50 qd, Allopurinol 300 qd, Digoxin 0.125 qd, Kdur, IV Heparin/Warfarin Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Lasix 40 mg Tablet Sig: Two (2) Tablet PO twice a day. 7. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 8. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). 11. Coumadin 3 mg Tablet Sig: Three (3) Tablet PO once a day for 2 days: please take 3mg on [**11-11**] and [**11-12**] - have INR checked [**11-13**] for further dosing. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Congestive Heart Failure, Aortic Stenosis, Atrial Fibrillation, Coronary Artery Disease with recent history of myocardial infarction, Hypertension, Hypercholesterolemia, Chronic Obstructive Lung Disease, Interstitial Lung Disease, Obesity, History of Rheumatic Heart Disease - s/p mitral valve commisurotomy in [**2149**], s/p Mitral Valve Replacement(Bjork Shiley) and Single Vessel Coronary Artery Bypass Grafting(vein graft to left anterior descending) in [**2158**], History of GI Bleed(secondary to AV Malformations), Cerebrovascular Disease - history of CVA in [**2178**], Chronic Renal Insufficiency, History of Gout, History of Gastritis/GERD, History of Pulmonary Embolus, Recent Deep Vein Thrombosis - s/p IVC Filter in [**2191-10-12**], Anemia Discharge Condition: Good Discharge Instructions: [**Month (only) 116**] shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Monitor prothrombin time as directed. Warfarin should be adjusted for goal INR between 3-3.5. Followup Instructions: Dr. [**Last Name (STitle) 1290**] in [**3-16**] weeks, please call for appt Dr. [**Last Name (STitle) 1295**] in [**1-14**] weeks, please call for appt Dr. [**Last Name (STitle) 17234**] in [**1-14**] weeks, please call for appt Completed by:[**2191-11-11**]

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icd9cm

[ [ [] ] ]

[ "44.19", "99.04", "88.72", "36.15", "43.41", "39.61", "45.23", "35.22", "00.14" ]

icd9pcs

[ [ [] ] ]

11262, 11336

7692, 9968

344, 668

12135, 12142

3869, 5059

12565, 12826

3069, 3088

10173, 11239

5096, 5145

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3103, 3850

294, 306

5174, 7635

696, 2108

7669, 7669

2130, 2967

2983, 3053

14,245

194,936

8025

Discharge summary

report

Admission Date: [**2147-8-15**] Discharge Date: [**2147-8-17**] Date of Birth: [**2068-2-6**] Sex: M Service: MEDICINE Allergies: Ambien Attending:[**First Name3 (LF) 2901**] Chief Complaint: hypotension, low urine output Major Surgical or Invasive Procedure: none History of Present Illness: 79 yo male with history of CAD status-post CABG in [**2139**] (LIMA->Diag, SVG->OM1, SVG->LAD) and stent to LAD, RCA (DES) in [**2146**], ischemic cardiomyopathy with CHF and EF 20%, and AICD placement in [**2141**], as well as DM2, peripheral vascular disease, CKD, and COPD on home O2 3L who is transferred from OSH for hypotension and low urinary output. . Patient was admitted to OSH on [**8-11**] with chest pressure and respiratory difficulty. Troponins negative x 3 and chest pain resolved. He was found to have BNP 4000 and was treated with lasix po, IV bolus, and drip which caused hypotension. . He also has severe peripheral vascular disease with wet necrosis of toes bilaterally. At OSH, cultured Staph aureus and corynebacterium. He was started on vancomycin 1 g q18 hr, levaquin 750 mg q 48 hrs, and flagyl 500 mg po tid on [**2147-8-14**]. He underwent diagnostic angio on [**2147-7-13**] demonstrating tibioperoneal trunk occlusion; he was seen by vascular surgery on admission [**2147-8-15**] and declined amputation. . Patient was given Ativan during transport and is somnolent on admission. Denies pain. Denies chest pain. Past Medical History: 1. CARDIAC RISK FACTORS: -Coronary Artery Disease (s/p MI x2) -Diabetes (Type 2 insulin-dependant) -Dyslipidemia -Hypertension 2. CARDIAC HISTORY: -CABG: -s/p CABG in [**2139**] (LIMA->diag, SVG->OM1, SVG->LAD) -PERCUTANEOUS CORONARY INTERVENTIONS: -s/p prior LAD stent and PTCA of diag -s/p DES to RCA in [**2146**] -PPM/ICD: - Ischemic cardiomyopathy, s/p ICD implantation [**2141-7-14**] - PPM (unclear when placed) -OTHER CARDIAC HISTORY: - Paroxysmal atrial fibrillation - Nonsustained ventricular tachycardia - Chronic systolic CHF [**2-14**] ischemic cardiomyopathy(last EF 20%) - Mitral regurgitation - Pulmonary Hypertension 3. OTHER PAST MEDICAL HISTORY: -Chronic Obstructive Pulmonary Disease on 3L home O2 since [**2146**] -Chronic Renal Insufficiency (baseline creatinine 1.5-1.8) -s/p right renal artery stent -Severe Peripheral Vascular Disease, s/p left fem-[**Doctor Last Name **] bypass [**2137**] -Obstructive sleep apnea intolerant to CPAP -GERD -Anxiety -Depression -Post Traumatic Stress Disorder Social History: Married and lives with his wife. Retired from Army. Most recently worked as a cook at the [**Hospital **] [**Hospital6 28623**]. He used to drink alcohol heavily, but has had none in 40 years. 40+ pack year h/o smoking, quit 40 years ago. Family History: Father died of an MI at age 48. Brother died of an MI at age 64. Physical Exam: GENERAL: alert, NAD, sitting comfortably HEENT: Sclera anicteric. EOMI. NECK: Supple CARDIAC: RR, normal S1, S2. LUNGS: tachypnic, mild crackles at bases bilaterally ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 1+ pitting edema bilaterally SKIN: cold, ulceration draining pus on right foot with chronic skin changes bilaterally, erythema with small sore on buttock PULSES: lower extremity pulses present on doppler, + femoral pulses Pertinent Results: [**2147-8-15**] 01:20AM BLOOD WBC-11.1* RBC-4.54* Hgb-13.0* Hct-40.0 MCV-88 MCH-28.7 MCHC-32.6 RDW-17.9* Plt Ct-257 [**2147-8-15**] 09:00AM BLOOD WBC-10.6 RBC-4.61 Hgb-13.2* Hct-40.5 MCV-88 MCH-28.5 MCHC-32.5 RDW-18.2* Plt Ct-262 [**2147-8-16**] 04:04AM BLOOD WBC-10.3 RBC-4.29* Hgb-12.5* Hct-38.1* MCV-89 MCH-29.1 MCHC-32.8 RDW-18.5* Plt Ct-246 . [**2147-8-15**] 09:00AM BLOOD Neuts-83.8* Lymphs-9.5* Monos-6.4 Eos-0.1 Baso-0.3 . [**2147-8-15**] 01:20AM BLOOD PT-17.8* PTT-35.1* INR(PT)-1.6* [**2147-8-15**] 09:00AM BLOOD PT-16.7* PTT-32.7 INR(PT)-1.5* [**2147-8-16**] 04:04AM BLOOD PT-18.5* PTT-33.7 INR(PT)-1.7* . [**2147-8-15**] 01:20AM BLOOD Glucose-132* UreaN-52* Creat-1.9* Na-136 K-4.6 Cl-100 HCO3-22 AnGap-19 [**2147-8-15**] 09:00AM BLOOD Glucose-115* UreaN-55* Creat-2.0* Na-138 K-5.3* Cl-98 HCO3-28 AnGap-17 [**2147-8-15**] 08:40PM BLOOD Glucose-150* UreaN-57* Creat-1.9* Na-138 K-4.6 Cl-99 HCO3-25 AnGap-19 [**2147-8-16**] 04:04AM BLOOD Glucose-248* UreaN-59* Creat-1.9* Na-135 K-4.2 Cl-98 HCO3-24 AnGap-17 . [**2147-8-15**] 01:20AM BLOOD ALT-137* AST-191* LD(LDH)-382* CK(CPK)-26* AlkPhos-238* TotBili-1.0 [**2147-8-16**] 04:04AM BLOOD ALT-113* AST-110* LD(LDH)-240 AlkPhos-196* TotBili-1.3 . [**2147-8-15**] 01:20AM BLOOD CK-MB-4 cTropnT-0.08* [**2147-8-15**] 01:20AM BLOOD Albumin-3.4* Calcium-9.3 Phos-5.5*# Mg-2.5 Cholest-132 . [**2147-8-15**] 09:00AM BLOOD Calcium-9.3 Phos-4.9* Mg-2.4 [**2147-8-16**] 04:04AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.4 . [**2147-8-15**] 01:20AM BLOOD Triglyc-53 HDL-40 CHOL/HD-3.3 LDLcalc-81 [**2147-8-15**] 01:20AM BLOOD TSH-9.6* . [**2147-8-15**] 12:59AM BLOOD Type-ART pO2-27* pCO2-46* pH-7.35 calTCO2-26 Base XS--1 [**2147-8-15**] 01:30AM BLOOD Type-ART pO2-172* pCO2-47* pH-7.37 calTCO2-28 Base XS-1 . IMAGING [**8-15**] Chest xray: As compared to the previous radiograph, the right PICC line has been removed. There are newly appeared bilateral areas of lateral and basal opacities associated with blunting of the costophrenic sinus. Distribution and bilateral occurrence of these changes, in conjunction with a moderately enlarged size of the cardiac silhouette, suggest hydrostatic pulmonary edema. No other relevant changes, notably no evidence of pneumonia. Brief Hospital Course: 79 yo male with history of CAD status-post CABG in [**2139**] (LIMA->Diag, SVG->OM1, SVG->LAD) and stent to LAD, RCA (DES) in [**2146**], ischemic cardiomyopathy with CHF and EF 20%, and AICD placement in [**2141**], as well as DM2, peripheral vascular disease, CKD, and COPD on home O2 3L who was transferred from OSH for hypotension and low urinary output, thought to be secondary to acute on chronic systolic HF. Of note, pt was made DNR/DNI with hospice care on [**2147-8-15**] after family meeting with wife, son, daughter. Patient admitted for acute on chronic systolic HF, with acute coronary syndrome ruled out at OSH. Possible etiology includes medication changes/non-compliance given multiple recent hospitalizations and medication changes. On admission, he appeared wet and cold on exam with distended neck veins. On admission, patient was somnolent which was thought to be due to ativan given during transportation. His blood pressures on admission ranged from SBP 80-100s, but per records, baseline blood pressures on recent hospitalizations have been in 80s. He was started on a lasix drip to goal of net negative 2L in 24 hours. Aspirin 325 mg daily, metolazone 5 mg daily, and metoprolol were continued. Metoprolol tartrate was decreased from home dose to 12.5mg [**Hospital1 **] due to SBPs in 100s. Coumadin, statin, and [**Last Name (un) **] were held. Patient declined central line. Pt remained hemodynamically stable and clinical status improved. He was transferred to the floor on [**2147-8-16**]. Per goals of care, preventative meds (statin, coumadin) were held and EP turned off AICD. Will discharge on Torsemide and Metoprolol succinate 25 mg qday. Other issues during hospitalization included moderate respiratory distress on admission attributed to fluid overload from CHF vs ?possible pneumonia. He was continued on home regimen of combivent and advair. He was evaluated by respiratory therapy who advised no need for CPAP at this time. Patient also has severe peripheral vascular disease with necrosis of toes bilaterally. OSH cultures demonstrated many Staph aureus and corynebacterium diphtheroids. Seen by vascular surgery: pt declined bilateral knee amputation. He was started on Vancomycin (started [**2147-8-14**]), cefepime (started [**8-15**]), and flagyl (started [**2147-8-14**]) which was switched to PO abx regimen of bactrim, flagyl, and ciprofloxacin on [**8-15**]. WBC 11.1 on admission. His WBC cont'd downtrending and he was afebrile during admission. Pt also has history of CKD, likely diabetic nephropathy, with baseline Cr 1.1-1.5 although ranges widely; admission Cr above baseline at 1.7. He likely had an element of acute pre-renal disease in addition to CKD and diabetic nephropathy. In terms of his paroxysmal Afib, [**Country **] score 2, amiodarone was restarted on [**8-15**] but coumadin was discontinued given goals of care. For his hypothyroidism, TSH [**2147-8-15**] was 9.6 and he was kept on levothyroxine 37.5mcg daily. DM2 managed with ISS. Home dose of effexor was continued, although pt requested that it be tapered off so he will be discharged on half of his home dose. Will be discharged on hospice with visiting nurses, f/u on labs, and sliding scale for torsemide. Medications on Admission: Ranitidine 150 mg daily trazodone 50 mg daily effexor 75 mg daily synthroid 25 mcg daily combivent 2 puffs qid aspirin 325 mg daily arixtra 2.5 subcu q 24 insulin SS, novolin 10 u [**Hospital1 **] lasix 40 mg tid vancomycin 1000 mg q18 levaquin 750 po q48 hrs flagyl 500 mg tid Discharge Medications: 1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*2* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous twice a day: Do not give if pt is not eating. Please dispense with quick pen. Disp:*1 bottle* Refills:*2* 5. Levothyroxine 25 mcg Tablet Sig: 1.5 Tablets PO QAM (once a day (in the morning)). Disp:*45 Tablet(s)* Refills:*2* 6. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. Disp:*30 packet* Refills:*2* 7. 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* 8. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 10. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 14. Outpatient Lab Work Please check Chem-7 on [**Hospital1 766**] [**8-21**] and call results to Dr. [**Last Name (STitle) 11493**] at [**Telephone/Fax (1) 28702**] 15. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day: Please see page 1 for titration directions. . Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2188**] Discharge Diagnosis: Acute on Chronic Systolic Congestive Heart Failure Acute on Chronic Kidney Disease Coronary Artery Disease ICD inactivated, pacemaker still functioning Severe peripheral vascular Disease with gangrene of right foot Chronic Obstructive Pulmonary Disease on oxygen chronically 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 28624**], It was a pleasure taking care of you at [**Hospital1 827**]. You were transferred from an outside hospital with low blood pressure and decrease urine. You were started on IV antibiotics to to treat the infection on your R foot. There was a family meeting on [**8-15**] to discuss goals of care. You and your family decided that the goal of your medical treatment would be to make you as comfortable as possible in the remaining time you have left of your life. Therefore, you will go home with hospice services who will help your family care for you and make sure you are comfortable. We discussed all of your medicines with you and discontinued all of the medicines that will not help make you comfortable. The vascular surgeons had a discussion with you about surgery for your legs and you declined an amputation. We changed your antibiotics to oral medications. We stopped your coumadin and cholesterol lowering medication. We continued to give you medication to decrease your fluid level to help your breathing. The heart doctors turned OFF your AICD but kept ON your pacemaker. . The following changes were made to your medications: STARTED Ciprofloxacin (antibiotic) STARTED Bactrim (antibiotic) Changed Furosemide to Torsemide 40 mg daily INCREASED Levothyroxine to help your thyroid work better. STOPPED Coumadin STOPPED Simvastatin STOPPED Arixtra STOPPED Combivent STOPPED Vancomycin and Levoquin Started Metoprolol to help your heart pump better Decreased the Effexor to 37.5 mg every day, stopping this medicine abruptly may cause a discontinuation syndrome that includes anxiety, insomnia, and emotional lability. Please taper this medicine gradually. . Please check your weight daily and call Dr. [**Last Name (STitle) 11493**] to adjust your medicines if your weight increases more than 3 pounds in 1 day or 6 pounds in 3 days. Your weight today was 234 pounds. Do not drink alcohol on the Metronidazole as this could make you sick. . We held your Diovan because in the past this has led to high potassium levels. WE will not be checking your labs anymore. Followup Instructions: Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6105**] [**Name8 (MD) 11493**],MD Department: Cardiology When: Wednesday [**8-30**] at 2pm Address: [**Apartment Address(1) 28703**], [**Location (un) **],[**Numeric Identifier 28704**] Phone: [**Telephone/Fax (1) 11650**] Name: [**Name6 (MD) **] [**Name6 (MD) **],MD Address: [**Last Name (un) 28705**], [**Location (un) 28706**],[**Numeric Identifier 28707**] Phone: [**Telephone/Fax (1) 24306**] Your primary care physician is on vacation until [**Last Name (LF) 766**], [**8-28**]. Please call then to schedule a follow up visit for your hospitalization for that week. Should an emergency come up, there is a covering physician for Dr. [**Last Name (STitle) 24305**] and you can reach them by calling your PCPs number. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

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Discharge summary

report+report

Admission Date: [**2184-7-5**] Discharge Date: [**2184-7-11**] Date of Birth: [**2141-5-14**] Sex: F Service: BLUE GENERAL SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 43 year-old female with a history of systemic lupus erythematosus and end stage renal disease on hemodialysis who presented to the Emergency Department on [**2184-6-26**] with nausea, vomiting and right upper quadrant abdominal pain. The patient was seen the evening prior in the Emergency Department for biliary colic with 9 out of 10 pain. Her liver function tests were significant for elevated amylase and lipase. Ultrasound at that time showed cholelithiasis with no evidence of cholecystitis or biliary obstruction. The patient was sent home where she refrained from eating, however, returned to the Emergency Department on the day of admission complaining of nausea and vomiting of clear emesis. Her abdominal pain decreased to 4 out of 10. The patient denied fevers or chills. The patient had flatus and her last bowel movement was the morning prior to admission. PAST MEDICAL HISTORY: 1. Systemic lupus erythematosus diagnosed in [**2173**]. 2. Lupus nephritis leading to end stage renal disease on hemodialysis for two years. 3. Hemolytic anemia. 4. Thrombocytopenia. 5. Raynaud's. 6. Hypercholesterolemia. 7. BOOP diagnosed in [**2179**]. 8. Hypertension. 9. Osteoporosis. 10. Cardiomyopathy (EF equals 35 to 40%). 11. Lupus cerebritis. PAST SURGICAL HISTORY: Significant for a lung biopsy in [**2179**]. ALLERGIES: Sulfa, which causes shortness of breath and Biaxin. SOCIAL HISTORY: No alcohol use. No tobacco use and no drug use. MEDICATIONS ON ADMISSION: 1. Prednisone 5 mg q.d. 2. Atenolol 100 mg q.d. 3. Zestril 40 mg q day. 4. Lipitor 40 mg q.d. 5. Prilosec 20 mg q.d. 6. Phos-Lo 666 mg three to four tablets each meal. 7. Folate 1 gram q.d. 8. Nephrocaps. PHYSICAL EXAMINATION: Vital signs temperature 97.6. Pulse 72. Blood pressure 193/103. Respiratory rate 20. O2 sat 100% on room air. In general, she was a well appearing African American woman in no acute distress. HEENT pupils are equal, round and reactive to light. Extraocular movements intact. Anicteric sclera. Chest clear to auscultation bilaterally. Cardiovascular regular rate and rhythm. Normal S1 and S2 with a 2 out of 6 systolic ejection murmur. Abdomen soft, decreased bowel sounds, nondistended, tender in the right upper quadrant, positive [**Doctor Last Name **] sign, no guarding or rebound tenderness. Rectal examination guaiac negative. Pelvic examination no cervical motion tenderness per Emergency Department examination. Extremities warm, no clubbing, cyanosis or edema. Left upper extremity AV fistula with a palpable thrill. LABORATORIES ON ADMISSION: White blood cell count 4, hematocrit 35.9, platelets 135, normal differential, sodium 135, potassium 5.2, chloride 94, bicarb 29, BUN 52, creatinine 10.5, glucose 77, ALT 12, AST 12, alkaline phosphatase 59, T bilirubin 0.3, amylase was 234 up from 180, lipase 148, which was up from 74. Urinalysis was positive for bacteria and protein. Ultrasound revealed no gallbladder wall thickening, no pericholecystic fluid. It was positive for gallstones. No ductal dilatation and the common bile duct equals 4 to 5 mm. Positive [**Doctor Last Name 515**] sign. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2184-6-26**] for gallstone pancreatitis. The patient was made NPO except for medications and pain was controlled with morphine. She was also begun on Cefazolin. Early in the a.m. of [**6-28**] the patient experienced severe headaches and was hypertensive to 200/100. Initially the patient experienced some left facial numbness and twitching of all extremities. At this point Lopressor intravenous was given with response noted, morphine was changed to Dilaudid and .5 mg of Ativan was given with resolution of symptoms. The patient went to dialysis later that day where she was noted to have a generalized tonic clonic seizure lasting three to five minutes with a blood pressure of 180/100. The patient was not dialyzed. The seizure occurred prior to dialysis. The patient denied ever having seizures or a seizure disorder before. Neurology was consulted and MRI and electroencephalogram were obtained at their suggestion. MRI revealed no morphological abnormality of the brain and no shift of intracranial structures. There were a few nonspecific fossa of increased T2 signal in the white matter of both cerebral hemispheres consistent with small vessel infarct. No abnormal intracranial enhancement was observed. The electroencephalogram was abnormal with a burst of generalized slowing, which is nonspecific for cerebral dysfunction, but suggests the possibility of deep midline brain dysfunction. The patient was begun on Dilantin 300 mg q.h.s. The patient was dialyzed on both [**6-29**] and [**6-30**]. Due to the patient again having twitching symptoms she was given an additional dose of Dilantin prior to her discharge on [**7-1**] as she initially refused to be loaded with the Dilantin on neurologies request. The patient's abdominal examination remained stable throughout her stay and was nontender to palpation on her date of discharge. The patient's amylase and lipase trended downward throughout her stay. The patient was tolerating a low fat renal fluid restricted diet well on her discharge and the patient is to return to the hospital for admission on Monday [**2184-7-5**] after her dialysis treatment for a preop admission for her laparoscopic cholecystectomy on [**2184-7-6**]. The patient will also follow up with neurology in clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7431**]. Dr. [**Last Name (STitle) 7431**] provided the patient with her card and information regarding making an appointment. MEDICATIONS ON DISCHARGE: 1. Keflex 500 mg po q 12 hours. 2. Dilantin 300 mg po q.h.s. 3. Prednisone 5 mg q.d. 4. Atenolol 100 mg q.d. 5. Zestril 40 mg q.d. 6. Lipitor 40 mg po q.d. 7. Prilosec 20 mg q.d. 8. Phos-Lo 666 mg three to four tablets each meal. 9. Folate 1 gram q.d. 10. Nephrocaps. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Discharged to home without services. DISCHARGE DIAGNOSES: 1. Resolved gallstone pancreatitis. 2. New onset generalized tonic clonic seizure. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**] Dictated By:[**Last Name (NamePattern1) 7432**] MEDQUIST36 D: [**2184-7-11**] 17:05 T: [**2184-7-13**] 14:07 JOB#: [**Job Number 7433**] Admission Date: [**2184-7-5**] Discharge Date: [**2184-7-30**] Date of Birth: [**2141-5-14**] Sex: F Service: Surgery, Blue Team HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 5655**] is a 43-year-old black female with multiple medical problems including a history of systemic lupus erythematosus and end-stage renal disease (on hemodialysis). She was admitted to the General Surgery Service on [**2184-7-5**] for a scheduled laparoscopic cholecystectomy. She had been admitted for one week prior to this admission to our service because of nausea, vomiting, and right upper quadrant abdominal pain. An ultrasound at that time showed cholelithiasis with no evidence of cholecystitis or biliary obstruction. The patient was diagnosed with a gallstones pancreatitis which was treated conservatively with intravenous hydration, pain medications, and antibiotics. That hospitalization was complicated by an episode of shaking which was suspect for a seizure disorder. A head magnetic resonance imaging and electroencephalogram were obtained which were nonspecific, and she was put on Dilantin; according to Neurology consultation suggestion. She did well at home for the four days between the discharge and this current admission. PAST MEDICAL HISTORY: 1. Systemic lupus erythematosus diagnosed in [**2173**]. 2. Lupus nephritis. 3. End-stage renal disease (on hemodialysis for two years). 4. Lupus cerebritis. 5. Hemolytic anemia. 6. Thrombocytopenia. 7. Raynaud's disease. 8. Hypercholesterolemia. 9. Bronchiolitis obliterans-organizing pneumonia diagnosed in [**2179**]; status post lung biopsy. 10. Hypertension. 11. Osteoporosis. 12. Cardiomyopathy with an ejection fraction of 35% to 40%. 13. Chronic pain in thorax and abdomen of unclear etiology. PAST SURGICAL HISTORY: Video-assisted thoracic surgery lung biopsy in [**2179**]. ALLERGIES: BIAXIN and SULFA. MEDICATIONS ON ADMISSION: 1. Prednisone 5 mg p.o. q.d. 2. Atenolol 100 mg p.o. q.d. 3. Zestril 40 mg p.o. q.d. 4. Lipitor 40 mg p.o. q.d. 5. Prilosec 20 mg p.o. q.d. 6. Phos-Lo 666 mg three to four tablets with each meal. 7. Folate 1 mg p.o. q.d. 8. Nephrocaps. 9. Lisinopril 40 mg p.o. q.d. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission showed a temperature of 98.6, pulse was 84, blood pressure was 138/80, respiratory rate was 16, and oxygen saturation of 100% on room air. The physical examination revealed that she was a black woman in no acute distress. Her head was normocephalic and atraumatic. Her chest was clear to auscultation bilaterally. Her neck was supple without lymphadenopathy. Her heart had a regular rate and rhythm with normal first heart sound and second heart sound, and a [**2-11**] ejection murmur. Her abdomen was soft and nondistended, mild tenderness in the right upper quadrant. No guarding, and no rebound. Her rectal examination showed no mass and was guaiac-negative. Her extremities were warm and well perfused. There was no peripheral edema. There was an arteriovenous fistula on the left arm with a palpable thrill. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory studies showed a white blood cell count of 5.1, hematocrit was 35.7, platelets were 135. Sodium was 138, potassium was 4.9, chloride was 95, bicarbonate was 33, blood urea nitrogen was 27, creatinine was 8.1, blood glucose was 105. ALT was 4, AST was 37, total bilirubin was 0.2, alkaline phosphatase was 69, amylase was 155, lipase was 54. PT was 11.9, PTT was 26.8. Dilantin level was 5.8. HOSPITAL COURSE: The patient was brought to the operating room on [**7-6**] for a scheduled laparoscopic cholecystectomy, intraoperative cholangiogram, and common bile duct exploration. She tolerated the procedure well and was sent to the Postanesthesia Care Unit in stable condition. Her postoperative stay in the hospital was a prolonged one, mostly because of her comorbid issues. On postoperative day two, she received 2 units of packed red blood cells for decreasing hematocrit levels. On the same day, and abdominal ultrasound was obtained which showed a hematoma in the surgical bed measuring 4 cm X 8 cm and showed no evidence of residual stones. On postoperative day three, she had an episode of flash pulmonary edema which necessitated a transfer to the Intensive Care Unit where she was closely monitored for fluid management. She returned to the floor one day later. During the hospital stay, she continued to receive hemodialysis on Monday, Wednesday and Friday and continued to complain of abdominal pain, and low energy level, and fevers. These complaints were essentially remaining as the same complaints during this entire hospital stay. Her abdominal examinations did not change. Two repeat abdominal ultrasounds done on [**7-9**] and [**7-12**] did not show any change in the size of the hematoma. A CT scan of the abdomen on [**7-14**] also confirmed the presence of the same hematoma without any change in appearance. A magnetic resonance cholangiopancreatography obtained during this hospitalization again did not show any stones. Incidentally, both the CT and magnetic resonance cholangiopancreatography showed possible pancreatic divisum. We did not think there was active bleeding, and there was no radiologic signs such as free air to suggest any infection of the hematoma. Below is a review by systems for her hospital stay. 1. GASTROINTESTINAL: She continued to have complaints of abdominal pain which was nonspecific and somewhat difficult to localize; although, she sometimes referred it to the epigastric region. This pain did not change whether she was n.p.o. or was taking a full diet. Her amylase level has a baseline of approximately 220. We initially started to advance her diet, but the amylase bumped up 430. However, she remained to have a good appetite, and there was no increase in abdominal pain. We again made her n.p.o. and started her on total parenteral nutrition. Later, we restarted the oral intake slowly. Her amylase had stabilized at her baseline level upon discharge. 2. INFECTIOUS DISEASE: Since postoperative day 15, she continued to spike fevers for several days. Blood, urine, and sputum cultures failed to grow any organisms. Because in the past hospitalization she also presented with fevers of unclear etiology, which responded well to steroids, we increased the prednisone to 30 mg every day. She remained more than 70 hours afebrile prior to the day of discharge. 3. RENAL: She had dialysis every other day while in the hospital. Because of her labile blood pressure, the amount of fluid removed varied significantly. She also suffered from fever, fatigue, and malaise after every dialysis. In fact, she has not tolerated hemodialysis well as an outpatient. She is currently on a list for renal transplant. 4. PAIN: There was a long history of chronic pain. The patient relayed that her chest/abdominal pain since she had video-assisted thoracic surgery biopsy of her lungs several years ago. Although she had an outpatient appointment with the Pain Clinic, she was not compliant. Before discharge, she was started on gabapentin 300 mg p.o. q.h.s.; according to the Pain Service suggestions. She also received thoracic nerve blocks from the Pain Clinic and received a TENS unit. She was to follow up with the Pain Clinic as an outpatient. 5. NEUROLOGY: During the workup of her fever, Neurology was consulted for the use of Dilantin; which can potentially cause fever. An electroencephalogram failed to identify any abnormalities. Therefore, according to Neurology recommendations, Dilantin was discontinued. She was discharged to home without any antiepileptic medications. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: To home without services. DISCHARGE DIAGNOSES: 1. Cholelithiasis. 2. Status post cholecystectomy. DISCHARGE INSTRUCTIONS: The patient was asked to make an appointment with Dr.[**Name (NI) 6275**] clinic in the next month. The patient was also instructed to follow up with the Pain Clinic, and also with her nephrologist, and rheumatologist. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**] Dictated By:[**Name8 (MD) 6276**] MEDQUIST36 D: [**2184-8-5**] 13:26 T: [**2184-8-13**] 08:14 JOB#: [**Job Number 6277**]

[ "585", "582.81", "401.9", "780.39", "425.4", "998.11", "574.70", "710.0", "272.0" ]

icd9cm

[ [ [] ] ]

[ "51.23", "39.95", "38.93", "51.88", "99.15" ]

icd9pcs

[ [ [] ] ]

14555, 14609

5947, 6232

8617, 10241

10259, 14437

14634, 15082

8500, 8591

1941, 2797

14452, 14534

6849, 7929

2812, 3372

7952, 8476

1622, 1672

6257, 6323

25,167

147,255

53180

Discharge summary

report

Admission Date: [**2155-9-4**] Discharge Date: [**2155-9-26**] Service: Surgery HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 1557**] is an 85-year-old female who was transferred from rehabilitation to the [**Hospital1 1444**] on [**2155-9-4**], for perfuse diarrhea associated with fevers. Originally, this 85-year-old female was underwent left total hip replacement secondary to a fracture in [**2155-8-2**]. She was discharged to rehabilitation where she was up until [**9-4**], the day when she was sent back to the Emergency Room at the [**Hospital1 69**] for evaluation due to her perfuse diarrhea and fevers. On presentation, the patient complained of abdominal pain and was noted to be hypotensive. She was started empirically on vancomycin, levofloxacin, and Flagyl and resuscitated with 6 units of crystalloid. She remained hypotensive so she was started on dopamine. PAST MEDICAL HISTORY: (Her other past medical history includes) 1. Urinary tract infections. 2. Depression. 3. Arthritis. 4. Gastroesophageal reflux disease. 5. Compression fracture of the lumbar disk. 6. Right breast cancer. 7. She is deaf in the left ear. 8. Hard of hearing in the right ear. ALLERGIES: The patient has no known drug allergies. HOSPITAL COURSE: A CT scan of the abdomen showed diffuse colonic thickening, and the differential included ischemic versus infectious colitis. With signs of peritonitis and sepsis, and because the patient was not improving she was brought to the operating room and underwent an emergent total abdominal colectomy and end-ileostomy. Intraoperatively, the patient was found to have a large amount of fluid in the abdomen. After the operation, she was transferred in a critical condition to the Intensive Care Unit, intubated, on pressors, and the antibiotics were ceftriaxone and Flagyl. On [**2155-9-8**], the patient self extubated herself. Antibiotics were continued as the patient continued to have persistent elevated white blood cell count and fevers. She was doing reasonably well. Total parenteral nutrition was started on [**9-9**], and the sample from the stool that was sent on [**2155-9-5**], was positive for Clostridium difficile colitis. Of note, after the surgery subsequent stool samples tested negative for Clostridium difficile. During this time, the patient continued to have small temperatures and elevated white blood cell counts. Orthopaedics was consulted, and an ultrasound of the left hip revealed a fluid collection adjacent to the left femur fracture site. Orthopaedics did not feel that this was evidence of infection, and it was most likely a resolving hematoma. On [**2155-9-11**], the patient developed tachypnea and dropped her saturations requiring reintubation. She had a repeat CT of the abdomen which showed bilateral loculated pleural effusions and a thickened rectal stump. She required pressor support again on and off. The patient underwent an ultrasound-guided thoracentesis on [**9-12**] and approximately 500 cc of fluid were drained from her left pleural site. She continued on full support and on intravenous antibiotics, but despite this she never completely improved. By [**2155-9-18**], it was decided among the clinical staff and the family that the patient would be extubated and made do not resuscitate/do not intubate and give her a chance to improve. The patient has been requiring nasal suction to raise secretions, and her saturations have been 80s to 90s with 60% face tent. Her systolic blood pressure was between 80s to 100s, and heart rates between 90s to 120s. The patient was made comfort measures only on [**2155-9-22**], by the family and the clinical staff. A morphine drip was started. Antibiotics and other medications were discontinued. A Foley was kept to gravity with an average urine output of 30 cc to 40 cc an hour. The son of the patient, Mr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], is the power of attorney. The patient was transferred to the Cardiothoracic Surgical Intensive Care Unit on [**2155-9-23**], and today she is being transferred to a rehabilitation facility to continue her care and comfort measures only protocol. [**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**] Dictated By:[**Last Name (NamePattern4) 26544**] MEDQUIST36 D: [**2155-9-25**] 19:43 T: [**2155-9-25**] 19:14 JOB#: [**Job Number 109484**] (cclist)

[ "428.0", "789.5", "008.45", "511.9", "311", "567.2", "427.31", "530.81" ]

icd9cm

[ [ [] ] ]

[ "99.15", "34.91", "38.91", "45.8", "46.01" ]

icd9pcs

[ [ [] ] ]

1277, 4471

119, 899

923, 1259

19,953

155,487

4678

Discharge summary

report

Admission Date: [**2117-1-19**] Discharge Date: [**2117-1-27**] Date of Birth: [**2046-12-23**] Sex: M Service: SURGERY Allergies: Oxycodone/Acetaminophen / Mirapex Attending:[**First Name3 (LF) 668**] Chief Complaint: The patient is a 70-year-old male with end stage renal disease and poor dialysis access. He presents for a renal transplant. Major Surgical or Invasive Procedure: Cadaveric Renal Transplant JP drain placement History of Present Illness: The patient is a 70-year-old gentleman with end-stage renal disease secondary to diabetes mellitus, currently on hemodialysis through a right tunneled catheter three times a week. He continues to make small amounts of urine- about 200 to 300 mL per day and has not received any recent blood transfusions. He is active on the blood group O list for both the standard and extended criteria donor kidney. He has received his Heptavax and Pneumovax vaccinations as well as the flu vaccine. His energy is currently diminished, with significant neuropathy involving the legs and upper extremities. He denies any ulcers, chest pain, shortness of breath, nausea, vomiting, diarrhea or difficulty urinating. Pertinent laboratory investigations for his transplant evaluation include his last PSA from [**2115**] of 6.3 and a stress test from [**9-/2115**] showing transient ischemic dilatation in addition to baseline left ventricular dilatation and an EF of 31% that decreased since his prior study. He had a colonoscopy also in [**2112**] that was normal. Past Medical History: 1. ESRD on hemodialysis M/W/F 2. DM type 1 3. Right ACA territory CVA 4. CAD s/p 3-vessel CABG in [**2107**] 5. CHF with EF 20-25% in [**9-/2115**] and severe MR. 6. Hypertension 7. Hypercholesterolemia 8. Hypothyroidism 9. Retinopathy 10. Neuropathy 11. COPD per patient report. No PFT's online. No prior psteroids, no intubation. 12. s/p right ACA and left PCA stroke Social History: Lives alone, retired. Does all ADLs. Social EtOH use. Smoked 1 ppdx35 yrs, quit 9 months ago. Family History: Father died of MI at 62. Brother [**Name (NI) 19762**]. Brother CAD. Sister DM2. Physical Exam: General: Elderly and chronically ill-looking gentleman, NAD Vitals: T98 BP 96/44 HR 80 RR 15 Wt 149lbs HEENT: benign Resp/CVS: unremarkable, right internal jugular tunneled catheter ABD: NTND, soft.He had a right internal jugular Ext: no edema and moderately diminished pedal pulses Pertinent Results: [**2117-1-19**] 05:08AM BLOOD WBC-6.9 RBC-3.59* Hgb-12.3* Hct-34.6* MCV-96# MCH-34.2* MCHC-35.5* RDW-14.9 Plt Ct-264 [**2117-1-19**] 04:25PM BLOOD WBC-8.6 RBC-3.01* Hgb-10.6* Hct-28.7* MCV-96 MCH-35.1* MCHC-36.8* RDW-16.2* Plt Ct-197 [**2117-1-19**] 04:00AM BLOOD PT-18.6* PTT-34.6 INR(PT)-2.4 [**2117-1-19**] 04:25PM BLOOD Plt Ct-197 [**2117-1-19**] 05:08AM BLOOD Glucose-290* UreaN-22* Creat-2.9*# Na-133 K-7.6* Cl-99 HCO3-26 AnGap-16 [**2117-1-19**] 04:25PM BLOOD Glucose-57* UreaN-23* Creat-2.6* Na-142 K-3.5 Cl-112* HCO3-23 AnGap-11 [**2117-1-19**] 05:08AM BLOOD ALT-11 AST-76* [**2117-1-19**] 05:08AM BLOOD Calcium-9.6 Phos-3.9 Cholest-117 [**2117-1-19**] 04:25PM BLOOD Phos-3.1 Mg-1.3* [**2117-1-19**] 05:08AM BLOOD Triglyc-115 HDL-56 CHOL/HD-2.1 LDLcalc-38 [**2117-1-19**] 01:24PM BLOOD freeCa-1.21 [**2117-1-19**] 03:15PM BLOOD Hgb-11.0* calcHCT-33 [**2117-1-20**] 06:27AM BLOOD WBC-11.5* RBC-2.99* Hgb-10.1* Hct-28.7* MCV-96 MCH-34.0* MCHC-35.4* RDW-16.3* Plt Ct-188 [**2117-1-21**] 06:00AM BLOOD PT-16.0* PTT-33.9 INR(PT)-1.8 [**2117-1-21**] 03:56PM BLOOD Fibrino-328 [**2117-1-22**] 04:11AM BLOOD Glucose-234* UreaN-59* Creat-4.0* Na-134 K-5.3* Cl-101 HCO3-20* AnGap-18 [**2117-1-21**] 11:48PM BLOOD CK(CPK)-406* [**2117-1-21**] 03:56PM BLOOD Lipase-7 [**2117-1-21**] 11:48PM BLOOD CK-MB-6 [**2117-1-21**] 03:56PM BLOOD CK-MB-7 cTropnT-0.26* [**2117-1-21**] 03:56PM BLOOD Albumin-2.9* Calcium-8.7 Phos-5.6* Mg-1.6 [**2117-1-22**] 07:03AM BLOOD FK506-3.5* [**2117-1-21**] 02:43PM BLOOD freeCa-1.22 [**2117-1-27**] 05:57AM BLOOD WBC-5.3 RBC-3.32* Hgb-11.1* Hct-31.4* MCV-95 MCH-33.5* MCHC-35.4* RDW-15.9* Plt Ct-207 [**2117-1-27**] 05:57AM BLOOD PT-14.5* PTT-31.2 INR(PT)-1.4 [**2117-1-27**] 05:57AM BLOOD Plt Ct-207 [**2117-1-27**] 05:57AM BLOOD Glucose-113* UreaN-74* Creat-2.5* Na-137 K-4.1 Cl-104 HCO3-23 AnGap-14 [**2117-1-27**] 03:40AM BLOOD CK(CPK)-29* [**2117-1-27**] 03:40AM BLOOD CK-MB-4 [**2117-1-26**] 07:39PM BLOOD CK-MB-NotDone cTropnT-0.31* [**2117-1-27**] 05:57AM BLOOD Albumin-2.8* Calcium-8.8 Phos-3.5 Mg-1.6 [**2117-1-26**] 06:00AM BLOOD FK506-13.0 [**2117-1-21**] 10:02AM ASCITES Creat-3.6 Brief Hospital Course: Prior to surgery, the patient underwent CXR and ECG evaluation, showing changes consistent with known CAD and CABG. On [**2117-1-19**] The patient underwent transplant of a cadaveric right kidney. A JP drain was also placed. Immunosuppressive therapy was begun pre-operatively, including ATG, MMF, and Solumedrol. Tacrolimus was later added, and titrated to 4mg [**Hospital1 **]. Due to minimally improved post-operative urine output (20-30cc/hr), a renal ultrasound was obtained, showing unremarkable appearance of the renal transplant. Endocrine was consulted regarding management of the patient's insulin regimen throughout his hospital stay. Post-operatively, the patient also developed abdominal pain for which a portable abdominal x-ray was ordered showing mildly dilated loops of mostly large bowel consistent with an ileus, which subsequently resolved. On [**2117-1-21**], the patient underwent hemodialysis for hyperkalemia, and became bradycardic with decreased respiration for several seconds. The patient was transferred to the ICU, where his cardiac enzymes were found to be negative x3. An EKG at the time revealed anterior ST-T wave changes from the pre-operative EKG, and CXR revealed mild pulmonary edema. An EKG on [**2117-1-22**] revelaed no new changes. On [**2117-1-24**], the patient was started on Lasix to increase urine output, which subsequently improved through the remainder of the [**Hospital 228**] hospital course to approximately 100cc/hr. The patient was restarted on his pre-operative Coumadin dose ([**2117-1-20**]), with an INR on [**2117-1-26**] of 2.4. Physical therapy worked with the patient and determined he would benefit from rehabilitation services. He was discharged to [**Hospital1 15962**] on post op day 8. Medications on Admission: ASA 81, Lipitor 20, Levothyroxine 125, Nephrocaps, Sevelamer 800 tid, Zyrtec 10, Quinapril, Coumadin 2.5, NPH 22 units AM, sliding scale humalog, NPH PM. Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*40 Tablet(s)* Refills:*1* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*40 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). Disp:*600 ML(s)* Refills:*1* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*40 Tablet(s)* Refills:*2* 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze. 9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 11. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Check level Friday [**1-29**]. Titrate to INR level 2.0-3.0. 12. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Insulin NPH-Regular Human Rec 70-30 unit/mL Suspension Sig: Sixteen (16) units Subcutaneous QAM. 14. Insulin NPH-Regular Human Rec 70-30 unit/mL Suspension Sig: Five (5) units Subcutaneous QPM. 15. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: One (1) Subcutaneous four times a day: sliding scale 101-150 2units 151-200 3units 201-250 5units 251-300 8units 301-350 10units 351-400 12units. 16. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2 times a day): Titrate to therapeutic levels. 17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 18. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 19. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 21. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 22. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for pain. 23. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) Intravenous Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: ESRD secondary to Type I Diabetes Mellitus Discharge Condition: Stable Discharge Instructions: Please follow the discharge instructions in your packet. Weight yourself and take your temperature every day, call for a temp of >101 or if your weight goes up more than 3 pounds in 2 days. Call if you have severe diarrhea, redness swelling or pain around teh incision, red or foul smelling discharge from the wound, or any problems with urination. You may shower, pat your incision dry. Take medications as prescribed and plan ahead so you do not run out of medicine. Please keep all appointments with your doctors. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2117-2-1**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2117-2-8**] 2:20 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2117-2-16**] 2:00 Completed by:[**2117-1-27**]

[ "250.51", "424.0", "250.41", "997.4", "996.81", "427.89", "V17.3", "244.9", "272.0", "250.61", "403.91", "997.1", "428.0", "V18.0", "V45.81", "276.7" ]

icd9cm

[ [ [] ] ]

[ "55.69", "39.95", "99.04", "00.93", "99.05" ]

icd9pcs

[ [ [] ] ]

9025, 9095

4618, 6378

419, 467

9182, 9191

2474, 4595

9756, 10239

2068, 2151

6582, 9002

9116, 9161

6404, 6559

9215, 9733

2166, 2455

254, 381

495, 1546

1568, 1940

1956, 2052

21,837

136,775

6850

Discharge summary

report

Admission Date: [**2190-7-11**] Discharge Date: [**2190-7-19**] Date of Birth: [**2119-3-15**] Sex: M Service: MEDICINE Allergies: Bacitracin / Percocet Attending:[**First Name3 (LF) 25876**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: ERCP with stent removal and re-placement History of Present Illness: Mr. [**Name14 (STitle) 25878**] is a 71 year-old man w/ metastatic melanoma recently completing 5 cycles of Taxol was admitted yesterday with fever and shaking chills, RUQ discomfort felt to possibly be septic from tumor burden biliary obstruction. He was placed on broad spectrum antibiotics and had ERCP this AM. Blood pressures during this stay had been generally in the 90's on the floor prior to the procedure. Endoscopists removed prior biliary stent and noted frank bleeding which appeared to emanate from tumor eroding into biiary vasculature. Patient transferred to the [**Hospital Unit Name 153**] for further management. As per admit notes, patient had been admitted from clinic earlier this month with fever and shaking chills. He was noted to have obstructive jaundice and underwent ercp which demonstrated common bile duct obstruction managed with stent placement. On discharge he did not complete his course of cipro and flagyl due to bad taste. At time of transfer Mr. [**Name14 (STitle) 25878**] is without complaint including no abdominal pain, nausea, vomiting, chest pain, shortness of breath, light-headedness. He has not noted any hematochezia or melena. Notes dark stools, on PO iron for sometime. Past Medical History: Past Medical History: 1. Metastatic melanoma--as per onc notes: "Mr. [**Known lastname **] was initially diagnosed w/ melanoma when he underwent left upper lobectomy in [**2185-5-16**] for a lung nodule discovered incidentally. PET scan showed uptake in the left neck but surgical exploration showed no evidence of melanoma, and no primary site was identified at that time. A CT scan in [**Month (only) 216**] [**2186**] revealed a small nodule in the area of the left kidney, and resection in [**2186-11-15**] revealed a perirenal soft tissue mass consistent with melanoma. He was enrolled in ECOG protocol 4697 on the HLA-A2 negative arm and received nine cycles on that protocol. F/U CT scan documented a soft tissue density behind the left lobe of the thyroid gland which was resected on [**11-18**]. Pathology revealed evidence of metastatic melanoma. He began radiation therapy to the neck completed on [**2188-2-14**]. Follow-up torso CT scans from late [**2188-2-16**] revealed several soft tissue masses within and around the head of the pancreas, consistent with metastatic disease. On [**2188-9-8**], the patient began a phase II trial involving treatment with DTIC +/- Sorafenib. The study was discontinued on [**2188-10-30**] when the patient's CT scan showed evidence of disease progression with significant growth in the pancreatic metastases. The patient was seen in the heme/onc clinic on [**2188-11-3**]. At that time, he was feeling well and remained active: he was walking daily and his ECOG performance status was zero. In [**12/2188**], he developed biliary obstruction requiring ERCP and stenting complicated by pancreatitis. He completed a one year course of IL-2 this past [**2-21**]. He had initial disease regression, but scans after cycle 3 showed mild disease progression evidenced by enlarging porta hepatis mass. He started on weekly Taxol on [**2190-2-17**] and has completed five cycles to date with evidence of stable disease. Biliary stent removed 2/[**2190**]. Need for new biliary stent on [**2190-6-30**], placed along with sphincterotomy. 2. CAD s/p MI 3. Prostate ca s/p radical prostatectomy 4. s/p L pulmonary lobectomy 5. Crohn's disease 6. GERD 7. Biliary obstruction [**12-20**], stent placed, then removed [**3-/2190**], recurrent obstruction [**2190-6-30**] with placement of new stent 8. hypothyroidism Social History: Married with no children. He has an 80 pack year history of smoking but quit about 10 or 20 years ago. He is a social drinker. Family History: He has no family history of melanoma. He has 10 siblings, of which one brother passed away secondary to leukemia at the age of 80. Physical Exam: VS: Temp: 99.5tmax/98 HR 75 BP 85/53 RR 16 SpO2 95% RA gen: comfortable at rest with no apparent distress, non-toxic skin: no rashes, mild jaundice HEENT: PERRL, EOMI, scleral mild icteric neck: supple, no jvd, no nodes lungs: CTAB, good air movement heart: RR, no M/R/G abd: +BS, not distended. very mild tenderness in RUQ, negative [**Doctor Last Name 515**]. Liver span approx 3cm below costal margin with palpable mass noted. ext: trace edema neuro: A&O x3, CNIII-XII grossly intact, no focal motor or sensory deficits. rectal: dark stool, guiaic negative Pertinent Results: Laboratory results: [**2190-7-10**] 09:30PM BLOOD WBC-12.5*# RBC-3.38* Hgb-8.8* Hct-27.5* MCV-81* MCH-25.9* MCHC-31.9 RDW-22.9* Plt Ct-306 [**2190-7-17**] 01:00AM BLOOD WBC-6.9 RBC-3.67* Hgb-10.5* Hct-32.0* MCV-87 MCH-28.5 MCHC-32.7 RDW-24.9* Plt Ct-175 [**2190-7-10**] 09:30PM BLOOD PT-12.5 PTT-22.5 INR(PT)-1.1 [**2190-7-10**] 09:30PM BLOOD Glucose-99 UreaN-13 Creat-0.9 Na-135 K-4.2 Cl-101 HCO3-24 AnGap-14 [**2190-7-10**] 09:30PM BLOOD ALT-233* AST-354* AlkPhos-832* Amylase-45 TotBili-5.2* [**2190-7-17**] 01:00AM BLOOD ALT-47* AST-27 LD(LDH)-595* AlkPhos-333* TotBili-2.4* [**2190-7-10**] 09:30PM BLOOD Lipase-61* [**2190-7-10**] 09:30PM BLOOD TotProt-6.5 Albumin-3.9 Globuln-2.6 Phos-2.8 Mg-2.0 [**2190-7-10**] 09:45PM BLOOD Lactate-1.3 Relevant Imaging: 1)Cxray ([**7-10**]): 1. No acute cardiopulmonary process. 2. Unchanged appearance of elevated left hemidiaphragm, now with some prominent loops of colon seen in the left upper abdomen. 2)RUQ ultrasound ([**7-10**]): Liver architecture is abnormal, distorted by a very large heterogeneous mass in the porta-hepatis that is consistent with known large metastases from metastatic melanoma. No definite intrahepatic biliary ductal dilatation is visualized. The common duct is not visualized, but the known CBD stent is seen traversing the large mass. There is a small right pleural effusion. There is no free fluid within the abdomen. Gallbladder is not distended, but there is a small amount of layering sludge within dependent portions of the gallbladder. There is mild gallbladder wall thickening and mild gallbladder wall edema. The main portal vein is patent, with appropriate direction of flow. 3)ERCP ([**7-12**]):The common bile duct was cannulized and opacified. A plastic stent is identified. There is a filling defect in the CBD extending in to the intrahepatic biliary tree. As per GI report, the previous plastic stent was removed and replaced by a 7 cm 10 French Cotton- [**Doctor Last Name **] biliary stent. Blood and clots were found in the bile duct. 4)ECHO ([**7-15**]): EF 40-45%. Regional left ventricular dysfunction consistent with coronary disease or focal myocarditis. No obvious vegetations identified to suggest endocarditis. Very small pericardial effusion located posterior to the atria. Mild to moderate mitral regurgitation. Brief Hospital Course: Mr. [**Known lastname **] is a 69yo male with metastatic melanoma s/p 5 cycles of Taxol and recent biliary stent placement now p/w fever and elevated bilirubin concerning for blocked biliary stent and possible cholangitis. 1)Cholangitis/bacteremia: Patient's initial symptoms of fevers, chills and elevated LFTs were thought to be due to blocked stent and possible cholangitis in the context of not completing his antibiotic regimen at home. He was initially started on Zosyn, Flagyl, and Vancomycin since [**3-21**] blood culture bottles were growing GPC's and GNR's. He underwent an ERCP the following day which was complicated by bleeding as the stent was removed. The patient was transferred to the MICU for closer monitoring. His hematocrit dropped to 24 and he was transfused with pRBCs. Cultures had been growing Serratia and Coag + staph aureus. Upon transfer to the floor, his antibiotic regimen was changed to Naficillin, Cipro, and Flagyl. Flagyl was stopped as per ERCP recommendations. Patient remained afebrile during the rest of the hospital stay and his LFTs slowly improved. He will be discharged on 2 week course of Naficillin and Cipro and last day will be [**2190-7-26**]. 2)Anemia: Secondary to blood loss during ERCP. Hematocrit dropped to 24.6 and he required multiple transfusions. Upon transfer to the floor his Hct slowly stabilized to the low 30's. His ASA and beta-blocker had been stopped in the setting of bleeding but was restarted at time of discharge. 3)Metastatic Melanoma: S/p 5 cycles of taxol. No further treatment was given during this admission. He is scheduled to see his outpatient oncologist on [**7-27**] for follow-up. 4)CAD: Patient remained asymptomatic during this hospital course. His ASA and beta-blocker were held in setting of bleeding. Statin was held in setting of elevated LFTs. All 3 medications were successfully restarted at time of discharge. 5)Thrombocytopenia: Patient was noted to have drop in platelet count within 1 week after being admitted to the OMED service. All heparin products were stopped and HIT antibody was sent. HIT antibody was negative. 6)Crohn's Disease: He was continued on Asacol. 7)Hypothyroidism: He was continued on Levothyroxine. Medications on Admission: ASA 81 mg PO qd Asacol 400mg 3 tab 3 times a day Metoprolol 25 mg daily omeprazole 20 mg once a day Zocor 20mg daily Niferex 150 mg tid Nitro quick 0.4mg take 1 tab daily prn angina pain Levothyroxine 100mcg qd Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nafcillin 2 gm IV Q4H 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 8. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): last day will be [**7-26**]. 10. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 23095**] - [**Location 8391**] Discharge Diagnosis: Primary diagnoses: 1)Cholangitis 2)Bacteremia 3)Anemia Seconady diagnoses: 1)Melanoma 2)Cardiovascular disease 3)Hyperlipidemia 4)Hypothyroidism Discharge Condition: Stable Discharge Instructions: 1)Please take all medications as listed in the discharge instructions. 2)You were found to have a blood infection. As a result, you are currently on two antibiotics which you must take for 2 weeks. Your last day of antibiotics will be [**7-26**]. 3)Please check weekly CBC with differential, liver function tests, and Bun/Cr. Results should be faxed to patient's oncologist at [**Telephone/Fax (1) 25879**]. 4)Please attend all appointments as listed below. 5)If you experience any fevers, chills, dizziness, chest pain, SOB, abdominal pain or any other concerning symptoms please return to the emergency room. Followup Instructions: 1)Provider: [**Name10 (NameIs) **] FELT, RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2190-7-27**] 11:00 2)Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2190-7-27**] 1:00 3)Provider: [**First Name11 (Name Pattern1) 14497**] [**Last Name (NamePattern1) 25880**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2190-7-27**] 1:00

[ "576.2", "998.11", "285.1", "E878.8", "198.89", "197.0", "287.4", "197.8", "530.81", "172.9", "576.1", "244.9", "790.7", "414.01", "555.9" ]

icd9cm

[ [ [] ] ]

[ "97.05", "38.93", "88.47", "51.10" ]

icd9pcs

[ [ [] ] ]

10550, 10624

7192, 9414

295, 337

10814, 10823

4849, 5594

11486, 11910

4121, 4253

9676, 10527

10645, 10793

9440, 9653

10847, 11463

4268, 4830

244, 257

5612, 7169

365, 1587

1631, 3961

3977, 4105

15,450

131,666

13468

Discharge summary

report

Admission Date: [**2144-10-28**] Discharge Date: [**2144-11-2**] Date of Birth: [**2083-3-26**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 61 year old male with a history of coronary artery disease, status post myocardial infarction in [**2135**], coronary artery bypass grafting times four in [**2135**] including left internal mammary artery to the left anterior descending artery, saphenous vein graft to ramus and saphenous vein graft to obtuse marginal one, cardiac catheterization in [**2141**]. The patient presented for an elective cardiac catheterization on [**2144-10-29**] after a Persantine stress test demonstrated diffuse anterior and inferolateral wall ischemia. The patient has been having worsening symptoms of shortness of breath as well as a 30 to 40 pound weight gain since early last year, requiring admission to [**Hospital6 33**], as well as an admission here from [**9-18**]. The patient presented on [**2144-10-28**] for prehydration, did well overnight and had a morning blood sugar in the 50s and was given one ampule of D50 to compensate for that. However, in the holding area, the patient was noted to become hypotensive with a systolic blood pressure in the 80s and, during the procedure itself, had a further decreased to a systolic blood pressure in the 70s. He was given a bolus of 250 cc of normal saline and started on Dopamine initially at 15 mcg/kg/minute and later decreased to 10 mcg/kg/minute. Because of the issue of hypotension, interventions were deferred until the patient was more stable after observation overnight in the Coronary Care Unit. PAST MEDICAL HISTORY: 1. As above. 2. Left ventricular ejection fraction 30%. 3. Peripheral vascular disease. 4. Status post femoral-popliteal bypass. 5. Left below the knee amputation. 6. History of bilateral carotid stenoses. 7. Type 2 diabetes mellitus with associated retinopathy and neuropathy as well as baseline morbid obesity. 8. Status post penile implant. 9. Cholecystectomy. 10. Appendectomy. 11. Carpal tunnel syndrome with release procedure in [**2144-4-23**]. 12. Baseline creatinine 2. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. q.d., Prilosec 20 mg p.o. q.d., iron 325 mg p.o.t.i.d., methotrexate, folic acid, digoxin 0.125 mg p.o. q.d., Coreg 6.25 mg p.o. b.i.d., Neurontin 100 mg p.o. b.i.d., Lipitor 10 mg p.o. q.d., valsartan 80 mg p.o. q.d., Imdur 60 mg p.o. q.d., prednisone 5 mg p.o. q.d., Lasix 40 mg p.o. q.d., multivitamins, insulin 70/30 1 to 2 units s.c.b.i.d. and weekly dose of 4,000 units of epoetin alfa. SOCIAL HISTORY: The patient is married and has no children. He has a 60 pack year history of tobacco, quit in [**2109**]. STUDIES: The patient's cardiac catheterization was notable for the following: Right dominant anatomy with a 60% distal left main coronary artery neat lesion, 100% stenosis of proximal left anterior descending artery, left circumflex 90% lesion, right coronary artery 100% lesion, saphenous vein graft to obtuse marginal one 100%, saphenous vein graft to the right coronary artery 100% lesion, saphenous vein graft to distal obtuse marginal patent, left internal mammary artery to left anterior descending artery patent, mild disease of left anterior descending artery. Cardiac output and index were 5.77 and 2.34 respectively with a mean wedge of 14 and pulmonary artery pressure mean of 31. PHYSICAL EXAMINATION: The physical examination was notable for a morbidly obese man in no acute distress. Head, eyes, ears, nose and throat: pupils equal, round, and reactive, extraocular movements intact, no jugular venous distention appreciated. Cardiovascular: Distant heart sounds. Abdomen: Soft, obese, nontender, hypoactive bowel sounds, no palpable organomegaly, no rebound tenderness, left groin sheath intact with no obvious bleeding hematoma. Extremities: Warm, palpable distal pulses. LABORATORY DATA: White blood cell count 11, hematocrit 31, platelet count 171,000, BUN 100 and creatinine 1.8. HOSPITAL COURSE: The patient was kept overnight for observation. He underwent an interventional cardiac catheterization subsequently on [**2144-10-30**]. During this procedure, a Cypher sirolimus oozing stent was applied at the proximal diagonal one and a second Cypher stent was placed at the left main coronary artery. Good post procedure flow was revealed. The patient was kept for observation. He was initially planned for a MRA of his carotid vessels given the recent stent placement. This procedure will be deferred as an outpatient. The patient was evaluated by physical therapy and was felt to be safe for discharge home. The patient was discharged in stable condition. DISCHARGE DIAGNOSIS: Coronary artery disease, status post percutaneous transluminal coronary angioplasty and stenting times two. DISCHARGE MEDICATIONS: Carvedilol 6.25 mg p.o. b.i.d. Diovan 40 mg p.o. q.d. Aspirin 325 mg p.o. q.d. Plavix 75 mg p.o. q.d. Prednisone to be tapered down, starting at 2.5 mg q.d for 14 days then 2.5 mg q.o.d. then stop. Lasix 40 mg p.o. q.d. Neurontin 100 mg p.o. b.i.d. Atorvastatin 10 mg p.o. q.d. Folate. ............ 10 mg p.o. q.d. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**] Dictated By:[**Last Name (NamePattern1) 8442**] MEDQUIST36 D: [**2144-11-3**] 01:31 T: [**2144-11-4**] 09:43 JOB#: [**Job Number 40807**]

[ "250.50", "414.01", "411.1", "250.60", "443.9", "278.01", "412", "428.0", "414.02" ]

icd9cm

[ [ [] ] ]

[ "36.01", "36.07", "88.56", "37.22", "37.23" ]

icd9pcs

[ [ [] ] ]

4912, 5500

4780, 4889

2220, 2634

4089, 4759

3477, 4071

157, 1628

1650, 2193

2651, 3454

57,377

179,645

19536

Discharge summary

report

Admission Date: [**2139-4-25**] Discharge Date: [**2139-4-26**] Date of Birth: [**2065-6-3**] Sex: M Service: MEDICINE Allergies: Phenergan Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: transfer for ERCP Major Surgical or Invasive Procedure: ERCP with sphincterotomy and common bile duct temporary stent placement. History of Present Illness: 73 yo man with COPD on 3L home O2, CAD s/p CABG ~12 yrs ago, atrial fibrillation on coumadin, HTN, HL, OSA on CPAP who presented to [**Hospital1 392**] on [**4-24**] with abdominal pain that started earlier that day. The pain was not associated with food and not releived by OTC antiacids. At the OSH he was found to have a fever to 100.5, elevated LFT's concerning for cholecystitis. RUQ U/S revealed distended gallbladder with stones but no evidence of cholecystitis and dilated common bile and intrahepatic ducts. MRCP revealed 4 large stones (up to 1 cm) in the common bile duct, no ductal dilation and periportal edema consistent with ascending cholangitis. He remained hemodynamically stable, he received one dose of gentamycin and was subsequently started on Zosyn/Flagyl, given 2 units of FFP and transfered to [**Hospital1 18**] for ERCP. Of note, he was found to have a new RBBB at OSH and was ROMI. . On admssion he was found to have WBC 12.1, BUN/Cr 41/2.0, ALT 340, AST 238, AP 253, Tbili 5.5 and amylase 564 and was taken directly to ERCP. Patient received ampicillin/gentamycin prior to procedure and was intubated. ERCP revealed two 1 cm stones, multiple smaller stones, CBD dilation to 12 mm, a stent was placed and a sphynteromy done. He was succesfully extubated after the procedure. . In the [**Hospital Unit Name 153**], patient denied any pain and stated that he was feeling well. Past Medical History: CAD s/p CABG AFib on coumadin COPD on home O2 at 3L OSA on CPAP DM II HTN HL Melanoma s/p resection Asthma GERD ? Dementia Depression Social History: Patient is retired. He has a 60 pk/yr smoking history, quit in the [**2109**]. Denies EtOH Family History: Non-contributory Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, DMM, oropharynx clear Neck: supple Lungs: Pursed lip breathing, clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs: [**2139-4-25**] 05:58PM WBC-12.1* RBC-4.43* HGB-11.8* HCT-36.9* MCV-83 MCH-26.7* MCHC-32.0 RDW-20.7* [**2139-4-25**] 05:58PM PT-22.7* PTT-30.0 INR(PT)-2.1* [**2139-4-25**] 05:58PM GLUCOSE-223* UREA N-41* CREAT-2.0* SODIUM-138 POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-19* ANION GAP-21* ALT(SGPT)-340* AST(SGOT)-238* ALK PHOS-253* AMYLASE-564* TOT BILI-5.5* CALCIUM-8.6 PHOSPHATE-5.3* MAGNESIUM-2.0 [**2139-4-26**] 05:43AM BLOOD WBC-8.3 RBC-4.04* Hgb-10.7* Hct-33.9* MCV-84 MCH-26.5* MCHC-31.6 RDW-21.1* Plt Ct-144* [**2139-4-26**] 05:43AM BLOOD PT-19.2* INR(PT)-1.8* [**2139-4-26**] 05:43AM BLOOD Glucose-200* UreaN-45* Creat-1.9* Na-141 K-4.3 Cl-106 HCO3-21* AnGap-18 ALT-281* AST-187* AlkPhos-240* Amylase-312* TotBili-3.9* ERCP Report: Date: Saturday, [**2139-4-25**] Endoscopist(s): [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 52995**], M.D. (attending) [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (fellow) Patient: [**Known firstname **] [**Known lastname 52996**] Ref.Phys.: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Anesthesiologists: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25731**], MD Assisting Nurse(s)/ Other Personnel: [**Name6 (MD) 39403**] [**Name8 (MD) **], RN Birth Date: [**2065-6-3**] (73 years) Instrument: TJF-160VF ([**Numeric Identifier 52997**]) [**Numeric Identifier 52998**] Indications: A level 4 consult was performed Fever, RUQ abdominal pain, jaundice, and an abnormal MRCP with dilated bile ducts and choledocholithiasis all consistent with cholangitis Medications: General Anesthesia Ampicillin 2 gm IV Gentamycin 60 mg IV Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. A physical exam was performed. The patient was administered General anesthesia. The patient was placed in the supine position and an endoscope was introduced through the mouth and advanced under direct visualization until the third part of the duodenum was reached. Careful visualization was performed. The procedure was not difficult. The quality of the preparation was good. The patient tolerated the procedure well. There were no complications. Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: A single periampullary diverticulum with a medium opening was found at the major papilla. There was also a medium-sized peri-ampullary lipoma. Cannulation: On the first attempt, cannulation of the biliary duct was successful and deep with a sphincterotome after a guidewire was placed. Contrast medium was injected resulting in complete opacification. The procedure was not difficult. The pancreatic duct was not cannulated. Biliary Tree: Two 10 mm piston-like stones that were causing partial obstruction were seen at the lower third of the common bile duct. There was post-obstructive dilation of the mid and distal CBD to 12 mm with a mild dilation of the upper CBD and CHD to 8-9 mm. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Two large 1 cm stones and a copious amount of small stones, stone fragments, and thick sludge were extracted successfully using a 9-12mm Rx balloon catheter. A 9cm by 10FR plastic biliary stent was placed successfully in the CBD using a Microvasive 10FR stent introducer kit. Multiple stones were seen in the gallbladder. The cystic duct did opacify with contrast and did not appear to be obstructed. Impression: A single periampullary diverticulum with a medium opening was found at the major papilla. There was also a medium-sized peri-ampullary lipoma. On the first attempt, cannulation of the biliary duct was successful and deep with a sphincterotome after a guidewire was placed. Contrast medium was injected resulting in complete opacification. The procedure was not difficult. The pancreatic duct was not cannulated. Two 10 mm piston-like stones that were causing partial obstruction were seen at the lower third of the common bile duct. There was post-obstructive dilation of the mid and distal CBD to 12 mm with a mild dilation of the upper CBD and CHD to 8-9 mm. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Two large 1 cm stones and a copious amount of small stones, stone fragments, and thick sludge were extracted successfully using a 9-12mm Rx balloon catheter. A 9cm by 10FR plastic biliary stent was placed successfully in the CBD using a Microvasive 10FR stent introducer kit. Multiple stones were seen in the gallbladder. The cystic duct did opacify with contrast and did not appear to be obstructed. Recommendations: Return to [**Hospital1 18**] ICU overnight. NPO overnight with aggressive IV hydration. He will need several liters of NS upfront and then a high infusion rate of 250-300cc/hr for cholangitis and gallstone pancreatitis. Continue IV antibiotics for cholangitis. Transfuse 2 units of FFP and please give 2.5 mg of vitamin K. No coumadin, ASA, plavix, or NSAIDs for 5-7 days. Repeat ERCP with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 10532**] in 4 weeks for stent removal. He will need to hold coumadin for 5 days prior to this procedure. Additional notes: The procedure was performed by the ERCP fellow and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 52995**]. Brief Hospital Course: 73 yo M with multiple medical problems who was transfered from OSH for ERCP after developing acute ascending cholangitis with obstructing stones. On admission to [**Hospital1 18**] found to have acute renal failure. . #. Ascending cholangitis: Patient presented to OSH with acute onset abdominal pain. Found to have acute ascending cholangitis and transfered to [**Hospital1 18**] for ERCP. Patient underwent procedure w/o complications, found to have two 1 cm stones, multiple small ones, a dilated CBD. Sphincterotomy was performed and a temporary stent was placed. His LFT's improved after procedure and Zosyn IV was continued. His pain was well controlled with morphine. He remained afebrile and hemodynamically stable throughout admission . #. Acute renal failure: Patient's BUN/Cr was WNL at the OSH. On admission labs found to have BUN/Cr 41/2.0. This was thought to be due to pre-renal azotemia due to dehydration as patient was NPO and FeNa was found to be 0.2%. He received IVF hydration and his renal function improved slightly. His lisinopril, lasix and digoxin were held due to ARF. Patient received gentamycin at the OSH and at prior to ERCP which could cause renal toxicity. Due to this renal function needs to be closely monitored. . #. CAD s/p CABG: Patient was found to have new RBBB at OSH and was ROMI. On admission EKG RBBB had resolved, but it did show atrial fibrillation and low voltage. Atenolol and verapamil were continued. Other meds held as above. . #. Atrial fibrillation: Patient currently in rate controlled atrial fibrillation in the 60's. Atenolol and verapamil were continued. He received 2 units of FFP and 5 mg of vitamin K for reversal of INR post-procedure as there was a risk for bleeding. Coumadin was held. . #. COPD/OSA: Patient with known COPD and was able to be extubated post-ERCP w/o complications. Home meds were continued. He has sats in the mid 90's on 5 L NC. He was on CPAP overnight for OSA. . #. GERD: He received IV pantoprazole while NPO and transitioned to PO pantoprazole one a diet was resumed. . #. DM II: Metformin and lantus were held due to ARF and NPO status respectively. Patient continued on humalog SS. . #. HTN: Patient was normotensive. Meds continued or held as above. . #. HL: Simvastatin was held due to liver injury. . #. Depression: Home meds continued. . #. ?Dementia: Home meds continued. . #. CODE STATUS: Full Code Medications on Admission: HOME MEDS: Malatonin 5/lorazepam 0.5mg QHS Advair 500/50 [**Hospital1 **] Spiriva 1 inhalation daily Proair IH prn Atenolol 50 mg daily Digoxin 0.25 mg daily Lisinopril 10 mg daily Metformin 1000 mg [**Hospital1 **] Verapamil 240 mg qam, 120 mg qpm Paroxetine 20 mg daily Omeprazole 20 mg daily Furosemide 80 mg daily Simvastatin 80 mg daily Coumadin 5 mg daily Aricept 10 mg daily Lantus Unknown dose Humalog SS .... Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for SOB. 8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 9. Verapamil 120 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 10. Verapamil 120 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 11. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 7 days. 12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 14. Lantus 100 unit/mL Cartridge Sig: unknown Subcutaneous once a day. 15. Humalog 100 unit/mL Cartridge Sig: 2-10 units Subcutaneous four times a day: per sliding scale. Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: Choledocholithiasis Ascending cholangitis Secondary diagnosis: Coronary artery disease Atrial fibrillation COPD OSA Hypertension Hyperlipidemia Dementia 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 transfered from [**First Name5 (NamePattern1) 392**] [**Last Name (NamePattern1) **] to [**Hospital1 18**] for ERCP. You underwent this procedure and a temporary stent was placed in your bile duct. You stayed in the ICU overnight for monitoring and you did well. DO NOT take coumadin (warfarin), aspirin, plavix (clopidogrel), or non steroidal anti inflammatory drugs (such as ibuprofen or naproxen) for the next 5-7 days. You will need to schedule another ERCP in 4 weeks to remove the stent that was placed. You will need to hold your coumadin 5 days before this procedure. You were noted to be in renal failure, so your lasix, digoxin, and lisinopril were held. These can be resumed when your renal function returns to normal. Due to your elevated liver function tests, simvastatin and metformin were stopped. You may resume these when your liver function returns to normal. No other changes were made in your medications. Followup Instructions: Please schedule a follow up appointment with your primary care doctor within a week of discharge from the hospital. Please schedule a repeat ERCP with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 10532**] in 4 weeks for stent removal. You will need to stop taking coumadin for 5 days prior to this procedure. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "401.9", "493.22", "427.31", "584.9", "214.3", "577.0", "V15.82", "574.91", "276.51", "327.23", "250.00", "294.8", "272.4", "V10.82", "V46.2", "V58.67", "576.1", "V58.61", "V45.81", "311", "530.81" ]

icd9cm

[ [ [] ] ]

[ "51.88", "96.71", "51.87", "51.85", "96.04" ]

icd9pcs

[ [ [] ] ]

12483, 12498

8199, 10594

294, 369

12715, 12715

2600, 8176

13861, 14317

2084, 2102

11064, 12460

12519, 12519

10620, 11041

12895, 13838

2117, 2581

237, 256

397, 1802

12602, 12694

12538, 12581

12730, 12871

1824, 1960

1976, 2068

23,058

162,448

2354

Discharge summary

report

Admission Date: [**2162-11-2**] Discharge Date: [**2162-11-10**] Date of Birth: [**2107-5-12**] Sex: F Service: Gold Surgery HISTORY OF PRESENT ILLNESS: This is a 55-year-old female with a history of chronic pancreatitis of greater than six years of duration with multiple GI interventions including a sphincterotomy in [**2156**] and multiple stent placements, the latest of which being in [**2162-8-27**]. These interventions did not provide resolution of pain or relief of the dilated dorsal duct. The patient still complaints epigastric pain, nausea, pruritus, decreased appetite, and diarrhea. The patient does not endorse weight loss, steatorrhea, or acholic stools. The patient was admitted for an elective Puestow procedure to be done by Dr. [**Last Name (STitle) 468**]. PAST MEDICAL HISTORY: 1. Pancreatitis. 2. Back surgeries x5. 3. Laparoscopic cholecystectomy. 4. Open appendectomy. 5. Post ERCP pancreatitis. 6. Fibromyalgia. 7. Pancreatic sphincteroplasty. 8. Cervical surgery x2. MEDICATIONS ON ADMISSION: 1. Vioxx. 2. Lipitor 20 mg q.d. 3. Codeine. 4. Elavil. 5. Calcium. 6. Viokase. 7. Amitriptyline. PHYSICAL EXAMINATION: All vital signs are stable. General: Healthy appearing alert and oriented times three, in no apparent distress. HEENT: PERRLA. Extraocular movements are intact. No thyromegaly noted. Cardiac: Regular, rate, and rhythm, no murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. Abdomen: Soft, mildly obese, nondistended, and slightly tender to palpation. LABORATORIES ON ADMISSION: White blood cells 8.2, hematocrit 38.9, platelets 380. PT 12, PTT 23.2, INR 1.0, ALT 16, AST 24, alkaline phosphatase 83, amylase 254, lipase 241, total bilirubin 0.2. On [**2162-11-2**], the patient underwent a Roux-en-Y longitudinal pancreaticojejunostomy (Puestow procedure) and two extensive lysis of adhesions. The patient tolerated the procedure well with no adverse hemodynamic or pulmonary consequences. She was extubated in the operating room and taken to the recovery room in stable condition. There were no complications during the procedure, and for full details, please see the operative note. The patient was transferred to the floor in the night post her procedure. Her recovery on the floor was complicated by a low urine output ranging from 10-15 cc throughout the hour as well as a decrease in the systolic blood pressure ranging in the 70s to low 80s. Patient required frequent fluid boluses and removal of her epidural in order to achieve hemodynamic stability. The patient was placed on PCA Dilaudid, but this was unable to control her pain adequately. Due to a lack of effective resuscitation on the floor, the patient was transferred to the SCRU, where she will be in a more controlled setting. The patient's course in the Intensive Care Unit was uneventful and postoperative day #2, the patient was transferred from the ICU to the floor. The patient continued to do well postoperatively. Pain was controlled on PCA Dilaudid. Patient was ambulating. On postoperative day #4, the patient had one episode of chest pain. An EKG was performed which showed normal sinus rhythm at 85 beats per minute, no T wave abnormalities, less than [**Street Address(2) 12255**] depressions in L4, and no other changes when compared to a previous EKG. The patient was able to localize the pain to subcostal area immediately next to the surgical incision site. It was deemed that this pain was unlikely cardiac in nature. Also on postoperative day #4, the patient's nasogastric tube was removed as was her Foley, and her PCA was weaned down in favor of oral pain medication. Patient's urinalysis sample showed a bacterial infection and the patient was placed on a five day course of Levaquin. By postoperative day #4, patient was on clear liquids and ambulating. Occasional bouts of nausea was still experienced. Patient continued to do well and by postoperative day #6, she was on a regular diet, taken off of all IV fluids. Electrolytes were being replaced as needed. Patient was ambulating and only experienced slight pain on her incision with motion. Postoperative day #7, the patient was concerned about increasing abdominal pain, which she was attributing to "gas pain" that she felt after eating. Requested that she remain in the hospital for one more day of observation. A CT scan was performed to rule out an abscess or any other fluid collection. The CT scan did not show any collection. By postoperative day #8, the patient states that she was feeling much better, tolerating full liquids without any difficulty, and was looking forward to going home. The patient was discharged to home with no services. DISPOSITION: The patient was discharged to home, no services, to followup with Dr. [**Last Name (STitle) 468**] on Monday, [**11-22**]. DISCHARGE CONDITION: Good, afebrile, pain well controlled on oral medications, ambulating, and tolerated food by mouth. FINAL DIAGNOSIS: 1. Laparotomy with Puestow procedure. 2. Laparoscopic cholecystectomy. 3. Lumbar surgery x2. 4. Cervical surgery x2. 5. Status post endoscopic retrograde cholangiopancreatography pancreatitis. 6. Fibromyalgia. 7. Pancreatic sphincteroplasty. 8. Pancreas divisum. DISCHARGE MEDICATIONS: 1. Propoxyfene/acetaminophen one tablet q.4-6h. as needed. 2. Oxycodone 20 mg one tablet q.12h. 3. Reglan 10 mg tablets one tablet 4x/day. 4. Albuterol 1-2 puffs q.4-6h. as needed for shortness of breath. 5. Amitriptyline 25 mg tablets two tablets p.o. q.h.s. 6. Prevacid 50 mg one tablet p.o. q.d. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**] Dictated By:[**Name8 (MD) 846**] MEDQUIST36 D: [**2162-11-11**] 10:52 T: [**2162-11-12**] 08:58 JOB#: [**Job Number 12256**]

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Discharge summary

report

Admission Date: [**2115-5-26**] Discharge Date: [**2115-5-30**] Date of Birth: [**2035-12-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 545**] Chief Complaint: transfer for management of cholangitis Major Surgical or Invasive Procedure: ERCP ([**2115-5-27**]) History of Present Illness: 79M with recently diagnosed, inoperable pancreatic cancer s/p palliative biliary stent in [**2-/2115**] presented to [**Hospital **] Hosp on [**5-25**] with rigors. The day of admission, he developed rigors and mid abd pain shortly after eating. He was also anuric at home. He presented to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with T102. . At [**Hospital1 **], he was treated with ertapenem, vancomycin, and levofloxacin empirically; blood cultures grew GNR in [**4-19**] bottles on HD #2. Pt was hypotensive with SBPs 70s-80s, responsive to IVF, on HD#2 as well. Cardiac enzymes showed a troponin peak of 0.2 with negative CPK. Coumadin, which he takes for afib, was stopped, and he received po vitamin K in anticipation of ERCP. DNR/DNI was confirmed with HCP and pt's brother, but risks and benefits of transfer were discussed and pt and family decided to proceed with palliative ERCP for stent change. Past Medical History: # Pancreatic Ca dx'd at [**Hospital1 112**] after presenting with fever and jaundice; staging CT scan apparently demonstrated 2 pulmonary nodules, which were not biopsy proven. After consultation with surgery and his family, he declined Whipple resection. Presenting cholangitis was palliated with ERCP and metal stent x2 in [**2115-2-15**] # MRSA pna rx'd with linezolid, [**1-/2115**] # CKD # BPH # GERD # PPM for sick sinus; afib # liver abscess in [**2111**] complicated by GNR sepsis and ARDS # recurrent pancreatitis # DM # NSTEMI in [**12/2113**]; ischemic myopathy with EF 40% Social History: SocHx: pt has developmental delay, lives with brother [**Name (NI) **]. sister [**Name (NI) **] [**Name (NI) 7710**] is HCP; [**Telephone/Fax (1) 78584**]. One daughter from previous marriage lives in western Mass. No EtOH. No tobacco. Family History: NC Physical Exam: Flowsheet Data as of [**2115-5-26**] 10:19 PM Tmax: 36.8 ??????C (98.2 ??????F) Tcurrent: 36.8 ??????C (98.2 ??????F) HR: 71 (70 - 71) bpm BP: 97/62(70) {97/61(69) - 119/70(70)} mmHg RR: 20 (13 - 20) insp/min SpO2: 99% Heart rhythm: A Paced Height: 67 Inch Respiratory O2 Delivery Device: Nasal cannula SpO2: 99% ABG: ///22/ Physical Examination General Appearance: Well nourished, hard of hearing Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath Sounds: Clear : ) Abdominal: Soft, Bowel sounds present, Tender: periumbilical, RUQ and epigastric fullness Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t) Clubbing Musculoskeletal: No(t) Muscle wasting Skin: Warm, No(t) Jaundice Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): person, time, and place, Movement: Not assessed, Tone: Not assessed Pertinent Results: Admit Labs: =========== [**2115-5-26**] 08:10PM BLOOD WBC-16.8* RBC-3.53* Hgb-11.1* Hct-34.0* MCV-96 MCH-31.4 MCHC-32.6 RDW-17.8* Plt Ct-140* [**2115-5-26**] 08:10PM BLOOD PT-29.2* PTT-32.9 INR(PT)-3.0* [**2115-5-26**] 08:10PM BLOOD Glucose-110* UreaN-19 Creat-1.3* Na-140 K-3.9 Cl-113* HCO3-22 AnGap-9 [**2115-5-26**] 08:10PM BLOOD ALT-49* AST-83* CK(CPK)-134 TotBili-1.6* [**2115-5-26**] 08:10PM BLOOD CK-MB-3 cTropnT-<0.01 [**2115-5-26**] 08:10PM BLOOD Calcium-6.9* Phos-2.9 Mg-1.5* . Studies: ======== TTE ([**5-30**]): The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No 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. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image qualiuty. No vegetations or significant valvular regurgitation seen. Preserved global biventricular systolic function. . ECG ([**5-27**]): Atrially paced rhythm and occasional intrinsic atrial activation with A-V conduction and A-V conduction delay. Low limb lead voltage. Prior anteroseptal myocardial infarction. Compared to the previous tracing of [**2115-5-26**] no diagnostic interim change. . ERCP ([**5-27**]): Impression: 1. Previously placed biliary stent was seen in the major papilla. The stent was removed with a rat tooth forceps. 2. Post stent pull a sphincterotomy was seen. 3. Cannulation of the biliary duct was performed with a balloon catheter 4. Cholangiogram showed a high grade distal CBD stricture measuring 3 cm. The extrahepatic biliary tree proximal to the stricture was hugely dilated. 5. A 60 mm by 10mm Covered biliary wall stent (Lot No [**Serial Number 78585**]) biliary stent was placed successfully across the distal biliary stricture with flow of pus and obstructed bile. . Discharge/Other Labs: ===================== [**2115-5-30**] 06:15AM BLOOD WBC-5.0 RBC-3.34* Hgb-10.1* Hct-31.8* MCV-95 MCH-30.3 MCHC-31.9 RDW-17.8* Plt Ct-175 [**2115-5-27**] 04:44AM BLOOD WBC-13.5* RBC-2.99* Hgb-9.4* Hct-28.4* MCV-95 MCH-31.4 MCHC-33.0 RDW-17.8* Plt Ct-129* [**2115-5-30**] 06:15AM BLOOD Glucose-107* UreaN-8 Creat-1.3* Na-142 K-4.1 Cl-111* HCO3-24 AnGap-11 [**2115-5-29**] 06:15AM BLOOD Glucose-111* UreaN-10 Creat-1.3* Na-139 K-4.4 Cl-109* HCO3-24 AnGap-10 [**2115-5-28**] 03:31AM BLOOD Glucose-89 UreaN-17 Creat-1.2 Na-142 K-3.4 Cl-114* HCO3-20* AnGap-11 [**2115-5-29**] 06:15AM BLOOD ALT-22 AST-26 LD(LDH)-191 AlkPhos-588* TotBili-1.5 [**2115-5-28**] 03:31AM BLOOD ALT-26 AST-32 AlkPhos-490* TotBili-1.2 [**2115-5-30**] 06:15AM BLOOD Calcium-7.3* Phos-2.8 Mg-1.7 [**2115-5-29**] 06:15AM BLOOD Albumin-2.1* Calcium-7.3* Phos-2.7 Mg-1.8 . Micro: ------ Blood Cx ([**5-27**], [**5-28**], [**5-30**] x 2) - No growth to date Blood Cx ([**5-25**], [**Hospital 5871**] Hospital) - E. Coli, ESBL (sensitive to Amikacin, Ertapenem, Nitrofurantoin, Imipenem, Bactrim, Zosyn) Brief Hospital Course: A/P 79M with non-operable pancreatic cancer s/p biliary stenting, now with cholangitis. Transferred from [**Hospital 5871**] Hospital to [**Hospital1 18**] for emergent ERCP. Initially admitted to ICU. . # cholangitis/#septicemia/#Pancreatic Cancer Initially covered with meropenem and ciprofloxacin. Antibiotics later changed to Zosyn. The patient underwent ERCP that showed CBD stricture. This was stented with good flow of bile and pus. Previously placed stent was removed. After the procedure, the patient was hemodynamically stable and defervesced. WBC count trended down. Diet was advanced to a regular diet, which he tolerated well. On [**5-29**], culture data was obtained from [**Hospital 5871**] Hospital which showed ESBL E. Coli. Given the pathogenesis of this bacteria, antibiotics were changed from Zosyn to Meropenem. This will need to be continued for 10 days (last dose on [**6-8**]) to ensure adequate treatment. A TTE was performed and did not show any evidence of endocarditis (however image quality was somewhat suboptimal). Blood cultures at [**Hospital1 18**] were negative to date. His pancreatic cancer is reportd to be inoperable given his overall risk factors (per surgeons at [**Hospital1 112**]). . # Atrial Fibrillatin The patient's B-blocker was held during this hospitalization. He had an INR of 3 at the OSH, where he was given Vitamin K. Prior to his ERCP, he received FFP. coagulopathy: INR 3.0, on coumadin as outpt but did receive vit K po at OSH. Repeat in am, plan to transfuse two units FFP and recheck prior to ERCP. INR subsequently 1.4. Coumadin restarted on [**5-29**]. Plan to restart B-blocker, however there was some reports of dizzy spells prior to initial admit. Would re-start at low-dose and monitor for tolerance. . # DM-2 Was maintained on an insulin sliding scale while in-house. Fingersticks were well controlled. . # BPH Tamsulosin was initially held, however subsequently was restarted. . # CKD, Stage III Cr remained relatively stable during this hospitalization . # Access Midline (placed [**5-30**]) . # Code - DNR/DNI Medications on Admission: colace 100 qhs omeprazole 20 daily flomax 0.4mg daily simethicone tid aspirin 81mg coumadin 2.5mg daily mvi HISS Metoprolol 50mg [**Hospital1 **] . Medications on transfer: ertapenem 1gm IV q24 levofloxacin 500mg IV q24 pantoprazole 20mg daily simethicone 80mg tid aspirin 81mg daily morphine 4mg IV q4h prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 7. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 10 days: Last dose on [**6-8**]. 8. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous qAC and qHS: As per sliding scale: Start with 2U for FS of 151, and increment by 2U for every 50 of fingerstick. 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day: Hold for HR<55 or sbp<100. Can up-titrate dose back to home dose of 50mg [**Hospital1 **] if tolerated by patient. Discharge Disposition: Extended Care Facility: [**Last Name (un) 6978**] House of [**Location (un) 5871**] Discharge Diagnosis: Cholangitis Septicemia (ESBL E. Coli) Pancreatic Cancer Atrial Fibrillation Type II Diabetes Mellitus Benign Prostatic Hypertrophy Chronic Kidney Disease, Stage III Discharge Condition: Afebrile, vital signs stable, tolerating PO Discharge Instructions: You will need to take antibiotics (Meropenem) for 10 more days (last dose on [**6-8**]) since you had bacteria in your blood. . Your B-blocker (metoprolol) was held while you were here due to your low initial blood pressures. This is being restarted on discharge, however at a lower dose (12.5mg twice daily instead of 50mg twice daily). You should see how you feel with this medication. If you feel dizzy or lightheaded or your heart rate is slow, it should be stopped. If you have a fast heart rate and room on your blood pressure, the dose can be slowly increased back to the dose you were taking. . Please call your doctor or return to the emergency room if you should have increased abdominal pain, high fevers, chest pain, shortness of breath, or any other concerning symptom. Followup Instructions: Primary Care: Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 47884**]. Please call to follow up 1-2 weeks after discharge from rehab. Gastroenterology: Dr. [**Last Name (STitle) 78586**]. Please call to follow up 1-2 weeks after discharge from rehab.

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Discharge summary

report

Admission Date: [**2198-11-27**] Discharge Date: [**2198-12-2**] Service: CHIEF COMPLAINT: Increased lethargy, decreased responsiveness, question of a gastrointestinal bleeding, hypotension, hypoxia. This was a transfer from [**Hospital3 **]. HISTORY OF PRESENT ILLNESS: This is an 81-year-old white male with a history of metastatic colon cancer, history of lung, testicular and basal cell cancer, hypertension, history of deep vein thrombosis, status post an ICD filter with recurrent C. difficile colitis here with hypotension, hypoxia, lethargy, "congestion", and unresponsiveness for two days. Got Levaquin yesterday and was transferred from [**Hospital1 **] for further evaluation at [**Hospital1 190**]. The patient is usually alert and verbal however, cannot do activities of daily living at baseline. Chest x-ray at [**Hospital1 **] revealed a "mild bilateral pneumonitis" and a 3 cm new right upper lobe nodule. Today increasing lethargy and no p.o. intake. Was sent to [**Hospital1 1444**] for further evaluation ( on route the patient decompensated with sats dropping to 80% on room air and agonal breathing. (In the Emergency Room the temperature was 101.8, blood pressure 118/32, heart rate 101, respiration rate of 20 and 98 to 100% on a non-rebreather). The patient was intubated for respiratory failure. Following this blood pressures decreased to 78/34 responding to intravenous fluid boluses back to a systolic blood pressure of 110. However, blood pressures decreased in the 80's and the patient required to be started on Dopamine. Got Ceftriaxone, Flagyl, Protonix. A right subclavian central line was placed as well as an A-line. PAST MEDICAL HISTORY: 1. Metastatic colon cancer. Status post colectomy diagnosed in [**2188**]. 2. Lung cancer diagnosed in [**2191**], status post left lower lobe lobectomy. 3. Testicular cancer diagnosed in [**2153**], status post orchiectomy. 4. Basal cell carcinoma. 5. Hypertension. 6. Bipolar disorder. 7. Deep vein thrombosis. Status post an IVC filter. 8. Recurrent C. diff colitis however, a last C. diff was negative on [**2198-11-7**]. 9. A mild chronic renal insufficiency with creatinines ranging from 1.1 to 1.3. 10. Anemia with a baseline hematocrit of 26. 11. Sacral decubitus, status post a failed flap in [**2198-1-26**] with wound dehiscence. 12. Pseudo gout. ALLERGIES: Gentamicin, Clindamycin, Erythromycin. MEDICATIONS: 1. Folic Acid 1 mg q day. 2. Ativan 0.5 mg q h.s. 3. Tegretol 20/100, 200/100, 200 mg q day. 4. Multivitamins. 5. Flomax 0.5 mg q day. 6. Verapamil 40 mg twice a day. 7. Protonix 40 mg twice a day. 8. Iron 325 mg twice a day. 9. Zyprexa 5 mg q h.s. 10. Loperamide p.r.n. 11. Benadryl p.r.n. 12. Tylenol p.r.n. 13. Fibercon p.r.n. 14. Vitamin C. 15. Lactate. 16. Keflex between [**11-2**] to [**11-9**]. 17. Vancomycin fro two week course that finished on [**10-30**]. PHYSICAL EXAMINATION: Temperature 100.8, heart rate 96, blood pressure 117/53, O2 sats 86% General: Intubated, sedated, cachectic and wasted appearing male. Head, eyes, ears, nose and throat: Pinpoint pupils, poor dentition, Entrotracheal tube in place. Right subclavian in place. Cardiovascular: Tachycardiac, regular, no murmurs, rubs or gallops appreciated. Lungs: Generally clear to auscultation bilaterally, decreased breath sounds at the right base. Abdomen soft, slightly distended, normal active bowel sounds. Rectal bag and Foley in place. Extremities: Right hip Tegaderm, right heel ulcer, no edema. Rectal: Per the Emergency Room, brown, OB positive stool. Sacrum: A deep, approximately 6x6 open ulcer with necrotic bone exposed. LABS: White blood count 32.1, hematocrit 31.8, platelets 462 with a differential of 83 polys, 7 bands, 1 lymphocyte. INR of 1.9, sodium 147, potassium 5.2, chloride 110, bicarbonate 21, BUN 82, creatinine 3.2. Glucose 170. CK 46, Troponin 1.4. Urinalysis revealed 1.025/5.5, small bili, trace leukocyte esterase, nitrate negative, moderate blood, greater than 300 protein, trace ketones, white blood count greater than 50, 11 to 20 red blood cells, many bacteria, no yeast, no squamous epi's. Chest x-ray revealed an endotracheal tube in place, an nasogastric tube in place, right subclavian tip in the SVC/right atrial junction, no pneumothorax. Bilateral parenchymal opacities, possible effusion. Arterial blood gases: 7.06/68/337 on an SIMV 600 times 12 with 5 of PEEP and 100% FIO2. Electrocardiogram revealed left axis deviation, rate of 101 and normal sinus rhythm, question of a Q in lead 5, T-wave inversions in Lead 1 and L. Lactate was 1.5. IMPRESSION: This is an 81-year-old white male with a history of metastatic colon cancer, lung cancer, history of testicular basal cell cancer, hypertension, deep vein thrombosis, status post an IVC filter, a recurrent C. diff and a sacral decubitus here with sepsis likely from bilateral aspiration pneumonia. Urosepsis, question of osteo and possible C. diff colitis. The patient had low grade temperature with an elevated white blood count. Hypoxia likely resulting in increase somnolence, change in mental status. He is also here in acute renal failure. HOSPITAL COURSE: On arrival the patient was in hypoxic respiratory distress and electively intubated. Given Ceftriaxone, Levofloxacin, Flagyl and then Vancomycin empirically. Had copious guaiac positive green stools. Got three liters of intravenous fluid but required Dopamine to maintain adequate pressures. White blood count was 72 with 10% bands. Stool returned C. diff positive and subsequently was started on p.o. Vancomycin in addition to the intravenous in order to treat this stubborn C. diff colitis. Also as cultures returned the patient was found to have Methicillin resistant Staphylococcus aureus pneumonia, Klebsiella, urosepsis and 1/4 bottles with gram negative diplococci that was likely a contaminant. His urine output continued to fall and renal was consulted and he was determined to have oliguric ATN, likely secondary to hypoperfusion. He also had a metabolic acidosis which was likely multi-factorial and secondary to his diarrhea, lactic acidosis and uremia. Treatment with bicarbonate was initiated. Because he had become hyponatremic, free water boluses were initiated. The patient had a TTE revealing an EF of 40 to 50%, left atrium mildly dilated, no Arteriosclerotic disease, anterior septum and anterior free wall may be slightly more hypokinetic. Plastic Surgery was consulted about possible vacuum dressing to the severe sacral decubitus however, they recommended supportive care as it was operatively unable to fix and vacuum dressing was not indicated. After five days Mr. [**Known lastname **] had not responded to antibiotics and was still intubated requiring pressors. Several days of discussion with both daughters had occurred and they were updated on his poor prognosis. On day five admission they decided to change the focus of his care to comfort and to stop aggressive measures. The patient passed away on [**2198-12-2**] at 4:40 AM. [**Last Name (LF) **], [**First Name3 (LF) **],A. Dictated By:[**Name8 (MD) 210**] MEDQUIST36 D: [**2198-12-9**] 18:14 T: [**2198-12-11**] 10:24 JOB#: [**Job Number 44109**]

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Discharge summary

report

Admission Date: [**2145-8-27**] Discharge Date: [**2145-9-8**] Service: MEDICINE Allergies: Penicillins / Ciprofloxacin / Lipitor / Erythromycin Base Attending:[**First Name3 (LF) 2474**] Chief Complaint: Hematuria Major Surgical or Invasive Procedure: Transurethral resection of bladder tumor History of Present Illness: 84 y/o with a past history significant for [**Last Name (un) 3696**] syndrome and hypothyroidism presented initially with vaginal bleeding. Patient has known history of bladder cancer, diagnosed in [**2140**]. Pt presented after noticing bleeding starting on [**8-24**] and progressively increasing over the next several days, with associated fatigue and lethargy. She was intially admitted to [**Hospital1 **] where abd CT showed pelvic mass adjacent to bladder and vagina. She has received 2 units PRBC's. Patient was noted on the floor two days after admission, after having received 2u pRBC, with hypertension to the 220s/100s, with decreased oxygen saturations to mid-80s. She was transferred to the MICU for management of flash pulmonary edema. This resolved initially with 10 IV Hydral,IV lopressor 5mg x2, nitro paste, 40 of lasix (U/O 1L). She was noted in this setting to have demand ischemia with increased ST dep in III, V5-6 compared to baseline with + troponin elevation. . In the MICU she was stable, with continued hematuria. She required 1U pRBCs on [**8-29**]. She was scheduled for an MRI to further evaluate her pelvic mass and for RAS with labile blood pressures, but was unable to complete the study [**1-14**] anxiety re: noise. She is now transferred to the floor for further workup of her bladder mass. . At baseline, she does not have SOB, has good exercise tolerance. No h/o PND/orthopnea. Past Medical History: 1. Hypertension 2. Hypothyroidism (last TSH [**2143-8-24**] 1.6) 4. Bladder mass existing since [**2137**]. Cytology positive for urothelial neoplasia [**2143-6-27**]. Was scheduled for cystoscopy in [**2143-3-14**] but did not follow up. Cystocopy with biopsy in [**12/2140**] (no biopsy results available in OMR). 5. Coronary artery disease. Positive exercise stress test in [**2138**] showing inferolateral ischemia. She also had an echocardiogram showing an ejection fraction of 55% without wall motion abnormalities and 2+ mitral regurgitation in [**2141**]. 6. Multinodular goiter diagnosed in [**2139**] with US. 7. Bilateral small pulmonary nodules in a diffuse pattern seen on chest CT in [**2141**] for which an etiology has not been determined. 8. She also has a very mild ascending aortic aneurysm that measures 3.8 x 3.6 cm seen on the same CT and a right brachiocephalic aneurysm measuring 1.8 x 1.7 cm in [**2141**]. 9. Depression 10. Hyperlipidemia ([**7-15**] CHOL 293, LDL 196, refusing lipid lowering therapy). 11. Osteoporosis 12. DJD 13. Carpal tunnel syndrome 14. Chronic cough secondary to GERD 15. [**Hospital Ward Name 4675**] cyst Social History: Patient lives alone in [**Location (un) 745**]. Closest family are brother and [**Name2 (NI) 12232**]. [**Name (NI) 1139**]: never EtOH: denies IVDU: denies Family History: Denies family history of cancer Physical Exam: VS: 96.8 BP 147/58 HR 88 O2 sat 98% RA Gen: well appearing in NAD. HEENT: PERRL. MMM. Hrt: RRR. No MRG. Lungs: CTAB no RRW. Abd: Soft. No masses felt. No organomegaly. Foley draining bloody urine. Ext: WWP. No CCE. Neuro: Grossly intact. Lymph: No cervical, axillary, inguinal LAD. Skin: Ecchymoses at IV sites. No petechiae. Pertinent Results: [**2145-8-27**] 08:15PM WBC-10.6 RBC-3.32* HGB-10.2* HCT-28.1* MCV-85 MCH-30.6 MCHC-36.1* RDW-14.8 [**2145-8-27**] 08:15PM GLUCOSE-128* UREA N-19 CREAT-1.2* SODIUM-137 POTASSIUM-4.7 CHLORIDE-108 TOTAL CO2-22 ANION GAP-12 [**2145-8-27**] 08:15PM PLT COUNT-193 MRI abdomen: These images show hydronephrosis and hydroureter on the right, with renal cortical thinning. There is a circumferential mass seen at the posterior right side of the bladder (in the region of the expected insertion of the right ureter) through which the ureter runs. This mass measures approximately 4.5 cm x 3.6 cm x 2.5 cm in size. There is a Foley catheter within the bladder. Vagina is not clearly delineated on these images; the uterus and adnexa are not identified. Brief Hospital Course: Assessment/Plan: 84 y/o F with history of bladder cancer admitted with vaginal bleeding, transferred to the MICU in the context of hypertensive urgency with hypoxia, with resultant NSTEMI, now stabilized and transferred to the floor for further workup of the bladder mass. S/P TURBT. . 1. Pelvic mass: Patient with h/o bladder cancer in [**2140**] now with new mass on US and MRI. Need tissue dx and metastatic w/u. Underwent TURBT with good improvement in hematuria. Foley removed without incident, patient able to urinate. Pathology pending at time of discharge. To follow up with Dr. [**Last Name (STitle) 3748**] in Urology for discussion of results. 2. ARF: Developed AIN with Bactrim during UTI treatment. Urine eosinophils positive. Creatinine improving during stay. Encouraging po intake. Also, mass covered part of right ureteral insertion on trigone resulting in hydronephrosis. . 3. HTN: Patient had episode of hypertensive urgency resulting in flash pulmonary edema. Per outpatient cardiologist, patient non-compliant wtih meds, and refused studies for renal artery stenosis. Avoiding ace-inhibitors. Up-titrated Metoprolol to 50 mg po tid. After the isolated episode, her blood pressure remained well controlled. . 4. CAD: Ms [**Known lastname 3271**] has a history of CAD and demand ischemia (ST depression V5-6) in the setting of SBP 200's. Repeat EKG after resolution of HTN urgency demonstrated resolved ST depressions. Aspirin was avoided in the context of hematuria. Questionable history of allergy to Lipitor. In the hospital, she was given low dose Lipitor, which she tolerated well. On beta-blocker. . 5. Hypothyroidism: The patient has a history of hypothyroidism, treated with levothyroxine. TSH checked in the hospital was elevated at 7.4. Dose increased to 100 mcg po qd. . 6. Osteoporosis: Continued on home calcium and vitamin D . 7. Oglivie's Syndrome: given a bowel regimen. Patient able to have bowel movements in the hospital. . 8. FEN: Maintained on a regular cardiac-healthy diet. Sore throat after intubation for TURBT, led to decreased po intake. Cepacol lozenges with good effect. Advancing diet at time of discharge to soft. . 9. Full Code. No HCP. Medications on Admission: ASPIRIN 81 mg--1 tablet(s) by mouth once a day ATENOLOL 50 mg--[**12-14**] tablet(s) by mouth once a day IBUPROFEN 800 mg--1 tablet(s) by mouth three times a day Levothyroxine 75 mcg--1 tablet(s) by mouth once a day 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. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:*60 Tablet, Chewable(s)* Refills:*2* 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Amlodipine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Last Name (un) 1687**] - [**Location (un) 745**] Discharge Diagnosis: Bladder mass Hematuria Hypertension Multinodular goiter/Hashimoto's thyroiditis Hypothyroidism Oglivie's Syndrome Osteoporosis Hyperlipidemia Valvular Heart Disease-AR/MR Basal Cell Skin Cancer Carpal Tunnel Syndrome [**Hospital Ward Name 4675**] Cyst DJD. Discharge Condition: Hemodynamically stable, afebrile. To rehab. Discharge Instructions: Please plan to follow-up with Dr. [**First Name (STitle) 1022**] and Dr. [**Last Name (STitle) 3748**] to discuss your hospitalization . If you develop worsening bleeding in the urine, abdominal pain, fever >101.3, or any other concerning symptom, please contact your primary care physician [**Name Initial (PRE) **]/or return to the emergency room. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2145-9-22**] 1:45 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2145-9-22**] 5:40 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**] MD, [**MD Number(3) 2478**]

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Discharge summary

report

Admission Date: [**2167-10-17**] Discharge Date: [**2167-11-3**] Date of Birth: [**2107-7-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Aspirin Attending:[**First Name3 (LF) 1943**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 60-year old woman with a history of CAD s/p IMI, CHF s/p AICD, SLE, scleroderma, severe pulmonary HTN, COPD on home O2 2 L NC, recent R hip fracture after fall s/p R ORIF and MICU stay for hypotension and difficulty with extubation who now has been transferred back to the hospital from rehab and admitted for respiratory distress. On [**2167-10-1**], patient was admitted to an OSH for C. diff pancolitis and discharged on PO Vancomycin. On [**2167-10-6**] at home, she tripped and fell off 2 stairs. She was taken to OSH, where she was found to have a displaced intertrochanteric hip fracture and was transferred to [**Hospital1 18**]. Although operative risk was high given multiple comorbidities, she underwent R ORIF on day of transfer. There were no complications during surgery. After extubation, she required non-rebreather and subsequently became hypotensive requiring pressors for 48 hours. She was transferred to MICU and reintubated. She was initially treated with Cefepime, Vancomycin, and Levaquin in addition to IV Flagyl and PO Vancomycin for C. diff. Her cultures only showed a UTI and her antibiotics were tapered down to Cipro in addition to PO vanc for C. diff. She was restarted on her home pulm HTN medications sildenfil and bosentan. Pt was extubated [**10-13**], was initially tachypneic and improved after gentle diuresis. She was also restarted on BB that was titrated up for MAT vs. Afib. She was discharged to rehab on [**2167-10-16**]. On [**2167-10-17**] at the rehab, the patient was noted to be hypoxic, satting 84% on 2L. She had denied SOB and had a nonproductive cough. Of note, she did have a bedside evaluation and aspirated on jello. On 5L O2, O2 sat was 93-94% post-nebulizer treatment. ABG was 7.47/34/57. She was then noted to be tachycardic to 120. She was given Lasix 20 mg IV and put on 1200 cc. She was also spiked a fever to 101.7 and was given Vanco and Cefepime. Patient was brought to the ED for re-evaluation. In the ED, initial vital signs were: 99.6, 132, 157/96, 36, 95. Tmax 104.8. Exam was [**Date Range 65**]. for erythematous RUE and RLE. PICC site was evaluated by IV team and felt to be bruised but clean. CTA chest shows singular small PE at LLL ant basal segment branch point, left pleural effusion, & bibasal atelectasis. She was also noted to have nodular consolidation and fluid in trachea and esophagus susp for aspiration pneumonitis. Pt was started on heparin gtt. CT abd was benign. Patient received 125 mg solumedrol. Tachypnea improved with nebs. Her troponin increased to 0.11. She has an aspirin allergy. Cardiology was consulted and recommended plavix if her troponin increases again. Pt also received toradol 30 mg IV and morphine 4 mg for pain. She had 1L NS. VS on transfer: BP 127/61, HR 117, RR 31, O2 sat 100% on 10L by NC. Past Medical History: - CAD s/p IMI, cardiac cath [**2164**] with PCI to LCx, minor irregularities in LAD and RCA territories, stress Test [**10-8**] without active ischemia - CHF, s/p AICD for low EF (30% in [**5-8**]% in [**10-8**]) thought to be due to systemic sclerosis, most recently 50-55% in [**10-9**] - Severe Pulmonary Hypertension, s/p RHC [**12-7**] to evaluate response to vasodilator therapy, no response, PAP 100mm Hg, Cardiac Index 2L/min - R-sided heart failure: ECHO in [**10-9**] shows dilated, hypertrophied, and markedly hypokinetic right ventricle. - Systemic Sclerosis with ischemia to L index finger with osteomyelitis - Severe Raynaud's syndome - SLE - Multiple episodes of C. Diff diarrhea while on antibiotics - COPD on 2L oxygen, ? scleroderma lung disease - GERD - Occipital Neuralgia - h/o SBO/lysis of adhesions - h/o meningitis [**3-9**], treated with braod-spectrum abx and developed C. Diff Social History: 25 pack year smoking history, quite smoking 11 years ago, no prior alcohol use. Married with two adult children, two grand children. Family History: Noncontributory, no history of autoimmune disease. Physical Exam: VS 99.1, 96.4, 88 (74-91), 121/63 (98-131/43-83), 18, 93%/2L I/O: -1300 cc/24H, 3 stools/24H Gen: NAD, NG and oxygen on, HOH (better in right ear) HEENT: Pupils markedly different, ERRL R eye, per hx and exam Left eye with cataract, moist oral mucosa CV: RRR, normal s1/s2 no murmurs, rubs, or gallops pulm: clear to auscultation abd: +bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly ext: 2+ b/l LE edema to mid calf, left hand edema 1+, right arm with PICC and large ecchymosis, but nontender neuro: alert, oriented to first name (not last), place, and not oriented to time (per ICU team this has been new baseline), CNs intact, sensation intact, strength diffusely [**4-5**]. Pertinent Results: ADMISSION LABS: [**2167-10-16**] Chem 7 146 114 27 101 3.8 25 0.9 CBC 12.3 > 9.7 / 30.7 < 352 Ca 7.5 Ph 1.8 Mg 2.1 Trop 0.11 Lipase 144 ALT(SGPT)-32 AST(SGOT)-64* CK(CPK)-168* ALK PHOS-45 TOT BILI-0.4 Lactate 1.5 U/A: few bacteria, no yeast, large nitrite, negative protein, negative ketone, negative leuks HCT downtrended to a nadir of 22.2 ([**2167-10-30**]), then after transfusion with 1 unit PRBC, HCT rose to about 25 where it remained stable for the remainder of the hospital stay. DISCHARGE LABS: Chem 7 132 97 30 100 4.7 28 0.5 CBC 5.9 > 8.3 / 25.0 < 379 PT: 23.0 PTT: 34.8 INR: 2.2 EKG: MAT with rate of 100. LAD. TWI in V1 (old), biphasic T in V2 (old), V3 (new) <1mm STE in V4-5 CXR [**10-17**]: R PICC line. Cardiomegaly. Mild perihilar fullness, slightly worsened than [**10-16**]. L pleural effusion. CTA chest/abd [**10-17**]: 1. Singular small pulmonary embolus in the pulmonay subsegmental artery to the left anterobasal segment. 2. Right lower lobe nodular opacities peripherally together with fluid in the esophagus and trachea suggest aspiration pneumonitis. 3. Upper normal diameter of pulmonary artery, together with biventricular and biatrial enlargement are more suggestive of a chronic elevated right heart pressure than acute right heart strain. CXR [**10-24**]: The right PICC line tip is at the level of low SVC. The NG tube tip is in the stomach. The pacemaker leads terminate in right atrium and right ventricle. Cardiomediastinal silhouette is unchanged including cardiomegaly. Pulmonary artery dilatation that is known based on the recent CT of the torso is redemonstrated. Bibasal opacities consistent with known interstitial changes appear to be slightly more prominent on the current study. Thus superimposed acute on chronic process cannot be excluded and should be closely followed. The upper lungs are clear. There is no interval development of pleural effusion and there is no pneumothorax. CXR [**2167-11-1**]: Cardiac silhouette remains enlarged and there is persistent enlargement of the central pulmonary arteries. Patchy opacities have developed at both bases predominantly in the retrocardiac regions, and could be due to clinically suspected aspiration. Small pleural effusions are also demonstrated. Minimal basilar interstitial abnormality, which could reflect interstitial edema or chronic scarring/fibrosis in the setting of scleroderma. Right femur [**10-17**]: Expected postop appearance. No subcutaneous air. [**10-21**] hip 2 view: Status post ORIF right intertrochanteric fracture, in overall anatomic alignment. Right upper extremity ultrasound [**10-18**]: No son[**Name (NI) 493**] evidence of right upper extremity DVT. Non-visualization of one of the two paired brachial veins, which cannot be evaluated for DVT, although there are no findings to suggest DVT. Video swallow evaluation [**10-23**] Video oropharyngeal swallow evaluation was performed in collaboration with the speech and swallow specialist. There are moderate oral phase deficits including free spill of all liquids to the pharynx. There are mild pharyngeal deficits including mild residue of puree in vallecula. There is penetration of thin and nectar before swallow. This leads to aspiration of thin only after swallow. CT head with contrast [**10-21**] The study is slightly limited in interpretation secondary to patient motion. Within that constraint there is no intracranial hemorrhage, edema, mass effect or vascular territorial infarction. Ventricles and sulci are enlarged consistent with global parenchymal volume loss. Periventricular white matter hypodensities are sequela of chronic microvascular infarction. Post-contrast images reveal no abnormal focus of enhancement. The visualized osseous structures reveal no fracture and the included paranasal sinuses are clear. The visualized mastoid air cells redemonstrate partial opacification/under- pneumatization of the mastoid air cells on the right. Left hand xray [**10-21**] No previous images. Surgical changes are seen at the base of the thumb with apparent placement of a metacarpal and portion of a proximal phalanx. Generalized narrowing and spurring is seen involving distal interphalangeal joints, consistent with degenerative change. Suggestion of acroosteolysis of about several digits, consistent with scleroderma. Abnormability is seen in the soft tissues adjacent to the proximal phalanx of the fourth digit. It is unclear whether this could be hydroxyapatite deposition or even a foreign body. Right UE U/S [**10-21**] nonoclusive basilic venous thrombosis (this is not a deep vein) Brief Hospital Course: In brief, Mrs. [**Known lastname 41330**] was admitted to the MICU with respiratory distress likely from Aspiration pneumonitis. Treatment with antibiotics (Vancomycin and Cefepime) and lasix diuresis helped the patient improve in her respiratory status and she was transferred to the floor to continue recovery. With all of the critical illness, Mrs.[**Last Name (un) 99995**] mental status also declined. On the floor, her mental status would gradually improve, but every several days or so, she would have days of poorer alertness. A family meeting took place on [**2167-11-2**] with Mrs.[**Known lastname 99995**] husband and two daughters. 1. GOALS OF CARE (see Palliative care note from [**2167-11-2**] for more details): In discussion with the patient's husband and two daughters, the patient's code status was changed to DNR/DNI. The patient has demonstrated that she is a high aspiration risk having had recurrent episodes of respiratory distress from aspiration events. The family has decided to continue tube feeds via Dobhoff as well as provide thickened liquids by mouth for patient satisfaction. They will give rehab another try to see if progress can be made with rehabilitation. If forward progress is not seen in several weeks or if there appears to be declining function, then the family may then decide to take the patient home with Hospice services so that she may spend the remainder of her days with family at home. 2. ASPIRATION PNEUMONITIS: Speech and Swallow recommended nectar thickened liquids to reduce aspiration risk. Intermittently the patient developed tachypnea with RR up to 30's and 40's. The patient's underlying pulmonary hypertension and right heart failure makes her pulmonary function much more tenuous. 3. PULMONARY HTN: Patient continued on Bosentan and Sildenafil. 4. RIGHT CHF: Patient initially volume overloaded. Lasix diuresis was administered for several days until the patient was euvolemic. 5. PULMONARY EMBOLISM: CTA chest showed singular small PE at LLL ant basal segment branch point and her lovenox was increased to treatment dosage. 6. COPD: Continued on home nebulizers. At the time of discharge she was saturating above 95% on her home regimen of 2L oxygen. 7. ANEMIA: Patient developed a gradually declining hematocrit across the later part of her hospitalization declining from a hematocrit of ~30 on admission to ~22 by [**10-30**]. Iron deficiency, hemolysis, and Vit B12/folate deficiencies were ruled out. Guaiac was positive for occult blood. She received 1 unit PRBC on [**10-30**] with an appropriate rise in her HCT to ~26, and she remained stable across the last 4 days of her hospitalization with no evidence of ongoing bleed. It was felt that given this patient's overall prognosis and heightened procedural risk further workup of any potential GI bleed should only be pursued if there was evidence of recurrence. 8. DELIRIUM: Per patient's husband, she had had a waxing and [**Doctor Last Name 688**] status for the 2 months prior to admission: one day she can do the bills and the next she would be very confused. CT head with contrast showed global parenchymal loss areas of likely microinfarcts. Many other factors may contribute to delirium including ICU stay, C. diff infection, recent hip fracture, pulmonary disease, right heart failure, and other. Neurology was consulted and an EEG was completed which did not show any evidence of underlying abnormalities. Standard labs for dementia and altered mental status revealed no underlying cause as well. An LP was attempted but was stopped due to patient discomfort. Given this patient's overall prognosis as well as her waxing and [**Doctor Last Name 688**] mental status it was decided not to further pursue an LP. Across the last few days of her hospitalization she continued to wax and wane with highs still altered from reported baseline. She is oriented to self and sometimes to place but not to time. She was speaking mostly in full grammatical and logical sentences. Of note she focuses better when you are on her right side. 9. CAD s/p PCI to LCx: This patient had slightly elevated troponins on admission but no evidence of an acute MI on EKG. Her troponins were followed and trended down. The initial elevation was felt to be likely due to demand ischemia. She was continued on a beta blocker and statin. Of note she is anticoagulated for her pulmonary embolism and paroxysmal atrial fibrilation. 10. PAROXYSMAL AFIB: Patient had episodes of atrial fibrilation across her hospitalization. She was rate controlled on metoprolol and diltiazem. She was started on anticoagulation with coumadin. At the time of discharge her INR was 2.2 on Coumadin 3mg. She should continue to have her INR checked regularly and her Coumadin adjusted accordingly. 11. SYSTEMIC SCLEROSIS: This patient presented with mottled extremities/peripheral necrosis of the 1st and 5th digits of her left hand and a single left toel. Overall picture was concerning for vasoconstriction due to Raynauds U/S showed nonocclusive basilic vein thrombus. TTE did not show evidence of endocarditis and BCxs were negative. Rheumatology recommended continuing the patient on diltiazem and hydroxychloroquine and keeping the patient's hands and feet warm and elevated. 12. RIGHT HIP FRACTURE: s/p R ORIF on [**2167-10-8**]. She was anticoagulated on Lovenox which was stopped once the patient became therapeutic on Coumadin. Pain was controlled on tylenol and a lidocaine patch. Her staples were removed. PT was consulted. A follow-up appointment with Dr. [**Last Name (STitle) **] should be arranged for approximately 3-5 weeks after discharge. 13. NUTRITION: Given her aspiration risk she was fed through a NGT across this hospitalization. Thin liquids were briefly restarted [**10-28**] but then stopped again due to heightened concern for another aspiration event. At the time of discharge she was receiving tube feeds 16 hours on (from 4PM to 8AM). PO intake of pureed food and nectar thickened liquids should also be encourated as detailed above. 14. C DIFFICILE COLLITIS: Admitted on PO vanc course for c diff. No evidence of megacolon. Her treatment course was continued and was not yet complete at the time of discharge. Specifically she was treated with PO vancomycin 125 QID through [**11-2**] followed by 125mg daily for 1 week and then then 125 mg every 3 days for 2 weeks. Unnecessary antibiotics should be avoided to the extent possible. She was having largely formed stools at the time of discharge. FAMILY CONTACT INFORMATION: Husband/HCP [**Name (NI) **] [**Name (NI) 41330**] [**Telephone/Fax (1) 99996**] (cell); [**Telephone/Fax (1) 99997**] (home) Daughter [**First Name8 (NamePattern2) **] [**Known lastname 41330**] [**Telephone/Fax (1) 99998**] Medications on Admission: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch QDAY for R hip. 2. Ciprofloxacin 250 PO Q12H for 4 days. 3. Enoxaparin 40 mg/0.4 mL Subcutaneous DAILY (Daily). 4. Metoprolol Tartrate 100 mg PO BID 5. Oxycodone 5 mg PO Q6H as needed for right hip pain 6. Bisacodyl 10 mg Tablet as needed for Constipation. 7. Albuterol Sulfate 8. Ipratropium Bromide 9. Bosentan 125 mg PO BID 10. Lansoprazole 30 mg PO DAILY 11. Senna 8.8 mg/5 mL Syrup [**Telephone/Fax (1) **]: One (1) Tablet PO BID as needed for Constipation. 12. Docusate Sodium 100 mg PO BID 13. Sildenafil 20 mg PO TID 14. Aspirin 81 mg PO DAILY 15. Atorvastatin 40 mg PO DAILY 16. Hydroxychloroquine 200 mg PO BID 17. Vancomycin 125 mg PO Q6H 18. Acetaminophen 325-650 mg PO Q6H (every 6 hours) as needed for fever. Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Telephone/Fax (1) **]: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Telephone/Fax (1) **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 3. Hydroxychloroquine 200 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO Q6H (every 6 hours). 5. Atorvastatin 40 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). 6. Bosentan 125 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a day). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. Sildenafil 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 9. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 10. Warfarin 1 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Once Daily at 4 PM. 11. Diltiazem HCl 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a day). 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q4H (every 4 hours). 13. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours). 14. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**1-2**] Sprays Nasal QID (4 times a day) as needed for dryness. 15. Vancomycin 125 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO DAILY (Daily) for 3 weeks: Please give 125mg PO daily for 5 more days (through Sunday, [**11-8**]) then give 125mg PO every other day for 2 weeks. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: PRIMARY: 1. Aspiration Pneumonitis 2. Systemic Sclerosis 3. Pulmonary Embolism 4. Pulmonary Hypertension 5. Right heart failure 6. C-difficile infection 7. Anemia SECONDARY: 1. Chronic obstructive pulmonary disease 2. Type 2 diabetes mellitus 3. Benign hypertension 4. Coronary artery disease Discharge Condition: Stable, breathing comfortably on 2L supplemental O2, NPO Discharge Instructions: You were admitted with shortness of breath. While you were here we ran many tests to better understand the causes of your shortness of breath. Please call your physician or return to the hospital if you experience any severe pain, discomfort, or concerning symtpoms. Followup Instructions: Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], ([**Telephone/Fax (1) 2007**] Follow up with Rheumatology as needed

[ "285.9", "V45.89", "V54.15", "427.89", "008.45", "599.0", "507.0", "710.0", "276.52", "348.31", "412", "041.3", "276.0", "443.0", "428.0", "530.81", "276.3", "496", "415.19", "416.8", "414.01", "790.5", "041.4", "710.1" ]

icd9cm

[ [ [] ] ]

[ "03.31", "96.6", "99.04" ]

icd9pcs

[ [ [] ] ]

19166, 19246

9699, 16489

336, 342

19583, 19641

5056, 5056

19957, 20113

4272, 4324

17309, 19143

19267, 19562

16515, 17286

19665, 19934

5571, 9676

4339, 5037

277, 298

370, 3179

5072, 5555

3201, 4106

4122, 4256

5,367

141,327

18005

Discharge summary

report

Admission Date: [**2157-4-16**] Discharge Date: [**2157-4-29**] Date of Birth: [**2084-3-2**] Sex: F Service: Medical Intensive Care Unit CHIEF COMPLAINT: Diarrhea HISTORY OF PRESENT ILLNESS: The patient is a 73 year old woman with chronic medical problems listed separately below who underwent bunion surgery [**67**] days prior to presentation (and also had a nosebleed two days prior to presentation for which she was seen in an outside hospital Emergency Department). She presented to the Emergency Department complaining of black diarrhea today. She denied abdominal pain, fevers, nausea, vomiting, sick contacts but has had chills. She reports that she was given a prescription for Augmentin following her bunion surgery and she has taken this medication. For the five days prior to presentation she has had larger volumes of diarrhea and also reports decreased p.o. intake. In the Emergency Department the patient underwent nasogastric lavage with bilious return. She received 4 liters of normal saline for hypotension (systolic blood pressure of 92). She was also found to be hyperkalemic for which she received Kayexalate 30 gm and Calcium Gluconate as well. REVIEW OF SYSTEMS: The patient states that she felt thirsty. She had no chest pain. She states that she had two pillow orthopnea, sleeps with bricks and pillows under the head of her bed. She also states that she is short of breath after climbing a flight of stairs at her house. She denied lower extremity edema, nocturia or chest pain. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease, she requires supplemental oxygenation at home. 2. Congestive heart failure, her last echocardiogram showed an ejection fraction of 40 to 45%. 3. Hypercholesterolemia. 4. Obstructive sleep apnea/obesity. 5. Status post total abdominal hysterectomy. 6. Status post cholecystectomy on [**2156-8-30**]. 7. Status post bilateral total knee replacement in [**2150**]. 8. Hiatal hernia. 9. Bunion surgery on [**2157-3-29**]. SOCIAL HISTORY: The patient lives with her husband. She has a 50 pack year smoking history. She quit smoking approximately 25 years ago. Of note, her husband also has chronic obstructive pulmonary disease and requires supplemental oxygenation. MEDICATIONS ON PRESENTATION: 1. Prilosec 20 mg daily; 2. Metoprolol extended release 25 mg daily; 3. Zocor 40 mg daily; 4. Quinine 260 mg daily; 5. Dicyclomine 20 mg as needed; 6. Guaifenesin LA 600 mg twice daily; 7. Vicodin 7.5 mg tablets as needed for pain; 8. Enteric coated Aspirin one capsule daily; 9. Vitamin B6 100 mg daily; 10. Vitamin B12, 500 mg daily; 11. Singulair 10 mg daily; 12. Advair 50/500 two puffs daily; 13. Atrovent 2 puffs q.i.d.; 14. Augmentin 875 mg p.o. b.i.d. since bunion surgery. PHYSICAL EXAMINATION: Physical examination on presentation revealed temperature 96.8, heartrate 83, blood pressure 89/64, respiratory rate 18 to 20. Oxygen saturation was 94 to 95% on 2 liters of nasal cannula. Generally, the patient was comfortable, awake, alert, slightly hard of hearing. Head, eyes, ears, nose and throat, normocephalic, atraumatic, anicteric, normal conjunctivae, pupils equal, round and reactive to light from 4 ml to 2.5 ml. Extraocular movements intact without nystagmus. Throat clear. Neck: Supple, full range of motion, jugular veins not appreciable. No lymphadenopathy, thyroid not palpable. Heart: Point of maximal impulse not displaced, regular, normal S1 and S2, II/VI systolic murmur at base bilaterally, contraction of arms. Lungs, decreased excursion, clear to auscultation bilaterally. Abdomen, obese, normal bowel sounds, slightly distended, soft, not tender. Liver edge and spleen not palpable. Extremities, equivocal clubbing, no rash, warm, dry. Sutures over second toes with rods in the second toes bilaterally. Vascular, radial, carotid and dorsalis pedis pulses +2 bilaterally. Neurologic, alert, oriented, speaking in full sentences, intact shortterm and longterm memory. Motor, upper extremity, lower extremity, proximal and distal muscle strength 5/5 although she was too lightheaded to stand. Cerebellum, normal rapid hand movements. Cranial nerves II, III, IV, VI normal as above, cranial nerves V and VII symmetric with normal sensation, cranial nerves IX, X and XII normal gag, tongue midline, clear phonation. Cranial nerves [**Doctor First Name 81**] normal shoulder shrug. LABORATORY DATA: At laboratory evaluation, white blood cell count 31.3, hematocrit 39.7, platelets 527. Chemistry, 128/7.7, 89/20, 100/4.2, glucose 140. Repeat chemistry panel revealed sodium 133, potassium 6.2, chloride 95, bicarbonate 22. Blood urea nitrogen 95, creatinine 3.9, glucose 125. ALT, AST, alkaline phosphatase, albumin, total bilirubin, amylase and lipase and INR were normal. Urinalysis was unremarkable. Urine electrolytes, sodium less than 10, urea nitrogen 233, urine creatinine 202, urine potassium 65, urine chloride less than 10. Fractional excreted sodium was less than 0.1%. Electrocardiogram, sinus at 82, PR interval less than 200 milliseconds, QRS interval was less than 120 milliseconds and the QT interval was 416 seconds. Axis was left with qR in leads 1 and AVL and a rS in 2, 3 and F. There were no peak T waves, there was no acute ST segment change. This was consistent with left anterior fascicle block. HOSPITAL COURSE: 1. Hyperkalemia - On the night of admission, the patient required several additional gm of calcium gluconate, approximately 30 units of regular insulin and several injections of sodium bicarbonate to acutely decrease the potassium. She also received Kayexalate as well. Following rehydration her BUN and creatinine returned to [**Location 213**] and she had normal renal function for the duration of the hospital course. 2. Upon arrival in the Medical Intensive Care Unit the patient's serial blood gases revealed hypercarbia and hypoxia. She was intubated. Central venous access was established. She received several boluses of fluids to maintain blood pressure. Ultimately she required administration of pressors to maintain her blood pressure. 3. Infectious disease - Given her history of prior surgery, long course of antibiotics and a visit to an outside Emergency Department, the patient was treated with Metronidazole by mouth and intravenously for presumed pseudomembranous colitis. Subsequent detection of Clostridium difficile A in her stool confirmed infection with the [**Doctor Last Name 360**] of this disease. She had large volumes of diarrhea as well as increased nasogastric suctioning contents. Ultimately her treatment for Clostridium difficile was switched to Vancomycin per os, per rectum and intravenously. Her white blood cell count remained elevated for the duration of her hospital course. Interval colonoscopy confirmed the presence of pseudomembranes, likewise computer tomograph evaluation of the abdomen and pelvis confirmed involvement on the entire large colon. Of note, the patient received a four day course of Xigris since she met inclusion criteria of sepsis. 4. Hypotension - The patient had persistent hypotension during her hospital course. She underwent Swan-Ganz catheterization which confirmed distributed and cardiogenic shock. The patient was unable to tolerate weaning from pressor agents, specifically requiring Dopamine for the duration of her hospital stay to maintain blood pressure. Of note, the patient was exquisitely sensitive to withdrawal of this [**Doctor Last Name 360**] and would have precipitous drop in her blood pressure as well as bradycardia upon its discontinuation. Similarly the patient could not tolerate higher than 20 mcg/kg/min of this medication as she developed an inferior myocardial infarction when the medication was increased to 37. Of note, the patient had a left lower lobe consolidation on chest x-ray. Sputum cultures confirmed that she had pneumonia with Methicillin-resistant Staphylococcus aureus although she was initially treated with Levofloxacin for community acquired pneumonia, the intravenous Vancomycin administered as part of the regimen for Clostridium difficile covered for this organism. The patient was unable to be weaned from assist control ventilation. She occasionally required increases in her fraction of inspired oxygen. Despite maximal medical therapy, the patient continued to have large volumes of diarrhea and was persistently hypotensive. After discussion with her family a decision was made to withdraw care, specifically discontinuing pressor agents. DISCHARGE DIAGNOSIS: 1. Pseudomembranous colitis complicated by sepsis 2. Methicillin-resistant Staphylococcus aureus pneumonia 3. Inferior myocardial infarction 4. Chronic obstructive pulmonary disease, she requires supplemental oxygenation at home. 5. Congestive heart failure, her last echocardiogram showed an ejection fraction of 40 to 45%. 6. Hypercholesterolemia. 7. Obstructive sleep apnea/obesity. 8. Status post total abdominal hysterectomy. 9. Status post cholecystectomy on [**2156-8-30**]. 10. Status post bilateral total knee replacement in [**2150**]. 11. Hiatal hernia. 12. Bunion surgery on [**2157-3-29**]. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-761 Dictated By:[**Name8 (MD) 7102**] MEDQUIST36 D: [**2157-4-29**] 13:25 T: [**2157-4-29**] 14:45 JOB#: [**Job Number 49832**]

[ "584.9", "410.41", "276.2", "276.7", "995.92", "496", "482.41", "008.45", "518.81" ]

icd9cm

[ [ [] ] ]

[ "45.25", "96.04", "99.15", "96.6", "38.91", "96.72", "00.11" ]

icd9pcs

[ [ [] ] ]

8633, 9463

5424, 8612

2835, 5406

1220, 1543

177, 187

216, 1200

1566, 2042

2059, 2812

45,505

188,276

37192

Discharge summary

report

Admission Date: [**2151-12-13**] Discharge Date: [**2151-12-18**] Date of Birth: [**2079-1-13**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: dypnea Major Surgical or Invasive Procedure: Aortic valve replacement (#25 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic Supra Porcine)/ Mitral valve repair (#32 [**Company 1543**] CG Future ring)[**2151-12-14**] History of Present Illness: This 72 year old male had rheumatic fever at the age of 5 years old. Has had a heart murmur since that time. Five years ago he developed atrial fibrillation and was found to have moderate aortic stenosis. Since that time he has been followed by serial echocardiograms which have shown worsening of his aortic stenosis with recent development of left ventricular hypertrophy with diminished LV function. Past Medical History: chronic atrial fibrillation aortic stenosis mitral regurgitation rheumatic fever at age 5 h/o compression fracture of vertebrae x 2 Osteoporosis s/p Left hernia repair Social History: Race:Caucasian Last Dental Exam:every 6 months Lives with:Lives with wife in [**Name (NI) 932**] Occupation:Retired Tobacco:Remote past use (quit 40 years ago) ETOH:Quit 5 years ago due to palpitations with drinking Family History: 48 y/o son with MI and stent otherwisw noncontributory Physical Exam: Admission: Pulse:63 Resp:18 O2 sat:96% RA B/P Right:120/82 Left: Height:72" Weight:195# General:AAOx3 in NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur IV/VII SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [], well-perfused [] 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: Left: transmitted murmur vs bruit Pertinent Results: [**2151-12-16**] 06:20AM BLOOD WBC-12.3* RBC-3.33* Hgb-11.1* Hct-33.2* MCV-100* MCH-33.4* MCHC-33.5 RDW-13.4 Plt Ct-92* [**2151-12-15**] 02:46AM BLOOD WBC-10.2 RBC-3.30* Hgb-11.2* Hct-33.4* MCV-102* MCH-34.1* MCHC-33.6 RDW-14.3 Plt Ct-115* [**2151-12-17**] 07:30AM BLOOD PT-17.9* INR(PT)-1.6* [**2151-12-16**] 11:30AM BLOOD PT-21.0* INR(PT)-1.9* [**2151-12-15**] 02:46AM BLOOD PT-15.4* PTT-30.9 INR(PT)-1.3* [**2151-12-14**] 01:23PM BLOOD PT-17.9* PTT-49.5* INR(PT)-1.6* [**2151-12-14**] 12:00PM BLOOD PT-20.2* PTT-38.9* INR(PT)-1.9* [**2151-12-16**] 06:20AM BLOOD Glucose-134* UreaN-18 Creat-0.9 Na-133 K-4.4 Cl-99 HCO3-28 AnGap-10 [**2151-12-15**] 02:46AM BLOOD Glucose-100 UreaN-13 Creat-0.7 Na-137 K-4.9 Cl-107 HCO3-25 AnGap-10 Brief Hospital Course: [**Known lastname 63347**] was a same day admission to the Operating Room for aortic valve replacement and mitral valve replacement on [**12-13**]. Please see the operative note for details, in summary he had and aortic valve replacement with #25 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic Supra porcine valve and a Mitral valve repair with 32 [**Company 1543**] CG Future annuloplasty ring. His bypass time was 107 minutes with a crossclamp of 87 minutes. He tolerated the operation well and was transferred to the cardiac surgery ICU in stable condition on a Neosynephrine infusion for blood pressure support. He remained stable in the immediate post-op period, his anesthesia was reversed, he woke neurologically intact was weaned from the ventilator and extubated. Following extubation he was weaned from the Neosynephrine infusion. He remained hemodynamically stable and on POD 1 was transferred from the ICU to the stepdown floor for continued care and recovery. All tubes, lines and drains were removed according to cardiac surgery protocol. He was started on beta blockers and diuretics and these were titrated to effect. Beacause of his atrial fibrillation his Coumadin was resumed on POD 2. He was seen by Physical Therapy and activity was advanced per cardiac surgery protocol. The remainder of his hospital stay was uneventful and on POD*** he was discharged home with visiting nurses. Arrangements were made for follow up. His INR is to be checked by the visiting nurses on [**12-20**] with results called to Dr [**Last Name (STitle) 40075**](PCP)@ [**Telephone/Fax (1) 40076**]. Diuretics were continued for two weeks after discharge as he was still fluid overloaded at the time of discharge, albeit asymptomatic. Stable for DC Medications on Admission: Medications at home: Coumadin 5 mg q night except 7.5 mg q Wed - last dose 11/26 Fosamax 70mg once a week Lipitor 20mg daily Candesartan 16mg daily Flonase 50mcg daily Lopressor 75mg twice daily Temazepam 15mg prn Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 weeks. Disp:*56 Tablet(s)* Refills:*0* 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 2 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 10. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). Disp:*20 Tablet(s)* Refills:*2* 11. Coumadin 5 mg Tablet Sig: as directed Tablet PO once a day: 5mg 12/5,6. INR drawn on [**12-20**] then dose as directed. Disp:*100 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: s/p Aortic valve replacement (#25 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic Supra Porcine)/Mitral valve repair (#32 [**Company 1543**] CG Future ring) chronic atrial fibrillation Aortic stenosis Mitral regurgitation h/o rheumatic fever h/o compression fracture of vertebrae x 2 Osteoporosis s/p Left hernia repair Discharge Condition: Mental Status: Clear and coherent Activity Status: Ambulatory - Independent Hemodynamically stable Wounds healing well, no drainage or erythema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) in 4 weeks scheduled for [**2152-1-20**] @1PM Dr. [**Last Name (STitle) 40075**](PCP) ([**Telephone/Fax (1) 40076**]) in [**1-15**] weeks call for appt Dr [**First Name8 (NamePattern2) 518**] [**Last Name (NamePattern1) 8579**] or Dr [**Last Name (STitle) 40149**](cardiologist) in [**2-16**] weeks [**Hospital Ward Name 121**] 6 wound clinic in 2 weeks. Your nurse [**First Name (Titles) **] [**Last Name (Titles) **] an appointment. Completed by:[**2151-12-18**]

[ "V17.3", "733.00", "285.9", "788.5", "E878.2", "458.29", "427.31", "V15.82", "398.91", "V58.61", "396.2" ]

icd9cm

[ [ [] ] ]

[ "35.33", "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

6333, 6396

2911, 4687

330, 524

6782, 6782

2155, 2888

7470, 7997

1400, 1456

4952, 6310

6417, 6761

4713, 4713

6954, 7447

4734, 4929

1471, 2136

284, 292

552, 958

6797, 6930

980, 1151

1167, 1384

15,537

108,446

9691

Discharge summary

report

Admission Date: [**2192-4-18**] Discharge Date: [**2192-4-26**] Date of Birth: [**2134-12-9**] Sex: M Service: [**Last Name (un) **] ADMITTING DIAGNOSIS: Post necrotic cirrhosis/hepatitis C virus waiting for liver transplant. HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old male with a history of hepatitis A and B, end-stage liver disease secondary to hepatitis C virus and alcohol abuse (the patient treated with Rebetol). Also a history of hepatopulmonary syndrome and with MELD score of 27. The patient has been to [**Hospital1 69**] 2 times prior to this admission for potential liver transplant surgery. History of ascites and encephalopathy. He has had no recent fevers or infections. No major weight loss or gain. He denies any shortness of breath or chest pain. No change in urinary or bowel movements. He has abstained from drugs/alcohol x 33 to 35 years. He is currently employed as a substance abuse counselor and remains active with AA and NA. The patient has been waiting for a liver transplant on the last 2 admissions, but the donated liver was not acceptable and had to be discharged home. PAST MEDICAL HISTORY: History of end-stage liver disease secondary to hepatitis C and alcohol abuse. Also a history of hepatitis A and B, history of stab wounds, history of sleep apnea, hypertension, rheumatoid arthritis, GERD, history of multi substance abuse, history of pneumothorax. No diabetes. No history of MI. No history of lower extremity blood clots. No history of asthma or emphysema. PAST SURGICAL HISTORY: Status post appendectomy. Status post right knee arthroscopy x 2. History of "blood clot" at the age of 5. ALLERGIES: TETANUS - reaction unknown. MEDICATIONS ON ADMISSION: Nadolol 60 mg daily, Prevacid 20 mg daily, spironolactone 50 daily, lactulose, Caltrate 600 b.i.d., nicotine patch 14 mg daily. SOCIAL HISTORY: Single. Lives alone. Patient has a girlfriend. Stopped tobacco 1 month ago; 2 packs per day x 48 years. Stopped alcohol abuse in [**2176**]. He drank for 36 years. Multiple drugs; stopped in [**2176**], abuse x 33 years. PHYSICAL EXAMINATION: The patient is an overweight friendly male in no acute distress. Temperature of 97.6, BP of 120/79, heart rate of 62, respirations of 18, 97% on room air. Skin with multiple well-healed lacerations on body. Warm to touch. HEENT is atraumatic except for a right facial well-healed laceration. Eyes reveal pupils equal, round, and reactive to light. EOMs are full. Tongue is midline. No exudates. The neck is supple with no palpable nodes. No thyromegaly. No carotid bruits. Lungs are clear to auscultation and percussion sitting erect bilaterally. CV with a regular rate and rhythm, normal S1 and S2 without murmurs or rubs. Abdomen is obese, distended, slight bowel sounds, soft, nontender, hepatomegaly. No splenomegaly. No flank pain bilaterally. Extremities: No C/C/E. ________________ dorsalis pedis. Cranial nerves II through XII intact. Motor in upper and lower are [**5-10**] bilaterally. No drift bilaterally. No asterixis bilaterally. LABORATORY DATA ON ADMISSION: WBC of 15.0, hematocrit of 30.3, platelets of 85. Sodium of 140, potassium of 3.9, chloride of 112, bicarbonate of 23, BUN of 15, and creatinine of 1.0. AST of 366, ALT of 209, alkaline phosphatase of 58, total bilirubin of 2.7 RADIOLOGIC STUDIES: The patient had a previous chest x-ray on [**4-13**] demonstrating no acute cardiopulmonary process. HOSPITAL COURSE: The patient went to the OR on [**2192-4-18**]. The patient went to the ICU postoperatively. The patient was kept intubated. Afebrile. Vital signs stable. The patient was placed on tacrolimus 2 and 2. The patient was put on morphine, ganciclovir, Bactrim. His LFTs were decreasing in number. On [**4-19**], postoperative day, the patient had an ultrasound of his liver, demonstrating widely patent hepatic artery and branches. Portal and hepatic veins were also patent. The patient had insertion of an internal jugular catheter on [**2192-4-20**] for IV access. On postoperative day 2, the patient was on tacrolimus 2 and 2. [**Last Name (un) **] was consulted. The wound was clean, dry, and intact. The patient had 2 JP drains in place. The patient had _________ written for. Cholangiogram was performed on [**2192-4-24**] demonstrating a nondilated intrahepatic and extrahepatic biliary ducts with the passage of contrast into the Roux-en-Y limb. There was no evidence of stricture or leak within the biliary tree. There was no retrograde opacification of the cystic duct along with the pancreatic duct. On [**4-24**] WBC was 10.9, 37.4, platelet count was 95, PT of 14.0, PTT of 43.7, INR of 1.2, sodium of 134, potassium of 4.4, chloride of 106, bicarbonate of 19, BUN and creatinine of 52 and 1.7, ALT of 117, AST of 164, alkaline phosphatase of 55, total bilirubin of 0.8. On the 15th tacrolimus was 13.7. He has been doing well since then. Diet was advanced. Foley was discontinued. Physical therapy evaluated the patient on the 19th and felt that he was able to go home without services. The day the patient was leaving, [**2192-4-26**], the right IJ was removed. Remaining JP drain was removed. The patient has been eating well and urinating well without difficulty, and patient is going home with VNA services. Tacrolimus level on [**2192-4-26**] was 8.2, so tacrolimus was increased from 0.5 b.i.d. to 1 mg daily. The patient is going to be leaving on the following medications. MEDICATIONS ON DISCHARGE: Fluconazole 400 mg q.24h., Bactrim SS 1 tablet daily, Percocet 1 to 2 tablets q.4-6h. p.r.n., Protonix 40 mg daily, MMF 1000 b.i.d., prednisone 20 mg daily, trazodone 50 mg p.o. at bedtime p.r.n., calcium carbonate 500 mg 1 tablet daily, vitamin D3 one tablet daily, Lopressor 100 mg daily, Valcyte 450 mg daily, tacrolimus 1 mg b.i.d., and Lasix 20 mg b.i.d. DISCHARGE FOLLOWUP: 1. The patient has a MRI appointment on [**2192-4-30**] at 12:30 p.m. 2. Also, the patient has an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2192-5-3**] at 10:10 a.m., and also another appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2192-5-10**] at 9:30 a.m. DISCHARGE INSTRUCTIONS: 1. The patient is to have laboratories every Monday and Thursday in which a CBC, Chem-7, AST, ALT, alkaline phosphatase, total bilirubin, albumin, and a Prograf level to be obtained. Please fax the results to [**Telephone/Fax (1) 697**]. 2. The patient should call the transplant team office at [**Telephone/Fax (1) 32749**] if there are any fevers, nausea, vomiting, any abdominal pain, any discharge from the drain sites, and difficulty urinating or with bowel movements, any lethargy, inability to tolerate p.o. foods. FINAL DIAGNOSES: Post necrotic cirrhosis/hepatitis C virus; status post liver transplant. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Last Name (NamePattern1) 4835**] MEDQUIST36 D: [**2192-4-26**] 14:17:31 T: [**2192-4-26**] 15:31:29 Job#: [**Job Number 32750**]

[ "530.81", "714.0", "401.9", "070.70", "780.57", "305.00", "571.2" ]

icd9cm

[ [ [] ] ]

[ "50.59", "87.54" ]

icd9pcs

[ [ [] ] ]

5498, 5859

1742, 1871

3480, 5471

6272, 6814

1566, 1715

6832, 7173

2133, 3095

5879, 6248

278, 1144

3110, 3462

176, 249

1167, 1542

1888, 2110

78,530

179,118

52505

Discharge summary

report

Admission Date: [**2183-6-24**] Discharge Date: [**2183-6-28**] Date of Birth: [**2107-9-30**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Fosamax / Tylenol Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion, fatigue Major Surgical or Invasive Procedure: [**2183-6-24**] Aortic valve replacement with a 21-mm St. [**Hospital 923**] Medical Biocor tissue valve. Coronary artery bypass grafting x2, with a left internal mammary artery graft to the left anterior descending and reversed saphenous vein graft to the marginal branch. History of Present Illness: 75 year old woman with history of aortic stenosis which has been followed by serial echocardiograms. Over the past 6 months, she has noticed an increase in her exertional dyspnea and fatigue. She denies chest pain, but does report occasional pain on her left side after gardening. She has been referred for surgical evaluation for AVR, ?MVR, +/-CABG. Past Medical History: Aortic Stenosis Coronary Artery Disease PMH: Bilat. carotid artery stenoses Breast cancer Hypertension Psoriasis Rhinitis Anemia Peripheral vascular disease Thalassemia trait Tympanic membrane perforation Urinary incontinence H/O myositis Depression Lichen sclerosus Osteopenia Polymyalgia rheumatica Hypothyroidism GERD Past Surgical History: Left lumpectomy (no radiation) bilateral cataracts tonsillectomy right tympanic membrane repair Social History: Lives: alone, husband is in palliative care at VA Occupation: retired from [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **] Tobacco: Quit in [**2156**]. 2ppd for 35 years ETOH: Denies Family History: mother died at 82 following complications from AVR/CABG father died at 42yo following complications of a brain tumor brother died at 39 MI sister died at 43 MI Physical Exam: Pulse: 59 Resp: 16 O2 sat: 99 B/P Right: 149/74 Left: 138/68 Height: Weight:152 General: NAD, WGWN, appears stated age Skin: Dry [x] intact [x] HEENT: PERRLA [] not reactive, s/p lens implants, EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [**2-9**] syst. Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [] mild spiders Neuro: Grossly intact x Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: NP Left: NP Radial Right: 2+ Left: 2+ Carotid Bruit Right: Left: radiation of cardiac murmur Pertinent Results: [**2183-6-24**]- intra-op TEE 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 with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). No aortic regurgitation is seen. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results before surgical start. POST-BYPASS: Normal RV and LV systolic function. LVEF 55%. Intact thoracic aorta. The aortic bioprosthesis is stable, functioning well with a residula mean gradient of 12 mm of Hg. There is no regurgitation seen across or around the aortic prosthesis. MR stays the same. 2+ MR Admission Labs: [**2183-6-24**] 12:40PM BLOOD WBC-9.4 RBC-2.87*# Hgb-7.5*# Hct-22.4* MCV-78*# MCH-26.1*# MCHC-33.4 RDW-18.1* Plt Ct-131* [**2183-6-24**] 12:40PM BLOOD PT-16.6* PTT-36.7* INR(PT)-1.5* [**2183-6-24**] 12:40PM BLOOD Fibrino-202 [**2183-6-24**] 02:33PM BLOOD UreaN-14 Creat-0.9 Na-136 K-5.2* Cl-112* HCO3-22 AnGap-7* [**2183-6-24**] 12:40PM PT-16.6* PTT-36.7* INR(PT)-1.5* [**2183-6-24**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG Discharge labs: [**2183-6-27**] 06:30AM BLOOD WBC-9.9 RBC-3.77* Hgb-10.4* Hct-29.6* MCV-79* MCH-27.7 MCHC-35.2* RDW-19.4* Plt Ct-100* [**2183-6-27**] 06:30AM BLOOD Plt Ct-100* [**2183-6-27**] 06:30AM BLOOD Glucose-100 UreaN-25* Creat-1.0 Na-130* K-4.3 Cl-97 HCO3-26 AnGap-11 [**2183-6-27**] 06:30AM BLOOD Mg-2.0 Radiology Report CHEST (PORTABLE AP) Study Date of [**2183-6-26**] 2:56 PM Final Report: Bilateral lung volumes are low with bibasilar atelectasis. Pulmonary vascularity is mildly plethoric, but there is no evidence of pulmonary edema. There are bilateral minimal pleural effusions which are unchanged since [**2183-6-24**]. Atelectasis of the bilateral lung bases is seen. The cardiac silhouette is enlarged due to cardiomegaly and is relatively stable. There is no evidence of pneumothorax. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 16988**] [**Name (STitle) 16989**] DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**] Brief Hospital Course: The patient was a same day admission for AVR/CABg on [**2183-6-24**]. On that day the patient underwent aortic valve replacement and coronary bypass grafting with Dr. [**Last Name (STitle) **]. Please see the operative report for details, in summary she had: Aortic valve replacement with a 21-mm St. [**Hospital 923**] Medical Biocor tissue valve, and coronary artery bypass grafting x2, with a left internal mammary artery graft to the left anterior descending and reversed saphenous vein graft to the marginal branch. Her bypass time was 114 minutes with a crossclamp of 85 minutes. The patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition on Neosynephrine and Propofol infusions. In the immediate post-op period she was hemodynamically stable, she woke from anesthesia neurologically intact and was extubated. POD 1 found the patient extubated, alert and oriented and breathing comfortably. She weaned from vasopressor support, Beta blocker was initiated and the patient was begun on diuretics. She also transferred from the ICU to the stepdown floor. All chest tubes, lines and epicardial pacing wires were removed per cardiac surgery protocol without complication. The remainder of the patients hospitalization was uneventful. She worked with the physical therapy service for assistance with strength and mobility. At the time of discharge on POD 4 the patient was ambulating, the wound was healing and pain was controlled with Ultram. The patient was discharged [**Hospital 108453**] Rehab in [**Hospital1 392**] in good condition. She is to follow up with Dr [**Last Name (STitle) **] on [**2183-7-17**] @1:15PM. Medications on Admission: ATENOLOL 25 mg Tablet - 0.5 Tablet(s) by mouth once a day COLESTIPOL - 1 gram by mouth twice a day LEVOTHYROXINE -50 mcg once a day LISINOPRIL - 40 mg once a day OMEPRAZOLE - 20 mg daily SIMVASTATIN - 80 mg once a day VENLAFAXINE - 37.5 mg twice a day ASPIRIN - 325 mg Tablet once a day CHOLECALCIFEROL Dosage uncertain Discharge Medications: 1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 2. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Tablet(s) 7. colestipol 1 gram Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days. 11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: Aortic Stenosis s/p AVR Coronary Artery Disease s/p CABG PMH: Bilateral carotid artery stenoses Breast cancer Hypertension Psoriasis Rhinitis Anemia Peripheral vascular disease Thalassemia trait Tympanic membrane perforation Urinary incontinence Myositis Depression Lichen sclerosus Osteopenia Polymyalgia rheumatica Hypothyroidism GERD Past Surgical History: Left lumpectomy (no radiation) bilateral cataracts tonsillectomy right tympanic membrane repair Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with Ultram Sternal Incision - healing well, no erythema or drainage Edema: trace bilat 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 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** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check-Cardiac Surgery Office [**Hospital Ward Name **] 2A on [**2183-7-2**] @10:30 [**Telephone/Fax (1) 170**] Surgeon Dr. [**Last Name (STitle) **] in [**Hospital Ward Name **] 2A on [**2183-7-17**] @1:15 phone:[**Telephone/Fax (1) 170**] Cardiologist Dr. [**Last Name (STitle) 33746**] in 1 month. Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) 68409**],[**First Name3 (LF) 20**] B. [**Telephone/Fax (1) 68410**] in 1 week after rehab. **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:[**2183-6-28**]

[ "282.49", "733.90", "443.9", "401.9", "424.1", "414.01", "244.9", "696.1", "V70.7", "433.10", "V10.3", "530.81", "287.5", "311", "433.30" ]

icd9cm

[ [ [] ] ]

[ "35.21", "36.15", "39.61", "36.11" ]

icd9pcs

[ [ [] ] ]

8572, 8661

5436, 7118

324, 600

9161, 9327

2614, 3847

10199, 10919

1682, 1844

7490, 8549

8682, 9019

7144, 7467

9351, 10176

4382, 5413

9042, 9140

1859, 2595

255, 286

628, 981

3863, 4366

1003, 1324

1461, 1666

59,194

186,826

9649

Discharge summary

report

Admission Date: [**2157-9-23**] Discharge Date: [**2157-10-21**] Date of Birth: [**2109-6-6**] Sex: M Service: EMERGENCY Allergies: lisinopril / Nafcillin Attending:[**First Name3 (LF) 2565**] Chief Complaint: fever, diarrhea Major Surgical or Invasive Procedure: Endotracheal Intubation Arterial Line placement PICC line placement History of Present Illness: [**Known firstname 449**] is a 48M with a history of diastolic CHF, CAD, morbid obesity, OSA on CPAP, HTN/HL. He was brought in by EMS with fever, diarrhea and cough. Patient recently discharged from CCU admission for CHF exacerbation requiring BiPAP and 30lbs diuresis, which was complicated by MSSA bacteremia (negative TEE) on nafcillin infusion through PICC. Three days ago, he developed low grade feve which increased to Tm 102 today. He's had diarrhea x 3 days at 6-7 watery and nonbloody bowel movements daily. There is no significant abdominal pain, and he denies any other sick contacts with similar symptoms. No myalgias, arthralgias, chest pain, shortness of breath. He abides by his 1500cc daily fluid restriction despite his diarrhea, and continued to take his diuretic and [**Last Name (un) **]. No NSAID usage. . With regards to his breathing, he feels he has worsened since last discharge, though cannot articulate why. He has occasional cough productive of brown phlegm. No PND or orthopnea. Does not weigh himself daily and unclear of any significant weight gain or loss. Diarrhea x 24 hours. 6-7 episodes today, non-bloody. Mild, crampy abdominal pain with the diarrhea. No vomiting. Breathing is at baseline per patient, but has productive cough. . In the ED inital vitals were, T 100.9, HR 78, BP 87/34, RR 24, 100% on 12L NRB. He had a mild leukocytosis to 11.7. Normal lactate to 1.3. He was treated broadly for antibiotics of possible bowel source with vancomycin/zosyn/levaquin. [**Last Name (un) **] noted with creatinine to 2.8 from baseline 1.0. He was placed on a NRB for apparent increased work of breathing- sats remained nearly 100%. Prior to transfer, VS 126/66, hr 83, rr 23, sat 99% on bipap . He was twice admitted to [**Hospital1 18**] for CHF exacerbations this past summer-initially in early [**Month (only) 205**] due to uncontrolled hypertension, and later in mid-[**Month (only) **] for the same. Of note, he developed a superficial thrombophlebitis during his last hospitalization that led to MSSA bacteremia. TTE did not reveal endocarditis. He was discharged with a PICC on IV nafcillin 2gq4hr to be completed on [**2157-9-29**]. . On arrival to the MICU, initial VS were T 102.6, BP126/91, P97, RR27, Sat99 on6LNC. He complains of chills. While breathing heavily, he feels he is near his baseline. . Review of systems: (+) Per HPI (-) Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -Morbid Obesity (BMI>70) -HTN -HLD -OSA on nocturnal bipap -tobacco abuse -heart failure with preserved ejection fraction Social History: -Tobacco history: active smoker, 25 pack-year -ETOH: was heavy alcohol user, 1 pint hard alcohol/day, quit cold [**Country 1073**] Father's Day this year -Illicit drugs: None -Herbal Medications: None - Patient has no stable home, stays at friends' [**Name2 (NI) **], currently separated from wife Family History: Multiple grandparents with DM and MI Physical Exam: On Admission: Vitals:T 102.6, BP126/91, P97, RR27, Sat99 on6LNC General: morbidly obese male, breathing heavily, but in no acute distress, alert HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, could not assess JVD due to habitus Lungs: diminished breath sounds bilaterally without crackles or rhonchi CV: distant heart sounds, but no MRG appreciated Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, could not assess organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: CXR: FINDINGS: The study is markedly limited secondary to massive body habitus and AP portable technique. The study is nearly nondiagnostic as there is also respiratory motion. It is difficult to exclude a mild interstitial edema. Additionally, a left lower lung consolidation cannot be excluded. The mediastinum demonstrates aortic tortuosity similar to prior. The cardiac silhouette is likely enlarged but stable. Effusions cannot be excluded. There is no large pneumothorax. IMPRESSION: Nearly nondiagnostic study due to massive body habitus and AP portable technique. . Unilateral US: IMPRESSION: No DVT of the left upper extremity. . CXR: As compared to the prior radiographs there is interval development of left lower lobe consolidation that potentially might reflect infectious process. In addition patient is in mild pulmonary edema. For precise characterization of the findings, correlation with cross-sectional imaging might be considered as well as re-evaluation of the patient after diuresis. Right PICC line is in place but its tip cannot be clearly seen. Brief Hospital Course: HOSPITAL COURSE: [**Known firstname 449**] [**Known lastname **] is a morbidly obese 48yoM initially presented with N/V/D and acute renal failure and was admitted to the MICU for labored breathing whose hospital course was complicated by hypercarbic respiratory failure requiring intubation and massive fluid diuresis and was found to have aortic valve endocarditis with worsening aortic regurgitation. . # ACTIVE ISSUES: 1) Respiratory Status: Patient was initially admitted with labored breathing requiring continuous use of BiPAP (settings IPAP 23, EPAP 18). Given renal failure (see below), diuretics were initially held. With resolution of diarrhea/fever and continuous use of BiPAP, patients dyspnea returned to baseline and patient was called out to the general medicine floors. While on the floor, patient's renal function continued to worsen and thus diuretics were continually held. Additionally pt received several fluid boluses given concern for hypovolemic status. Cardiology was consulted (given history of heart failure with preserved ejection fraction) who suggested diuresis despite renal failure as patient's wt was trending upward. Renal agreed with plan and pt was started IV diuresis. On [**10-9**], patient developed acute onset of dyspnea that resulted on hypercarbic respiratory failure requiring intubation. While in MICU, patient was aggressively diuresed under concern for flash pulmonary edema. PE was considered and was empirically started on heparin however after further evaluation, it was discontinued as patient improved with diuresis. Pt was on lasix drip initially then changed to bolus lasix and ultimately to PO torsemide. Pt was ultimately extubated and continued on diuresis. Pt uses BiPAP at night at with the following settings: IPAP 22 and EPAP 12. Pt's wt on discharge was 185kg. TRANSITION ISSUES: - Continue torsemide 80mg with goal to be euvolemic to negative to 500cc. Please titrate torsemide dose to achieve this goal. - Will need electrolytes to monitor K and Creatinine twice a week - Will need to remain on 2L fluid restriction - Needs agressive physical therapy in order to improve respiratory status . 2) Aortic Valve Endocarditis with Worsening Aortic Regurgitation: Of note patient completed course of MSSA bacteremia with vancomycin on [**2157-9-29**]. Cardiology suggested a TEE to better evaluate cardiac function given respiratory decompenstion, which revealed a new aortic valve vegetation and worsening aortic regurgitation, which likely caused acute decompensation. ID was reconsulted who suggested placing patient on daptomycin. Serial blood cultures were negative although patient was intermittently febrile during stay. Cardiac surgery was consulted who recommended finishing 6 week course of antibiotics as well as cardiac catheterization prior to evaluation for surgery. PICC line was changed on [**10-15**]. Of note patient complained of muscle spasms with daptomycin infusion. After review with pharmacy, this does not appear to be known drug reaction. Pt willing to cope with spasms as long as infusion is during the day. Please infusion daptomycin during the day. Lastly given worsening aortic valve endocarditis, aggressive afterload reduction was implemented with goal Systolic BP < 160. Nodal agents were stopped and should be avoided. TRANSITION ISSUES: - Complete 6 (six) week course of daptomycin. Last day will be on [**2157-11-24**] - Will need weekly CK, CBC with diff, BUN, Creatinine to be faxed to [**Telephone/Fax (1) 1419**] attn: ID nurse [**First Name (Titles) **] [**Last Name (Titles) **] follow up - Has follow up with Dr. [**First Name (STitle) 437**] in heart failure clinic - who will arrange for follow up Echo - Has follow up with Dr. [**Last Name (STitle) **] with cardiac surgery - Monitor BP and titrate medication as tolerated to keep systolic BP < 160. - Needs agressive physical therapy for strength prior to AVR - Patient will need dental evaluation prior to cardiac surgery . 3) Acute Renal Failure: Patient initially presented with acute renal failure. Renal was consulted who felt that presentation was consistent with acute interstitial nephritis [**1-26**] nafcillin. Antibiotic was changed to cefazolin however after having a rash, pt was started on vancomycin. Creatinine continued to raise despite removal of offending [**Doctor Last Name 360**] which was thought to be [**1-26**] ongoing diuresis. Renal agreed with diuresis given respiratory status and felt that creatinine would slowly improve with time. TRANSITION ISSUES: - Will need to monitor creatining for worsening kidney function twice a week - No need for renal follow up . 4) Morbid Obesity/Severe physical deconditioning: Patient is morbidly obese with BMI > 40. Given prolonged hospitalization and poor physical strength prior to admission, patient needs agressive physical therapy in order to recover. His medical issues are now stable and can be adequately cared for by daily medical evaluation however patietn needs more attention in physical strengthing training. TRANSITION ISSUES: - Aggressive Physical Therapy . 5) Obstructive Sleep Apnea: Patient severe obstructive sleep apnea likely [**1-26**] morbid obesity. Pt initially presented with respiratory complaints (see above) requiring continuous BiPAP. TRANSITION ISSUES: - Needs agressive physical therapy in order to lose wt . 6) Cardiac Dysfunction with Preserved Function/Hypertension/CAD/Hyperlipidemia: Echo showed preserved EF. [**Last Name **] Problem#2 for changes and updates. Patient will need cardiac catheterization prior to surgery. TRANSITION ISSUES: - [**Last Name **] problem #2 . 7) FEVERS/NAUSEA/DIARRHEA: Initially presenting symptoms however resolved with definitive etiology. No further interventions were necessary. . 8) Muscle Spasms: Patinet complained of muscle spasms while receiving daptomycin infusion. Seroquel and flexeril were both tried with limited response. Pt will to cope with spasms as long as daptomycin infusion is during day time hours. Medications on Admission: 1. potassium chloride 10 mEq Capsule, Extended Release Sig: Four (4) Capsule, Extended Release PO once a day. Disp:*120 Capsule, Extended Release(s)* Refills:*2* 2. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. 3. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 4. ipratropium bromide 0.02 % Solution Sig: One (1) vial Inhalation every six (6) hours. 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 6. torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 7. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1) bag Intravenous Q4H (every 4 hours): Last day is [**2157-9-29**]. Disp:*78 doses* Refills:*0* 8. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day for 6 weeks. 10. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-26**] Sprays Nasal QID (4 times a day) as needed for nasal congestion. 4. petrolatum Ointment Sig: One (1) Appl Topical TID (3 times a day). 5. isosorbide dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 9. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for twtching sensation. 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing, dyspnea. 11. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 13. daptomycin 500 mg Recon Soln Sig: 1200 (1200) mg Intravenous Q24H (every 24 hours): Last dose on [**2157-11-24**]. Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: Primary: -acute renal insufficiency (suspected acute interstitial nephritis due to nafcillin) -viral gastroenteritis Secondary: morbid obesity obstructive sleep apnea congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You came to the hospital because you were experiencing weakness, fevers, and diarrhea. When you came to the emergency room, you appeared to have significant difficulty breathing. You were sent to the medical ICU, where you were given antibiotics and fluids. Your kidneys were not functioning well, which was attributed to a negative reaction to your prior antibiotic, nafcillin, which you were receiving for your prior blood stream infection. You ultimately finished a course of antibiotics while on the general medicine floor. . While you were on the medicine floors, you developed signficant difficulty with your breathing requiring you to come back to the ICU. A breathing tube was placed to help your breath. You were started on a medication help remove fluid to help with your breathing. An ultrasound was completed of your heart which should that there was an infection on your heart valve that caused your valve to not work properly. This valve will likely need to be replaced in the future. You will have to remain on antibiotics until [**11-24**] in order to appropriately clear this infection. We had the cardiologist and cardiac surgeons evaluate for this valve replacement and they will continue to follow you as outpatient. . Because of the long hospital stay, you became deconditioned and you will need intense physical therapy in order to get better. . Please see the attached for your new set of medications. Followup Instructions: Please be sure to keep the following appointments: Department: CARDIAC SERVICES When: WEDNESDAY [**2157-10-26**] at 10:00 AM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SURGERY When: MONDAY [**2157-11-14**] at 1:45 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 170**] Building: LM [**Hospital Unit Name **] [**Location (un) 551**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE Completed by:[**2157-10-21**]

[ "790.7", "401.9", "272.4", "428.33", "E930.0", "327.23", "305.1", "428.0", "278.01", "580.89", "008.8", "414.01", "518.81", "276.0", "041.11", "424.1", "V85.45", "421.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "88.72", "38.91", "96.04", "38.97", "96.72" ]

icd9pcs

[ [ [] ] ]

13770, 13811

5391, 5391

300, 369

14048, 14048

4293, 5368

15680, 16377

3638, 3677

12451, 13747

13832, 14027

11430, 12428

5408, 5798

14231, 15657

3692, 3692

2774, 3159

245, 262

5813, 11404

397, 2755

3706, 4274

14063, 14207

3181, 3305

3321, 3622

17,827

131,142

22843

Discharge summary

report

Admission Date: [**2133-2-1**] Discharge Date: [**2133-2-5**] Date of Birth: [**2087-2-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11495**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization intra-aortic balloon pump placement History of Present Illness: 45 y/o M w/no prior cardiac hx, who presented to [**Hospital3 3583**] on [**2133-2-1**] after noting chest pain while shoveling snow off of his roof. He had never had CP before, but had noted an episode of neck pain a few weeks prior which resolved. The CP was associated with radiation to jaw/throat/L axilla/teeth, as well as diaphoresis and mild SOB. He presented to [**Hospital3 3583**] and was noted to have inferior ST elevations. He was hypotensive there, so was begun on dopamine and medflighted to [**Hospital1 18**] for cath. At cath, he was noted to have an RCA occlusion s/p PCI with 2 cypher stents. He had a 60% LMCA, 95% prox LCx, 80% ramus intermedius which were not intervened upon. He was placed on the IABP b/c of the prox Cx lesion and his RCA stent. He was weaned off dopamine. He developed new afib during the cath, which was subsequently cardioverted in the CCU. He was placed on integrillin, heparin, ASA, plavix prior to transfer to the CCU, and also received a total of 10 mg IV metoprolol for afib prior to cardioversion. He was chest pain free after his procedure. Past Medical History: GERD ADHD hx lymphoma [**2115**], s/p CHOP, XRT R knee arthroscopy hx "tick bite" on ankle, treated w/abx Social History: institutional stock broker married occasionally smokes a cigar no EtOH Family History: noncontributory Physical Exam: P: 92 BP: 85/62 RR: 8 99% RA Pertinent Results: Admission labs: [**2133-2-1**] 05:52PM PT-14.2* PTT-62.2* INR(PT)-1.3 [**2133-2-1**] 05:52PM PLT COUNT-218 [**2133-2-1**] 05:52PM NEUTS-88.3* LYMPHS-9.2* MONOS-2.1 EOS-0.2 BASOS-0.2 [**2133-2-1**] 05:52PM WBC-11.7* RBC-4.28* HGB-14.2 HCT-39.0* MCV-91 MCH-33.2* MCHC-36.5* RDW-12.9 [**2133-2-1**] 05:52PM TSH-2.1 [**2133-2-1**] 05:52PM ALBUMIN-4.0 CALCIUM-7.9* PHOSPHATE-3.3 MAGNESIUM-1.6 [**2133-2-1**] 05:52PM CK-MB-136* MB INDX-10.1* cTropnT-2.61* [**2133-2-1**] 05:52PM LIPASE-53 [**2133-2-1**] 05:52PM GLUCOSE-90 UREA N-14 CREAT-0.8 SODIUM-135 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-21* ANION GAP-13 [**2133-2-1**] 05:52PM ALT(SGPT)-59* AST(SGOT)-120* LD(LDH)-324* CK(CPK)-1342* ALK PHOS-58 TOT BILI-0.5 [**2133-2-1**] 08:32PM HGB-13.8* calcHCT-41 O2 SAT-73 [**2133-2-1**] 11:12PM PLT COUNT-199 [**2133-2-1**] 11:12PM MAGNESIUM-2.1 [**2133-2-1**] 11:12PM CK-MB-218* MB INDX-12.2* [**2133-2-1**] 11:12PM CK(CPK)-1780* [**2133-2-1**] 11:12PM POTASSIUM-3.6 Discharge and other pertinent labs: [**2133-2-5**] 07:00AM BLOOD WBC-6.2 RBC-4.23* Hgb-13.9* Hct-39.4* MCV-93 MCH-32.9* MCHC-35.4* RDW-12.5 Plt Ct-180 [**2133-2-5**] 07:00AM BLOOD Glucose-91 UreaN-15 Creat-0.9 Na-142 K-4.3 Cl-105 HCO3-28 AnGap-13 [**2133-2-1**] 05:52PM BLOOD ALT-59* AST-120* LD(LDH)-324* CK(CPK)-1342* AlkPhos-58 TotBili-0.5 [**2133-2-1**] 11:12PM BLOOD CK(CPK)-1780* [**2133-2-2**] 11:39AM BLOOD CK(CPK)-565* [**2133-2-3**] 05:41AM BLOOD CK(CPK)-888* [**2133-2-4**] 10:00AM BLOOD CK(CPK)-507* [**2133-2-1**] 05:52PM BLOOD CK-MB-136* MB Indx-10.1* cTropnT-2.61* [**2133-2-1**] 11:12PM BLOOD CK-MB-218* MB Indx-12.2* [**2133-2-2**] 11:39AM BLOOD CK-MB-153* MB Indx-27.1* cTropnT-3.26* [**2133-2-3**] 05:41AM BLOOD CK-MB-44* MB Indx-5.0 cTropnT-2.45* [**2133-2-5**] 07:00AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9 Cholest-168 [**2133-2-5**] 07:00AM BLOOD Triglyc-159* HDL-51 CHOL/HD-3.3 LDLcalc-85 LDLmeas-98 [**2133-2-1**] 05:52PM BLOOD TSH-2.1 [**2133-2-3**] 05:41AM BLOOD %HbA1c-4.7 Cardiac Cath: hemodynamics: RA 17/16/15 PA 35/24/26 wedge 22 CO 4.7 CI 2.2 SVR 1157 PVR 68 1. Selective coronary arteriography revealed a right dominant system with three vessel coronary artery disease and acute occlusion of the RCA. The LMCA had a 60% proximal stenosis. The LAD had no angiographically apparent CAD. The LCx had a 95% proximal stenosis. There was a large ramus branch that coursed towards the apex of the heart. It had a proximal 80% stenosis. The RCA was a large dominant vessel that had complete occlusion proximally before the take-off of any of the marginal arteries. 2. Resting hemodynamics revealed reduced central aortic pressures and a narrow pulse pressure in keeping with cardiogenic shock. The left and right filling pressures were slightly elevated. The cardiac index was reduced at 2.2. 3. Left ventriculography was not performed. 4. Successful PCI of the proximal RCA with two overlapping Cypher DES (3.0 x 23 mm and 3.0 x 8 mm), complicated by distal embolization into the R-PL system. 5. Towards the end of the procedure, the patient developed atrial fibrillation. TTE: Conclusions: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with focal severe hypokinesis of the inferior and inferolateral walls. The remaining segments contract well. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with moderate global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Regional left ventricular systolic dysfunction c/w CAD. Mild aortic regurgitation. Brief Hospital Course: 1. CV: Coronaries - His CAD was felt to be likely related to CHOP/XRT without other risk factors. He was begun on ASA, plavix, and a statin, and received integrillin for 18 hours post-cath. His cardiac enzymes trended down appropriately. His IABP was weaned off. He was evaluated by CT surgery who arranged for him to return in a couple of weeks for CABG. He remained CP-free. He was begun on an ACE inhibitor and beta-blocker which were titrated up as his BP tolerated. Pump - Because of his large RV infarct, he was preload-dependent and was not diuresed. He did not appear volume-overloaded. TTE revealed an EF was 35-40%. Rhythm - He developed afib post-cath which was successfully cardioverted. He remained in normal sinus rhythm after that. 2. PSYCH: His adderall was held given his ischemia and afib. He was continued on his Luvox and given ativan prn for anxiety. Medications on Admission: Adderall 30 mg daily Fluvoxamine 50 mg qam, 100 mg qhs Advil prn ASA prn Maalox prn Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 9 months. Disp:*30 Tablet(s)* Refills:*8* 3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Fluvoxamine Maleate 50 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. Fluvoxamine Maleate 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Enalapril Maleate 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. 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 Discharge Diagnosis: CAD Discharge Condition: stable Discharge Instructions: Please call your doctor or return to the emergency room if you have chest pain/tightness, shortness of breath, nausea, vomiting, abdominal pain, weakness, palpitations, lightheadedness, or any other concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] after your surgery. Call his office within one week after discharge from your surgery to ask him when he wants you to follow-up.

[ "998.2", "997.1", "427.31", "V10.79", "414.01", "410.71" ]

icd9cm

[ [ [] ] ]

[ "37.61", "99.20", "36.01", "36.07", "99.61", "37.21", "97.44", "88.55" ]

icd9pcs

[ [ [] ] ]

7868, 7874

5809, 6697

324, 385

7922, 7930

1838, 1838

8187, 8372

1754, 1771

6831, 7845

7895, 7901

6723, 6808

7954, 8164

1786, 1819

274, 286

413, 1520

1854, 2841

2863, 5786

1542, 1649

1665, 1738

76,056

192,459

49034

Discharge summary

report

Admission Date: [**2118-2-13**] Discharge Date: [**2118-2-17**] Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 678**] Chief Complaint: Dyspnea, cough Major Surgical or Invasive Procedure: none History of Present Illness: (Patient is extremely hard of hearing so much of her history is obtained from her husband, with whom she lives.) She is a [**Age over 90 **] F with a history of bronchiectasis, atherosclerosis, PVD, HTN who presents with 2-day history of an illness which began with severe sore throat and nausea two nights ago (felt she would vomit, never did). Over the course of the day yesterday, she continued to feel nauseous. She had some RLQ abdominal pain though belly was soft per her husband. She developed increasingly rapid breathing and cough. This morning both her breathing and her cough seemed worse so her husband brought her into the [**Name (NI) **]. Of note, her husband was also recently ill with a viral-like illness, though he had rhinorrhea which she has not had. . Upon arrival to the ED vitals were T 97.7, HR 99, BP 149/75, RR 20, 96% on 4L by NC. She received ipratropium and albuterol nebs, cetriaxone and azithromycin in the ED. While in the ED, she spiked a fever to 100.4. She became agitated and increasingly tachypneic in the ED, which her husband says is usual for her when she is being admitted to the hospital, as she tends to feel scared and become somewhat paranoid. Vitals prior to transfer to the MICU were T 100.4, HR 95, BP 104/50, RR 35, O2 96% on 6L. . On arrival to the floor, she was resting comfortably in bed. She reported breathing was more comfortable than yesterday or than earlier in the ED. . REVIEW OF SYSTEMS: Complete review of systems was compromised by patient's hearing loss. Per husband, she has had chronic poor appetite and weight loss of ~25 lbs over the past few years which he attributes to depression. She has not been febrile at home. She also has chronic nausea for which she has been followed by Dr. [**First Name (STitle) 452**], though this was significantly worse in the past two days. She denies any pain at this time. Past Medical History: - Bronchiectasis (older notes "COPD") - Diffuse atherosclerosis (aortic arch, carotids) - Hypertrophic cardiomyopathy - Peripheral vascular disease - Pulmonary hypertension (37 mmHg) - Hypertension - Hypercholesterolemia - Parkinsonism (tremor, rigidity, memory impairment) - Dementia (mild but has progressed in last few years per husband) - Head injury - left frontal intraparenchymal hemorrhage and contusion [**10/2115**] - Peripheral neuropathy ("cramping" in legs with walking, not felt to be claudication per vascular w/u) - Depression - MGUS - L1, L3 compression fractures [**10/2117**] s/p kyphoplasty ~[**11/2117**]; T12 compression fracture s/p kyphoplasty 2 weeks ago (both through [**Location (un) 745**] [**Location (un) 3678**]) Social History: Lives with her husband. [**Name (NI) **] two adult children on the west coast. Has previously been independent in ADLs but recently has had a decline in functional status; has had trouble with her personal hygiene (no longer showers without husband in room with her after a fall in the shower) and toileting (has recently been using bedpan but has had some incontinence). Former smoker, quit > 30 years ago. No recent alcohol. Family History: Father had recurrent pneumonias and ultimately passed away of pulmonary complications following MVA. Otherwise no known FH of lung disease. Physical Exam: ON ADMISSION: GEN: Resting in bed, sleepy but arousable, oriented to husband and hospital, very hard of hearing HEENT: Nasal canula in place, mucous membranes slightly dry, NECK: Supple, no JVD PULM: Diffuse expiratory wheezing b/l, mildly tachypneic (mid-20s) worse with talking (breathes mid-sentence) but no desaturation with speech, significant referred upper airway noise and congestion with cough CARD: RRR, no M/R/G ABD: Soft, NT/ND, +NABS EXT: Chronic venous stasis changes of LE, palpable DP pulses b/l ON DISCHARGE: Pertinent Results: LABS ON ADMISSION: [**2118-2-13**] 12:20PM WBC-11.2* RBC-4.39 HGB-13.3 HCT-39.9 MCV-91 MCH-30.3 MCHC-33.3 RDW-13.8 [**2118-2-13**] 12:20PM NEUTS-85.6* LYMPHS-6.0* MONOS-5.8 EOS-0.4 BASOS-2.2* [**2118-2-13**] 12:20PM cTropnT-<0.01 [**2118-2-13**] 12:20PM GLUCOSE-147* UREA N-32* CREAT-0.8 SODIUM-131* POTASSIUM-4.8 CHLORIDE-89* TOTAL CO2-31 ANION GAP-16 [**2118-2-13**] 12:22PM LACTATE-2.6* [**2118-2-13**] 02:14PM TYPE-ART PO2-64* PCO2-46* PH-7.45 TOTAL CO2-33* BASE XS-6 [**2118-2-13**] 03:35PM URINE MUCOUS-RARE [**2118-2-13**] 03:35PM URINE RBC-2 WBC-7* BACTERIA-MOD YEAST-MOD EPI-4 TRANS EPI-1 [**2118-2-13**] 03:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2118-2-13**] 03:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 Sodium [**2118-2-13**] 12:20PM BLOOD Na-131* [**2118-2-15**] 03:11AM BLOOD Na-130* [**2118-2-16**] 05:40AM BLOOD Na-134 [**2118-2-17**] 06:40AM BLOOD Na-131* PORTABLE UPRIGHT VIEW OF THE CHEST: Hardware noted at the lower c-spine. Cardiomegaly is again noted. Calcified granulomas in the RUL noted as seen on prior CT. Bibasilar interstitial abnormality and mucoid impaction has increased compared to the prior study. Upper lobe lucency is due to emphysema. There is no sign of pneumonia or CHF. The heart is mildly enlarged. There may be a trace right pleural effusion. There is no pneumothorax. There is tortuosity of the thoracic aorta with atherosclerotic calcification, but the mediastinal silhouette is otherwise unremarkable. Hilar contours are normal. There is degenerative change of the thoracolumbar spine with evidence of prior vertebroplasty in the lower thoracic and upper lumbar spine. Old right rib fractures noted. IMPRESSION: Mild cardiomegaly, emphysema, bibasilar scarring slightly progressed. EKG: Sinus rhythm with borderline sinus tachycardia. Consider biatrial abnormality, although is non-diagnostic. Prominent/peaked T waves raise the consideration of hyperkalemia. Findings are non-specific but clinical correlation is suggested. Since the previous tracing of [**2117-10-11**] the rate is faster, and delayed R wave progression pattern is less prominent. Brief Hospital Course: Ms. [**Known lastname 35852**] is a [**Age over 90 **] F with a history of bronchiectasis who presents with 2-day history of worsening cough/dyspnea. In the ED, she was noted to be hypoxic requiring 6L by NC to maintain O2 sats in mid-90s and had elevated lactate to 2.6 and was referred to the ICU given concern for deterioration. In the ICU, she received initial broad coverage with oseltamavir and antibiotics and respiratory status stabilized. She was called out to the floor on hospital day #2 and continued to require less oxygen prior to discharge. ACTIVE ISSUES: #. HYPOXIC RESPIRATORY DISTRESS: Patient has a history of bronchiectasis but based on imaging findings may also have an element of COPD/emphysema. She had wheezing on exam on admission and felt symptomatically improved after nebs in the ED. She also had dry rales at the bases. She was swabbed for influenza (DFA negative; oseltamavir stopped) and urinary legionella antigen was also noted to be negative. She was covered with broad spectrum antibiotics with vancomycin, cefepime and azithromycin to cover HAP given her recent admission for kyphoplasty. Despite wet-sounding cough, she was unable to produce a sputum sample suitable for analysis. At the time of call out from the ICU, her O2 sat was 88-90% on RA and mid-90s on 4L NC. During her time on the floor, she only required 1-2 L O2 for saturations in the mid 90s. She will continue on antibiotics (Cefpodoxime and Cipro) for a 10-day total course, or 5 more days after discharge. #. HYPONATREMIA: Sodium on admission is 131. Patient has had frequent hyponatremia in the past per OMR records with a baseline 133-136. Given elevated BUN and physical exam, she was felt likely somewhat dry and received IVF wtih normal saline. Over the course of hospital stay, sodium remained low, but briefly improved without IVF. Elevated urine osmolality >400 and lack of IVF causing improvement would point to SIADH as a possible cause. #. URINARY SYMPTOMS: Patient is followed by Dr. [**Last Name (STitle) **]. Can develop incontinence and is not always aware when she is urinating. Has been using urinal at home recently due to difficulty getting up to the bathroom post-op. Methenamine was held during this admission (not on hospital formulary, no alternative), and patient was started on Detrol instead of trospium per hospital formulary. Foley was not placed given attempt to minimize lines/tubes. Patient was noted to be incontinent and U/A showed some yeast, for which she was treated with a single dose of Diflucan PO. #. DELIRIUM: Patient periodically scared/paranoid despite orientation to place. She did better in the day and when her husband was present. She was noted to sundown and remove nasal canula at night due to agitation. One dose of Zyprexa was tried in the ICU with some effect. Attempt was made to minimize lines/tubes and to re-orient. Delirium was likely compounded by very poor hearing, as she had persistent difficulty understanding staff. #. COUGH: Patient reported worsening cough x 2 days. Treated symptomatically with guaifenisen and cough improved. #. LEUKOCYTOSIS: WBC count elevated to 11.2 on admission with left shift. UA with WBC of 7 but negative leuk esterase, nitrites. Most likely infectious source is pulmonary as above. WBC improved to normal. TRANSITIONAL ISSUES #. POST-DISCHARGE: She will be discharged to the rehabilitation [**Doctor First Name 362**] of her current residence, where her husband feels she will feel most at home, despite negative experiences in the past. After a lengthy discussion, it was decided to change her code status to DNR/DNI. This will likely need to be done legally as well. Medications on Admission: - Diltiazem 120 mg PO daily - Metoprolol 25 mg PO BID - Aspirin 81 mg PO daily - Buproprion 100 mg PO BID - Hydrochlorothiazide 25 mg PO daily - Methenamine 1 g PO BID - Vitamin C 500 mg PO BID - Ondansetron 4 mg PO PRN nausea - Premarin vaginal cream Q Sunday - Multivitamin 1 tab PO daily - Calcium 600 mg + vitamin D3 2 tablets PO daily - Simvastatin 80 mg PO daily - Colace 100 mg [**11-21**] tab PO QHS - Trospium 20 mg PO QHS - Miralax PRN constipation - Milk of magnesia PRN constipation - Suppository PRN constipation - Fleet enema PRN constipation - Tylenol PRN pain Discharge Disposition: Extended Care Facility: [**Last Name (un) 1687**] - [**Location (un) 745**] Discharge Diagnosis: Primary diagnosis: Bronchiectasis flare Secondary diagnosis: Dementia w/ features of delirium Pulmonary hypertension Compression fractures (lumbar and thoracic) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 35852**], It was a pleasure taking part in your care at the [**Hospital1 771**]. You were admitted with increasing shortness of breath and fast breathing. When you got the hospital you required a lot of extra oxygen to help you breathe. You were brought to the intensive care unit to be watched very closely and we started antibiotics to treat what we believe was a lung infection. When you were stable enough, you were transferred to a general medical floor where we continued to decrease the amount of oxygen you received since you were breathing much better. You will continue on antibiotics as an outpatient for a few more days. We have made the following changes to your medications: START Cefpodoxime 200mg twice a day until [**2-22**] START Ciprofloxacin 250mg twice a day until [**2-22**] START Lidocaine patch as needed for back pain Please continue to take the rest of your medications as prescribed Followup Instructions: Please call Dr. [**First Name (STitle) 216**] at [**Telephone/Fax (1) 250**] to arrange a follow-up appointment if you'd like. The following appointments are scheduled for you: Department: SURGICAL SPECIALTIES When: THURSDAY [**2118-2-24**] at 10:45 AM With: [**Name6 (MD) 161**] [**Name8 (MD) 6476**], MD [**Telephone/Fax (1) 2998**] Building: None [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site Department: GERONTOLOGY When: WEDNESDAY [**2118-3-2**] at 2:00 PM With: [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11793**], MD [**Telephone/Fax (1) 719**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]

[ "294.10", "293.0", "112.2", "494.1", "416.8", "331.82", "276.1", "425.1", "272.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10653, 10731

6343, 6900

253, 260

10937, 10937

4100, 4105

12056, 12898

3396, 3538

10752, 10752

10052, 10630

11088, 11781

3553, 3553

4081, 4081

11810, 12033

1738, 2167

199, 215

6916, 10026

288, 1719

10814, 10916

10771, 10793

4119, 6320

10952, 11064

2189, 2935

2951, 3380

18,363

196,681

142

Discharge summary

report

Admission Date: [**2179-3-31**] Discharge Date: [**2179-4-15**] Date of Birth: [**2105-12-17**] Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 943**] Chief Complaint: dizziness x 1 day Major Surgical or Invasive Procedure: None History of Present Illness: 73 yo F with h/o PBC, decompensated cirrhosis c/b encephalopathy, ascites, and esoph varices who presents with c/o lightheadedness, dizziness x 1 day. Feels weak with decreased energy level. Of note, recently discharged on [**2179-3-24**] after hypotensive/hypothermic episode w/ suspected sepsis, treated empirically with a course of ceftriaxone, flagyl and stress-dose steroids. No infectious source was identified. Discharged to home to complete prednisone taper. . In ED today, found to be hypotensive (SBP's in 80's) and hypothermic (31 C rectal temp). EKG w/ bradycardia to 40's. Plt 18. INR 1.5. given rewarming blankets. b/l EJ PIV placed. given 3L IVF's followed by peripheral dopa in ED. Recieved empiric steroids w/ dex for ?adrenal insuff. Vanco, levo, flagyl initiated. Given plt, coags, then right femoral line placed. . Denies N/V/Abd pain. + Loose stools x 7 days. No BRBPR . Admit to MICU for hypotension, sepsis w/u Past Medical History: 1. PBC cirrhosis x 13 yrs, known varices, followed by Dr.[**Last Name (STitle) 497**] 2. Liver cirrhosis 3. Hypothyroidism 4. Osteopenia 5. Status post cholecystectomy 6. History of ankle fractures 7. Hypertension Social History: Tobacco stopped 15 yrs ago, 30 pack-yrs, no alcohol or drug use, married with three children. Lives at home with husband Family History: No family history of strokes, seizures. Mother and father died in 90s. Physical Exam: T 33.9, BP 101/47, HR 45, RR 18, 98% RA gen- sleepy but arousable, garbled speech, non-toxic appearing heent-EOMI. Pupils 4->2 b/l. MM dry neck- diff to assess jvp 2/2 body habitus, b/l EJ's in place CV- brady. regular. no murmurs Pulm- anteriorly clear to auscultation w/o ronchi,rales,wheezes Abd- distended w/ dull flanks. non-tender to palpation. eXt- 3+ periph edema b/l. ext warm (bear hugger in place) neuro- follows commands, grip strength equal b/l, moving all extremities, oriented to person, [**Hospital 1498**] hospital; no asterixis. skin- superficial ulcerations on r elbow, hand. rect- yellow-brown stool, trace guaiac positive Pertinent Results: [**2179-3-31**] 09:20PM GLUCOSE-90 UREA N-46* CREAT-1.0 SODIUM-143 POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-25 ANION GAP-13 [**2179-3-31**] 09:20PM ALT(SGPT)-70* AST(SGOT)-90* CK(CPK)-112 ALK PHOS-154* AMYLASE-107* TOT BILI-3.6* [**2179-3-31**] 09:20PM cTropnT-<0.01 [**2179-3-31**] 09:20PM CK-MB-12* MB INDX-10.7* [**2179-3-31**] 09:20PM ALBUMIN-3.4 CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.1 [**2179-3-31**] 09:20PM WBC-5.6 RBC-3.51* HGB-10.7* HCT-32.5* MCV-93 MCH-30.5 MCHC-33.0 RDW-21.0* [**2179-3-31**] 09:20PM NEUTS-82.7* BANDS-0 LYMPHS-7.7* MONOS-3.8 EOS-5.3* BASOS-0.5 [**2179-3-31**] 09:20PM PLT COUNT-99*# [**2179-3-31**] 09:20PM PT-15.6* PTT-35.8* INR(PT)-1.4* [**2179-3-31**] 07:16PM LACTATE-1.7 [**2179-3-31**] 07:02PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2179-3-31**] 07:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2179-3-31**] 07:02PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-MOD EPI-0 [**2179-3-31**] 05:36PM GLUCOSE-98 UREA N-49* CREAT-1.1 SODIUM-142 POTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-26 ANION GAP-13 [**2179-3-31**] 05:36PM AST(SGOT)-96* CK(CPK)-114 ALK PHOS-155* TOT BILI-3.4* [**2179-3-31**] 05:36PM CK-MB-13* MB INDX-11.4* cTropnT-0.02* [**2179-3-31**] 05:36PM ALBUMIN-2.9* [**2179-3-31**] 05:36PM TSH-1.9 [**2179-3-31**] 05:36PM FREE T4-1.4 [**2179-3-31**] 05:36PM CORTISOL-9.2 [**2179-3-31**] 05:36PM WBC-4.5 RBC-3.61* HGB-11.2* HCT-33.4* MCV-93 MCH-31.0 MCHC-33.4 RDW-20.9* [**2179-3-31**] 05:36PM NEUTS-75.3* LYMPHS-13.4* MONOS-5.6 EOS-5.5* BASOS-0.3 [**2179-3-31**] 05:36PM HYPOCHROM-1+ ANISOCYT-2+ MACROCYT-2+ MICROCYT-1+ [**2179-3-31**] 05:36PM PLT SMR-RARE PLT COUNT-18*# LPLT-2+ [**2179-3-31**] 05:36PM PT-16.4* PTT-38.5* INR(PT)-1.5* CXR- RUL opacity EKG- sinus brady 49 bpm, LAD, QT 489, no ST/T changes, no block . Recent Studies: CT abd [**3-19**]- 1. Diffuse anasarca with soft tissue edema as well as ascites and nonspecific mesenteric stranding. Ascites is increased compared to the previous study. 2. Limited evaluation of the bowel with no definite wall thickening. There is no pneumatosis or free air. Patency within mesenteric vessels cannot be assessed without IV contrast. 3. Acute right posterior rib fracture that does not appear to be present on the study of [**2179-1-20**]. No evidence of pneumothorax in the imaged portions of the lungs . RUQ U/S [**2179-3-18**] 1. Patent portal vein with hepatopetal flow. 2. Small amount of ascites. . EGD [**2179-3-19**]: No active bleeding in esophagus, stomach, duodenum Mosaiac pattern in stomach c/w portal gastropathy . Colonoscopy [**2179-3-19**]: grade 1 internal hemmoroids few diverticula. no ischemic colitis Brief Hospital Course: Hospital Course: 73 y/o F w/ PBC, decompensated cirrhosis c/b encephalopathy, ascites, and esoph varices who presents with c/o lightheadedness, dizziness x 1 day, found to be hypotensive, hypothermic requiring the ICU. She was called out to the floor but remained medically tenuous and elected to be made CMO. . # Hypotension/hypothermia: On admission the likely causes were felt to be adrenal insufficiency and sepsis. [**First Name9 (NamePattern2) 1499**] [**Last Name (un) 104**]-stim test, the patient was started on fludro and hydrocort empirically presuming her to be adrenally insufficient. She was also covered broadly with vanc,levo, flagyl as concerned for sepsis and question of PNA on CXR. Her abdominal ultrasound was negative for significant ascites for diagnostic paracentesis. Blood cultures from admission returned positive for streptococcus and flagyl was discontinued. With antibiotics and steroids, pt was weaned off dopamine and blood pressure remained stable for pt to go to the floor. Once on the floor she was weaned off iv steroids and then completed a taper of po steroids. She also completed a course of levofloxacin and vanc. . # Primary biliary Cirrhosis- Initially the patient's medications were held in the setting of sepsis. However, once on the floor, her ursodiol, lactulose, rifaximin, and diuretics were resumed. Her diuretics were titrated up as her renal function could tolerate it. Her ursodiol was discontinued as it was felt to be of little benefit. Her rifaximin and lactulose were discontinued when the patient elected to be CMO. Her diuretics were continued anticipating that they would provide some relief, given her fluid burden. . # ARF- This was likely [**2-11**] hypotension, some component of acute renal failure on hepatorenal syndrome. She was placed on midodrine and octreotide and with improved hypotension, her urine out-pt increased. However, her creatinine elevated and remained persistently elevated on increased diuretics for her anasarca. . # Thrombocytopenia- The patient had progressively lowering platelets throughout the admission. Further work-up was done and her labwork was also revealed to possibly be c/w DIC. However, on discussion with heme/onc, it was felt that her low platelets, low fibrinogen, and elevated coags were in fact related to her end stage liver disease. . # hypothyroidsm: The patient was continued on her levothyroxine throughout the admission. . # FEN: Once her mental status was improved on the floor she was maintained on a regular diet. Her electrolytes were followed daily. . # PPx - She was placed on a PPI and sc heparin during the admission. . # Communication/Dispo - Several discussions were held with Ms. [**Known lastname 1500**] family regarding her medical course and prognosis. She and her family agreed that she be made DNR/DNI on [**2179-4-5**]. A later discussion was held with the patient, her family, the medical team, palliative care team, and social work. The patient and her family expressed understanding that the pt was not a liver transplant candidate and that recovery of her independence prior to admission would be unlikely. At that time, given her prognosis, the patient decided to be made CMO with anticipation for discharge to a [**Hospital1 1501**] with hospice. Medications on Admission: Levothyroxine 75 mcg PO DAILY Furosemide 40 mg PO DAILY Spironolactone 100mg PO DAILY (recently increased from 50 mg [**3-30**]) Rifaximin 400mg PO TID Lactulose(30) ML PO Q6H prn (once/day per pt) Pantoprazole 40 mg PO Q24H Ursodiol 500mg PO QAM Ursodiol 750 mg QPM Nadolol 10 mg PO DAILY Citracal lD 2 pills [**Hospital1 **] Prednisone taper- completed on: [**3-29**] Discharge Disposition: Extended Care Facility: [**Last Name (un) 1502**] Family Hospice House - [**Location (un) **] Discharge Diagnosis: Primary: primary biliary cirrhosis, encephalopathy Secondary: hypothyroidism, osteopenia Discharge Condition: Ms. [**Known lastname 1500**] needs related to comfort are continuing to be addressed. Discharge Instructions: You will be discharged to a specialized nursing facility. If you have any needs related to your comfort there, you should feel free to address them with the staff of the facility. Followup Instructions: You will be followed closely by your health care providers at your specialized nursing facility. You will also be followed closely by the hospice providers.

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icd9cm

[ [ [] ] ]

[ "00.17", "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

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5186, 5186

293, 300

9128, 9217

2411, 5163

9445, 9605

1657, 1730

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236, 255

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1517, 1641

19,375

127,331

6642

Discharge summary

report

Admission Date: [**2102-3-18**] Discharge Date: [**2102-3-20**] Service: MEDICINE Allergies: Penicillins / Motrin / Vioxx / Colchicine / Optiray 320 Attending:[**Doctor Last Name 10493**] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: none History of Present Illness: 83 yo female w/ hx of PE in [**2100**] - anticoagulated on coumadin, CHF, HTN, hyperlipidemia, who presents with BRBPR. Patient first noticed bright red blood per rectum on evening of [**3-16**] and then again on am of [**3-17**]. She has had rectal bleeding [**2-14**] x per week for the last several months and though it was due to hemorrhoids. She was concerned as the bleeding was increased in quantity over the last two days so she called her PCP who sent her to the ED. Patient had also noted some mild nausea and crmping and mild LLQ pain and cramping. No vomiting or hematemesis. Patient had a colonscopy in [**2099**] which showed int and ext hemorrhoids, also had a polypectomy which demonstrated a benign adenoma. . Vitals in the ED: T 97.6, HR 59, BP 145/60 RR 20 sat 100% ra. On exam was found to have frank blood in rectal vault. Given her LLQ pain, an abd u/s was done to r/o AAA - scan was negative. While in the ED she had an episode of chest pain. No EKG changes, CE were neg x 3. CP ultimately relieved by SLN x 1. Per patient, she has a history of intermittent chest pain at home for which she takes [**2-14**] SL nitro every 1-3 weeks. Given her history of PE, patient also underwent a V/Q scan, which was negative. She also has intermittent shortness of breath which she attributes to her CHF, although at present is not dyspneic. She has had no cough or fevers. CXR was negative. At home she sleeps with her head elevated. Her mobility is limited both by her CHF and her arthritis, but she does have difficulty walking long distances and going up stairs. . On arrival to the MICU her vitals were: T 97.7 HR 61 BP 141/64 RR 17 sat 100% on 3Lnc. She had another episode of chest pain when she first came to the unit. EKG was repeated, no changes concerning for ischemia. Patient received SLN x 1 and pain resolved. At present she is CP free. Denies shortness of breath, nausea, abdominal pain. States she has not had any BRBPR since yesterday. At home she sleeps with her head elevated. Her mobility is limited both by her CHF and her arthritis, but she does have difficulty walking long distances and going up stairs. . Past Medical History: 1) CHF (right-sided). Echo [**7-19**]: LV EF 65%, 1+ TR, PA systolic hypertension 2) CAD - cath in [**9-16**] w/ 50% stenosis in LAD 3) Atypical Chest Pain 4) Hypercholesterolemia 5) OSA (does not use CPAP) 6) HTN 7) DJD, OA 8) Spinal Stenosis 9) Cervical Spondylosis 10) diverticulosis 12) hx of strangulated hernia - s/p partial bowel resection 13) s/p CCY 14) h/o recurrent LE cellulitis 15) Gout (last flare-up 2 years ago, fingers and toes; proven by joint tap per patient) 16) PE ([**2-17**]) - still on coumadin 17) Hemorrhoids - internal and external - documented via colonscopy in [**2099**] 18) benign colonic admenoma [**2099**] 19) Neuropathy (w/ postural lightheadedness) 20) Glaucoma 21) hx of "sour stomach" (? GERD) Social History: Lives alone, however, daughter lives downstairs. She has help from VNA and has home PT. She does not drink EtOH, has never used tobacco. Family History: father, brother - [**Name2 (NI) 499**] ca, son - prostate ca, daughter - thyroid ca Physical Exam: Vitals: T 97.7 HR 61 BP 141/64 RR 17 sat 100% on 3Lnc Gen: comfortable, NAD HEENT: eomi, op-clear Neck: no lad, no jvd Lungs: min bibasilar crackles Heart: reg, no mrg Abd: + bs, soft, well healed [**Doctor First Name **] scars, non-tender, no rebound/guarding Rectal: (performed by GI in MICU) guaiac + brown stool Ext: warm, 2+ lower ext pitting edema to knees, chronic venous changes over skin, DP 2+ bilat Neuro: aao x 3 Pertinent Results: Imaging: LUNG SCAN [**2102-3-17**] IMPRESSION: Normal ventilation/perfusion study. . RETROPERITONEAL US [**2102-3-17**] 7:57 PM IMPRESSION: No evidence of AAA. . CHEST (PORTABLE AP) [**2102-3-17**] 4:14 PM IMPRESSION: No acute infiltrates or pneumonia . Colonoscopy [**2102-3-20**] Findings: Protruding Lesions Grade 2 internal hemorrhoids were noted. Excavated Lesions Multiple diverticula with medium openings were seen in the sigmoid [**Month/Day/Year 499**].Diverticulosis appeared to be of moderate severity. A few diverticula with small openings were seen in the ascending [**Month/Day/Year 499**], transverse [**Month/Day/Year 499**] and descending [**Month/Day/Year 499**].Diverticulosis appeared to be of mild severity. Impression: Grade 2 internal hemorrhoids Diverticulosis of the sigmoid [**Month/Day/Year 499**] Diverticulosis of the ascending [**Month/Day/Year 499**], transverse [**Month/Day/Year 499**] and descending [**Month/Day/Year 499**] Otherwise normal EGD to cecum . Micro: None . Labs: [**2102-3-17**] 04:00PM BLOOD WBC-8.2 RBC-4.11* Hgb-12.3 Hct-35.4* MCV-86 MCH-29.8 MCHC-34.7 RDW-14.8 Plt Ct-259 [**2102-3-20**] 06:15AM BLOOD WBC-7.0 RBC-3.78* Hgb-11.3* Hct-34.5* MCV-91 MCH-29.9 MCHC-32.8 RDW-14.4 Plt Ct-190 [**2102-3-17**] 04:00PM BLOOD PT-23.1* PTT-27.7 INR(PT)-2.3* [**2102-3-19**] 04:39AM BLOOD PT-20.0* PTT-42.1* INR(PT)-1.9* [**2102-3-20**] 11:30AM BLOOD PT-15.4* PTT-70.4* INR(PT)-1.4* [**2102-3-17**] 04:00PM BLOOD Glucose-109* UreaN-22* Creat-1.0 Na-142 K-3.5 Cl-103 HCO3-28 AnGap-15 [**2102-3-20**] 06:15AM BLOOD Glucose-98 UreaN-10 Creat-0.8 Na-143 K-4.6 Cl-111* HCO3-22 AnGap-15 [**2102-3-17**] 04:00PM BLOOD CK(CPK)-43 [**2102-3-17**] 09:54PM BLOOD CK(CPK)-40 [**2102-3-18**] 04:20AM BLOOD CK(CPK)-47 [**2102-3-17**] 04:00PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2102-3-17**] 09:54PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2102-3-18**] 04:20AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2102-3-18**] 04:20AM BLOOD Calcium-8.0* Phos-4.2 Mg-2.1 [**2102-3-20**] 06:15AM BLOOD Calcium-8.4 Phos-2.2*# Mg-2.2 Brief Hospital Course: 83F with MMP admitted with GIB . 1. GI bleed - presumed a LGIB in the setting of increased INR (2.3). She was initially monitored in the ICU and [**Hospital 25376**] transferred to floor with stable hemodynamics. She had a colonscopy in house that revealed bleeding diverticula. She had stable Hcts and hemodynamics while in house. she was instructed to stop taking her coumadin and return to the ED if she had any continued bleeding. . 2. HTN - maintained on regimen of metoprolol, losartan, and furosemide. BP initially held in setting of acute bleed. She had stable BPs while in house and was normotensive on her full regimen at the time of discharge. . 3. Chest pain - has hx of atypical chest pain, cath w/ 50% lad lesion, EKG w/out ischemic changes, CE neg x 3. This was thought to be her atypical CP. She was maintained on telemetry throughout the hospital course without event. she was continued on her BB, [**Last Name (un) **], statin. . 4. CHF -R sided - EF 65%, has lower ext edema - Maintained on home dose lasix 40 mg po qd . 5. Hx of spinal stenosis, cervical spondylosis - continued on percocet prn - continued on neurontin . 6. Hx of GERD - continued on PPI . 7. Glaucoma - cont home regimen . . After discussion with the patient and the medical staff, all were in agreement that [**Known firstname **] [**Known lastname 4026**] was a suitable candidate for discharge. Medications on Admission: neurontin 300 mg [**Hospital1 **] furosemide 40 mg qd cozaar 50 mg qd lipitor 20 mg qd metoprolol 25 mg qd pepcid [**Hospital1 **] SL nitro prn warfarin lumigan eye drops colace senna Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:*5 5* Refills:*2* 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 9. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: Diverticular Bleed . Secondary Diagnoses: 1) CHF (right-sided). Echo [**7-19**]: LV EF 65%, 1+ TR, PA systolic hypertension 2) CAD - cath in [**9-16**] w/ 50% stenosis in LAD 3) Atypical Chest Pain 4) Hypercholesterolemia 5) OSA (does not use CPAP) 6) HTN 7) DJD, OA 8) Spinal Stenosis 9) Cervical Spondylosis 10) diverticulosis 12) hx of strangulated hernia - s/p partial bowel resection 13) s/p CCY 14) h/o recurrent LE cellulitis 15) Gout (last flare-up 2 years ago, fingers and toes; proven by joint tap per patient) 16) PE ([**2-17**]) 17) Hemorrhoids - internal and external - documented via colonscopy in [**2099**] 18) benign colonic admenoma [**2099**] 19) Neuropathy (w/ postural lightheadedness) 20) Glaucoma 21) hx of "sour stomach" (? GERD) Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating with assistance. Discharge Instructions: You were admitted with a GI bleed likely from your diverticulosis, as seen on your colonoscopy. You should no longer take your coumadin. . 1. Please take your medications as prescribed. 2. Please attempt to make all medical appointments. 3. Please return to the Emergency Room if you have any concerning symptoms. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] on [**2102-3-30**] @ 10:00 am. [**Telephone/Fax (1) 10492**] . Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 23961**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2102-4-18**] 1:00 . Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2102-5-16**] 11:40 . Provider: [**Name10 (NameIs) 13228**] [**Name11 (NameIs) 13229**], [**First Name3 (LF) **] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2102-6-6**] 10:30 . Please call to confirm all medical appointments. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**] Completed by:[**2102-3-22**]

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icd9cm

[ [ [] ] ]

[ "45.23" ]

icd9pcs

[ [ [] ] ]

8734, 8791

6012, 7409

292, 298

9609, 9685

3946, 5989

10169, 10982

3399, 3484

7644, 8711

8812, 8812

7435, 7621

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3499, 3927

8873, 9588

225, 254

327, 2472

8831, 8852

2494, 3229

3245, 3383

7,952

133,762

15130

Discharge summary

report

Admission Date: [**2190-9-27**] Discharge Date: [**2190-11-11**] Date of Birth: [**2130-4-8**] Sex: M Service: GENERAL SURGERY HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 3265**] is a 60-year-old white male with a long history of acid reflux disease. Recently he was treated with antacid therapy and baking soda, but has been having refractory acid reflux symptoms. He underwent an upper endoscopy in [**2190-5-24**] which basically revealed a friable, nonobstructing lower esophageal adenocarcinoma. The adenocarcinoma involved one-third of the esophageal circumference. The biopsies taken at the time confirmed moderately-differentiated adenocarcinoma with papillary features and widespread necrosis. In addition, gastritis of the antrum was noted, but the gastroesophageal junction was not involved based on pathology. The duodenum was normal. The ultrasound-guided staging was performed as well. The ultrasound-guided examination of the mid-esophageal mass demonstrated invasion into the muscularis propria, but no evidence of invasion beyond this, consistent with a T2 tumor. Careful examination of the remainder of the Barrett's esophagus demonstrated mild wall thickening to 4 mm, limited to the submucosa, with no focal masses noted. In addition, there was an 11 mm round isoechoic periesophageal lymph node noted at 33 cm. No other lymphadenopathy was noted. A CT scan of the abdomen and chest was performed, which revealed two hyperdense lesions in the liver, but no mediastinal or hilar lymphadenopathy. The bilateral pleural effusions noted were thought to be related to congestive heart failure and left lobe atelectasis, but there was no radiologic evidence of metastatic disease. Subsequently an MRI of the liver was performed, which was negative for any evidence of metastatic disease to the liver. The patient was consequently seen by Dr. [**Last Name (STitle) **], and a surgical intervention was recommended. PAST MEDICAL HISTORY: 1. Chronic myeloid leukemia, first diagnosed in [**2183**] 2. Adenocarcinoma of the esophagus 3. Barrett's esophagus 4. Congestive heart failure 5. Myocardial infarctions x 2 6. Noninsulin dependent diabetes MEDICATIONS ON ADMISSION: 1. Gleevec 2. Glyburide 3. Tenormin 4. Accupril 5. Pravachol 6. Protonix 7. Lasix 8. Oxycontin as needed ALLERGIES: 1. Neurontin 2. Vancomycin (results in vomiting) SOCIAL HISTORY: Mr. [**Known lastname 3265**] is a retired police officer. He has a history of smoking, and quit in [**2173**]. No history of alcohol use. PHYSICAL EXAMINATION: Temperature 98.2, heart rate 69, blood pressure 153/72. General examination: A healthy-looking mal, in no apparent distress. Head, eyes, ears, nose and throat examination: No evidence of lymphadenopathy. No bruits. Neck with full range of motion. No evidence of ptosis. Chest examination: Clear to auscultation bilaterally. Cardiac examination: Regular rate and rhythm, no murmurs, gallops or rubs. Abdomen: Soft, nontender, nondistended. No masses palpable. No organomegaly. Normal bowel sounds. Rectal examination: Deferred. Extremities: Warm, well perfused, no signs of edema. IMAGING STUDIES: Upper endoscopy performed in [**2190-5-24**] showed a friable, nonobstructing lower esophageal adenocarcinoma involving one-third of the esophageal circumference. CT scan of the abdomen performed preoperatively showed two hyperdense lesions in the liver, but no mediastinal or hilar adenopathy. In addition, bilateral pleural effusions were seen, which were thought to be due to congestive heart failure. The MRI of the liver performed preoperatively was negative for any evidence of metastatic disease in the liver. HOSPITAL COURSE: Given the diagnosis of moderately-differentiated adenocarcinoma of the esophagus, surgery was recommended. The risks and the benefits of the procedure were discussed with the patient. On [**2190-9-27**], the patient underwent Ivor-[**Doctor Last Name **] esophagogastrectomy with feeding jejunostomy and left tube thoracotomy. The patient tolerated the procedure well. The estimated blood loss was 500 cc. There were no complications. Please see the full operative note for details. The patient remained intubated, and was transferred to the Intensive Care Unit in stable condition. His urine output was noted to be low. A Swan-Ganz catheter was in place. He remained on ventilator support. The patient was transfused with packed red blood cells and received multiple boluses postoperatively to maintain his urine output. His pain was controlled with the epidural catheter. The antibiotic coverage included Flagyl and Kefzol originally. In addition, the patient received several packs of platelets. The tube feeds were initiated. His blood pressure and heart rate were controlled with beta blocker. The patient remained in sinus rhythm. The heart rate and blood pressure remained stable. The chest tube remained in place, and the nasogastric tube remained to suction. On [**2190-10-1**], chest x-ray was taken showing a slight interval increase in the left lower lobe consolidation/collapse. The patient was transfused again with packed red blood cells. The ventilator support was slowly weaned. His arterial gas was stable. The Hematology/Oncology service was consulted, given the history of chronic myelogenous leukemia and decreasing white blood cell count. The recommendation was to restart Gleevec in order to avoid CML relapse. The patient was followed by the Hematology/Oncology service during his hospitalization. The patient was extubated on postoperative day three. His urine output increased and remained stable. The patient was gently diuresed. A barium swallow study was performed on [**2190-10-2**], which showed no evidence of contrast extravasation from the esophagogastric anastomosis. The fluids were decreased. The patient was transferred to the floor on postoperative day six in stable condition. Chest physical therapy was initiated. The patient was encouraged to get out of bed. On postoperative day six, the patient complained of severe chest pain and shortness of breath, but no nausea, vomiting, and no radiation of the pain. No diaphoresis at the time. His vital signs were stable except for a respiratory rate of 28. He was 95% on 2 liters, and had decreased breath sounds. Electrocardiogram obtained at the time showed no change from the baseline. His diet was slowly advanced to full liquids in addition to the tube feeds. Nutrition followed the patient throughout his hospitalization. On [**2190-10-4**], the patient was noted to have right arm swelling. A right upper extremity venous ultrasound was obtained, which showed no evidence of deep venous thrombosis. The antibiotics were discontinued at the time. On postoperative day ten, the patient again complained of difficulty breathing. However, he did not appear to be in acute respiratory distress given no tachycardia and no desaturation. An echocardiogram was obtained on [**2190-10-8**] to rule out pericardial effusion. The findings were symmetric left ventricular hypertrophy and regional systolic dysfunction consistent with multivessel coronary artery disease. A PICC line was placed on [**2190-10-8**]. The patient again complained of shortness of breath and had coarse sounds on lung examination. A chest x-ray at the time showed right basilar atelectasis/consolidation. The echocardiogram mentioned previously showed an ejection fraction of 25%. On [**2190-10-10**], the serum troponin levels were 6.5 at their peak. Thus the patient ruled in for a myocardial infarction by enzymes. Given increased wheezing and shortness of breath, the patient was transferred to the Intensive Care Unit. The chest tubes were removed a few days prior to this transfer. The patient was diuresed with lasix in the Intensive Care Unit, and was rate controlled with a beta blocker. Cardiology was consulted at the time. A chest x-ray obtained on [**2190-10-10**] showed probable congestive heart failure with bilateral pleural effusions, increased in size since the previous study. Given the fever and a large right pleural effusion, it was successfully aspirated by the radiologist. The patient's creatinine was also noted to be increasing, peaking at 2.4, with BUN of 100. The Renal service was consulted. The etiology of his worsening renal function was thought to be due to decreased left ventricular ejection fraction. The patient's BUN and creatinine subsequently improved. The patient was consequently reintubated for worsening respiratory distress. Aggressive pulmonary toilet was continued. He continued on tube feeds. He continued on the antibiotic prophylaxis. The sputum culture from [**2190-10-9**] grew Enterobacter, E. coli, and beta streptococcus. The E. coli and Enterobacter were pansensitive. His urine culture from [**2190-10-11**] grew Klebsiella, which again was pansensitive. The pleural fluid obtained by thoracentesis on [**2190-10-12**] grew staphylococcus aureus (coagulase positive), which was sensitive to clindamycin, gentamicin, Rifampin and vancomycin, but resistant to oxacillin (methicillin resistant staphylococcus aureus). The consequent pleural taps grew no bacteria. His blood cultures remained negative. The patient consequently failed another extubation attempt. He was aggressively diuresed. He continued to receive serial chest x-rays. The patient continued to maintain good urine output. The patient was closely followed by the Cardiology/Heart Failure consult. He was continued on lasix diuresis and Enalapril was added. In addition, he was maintained on aspirin and Lopressor. After failing one extubation attempt, the patient was continued to be diuresed, and was weaned off of the ventilator support. He was finally extubated, which he tolerated well. His nasogastric tube was eventually removed. He continued to be in congestive heart failure with moderately-sized effusions, which were tapped several times. He was started on vancomycin, given his methicillin resistant staphylococcus aureus, which was dosed according to serum levels. His daily weights were closely monitored. The patient was eventually transferred to the regular floor in stable condition. Physical Therapy and Occupational Therapy followed the patient closely. He remained on supplemental oxygen with good oxygenation levels. He complained of another episode of shortness of breath while on the regular floor. His creatine kinase and troponins were negative for any signs of myocardial infarction, and his electrocardiogram was unchanged from baseline. He was tolerating tube feeds well. He was started on clears, and his diet was advanced to a gastrectomy-type diet, which he also tolerated well. He remained afebrile. His hematocrit and white count remained stable, and his renal function returned to his baseline levels. He continued to have upper extremity edema, which decreased somewhat during his hospitalization. His congestive heart failure was managed by the Cardiology service, and medications were adjusted regularly. The patient was consequently discharged to a rehabilitation facility on [**2190-11-11**]. CONDITION ON DISCHARGE: Good DISCHARGE DESTINATION: Rehabilitation facility DISCHARGE DIAGNOSIS: 1. Esophageal carcinoma status post Ivor-[**Doctor Last Name **] esophagectomy 2. Respiratory failure 3. Acute renal failure 4. Congestive heart failure 5. Pneumonia 6. Methicillin resistant staphylococcus aureus 7. Hypertension DISCHARGE MEDICATIONS: 1. Lasix 60 mg by mouth four times a day 2. Insulin sliding scale as per instructions 3. Enalapril 20 mg by mouth twice a day 4. Isosorbide mononitrate 30 mg by mouth once daily 5. Aspirin 81 mg by mouth once daily 6. Protonix 40 mg by mouth once daily 7. Reglan 10 mg by mouth four times a day 8. Hydralazine 20 mg by mouth every six hours 9. Lopressor 25 mg by mouth twice a day 10. Albuterol nebulizers/inhaler every four hours as needed 11. Dulcolax 10 mg by mouth/per rectum as needed 12. Epogen 4000 units subcutaneously three times a week (Monday, Wednesday and Saturday) 13. Subcutaneous heparin 5000 units twice a day 14. Ipratropium bromide four puffs inhaler four times a day as needed 15. Tube feeds, Nepro full strength 45 ml/hour x 12 hours, cycled from 8 P.M. to 8 A.M. DISCHARGE INSTRUCTIONS: 1. The patient is to continue on tube feeds at night and be allowed to eat gastrectomy-type diet during the day. Wean tube feeds as needed. 2. The patient is to follow up with Dr. [**Last Name (STitle) **], his surgeon, within the next one to two weeks as scheduled. 3. The patient is to follow up with the Heart Failure specialists within the next week. 4. The patient is to follow up with his primary care physician. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**] Dictated By:[**Last Name (NamePattern1) 10097**] MEDQUIST36 D: [**2190-11-10**] 21:16 T: [**2190-11-11**] 00:00 JOB#: [**Job Number **]

[ "584.9", "482.41", "410.71", "428.0", "205.10", "150.5", "518.81", "151.0", "599.0" ]

icd9cm

[ [ [] ] ]

[ "34.09", "03.90", "38.93", "46.39", "38.91", "43.99", "34.91", "40.3", "89.64", "96.72", "96.6", "99.15" ]

icd9pcs

[ [ [] ] ]

11614, 12409

11354, 11591

2233, 2410

3749, 11253

12433, 13130

2592, 3192

177, 1970

1992, 2207

2427, 2569

11278, 11333

3210, 3731

75,029

100,699

54970

Discharge summary

report

Admission Date: [**2199-5-17**] Discharge Date: [**2199-5-27**] Date of Birth: [**2138-8-14**] Sex: M Service: CARDIOTHORACIC Allergies: epinephrine Attending:[**First Name3 (LF) 165**] Chief Complaint: Unstable angina Major Surgical or Invasive Procedure: Coronary artery bypass (LIMA>LAD, SVG>Diag, SVG>Ramus, SVG>OM, SVG>OM, SVG>PDA) [**5-21**] History of Present Illness: Mr. [**Known lastname 43681**] is a 60 year old male with coronary artery disease as documented by catheterization at the [**Hospital6 13185**] in [**2189**]. Recently he developed exertional chest discomfort, for which he was sent for an exercise echo on [**2199-5-7**]. This test showed ST depression. During a stress mibi on [**2199-5-15**] he developed 3 episodes of NSVT and 1/10 chest pain. Perfusion images showed a small area of ischemia in the basal-mid inferolateral wall, LCx/OM territory. After he completed the stress test he went home and developed a recurrence of chest pain. Initially a work-up at [**Hospital **] Hospital was negative for MI but he was referred to [**Hospital1 18**] for cardiac catheterization. This test revealed multi-vessel coronary artery disease. Past Medical History: Coronary Artery Disease Sleep apnea Hypertension Hyperlipidemia Gout Social History: Mr. [**Known lastname 43681**] is a former smoker, having quit in [**2189**]. He is an occasional drinker, stating that he has a couple drinks with friends. [**Name (NI) **] denies illicit drugs. Family History: Mr. [**Known lastname 112247**] mother has heart disease, s/p a coronary artery bypass grafting in her late 60s, early 70s. His maternal uncle has a history of heart uncle. Physical Exam: Admission physical exam: VS: T 98.2, BP 128/65, HR 56, RR 18, SpO2 96% on RA WEIGHT: 107kg GENERAL: WDWN sitting up in bed in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD. CARDIAC: 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 abdominial bruits. EXTREMITIES: No c/c/e. RIght wrist with TR band in place. 2+ radial pulses bilaterally. Hair loss of the lower extremities bilaterally. NEURO: CN II-XII tested and [**Known lastname 5235**], strength 5/5 throughout, sensation grossly normal. Gait not tested. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Date/Time: [**2199-5-21**] Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.2 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Low normal LVEF. RIGHT VENTRICLE: Borderline normal RV systolic function. [**Year (4 digits) **]: Normal ascending [**Year (4 digits) 5236**] diameter. Simple atheroma in descending [**Year (4 digits) 5236**]. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Physiologic MR (within normal limits). TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). with borderline normal free wall function. There are simple atheroma in the descending thoracic [**Year (4 digits) 5236**]. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. Post-CPB: The patient is A-Paced, on no inotropes. Preserved biventricular systolic fxn. No AI, no MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. [**2199-5-27**] 05:07AM BLOOD Hct-30.7* [**2199-5-26**] 05:10AM BLOOD WBC-6.5 RBC-2.95* Hgb-9.1* Hct-26.5* MCV-90 MCH-30.9 MCHC-34.4 RDW-12.7 Plt Ct-219 [**2199-5-27**] 05:07AM BLOOD PT-12.4 INR(PT)-1.1 [**2199-5-27**] 05:07AM BLOOD UreaN-41* Creat-1.6* Na-133 K-5.2* Cl-94* HCO3-27 AnGap-17 [**2199-5-27**] 05:07AM BLOOD Mg-2.4 [**5-26**] PA&Lat: The right IJ line tip is in the mid SVC. There is volume loss in the retrocardiac region but the effusions are much smaller. A small left lower lobe retrocardiac infiltrate could be present versus volume loss. Overall, the aeration of the left lung is improved. Brief Hospital Course: Patient is a 60 yo male with PMHx of CAD by cath at the [**Hospital1 112**] in [**2189**], HTN, HLD, and OSA (does not use CPAP regularly) recently with chest pain and oupatient ETT revealing significant ST depression admitted last night with chest pain at OSH and transferred to [**Hospital1 18**] for cardiac catheterization found to have extensive 3-vessel CAD referred to cardiac surgery for CABG. The patient was brought to the Operating Room on [**2199-5-21**] where the patient underwent a coronary artery bypass grafting times six (LIMA>LAD, SVG>Diag, SVG>Ramus, SVG>OM, SVG>OM, SVG>PDA). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically [**Date Range 5235**] and hemodynamically stable. Beta blocker was initiated and the patient was diuresed towards the preoperative weight.Baseline creat 1.4-1.6. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. On the morning of post-operative day three Mr. [**Known lastname 43681**] had intermittent rapid atrial fibrillation 150-160's which converted to sinus rhythm with increased beta blockers and was bolused with amiodarone and placed on taper. Anticoagulation was started, goal INR [**1-4**] to be managed by [**Hospital 6435**] [**Hospital3 **]. At discharge his creat was 1.6 and potassium sightly elevated. He has been aggressively diursed and is being discharged on low dose lasix and no potassium supplement. He will need to have chem 7 checked over the next couple of days and diuretics/potassium adjusted as needed. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 6 the patient was ambulating freely, his wounds were healing well and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. VNA Allcare network to f/u with him at home. Medications on Admission: --ASA 81mg daily --Pravastatin 20mg daily --Atenolol 25mg daily --Linsopril 20mg daily --Fenofibrate 200mg daily Discharge Medications: 1. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 Tablet(s) by mouth daily Disp #*60 Tablet Refills:*2 2. Pravastatin 20 mg PO DAILY RX *pravastatin 10 mg 1 Tablet(s) by mouth daily Disp #*60 Tablet Refills:*1 3. Acetaminophen 650 mg PO Q4H:PRN pain/fever 4. Amiodarone 400 mg PO BID Duration: 3 Days then decrease 200mg [**Hospital1 **] x 1 week then decrease to 200mg daily RX *amiodarone 200 mg 2 Tablet(s) by mouth twice daily for 3 days Disp #*90 Tablet Refills:*0 5. Docusate Sodium 100 mg PO BID Duration: 1 Months 6. Furosemide 40 mg PO DAILY Duration: 1 Weeks RX *furosemide 40 mg 1 Tablet(s) by mouth daily Disp #*7 Tablet Refills:*0 7. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain RX *hydromorphone 2 mg [**12-3**] Tablet(s) by mouth every 4 hrs Disp #*40 Tablet Refills:*0 8. Metoprolol Tartrate 37.5 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. [**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg [**10-4**] Tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*2 9. Ranitidine 150 mg PO DAILY Duration: 1 Months RX *ranitidine HCl 150 mg 1 Capsule(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Warfarin MD to order daily dose PO DAILY RX *warfarin 5 mg as directed Tablet(s) by mouth daily as directed Disp #*90 Tablet Refills:*0 11. fenofibrate *NF* 200 mg Oral daily 12. Potassium 20meq tabs po to be taken as directed Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary artery disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage +1 lower ext edema 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 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** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**2199-6-4**] at 11 am [**Telephone/Fax (1) 170**] Surgeon Dr. [**Last Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2199-6-25**] 1:30 Cardiologist Dr. [**Last Name (STitle) **] (Dr.[**Name (NI) 112248**] office will call patient to arrange) Please call to schedule the following: Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 69482**] ([**Telephone/Fax (1) 112249**] in [**3-7**] 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** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2199-5-27**]

[ "V15.82", "427.31", "327.23", "272.4", "593.9", "401.9", "414.01", "274.9", "411.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8622, 8671

4871, 7054

293, 386

8739, 8914

2700, 4848

9785, 10603

1531, 1705

7217, 8599

8692, 8718

7080, 7194

8938, 9762

1745, 2681

238, 255

414, 1208

1230, 1300

1316, 1515

13,033

111,075

43051

Discharge summary

report

Admission Date: [**2187-12-17**] Discharge Date: [**2187-12-20**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypertensive urgency and hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 39 M with DM, ESRD on HD, gastroparesis, autonomic dysfunction, CAD (STEMI, NSTEMI), ; was admitted to MICU with usual nausea, vomiting, abdominal pain and hypoxemia of unknown origin. Mr [**Known firstname 6164**] was recently admitted from [**2103-12-5**] with concern of line infection/positive blood cultures; started on vancomycin with HD. . Pt. reported sudden onset N/V x4 on day of admission. Emesis was non-bloody or bilious. No prodorome or associated symptoms, except slight abdominal pain, no diarrhea, occasional dry cough x 2+ months. . Pt also reports being "high on fluid" as he notes that he senses that with increased abdominal girth and neck swelling. This onset of these symptoms could not be clarified by the patient. He reports being at a party the day before and drinking cranberry juice and water, but denies use of EtOH, drugs or dietary indiscretions. This episode is similar in nature to previous exacerbations of gastroparesis per patient and renal attending who knows patient well (Dr. [**Last Name (STitle) 1366**]. Saw Dr. [**Last Name (STitle) **] (his cardiologist) on day of admission; was feeling ill at the time. He recommended increasing lisinopril and labetalol, adding HCTZ and stopping clonidine patch. . From ICU admit note: "In the ED, patient received 20 IV labetalol for elevated BP; 4 mg IV ativan and 2 mg IV dilaudid. Femoral CVL placed. Initial vitals 97.8, HR 90, 190/120, 97% on RA. Desatted to upper 80s on RA and ?lower into 70s per ED signout (but not documented in written notes), ABG with pO2 of 71. Placed on 3 L NC. CXR with volume overload; CTA obtained due to hypoxemia and was negative for PE. SBP range 170s-180s. In ICU pt c/o [**9-23**] abdominal pain, asking for dilaudid and ativan, 2 mg of each." . While in ICU, patient completed ROMI, CTA and repeat XRs did not show apparent PNA and he continued to have a 2L O2 requirement. He was started NPO, abdominal pain and N/V impoved and was then advanced to clears. Pain was treated with IV dilaudid, IV ativan and zofran. CTA review revealed a new LAD aneurysm. Pt underwent HD today where he received Vanco per HD protocol and was deemed stable enough for transfer to floor. . Pt. was seen in HD, NAD, somewhat sleepy s/p Ativan for nausea. In addition to above, he reported one episode of CP 2 d PTA, lasting 30seconds, w/o associated symptoms and resolution on its own. He denied N/V, CP, SOB, diarrhea, fevers, chills, HA, diplopia. Past Medical History: - Diabetes Mellitus Type I - Gastroparesis with chronic hospitalizations - ESRD on HD since [**2-/2184**] - Autonomic dysfunction, frequent HTN emergency & orthostatic hypotension - Peripheral neuropathy - Coronary artery disease, STEMI [**2186-12-17**] in setting of cocaine, s/p BMS to LAD - Aortic valve endocarditis ([**4-21**]) and [**2187-9-12**] (MSSA tx with nafcillin) - Frequent bacteremia/line infections, often coag neg staph. - prior line sepsis with klebsiella and enterobacteremia - Esophageal ulceration: H pylori neg, active esophagitis seen on EGD [**2187-4-18**], h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear - History of substance abuse (cocaine, marijuana, alcohol) - History of thrombosed AV fistula in LUE [**4-20**], [**Doctor Last Name **]-tex in place - Fungemia completed caspofungin IV on [**2187-7-12**] - GI bleed associated with hypotension-colonscopy showed friable and inflammed ascending and transverse colon,suggestive either of ischemia or infection [**2187-7-19**] - NSTEMI in setting hypertension on [**2187-10-21**] Social History: Patient has a prior history of tobacco and marijauna use, but he does not currently smoke. He has a prior history of alcohol abuse and has been sober for 9 years. He has a past history of cocaine use. He currently denies illicit drugs. Currently lives with his mother and brothers. Family History: Father deceased of ESRD and DM. Mother aged 50's with hypertension. Two sisters, one with diabetes. Six brothers, one with diabetes. There is no family history of premature coronary artery disease or sudden death. Physical Exam: On admission to MICU: Tmax: 36.3 ??????C (97.4 ??????F) Tcurrent: 36.3 ??????C (97.4 ??????F) HR: 81 (81 - 86) bpm BP: 133/90(100) {133/90(100) - 167/123(134)} mmHg RR: 14 (14 - 25) insp/min SpO2: 97% General Appearance: No acute distress Eyes / Conjunctiva: No(t) PERRL, + anisocoria, R 4->3, L 2.5->2 Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL, No(t) Cervical adenopathy Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), apical SM Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : faint end inspiratory crackles at bases, No(t) Wheezes : , Diminished: bilat bases) Abdominal: Soft, Bowel sounds present, No(t) Distended, Tender: diffuse in abdomen, voluntary guarding, hypoactive BS Extremities: Right: Absent, Left: Absent Skin: Cool, No(t) Rash: Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): place, day -1, Movement: Not assessed, Tone: Not assessed, slightly lethargic On transfer to the floor VS: Tc: 96 ??????F HR: 84 BP: 149/110mmHg RR: 18 SpO2: 95% RA General Appearance: No acute distress HEENT - normocephalic, No LAD. PERRL, R 2->1.5, L 2->1.5 CV: S1, S2 nl, [**3-21**], SEM at apex. Pulm: CTA b/l. Abdominal: Soft, Bowel sounds present, NT/ND, BS+ Skin: warm, dry, no edema, no lesions Ext: warm, dry, no edema, R tunneled catheter, C/D/I. Neuro: slightly sleepy, but arouses and maintains attention to voice, CN 2-12 intact, strength 5/5 b/l UE and LE, sensory grossly intact, DTRs 2+. Pertinent Results: Laboratory studies: [**2187-12-17**] 02:30PM BLOOD WBC-9.9 RBC-3.80* Hgb-9.6* Hct-32.5* MCV-86 MCH-25.3* MCHC-29.6* RDW-20.4* Plt Ct-275 [**2187-12-18**] 03:25AM BLOOD WBC-8.5 RBC-3.43* Hgb-8.8* Hct-29.2* MCV-85 MCH-25.6* MCHC-30.0* RDW-19.1* Plt Ct-288 [**2187-12-19**] 07:00AM BLOOD WBC-6.3 RBC-3.85* Hgb-10.0* Hct-33.6* MCV-87 MCH-25.9* MCHC-29.7* RDW-19.4* Plt Ct-251 [**2187-12-20**] 04:09AM BLOOD WBC-4.8 RBC-3.78* Hgb-9.9* Hct-31.6* MCV-84 MCH-26.2* MCHC-31.3 RDW-20.3* Plt Ct-272 [**2187-12-17**] 02:30PM BLOOD Neuts-85.5* Lymphs-7.6* Monos-4.4 Eos-2.2 Baso-0.4 . [**2187-12-17**] 02:30PM BLOOD PT-12.9 PTT-29.0 INR(PT)-1.1 . [**2187-12-17**] 02:30PM BLOOD Glucose-274* UreaN-60* Creat-9.3*# Na-140 K-5.8* Cl-98 HCO3-28 AnGap-20 [**2187-12-18**] 03:25AM BLOOD Glucose-124* UreaN-69* Creat-10.5*# Na-143 K-5.4* Cl-101 HCO3-29 AnGap-18 [**2187-12-19**] 07:00AM BLOOD Glucose-64* UreaN-37* Creat-7.4*# Na-138 K-4.3 Cl-95* HCO3-25 AnGap-22* [**2187-12-20**] 04:09AM BLOOD Glucose-101 UreaN-45* Creat-9.0*# Na-136 K-4.8 Cl-92* HCO3-28 AnGap-21* . [**2187-12-17**] 02:30PM BLOOD ALT-12 AST-16 CK(CPK)-164 AlkPhos-115 TotBili-0.1 [**2187-12-17**] 10:30PM BLOOD CK(CPK)-123 [**2187-12-18**] 03:25AM BLOOD CK(CPK)-112 . [**2187-12-17**] 02:30PM BLOOD cTropnT-0.22* [**2187-12-17**] 10:30PM BLOOD CK-MB-6 cTropnT-0.24* [**2187-12-18**] 03:25AM BLOOD CK-MB-6 cTropnT-0.26* . [**2187-12-18**] 03:25AM BLOOD Calcium-9.2 Phos-8.6*# Mg-2.1 [**2187-12-19**] 07:00AM BLOOD Calcium-8.4 Phos-7.0*# Mg-1.7 [**2187-12-20**] 04:09AM BLOOD Calcium-8.7 Phos-7.7* Mg-1.9 . [**2187-12-18**] 03:25AM BLOOD Vanco-13.3 . [**2187-12-17**] 02:50PM BLOOD Type-ART Rates-/1 pO2-71* pCO2-48* pH-7.36 calTCO2-28 Base XS-0 Intubat-NOT INTUBA Vent-SPONTANEOU Micro: Blood culture from [**12-18**] - negative. . Imaging/Studies: . CXR [**12-17**] - IMPRESSION: Findings most compatible with volume overload. Repeat PA and lateral radiographs may be helpful once symptoms resolved. . CTA [**12-17**] - CT OF THE CHEST WITH IV CONTRAST: There are extensive atherosclerotic calcifications involving the left anterior descending, left circumflex, and right coronary arteries. A focal area of aneurysmal dilatation of the distal left anterior descending coronary artery is evident, measuring 2.7 x 0.7 cm in the sagittal plane (2:81, 302b:43). The heart is moderately enlarged in size. There is no pericardial effusion. The aorta is normal in caliber and contour. There are no filling defects within the pulmonary arterial vasculature. A tiny linear defect within a right lower lobe subsegemental branch may represent mixing of contrast or other artifact (2:71). The pulmonary artery is enlarged, measuring 3.6 cm in diameter. Prevascular lymph nodes measuring 10 and 6 mm in short- axis diameter are evident (2:35). A precarinal mediastinal lymph node measures 10 mm in short- axis diameter (2:34). There are no pathologically enlarged hilar or axillary lymph nodes. There is a small right- sided pleural effusion. Lung windows demonstrate extensive septal thickening and diffuse ground-glass changes compatible with pulmonary edema. Small hiatal hernia is noted. The imaged portions of the upper abdomen are otherwise unremarkable. There are no suspicious lytic or blastic lesions. IMPRESSION: 1. No acute pulmonary embolism. 2. Aneurysmal dilatation of the left anterior descending coronary artery. 3. Enlarged pulmonary artery, indicative of pulmonary hypertension. 4. Evidence of volume overload including small right-sided pleural effusion. 5. Extensive coronary artery atherosclerotic calcifications. 6. Mediastinal lymphadenopathy, likely reactive. . ECG [**12-18**] - Sinus rhythm. Anteroseptal myocardial infarction, age indeterminate. Possible left atrial abnormality. Since the previous tracing of [**2187-12-5**] no significant change. TRACING #1 Read by: [**Last Name (LF) 2052**],[**First Name3 (LF) 2053**] J. Intervals Axes Rate PR QRS QT/QTc P QRS T 82 184 78 396/434 37 11 46 . CXR [**12-18**] - FINDINGS: In comparison with the study of [**12-17**], the pulmonary vascularity is now essentially within normal limits. Enlargement of the cardiac silhouette persists. No evidence of acute focal pneumonia. . ECG [**12-19**] - Sinus rhythm with one ventricular premature beat. Probable left atrial abnormality. Anteroseptal myocardial infarction, age indeteminate. Compared to the previous tracing of [**2187-12-18**] no significant change. TRACING #2 Read by: [**Last Name (LF) 2052**],[**First Name3 (LF) 2053**] J. Intervals Axes Rate PR QRS QT/QTc P QRS T 87 182 80 392/439 55 -15 39 Brief Hospital Course: 39 M with history of ESRD on HD, DM c/b gastroparesis and autonomic dysfunction, CAD s/p STEMI, frequent admissions for nausea/vomiting and abdominal pain; now admitted with N/V/abdominal pain and hypoxemia. In the MICU he was stabilized with pain medication and underwent HD with subsequent improvement of volume overload and resporatory function. He was transferred to the floor for further management on HD2. . # Hypoxemia. Patient had a new O2 requirement in ED/MICU that had resolved with ESRD. Differential included hypoventilation from narcotics, pain/splinting (elevated pCO2 on ABG) and volume overload [**3-17**] ESRD, CAD/ischemia. He was ruled out for PE and MI, had no apparent focal pneumonia clinically or on CT, but did have pulmonary edema on CT at presentation. After HD, this had resolved. Repeat ECG was unchanged from priors w/ anteroseptal MI and possible LAE. Patient was continued on ASA, statin, Plavix and BBK. . # N/V/abdominal pain. Similar to prior presentations was felt to be likely related to DM gastroparesis. His lipase and LFTs were wnl. The abdominal pain improved slightly from HD2 to 3, however patient could not tolerate PO diet w/ return of abdominal pain and N/V. He was given Dilaudid IV for pain control and ativan IV as an antiemetic. Reglan 10mg IV/PO was continued throughout hospitalization. By HD 4, the nausea/emesis and abdominal pain improved significantly. Pt. was switched to PO medications and advanced to regular diet with good tolerance. He was discharged home with PO reglan, dilaudid, vicodin and ativan for pain/nausea control and prevention of future episodes. . # ESRD on HD & Bacteremia. Patient underwent two HD sessions while hospitalized. He had a tunnelled femoral line. His vancomycin for coagulase negative staph bacteremia from prvious hospitalization was completed. Vanco trough measured was 13.3 and his dosing was adjusted per HD protocol. Blood cultures were repeated and were negative. Patient's phosphate levels were significantly elevated. He received only one dosde of aluminum hydroxide while hospitalized due to n/v. He was continued on Lanthanum, Nephrocaps as per home regimen. . # LAD aneurysm. Noted on CTA, was new since [**2186**]. The case was discussed with cardiology and it was felt that no further work up or anticoagulation were required at this time, given the location distal to previous STEMI site. This was also discussed with Mr. [**Known firstname 6164**]' outpatient cardiologist and will be followed as OP. . # DM. Poorly controlled during hospitalization with inconsistent dietary intake. He was continued on home dosing NPH plus sliding scale. On HD4, BG control improved to BG > 150 throughout the day. Patient was discharged w/ 5U of NPH qAM and regular insulin SS. Gastroparesis was treated as above. Gabapentin was continued as per home regimen. . # HTN. This was poorly controlled since admission and required IV labetalol prn in MICU. On the floor BPs reanged to 160s/110s. Antihypertensive medication reconcilliation was performed in consultation with Dr. [**Last Name (STitle) 1366**]. It was noted that the patient has not benefited from HCTZ and relative hypotension with [**Name (NI) 8213**]. Mr. [**Known firstname 6164**]' labetalol was increased to 200mg [**Hospital1 **], clonidine patch was continued at 0.3mg Qweekly and lisinopril was started at 20 and advanced to 40mg QD at time of discharge. BP at discharge 142/100 mmHg. . # CAD s/p STEMI. Patient was asymptomatic. He was continued on ASA, plavix, statin, BB. Lisinopril was started prior to discharge. He will be scheduled as OP for catheterization. . For prophylaxis he was placed on heparin SC and continued outpatient PPI regimen. . He was discharged in a hemodynamically stable condition with appropriate follow up. Patient was pain free and free of n/v. Medications on Admission: 1. Aspirin 325 mg daily 2. Clopidogrel 75 mg daily 3. Simvastatin 40 mg daily 4. Clonidine 0.3 mg/24 hr Patch Weekly qSunday 5. Labetalol 200 mg [**Hospital1 **] 6. Lanthanum 1000 mg TID c meals 7. Metoclopramide 10 mg QIDACH 8. B Complex-Vitamin C-Folic Acid 1 daily 9. Gabapentin 300 mg with HD 10. Pantoprazole 40 mg daily 11. Zofran 4 mg TID 12. Ativan 1 mg q4-6hrs prn 13. Insulin NPH 5 U qAM 14. Vicodin 5-500 mg TID prn 15. Vancomycin with HD 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). Disp:*30 Tablet(s)* Refills:*2* 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). Disp:*14 Patch Weekly(s)* Refills:*2* 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). Disp:*30 Capsule(s)* Refills:*2* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID with meals. Disp:*90 Tablet, Chewable(s)* Refills:*2* 9. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*60 Tablet(s)* Refills:*2* 11. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 12. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1) Injection three times a day: as per your sliding scale provided to you. Disp:*10 cartriges* Refills:*2* 13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 14. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO QAM. Disp:*30 Tablet(s)* Refills:*2* 15. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Five (5) Units Subcutaneous QAM. 16. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for abdominal pain: gastroparesis. Disp:*30 Tablet(s)* Refills:*0* 17. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 18. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*90 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Gastroparesis, pulmonary edema, uncontrolled hypertension Secondary: Diabetes type I, Coronary artery disease, autonomic dysfunction. Discharge Condition: Hemodynamically stable, without pain. Discharge Instructions: You were admitted to the hopital because you have developed an exacerbation of your recurrent abdominal pain and nausea and vomiting. In addition you were found to have fluid in your lungs, likely due to drinking too much fluid between dialysis sessions. Initially, you had low blood oxygen levels and required supplemental oxygen, but once you went to dialisis, your oxygen levels improved as did your breathing. You were treated with pain medication, nause medication and went to dialisis. You were also continued on Vancomycin for a blood infection, you did not have any fevers. You completed this antibiotic while in the hospital. You went to dialisis on your regularly scheduled days. At Dialysis more blood cultres were drawn. In addition, you were found to have an anneurysm (small outpouching) of a blood vessel around your heart. Your cardiologist's team saw you and felt that this will not require further intervention. You will need to follow up with your cardiologist for this as well as to have a heart catheterization. Your blood pressure was also high during this admission. This was discussed in detail with your Nephrologist Dr. [**Last Name (STitle) 1366**] and the new regimen was provided for you (new medication includes Lisinporil and you will continue Labetalol and clonidine). You will need to follow up the blood pressure regimen and the blood culture results with Dr. [**Last Name (STitle) 1366**]. Should you experience new abdominal pain, chest pain, shortness of breath, palpitations, fever, chills, cough, faintness or any other symptoms concerning to you, please call your primary care provider or go to the nearest emergency room. Please adhere to a regular diabeti, heart healthy diet. You were provided with prescriptions and refills for medications you are taking. Followup Instructions: Please follow up with you PCP and the following providers: Please call your PCP to follow up within two weeks. [**First Name4 (NamePattern1) 31804**] [**Last Name (NamePattern1) 7405**] ([**Company 191**] resident). [**Telephone/Fax (1) 250**]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2187-12-31**] 11:00. [**Hospital6 29**], [**Location (un) **], CC7 CARDIOLOGY Please call Dr.[**Name (NI) 4857**] office to arrange follow up within one to two weeks: ([**Telephone/Fax (1) 773**]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2188-1-19**]

[ "428.22", "428.0", "403.01", "790.7", "337.1", "V45.82", "285.21", "041.19", "414.11", "414.01", "536.3", "999.31", "585.6", "250.63" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

17258, 17264

10804, 14669

349, 355

17451, 17491

6199, 10781

19355, 20086

4290, 4506

15169, 17235

17285, 17430

14695, 15146

17515, 19332

4521, 6180

277, 311

383, 2847

2869, 3974

3990, 4274

21,370

186,576

54403

Discharge summary

report

Admission Date: [**2184-1-13**] Discharge Date: [**2184-1-28**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old woman with a history of hypertension, anemia, and possible atrial fibrillation. She lives alone and had last been seen three days prior to admission. On the day of admission she was found unresponsive on her floor and was subsequently Department. PAST MEDICAL HISTORY: 1. Diaphragmatic hernia. 2. Chronic lower back pain. 3. Osteoporosis. 4. Osteoarthritis. 5. Hypertension. 6. Hypertrophic cardiomyopathy with an ejection fraction of 60% in [**2181**]. 7. PPD positive with a negative chest x-ray. 8. Chronic anemia. 9. Chronic MEDICATIONS ON ADMISSION: Salsalate 750 mg p.o. b.i.d., Fosinopril 20 mg p.o. b.i.d., Atenolol, Aspirin 81 mg p.o. q.d. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient lives alone. Further information regarding the social history was not available at the time of admission. PHYSICAL EXAMINATION: Vital signs: Initial exam revealed a temperature of 99.9??????, heart rate 102, blood pressure 219/133 with transient fluctuations to as low as 140/90, respirations 23. General: The patient was ill appearing. HEENT: Dry mucous membranes. Lungs: Clear to auscultation anteriorly. There was a prominent systolic murmur at the right upper sternal border. Abdomen: Soft. Extremities: No clubbing, cyanosis or edema. There was no evidence of trauma. Neurological: Exam revealed that the patient would transiently open her eyes in response to calling her name loudly. She would not follow commands and would occasionally attempt to speak with mumbling. She did not track and would not blink to threat. Pupils were reactive from 3-2 mm. Her left eye was mid position with the right eye with lateral deviation at rest. OCR was intact. There was right facial droop with flaccid right upper extremity tone and power. There was minimal withdraw to bed pressure in all extremities. Her right lower extremity was externally rotated. There was no spontaneous limb movement. Reflexes were absent in the right arm with trace reflexes in the left arm. Reflexes could not be elicited for the patellar or gastrocnemius. Her plantar response was extensor bilaterally. LABORATORY DATA: Initial laboratory findings included a white count of 10.6; sodium 150, total CPK of 2742. Head CT revealed low attenuation in the posterior limb of the left internal capsule. There was calcification in the globus pallidi. The patient was admitted to the Intensive Care Unit for further treatment of her cerebral ischemic infarction and hypernatremia. HOSPITAL COURSE: The patient underwent an MRI/MRA of the brain that revealed subacute infarcts of the left anterior middle cerebral artery territory involving the inferior aspect of the posterior limb of the internal capsule, as well as the medial aspect of the left hippocampus. Her MRA demonstrated decreased flow of the left internal carotid artery suggestive of significant proximal stenosis. The distal left vertebral artery was poorly visualized. The basilar artery was small but widely patent. These findings were consistent with a left MCA ischemic infarction. The patient had an episode of hypotension that required pressor support. On the night of admission, the patient had runs of atrial fibrillation. She had been started on Heparin soon after admission. The patient was transferred to the floor on her second hospital day. On her third hospital day, she had an episode of hypotension with a decrease in her hematocrit, and was subsequently determined to have a left inguinal bleed. She was transferred back to the Intensive Care Unit for further management. Heparin was discontinued, and the patient was started on Aspirin. In the future she will likely require anticoagulation for her paroxysmal atrial fibrillation. During her second Intensive Care Unit stay, she developed an E. coli urinary tract infection and was treated with Bactrim. Subsequent physical exams revealed evidence of a strong left gaze preference, right hemifield cut and flaccid right arm and face. She also has evidence of a global aphasia. She was subsequently weaned off pressor support. Through her hospital stay, her elevated CPKs returned towards baseline. The patient underwent PEG tube placement on [**2184-1-27**]. On [**2184-1-25**], the patient was noted to have decreased movement of her left lower extremity, and given her level of decreased mental status and limited communication ability, a repeat MRI was obtained. This showed new regions of subacute infarct in the left basal ganglia with areas of restricted fusion. There was also further evolution of the left internal capsular infarct, and MRA demonstrated evidence of 70-80% stenosis involving the left internal carotid artery. The MRA was degraded by motion artifact however. There was also the possibility of moderate basilar disease. Towards the end of her hospital stay, she had episodes of supraventricular tachycardia, and Cardiology had recommended increasing her Lopressor to 25 mg p.o. b.i.d. After placement of her PEG, tube feeds were started with Promote and Fiber at 20 cc/hr and increased gradually to a goal of 65 cc/hr. The patient will be discharged to rehabilitation. DISCHARGE DIAGNOSIS: 1. Left basal ganglion and posterior internal capsular infarction, likely of embolic etiology. 2. Moderate left internal carotid stenosis. 3. Paroxysmal atrial fibrillation. 4. Recent urinary tract infections. 5. Status post left inguinal bleed requiring transfusions and pressor support. 6. Hypertension. 7. Hypertrophic cardiomyopathy. DISCHARGE MEDICATIONS: Zantac 150 mg per PEG b.i.d., Lopressor 25 mg per PEG b.i.d., hold for systolic blood pressure less than 110 or pulse less than 60, Plavix 75 mg per PEG q.d., Heparin 5000 U subcue b.i.d., Aspirin 325 mg p.o. q.d. ISSUES PENDING ON DISCHARGE: The patient will need to be restarted on an anticoagulation for paroxysmal atrial fibrillation at some point in the future. She should have a repeat urinalysis obtained approximately one week after discharge to reevaluate adequate clearance of her urinary tract infection. DISCHARGE DIET: The patient is on Promote with fiber at a goal of 65 cc/hr. CONDITION ON DISCHARGE: Fair. ACTIVITY: As defined by physical therapy. FOLLOW-UP: The patient should follow-up with the [**Hospital 4038**] Clinic at [**Hospital1 **] in [**2-8**] weeks. DISPOSITION: The patient is discharged to rehabilitation. CODE STATUS: FULL CODE. Family members to contact in case of an emergency include a cousin whose name is [**Name (NI) **] [**Name (NI) 111368**] in White Plains, [**State 531**], [**Telephone/Fax (1) 111369**]. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Dictated By:[**Doctor First Name 38670**] MEDQUIST36 D: [**2184-1-28**] 17:36 T: [**2184-1-28**] 18:24 JOB#: [**Job Number **]

[ "433.11", "599.0", "707.0", "276.0", "427.31", "922.2", "276.5", "E888.9", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "46.32" ]

icd9pcs

[ [ [] ] ]

5715, 5945

5345, 5691

718, 851

2676, 5324

1011, 2658

5960, 6313

112, 392

415, 692

868, 988

6338, 7006

2,130

155,612

27412+57547

Discharge summary

report+addendum

Admission Date: [**2166-5-31**] Discharge Date: [**2166-6-17**] Date of Birth: [**2148-12-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p Fall onto head while on trampoline Major Surgical or Invasive Procedure: [**2166-6-2**] ACDF/PCLF C4-C5 [**2166-6-3**] IVC filter History of Present Illness: 17 yo male s/p fall onto his head while on a trampoline; loss of sensation below nipple line. He was taken to an area hospital, Solumedrol protocol initiated. He was later transferred to [**Hospital1 18**] for continued trauma care. Past Medical History: None Family History: Noncontributory Physical Exam: Lunga CTA HEART RRR NM NG ABD soft nt nd Ext no movement inferior extremities no fine motor activity Pertinent Results: [**2166-5-31**] 01:12AM GLUCOSE-132* LACTATE-1.2 NA+-142 K+-4.4 CL--104 TCO2-27 [**2166-5-31**] 01:12AM WBC-10.7 RBC-5.14 HGB-15.4 HCT-43.5 MCV-85 MCH-29.9 MCHC-35.3* RDW-12.5 [**2166-5-31**] 01:12AM PLT COUNT-233 [**2166-5-31**] 01:12AM PT-12.9 PTT-25.0 INR(PT)-1.1 [**2166-5-31**] 01:12AM FIBRINOGE-208 [**2166-5-31**] 01:12AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2166-5-31**] 01:12AM ASA-NEG ETHANOL-NEG ACETMNPHN-5.5 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CHEST (PORTABLE AP) [**2166-6-16**] 4:49 AM CHEST (PORTABLE AP) Reason: ? improved atelectasis/consolidations [**Hospital 93**] MEDICAL CONDITION: 17M s/p c-spine cord injury with, on trach collar, desaturation and fever , bronch'd [**6-14**] for LLL consolidation REASON FOR THIS EXAMINATION: ? improved atelectasis/consolidations AP CHEST, 5:16 A.M. ON [**6-16**]. HISTORY: Spinal cord injury, fever and desaturation. IMPRESSION: AP chest compared to [**2077-6-9**], and 19: Diffuse interstitial pulmonary abnormality has resolved, but left lower lobe consolidation has not and could be due to persistent atelectasis or pneumonia. Heart is normal size. There is no appreciable pleural abnormality. Tracheostomy tube in standard placement. CT CHEST W/CONTRAST [**2166-6-13**] 12:45 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: Looking for a source of infection. Field of view: 33 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 17 year old man with c-spine fx, s/p c spine surgery, now with unexplained fevers while on Abx.Small leakage from PEG site. REASON FOR THIS EXAMINATION: Looking for a source of infection. CONTRAINDICATIONS for IV CONTRAST: None. INDICATIONS: 17-year-old man with cervical spine fracture status post cervical spine surgery, now with unexplained fever. Also small amount of leakage around the PEG site. COMPARISONS: [**2166-5-31**]. TECHNIQUE: Axial CT images of the chest, abdomen, and pelvis were obtained with oral and intravenous contrast. CT OF THE CHEST WITH IV CONTRAST: There is a tracheostomy tube. There is no mediastinal, hilar, or axial lymphadenopathy. The heart, great vessels, and pericardium are unremarkable. There are no pleural or pericardial effusions. There is a small density at the right lung base peripherally, probably atelectasis. In addition, there is a vaguely increased ground glass opacity throughout the right lower lobe, sparing the right middle and upper lobes. This appearance could represent the very early appearance of the consolidation or perhaps atypical pneumonia. The left upper lobe is clear. The left lower lobe is mostly collapsed. Although the presence of infection cannot be excluded, the left lower lobe opacity, with volume loss, is most consistent with atelectasis. CT OF THE ABDOMEN WITH IV CONTRAST: There is a gastrostomy tube in position. The liver, gallbladder, pancreas, spleen, and adrenal glands are unremarkable. A hypoattenuating focus in the right kidney of 11 x 16 mm in axial dimensions is not fully characterized but most likely represents a simple cyst. There is an infrarenal inferior vena cava filter in appropriate position. The stomach, small and large bowel are within normal limits. There is no lymphadenopathy or free air or fluid. CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter in the bladder, and a small catheter in the rectum. The rectum, sigmoid, bladder, prostate, and seminal vesicles are unremarkable. There is no lymphadenopathy or free fluid. BONE WINDOWS: There are no suspicious lytic or blastic lesions. IMPRESSION: 1. Near collapse of the left lower lobe. 2. Diffuse nodular ground-glass opacity throughout the right lower lobe, suggestive of atypical infection and/or very early consolidation. Findings were discussed with Dr. [**First Name (STitle) 1022**] on the same day. BILAT LOWER EXT VEINS PORT [**2166-6-10**] 4:29 PM BILAT LOWER EXT VEINS PORT Reason: FEVER AND BEDREST SPINAL CORD INJURY [**Hospital 93**] MEDICAL CONDITION: 17 year old man with C-spine injury, REASON FOR THIS EXAMINATION: looking for DVT HISTORY: 17-year-old male with cervical spine injury and concern for lower extremity DVT. BILATERAL LOWER EXTREMITY ULTRASOUND: [**Doctor Last Name **] scale and Doppler son[**Name (NI) 1417**] of the bilateral common femoral, superficial femoral, deep femoral, and popliteal veins were performed. There is normal compressibility, waveform, flow and augmentation. No intraluminal echogenic material is identified. IMPRESSION: No evidence of DVT in the bilateral lower extremities. Sinus rhythm. Left ventricular hypertrophy. Since the previous tracing the rate is faster. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] T. Intervals Axes Rate PR QRS QT/QTc P QRS T 68 130 84 372/388.85 72 70 -127 MR CERVICAL SPINE [**2166-5-31**] 2:33 AM MR CERVICAL SPINE Reason: Please eval cord compression/injury [**Hospital 93**] MEDICAL CONDITION: 17 year old man with sensory motor loss following trampoline accident w/ evidence SCI on CT REASON FOR THIS EXAMINATION: Please eval cord compression/injury EXAM: MRI of the cervical spine. CLINICAL INFORMATION: Patient with sensory motor loss following accident, for further evaluation. TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the cervical spine were acquired. Correlation was made with the cervical spine CT examination of [**2166-5-31**]. FINDINGS: At C4-5 level, there is increased signal seen within the interspinous ligament and disruption of the ligament identified. Additionally, subtle increased signal is seen anteriorly at this level. There is mild focal loss of lordosis seen at this level in the cervical spine curvature. Additionally, there is diffuse bulging of the disc and disc herniation seen at this level indenting the spinal cord. The spinal cord demonstrates increased signal with areas of increased signal at this level and extending slightly superiorly and inferior to this level. Additionally, foci of low signal are identified within the spinal cord on T2-weighted images indicative of blood products. These findings indicate spinal cord contusion. At other levels in the cervical region, no evidence of disc herniation seen. No spinal stenosis seen. The facet joints are well aligned in the cervical region. Increased signal is seen in the posterior soft tissues secondary to trauma. IMPRESSION: Findings indicative of disruption of the interspinous ligament at C4-5 level with possible partial interruption of the posterior longitudinal ligament. Disc protrusion at C4-5 level indenting the spinal cord. Signal changes within the spinal cord indicative of spinal cord contusion. No evidence of facet joint malalignment. The injury may be unstable. The findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] at the time of interpretation of the study on [**2166-5-31**]. Brief Hospital Course: 17M xfer from osh with sci s/p falling onto head from trampoline @ 2230. loss sensation below nipple line, able to flex upper extr, loss rectal tone. no resp sxs. Started on solumedrol protocol.[**5-31**] CT spine: cord compression @ c4-5 with disc vs blood in [**Last Name (un) **].[**5-31**] CT [**Last Name (un) 103**] neg.[**5-31**] MRI complete cord injury .[**6-13**] CT of neck, chest and abd - collaped LLL . Injuries C-spine at 4-5 c complete cord injury . Procedures [**6-2**] OR for ACDF/PCLF C4-5 [**6-3**] IVC filter . Micro [**6-8**] sputum - beta strep PT not spiking fevers any more. Seen By ID . Recs: Unasyn for 14 days. PICC placement done. Hemodynamicly stable . Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 8. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every 8 hours) as needed for pain. 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 10. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for agitation/anxiety. 11. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 12. Oxycodone 5 mg/5 mL Solution Sig: [**1-27**] PO Q4-6H (every 4 to 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: s/p Fall onto head Spinal cord injury C4-C5 (complete) Discharge Condition: Stable Discharge Instructions: Follow up with Orthopedic Spine and Trauma Surgery Followup Instructions: Follow up with Dr. [**Last Name (STitle) 363**] in [**9-4**] weeks, call [**Telephone/Fax (1) 3573**] for an appointment. Follow up in Trauma Clinic in the next 4-8 weeks, call [**Telephone/Fax (1) 6439**] for an appointment. Completed by:[**2166-6-17**] Name: [**Known lastname 11650**],[**Known firstname **] Unit No: [**Numeric Identifier 11651**] Admission Date: [**2166-5-31**] Discharge Date: [**2166-6-17**] Date of Birth: [**2148-12-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3524**] Addendum: 17 yo male who was jumping on a trampoline and landed on his head. Pt was taken to OSH. OSH noted no movement in bilateral lower extremities and no sensation from nipple line down. Pt was med flighted to [**Hospital1 8**] on [**2166-5-31**]. Imaging showed C4-C5 disc herniation, ligament injury and spinal cord contusion at this level causing complete C4-C5 cord injury. Pt went to the OR for an anterior C4-5 discectomy and fusion and posterior C4-5 laminectomy and fusion on [**6-2**].. Percutaneous tracheostomy and gastrostomy was performed on [**2166-6-6**] . Diagnostic venogram of IVC and iliac veins and placement of Optease IVC filter was perform for DVT prophylaxis on [**2166-6-3**] Chest CT on [**6-13**] showed near collapse of the left lower lobe and diffuse nodular ground-glass opacity throughout the right lower lobe, suggestive of atypical infection and/or very early consolidation. A bronch was performed on [**6-14**] for persistent hight temperatures BAL cultures negative. Pt was pan cultured several times for increased temperature all cultures had been negative. ID consult was obtained recommending coverage for 14 days of Unasyn.Pt had PICC line placement on [**6-16**]. Psychiatry assessment revealed normal greef.Psychiatry recommendations were the following: 1) The pt appears to be experiencing normal grief 2) Continue to monitor mood and sleep 3) [**Month (only) 412**] offer Ativan 1mg PO prn anxiety or panic if it develops 4) Continue to involve SW in case, offer educational materials 5) Cont to involve pt??????s family in case 6) Discussed with primary team, [**Last Name (LF) 11652**],[**Name8 (MD) 11653**], MD Beeper#: [**Numeric Identifier 11654**] 7) Psychiatry will continue to follow, please page with questions #[**Numeric Identifier 11655**], or Psychiatry on call nights/weekends #[**Numeric Identifier 11656**]; Last evaluation form speech and swallow where the following: SECRETIONS / ABILITY TO HANDLE CUFF DEFLATION:Cuff was deflated prior to our evaluation and pt was tolerating cuff deflation without O2 desaturation or distress. RN was present to suction pt from the Trach tube with minimal/scant white, thick secretions retrieved. Unlike the last evaluation, pt did not request oral suctioning via the Yankauer during the evaluation. According to the RN, pt has not requested oral suctioning this morning. PMV TOLERANCE / VOCAL QUALITY / O2 SATS:Pt was able to achieve voicing upon placement of the valve and at first noted that it felt hard to exhale with the valve in place. The valve remained in place to allow the pt to adjust and pt stated that he was trying to get used to it. Pt's tracheal pressure measures were between -2 to +10 cm H20(normal range is between -/+10 cm H20). Pt's vocal quality was adequate and his O2 sats were between 94-99% while for 15 minutes while the valve was in place. SUMMARY: At this time pt is able to tolerate the PMV without respiratory distress, O2 desaturation, or c/o significant discomfort. It is recommended that the valve be removed when pt complains of discomfort, effortful breathing, or fatigue. It was discussed with the pt that he will need time to build up endurance to wear the valve for extended periods of time. We also discussed adjusting positioning as needed if valve tolerance appears difficult. Pt was last seen on [**2166-6-13**] for a PMV eval only and the recs were to return on [**2166-6-17**]. However, the re consult was placed today for both the PMV and swallowing. However, as per the recommendations from previous evaluations, swallow eval was deferred today, especially in light of potential discharge to rehab yesterday, and evidence of LLL collapse, RLL ground opacity on prior chest CT. PT is just beginning to demonstrate improved endurance and respiratory drive to tolerate the valve. As such, would prefer to allow him to establish consistent strength/endurance for this prior to assessing swallowing, as he has already demonstrated inability to tolerate aspiration (prior to Trach placement) in the setting of poor respiratory reserve. RECOMMENDATIONS: 1. ALWAYS DEFLATE CUFF PRIOR TO PLACING THE PASSY-MUIR VALVE! 2. Monitor O2 Sats / respiration while valve is in place. 3. Do not allow the patient to sleep with the valve in place. 4. PMV wear schedule is up to the discretion of the nurse and/or respiratory therapist. Pt as remained afebrile for 36 hours. Will be send to rehab today. Pt will have to follow up with Neurosurgery, and trauma surgery as an out patient. Chief Complaint: s/p Fall onto head while on trampoline Major Surgical or Invasive Procedure: [**2166-6-2**] ACDF/PCLF C4-C5 [**2166-6-3**] IVC filter History of Present Illness: 17 yo male s/p fall onto his head while on a trampoline; loss of sensation below nipple line. He was taken to an area hospital, Solumedrol protocol initiated. He was later transferred to [**Hospital1 8**] for continued trauma care Past Medical History: None Social History: The patient was born and raised in [**Location (un) **], NH, where he lives in a trailer with his parents and brother who is 4 years older. The patient is in the 11th grade at high school, and was working in the produce department of a grocery store. He enjoys English class and has some difficulty with math. He was an active athlete, playing soccer and snowboarding. He plans to be the assistant coach to his soccer team. He has been dating his girlfriend for 4 months total, with a hiatus in between ??????for stupid reasons.?????? Family History: Noncontributory Physical Exam: Physical Exam: Lunga CTA HEART RRR NM NG ABD soft nt nd Ext no movement inferior extremities no fine motor activity Pertinent Results: 10.4 4.03* 12.1* 35.3* 88 30.1 34.4 13.4 339 Import Result [**2166-6-15**] 04:45AM 10.9 4.11* 12.2* 35.7* 87 29.7 34.1 13.3 282 Import Result [**2166-6-14**] 06:43AM 12.9* 4.04* 12.1* 35.4* 87 30.0 34.3 13.2 299 Import Result [**2166-6-13**] 09:08AM 10.5 4.39* 13.0* 38.4* 87 29.6 33.9 13.0 302 Import Result [**2166-6-13**] 02:02AM 10.9 4.11* 12.2* 36.0* 88 29.7 33.9 13.1 267 Import Result [**2166-6-12**] 02:49AM 12.8* 4.10* 12.1* 35.9* 88 29.5 33.7 13.3 245 Import Result [**2166-6-11**] 05:28AM 11.9* 4.05* 12.2* 35.6* 88 30.2 34.4 13.0 237 Import Result [**2166-6-10**] 02:03AM 9.1 3.92* 12.0* 34.5* 88 30.6 34.8 13.0 207 Import Result [**2166-6-8**] 10:07PM 15.5*# 3.79* 11.6* 32.5* 86 30.5 35.6* 12.7 176 Import Result [**2166-6-7**] 12:34AM 8.9 4.21* 12.7* 35.6* 85 30.3 35.7* 12.6 164 Import Result [**2166-6-6**] 12:59AM 9.6 4.49* 13.5* 38.4* 86 30.0 35.1* 12.7 190 Import Result [**2166-6-5**] 02:35AM 10.1 4.38* 13.5* 37.7* 86 30.8 35.8* 12.4 159 Import Result [**2166-6-4**] 02:59AM 8.6 4.67 13.8* 39.6* 85 29.5 34.8 12.3 159 Import Result [**2166-6-3**] 01:58AM 37.7* Import Result [**2166-6-2**] 07:58PM 10.5 3.93* 12.3* 33.9* 86 31.2 36.1* 12.7 158 Import Result [**2166-6-2**] 04:14AM 14.5* 4.52* 13.7* 38.6* 85 30.3 35.6* 12.6 191 Import Result [**2166-6-1**] 02:48AM 11.9* 4.78 14.4 40.1 84 30.0 35.8* 12.5 245 Import Result [**2166-5-31**] 01:12AM 10.7 5.14 15.4 43.5 85 29.9 35.3* 12.5 233 Import Result DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos Promyel [**2166-6-13**] 09:08AM 73* 1 11* 3 2 0 0 7* 1* 2* Import Result [**2166-6-10**] 02:03AM 79.8* 13.2* 4.8 2.0 0.2 Import Result RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr [**2166-6-13**] 09:08AM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL Import Result BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2166-6-16**] 05:10AM 339 Import Result [**2166-6-16**] 05:10AM 13.4* 26.4 1.2* Import Result [**2166-6-15**] 04:45AM 282 Import Result [**2166-6-15**] 04:45AM 13.1 25.8 1.1 Import Result [**2166-6-14**] 06:43AM 299 Import Result [**2166-6-14**] 06:43AM 13.2* 25.9 1.2* Import Result [**2166-6-13**] 09:08AM NORMAL 302 Import Result [**2166-6-13**] 02:02AM 267 Import Result [**2166-6-13**] 02:02AM 13.8* 26.9 1.2* Import Result [**2166-6-12**] 02:49AM 245 Import Result [**2166-6-12**] 02:49AM 14.2* 27.6 1.3* Import Result [**2166-6-11**] 05:28AM 237 Import Result [**2166-6-10**] 02:03AM 207 Import Result [**2166-6-8**] 10:07PM 176 Import Result [**2166-6-7**] 12:34AM 164 Import Result [**2166-6-6**] 04:53AM 12.8 30.8 1.1 Import Result [**2166-6-6**] 12:59AM 190 Import Result [**2166-6-5**] 02:35AM 159 Import Result [**2166-6-4**] 02:59AM 159 Import Result [**2166-6-2**] 07:58PM 158 Import Result [**2166-6-2**] 04:14AM 191 Import Result [**2166-6-1**] 02:48AM 245 Import Result [**2166-6-1**] 02:48AM 14.5* 31.6 1.3* Import Result [**2166-5-31**] 01:12AM 233 Import Result [**2166-5-31**] 01:12AM 12.9 25.0 1.1 Import Result BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [**2166-5-31**] 01:12AM 208 Import Result Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2166-6-16**] 05:10AM 126* 27* 0.7 140 4.3 104 27 13 Import Result [**2166-6-15**] 04:45AM 131* 25* 0.6 139 4.1 104 28 11 Import Result [**2166-6-14**] 06:43AM 127* 29* 0.6 139 3.9 102 27 14 Import Result [**2166-6-13**] 02:02AM 115* 29* 0.8 138 4.7 101 29 13 Import Result [**2166-6-12**] 02:49AM 157* 24* 0.7 138 4.6 101 28 14 Import Result [**2166-6-11**] 05:28AM 127* 26* 0.7 138 4.9 101 28 14 Import Result [**2166-6-10**] 02:03AM 134* 19 0.8 139 4.5 102 28 14 Import Result [**2166-6-7**] 12:34AM 115* 16 0.7 133 5.1 99 25 14 Import Result [**2166-6-6**] 12:59AM 121* 15 0.6 134 4.7 102 26 11 Import Result [**2166-6-5**] 02:35AM 122* 21* 0.8 137 4.6 103 28 11 Import Result [**2166-6-4**] 02:59AM 108 18 0.7 138 4.3 104 27 11 Import Result [**2166-6-3**] 01:58AM 115* 19 0.8 143 3.9 108 29 10 Import Result [**2166-6-2**] 07:58PM 104 22* 1.0 145 3.7 111* 27 11 Import Result [**2166-6-2**] 04:14AM 123* 22* 0.8 141 4.2 106 27 12 Import Result [**2166-6-1**] 02:48AM 181* 18 1.0 140 4.4 106 24 14 Import Result [**2166-5-31**] 01:12AM 15 1.1 Import Result ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2166-6-16**] 05:10AM 182* 69* Import Result [**2166-6-15**] 04:45AM 208* 87* 210 130* 41 0.5 Import Result [**2166-6-14**] 03:48AM 238* 133* 243 161* 57 0.8 Import Result [**2166-6-12**] 01:51PM 205* 181* 274* 221* 0.7 Import Result [**2166-5-31**] 01:12AM 37 Import Result OTHER ENZYMES & BILIRUBINS Lipase [**2166-6-15**] 04:45AM 74* Import Result [**2166-6-14**] 03:48AM 100* Import Result CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2166-6-16**] 05:10AM 9.3 4.4 2.3* Import Result [**2166-6-15**] 04:45AM 9.1 4.3 2.2 Import Result [**2166-6-14**] 06:43AM 9.3 3.7 2.3* Import Result [**2166-6-14**] 03:48AM 3.5 Import Result [**2166-6-13**] 02:02AM 9.0 2.9# 2.3* Import Result [**2166-6-12**] 02:49AM 9.1 5.7*# 2.2 Import Result [**2166-6-11**] 05:28AM 9.0 3.2 1.9 Import Result [**2166-6-7**] 12:34AM 2.6* 1.7 Import Result [**2166-6-6**] 12:59AM 2.7 1.9 Import Result [**2166-6-5**] 02:35AM 8.2* 2.7 2.0 Import Result [**2166-6-4**] 02:59AM 8.1* 4.0 1.8 Import Result [**2166-6-3**] 01:58AM 8.2* 3.6 2.3* Import Result [**2166-6-2**] 07:58PM 1.8 Import Result [**2166-6-2**] 04:14AM 8.7* 4.1 2.0 Import Result [**2166-6-1**] 02:48AM 9.2 4.4 1.9 Import Result PITUITARY TSH [**2166-6-13**] 02:02AM 3.5 Import Result HEPATITIS HBsAg HBsAb HAV Ab IgM HAV [**2166-6-14**] 01:31PM NEGATIVE PND Import Result [**2166-6-13**] 02:02AM POSITIVE NEGATIVE Import Result IMMUNOLOGY [**Doctor First Name **] [**2166-6-14**] 01:31PM NEGATIVE Import Result ANTIBIOTICS Vanco [**2166-6-12**] 01:51PM 34.2 Import Result [**2166-6-10**] 07:49PM 2.7* Import Result [**2166-6-10**] 02:03AM 8.8* Import Result TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp Barbitr Tricycl [**2166-6-14**] 03:48AM NEG Import Result [**2166-5-31**] 01:12AM NEG NEG 5.5 NEG NEG NEG Import Result LAB USE ONLY HoldBLu RedHold [**2166-6-2**] 04:14AM HOLD Import Result [**2166-5-31**] 01:12AM HOLD Import Result HEPATITIS C SEROLOGY HCV Ab [**2166-6-13**] 02:02AM NEGATIVE Import Result Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calHCO3 Base XS Intubat Vent [**2166-6-13**] 05:13AM ART 60 114* 39 7.48* 30 6 Import Result [**2166-6-6**] 04:06AM ART 203* 50* 7.36 29 2 Import Result [**2166-6-6**] 01:08AM ART 56* 49* 7.39 31* 3 Import Result [**2166-6-3**] 12:00PM ART 35.8 /16 450 0 40 112* 48* 7.38 29 2 INTUBATED SPONTANEOU Import Result [**2166-6-3**] 08:35AM ART 35.8 /14 400 5 30 73* 45 7.38 28 0 INTUBATED Import Result [**2166-6-3**] 02:07AM ART 35.8 155* 46* 7.43 32* 5 Import Result [**2166-6-2**] 08:10PM ART 37.3 237* 46* 7.38 28 1 INTUBATED Import Result [**2166-6-2**] 04:08PM ART 182* 36 7.50* 29 5 INTUBATED Import Result [**2166-5-31**] 01:12AM [**Last Name (un) **] 7.39 Import Result WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl calHCO3 [**2166-6-6**] 01:08AM 121* Import Result [**2166-6-3**] 08:35AM 91 Import Result [**2166-6-3**] 02:07AM 0.9 Import Result [**2166-6-2**] 08:10PM 95 2.5* 3.2* Import Result [**2166-6-2**] 04:08PM 99 1.5 143 3.8 107 Import Result [**2166-5-31**] 01:12AM 132* 1.2 142 4.4 104 27 Import Result HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT [**2166-6-2**] 04:08PM 13.6* 41 Import Result CALCIUM freeCa [**2166-6-13**] 05:13AM 1.20 Import Result [**2166-6-6**] 01:08AM 1.22 Import Result [**2166-6-3**] 02:07AM 1.16 Import Result [**2166-6-2**] 08:10PM 1.07* Import Result [**2166-6-2**] 04:08PM 1.13 Import Result [**2166-5-31**] 01:12AM 1.16 Import Result Brief Hospital Course: 17 yo male who was jumping on a trampoline and landed on his head. Pt was taken to OSH. OSH noted no movement in bilateral lower extremities and no sensation from nipple line down. Pt was med flighted to [**Hospital1 8**] on [**2166-5-31**]. Imaging showed C4-C5 disc herniation, ligament injury and spinal cord contusion at this level causing complete C4-C5 cord injury. Pt went to the OR for an anterior C4-5 discectomy and fusion and posterior C4-5 laminectomy and fusion on [**6-2**].. Percutaneous tracheostomy and gastrostomy was performed on [**2166-6-6**] . Diagnostic venogram of IVC and iliac veins and placement of Optease IVC filter was perform for DVT prophylaxis on [**2166-6-3**] Chest CT on [**6-13**] showed near collapse of the left lower lobe and diffuse nodular ground-glass opacity throughout the right lower lobe, suggestive of atypical infection and/or very early consolidation. A bronch was performed on [**6-14**] for persistent hight temperatures BAL cultures negative. Pt was pan cultured several times for increased temperature all cultures had been negative. ID consult was obtained recommending coverage for 14 days of Unasyn.Pt had PICC line placement on [**6-16**]. Psychiatry assessment revealed normal greef.Psychiatry recommendations were the following: 1) The pt appears to be experiencing normal grief 2) Continue to monitor mood and sleep 3) [**Month (only) 412**] offer Ativan 1mg PO prn anxiety or panic if it develops 4) Continue to involve SW in case, offer educational materials 5) Cont to involve pt??????s family in case 6) Discussed with primary team, [**Last Name (LF) 11652**],[**Name8 (MD) 11653**], MD Beeper#: [**Numeric Identifier 11654**] 7) Psychiatry will continue to follow, please page with questions #[**Numeric Identifier 11655**], or Psychiatry on call nights/weekends #[**Numeric Identifier 11656**]; Last evaluation form speech and swallow where the following: SECRETIONS / ABILITY TO HANDLE CUFF DEFLATION:Cuff was deflated prior to our evaluation and pt was tolerating cuff deflation without O2 desaturation or distress. RN was present to suction pt from the Trach tube with minimal/scant white, thick secretions retrieved. Unlike the last evaluation, pt did not request oral suctioning via the Yankauer during the evaluation. According to the RN, pt has not requested oral suctioning this morning. PMV TOLERANCE / VOCAL QUALITY / O2 SATS:Pt was able to achieve voicing upon placement of the valve and at first noted that it felt hard to exhale with the valve in place. The valve remained in place to allow the pt to adjust and pt stated that he was trying to get used to it. Pt's tracheal pressure measures were between -2 to +10 cm H20(normal range is between -/+10 cm H20). Pt's vocal quality was adequate and his O2 sats were between 94-99% while for 15 minutes while the valve was in place. SUMMARY: At this time pt is able to tolerate the PMV without respiratory distress, O2 desaturation, or c/o significant discomfort. It is recommended that the valve be removed when pt complains of discomfort, effortful breathing, or fatigue. It was discussed with the pt that he will need time to build up endurance to wear the valve for extended periods of time. We also discussed adjusting positioning as needed if valve tolerance appears difficult. Pt was last seen on [**2166-6-13**] for a PMV eval only and the recs were to return on [**2166-6-17**]. However, the re consult was placed today for both the PMV and swallowing. However, as per the recommendations from previous evaluations, swallow eval was deferred today, especially in light of potential discharge to rehab yesterday, and evidence of LLL collapse, RLL ground opacity on prior chest CT. PT is just beginning to demonstrate improved endurance and respiratory drive to tolerate the valve. As such, would prefer to allow him to establish consistent strength/endurance for this prior to assessing swallowing, as he has already demonstrated inability to tolerate aspiration (prior to Trach placement) in the setting of poor respiratory reserve. RECOMMENDATIONS: 1. ALWAYS DEFLATE CUFF PRIOR TO PLACING THE PASSY-MUIR VALVE! 2. Monitor O2 Sats / respiration while valve is in place. 3. Do not allow the patient to sleep with the valve in place. 4. PMV wear schedule is up to the discretion of the nurse and/or respiratory therapist. Pt as remained afebrile for 36 hours. Will be send to rehab today. Pt will have to follow up with Neurosurgery, and trauma surgery as an out patient. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 8. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every 8 hours) as needed for pain. 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 10. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for agitation/anxiety. 11. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 12. Oxycodone 5 mg/5 mL Solution Sig: [**1-27**] PO Q4-6H (every 4 to 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] Discharge Diagnosis: s/p Fall onto head Spinal cord injury C4-C5 (complete) Discharge Condition: Stable Discharge Instructions: Follow up with Orthopedic Spine and Trauma Surgery Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in [**9-4**] weeks, call [**Telephone/Fax (1) 1742**] for an appointment. Follow up in Trauma Clinic in the next 4-8 weeks, call [**Telephone/Fax (1) 8472**] for an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**] Completed by:[**2166-6-17**]

[ "E884.0", "507.0", "518.5", "512.1", "806.01", "794.8", "518.0", "482.32" ]

icd9cm

[ [ [] ] ]

[ "84.52", "96.04", "81.03", "03.53", "96.72", "80.51", "31.1", "84.51", "38.93", "38.7", "81.62", "81.02", "43.11", "96.6" ]

icd9pcs

[ [ [] ] ]

31103, 31173

25339, 29862

15309, 15368

31272, 31281

16398, 25316

31380, 31763

16229, 16246

29885, 31080

5841, 5933

31194, 31251

31305, 31357

16276, 16379

15230, 15271

5962, 7816

15396, 15630

15652, 15658

15674, 16213

507

136,251

14577

Discharge summary

report

Admission Date: [**2148-9-15**] Discharge Date: [**2148-10-23**] Date of Birth: [**2071-3-6**] Sex: M Service: CSU HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 77 year old gentleman with known aortic stenosis and cardiomyopathy who had been complaining of a several month history of increasing fatigue and muscle ache with worsening dyspnea on exertion. Echocardiogram [**2148-7-18**], showed an ejection fraction of 20 percent with a dilated right ventricle, aortic valve area of 0.8, aortic valve gradient of 80 mmHg, 1 to 2 plus aortic insufficiency, 1 to 2 plus mitral regurgitation. The patient had a cardiac catheterization in [**Month (only) 205**] which showed aortic valve area of 0.6 cm squared and aortic valve gradient of 45 mmHg, 2 plus aortic regurgitation, 2 to 3 plus mitral regurgitation and ejection fraction of 26 percent, global hypokinesis and a 50 percent mid left anterior descending coronary artery occlusion and moderate pulmonary hypertension. The patient was referred to Dr. [**Last Name (Prefixes) **] for operative management. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. Dilated cardiomyopathy. Atrial fibrillation. Status post cholecystectomy. Status post left optic nerve infarct. Status post hernia repair. Status post permanent pacer insertion for heart block. ALLERGIES: No known drug allergies. PREOPERATIVE MEDICATIONS: 1. Lasix 20 mg p.o. q. day. 2. Coumadin 5 mg p.o. q. day. 3. Norvasc 5 mg p.o. q. day. SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] is a retired real estate [**Doctor Last Name 360**]. The patient drinks three to five alcoholic drinks per week. He is a remote smoker. HO[**Last Name (STitle) **] COURSE: The patient was admitted to [**Hospital3 **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2148-9-15**], preoperatively for anticoagulation though the patient had stopped his Coumadin therapy in anticipation of going to the Operating Room. Laboratory data was significant for a hematocrit of 43.8 and INR of 1.3, otherwise unremarkable. The patient had carotid ultrasound which showed no significant hemodynamic lesion of the right or left carotid artery and the patient was taken to the Operating Room on [**2148-9-17**], by Dr. [**Last Name (Prefixes) **] where he underwent aortic valve replacement and mitral valve replacement and a Maze procedure. The aortic valve was a 27 mm pericardial [**Last Name (un) 3843**]-[**Doctor Last Name **] and the mitral valve was 29 mm Mosaic pig valve. Total cardiopulmonary bypass time 176 minutes, crossclamp time 90 minutes. The patient was transferred to the Intensive Care Unit on epinephrine infusion. The patient required moderate volume resuscitation postoperatively with labile hemodynamics and on postoperative day Number 2 the patient was started on a Milrinone infusion to improve his hemodynamics with moderate improvement. Electrophysiology Service was consulted to increase the rate in his permanent pacemaker to improve his hemodynamics. The patient remained intubated. The patient continued to require volume resuscitation and increase in his inotropic support for low cardiac indices. The patient was started on a heparin infusion as he was found to be in atrial fibrillation when his pacemaker was interrogated. The patient had a transesophageal echocardiogram on postoperative day Number 4 which showed an ejection fraction of 40 percent, mild local left ventricular and right ventricular systolic depression, mild tricuspid regurgitation, stable aortic and mitral prosthesis. The patient was started on amiodarone infusion for control of the atrial fibrillation. The patient was still unable to wean from mechanical ventilation, due to his unstable hemodynamics. The patient was started on Natrecor to decrease his pulmonary artery pressures. On postoperative day Number 5, the patient spiked a fever to 102. He was pancultured. The patient had blood cultures that were drawn from his PA catheter which grew gram positive cocci in pairs and clusters. The line was removed and resited. The blood cultures were eventually one out of four which was coagulase negative Staphylococcus. The patient was started on vancomycin. The patient was cardioverted from atrial fibrillation to sinus rhythm with some improvement in his hemodynamics. Over the next several days, the patient's Milrinone was weaned. The patient remained sedated and intubated. The patient was hemodynamic. The patient had several more episodes of atrial fibrillation all which caused increase in his hemodynamics and required cardioversion. As the patient was unable to be awoken and weaned from the ventilator by postoperative day Number 10, it was decided that the patient should undergo a tracheostomy which was done and a Number 8 Portex Trach was placed. The bronchoscopy at that time showed copious thick secretions with edematous mucosa. The sputum subsequently grew out methicillin- resistant Staphylococcus aureus. The patient continued to require low dose epinephrine to maintain adequate cardiac output. The patient's sedation was gradually weaned with intermittent increasing agitation and a drop in his hemodynamics. By postoperative day Number 17, the patient's epinephrine had been weaned down and he appeared to be tolerating it well. The patient continued on Natrecor, however, on postoperative day Number 19, it was noted that the patient had dropping mixing his oxygen saturation and appeared to be volume depleted. The patient had all of his lines changed. The patient was found to have a continued drop in hematocrit, and it was realized that the patient had an increasing abdominal distention. The patient had a computerized axial tomography scan of his abdomen which showed a retroperitoneal bleed. The heparin anticoagulation was stopped. A vascular surgery consult was obtained, and it was recommended to continue to treat the patient medically. The measurement of the hematoma was measured at 11 by 11 cm, extending from the right iliacus muscles to the right psoas and then extending superiorly with the displacement of the right kidney anteriorly. The patient had significant abdominal distention at this time with concerns for abdominal compartment syndrome. The patient had continuous bladder pressure monitors which remained relatively stable. However, the patient's creatinine began to rise with concerns for renal perfusion. The patient continued to require blood transfusions. A renal consult was obtained and they felt that the rise in creatinine was due to the patient's acute bleed and volume depletion, and hypotension requiring pressors. On postoperative day Number 22, the patient was noted to have a drop in his platelet count. A heparin antibody was sent which was subsequently negative. The patient was transfused platelets as it was felt that he was continuing to have some bleeding from the retroperitoneal hematoma. The patient's creatinine gradually began to decrease over the next several days. Critical care consult was obtained for the patient's failure to wean from the ventilator and continued agitation. It was recommended that the patient undergo bronchoscopy and increase some of his ventilator settings. The patient's sputum culture continued to grow methicillin-resistant Staphylococcus aureus and the patient was switched from vancomycin to linezolid which resulted in a decrease in his temperature. The patient's epinephrine over the next several days was slowly weaned off. The fentanyl and Versed drips which had been used for sedation were slowly weaned off. As the intravenous sedation was weaned off the patient continued to be more awake and more agitated. The ventilator was gradually weaned. The epinephrine was weaned off by postoperative day Number 28. The Natrecor was weaned off by postoperative day Number 30. The patient's pulmonary artery catheter had been removed and his clinical staff indicated that he was tolerating the wean of his inotrope. On postoperative day Number 32, the patient was taken to the Operating Room for an open gastrostomy tube which he tolerated well. The patient has been able to wean off the ventilator with periods of trach collar and at this point it is felt that he is stable for discharge to a rehabilitation facility. CONDITION ON DISCHARGE: Temperature 98.4, pulse 80 AV paced, blood pressure 129/58, respiratory rate 25. He is currently on a 50 percent trach mask. Neurologically the patient is awake and alert, following commands, unable to evaluate whether or not the patient is oriented, however, he responds appropriately. Heart is regular rate and rhythm. Breath sounds are coarse bilaterally. Abdomen, positive bowel sounds, soft, nontender, nondistended. G-tube site is clean, dry and intact. There is no drainage. The extremities have 1 to 2 plus edema. Laboratory data is white blood cell count 6.2, hematocrit 33.7, platelet count 103, sodium 145, potassium 4.9, chloride 112, bicarbonate 25, BUN 33, creatinine 1.0 and glucose 92. His sternal incision is clean, dry, well healed and intact. Sternum is stable. DISCHARGE DIAGNOSIS: Status post aortic valve replacement, mitral valve replacement and Maze procedure. Atrial fibrillation. Dilated cardiomyopathy. Postoperative respiratory failure. Postoperative acute renal failure which is resolved. Status post tracheostomy. Status post open gastrostomy tube placement. Status post spontaneous retroperitoneal bleed. Methicillin-resistant Staphylococcus aureus pneumonia. History of permanent pacemaker. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. once daily. 2. Prevacid 30 mg p.o. q. day. 3. Lasix 20 mg p.o. q. day. 4. Captopril 6.25 mg p.o. t.i.d. 5. Clonazepam 1 mg p.o. t.i.d. 6. Linezolid 600 mg p.o. b.i.d., the last dose should be [**10-25**]. The patient should be receiving humidified oxygen via his tracheostomy to maintain oxygen saturation greater than 92 percent. The patient should be receiving tube feeds and all medications via his percutaneous endoscopic gastrostomy tube. Tube feedings should be ProMod fiber with goal rate of 80 cc/hr. When the patient is sufficiently stable from a respiratory standpoint, he should have a swallowing evaluation to clear him for p.o. intake. FO[**Last Name (STitle) 996**]P: The patient should follow up with Dr. [**Last Name (Prefixes) **] upon discharge from rehabilitation. He should follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 31187**] in two to three weeks and he should follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] upon discharge from rehabilitation. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern4) 8524**] MEDQUIST36 D: [**2148-10-22**] 18:58:47 T: [**2148-10-22**] 19:53:01 Job#: [**Job Number 43001**]

[ "396.3", "272.0", "482.41", "518.0", "427.31", "V45.01", "425.4", "997.3", "427.32", "584.9", "459.0", "V09.0", "396.0", "997.5", "401.9", "518.5" ]

icd9cm

[ [ [] ] ]

[ "35.23", "43.19", "39.61", "37.33", "00.13", "33.22", "31.1", "35.21" ]

icd9pcs

[ [ [] ] ]

9683, 11038

9229, 9660

1422, 1511

1120, 1396

1528, 8389

8414, 9207

47,104

187,606

3928

Discharge summary

report

Admission Date: [**2138-6-24**] Discharge Date: [**2138-7-1**] Date of Birth: [**2070-11-6**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2138-6-24**] Cardiac Catheterization [**2138-6-27**] Four Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending artery, with saphenous vein grafts to first and second obtuse marginal, and posterior descending artery History of Present Illness: Mr. [**Known lastname 17492**] is a 67-year-old male patient with a history of hypertension, hyperlipidemia, diabetes, and CAD, s/p MI and multiple PCIs. His most recent cardiac catheterization was on [**2138-3-3**] where he was found to have a 40% lesion in his LMCA, a 50% stenosis in the proximal LAD, and a 100% stenosis in the OM2. The RCA was known to be occluded and not engaged. His stents were patent. . Of note, he began using nitroglycerin tablets about a month ago. This helped his chest pain which usually last about 10mins. The CP usually occurs one hour after he eats. He reports that the nitroglycerin used to work within 5 secs and now after a month of use, the NG start to work after a minute. The CP also increased in intensity from previously [**2-4**] to about [**7-7**]. Chest Pain is substernal without any radiation. Prior to the month, he did not use NG and suffered through the CP - usually waiting for it to pass by resting. He used to be able to finish a golf game by taking frequent rest on the golf cart. During his previous admission earlier this year, he deferred CABG due to the fact that it did not fit with his schedule. . He presented to [**Hospital3 **] ED with complaints of chest discomfort on and off all night. Apparently he would take a nitroglycerin and the pain would resolve for approximately 30 minutes then return. He did not tell his wife who is a RN at [**Name (NI) **] because he didn't want her to call EMS. On the morning of admission, he was diaphoretic and she asked what was the matter. He told her he had been having chest discomfort all night and taken a total of 8 nitroglycerin. He presented to the ED at 9:30 am this morning pain free with a blood pressure of 181/105 (question nitroglycerin outdated). He was given an inch of nitropaste and his b/p is now 132/75, HR 69. Dr. [**Last Name (STitle) 7047**] has requested patient be transferred for cardiac catheterization. His first troponin is 0.18, his finger stick was 279 but he was not given any coverage because he took his am hypoglycemics. . 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. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for chest pain and dyspnea on exertion. Negative for paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: [**2112**]: s/p PTCA LAD/LCx [**2116**]: MI, s/p cath revealed totally occluded RCA, medically managed [**2125**]: BMS x 4 to LCx [**2133**]: Cypher DES for ISR of LCx [**2137-10-21**]: PTCA/cypher DES to proximal LAD [**2138-3-3**]: S/P cath no intervention -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: H/O kidney stones Anxiety Depression tonsillectomy cholecystectomy Arthritis Social History: He is married with two grown children. He continues to smoke and has an occasional beer. He works as asalesman. His wife [**Name2 (NI) 17493**] is a RN. Tobacco history: 1 ppd x 50 years Family History: Father died at 49 from MI Physical Exam: PHYSICAL EXAMINATION: VS: T= 97 BP=140/72 HR=75 RR= 18 O2 sat= 96 on 2L GENERAL: WDWN, in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD. CARDIAC: RR, normal S1, S2. soft 1-2/6 systolic murmur, No r/g. No S3 or S4. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. + BS. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits, cath site clean, dressing intact without bleed. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: CARDIAC CATH [**2138-6-24**]: Coronary angiography in this right dominant system demonstrated three vessel disease. The LMCA had a distal 20% stenosis. The LAD had a proximal 70% stenosis that extended from the LMCA to the proximal edge of the Cypher stent placed in [**10-5**]. The LCx had mild diffuse plaquing associated with a 30% stenosis proximal to the mid-LCx stents after OM2. The OM1 had a 20% stenosis at its origin. The LCx provided collaterals to a long right posterolateral branch. The RCA was moderately calcified and had a 70% proximal-mid stenosis, a 90% mid stenosis, and a distal occlusions with right-right collaterals filling a small PDA and posterolateral branches. ECHO [**2138-6-25**] : The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal inferior and infero-lateral segments. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. CAROTID ULTRASOUND [**2138-6-25**]: 1. 70-79% stenosis of the right internal carotid artery. 2. 80-89% stenosis of the left internal carotid artery. HEAD/CHEST/NECK CTA [**2138-6-25**]: 1. Two tiny pulmonary nodules in the right middle lobe and one in the right upper lobe. Further followup is recommended. 2. Moderate right internal carotid and mild right external carotid artery narrowing caused by mixed calcified and noncalcified atherosclerotic plaque. 3. Very severe left internal carotid artery stenosis, caused by calcified and noncalcified atherosclerotic plaque. 4. Findings concerning for periapical abscess formation in the right anterior maxillary teeth. 5. There is no intracranial hemorrhage, mass effect, shift of normally midline structures or edema. [**Doctor Last Name **]-white matter differentiation is normally preserved. The ventricles, basal cisterns and sulci are normal in size and configuration. [**2138-6-29**] WBC-18.3* RBC-3.93* Hgb-12.2* Hct-38.3* MCV-98 MCH-31.1 MCHC-31.9 RDW-12.5 Plt Ct-222 [**2138-6-30**] WBC-11.6* RBC-3.40* Hgb-10.6* Hct-32.5* MCV-95 MCH-31.1 MCHC-32.5 RDW-12.5 Plt Ct-228 [**2138-7-1**] WBC-9.7 RBC-3.28* Hgb-10.5* Hct-31.1* MCV-95 MCH-32.0 MCHC-33.7 RDW-12.9 Plt Ct-286 [**2138-6-28**] Glucose-98 UreaN-15 Creat-0.8 Na-138 K-4.8 Cl-108 HCO3-25 AnGap-10 [**2138-6-29**] Glucose-154* UreaN-19 Creat-0.8 Na-137 K-4.3 Cl-102 HCO3-26 AnGap-13 [**2138-7-1**] UreaN-20 Creat-0.8 K-4.0 [**2138-7-1**] Mg-2.1 [**2138-6-24**] %HbA1c-6.9* Brief Hospital Course: Mr [**Known lastname 17492**] was transfered to [**Hospital1 18**] for catheterization. In catheterization, he was found to have an LAD lesion proximal to his previous stent that was unamenable to another stent intervention - see result section for further details. Cardiac surgery was therefore consulted and further preoperative evaluation was performed. Carotid ultrasound revealed moderate-to-severe disease in the bilateral internal carotid arteries. Given the findings, Neurology was consulted and CTA was obtained - see result section for details. Given that he was asymptomatic, with no prior history of stroke, it was recommended to proceed with coronary surgical revascularization. It is recommended to stay on Aspirin and Plavix, and would favor revascularizing one of his carotid arteries in the future(most likely carotid stenting). Preoperative evaluation was also notable for incidental findings of pulmonary nodules for which 6 month follow up with Dr. [**Last Name (STitle) **] is recommended. He was also seen by a dentist pre-operatively and it was recommended that he continue on Clindamycin as an outpatient post-surgically until he is able to have a chipped tooth extracted. On [**2138-6-27**] he underwent a coronary artery bypass grafting times four performed by Dr. [**Last Name (STitle) 914**]. 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. Within 24 hours, he awoke neurologically intact and was quickly extubated and weaned from his pressors without incident. By the following day he was transferred to the surgical step-down floor. His chest tubes and epicardial wires were removed without complication. His beta-blockade was titrated up as tolerated and he was gently diuresed. He remained in a normal sinus rhythm without atrial or ventricular arrhythmias. Given his carotid disease and prior coronary stents, he should remain on Aspirin and Plavix. He should continue on Clindamycin for possible tooth abscess until tooth extraction is performed. Prior to discharge, he was started on Zoloft per Psychiatry for experiencing significant pain and recalling that he was awake during his operation. The remainder of his postoperative course was uneventful and he was discharge to home on postoperative day four. Medications on Admission: MEDICATIONS: Plavix 75 mg daily Ezetimibe-Simvastatin 10-40mg daily Insulin Lispro Protam and Lispro (Humalog Mix 75-25) 8 units [**Hospital1 **] Isosorbide Mononitrate 30mg Daily Metformin 1000mg [**Hospital1 **] Metoprolol tartrate 50mg [**Hospital1 **] Aspirin 325mg PO daily Nicotine patch 21mg /24hr daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Amlodipine 5 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. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) as needed for oral infection: take until tooth extracted. Disp:*200 Capsule(s)* Refills:*1* 7. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*2* 9. 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* 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 13. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Coronary Artery Disease, s/p CABG Diastolic Congestive Heart Failure, Acute Diabetes Mellitus Type II Dyslipidemia Hypertension Pulmonary Nodules Carotid Disease Discharge Condition: Good Discharge Instructions: 1)No driving for one month 2)No lifting more than 10 lbs for at least 10 weeks from the date of surgery 3)Please shower daily. Wash surgical incisions with soap and water only. 4)Do not apply lotions, creams or ointments to any surgical incision. 5)Please call cardiac surgeon immediately if you experience fever, excessive weight gain and/or signs of a wound infection(erythema, drainage, etc...). Office number is [**Telephone/Fax (1) 170**]. 6)Remain on Clindamycin until you are able to have your chipped tooth extracted. A copy of your panorex film/x-ray CD has been attached for you to give your dentist as a reference. 7)Call with any additional questions or concerns. Followup Instructions: - Dr. [**Last Name (STitle) 914**] in [**3-2**] weeks, call for appt - Dr. [**Last Name (STitle) 7047**] in [**12-31**] weeks, call for appt - Dr. [**Last Name (STitle) **] (thoracic surgery) in 6 months with a noncontrast chest CT. - Local Dentist. Remain on Clindamycin until you are able to have your chipped tooth extracted. A copy of your panorex film/x-ray CD has been attached for you to give your dentist as a reference. Completed by:[**2138-7-1**]

[ "410.71", "300.4", "412", "V58.66", "518.89", "272.4", "250.00", "428.31", "V45.82", "414.01", "401.0", "428.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12092, 12155

7792, 10160

330, 607

12360, 12366

4751, 7769

13092, 13552

4016, 4043

10522, 12069

12176, 12339

10186, 10499

12390, 13069

4058, 4058

3362, 3685

4080, 4732

280, 292

635, 3230

3716, 3795

3274, 3342

3811, 4000

22,557

157,208

12772+12773

Discharge summary

report+report

Admission Date: [**2198-9-26**] Discharge Date: [**2198-10-5**] Date of Birth: [**2122-4-3**] Sex: M Service: Urology HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old gentleman with a history of diabetes for 63 years, hypertension, hypercholesterolemia, who on work-up for hematuria had a suspicious cytology and was found to have a filling defect in the upper pole of the right kidney by retrograde pyelogram. The brush biopsy of the right renal lesion was suspicious for transitional cell carcinoma. After consideration of conservative options, a decision was made by patient and surgeon to proceed with a right nephrourterectomy. PAST MEDICAL HISTORY: Significant for insulin dependent diabetes for more than 40 years, managed in the [**Last Name (un) **] Diabetes Status post open reduction and internal fixation in [**2198**], hypertension, hypercholesterolemia. ALLERGIES: No known drug allergies. MEDICATIONS: Hydrochlorothiazide 25 mg q day, Cardia 120 mg q day, Aspirin 81 mg q day, Pravachol and Insulin. REVIEW OF SYSTEMS: He denied any history of chest pain, shortness of breath, or weakness. Most recent stress test was normal. PHYSICAL EXAMINATION: During admission showed a well appearing overweight white gentleman in no acute distress. He is afebrile. Blood pressure is 175/79 and heart rate is 73. He weighs approximately 190 lbs. His pupils are round, equal, reactive to light and extraocular movements are intact. His neck is supple, no lymphadenopathy, no carotid bruits. His chest is clear bilaterally to auscultation. Heart has a regular rate and rhythm, no extra heart sounds, no murmurs. The abdomen is distended and somewhat firm with active bowel sounds. There is no palpable mass, no hepatosplenomegaly. Rectal exam showed normal tone. The prostate feels smooth, there is no rectal mass, guaiac negative. Extremities are well perfused with no obvious edema. Pre-operative laboratory work showed a hematocrit of 39.7 and a stress test showed no reversible ischemia and ejection fraction was 66%. HOSPITAL COURSE: On [**2198-9-26**] the patient was brought to the OR for a scheduled right sided nephroureterectomy. The operation was complicated by excessive bleeding with estimated blood loss of 3,500 cc. The patient received 10 liters of crystalloids during the operation. Postoperatively he was moved to Intensive Care Unit for better management of the fluid status and his blood pressure. The patient was extubated on postoperative day #1 without complications. While in the Intensive Care Unit he remained hypertensive. That required nitro drip to obtain adequate control. At the same time he also suffered from low urine output. He required multiple doses of IV fluid bolus. However, he responded to IV doses of Lasix for diuresis. His creatinine stabilized at level of 2.1 to 2.4 from his baseline of 1.6. Renal consult was obtained and the decreasing renal function was felt to be due to the transient hypoperfusion during the operation when his blood pressure was dropped to low 100's for approximately an hour. The patient's stay in the MICU was otherwise uneventful. He was then transferred back to the floor on postoperative day #3. On the evening when he transferred to the floor, he experienced an episode of atrial fibrillation with rapid rate of around 160 times per minute and there were associated ischemic changes seen in the EKG. He required several doses of IV Lopressor and IV Diltiazem to slow down his heart rate and convert it back to sinus rhythm. A cardiac enzyme was sent and chest x-ray was also obtained. He was then transferred back to the Intensive Care Unit for continuous IV infusion of Diltiazem to control his heart rate. His heart rhythm converted to sinus rhythm a few hours after the IV Diltiazem instillation. He remained to be stable for the MICU stay. The etiology of this episode of atrial fibrillation without prior history remained unclear, however, it was thought that his status of fluid overload may contribute to the cause. On postoperative day #6 the patient was then transferred back to the floor in stable condition. He started to pass gas and diet was slowly restarted. On the day of discharge he tolerated a full diet without any problems. His central line and Foley catheter was discontinued on postoperative day #8. He required a minimum amount of pain medication and made good amount of urine. His laboratory studies including CBC and electrolytes remained unchanged until the day of discharge. His creatinine level is 2.4 on the day of discharge. During this hospital stay the patient had very limited amount of physical activity. He feels weak in general and could not ambulate without significant help. He has pre-existing diabetic neuropathy. Therefore, he is arranged to be discharged to a rehab facility to help ambulating and regain his capacity of maintaining daily home activity. DISCHARGE MEDICATIONS: Hydrochlorothiazide 25 mg q day, NPH insulin 10 units in the morning, 6 units in the evening, insulin sliding scale with regular insulin, Lopressor 25 mg [**Hospital1 **], Percocet [**2-14**] po q 4-6 hours as needed and Diltiazem long release 240 mg every morning. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehab facility. DISCHARGE DIAGNOSIS: 1. Transitional cell carcinoma of the right kidney Complications: 1. Operative blood loss 2. Postoperative renal insufficiency 3. Postoperative Atrial fibrillation [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13269**] Dictated By:[**Name8 (MD) 39394**] MEDQUIST36 D: [**2198-10-5**] 18:32 T: [**2198-10-5**] 19:46 JOB#: [**Job Number 39395**] Admission Date: [**2198-9-26**] Discharge Date: [**2198-10-7**] Date of Birth: [**2122-4-3**] Sex: M Service: Urology HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old gentleman with a history of diabetes for 63 years, hypertension, hypercholesterolemia, who on work-up for hematuria was noted to have a right feeling defect in the renal pelvis. The brush biopsy of renal pelvis was suspicious for transitional cell carcinoma and he came back for elective right nephrectomy. PAST MEDICAL HISTORY: Significant for diabetes, who is managed in the [**Last Name (un) **] Diabetes Center, also Paget's disease status post open reduction and internal fixation in [**2198**], hypertension, hypercholesterolemia. ALLERGIES: No known drug allergies. MEDICATIONS: Hydrochlorothiazide 25 mg q day, Cardia 120 mg q day, Aspirin 81 mg q day, Pravachol and Insulin. REVIEW OF SYSTEMS: He denied any history of chest pain, shortness of breath, or weakness. Most recent stress test was normal. PHYSICAL EXAMINATION: During admission showed a well appearing overweight white gentleman in no acute distress. He is afebrile. Blood pressure is 175/79 and heart rate is 73. He weighs approximately 190 lbs. His pupils are round, equal, reactive to light and extraocular movements are intact. His neck is supple, no lymphadenopathy, no carotid bruits. His chest is clear bilaterally to auscultation. Heart has a regular rate and rhythm, no extra heart sounds, no murmurs. The abdomen is distended and somewhat firm with active bowel sounds. There is no palpable mass, no hepatosplenomegaly. Rectal exam showed normal tone. The prostate feels smooth, there is no rectal mass, guaiac negative. Extremities are well perfused with no obvious edema. Pre-operative laboratory work showed a hematocrit of 39.7 and a stress test showed no reversible ischemia and ejection fraction was 66%. HOSPITAL COURSE: On [**2198-9-26**] the patient was brought to the OR for a scheduled right sided nephroureterectomy. The operation was complicated by excessive bleeding with estimated blood loss of 3,500 cc. The patient received 10 liters of crystalloids during the operation. Postoperatively he was moved to Intensive Care Unit for better management of the fluid status and his blood pressure. The patient was extubated on postoperative day #1 without complications. While in the Intensive Care Unit he remained hypertensive. That required nitro drip to obtain adequate control. At the same time he also suffered from low urine output. He required multiple doses of IV fluid bolus. However, he responded to IV doses of Lasix for diuresis. His creatinine stabilized at level of 2.1 to 2.4 from his baseline of 1.6. Renal consult was obtained and the decreasing renal function was felt to be due to the transient hypoperfusion during the operation when his blood pressure was dropped to low 100's for approximately an hour. The patient's stay in the MICU was otherwise uneventful. He was then transferred back to the floor on postoperative day #3. On the evening when he transferred to the floor, he experienced an episode of atrial fibrillation with rapid rate of around 160 times per minute and there were associated ischemic changes seen in the EKG. He required several doses of IV Lopressor and IV Diltiazem to slow down his heart rate and convert it back to sinus rhythm. A cardiac enzyme was sent and chest x-ray was also obtained. He was then transferred back to the Intensive Care Unit for continuous IV infusion of Diltiazem to control his heart rate. His heart rhythm converted to sinus rhythm a few hours after the IV Diltiazem instillation. He remained to be stable for the MICU stay. The etiology of this episode of atrial fibrillation without prior history remained unclear, however, it was thought that his status of fluid overload may contribute to the cause. On postoperative day #6 the patient was then transferred back to the floor in stable condition. He started to pass gas and diet was slowly restarted. On the day of discharge he tolerated a full diet without any problems. His central line and Foley catheter was discontinued on postoperative day #8. He required a minimum amount of pain medication and made good amount of urine. His laboratory studies including CBC and electrolytes remained unchanged until the day of discharge. His creatinine level is 2.4 on the day of discharge. During this hospital stay the patient had very limited amount of physical activity. He feels weak in general and could not ambulate without significant help. Therefore, he is arranged to be discharged to a rehab facility to help ambulating and regain his capacity of maintaining daily home activity. DISCHARGE MEDICATIONS: Hydrochlorothiazide 25 mg q day, NPH insulin 10 units in the morning, 6 units in the evening, insulin sliding scale with regular insulin, Lopressor 25 mg [**Hospital1 **], Percocet [**2-14**] po q 4-6 hours as needed and Diltiazem long release 240 mg every morning. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehab facility. DISCHARGE DIAGNOSIS: 1. Papillary transitional cell carcinoma status post right nephroureterectomy. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13269**] Dictated By:[**Doctor First Name 7429**] MEDQUIST36 D: [**2198-10-5**] 18:32 T: [**2198-10-5**] 19:46 JOB#: [**Job Number 39396**]

[ "584.9", "285.1", "189.0", "997.5", "997.1", "997.3", "250.61", "486", "427.31" ]

icd9cm

[ [ [] ] ]

[ "55.51" ]

icd9pcs

[ [ [] ] ]

10565, 10832

10926, 11304

7726, 10541

6836, 7708

6704, 6813

5963, 6301

6324, 6684

10857, 10905

9,277

156,678

29311

Discharge summary

report

Admission Date: [**2189-12-13**] Discharge Date: [**2189-12-23**] Date of Birth: [**2150-7-28**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p multiple gunshot wounds to left arm and right thigh Major Surgical or Invasive Procedure: [**2189-12-13**] ORIF left distal radius fracture [**2189-12-13**] ORIF right hip [**2189-12-13**] Irrigation and packing right burttock wound [**2189-12-13**] Comparmtment fasciotomy RLE [**2189-12-13**] Interposition vein graft repeair right SFA History of Present Illness: 39 yo female s/p multiple gunshot wounds at close range with large blood loss at scene, to her right hip, left foremarm, left thigh. She was taken to an area hospital; tachycardic en route per EMS and was sintubated, then became hypotensive, she was later Medflighted to [**Hospital1 18**] for further care. Past Medical History: None Social History: Has 2 children Family History: Noncontributory Pertinent Results: [**2189-12-13**] 09:22PM CALCIUM-8.2* PHOSPHATE-5.5* MAGNESIUM-1.2* [**2189-12-13**] 05:36PM LACTATE-1.5 NA+-139 K+-4.2 [**2189-12-13**] 11:44AM PT-16.3* PTT-47.6* INR(PT)-1.5* [**2189-12-13**] 06:30AM ALT(SGPT)-16 AST(SGOT)-33 ALK PHOS-43 AMYLASE-35 TOT BILI-0.9 [**2189-12-13**] 06:30AM CALCIUM-8.1* PHOSPHATE-4.1 [**2189-12-13**] 06:30AM WBC-10.3 RBC-4.00*# HGB-12.7# HCT-34.5*# MCV-86 MCH-31.8 MCHC-36.9* RDW-14.6 [**2189-12-13**] 06:30AM PLT COUNT-93* [**2189-12-13**] 03:15AM PLT COUNT-113*# CHEST (PORTABLE AP) Reason: eval infil/PTX [**Hospital 93**] MEDICAL CONDITION: 39 year old woman s/p GSW to [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 15016**] w/ PTX on R, CT in place to water seal. REASON FOR THIS EXAMINATION: eval infil/PTX STUDY: AP chest, [**2189-12-20**]. HISTORY: 39-year-old woman with gunshot wound. FINDINGS: Comparison is made to prior chest radiograph from [**2189-12-18**]. Small right apical pneumothorax is not well seen. Cardiac silhouette and mediastinum is normal. Lungs are clear. There is gas seen within the subcutaneous soft tissues of the left upper chest and of the right lower chest HIP UNILAT MIN 2 VIEWS RIGHT; LOWER EXTREMITY FLUORO WITHOUT Reason: FX HIP, DHS RIGHT HIP ON [**2189-12-13**] AT 17:50 INDICATION: Intraoperative films. Multiple images from the OR procedure were submitted for review ultimately showing a compression screw and fixation plate for treatment of the right intertrochanteric fracture. CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: eval for retroperitoneal hematoma related to R pelvic fx Field of view: 43 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 39 year old woman with multiple gunshot wounds, pelvic fracture REASON FOR THIS EXAMINATION: eval for retroperitoneal hematoma related to R pelvic fx CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 39-year-old female with multiple gunshot wounds. Evaluate for retroperitoneal hematoma. No prior studies are available for comparison. TECHNIQUE: MDCT axial images of the chest, abdomen and pelvis were obtained following the administration of IV Optiray contrast. CT CHEST WITH IV CONTRAST: An ETT terminates 1 cm above the carina. A left subclavian central venous catheter tip terminates in the left subclavian vein. The heart and great vessels are unremarkable. A small area of hyperattenuation within the anterior mediastinum represents residual thymus or mediastinal hematoma. There is a clear fat plane between this and the aorta. Lung windows demonstrate opacity within the right upper lobe likely representing contusion as well as a small right-sided pneumothorax. CT ABDOMEN WITH IV CONTRAST: A nasogastric tube abuts the stomach wall. The liver, spleen, adrenal glands and left kidney are unremarkable. A small hypodensity within the lower pole of the right kidney likely represents a cyst but cannot be further characterized. The pancreas is markedly edematous. There is a large amount of fluid surrounding the liver, gallbladder, pancreas and abdominal loops of bowel. Fluid is seen between the SMV and pancreas, although there is no clear evidence of pancreatic injury. There is marked enhancement of the bowel wall and narrowing of the IVC likely related to hypovolemic shock. There is no intraperitoneal free air or active extravasation. CT PELVIS WITH IV CONTRAST: Low attenuation fluid tracks along the paracolic gutters into the pelvis. There is no evidence of retroperitoneal hematoma. A Foley catheter is seen within the bladder. The rectum and sigmoid colon are unremarkable. The iliac arteries are narrowed suggestive of hypovolemia. Of note, there is a bullet fragment adjacent to the proximal SFA. The SFA is bulbous in appearance approximately 5cm distal to its takeoff, which may be from vascular injury. The profunda femoris artery appeares to have a short segment occlusion after its origin with reconstitution distally. This is near to bullet fragments and the JP drain. The right gluteus muscle is indistinct and there is air and areas of hematoma. A similiar appearance is seen within the muscles of the right thigh. Post- surgical changes are also noted in the right thigh with packing and a drain. The osseous windows demonstrate a comminuted fracture of the right femur. Multiple bullet fragments are seen within this area, the largest measuring 7 mm. IMPRESSION: 1. Small right apical pneumothorax. Right lung contusion. 2. Retroperitoneal and extraperitoneal fluid more than ascites with shock bowel. Small IVC and Iliac arteries indicating hypovolemia and vascular contraction. 3. Comminuted right femoral fracture with retained bullet fragments. 4. Apparent right profunda femoris occlusion just distal to its origin with distal reconstitution. Small bullet fragment in the wall or adjacent to the right proximal SFA near this level. The SFA is bulbous in appearance 5 cm distal to its takeoff as well which may be from acute injury. 5. Stranding and hematoma within the gluteus muscles and muscles of the right thigh. Brief Hospital Course: She was admitted to the Trauma Service. Orthopedics and Vascular Surgery were all consulted because of her injuries. She was immediately taken to the operating due to hemodynamic instability. Her right buttock wound was explored, irrigated and packed by Trauma Surgery. She requires tid wet to dry loose packing dressing changes to this site. Her vascular injuries from the gunshot wounds were repaired by Vascular Surgery, she underwent interposition graft repair of right superficial femoral artery, ligation of profunda femoris artery, four-compartment fasciotomy of right lower leg and irrigation of left upper extremity wound. Her Orthopedics injuries were also repaired on the same day as her other injuries; she underwent Irrigation debridement of open right intertrochanteric, irrigation debridement of open left forearm fracture, open reduction and internal fixation left mid-shaft open radius fracture, open reduction and internal fixation (DHS) open right intertrochanteric/subtrochanteric/femoral neck femur fracture. Social work and the Center for Violence Prevention and Recovery were all closely involved in her care. Physical and Occupational therapy were consulted and have recommended short term rehab. Discharge Medications: 1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) dose Subcutaneous Q12H (every 12 hours). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 7. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital6 63271**] Discharge Diagnosis: s/p Multiple gunshot wounds to left forearm and right hip Discharge Condition: Stable Discharge Instructions: DO NOT bear any weight on your right lower extremity or left upper extremity. You must continue to wear your Orthopast splint on your left arm. Followup Instructions: Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Vascular Surgery, call [**Telephone/Fax (1) 1237**] for an appointment. Follow up in 2 weeks in trauma Clinic, call [**Telephone/Fax (1) 6429**] for an appointment. Follow up with Dr. [**Last Name (STitle) **], Orthopedics in 2 weeks, call [**Telephone/Fax (1) 1228**] for an appointment. Completed by:[**2189-12-23**]

[ "958.92", "731.3", "E965.0", "998.11", "877.0", "861.21", "904.7", "890.1", "820.19", "813.31", "904.1", "860.0", "958.4" ]

icd9cm

[ [ [] ] ]

[ "79.32", "86.22", "99.05", "39.56", "38.88", "86.05", "99.04", "99.07", "38.93", "83.09", "34.09", "79.65", "79.35", "79.62" ]

icd9pcs

[ [ [] ] ]

8113, 8161

6146, 7377

371, 621

8263, 8272

1070, 1630

8464, 8844

1034, 1051

7400, 8090

2748, 2812

8182, 8242

8296, 8441

276, 333

2841, 6123

649, 958

980, 986

1002, 1018

18,490

166,658

6801+6802

Discharge summary

report+report

Admission Date: [**2105-7-22**] Discharge Date: [**2105-7-29**] Date of Birth: [**2039-2-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor Last Name 10493**] Chief Complaint: Fevers and rigors. Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 66yo M h/o recently diagnosed prostate cancer who presents with intermittent fever, chills and burning on urination over the past 19 days. . Mr. [**Known lastname 25770**] had a prostate biopsy performed on [**2105-7-3**] revealing prostatatic adenocarcinoma (Maximum [**Doctor Last Name **] 7). The same day, he developed painful urination, burning on urination, nocturia (6x per night up from baseline of 3x per night), fever to 101.1 and shaking chills. He went to his urologist's office (Dr. [**Last Name (STitle) 770**] on [**7-17**], complaining of continued rigors and fevers to 101.1 degrees. He was started on Flomax and Ciproflaxacin, and in the subsequent days experienced a reduction in pain/burning on urination and decreased urination at night. However, this morning he developed fevers to 104.3 degrees together with violent shaking chills, prompting him to go to the ED. . ROS is additionally remarkable for increased fatigue since the biopsy and shortness of breath unchanged from baseline. There is no chest pain, nausea, vomiting, diarrhea, and no current complaint of pain anywhere in the body. Past Medical History: Prostate Cancer, Dx [**2105-7-3**], patient anticipating prostatectomy in [**Month (only) **] Asthma, no acute attacks since young man Gout Total Hip Replacement, Rt side, [**2098**] Multiple right knee surgeries, most recent [**2102**] Depression, not currently symptomatic or undergoing treatment Social History: The patient is a former [**Location (un) 511**] [**Company **] football player with a distinguished football career. He spends ?????? the year in [**State 108**] and ?????? the year in [**Location (un) 86**]. Currently married to supportive wife; has 3 daughters age 43, 40 and 37 from a previous marriage. Denies TOB and illicit drugs. Does report previous drinking history max 8 drinks per night. Currently has 3 drinks per night, says that both he and his wife enjoy drinking recreationally. No guilt associated with drinking; says he is able to stop drinking when he wants to. PCP feels that his drinking is under control. Family History: Non-contributory. Physical Exam: Vitals: T 102.8 BP 110/64 HR 92 RR 18 O2 Sat 98% RA Appearance: comfortable, in supine in bed, well-kept, NAD, talkative HEENT: NC/AT. Anicteric. Oropharynx clear and without exudates/erythema. Neck: Negative LAD. Supple neck. No carotid bruis. Pulm: CTA BL. No R/W/C. Cardio: Distant S1, S2. No M/T/R. ABD: S/NT. No Distention. + BS. EXT: Warm, well-perfused. No calf-tenderness. Intact pedal, radial pulses. Trace non-pitting edema BL. NEURO: MS: Gen: Appropriate, pleasant. Orientation: Aox3 Speech/[**Doctor Last Name **]: Fluent w/o paraphasic errors Memory: Deferred. CN: I: Not tested. II: PERRL. III,IV,VI EOMI. No ptosis. V: Sensation intact to LT. VII: Face symmetric without weakness. VIII: No gross deficits. IX,X: Voice normal. [**Doctor First Name 81**]: SCM and trapezii [**4-17**]. XII: Tongue protrudes midline without atrophy or fasciculations. Motor: Normal bulk and tone; no tremor, rigidity, or bradykinesia. [**Last Name (un) **]: LT intact. Joint position deferred. Pertinent Results: [**2105-7-22**] 02:43PM LACTATE-2.1* [**2105-7-22**] 02:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2105-7-22**] 02:00PM URINE BLOOD-MOD NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2105-7-22**] 02:00PM URINE RBC-0-2 WBC-[**5-23**]* BACTERIA-MOD YEAST-NONE EPI-0 [**2105-7-22**] 11:30AM GLUCOSE-127* UREA N-30* CREAT-2.1* SODIUM-138 POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17 [**2105-7-22**] 11:30AM WBC-18.1*# RBC-3.94* HGB-11.8* HCT-33.9* MCV-86 MCH-30.0 MCHC-34.9 RDW-15.0 [**2105-7-22**] 11:30AM NEUTS-93.3* BANDS-0 LYMPHS-5.6* MONOS-0.9* EOS-0.1 BASOS-0.1 [**2105-7-22**] 11:30AM PLT SMR-NORMAL PLT COUNT-432 Brief Hospital Course: This is a 66 yo male with a recent diagnosis of prostatic adenocarcinoma who presented with likely prostatitis and subsequently developed sepsis and septic shock with blood cultures positive for E. coli. . 1.Prostatitis, Sepsis On arrival to ED, patient was T 98.9, BP 99/60, HR 78. He recieved Tylenol, demerol, Ceftriaxone for empiric coverage and Ativan in the emergency department, as well as 2-3 L of fluids. White count at that time was 18.1, and Cr was 2.1. . On the day after admission, the patient was sent to the Intensive Care Unit following desaturations to 84% and fever to 104 degrees. At the time, he was exhibiting hypotension despite fluids, lactic acidosis (serum lactate = 4), mental status changes, and gram negative rods in [**3-17**] blood cultures, thus meeting the definition for septic shock (SIRS + infection). He was started on Vancomycin, Ceftriaxone and Levofloxacin, later tapered to Ceftriaxone only. He quickly stabalized and was called-back to the floor, where ID was consulted. A PICC was placed on [**2105-7-26**]. LFT's were found to be elevated, likely secondary to Ceftriaxone. The patient was started on IV Aztreonan (Vanco, CTX and Levo were discontinued). A rectal ultra-sound was obtained to rule out abscess as source of infection. . The patient remained afebrile on Aztreonam throughout the remainder of his stay. However, on the night before discharge he experienced night sweats and gouty pain in the hands. The latter was treated with Indomethacin. The patient recieved his first dose of Erdepenam prior to leaving the hospital, and was discharged on a 10 day course of Erdepenam scheduled to end on [**8-6**]. Additionally, he was proveded with a script for Bactrim DS 1 tablet [**Hospital1 **] (to be taken at the conclusion of the Erdepenam course) for 7 days. 2. Acute renal failure: Patient's creatinine reached maximum value of 2.1. U/s was negative for hydronephrosis so renal failure and BUN:Cr ration no markedly elevated so the spike in Creatinine was presumed due to multiple organ dysfunction syndrome secondary to septic shock. Creatinine normalized as antibiotic therapy took effect and had fully returned to baseline by [**2105-7-26**]. 2. h/o Asthma: Patient was stable and rarely used Ipratropium or Albuterol during his stay. 3. h/o depression: Patient remaiend in excellent spirits throughout his stay, often noting "I still have a lot that I want to do with my life" and speaking with a spirit of excited anticipation about travels scheduled for the next 12 months. Medications on Admission: Ambien Xanax Discharge Medications: 1. Ertapenem 1 g Recon Soln Sig: One (1) Injection once a day for 8 doses. Disp:*qs qs* Refills:*0* 2. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed for 8 days. Disp:*qs ML(s)* Refills:*0* 3. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: start on [**2105-8-7**] and continue for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: 1. Prostatitis 2. Sepsis, Septic shock 3. Acute Renal Failure Discharge Condition: Good Discharge Instructions: Please contact your PCP and return to the [**Name (NI) **] for fever greater than 101 degrees, rigors, night sweats, dizziness, decreased urine output, new pain on urination, or any other concerning symptom. Please follow-up with your health care providors as outlined below. Followup Instructions: Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**], on Friday at 2:30. You will have blood work done by a visiting nurse prior to the appointment so that the results (WBC, Cr, LFT's) may be reviewed by Dr. [**Last Name (STitle) 1007**] on Friday. This is very important in order to make sure that you infection and elevated liver enzymes have resolved, and to confirm good kidney function. For your information, Dr.[**Name (NI) 19421**] office phone numbers are:([**Telephone/Fax (1) 25771**] or ([**Telephone/Fax (1) 21461**]. His fax number is [**Telephone/Fax (1) 25772**]. . As you know, follow-up is also required with Dr. [**Last Name (STitle) 770**] for your diagnosis of prostate adenocarcinoma. Dr.[**Name (NI) 825**] office has requested that you phone him sometime this week do discuss follow-up plans. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**] Completed by:[**2105-7-31**] Admission Date: [**2105-7-29**] Discharge Date: [**2105-8-3**] Date of Birth: [**2039-2-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor Last Name 10493**] Chief Complaint: fever and rigors Major Surgical or Invasive Procedure: None History of Present Illness: This is a 66yo M h/o recently diagnosed prostate cancer who was recently admitted for fevers and hypotension. Found to have prostatitis with subsequent sepsis and brief ICU admission. Pt found to have GNR in blood and was treated initially with CTX, Levo and Vanc which was eventually tapered to CTX alone. PICC line placed on [**2105-7-26**] and plan was to treat with extended course of IV abx. Pt was discharged on Ertapenem and Aztreonam and Bactrim (Bactrim to be started after pt finished 7 day course of Ertapenem), as pt has LFT elevation [**1-15**] ceftriaxone. Rectal U/s performed on [**2105-7-27**] showed no evidence of abscess. On return home, pt re-developed fevers/chills, so returned to [**Location **]. In ED, lab values notable for elevated WBC, elevated Cr. ID notified and believed fevers [**1-15**] to recurrent prostatis vs line sepsis (from PICC line placement) - will see in AM. Past Medical History: -Prostate Cancer, Dx [**2105-7-3**], patient anticipating prostatectomy in Septemeber -Asthma, no acute attacks since young man -Gout -Total Hip Replacement, Rt side, [**2098**] -Multiple right knee surgeries, most recent [**2102**] -Depression, not currently symptomatic or undergoing treatment Social History: The patient is a former [**Location (un) 511**] [**Company **] football player with a distinguished football career. He spends ?????? the year in [**State 108**] and ?????? the year in [**Location (un) 86**]. Currently married to supportive wife; has 3 daughters age 43, 40 and 37 from a previous marriage. Denies TOB and illicit drugs. Does report previous drinking history max 8 drinks per night. Currently has 3 drinks per night. Family History: Non-contributory. Physical Exam: Vitals - T 97.8, BP 110/60, HR 66, RR 18, O2 96% RA General - awake, alert, lying in bed, NAD HEENT - PERRL, EOMI, MMM CVS - RRR, nl S1, S2, no noted M/R/G Lungs - CTA b/l Abd - soft, NT/ND, normoactive BS Ext - No LE edema b/l Skin - PICC line in place R arm, no noted surrounding erythema Pertinent Results: [**2105-7-29**] 07:27PM GLUCOSE-129* UREA N-27* CREAT-1.7* SODIUM-137 POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-27 ANION GAP-17 [**2105-7-29**] 07:27PM WBC-11.9* RBC-4.32* HGB-12.6* HCT-37.5* MCV-87 MCH-29.2 MCHC-33.7 RDW-15.1 [**2105-7-29**] 07:27PM NEUTS-79.6* LYMPHS-16.0* MONOS-2.8 EOS-1.4 BASOS-0.1 [**2105-7-29**] 07:27PM PLT COUNT-538* [**2105-7-29**] 07:21PM LACTATE-1.3 [**2105-7-29**] 05:49AM GLUCOSE-132* UREA N-23* CREAT-1.4* SODIUM-138 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-31 ANION GAP-10 [**2105-7-29**] 05:49AM ALT(SGPT)-146* AST(SGOT)-69* ALK PHOS-80 TOT BILI-0.5 [**2105-7-29**] 05:49AM ALBUMIN-3.3* [**2105-7-29**] 05:49AM PLT COUNT-491* [**2105-7-28**] 05:23AM ALT(SGPT)-176* AST(SGOT)-126* ALK PHOS-82 TOT BILI-0.3 Brief Hospital Course: This is a 69-year old male recently diagnosed with prostate cancer was discharged from the [**Hospital1 18**] on [**7-29**] following a course of complicated prostatitis and readmitted later in the evening following the development of fever, rigors and malaise. For the sake of completeness, both the history of the recent hospitalization ([**Date range (1) 23135**]) and this hospitalization ([**2020-7-28**]) will be reviewed here. Hospitalization [**Date range (1) 23135**]: On arrival to ED, patient was T 98.9, BP 99/60, HR 78. He received Tylenol, demerol, Ceftriaxone for empiric coverage and Ativan in the emergency department, as well as 2-3 L of fluids. White count at that time was 18.1, and Cr was 2.1. On the day after admission, the patient was sent to the Medical Intensive Care Unit following desaturations to 84% and fever to 104 degrees. At the time, he was exhibiting hypotension despite fluids, lactic acidosis (serum lactate = 4), mental status changes, and gram negative rods in [**3-17**] blood cultures, thus meeting the definition for septic shock (SIRS + infection). He was started on Vancomycin, Ceftriaxone and Levofloxacin, later tapered to Ceftriaxone only. He quickly stabilized and was called-back to the floor, where ID was consulted. A PICC was placed on [**2105-7-26**]. He developed elevated LFT's and eosinophils on Ceftriaxone, and so the medication was stopped. Cultures returned positive for e. coli. The patient was started on IV Aztreonam (Vanco, CTX and Levo were discontinued). A rectal ultra-sound was obtained to rule out abscess as source of infection. . The patient remained afebrile on Aztreonam throughout the remainder of his stay. However, on the night before discharge he experienced night sweats and gouty pain in the hands. The latter was treated with Indomethacin. Blood cultures were again drawn. The patient received his first dose of Erdepenam prior to leaving the hospital, and was discharged on a 10 day course of Erdepenam (scheduled to end on [**8-6**]). Additionally, he was provided with a script for Bactrim DS 1 tablet [**Hospital1 **] (to be taken at the conclusion of the Erdepenam course) for 7 days. Hospitalization [**Date range (1) 25773**] The patient returned to the ED hours after discharge because of fever to 101.7 degrees, weakness and rigors. On arrival to the ED, T 98.4, HR 73, BP 134/74 RR16 O2 Sat 96% RA. The patient received 1L NS. His PICC line was pulled and the tip was cultured given the suspicion that the locus of infection was the line. Blood cultures were obtained. ECHO [**7-30**] was negative for signs of endocarditis. CXR [**7-30**] was negative for signs of PNA. Abdominal U/S [**7-30**] did not reveal a cause of transaminitis or infection. The patient was started on Vancomycin with a presumptive diagnosis of bacteremia secondary to line infection. Blood and line cultures, however, continued to be negative throughout the hospitalization, and Vancomycin was discontinued. ID was consulted regarding the utility of PICC placement for further IV antibiotic therapy; it was felt that an additional 3 days of IV antibiotics would not effect post-hospital course, and that re-placement of the PICC would present an unnecessary opportunity for re-infection. The patient received one dose of Erdepenam on the day of discharge, and was sent home with a prescription for 8 additional days of Bactrim DS, 2 tablets [**Hospital1 **]. The patient was asked to schedule follow-up with Dr. [**Last Name (STitle) 1007**] in one week. Medications on Admission: Ertapenem 1g Q8h Aztreonam 1g Q8h Bactrim (not yet started)Alprazolam Flomax Multi-vitamin Advair (occasionally used) Ambien (rarely used) Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 8 days. Disp:*36 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Prostatitis Line Sepsis Discharge Condition: Good Discharge Instructions: 1. Please contact your PCP or return to the [**Name (NI) **] for fever greater than 101, night sweats, rigors, chills, or tachychardia in the setting of worsening malaise. 2. Please take Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 8 days. Your first dose will be Tuesday [**2105-8-4**]. Your last dose will be Tuesday, [**8-11**]. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 1007**] in one week. Please call [**Telephone/Fax (1) 25774**] to make the appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**] Completed by:[**2105-8-3**]

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Discharge summary

report

Admission Date: [**2116-12-29**] Discharge Date: [**2117-1-8**] Date of Birth: [**2057-12-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2751**] Chief Complaint: Altered mental status and respiratory distress Major Surgical or Invasive Procedure: [**2116-12-31**]: Intubation [**2117-1-1**]: Extubation [**2117-1-1**]: right internal jugular central line placement History of Present Illness: Mr. [**Known lastname 88504**] is a 59 year old male with COPD, NSCLC and SCLC with metastases to brain s/p chemotherapy and radiation admitted with hypokalemia on [**2116-12-29**]. His hypokalemia was difficult to replete with oral and IV potassium and eventually attributed to inappropriate ACTH secretion from his tumor. He was noted to be alert and oriented yesterday with change in mental status to confusion to year and somnolence along with increased work of breathing this morning. Vital signs: 89% RA with baseline low 90% on RA. He was given 2LNC which improved his oxygenation to 96%RA. ABG on room air showed alkalosis with 7.55/46/63. P:120. RR:22. Lactate of 2.5. CXR showed no acute process on my read though cannot completely rule out LLL process in setting of AP CXR with cardiomegaly. . He triggered for tachypnea in the morning. We evaluated him at that time, and his lungs were clear, and had no signs of fluid overload. A CTA Chest was performed that did not show evidence of PE, but did show evidence of PNA. He was started on vanc/cefepime for HAP. . The evening of [**2116-12-29**] he was found to be in respiratory distress and hypoxic with O2 sat of 30%. He was profundly somnolent. He was placed on a NRB and O2 sat came up to 100%. On exam he had extremely poor air movement, wheezing, and extended expiratory phase. Hypertensive to 200/100/. ABG 7.15/109/256/39. He was intubated for hypercarbic respiratory failure and transferred to the MICU. Given etomidate, succinylcholine prior to intubation. Past Medical History: NSCLC SCLC Metastases to brain HTN GERD COPD Social History: Lives with wife. Started smoking at age 13, continues to smoke [**6-5**] cigarettes daily. Also uses marijuana. Rare alcohol intake currently. Family History: father with MI Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.6 130/70 108 18 93%RA GEN: No acute distress. HEENT: Mucous membranes moist, white plaques at roof of mouth and back of throat. Sclerae anicteric. No conjunctival pallor noted. NECK: JVP not elevated. No lympadenopathy. CV: Regular rate and rhythm, no murmurs, rubs or [**Last Name (un) 549**] PULM: Wheezes diffusely, decreased breath sounds at left upper lobe. ABD: Soft, non-tender, non distended, bowel sounds present. No hepatosplenomegaly EXTR: No edema, 2+ Dorsalis pedis and radial pulses bilaterally. NEURO: Alert and oriented x3. SKIN: No ulcerations or rashes noted. Multiple tattoos . ON ADMISSION TO ICU: Vitals: 95.1 103 109/69 GEN: Intubated, Sedated HEENT: Mucous membranes moist, white plaques at roof of mouth and back of throat. Sclerae anicteric. No conjunctival pallor noted. NECK: JVP not elevated. No lympadenopathy. CV: Regular rate and rhythm, no murmurs, rubs or [**Last Name (un) 549**] PULM: Tight, wheezy bilaterally, poor expiration EXTR: No edema, 2+ Dorsalis pedis and radial pulses bilaterally. Cool extremities. NEURO: Alert and oriented x3. SKIN: No ulcerations or rashes noted. Multiple tattoos . ON TRANSFER TO FLOOR: VS: 97.2 102 144/77 97% 2LNC Gen: awake, alert, oriented to recent events, people, and time HEENT: mucous membrane dry, clear oropharynx, PERRL, EOMI Lungs: Coarse wheezes throughout with crackles in midlung to bases bilaterally, decreased lung sounds at left lung base. CV: tachycardic, Nl S1/S2, No MRG Abd: Soft, ND/NT, normoactive bowel sounds Extremities: Cool feet, 2+ peripheral pulses bilaterally, 1+ pitting edema in feet bilaterally . ON DISCHARGE: VS: 97.6 (98.2) 154/82 (130-160/82-90) 93 (92-103) 20 95%RA FSBS 159-227 Gen: Awake, alert, oriented to recent events, people, and time. Comfortable. HEENT: moist mucous membrane Lungs: breathing comforably Extremities: 2+ pitting edema in feet, extending up leg with 1+ at knees Pertinent Results: ADMISSION LABS: [**2116-12-29**] 02:29PM BLOOD WBC-10.5 RBC-3.50* Hgb-11.5* Hct-34.3* MCV-98# MCH-32.8* MCHC-33.4 RDW-20.4* Plt Ct-249 [**2116-12-29**] 02:29PM BLOOD Neuts-93* Bands-1 Lymphs-2* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-4* [**2116-12-31**] 09:53PM BLOOD PT-11.8 PTT-23.2* INR(PT)-1.1 [**2116-12-29**] 02:29PM BLOOD Glucose-198* UreaN-12 Creat-0.8 Na-142 K-2.6* Cl-88* HCO3-48* AnGap-9 [**2116-12-29**] 02:29PM BLOOD ALT-45* AST-25 AlkPhos-83 TotBili-1.1 [**2116-12-29**] 02:29PM BLOOD Lipase-183* [**2116-12-29**] 02:29PM BLOOD cTropnT-0.02* [**2116-12-29**] 02:29PM BLOOD Calcium-8.1* Phos-3.6 Mg-1.5* [**2116-12-30**] 06:35AM BLOOD %HbA1c-5.7 eAG-117 [**2116-12-31**] 01:25PM BLOOD Ammonia-29 [**2116-12-30**] 10:30AM BLOOD Cortsol-164.6* [**2116-12-31**] 08:38AM BLOOD Type-ART pO2-63* pCO2-46* pH-7.55* calTCO2-42* Base XS-15 [**2116-12-31**] 08:38AM BLOOD Lactate-2.5* K-3.5 calHCO3-42* [**2117-1-1**] 05:07AM BLOOD O2 Sat-76 [**2116-12-31**] 10:12PM BLOOD freeCa-1.00* . PENDING LABS: [**2117-1-1**] ACTH, PLASMA 319 H [**2116-12-31**] ALDOSTERONE 7 ng/dL [**2116-12-30**] PLASMA RENIN ACTIVITY 0.31 ng/mL . DISCHARGE LABS: [**2117-1-7**] 06:15AM BLOOD WBC-8.9 RBC-2.81* Hgb-9.7* Hct-28.7* MCV-102* MCH-34.5* MCHC-33.8 RDW-21.2* Plt Ct-135* [**2117-1-8**] 06:25AM BLOOD Na-146* K-3.0* Cl-99 [**2117-1-7**] 06:15AM BLOOD ALT-48* AST-27 AlkPhos-96 TotBili-1.3 [**2117-1-7**] 06:30PM BLOOD Calcium-8.0* Phos-3.1 Mg-1.7 [**2117-1-8**] 06:25AM BLOOD Cortsol-117.6* . MICROBIOLOGY: [**2116-12-30**] URINE CULTURE: <10,000 organisms/ml. [**2116-12-31**] BLOOD CULTURE: NO GROWTH. [**2116-12-31**] URINE CULTURE: NO GROWTH. [**2116-12-31**] MRSA SCREEN: No MRSA isolated. [**2116-12-31**] BLOOD CULTURE: NO GROWTH. [**2117-1-1**] BLOOD CULTURE: NO GROWTH. [**2117-1-1**] SPUTUM (ENDOTRACHEAL): GRAM STAIN (Final [**2117-1-1**]): >25 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. [**2117-1-2**] STOOL C DIFF TOXIN: Feces negative for C.difficile toxin A & B by EIA. [**2117-1-3**] BLOOD CULTURE: NO GROWTH. . IMAGING: [**2116-12-29**] CHEST X-RAY PA/LAT: FINDINGS: PA and lateral views of the chest were obtained. Surgical clips are noted along the left mediastinal border with extensive scarring and upward hilar retraction. There is volume loss in the left lung compatible with prior partial lung resection with partial osteotomy in the left rib cage. There is right hilar prominence and lymphadenopaty cannot be excluded. There is no definite sign of pneumonia. Bony structures are intact. IMPRESSION: Post-surgical changes in the left upper lung. No evidence of pneumonia. Right hilar prominence. Recommend correlation with nonemergent CT. . [**2116-12-31**] CTA CHEST: TECHNIQUE: Axial CT images through the chest were acquired before and after administration of intravenous contrast. Coronal, sagittal, and bilateral oblique reformatted images were reviewed. FINDINGS: There is a new large left lower lobe consolidation and small right upper lobe consolidation, concerning for pneumonia. There is increased right upper lobe bronchial wall thickening, also suggestive of infection. There is a new small right pleural effusion. No pneumothorax is seen. The pulmonary arteries appear patent to the subsegmental levels without evidence for pulmonary embolus. Left upper lobe lobectomy changes are again seen with left-sided volume loss. The heart and great vessels are grossly within normal limits. No pericardial effusion is seen. Subcarinal lymphadenopathy measuring 2 cm is stable (4:27). A large right hilar lymph node measures 26 mm (4:27, previously 18 mm). This study is not optimized for evaluation of subdiaphragmatic structures. Within this limitation, there appear to be innumerable new hypodensities within the liver, concerning for metastases. Bilateral adrenal glands are markedly enlarged compared to prior, also concerning for metastases. The visualized portion of the spleen and stomach are unremarkable. Residual oral contrast is seen in the colon. Few arterial calcifications are noted. The visualized portion of the thyroid appears homogeneous. No concerning lytic or sclerotic osseous lesions are detected. Left thoracotomy changes are noted. IMPRESSION: 1. Large left lower lobe consolidation and small focus of consolidation in the right upper lobe with right upper lobe bronchial wall thickening, concerning for infection. New small right pleural effusion. 2. Multiple new hypodense lesions in the liver, incompletely evaluated, but concerning for metastatic disease. Markedly enlarged adrenal glands bilaterally, also concerning for metastatic disease. Increased size of right hilar lymph node, may be related to infection although increased metastasis cannot be excluded. . [**2116-12-31**] MRI HEAD: COMPARISON: MR head dated [**2116-11-16**]. TECHNIQUE: Given the patient's inability to cooperate, the study was limited and no contrast enhanced images were obtained. Acquired sequences included sagittal T1, axial T1, FLAIR, diffusion with ADC map images. FINDINGS: Given the patient's inability to cooperate, a limited study without gadolinium was acquired. Since those images obtained are significantly degraded by motion artifacts, the overall exam is of limited diagnostic value. Judged by sagittal T1 images, the cerebral sulci, ventricles, and extra-axial CSF-containing spaces have normal and stable configuration. There is no new midline shift or hydrocephalus. Metastatic, partly cystic masses in the left parietotemporal lobe as well as the left cerebellar hemisphere appear grossly unchanged from the previous exam. While small new lesions cannot be excluded, there is no evidence of major progress with new significant mass effect. There is no evidence of ischemic infarct on well diagnostic diffusion weighted images. Incidental note is made of persistent sinusitis involving the ethmoid and bilateral maxillary sinuses. IMPRESSION: No evidence of significant progression of metastatic disease in this limited study. No evidence of acute ischemic infarct or major hemorrhage. . [**2117-1-6**] RIGHT UPPER EXTREMITY ULTRASOUND: FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of right internal jugular, right subclavian, axillary, and brachial veins were performed. There is normal compressibility, flow and augmentation throughout. A PICC is seen within the right basilic, axillary and subclavian veins. The basilic and cephalic veins demonstrate normal flow. IMPRESSION: No DVT in the right upper extremity. . Brief Hospital Course: Mr. [**Known lastname 88504**] is a 59 year old male with history of non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) with metastases to brain status post chemotherapy and radiation, admitted with profound weakness, found to have hypokalemia, high serum ACTH, and hypercortisolism secondary to bilateral adrenal hyperplasia; hospital course complicated by hypercarbic respiratory failure, shock, delirium, pneumonia, and thrush. Due to progressive illness with poor prognosis, . . ACUTE ISSUES: # Hypokalemia/hyperaldersteronism: Patient's presenting symptom was progressive weakness over the weeks prior to admission, with subsequent decreased PO intake. He was found to have low potassium at PCP's office and referred to ED where K was 2.6. Per his wife, patient had not been taking his potassium supplements as prescribed. Patient had associated symptom of hypertension, mood changes and delirium prior to and during his admission. He was repleted aggressively with both oral and IV potassium, but potassium levels remained low during this admission. On further testing, the patient was found to have elevated cortisol levels, peaking at 219, with elevated serum ACTH (319) and normal aldosterone. On CT imaging during this admission, bilateral adrenal hyperplasia was present. Lab values and imaging were thought to be consistent with hypercortisolemia from bilateral adrenal hyperplasia, which was likely secondary to an ACTH-secreting tumor. Per Endocrinology consult, cortisol suppression treatment was implemented with ketoconazole, spironolactone and metyrapone. The Urology team did not believe the patient was a good candidate for palliative bilateral adrenalectomy. Additionally, potassium was repleted on an ongoing basis. After initiation of treatment, cortisol levels decreased substantially to range 60s-100s. With potassium repletion, levels ranged in the low to mid-3s. The patient's delirium was also better-controlled with correction of hypercortisolemia. . # Hypercarbic Respiratory Failure: While on the medicine floor initially, patient had been on room air, but began to have desaturations to high 80%s, and was tachycardic. Acute episode of respiratory failure was multifactorial, secondary to pneumonia, baseline decreased pulmonary function from COPD and lung cancer, and profound muscle weakness/fatigue secondary to hypokalemia: CTA was performed which ruled out PE but did show large left lower lobe consolidation and small focus of consolidation in the right upper lobe with right upper lobe bronchial wall thickening, concerning for infection, for which vanc/cefepime were started empirically. For continued desaturations likely secondary to diaphragmatic fatigue and possible bronchospam, patient was found to be hypercarbic (pCO2 109, pH 7.14), intubated and transferred to the ICU. He was treated with albuterol/ipratropium nebulizers while intubated. His bronchoscopy was negative for infectious etiology. The patient did well with extubation the next day. He was then continued on empiric antibiotics and standing albuterol/ipratropium nebulizers, along with supplemental oxygen as needed, with improved symptoms during the rest of his admission. . # Shock: While the patient was in the ICU, he was noted to be acutely hypotensive just prior to intubation. This was attributed to the use of propofol, and resolved with subsequent weaning of propofol. It was not felt to be secondary to infection, since his bronchoscopy was negative and he recovered with medication changes. . # Delirium: Over the course of the hospitalization, patient was noted to have labile mental status. Delirium was attributed to hypercortisolism, extensive metastases to the brain, and unfamiliarity of the hospital setting. Symptoms were much better controlled with suppression of cortisol, along with consistent family involvement, frequent reorientation, and standing/PRN lorazepam. At the time of discharge, the patient's mental status was much clearer. He expressed clear wishes to transition his care to the home setting, where he would be more comfortable. . # Pneumonia: Noted to have a large left lower lobe consolidation and small focus of consolidation in the right upper lobe with right upper lobe bronchial wall thickening, concerning for infection, along with a small right pleural effusion. This was accompanied by a leukocytosis, to a peak of 20.4. The patient was treated empirically for HCAP with intravenous vancomycin and cefepime, which were both discontinued on day 7 of 8, per patient and family wishes. Patient was continued on albuterol and ipratropium nebulizers for symptoms of shortness of breath/wheezing and comfort. . # Thrush: Patient was noted to have white plaques at back of tongue and roof of mouth consistent with thrush. He denies dysphagia/odynophagia. He was treated with nystatin swish and swallow . # Small cell lung cancer: Stage IV, with poor prognosis of weeks to months; with metastases involving the brain and liver. Due to high levels of serum cortisol, it was suspected that the patient's cancer is secreting ectopic ACTH. During this admission, there were ongoing discussions with the patient, his family and his primary oncologist about his prognosis. The patient and his wife had a good understanding of his advancing disease, and hoped for increased comfort over the patient's future course. There will not be any future surgical or chemotherapeutic interventions. . . CHRONIC ISSUES: # COPD: Continued on albuterol and ipratropium nebulizers with supplemental oxygen as needed. . . TRANSITIONAL ISSUES: # Goals of care: Patient has now undergone a complicated hospital course, including an ICU stay for respiratory failure; however, his stage IV lung cancer bears a poor prognosis. The patient and his family understand likely decline in the near future, and are focusing on symptom management, including ongoing cortisol suppression. Patient and family ultimately decided to continue care at home with hospice. Palliative Medicine was helpful in constructing a home regimen to maximize comfort; this included lorazepam 1mg PO q6 hours standing, lorazepam 1mg PO q4 hours PRN and morphine 5-10 mg PO (elixir) q2 hours PRN pain/dyspnea. Additionally, lab draws will be minized to a weekly basis for follow-up and management of the patient's electrolytes. # Code status: DNR/DNI, CMO, confirmed with patient and HCP (wife, [**Doctor First Name **] Medications on Admission: Keppra 500mg [**Hospital1 **] Omeprazole 20mg daily Trazodone 100mg qhs Lorazepam 1-2mg prn Albuterol Spiriva 18mcg inhalation Flovent 220mcg; 3 puffs [**Hospital1 **] Potassium chloride 20meq TID Zofran 8mg rapid dissolve compazine 10mg; q6h prn enalapril-HCTZ 10-25mg daily Salmeterol 50mcg; 1 inhalation [**Hospital1 **] Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) puff Inhalation q4 prn as needed for wheeze. 2. ipratropium bromide 0.02 % Solution Sig: One (1) inhalation Inhalation q4 prn as needed for wheeze. 3. insulin glargine 100 unit/mL Solution Sig: Five (5) units Subcutaneous at bedtime. Disp:*150 units* Refills:*0* 4. insulin regular human 100 unit/mL Solution Sig: One (1) unit Injection QID PRN as needed for hyperglycemia. Disp:*200 units* Refills:*0* 5. spironolactone 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 6. dexamethasone 0.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. potassium chloride 10 mEq Tablet Extended Release Sig: Four (4) Tablet Extended Release PO QID (4 times a day). Disp:*480 Tablet Extended Release(s)* Refills:*0* 8. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*0* 9. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for agitation. Disp:*120 Tablet(s)* Refills:*0* 10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO daily prn as needed for constipation. Disp:*30 packet* Refills:*0* 11. metyrapone 250 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day) for 14 days. Disp:*56 Capsule(s)* Refills:*0* 12. morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q2H (every 2 hours) as needed for pain, shortness of breath. Disp:*1000 mg* Refills:*0* 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO bid prn as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 15. ketoconazole 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*0* 16. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: Five (5) ML PO q6 prn as needed for cough. Disp:*1000 ML(s)* Refills:*0* 17. Outpatient Lab Work Please potassium once per week on: [**2117-1-11**], [**2117-1-18**], [**2117-1-25**], [**2116-2-9**], [**2116-2-16**], [**2116-2-23**], etc., and fax results to Dr. [**First Name8 (NamePattern2) 2127**] [**Last Name (NamePattern1) 4681**] Hunt at (Fax: [**Telephone/Fax (1) 6808**], Phone: [**Telephone/Fax (1) 88505**]), who will modify medications as needed. 18. syringe (disposable) 10 mL Syringe Sig: One (1) syringe Miscellaneous qid prn as needed for hyperglycemia. Disp:*90 syringes* Refills:*0* 19. Equipment Glucometer, testing strips and lancets 20. potassium chloride 20 mEq Packet Sig: Two (2) packets PO four times a day: Only use if not able to swallow pill. Disp:*24 packets* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 3005**] Hospice and Palliative Care Discharge Diagnosis: Primary diagnoses: Hypercortisolemia Pneumonia . Secondary diagnosis: Small cell lung cancer, metastatic to brain and liver Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 88504**], . You were admitted to the hospital because you were having difficulty breathing. We believe this happened because your potassium was very low, secondary to hormones (cortisol) that are elevated because of your lung cancer. During this admission, you needed to be intubated briefly because of weakness and difficulty breathing. You improved after you started treatment to control your cortisol levels. You were treated for healthcare associated pneumonia as well with intravenous antibiotics. You were also followed by the Palliative Care Service, who helped us find a good treatment for your pain and anxiety. . Please note, the following changes were made to your medications: - START ketoconazole 400 mg by mouth three times per day - START spironolactone 200 mg by mouth twice daily - START metyrapone 500 mg by mouth twice daily - START lorazepam 1 mg by mouth every 6 hours - START potassium chloride 40 mEq by mouth four times daily - START metyrapone 500 mg by mouth twice daily - START dexamethasone 0.5 mg by mouth daily - START morphine sulfate 5-10 mg by mouth every two hours as needed for pain or agitation . Please Wishing you peace in this difficult time. Followup Instructions: Name: HUNT,[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Location: [**Hospital1 641**] Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**] Phone: [**Telephone/Fax (1) 88505**] *It is recommended that you see Dr. [**Last Name (STitle) **] within one week. A nurse form her office will contact you to schedule an appointment.

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icd9cm

[ [ [] ] ]

[ "33.23", "38.97", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

20479, 20557

10932, 16418

353, 472

20725, 20725

4283, 4283

22117, 22501

2289, 2305

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266, 315

500, 2044

20648, 20704

4299, 5424

20740, 20854

16434, 16532

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66,686

184,334

38617

Discharge summary

report

Admission Date: [**2197-3-30**] Discharge Date: [**2197-4-1**] Date of Birth: [**2151-11-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11892**] Chief Complaint: Altered mental status. Major Surgical or Invasive Procedure: Mechanical ventilation. History of Present Illness: This is a 45-year-old gentleman with a pmhx. of tonic-clonic seizures (in context of history of head injury and skull fracture 25 years ago) on Lamotrigine, HTN, hypercholesterolemia, and anxiety who is transferred from the MICU to the general medicine floor after an acute change in mental status at work and gait instability. . Patient states he has experienced progressive fatigue for the past 6 months. He developed a headache and "sinus congestion" 2 days ago, and began taking OTC medication (sudafed) for nasal stuffiness. Patient has also been taking herbal supplement (one of which contains lithium) for the past 2 months, which he buys on the internet; patient states that his doctor will no longer refill his prescriptions, as he hasn't been in to see her for a long time. . Patient drove to work on day of admission without any trouble. However, when he got to his office he was found to be increasingly confused and with slurred speech. He was told to "go home" by his boss, but his behavior became increasingly more bizzare (couldn't lift bottle of water to his lips, weak, confused, unbalanced, etc). and EMS was called. . On arrival to the ED, VS were: T97.3, HR 110->95, BP 140/110, RR 16, O2 Sat 100% on 100% NRB. Patient was found to be somnolent in the ED and neurology was consulted. Thought that episode was likely due to intoxication from multiple medications, including lithium (in one of the herbal supplements he was taking). His tox screen was positive for: tricyclics, amphetamine (sudafed), and methadone (possibly from Ultram). Patient was given ceftriaxone and vanc for presumed meningitis. An LP was done, which was not consistent with bacterial infection however, patient was continued on acyclovir. Mr. [**Known lastname 55334**] was intubated for a GCS of [**5-23**] (withdrawal to pain). and transferred to the MICU. He did well overnight and was extubated the following morning. His lithium level is coming down, and he is being followed by neurology and toxicology. Vitals on transfer: BP: 124/78, HR: 100, RR: 16, SP02: 99% on RA. . ROS: As per HPI. Patient denies chest pain, shortness of breath, headache, nausea, vomiting, diarrhea, pain with urination, current fevers or chills. Past Medical History: - Generalized seizure disorder on lamictal, no recent dose changes. Patient states that last seizure was a few days prior to arrival and wittnesed by wife. Normally post-ictal. - Migraines that are temporally related to seizures and started recently after seizure disorder diagnosis made - Anxiety (?) - takes clonazepam prn - HTN - HL - Gout - History of MVA with skull fracture while in his 20s. Social History: Patient works as a development programmer for MedTech. He is married and has no children. Lives with his wife and 3 cats. No tobacco, alcohol, or other illicits. Patient used to chew tobacco but quit 10 years ago. Family History: Uncle with bladder cancer. Another uncle with myeloma. Two uncles with lung cancer. High cholesterol in mother's side of the family. Physical Exam: Vitals: BP: 124/78 P: 100 R: 16 18 SPO2: 99% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, 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, with pneumoboots on. Neuro: Grossly intact bilaterally without focal deficits Pertinent Results: Labs on admission: [**2197-3-30**] 08:45AM PT-10.9 PTT-22.1 INR(PT)-0.9 [**2197-3-30**] 08:45AM PLT COUNT-214 [**2197-3-30**] 08:45AM NEUTS-54.5 LYMPHS-39.0 MONOS-3.7 EOS-1.6 BASOS-1.1 [**2197-3-30**] 08:45AM WBC-8.8 RBC-4.56* HGB-13.6* HCT-39.3* MCV-86 MCH-29.8 MCHC-34.5 RDW-13.0 [**2197-3-30**] 08:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-POS [**2197-3-30**] 08:45AM LITHIUM-0.3* [**2197-3-30**] 08:45AM CALCIUM-9.2 PHOSPHATE-3.8 MAGNESIUM-1.9 [**2197-3-30**] 08:45AM LIPASE-25 [**2197-3-30**] 08:45AM ALT(SGPT)-34 AST(SGOT)-18 LD(LDH)-150 ALK PHOS-102 TOT BILI-0.2 [**2197-3-30**] 08:45AM estGFR-Using this [**2197-3-30**] 08:45AM UREA N-10 CREAT-1.0 [**2197-3-30**] 08:50AM HGB-14.4 calcHCT-43 [**2197-3-30**] 08:50AM HGB-14.4 calcHCT-43 [**2197-3-30**] 09:41AM CEREBROSPINAL FLUID (CSF) PROTEIN-42 GLUCOSE-61 [**2197-3-30**] 09:42AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 POLYS-0 LYMPHS-37 MONOS-63 [**2197-3-30**] 09:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2197-3-30**] 09:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2197-3-30**] 09:45AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2197-3-30**] 09:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-POS mthdone-POS [**2197-3-30**] 09:45AM URINE HOURS-RANDOM [**2197-3-30**] 12:52PM LITHIUM-0.9 [**2197-3-30**] 01:00PM TYPE-[**Last Name (un) **] PO2-38* PCO2-51* PH-7.36 TOTAL CO2-30 BASE XS-1 IMAGES / STUDIES: CT of C-spine [**2197-3-30**]: CT CERVICAL SPINE: There is no acute fracture or malalignment within the cervical spine. Patient is intubated with secretions in the posterior nasopharynx. Prevertebral soft tissue appears within normal limits. Extensive opacification of the right greater than left maxillary sinuses is noted. Slight atelectatic appearance of the right maxillary sinus is better depicted on accompanying head CT, suggestive of chronic sinusitis. There is no focal thyroid lesion. Deep cervical soft tissues are unremarkable. There is no lymphadenopathy. Lung apices are clear. IMPRESSION: No cervical spine fracture or malalignment. CT Head [**2197-3-30**]: NON-CONTRAST HEAD CT: There is no intracranial hemorrhage, mass effect, edema, midline shift, or acute hydrocephalus. There is no major vascular territorial infarction. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Prominent right frontal extra-axial space with mild mass effect on the right frontal lobe as well as right frontal osseous cortical thinning likely represents an arachnoid cyst. Tiny hypodensity in the left basal ganglia is likely a dilated perivascular space. Suprasellar and basilar cisterns are patent. There is extensive mucosal thickening within the right maxillary sinus with a slight atelectatic appearance to the bony sinus, suggestive of chronic sinusitis. Mild mucosal thickening is also noted in the left maxillary sinus and ethmoidal air cells. Remainder of paranasal sinuses and mastoid air cells are well aerated. Soft tissues and globes are intact. IMPRESSION: 1. No acute intracranial pathology. 2. Right frontal arachnoid cyst. 3. Likely chronic paranasal sinus disease. Chest x-ray [**2197-3-30**]: CHEST, AP: Endotracheal tube terminates 4.5 cm from the carina. Nasogastric tube has side port in the distal esophagus and tip just beyond the gastroesophageal junction. There is no pneumothorax or pleural effusion. The cardiomediastinal and hilar contours are normal. The lungs are clear. IMPRESSION: ETT in standard position. NGT at GEJ, please advance. MRI/MRV/MRA Head [**2197-3-30**]: MRI OF THE BRAIN: There is no evidence of intracranial hemorrhage, edema, intra-axial masses, mass effect or infarction. Again seen is an arachnoid cyst anterior to the right frontal lobe (8:19), unchanged from the prior CT. The ventricles and sulci are normal in size and configuration. There is circumferential mucosal thickening at right maxillary sinus with a central hypointense signal, likely representing inspissated secretions or fungus ball. There is a mucus retention cyst at the anterior wall of the left maxillary sinus. The remainder of the paranasal sinuses and mastoid air cells are clear. MRV OF THE HEAD: There is no evidence of deep or superficial cortical or dural sinus venous thrombosis. The right transverse sinus is dominant, the left appears hypoplastic without evidence of thrombosis. There is a small Pacchioni granulation in the left transverse sinus (1103:86). MRA OF THE HEAD: There is no evidence of hemodynamically significant stenosis, occlusion, dissection, aneurysm or vascular malformation of the intracranial vertebral arteries, basilar arteries, carotid arteries, circle of [**Location (un) 431**] or their major branches. IMPRESSION: 1. No evidence of intracranial hemorrhage, edema or infarction. 2. There is no evidence of intracranial venous thrombosis. 3. Mucosal thickening of the right maxillary sinus with central hypointense signal, likely representing inspissated secretions from chronic sinusitis or less likely a fungus ball. Chest X-ray [**2197-3-30**]: CHEST, AP: New orogastric tube has side port in the distal esophagus and tip just beyond the gastroesophageal junction. Endotracheal tube remains 5 cm from the carina. There is no pneumothorax or pleural effusion. The cardiomediastinal and hilar contours are normal. IMPRESSION: OGT at GEJ; this may be advanced a few centimeters for optimal positioning. Brief Hospital Course: This is a 45-year-old gentleman with a past medical history of epilepsy (attributed to MVA in his 20s), anxiety, hypertension, gout, and hypercholesterolemia who is admitted with altered mental status and fall. . CHANGE IN MENTAL STATUS: Resolved gradually over course of hospitalization, but likely from gradual "build-up" of multiple prescribed and herbal medications. Mr. [**Name14 (STitle) 85823**] states that his PCP has stopped giving him prescriptions for many of his anti-anxiety medications (because he hasn't gone to see her in a while), and he has needed to buy anxiolytics over the internet. Patient is taking clonapin, amitryptiline, and tramadol in addition to sudafed and a supplement that contains lithium. These medications are undoubtedly contributing to confusion, slurred speech, and change in mental status. However, other etiologies of mental status change must also be considered such as infection or seizure. Patient did complain of sinus congestion for a few days prior to admission (even missed work on the day prior to admission) but CXR and u/a unremarkable, and LP not consistent with bacterial infection. Patient was satrted on acyclovir during hospitalization, but this was stopped prior to discharge. His HSV PCR is pending, and must be followed up by his outpatient provider. . Another potential etiology of mental status change is seizure (given history) however, patient had a slowly declining mental status (over an hour or two) and no seziure activity was wittnesed and he was not post-ictal. He was seen by neurology and an EEG was done, which showed general encephalopathic changes. . Patient's unnecessary medications were discontinued: provigil, ultram, citalopram, clonazepam. His Lamictal was continued. His lithium level was checked until it was 0.3. An MRI brain did not show evidence of hemorrhage, edema, or infarction. Patient improved on his own and was extubated on [**4-1**]. He was transferred to the general medical floor in stable condition, and was completely alert and oriented. He was eager to go home on day of discharge. Neurology also suggested neuro-cognitive testing (patient was complaining of gradual memory loss) as an outpatient. . # SEIZURE DISORDER: Event unlikely seizure related, with no witnessed event, no post-ictal state, and negative EEG. Patient was continued on Lamictal 200 mg [**Hospital1 **], and follow-up with his outpatient neurologist, Dr [**Last Name (STitle) 12552**]. . # HTN: Will clarify home BP medications and touch base with patient's PCP. [**Name10 (NameIs) **] [**Name11 (NameIs) 26998**] for now, but will treat high pressures as needed. . # HYPERLIPIDEMIA: Home regimen unknown. Patient will follow up with PCP for lipid management. . # ANXIETY/DEPRESSION: No evidence of overdose except +tox for methadone (which could be related to Ultram patient was taking at home). Home medication list contains clonazepam and celexa. According to patient, he bought anxiolytics over the internet (the herbal supplements) because he hadn't seen his PCP in some time, and she refused to give him any more prescriptions until he made an appointment. During admssion, patient was not given any anxiolytics, and exhibited no over signs of anxiety. He will likely need further treatment for anxiety and depression as an outpatient. Patient will follow-up with PCP for this issue. He is in agreement with this plan. . # SINUSITIS: As seen on MRI. Patient has chronic frontal headaches and post-nasal drip. He had low-grade fevers on first day of admisison. Patient will take Augmentin for 14 days as an outpatient. He will follow-up with his PCP. Medications on Admission: Precsiption medications per Rite-Aid Pnarmacy: 1) Provigil 200 mg PO daily (last refill [**1-/2197**]) 2) Midrin (generic version) 2 capsules PO at onset of headache, repeat once PRN (last refill [**2-/2197**]) 3) Astelin nasal spray 2 sprays to each nostril [**Hospital1 **] (last refill [**1-/2197**]) 4) Lamotrigine 200 mg PO BID (last refill [**11/2196**]) 5) Clonazepam 0.5 mg once daily PRN (last refill [**10/2196**]) 6) Lisinopril/HCTZ 20/12.5 mg PO once daily (last refill [**6-/2196**]) 7) Citalopram 20 8) Tramadol 50-100mg q4-6 9) Amitriptyline 100mg [**Hospital1 **] 10) Allopurinol ?dose unclear 11) Cholesterol meds unknown Herbals -Lithium orotate 120mg po q24 -Pregnesolone -centropheoxine Discharge Medications: 1. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Augmentin XR 1,000-62.5 mg Tablet Sustained Release 12 hr Sig: Two (2) Tablet Sustained Release 12 hr PO every twelve (12) hours for 14 days. Disp:*56 Tablet Sustained Release 12 hr(s)* Refills:*0* 3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Herbal medication overdose/interaction . Secondary: 1. Epilepsy 2. Anxiety 3. Hypercholesterolemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 55334**], It was a pleasure taking care of you on this admission. You came to the hospital because you had a change in mental status and some confusion. We believe that this was because of some herbal supplements you were taking at home. It is very important that you stop taking these supplements, and see your primary care doctor on a regular basis. . Your primary care doctor will need to follow-up on blood cultures that are pending from this hospitalization. . You were also found to have a sinus infection on MRI. Please take Augmentin (antibiotic) for a 14 day course. . The following changes were made to your medications: 1. START taking Augmentin two 1000 mg tablets every 12 hours for 14 days. 2. CONTINUE taking Lamictal (anti-seizure medication) 200mg twice a day 3. CONTINUE taking allopurinol 300mg QD . Please take all of your medication as prescribed. Please keep all of your follow-up appointments. . Return to the hospital if you develop fever, chest pain, shortness of breath, change in mental status/confusion, loss of consciousness, dizziness, palpitations, seizures, abdominal pain, nausea, vomiting, diarrhea, or any other concerning signs or symptoms. Followup Instructions: Please call your PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at: [**Telephone/Fax (1) 3393**] early next week to make an appointment in 1 week. . Please call your neurologist early next week to make an appointment for the next 1-2 weeks. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

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339, 365

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42,021

132,949

54820

Discharge summary

report

Admission Date: [**2151-9-1**] Discharge Date: [**2151-9-6**] Date of Birth: [**2086-5-15**] Sex: F Service: NEUROSURGERY Allergies: adhesive tape Attending:[**First Name3 (LF) 1835**] Chief Complaint: Skull lesion Major Surgical or Invasive Procedure: Resection Left skull lesion and cranioplasty Dr. [**Last Name (STitle) **] [**2151-9-1**] History of Present Illness: Ms. [**Known lastname 3708**] is otherwise healthy,64-year-old lady who was originally diagnosed with renal cell cancer in [**2144**]. She had metastatic disease in the adrenal gland. She has had resection following whichshe was on steroid replacements. She also has other pulmonary disease. CT scan in [**2150-5-31**] showed some lung infiltrates. She was being on followup and further staging CT scans were done. More recently, she had a history of what she thought was a hit to her head and she noticed some bump and initially thought to have trauma and skull film was done on [**8-20**], [**2149**], which was followed up by an MRI. MRI showed an expansile 4 x 2.2 x 3.0 cm enhancing mass centered in the diploic space at the left frontal bone marginated by frontal suture posteriorly with thinning and depression inner table. The patient was then seen by me for consideration of radiation after consideration of histologic diagnosis. The patient herself noticed a bump, some achiness in this area, but otherwise no other higher function, cranial nerves, sensory, motor, or neurological dysfunction. Past Medical History: Metastatic renal cell cancer status post radical nephrectomy in [**2144**], adrenal insufficiency and disposition of the chronic renal disease, however, prior obesity, hypertension, chronic obstructive pulmonary disease, hypercholesterolemia, and depression. Social History: She does not abuse tobacco or alcohol Family History: No history of cancer in family Physical Exam: Pre-op She appears comfortable at rest, alert, and oriented. Eyes, ears, nostrils, and oropharynx are unremarkable. Neck is soft. No nodes, elevated JVP, or thyroid swelling. Chest, bilateral good air entry. Normal heart sounds. No decreased heart sounds. Abdomen is soft. No mass, tenderness, or hepatosplenomegaly. Neurological and musculoskeletal examination is grossly intact. Examination of the skull itself reveals circumscribed bump on the scalp from the underlying calvaria in the left frontal area On discharge: AVSS AxOx3 NAD pleasant symmetric chest rise, breathimg comfortably sitting up in bed incision c/d/i w/o induration or erythema CNII-XII intact No focal or diffuse neurologic deficits appreciated. Pertinent Results: [**9-1**] MRI brain with and without contrast: Enhancing left frontal skull mass as described corresponding to a lytic lesion in the skull radiograph in keeping with metastatic disease. No intraparenchymal extension of this mass. No enhancing lesions within the brain. [**9-1**] CT head: The patient is post left frontal craniectomy and resection of a large calvarial-based mass, seen on the preoperative [**2151-9-1**] MR examination. There is mild pneumocephalus (2:12). A cranial plate overlies the resection site. There is a small amount of subcutaneous emphysema. No large hemorrhage, edema, or mass effect is seen. The middle ear cavities, mastoid air cells, and included views of the paranasal sinuses are clear. [**9-2**] MRI Brain with and without: 1. Expected post-surgical appearance of left frontal craniectomy and resection of the left calvarial mass. 2. No mass-like enhancement around the surgical cavity. Persistent left frontal dural enhancement, also seen in the pre-operative study. 3. No acute infarcts. Brief Hospital Course: Ms. [**Known lastname 3708**] was admitted to [**Hospital1 18**] under the care of Dr. [**Last Name (STitle) **] for resection of left calvarial mass and cranioplasty. She was given stress dose steroids prior to case for adrenal insufficiency. During the operative case she lost 2L of blood and received 2 units PRBS. Post-op hct was 37. She had hypokalemia intra-op due to her adrenal insufficiency but this corrected to 3.1. She was extubated post-op and was taken to the ICU. Postoperatively she remained neurologically intact. Postop Head CT demonstrated no hemorrhage. On [**9-2**], POD1 she was doing well, advanced her diet and was up and out of bed. Postoperative MRI was performed and she was transfered to the regular floor. On [**9-3**] the patient was noted to be delerious, not oriented to the month or specific hospital. She was afebrile, urinalysis was negative for infection and possibly delerium inducing medications were stopped. BMP did reveal significant abnormalities including hypokelemia, hypophosphotemia and low magnesium. A geriatric consult was called and they felt that the electrolyte abnormalities were most likely responsible for the delerium. These were repleted and her chlorthalidone was d/c'd . Overnight the patient was refusing care and IV placement. She was temporarilly restrained in order to get an IV placed. On [**9-4**] her exam was much improved. She was alert and oriented but still slow compared to her baseline. Repeat electrolytes showed improvement but were still low so they were again repleted per Geriatrics recommendation. Creatinine was back to baseline. Also she was started on standing tylenol for pain control. On [**9-4**], the patient returned to baseline level of functioning and electrolytes normalized. Discharge planning to rehabilitation facility was undertaken. On [**9-5**], the patient awaited transfer to rehabilitation facility. On [**9-6**], the patient was discharged in stable condition. The patient expressed readiness for discharge and was alert and oriented to person, place, and date. All questions were answered. ESTIMATED LENGTH OF STAY AT ACUTE REHAB FACILITY <30DAYS Medications on Admission: hydrocortisone, chlorthalidone, fludrocortisone, mirtazapine, sertraline, simvastatin, atenolol, albuterol, combivent Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H 2. Albuterol-Ipratropium [**2-1**] PUFF IH Q6H:PRN wheeze 3. Atenolol 100 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Fludrocortisone Acetate 0.1 mg PO DAILY 6. Heparin 5000 UNIT SC TID 7. Hydrocortisone 15 mg PO QAM 8. Hydrocortisone 10 mg PO QPM 9. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain 10. Senna 1 TAB PO HS 11. Sertraline 200 mg PO DAILY 12. Simvastatin 20 mg PO HS 13. Phosphorus 500 mg PO BID Discharge Disposition: Extended Care Facility: [**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: Left skull lesion 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: ?????? 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. ?????? **Your wound was closed with staples or non-dissolvable sutures then you must wait until after they are removed to wash your hair. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ESTIMATED LENGTH OF STAY AT ACUTE REHAB FACILITY <30DAYS ??????Please return to the office in [**8-10**] days(from your date of surgery) for removal of your sutures and/or a wound check. This appointment can be made with the Physician Assistant 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 also may have them removed at your rehab facility. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain Completed by:[**2151-9-6**]

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icd9cm

[ [ [] ] ]

[ "01.6", "02.06" ]

icd9pcs

[ [ [] ] ]

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289, 381

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59,854

111,081

35842

Discharge summary

report

Admission Date: [**2102-2-15**] Discharge Date: [**2102-2-21**] Date of Birth: [**2046-8-19**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor Attending:[**First Name3 (LF) 922**] Chief Complaint: coronary artery disease Major Surgical or Invasive Procedure: Coronary artery bypass grafts x 4 (LIMA-LAD, SVG-Dg1,SVG-Dg2,SVG-OM) History of Present Illness: This is a 55 year old white male with several months of progressive dyspnea on exertion. Catheterization on [**2-1**] revealed triple vessel disease with preserved LV by echo (55%). He is admitted now for elective revascularization. Past Medical History: Coronary artery disease obesity obstructive sleep apnea insulin dependent diabetes mellitus hypertension hyperlipidemia diabetic neuropathy Social History: Works as a mechanic for UPS. Social ETOH use. Stopped smoking 23 years ago. Lives with his wife. Family History: Father underwent CABG in his 70s Physical Exam: Admission: VSS, afebrile. BP 92/52 Awake, alert and intact. Lungs- clear Cor- SR w/o murmur. Abd- obese but benign. Exts-no edema, Charcot Joint L foot Vasc- [**Last Name (un) **] pulses present PT/DP bilat. Pertinent Results: [**2102-2-19**] 07:00AM BLOOD WBC-13.9* RBC-3.95* Hgb-11.1* Hct-32.3* MCV-82 MCH-28.2 MCHC-34.5 RDW-13.2 Plt Ct-269 [**2102-2-21**] 06:40AM BLOOD WBC-11.5* RBC-4.33* Hgb-11.7* Hct-35.1* MCV-81* MCH-27.1 MCHC-33.4 RDW-13.5 Plt Ct-338 [**2102-2-19**] 07:00AM BLOOD Glucose-111* UreaN-27* Creat-0.8 Na-137 K-4.1 Cl-100 HCO3-27 AnGap-14 [**2102-2-21**] 06:40AM BLOOD UreaN-25* Creat-1.0 K-4.8 [**2102-2-21**] 06:40AM BLOOD Mg-2.4 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 81479**] (Complete) Done [**2102-2-15**] at 1:19:19 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2046-8-19**] Age (years): 55 M Hgt (in): 72 BP (mm Hg): 120/70 Wgt (lb): 270 HR (bpm): 72 BSA (m2): 2.42 m2 Indication: CABG ICD-9 Codes: 402.90, 786.05 Test Information Date/Time: [**2102-2-15**] at 13:19 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW01-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Ascending: 3.2 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AS. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. The patient appears to be in sinus rhythm. patient. See Conclusions for post-bypass data Conclusions PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on Mr.[**Name13 (STitle) 81480**] at 10AM before initiation of surgery. POST-BYPASS: Preserved biventricular systolic function. LVEF 55%. Normal RV systolic function. Intact thoracic aorta. Other exam is unchanged. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2102-2-15**] 15:20 ?????? [**2096**] CareGroup IS. All rights reserved. Brief Hospital Course: On [**2-15**] the patient was brought to the Operating Room where quadruple bybass grafting was performed as noted. He weaned from bypass in stable condition on neo synephrine and Propofol. As he was a difficult intubation, anesthesia was at the bedside when he was extubated. He spent the night on CPAP mask due to his sleep apnea, having refused to use the mask in the past. He weaned from pressors easily. An insulin infusion was necessary to control his hyperglycemia. His preoperative Lantus and sliding scale insulin were give the day after surgery. His chest tubes were removed on POD 1. His insulin was resumed and sugars adequately controlled to transfer to the floor. Pacing wires were removed on the second postoperative day and diuresis was continued towards his preoperative weight. The physical therapy staff worked with the patient for mobilization and endurance. The patient was noted to have serosanguinous drainage from the lower portion of his incision on POD 4. The incision was opened approximately 4 inches longitudinally and [**3-22**]" deep. This revealed apparently healthy tissue, with no pus or signs of infection. The patient was started on empiric antibiotics and the infectious disease service was consulted. He remained afebrile, and the wound remained stable. Wet to dry dressings were started at the open site. Gram stain did not reveal any microorganisms, and blood cultures were pending at the time of discharge. He was discharged home on Keflex with instructions to follow up with Dr. [**Last Name (STitle) 914**] in 1 week. VNA was arranged to follow up with a wound-vac in the home. The patient was discharged on POD 5. Medications on Admission: Lantus 110U [**Hospital1 **] Humalog 30U bkfst, 40U lunch, 30U dinner Gabapentin 300mg TID Crestor 10mg/D Atenolo25mg/D ASA 325mg/D MVI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Disp:*28 Capsule(s)* Refills:*0* 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 1 months. Disp:*60 Tablet(s)* Refills:*0* 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 1 months. Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 12. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: 100 units Subcutaneous twice a day. Disp:*qs * Refills:*2* 13. Insulin Lispro 100 unit/mL Insulin Pen Sig: varies Subcutaneous four times a day: see sliding scale. Disp:*qs * Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass grafts x 4 obesity obstructive sleep apnea insulin dependent diabetes mellitus hypertension hyperlipidemia diabetic neuropathy Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) wound clinic in 2 weeks Dr. [**Last Name (STitle) **] in [**1-20**] weeks ([**Telephone/Fax (1) 30453**]) Dr. [**Last Name (STitle) 1270**] in 2 weeks please call for appointments Completed by:[**2102-2-21**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

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136,218

47323

Discharge summary

report

Admission Date: [**2114-9-20**] Discharge Date: [**2114-10-7**] Date of Birth: [**2038-10-25**] Sex: M Service: MEDICINE Allergies: Penicillins / Amiodarone Attending:[**First Name3 (LF) 2962**] Chief Complaint: VT Major Surgical or Invasive Procedure: ICD revision (implantation of subcutaneous coil and generator change) History of Present Illness: 78 year old male with CAD and end stage cardiomyopathy with EF of 10%. He has a BIV ICD and presented to [**Hospital3 7362**] today after having a syncope episode this morning, witnessed by his wife. She believes he was shocked several times as she saw him get jolted. En route to the hospital he had some transient vtach noted by EMS but no further VT at [**Hospital3 7362**]. Enzymes so far negative. . On arrival at [**Hospital1 **], he states that he feels back to baseline. No fever, chills, N/V/Cough/SoB, diarrhea, constipation, muscle aches or pains. His wife thinks he was unconscious for approximately 30 seconds. He does not remember the episode but remembers feeling lightheaded prior to syncopizing. He awoke on the floor of his bedroom. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, 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, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema. Past Medical History: -CAD s/p 2 MIs ([**2094**]; [**2101**] w/ VF arrest, coma, and neurological sequelae) and AICD/pacemaker placement. Cath [**10-9**] w/ LCX occlusion distal to OM1, which was widely patent. -s/p ICD/pacemaker placement: 4.5 yr old [**Company 1543**] InSync model 7272 BiVentricular ICD.(ICD is an abdominal implant, LA and LV leads are epicardial; RV lead is a Transvene and there is a stand-alone SCV coil; abandoned RV/RA leads located in right pectroal region) implanted in [**2110**], first ICD in [**2101**] - Ischemic cardiomyopathy: echo [**2113-6-19**] w/ global LV hypokinesis (LVEF [**10-27**] percent) w/ akinesis of the inferior, posterior, and lateral walls; 3+ MR; 2+ TR; moderate PA systolic hypertension. - Hypertension - Hyperlipidemia - Valvular heart disease: moderate MR [**First Name (Titles) **] [**Last Name (Titles) **] - chronic kidney dz: baseline creat 1.3-1.4 since [**2112**] - anemia: baseline HCT 37-38 - h/o SVC thrombosis (dx [**2-/2105**]); on warfarin since early 90s - h/o nephrolithiasis - s/p tonsillectomy - s/p appendectomy - s/p bilateral inguinal hernia repairs x 2 - GI bleed in [**2-14**] from [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear Social History: The patient lives in [**Location (un) 100183**] with his wife. They are both retired (he is a retired banker). He goes to cardiac rehab 2 times per week. He walks with a walker at home. They are independent and have no in-home health services. He denies ever smoking or using illicit drugs. He drank in the past but not for many years. Family History: - CAD: sister - prostate CA: father Physical Exam: VS - 121/75, 74, 18, 100% on RA Gen: Cachectic elderly 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. Eccymosis under tongue. Neck: Supple with JVP of 5 cm (by EJ) 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:+ kyphosis. Resp were unlabored, no accessory muscle use. Scattered crackles bilaterally. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Left abdominal ICD pocket benign. Ext: No c/c/e. No femoral bruits. Decubitous ulcers on bilateral hips w/ duoderm in place. . Pulses: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: [**2114-9-20**] 06:35PM BLOOD WBC-7.2 RBC-3.73* Hgb-12.0* Hct-36.2* MCV-97 MCH-32.3* MCHC-33.2 RDW-13.6 Plt Ct-188# [**2114-9-20**] 06:35PM BLOOD PT-26.4* PTT-34.3 INR(PT)-2.7* [**2114-9-20**] 06:35PM BLOOD Glucose-91 UreaN-18 Creat-1.1 Na-140 K-4.4 Cl-102 HCO3-30 AnGap-12 [**2114-9-20**] 06:35PM BLOOD CK(CPK)-213* [**2114-9-20**] 06:35PM BLOOD CK-MB-7 cTropnT-0.04* [**2114-9-20**] 06:35PM BLOOD Albumin-4.0 Calcium-9.0 Phos-2.6* Mg-2.5 Iron-44* [**2114-9-20**] 06:35PM BLOOD calTIBC-246* VitB12-650 Folate-GREATER TH Ferritn-142 TRF-189* [**2114-9-20**] 06:35PM BLOOD TSH-0.80 . [**9-20**] CXR Lungs are mildly hyperinflated and clear. There is no pulmonary edema or vascular engorgement. Heart size is normal. No pleural effusion is present or indication of pneumothorax. Two left subclavian [**Month/Year (2) **] defibrillator leads arising below the field of view end in the right atrium and right ventricle, as before. Two additional remnant pacemaker leads rising in the right axilla end in the right atrium and right ventricle as before. Three epicardial leads projecting over the left heart border are unchanged in their respective positions. . [**9-21**] PMIBI: INTERPRETATION: The image quality is adequate. The patient's arms are down. Left ventricular cavity size is markedly enlarged. EDV is 300 mL. Rest and stress perfusion images reveal a large severe fixed perfusion defect involving the apical inferior to basal inferior segments. Gated images reveal global hypokinesis. The calculated left ventricular ejection fraction is 14%. IMPRESSION: 1) Severe fixed perfusion defect involving the apical inferior to basal inferior segments. 2) Marked ventricular enlargement. 3) Ejection fraction is 14%. . [**9-21**] Stress: HR 52% INTERPRETATION: 75 yo man (h/o CAD and ischemic cardiomyopathy with LVEF ~10%; BIV/ICD placement [**2101**]) was referred for evaluation following an episode of VT. The patient was administered 0.142 mg/kg/min of persantine over 4 minutes. No chest, back, neck or arm discomforts were reported by the patient during the procedure. The ECG is uninterpretable in the presence of ventricular pacing. The rhythm was AV paced with frequent isolated multiformed VPDs and rare ventricular couplets. Rare isolated APDs were noted. The hemodynamic response to the persantine infusion was appropriate. Three min post-MIBI, the patient was administered 125 mg aminophylline IV. IMPRESSION: No anginal symptoms with an uninterpretable ECG. Nuclear report sent separately. Brief Hospital Course: . VT: Thought to be from ischemic cardiomyopathy, ICD interrogation showed that he was in VT-->VF-->resulting in 3 shocks with the first two shocks at 35 J being unsuccessful and the third shock at 35 J successful. On admission, his mexiletine was discontinued and he was started on dofetilide 500 [**Hospital1 **]. On [**9-28**], in order to improve his shock vector, he underwent a subcutaneous shocking coil placement and upgraded to [**Company 1543**] Concerto. The SCV coil was capped and replaced by the SQ coil . See separte OP and EP notes for technical details. The ICD generator was upgraded to a newer model to have the ability to remoive the ICD can from the shock vector noninvasively if need be. On [**9-29**], he was noted to have multiple episodes of fast VT, polymorphic VT, and VF requiring shock (first one successful). He was transferred to the CCU at this time (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2232**]) and his dofetilide was stopped. Lidocaine drip was started with improvement in ventricular ectopy. He was then restarted on mexilitene 150 TID. However, on the mexilitene he was noted to have increasing ventricular ectopy and his dose was increased to 200 TID. He was however unable to tolerate this dose of mexilitene and due to nausea, vomitting, his dose was decreased once again to 150 TID. He tolerated this dose, but did continue to have episodes of VT. He was advised to refrain from driving for 6 months. . CHF: He has known cardiomyopathy with EF 10%. He remained relatively euvolemic throughout his hospital course. He was continued on his home regimen of lasix, digoxin, carvedilol and lisinopril. . Anemia: He was noted to have a Hct drop from 30-->26 on [**10-3**]. He was found to be guaiac negative. He was however noted to have a left sided flank hematoma on [**10-3**] which is presumed to be from heparin during bridge to coumadin. Heparin was discontinued at this time and he was continued on coumadin. His hematoma remained stable. His hematoma remained stable to improved during his hospital course. . Atrial fibrillation: He was started on a bridge with heparin to coumadin. However on [**10-3**], due to a new hematoma (see above), his heparin was discontinued. His coumadin dose was increased to 7.5. His INR was 2 on discharge. . Diarrhea: He was noted to have diarrhea, which was thought to be a side effect of mexiletine. His c. diff toxin was negative x 3. Medications on Admission: Simvastatin 80 mg daily Mexiletine 150 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO Q12H (every 12 hours). Digoxin 125 mcg Tablet [**Month/Year (2) **]: [**1-9**] Tablet PO EVERY OTHER DAY (Mon, Wed, [**Last Name (LF) **], [**First Name3 (LF) **]). Digoxin 125 mcg Tablet [**First Name3 (LF) **]: One (1) Tablet PO EVERY OTHER DAY (Tues, Thurs, Sat). Lisinopril 5 mg Tablet [**First Name3 (LF) **]: [**1-9**] Tablet PO DAILY (Daily). Omeprazole 20 [**Hospital1 **] Furosemide 5 mg Tablet daily Aspirin EC 81 mg Tablet daily Magnesium Oxide 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. Carvedilol 3.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) Warfarin Mag oxide 400 mg po bid Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 2. Digoxin 125 mcg Tablet [**Hospital1 **]: half Tablet PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR). 3. Digoxin 125 mcg Tablet [**Doctor First Name **]: One (1) Tablet PO 3X/WEEK (TU,TH,SA). 4. Furosemide 20 mg Tablet [**Doctor First Name **]: 0.5 Tablet PO EVERY OTHER DAY (Every Other Day). 5. Mexiletine 150 mg Capsule [**Doctor First Name **]: One (1) Capsule PO Q8H (every 8 hours). 6. Zolpidem 5 mg Tablet [**Doctor First Name **]: One (1) Tablet PO HS (at bedtime) as needed. 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. Oxycodone-Acetaminophen 5-325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4-6H () as needed for pain. 9. Lisinopril 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 10. Carvedilol 3.125 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 11. Coumadin 7.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime. 12. Simvastatin 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Cardiac arrest Ventricular tachycardia Systolic congestive heart failure Hypertension Anemia Discharge Condition: Hemodynamically stable. Ambulatory with a walker. Discharge Instructions: You were admitted after having ventricular tachycardia, which as an abnormal heart rhythm, and were shocked by your intra-cardiac defribrillator. You had your ICD revised and tested. You were also continued on your antiarrhythmic medication. As discussed, you are not to drive for 6 months. Based on the RMV laws of Massachusettes, you cannot drive for 6 months time because you passed out as a result of your abnormal heart rhythm. After the 6 months, your doctor [**First Name (Titles) 4801**] [**Last Name (Titles) 4656**] you to decide if you can drive at that point. Please seek medical attention immediately if you faint, or develop fever, chills, chest pain, shortness of breath or any other concerning symptoms. You should take all of your medications as directed. Of note, your mexiletine dose was increased to 150 three times per day. In addition, your coumadin dose was increased to 7.5 mg daily. You should have your INR (coumadin level) checked in [**2-10**] days. Followup Instructions: You have a cardiology appointment with Dr. [**First Name (STitle) 437**]: [**2114-11-12**] at 11AM. His office can be reached at [**Telephone/Fax (1) 1144**]. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2114-10-31**] 9:45 Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**] Date/Time:[**2114-11-14**] 11:30 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2114-10-5**] 1:00 . [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2964**] MD, [**MD Number(3) 2965**] Completed by:[**2114-10-7**]

[ "414.01", "424.2", "V58.61", "427.1", "787.91", "V17.3", "783.0", "424.0", "272.4", "403.90", "996.01", "585.9", "V16.42", "459.2", "428.23", "453.8", "427.31", "428.0", "V65.3" ]

icd9cm

[ [ [] ] ]

[ "88.63", "37.20", "00.51" ]

icd9pcs

[ [ [] ] ]

11110, 11190

6639, 9107

289, 361

11327, 11379

4101, 6616

12413, 13169

3221, 3261

9884, 11087

11211, 11306

9133, 9861

11403, 12390

3276, 4082

247, 251

389, 1592

1614, 2849

2865, 3205

22,682

166,497

23807+57377

Discharge summary

report+addendum

Admission Date: [**2170-3-25**] Discharge Date: [**2170-3-30**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1055**] Chief Complaint: Coffee ground emesis Major Surgical or Invasive Procedure: Endoscopic gastroduodenoscopy History of Present Illness: Pt states that for the past month she had had a sense of epigastric heaviness and more recently a sense of fatigue. On [**2170-3-19**] she attempted to have a bowel movement and after arising from the toilet she got lightheaded, weak and fell to the floor. No LOC or head contact. She was taken to [**Hospital3 **] were she was noted to have coffee ground emesis, Hct=28.5, and ED showed a large gastric ulcer. She received 3 units of PRBCs which bumped her Hct to 33. Her Hct remained stable and she was discharged on [**2170-3-23**]. On [**2170-3-24**] she again had an episode of lightheadedness and weakness and returned to [**Hospital3 **]. She again had bloody emesis, Hct=26, and a repeat EGD w/ epinephine injections x4 that were reported to control the bleeding. She received six units PRBCs and had a Hct bump to 34.5, Protonix IV, Lopressor IV for elevated BPs. She was also noted to have a new onset A-flutter as well as one bout of tarry black watery diarrhea. She was never in hemodynamic compromise or requiring O2 supplementation. Overnight she had recurrence of hematemesis and due to an inadequate supply of 0 negative blood was transferred to [**Hospital1 18**]. There is a question of a recent H. pylori positive test. No NSAID use. Past Medical History: 1) HTN (dx: 20+ yrs ago) 2) Lupus (dx: 20 yrs ago) associated arthritis 3) Hypothyroid (s/p surgery [**14**] yrs ago) 4) Glaucoma left eye Social History: Lives in [**Location 18825**] with son and husband. Active physical life -- dances once a week and walks 2 miles daily. No tobacco. No drugs. Social drinker in past. Family History: NC Physical Exam: 98.9/98.9, bp 142/80, hr 83 , rr 18, spo2 96%ra gen- pleasant, non-ill appearing f in nad heent- op clear with mmm neck- no jvd, no lad cv- rrr, s1s2, occ ectopy, no m/r/g pul- moves air well, no w/r/r abd- soft, nt, nd, nabs extrm- no c/c/e, warm/dry neuro- a&ox3, no focal cn/motor deficits Pertinent Results: [**2170-3-25**] 03:30PM BLOOD WBC-13.1* RBC-4.33 Hgb-13.3 Hct-36.9 MCV-85 MCH-30.7 MCHC-36.0* RDW-13.6 Plt Ct-281 [**2170-3-27**] 04:58AM BLOOD WBC-8.0 RBC-3.67* Hgb-11.2* Hct-32.0* MCV-87 MCH-30.6 MCHC-35.0 RDW-13.8 Plt Ct-253 [**2170-3-30**] 06:35AM BLOOD WBC-10.6 RBC-4.57 Hgb-14.0 Hct-40.1 MCV-88 MCH-30.7 MCHC-34.9 RDW-13.7 Plt Ct-388 [**2170-3-25**] 03:30PM BLOOD Glucose-76 UreaN-22* Creat-0.7 Na-142 K-3.3 Cl-103 HCO3-29 AnGap-13 [**2170-3-29**] 07:00AM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-137 K-3.8 Cl-97 HCO3-30* AnGap-14 Brief Hospital Course: 84 y/o F w/ UGIB secondary to gastric ulcer and new onset a-flutter. 1.)UGIB: Mrs. [**Known lastname 60459**] came in with a known bleeding ulcer and a hematocrit that was still off of her baseline despite transfusion of six units of pRBCs at the outside hospital. She underwent an EGD that showed gastritis and an ulcer on the lesser curvature that was cauterized with good effect. H. pylori was positive, so clarithromycin/metronidazole/[**Hospital1 **] pantoprazole were started on [**3-27**] for a fourteen day course. Once this is finished, she will remain on the pantoprazole, but take it once daily. Following this, her hematocrit remained stable throughout the rest of her hospital stay, with only one further transfusion performed 4 days prior to discharge. A gastrin level was checked and was still pending at discharge; she was asked to follow-up with her gastroenterologist to follow this value. She has an appointment in eight weeks to repeat the EGD for re-assessment and biopsies. She has been advised to avoid NSAID's and ASA. 2) HTN: She was started on metoprolol for blood pressure control, and as she appeared stable hemodynamically, her lisinopril and felodipine were severally re-added. This provided good blood pressure control, so her Aldamet was held, with the understanding that this could be re-started as an outpatient at the discretion of her primary care doctor. 3) Atrial flutter: A new finding not previously noted, Mrs. [**Known lastname 60459**] was found to be in a-flutter at OSH on ECG. She suffered no hemodynamic compromise from the rhythm and was begun on metoprolol at [**Hospital1 18**] for rate control. She remained stable and eventually converted into a sinus rhythm with occasional atrial ectopy. The plan is for her to follow-up as an outpatient with cardiology, for possible consideration of cardioversion, as it was felt that this decision should wait until she was through the acute course of her GI bleed. She was not anticoagulated given her GI bleed and the risk of re-bleeding. 4) HYPOTHYROID: Her levothyroxine was intially continued at her home dose of 50, yet as her TSH value was 4.4, the dose was increased to 100mcg daily. She tolerated the dose increase well with a plan for her to follow-up with her primary care doctor for repeat thyroid function tests in six to eight weeks. 5) LUPUS: Stable and without symptoms obvious symptoms (see below) as an inpatient, she was continued on her home dose of hydroxychloroquine. 6) Right ankle swelling: This appeared during the admission. There was no warmth to indicate cellulitis or gout, and there was no fluid to tap for analysis. It was felt this may have represented an aspect of her lupus, and in addition to her hydroxychloroquine, acetaminophen was initiated with good relief of discomfort. LENI's were performed and showed no evidence of DVT. Medications on Admission: --levothyroxine 50 mcg --digoxin 0.125 mg QD --aldomet --lisinopril --calcium channel blocker --hydroxychloroquine Discharge Medications: 1. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 10 days. 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: To start after patient has received ten days of the same medication/dose twice daily. 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Hydroxychloroquine Sulfate 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Felodipine 5 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). 10. Aldomet 250 mg Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Extended Care Facility: NAMASKET Discharge Diagnosis: Gastric ulcer Acute blood loss Secondary: 1) HTN (dx: 20+ yrs ago) 2) Lupus (dx: 20 yrs ago) associated arthritis 3) Hypothyroid (s/p surgery [**14**] yrs ago) 4) Glaucoma left eye Discharge Condition: Good, with stable hematocrit and hemodynamics Discharge Instructions: Call your PCP or return to the emergency department for blood in your stool, tarry-black stools, lightheadedness, shortness of breath, chest pain, fevers/chills, or other concerning symptoms. We have held one of your blood pressure medications, Aldamet. We recommend that you do not take this medication until you see your primary care physician, [**Name10 (NameIs) 151**] whom you can decide whether or not to restart the medication. Take your medications as prescribed. Follow-up as below. Followup Instructions: Please see your primary care doctor in one to two weeks. Call to make an appointment. As above, you will need to discuss restarting your Aldamet (blood pressure medication) with him/her. . Please see your GI doctor in [**1-11**] weeks. Ask him/her to follow-up on the results of your gastrin study. . You will need a repeat EGD (scope to examine your stomach) in eight weeks. A letter has been to your home to explain this follow-up. The appointment is: Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], MD Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2170-5-29**] 9:00 Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Where: GI ROOMS Date/Time:[**2170-5-29**] 9:00 . You have follow-up with a cardiologist for evaluation of your heart rhythm (atrial flutter): Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2170-5-1**] 10:00 Name: [**Last Name (LF) 3133**],[**Known firstname 1073**] Unit No: [**Numeric Identifier 11078**] Admission Date: [**2170-3-25**] Discharge Date: [**2170-3-30**] Date of Birth: [**2085-4-2**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1852**] Addendum: Atrial flutter -- Would recommend beginning anticoagulation once the patient has been re-scoped and if the ulcer has healed. The patient will have follow-up with cardiology and her PCP, [**Name10 (NameIs) **] they will make the decision once the patient has had her repeat EGD. Discharge Disposition: Extended Care Facility: NAMASKET [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 692**] MD [**MD Number(2) 693**] Completed by:[**2170-3-30**]

[ "427.32", "710.0", "285.1", "531.40", "401.9", "244.9" ]

icd9cm

[ [ [] ] ]

[ "44.43", "99.04" ]

icd9pcs

[ [ [] ] ]

9514, 9706

2808, 5685

240, 272

7131, 7178

2249, 2785

7721, 9491

1916, 1920

5851, 6849

6928, 7110

5711, 5828

7202, 7698

1935, 2230

180, 202

300, 1554

1576, 1717

1733, 1900

72,528

151,316

47477

Discharge summary

report

Admission Date: [**2111-3-29**] Discharge Date: [**2111-4-11**] Date of Birth: [**2032-2-3**] Sex: F Service: MEDICINE Allergies: Lasix / Bentyl Attending:[**First Name3 (LF) 1257**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Endotracheal intubation Left central line placement PICC line placement History of Present Illness: The patient is a 79 yo woman with h/o moderate AS (aortic valve area of 1.2 cm2), complete heart block s/p PMP, DM2, HTN, and HL, who presented from home with shortness of breath. Per the patient's family, she was in her normal state of health until approximately 4 days ago, when she developed a cough and worsening congestion, which was thought to be an upper respiratory infection. She started taking Mucinex last night, which did not improve her symptoms. Overnight, she did not wear her BiPap, as she did not want to mess up her hair for Mother's Day. At 3 am this morning, she acutely developed shortness of breath. EMS was called and she was brought to the ED for further evaluation. . In the ED, her initial VS were P 123, BP 183/93, R 36, O2 64% on NRB. She was urgently intubated (difficult airway, placed over a bougie) and was started on a nitro gtt for her hypertension. Her SBP then acute dropped to the 50s in the setting of the nitro gtt, so she was given 1L of NS. Two CVLs were placed (subclavian and femoral, each requiring multiple sticks) and she was started on Levophed. She had a bedside TTE, which showed poor LV contraction (prior EF 55%), so she was given ASA 325 mg. She then spiked a fever to 102, and WBC was elevated at 17, so she was cultured and was started on CTX, Levoquin, and Vancomycin for presumed sepsis. CXR at that time was consistent with pulmonary edema without evidence of an obvious infiltrate. EKG showed LAD with V-pacing spikes. Given the concern for flash pulmonary edema in the setting of septic shock, she was admitted to the CCU for further evaluation. Her VS at the time of transfer were T 102, P 66, R 20, BP 125/38. In the CCU, the patient was initally given Ethacrynic acid 50 mg IV for presumed flash pulmonary edema and her respiratory status improved. She then becamse febrile to 104 and required both IVFs and Levophed for hemodynamic support. Her blood pressures were incredibly labile, ranging from 60s to 240s systolic with minimal support. It was eventually determined that her blood pressure was heart-rate dependant, and she was unable to hold a stable blood pressure with a rate of < 70. Her pacemaker was thus adjusted to a rate of 70, and she was weaned off pressors on [**3-31**]. She had significant anxiety when weaning from the ventilator, so she was started on Seroquel 25 mg PO BID for agitation. Despite this, during her PST/RSBI on [**3-31**], she developed hypercarbia and was unable to be extubated. Given concern for an underlying respiratory etiology, she underwent a CT scan, which demonstrated bibasilar opacities, concerning for PNA. She also had a viral DFA, which returned as positive for parainfluenza 3. Given her ongoing respiratory issues, she was transferred to the MICU for further evaluation. Past Medical History: DM2 Hyperlipidemia Hypertension Complete heart block s/p pacemaker implant in [**2101-6-22**] at [**Hospital1 34**] (St. [**Male First Name (un) 1525**]), with a revision in [**2110**] Moderate Aortic stenosis Diastolic dysfunction Anemia Sleep apnea (CPAP) Vitamin D deficiency Vitamin B12 deficiency Hx of diaphragm paralysis Social History: The patient is widowed and lives with her brother. She has three children. She is originally from [**Country 3399**] but has lived here for 48 years. She does not smoke and does not drink EtOH. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ON ADMISSION: VS: P 98, BP 139/60, O2 100% on CMV 50% FiO2, TV 500, RR 22, PEEP 5 General Appearance: Well nourished Eyes / Conjunctiva: PERRL, Pinpoint pupils Head, Ears, Nose, Throat: Endotracheal tube, OG tube Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : At bases bilaterally) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent . ON DISCHARGE: VS: T 96.6, BP 104-115/49-70, HR 76-90, RR 18, O2 sat 99% on RA. GEN: Well-appearing, NAD HEENT: NC/AT, anicteric NECK: supple, no JVD CV: RRR, IV/VI holosystolic murmur LUNGS: B/L basilar rales, no wheezing ABD: + BS, soft, non-tender EXT: no edema Pertinent Results: ADMISSION LABS: [**2111-3-29**] 06:25AM WBC-17.4*# RBC-4.89 HGB-14.1 HCT-45.6 MCV-93 MCH-28.9 MCHC-31.0 RDW-15.0 [**2111-3-29**] 06:25AM PLT COUNT-311 [**2111-3-29**] 06:25AM NEUTS-47.7* LYMPHS-43.6* MONOS-4.9 EOS-1.6 BASOS-2.1* [**2111-3-29**] 06:25AM PT-11.9 PTT-22.1 INR(PT)-1.0 [**2111-3-29**] 06:25AM proBNP-1140* [**2111-3-29**] 06:25AM GLUCOSE-435* UREA N-18 CREAT-0.9 SODIUM-134 POTASSIUM-7.6* CHLORIDE-101 TOTAL CO2-20* ANION GAP-21* [**2111-3-29**] 06:25AM ALT(SGPT)-46* AST(SGOT)-109* ALK PHOS-46 TOT BILI-0.3 [**2111-3-29**] 06:25AM cTropnT-0.01 [**2111-3-29**] 06:43AM GLUCOSE-375* LACTATE-3.9* NA+-135 K+-10.2* CL--102 TCO2-20* [**2111-3-29**] 07:11AM TYPE-ART TIDAL VOL-500 PEEP-8 O2-100 PO2-48* PCO2-67* PH-7.17* TOTAL CO2-26 BASE XS--5 AADO2-609 REQ O2-98 -ASSIST/CON INTUBATED-INTUBATED [**2111-3-29**] 08:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2111-3-29**] 08:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2111-3-29**] 08:00AM URINE RBC-4* WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 [**2111-3-29**] 08:00AM URINE HYALINE-8* [**2111-3-29**] 08:00AM URINE MUCOUS-RARE . DISCHARGE LABS: [**2111-4-11**] 05:49AM BLOOD WBC-13.8* RBC-3.67* Hgb-10.5* Hct-32.1* MCV-87 MCH-28.5 MCHC-32.7 RDW-14.9 Plt Ct-449* [**2111-4-11**] 05:49AM BLOOD Glucose-160* UreaN-34* Creat-0.9 Na-142 K-3.5 Cl-100 HCO3-32 . MICRO: [**2111-3-29**] 7:05 am BLOOD CULTURE ARTERIAL #2. GRAM POSITIVE ROD(S). CONSISTENT WITH CORYNEBACTERIUM OR PROPIONIBACTERIUM SPECIES. [**2111-3-29**] BLOOD CULTURES X2: PENDING (NGTD) [**2111-3-29**] URINE CULTURE: NO GROWTH. [**2111-3-29**] SPUTUM: GRAM STAIN (Final [**2111-3-29**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2111-3-31**]): RARE GROWTH Commensal Respiratory Flora. [**2111-3-31**] BLOOD CULTURE X2: NGTD (PENDING) [**2111-3-31**] SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2111-3-31**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): NO GROWTH. [**2111-4-1**] Respiratory Virus Identification (Final [**2111-4-1**]): POSITIVE FOR PARAINFLUENZA TYPE 3. [**2111-4-5**] 3:46 pm Mini-BAL negative grams stain and Cx [**2111-4-5**] Blood culture x 2 - no growth [**2111-4-9**] Stool culture - Negative for C. difficile. . STUDIES: [**3-29**] EKG: Sinus tachycardia with atrial sensing and ventricular pacing. Compared to the previous tracing of [**2111-2-11**] atrial pacing is no longer present. . [**3-29**] CXR: 1. Likely asymmetrical edema, but follow up radiograph after diuresis is recommened to ensure resolution of these findings and to exclude pneumonia. 2. Satisfactory ET tube positioning. 3. Right hemidiaphragm elevation, which was present by report on prior Atrius studies. Small right effusion or pleural thickening. . [**3-30**] Echo: Suboptimal image quality.The left atrium is elongated. 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. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. with normal free wall contractility. The aortic valve is not well seen. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. There is severe mitral annular calcification. There is moderate functional mitral stenosis (mean gradient 13 mmHg) due to mitral annular calcification. Tricuspid regurgitation is present but cannot be quantified. There is severe pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2104-9-30**], the degree of AS may have increased. Poor image quality limits the accuracy of this study. . [**3-30**] CT HEAD: 1. Somewhat limited by motion, but no acute intracranial findings. 2. Parenchymal atrophy and small vessel disease. 3. Ethmoid sinus opacification. Sphenoid and mucosal sinus thickening. Findings are likely related to patient's intubated status. . [**3-31**] CT CHEST: Extensive left more than right, predominantly basal parenchymal consolidations and opacities with air bronchograms, suggestive over a combination of pneumonia and atelectasis. No reticulation suggesting pulmonary edema. Increase in lung density at the lung apices could be interpreted as an indirect sign for overhydration. Reactive moderate mediastinal lymphadenopathy. Coronary and valvular calcifications. Bilateral mild-to-moderate pleural effusions. No pericardial effusion. Pacemaker and monitoring and support devices in correct position. . [**4-8**] PA & LAT and LAT DECUB CXR - There is significant improvement in pulmonary edema, almost completely resolved. Right basal consolidation accompanied by pleural effusion as well as left basal atelectasis and effusion appears to be unchanged. No pneumothorax seen. Brief Hospital Course: The patient is a 79 yo woman with a history of aortic stenosis (valve area 1.2 cm2), complete heart block s/p PMP, DM2, HTN, and HL, who presented from home with acute hypoxemic respiratory failure. . #. Hypoxemic Respiratory Failure: The patient presented with acute shortness of breath with preceding URI symptoms and was intubated in the ED for hypoxemic respiratory failure. It was initially believed that this was due to flash pulmonary edema and the patient was diuresed with ethacrynic acid (given her lasix allergy) with improvement in her respiratory status. Echocardiogram showed relatively stable cardiac function. She remained difficult to wean from the vent, secondary to agitation and was started on seroquel to help address this. She underwent CT chest for further evaluation of pulmonary pathology given her persistent ventilator dependence (particularly in the setting of a fever to 104), which was concerning for a pneumonia. Respiratory viral panel was positive for parainfluenza 3 and patient's presentation was felt to be consistent with a viral syndrome with superimposed bacterial pneumonia. She was started on vancomycin and levofloxacin and transferred to the MICU for further management. . In the MICU, her antibiotics were broadedned to vanco/cefepime/levoflox for concern for HAP. She initially did improve but then spiked fever and had increasing sputum production so she was treated for a VAP with Vanc/Meropenem/Levoflox and mini-BAL was performed which showed no growth. . The patient had difficulty weaning from the vent due to her delerium. Seroquel was uptitrated with some effect and then decreased after extubation. Of note, the patient is a difficult airway (grade 3) and required Bougie on last attempt. Once extubated on [**2111-4-7**], the patient continued to have delirium which eventually resolved upon transfer to the floor. Her oxygen requirement decreased and she maintained her O2 sats > 95% on room air on day of discharge. . #. Hypotension: The patient had an episode of hypotension, with systolic blood pressures in the 50s in the emergency room. This occurred after the patient was started on a nitroglycerin gtt. She was given 1.5L of NS in the ED, and her SBP increased to the 130s by the time of arrival to the CCU. She then becamse febrile to 104 and required both IVFs and Levophed for hemodynamic support. Her blood pressures were incredibly labile, ranging from 60s to 240s systolic with minimal support. It was eventually determined that her blood pressure was heart-rate dependant, and she was unable to hold a stable blood pressure with a rate of < 70. Her pacemaker was thus adjusted to a rate of 70, and she was weaned off pressors on [**3-31**]. Her home blood pressure medications of lisinopril and metoprolol were held. Metoprolol was restarted at a low dose on day of discharge due to SBPs 100s-115. Her blood pressure medications should be restarted and gradually uptitrated as tolerated. . #. Type 2 diabetes mellitus: The patient has a history of DM2, for which she takes Metformin and a HISS at home. Her glucose on arrival to the ED was 435, for which she was started on an insulin gtt. However, this was weaned to SSI. Patient then transitioned to lantus with SSI. Lantus uptitrated to 20 units daily. She is being discharged on insulin. If her kidney function remains stable, metformin may be restarted and insulin titrated down as tolerated. . #. Anemia: Ms. [**Known lastname 100407**] Hct was 45 on admission and decreased to 35 five hours later in the setting of IVFs. Her family does not endorse recent GIB or changes in her stool. Patient was guaiac negative and had stable HCT. Iron studies indicated iron deficiency anemia and patient was started on PO iron repletion. . # Transition of Care Issues: - Patient will require follow-up with her cardiologist given pacemaker changes and appropriate diuretic titration. Of note, she is allergic to Lasix which is why she was started on ethacrynic acid. She was on ethacrynic acid 50 mg [**Hospital1 **] until the day of discharge when she was changed to 50 mg daily due to rising BUN and improved volume status. She may be able to stop this medication eventually or transition to intermittent dosing. - Hypertension: Home metoprolol was restarted on day of discharge at a low dose. Lisinopril continues to be held. If her blood pressure increases - Patient should have Chem7 checked on [**2111-4-13**] to ensure adequate potassium repletion and that she is not having renal failure from her diuretic. - Patient likely has some degree of critical illness myopathy and would benefit greatly from physical therapy for deconditioning. She was independent prior to this hospitalization. . Addendum: After patient was discharged, [**Hospital3 2558**] called regarding her PICC line which had inadvertently not been discontinued. Arrangements were made for the physician there to remove the PICC line on Monday. Medications on Admission: (Per atrius website): Alendronate (FOSAMAX) 70 mg Oral Tablet TAKE 1 TABLET every week in the morning 30 minutes before food do not lie down for at least 30 minutes Lisinopril 40 mg daily Metoprolol Tartrate 50 mg Oral Tablet 1 tab [**Hospital1 **] Metformin 1,000 mg Oral Tablet TAKE 1 TABLET TWICE DAILY Simvastatin 20 mg qhs Insulin Lispro (HUMALOG KWIKPEN) sliding scale before meals- CYANOCOBALAMIN SR 1,000 MCG TAB daily ASPIRIN TABLET EC 81MG PO 1 TAB PO QD CALCIUM CARBONATE TABLET 1.25G PO bid Discharge Medications: 1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Humalog 100 unit/mL Solution Sig: as directed per sliding scale Subcutaneous QIDACHS. 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Until mobile to prevent DVTs. 7. ethacrynic acid 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. B-12 DOTS 500 mcg Tablet Sig: Two (2) Tablet PO once a day. 9. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day. 10. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. 11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 12. 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. 13. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 14. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. potassium chloride 10 mEq Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO once a day: While on ethacrynic acid. 16. Outpatient Lab Work Please check Chem7 on [**2111-4-13**]. Please adjust potassium repletion and diuretic dose as necessary. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary Diagnoses: Parainfluenza Acute on chronic congestive heart failure . Secondary Diagnoses: Type 2 diabetes mellitus Hyperlipidemia Hypertension Complete heart block s/p pacemaker Moderate Aortic stenosis Anemia Sleep apnea on CPAP Vitamin D deficiency Vitamin B12 deficiency 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 intensive care unit for shortness of breath. This was likely due to fluid accumulation in your lungs and pneumonia. You were treated with antibiotics and diuretics and your breathing improved. You remain very weak, which sometimes happens after being as sick as you were. You are going to [**Hospital3 2558**] to receive physical therapy and get stronger. . The following changes were made to your medications: - START ethacrynic acid 50 mg daily. This is a diuretic. If you become dehydrated or your kidney function worsens, this medication should be stopped. - START potassium supplement. Please get your electrolytes checked in 2 days and have the dose adjusted as needed. You can stop this medication when you stop the ethacrynic acid. - STOP lisinopril. Your blood pressure is low. If your blood pressure recovers this medication can be slowly restarted - DECREASE metoprolol to 12.5 mg twice a day. Your blood pressure remains low. If it improves, you may slowly increase to your prior home dose. - STOP metformin and START insulin therapy. If your blood sugars remain elevated and your kidney function remains good, you may restart metformin and decrease your insulin dose. - START heparin to decrease your risk of blood clots until you are more mobile. - START albuterol as needed for shortness of breath - START dextromethorphan and guiafenesin as needed for cough . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], when you are ready to leave [**Hospital3 2558**]. . Please also follow-up with your cardiologist within the next [**11-23**] weeks.

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icd9cm

[ [ [] ] ]

[ "38.91", "33.29", "96.04", "38.97", "96.72", "89.45", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

17207, 17277

10138, 15091

294, 368

17604, 17604

4819, 4819

19305, 19551

3763, 3878

15645, 17184

17298, 17375

15117, 15622

17780, 19282

6042, 7056

3893, 3893

17396, 17583

7094, 9015

4548, 4800

235, 256

396, 3184

9024, 10115

4835, 6026

3907, 4534

17619, 17756

3206, 3536

3552, 3747

55,334

191,262

30311

Discharge summary

report

Admission Date: [**2104-10-6**] Discharge Date: [**2104-10-16**] Date of Birth: [**2030-11-2**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 30**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Blood transfusions Fresh frozen plasma transfusions History of Present Illness: 73 yo M with ESRD on HD, severe PVD s/p multiple interventions, PUD/GERD, past RA thrombus on coumadin, who presents from routine HD with BRBPR. The patient states that he otherwise felt well today when he had a large bloody BM during HD. He denies dizzyness, lightheadedness, CP, abd pain, n/v when this occurred. He states that prior to this he had been having regular brown BMs frequently which he attributed to C. diff. He denies any black or tarry stool at that time, or pain with bowel movements. His vital signs were reportedly stable at that time, but he was referred to [**Hospital6 19155**] for further evaluation. . At the OSH, initial VS HR 64, BP 140/68. Orthostatics were 157/67->147/68, HR 53->76. He was noted to have another episode of BRBPR with clots. Initial labs with Hct 38.9 9lats Hct 40 per record), INR 15.4 (last INR 2.7 on [**9-30**]). IV access was attempted multiple times by surgery, including LIJ, LSC line unsuccessfully. Ultrasound showed narrowing/stenosis. RIJ could not be performed given tunneled R HD line. Groin line unable to be performed given extensive PVD and surgical history. A 20 guage PIV was obtained and patient was transferred to [**Hospital1 18**]. Out OSH, INR found to be 15.4. No record that patient received FFP or Vitamin K. . On arrival, pt had additional moderate sized BRBPR with clot. He otherwise feels well and denies any complaints except for fatigue. He denies f/c, HA, lightheadedness, CP, SOB, n/v, abd pain, rectal pain, swelling, rash. His vitals were BP 156/64, HR 52, RR 20, 98% on RA. His INR was found to be 9.0, so he was given 10 mg of Vit K and 2 units of FFP. After discussion with the GI fellow, decision was made to further monitor patient in the ICU. Past Medical History: ESRD on HD PVD (see below) GERD/PUD [**3-1**] ASA -> EGD [**10-4**] with ulceration of posterior wall ? MDS Hyperlipidemia HTN h/o C.diff DM2 Prostate ca s/p XRT RCC s/p Nephrectomy RA thrombus in [**5-5**] Blood dyscrasian, on hydrea h/o dialysis catheter thrombosis . PSH (taken from vascular notes): 11/12 L CFA thromboendarterectomy w/ patch profunda plasty, L EIA stenting [**2103-10-30**]- Redo right interposition tube graft between external iliac artery and profunda femoral artery with 8 mm Dacron tube graft, Reopening of previous incision on right groin, release of contained hematoma and repair of leak at the distal anastomosis between Dacron tube graft and profunda femoral artery on the right [**2103-10-16**]- diagnostic angio, Right common iliac plaque seen on prior angiograms, Occlusion of the Dacron graft distal to the take-off of the right internal iliac artery. There is reconstitution of the right profunda femoral artery. Complete occlusion of the superficial femoral artery and popliteal artery with only a small 1 cm opening in that popliteal vessel. Reconstitution of the posterior tibial artery which continues down to the foot with a short 1 cm occlusion in the mid leg. There is no DP artery in the foot. There is a large posterior tibial artery with collaterals in the foot. [**2103-8-20**]- L jump graft. From the in-situ bypass from above the knee to below the knee to a posterior tibialis. [**2103-7-27**]- percutaneous balloon angioplasty of a left external iliac in-stent restenosis, percutaneous balloon angioplasty of the distal external iliac and proximal common femoral arteries, percutaneous balloon angioplasty of distal femoral to posterior tibialis in situ bypass graft and distal anastomoses, stent placement within the distal bypass graft [**2103-4-30**]- Resection of common femoral artery aneurysm with 8 mm Dacron graft from the external iliac artery to the profunda artery [**2103-4-12**]- Left femoral endarterectomy with Dacron patch angioplasty, left in situ femoral to posterior tibialis bypass graft [**2103-4-11**]- left external iliac artery stent, left external iliac artery percutaneous angioplasty R nephrectomy (hydronephrosis), tunneled dialysis cath Social History: Lives alone and semi-independent with wheelchair. Smokes 1ppd x50 yrs. Denies EtOH use Family History: noncontributory Physical Exam: VS: BP 156/65, HR 56, RR 18, 99% on RA Gen: awake, alert, talkative, NAD HEENT: EOMI, anicteric sclera, MM moist, OP clear Neck: supple, central line attempts dressed, R tunneled HD line intact Lung: CTAB no wheezes or crackles Heart: RRR nl S1 S2 no m/r/g Abd: thin, soft, NT/ND +BS, no rebound or guarding, no masses Back: no CVA tenderness Rectal: normal rectal tone, no stool in vault though exam limited by patient cooperation, dried red blood externally, no obvious bleeding in external structures Ext: no pitting edema, warm Skin: no rash Pertinent Results: ADMIT LABS: 139 | 103 | 41 / --------------- 84 5.0 | 23 | 5.9 \ . .. .. \ 12.1 / 6.5 ------ 487 .. / 37.5 \ . PT 72.5 PTT 48.9 INR 9.0 . IMAGING: [**2102-10-24**]. EGD. 1cm duodenal ulcer with clot . Echo. [**5-5**] Left ventricular cavity size and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. A mass is seen in the right atrium measuring 3.0 x 1.4 cm. The mass appears to be attached to the eustachian valve or may be a prominent eustachian valve . No vegitation is seen in the tricuspid, aortic or mitral valves. The pulmonic valve was not adequately visualized. Mild (grade I) diastolic dysfunction. No atrial septal defect is seen by 2D or color Doppler. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. Trivial mitral regurgitation is seen. There is no pericardial effusion. . Stress test. [**2103-7-31**]. IMPRESSION: No anginal type symptoms or ischemic EKG changes. Nuclear report sent separately. Brief Hospital Course: STUDIES: ABD U/S: 1. Patent hepatic vasculature. 2. Increased echogenicity of the portal triads, a nonspecific finding. While this finding may be seen in acute hepatitis as well as other entities, it can be considered a normal variant as well. Please correlate clinically. The liver contour is not nodular and there are no signs of portal hypertension to suggest cirrhosis. PICC LINE CULTURE: Negative HD CATHETER CULTURE: Positive for staph . #. GI bleed. No brisk bleeding while in ICU, one episode of BRBPR afternoon of [**10-7**]. INR now down to 2.0-2.7, Hct has remained stable on transfer. Patient is prepped for colonoscopy but will not be done prior to transfer given supratherapeutic INR. Tagged RBC scan showed delayed bleeding in LLQ, no indication for emergent angio, especially given PVD. Underwent golytely prep prior to transfer to floor. Ddx includes bleeding in sigmoid/rectum as pt s/p radiation for prostate cancer vs diverticulum vs AVM. Pt also with h/o duodenal ulcer but sxs and imaging more c/s with lower GIB. GI, vascular [**Doctor First Name **], and general surgery have been following patient. Patient was not emergently taken to angio or colonoscopy/flex sig. Had bleeding study that showed bleeding from rectum. Plavix and coumadin held. Colonoscopy later showed two non-bleeding rectal ulcers and radiation proctitis. Pathology showed normal mucosa with no evidence of IBD. Patient's diet was advanced and his hct remained stable. He experienced no further episodes of melena/BRBPR. His hct on dc was 38.6 and stable. . #. Anticoagulation. Patient noted to have a RA thrombus in [**5-5**]. As outpatient, was anticoagulated with coumadin. Found to have supratherapeutic INR to 9 on admission which has been reversed to 2-2.7 with PO vitamin K and FFP. Started on heparin drip when INR <2. After procedures was bridged back to coumadin. However after TTE was negative for right atrial thrombus the heparin drip was turned off and coumadin was d/cd as the patient no longer had a reason to be anticoagulated and was at high risk of further bleeding from the GI tract. . #. ESRD on HD. Continued on home HD schedule (MWF). Continued on nephrocaps, renvela. HD catheter replaced over wire on [**2104-10-10**] and subsequently found to be leaking a few days later so was changed over a wire. The catheter tip subsequently grew staph on culture. He was treated with IV vanco per HD protocol. . #. HTN. Antihypertensives (nifedepine, atenolol, lisinopril) held in context of GIB. Then restarted slowly. . #. Bacteremia: Patient had fever and blood cultures showed coag negative staph sensitive to Vancomycin in [**5-2**] bottles. Started on Vanco for a course of 14 days. Source was presumed to be the HD line. The PICC line was pulled and cultured with no growth. The HD line was changed over a wire and culture results showed staph on the tip. As the patient has such difficult access this was felt to be the best approach. He may need a replacement HD catheter placed eventually if he has persistent bacteremia although subsequent blood cultures taken here since the catheter was changed show no growth to date. . #PVD: Held plavix in setting of GIB. Vascular surgeons thought no change to foot. In setting of bacteremia had foot XR that showed no evidence of osetomyelitis and vascular surgery felt the foot had not changed in appearance. He was restarted on his plavix as Dr. [**Last Name (STitle) 1391**] felt it was necessary to keep his stents patent. . #. H/o C. Diff. Per patient, currently on Flagyl for C. diff. In our system, had positive cdiff in 1/[**2104**]. Patient's PCP was called and had not placed patient on long course of flagyl. CDiff cultures X 3 were negative. Flagyl was d/cd. . #. Hyperlipidemia. continued on pravastatin . #. Possible Blood Dyscrasia/thrombocytosis. Patient on hydrea as outpatient which was continued as an inpatient. He will follow up with his hematologist as an outpatient for further management. . #. Diabetes. Maintained on insulin sliding scale . #.Chronic foot pain. continued on amytriptyline and percocet. . #. Atrial tachycardia: Patient had several episodes of acute tachycardia felt to be sinus tach vs atrial tachycardia usually associated with volume depletion after HD. His electrolytes were kept wnl and the dose of his beta blocker was increased with good effect. The patient remained asymptomatic with stable blood pressures and mentation throughout all episodes of the tachycardia. His beta blocker was up-titrated and he was sent home on toprol XL 50mg daily. Medications on Admission: Plavix 75 mg daily Atenolol 25 mg daily Folic Acid 1 mg daily Nifedipine 30mg daily Omeprazole 30 mg daily Renvela 1600mg TID Lipitor 10 mg daily Nephrocap 1 cap daily Percocet 1 tab TID prn Coumadin 5mg daily --has not refilled since [**7-6**] Hydrea 500mg daily -- has not refilled since [**8-5**] Lisinopril 20mg daily --has not refilled since [**8-5**] Amitriptyline 25mg daily --has not refilled since [**8-4**] Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed. Disp:*20 Tablet(s)* Refills:*0* 5. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 8. Renvela 800 mg Tablet Sig: Two (2) Tablet PO three times a day. Disp:*180 Tablet(s)* Refills:*2* 9. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Amitriptyline 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 11. Vancomycin 1000 mg IV HD PROTOCOL please give after HD every other day 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital3 **]Hospice Discharge Diagnosis: Lower GI bleed from rectal ulcers and radiation proctitis. Atrial tachycardia. Coagulase negative bactermia from HD catheter line Discharge Condition: The patient was normotensive, not tachycardic, afebrile, and with a stable hematocrit for >24hours before discharge. Discharge Instructions: You were admitted to the hospital with bleeding from your rectum. This bleeding likely happened because your blood was too thin. Your plavix and coumadin were not given to you and you were given clotting factors and vitamin K to help your blood thicken. You then had a colonoscopy that showed the bleeding was from two ulcers in your rectum and possibly from injury to your rectum caused by radiation. You had an ultrasound of you heart to look for the clot in your heart. We did not see the clot in your heart so we have stopped your coumadin. You no longer need to take it. While you were here you were continued on your hemodialysis treatments every other day. Your dialysis catheter needed to be exchanged and this was done. You had a fever from an infection in your blood that came from your dialysis catheter. You have been given antibiotics for this infection and should continue these antibiotics for four weeks. Your hemodialysis doctor will give you these medicines when you go for your dialysis treatments. MEDICATION CHANGES: CHANGE: Omeprazole 30mg by mouth daily to omeprazole 40mg by mouth daily STOP: Coumadin STOP: Atenolol STOP: Nifedipine STOP: Lisinopril START: Toprol XL 50mg by mouth daily START: Vancomycin each time you go to dialysis they will dose this for you and you should continue this for 4 weeks. You should call your doctor or come to the emergency room if you experience light-headedness, dizziness, chest pain, shortness of breath, worsening foot pain, fevers, blood in your stool or black tarry stools, or any other concerning symptoms. Followup Instructions: Please followup with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 19154**] next wednesday [**2104-10-22**] at 10:45am. Please continue your hemodialysis treatments at your regular clinic on Mondays, Wednesdays, and Fridays once you are discharged from the hospital. Your nephrologist should check your vancomycin level on [**2104-10-17**] when you go to HD. Please follow up with your hematologist/oncologist, Dr. [**Last Name (STitle) 1492**], Thursday [**10-30**] at 3:00pm. Fax [**Telephone/Fax (1) 72156**] Completed by:[**2104-10-16**]

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icd9cm

[ [ [] ] ]

[ "38.95", "38.93", "99.07", "99.04", "39.95", "45.25" ]

icd9pcs

[ [ [] ] ]

12359, 12413

6188, 10757

295, 348

12586, 12704

5069, 6165

14330, 14894

4471, 4488

11227, 12336

12434, 12565

10783, 11204

12728, 13749

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13769, 14307

228, 257

376, 2112

2134, 4351

4367, 4455

14,520

179,868

4208

Discharge summary

report

Admission Date: [**2184-12-8**] Discharge Date: [**2184-12-17**] Date of Birth: [**2135-1-27**] Sex: F Service: MEDICINE Allergies: Heparin Agents / Augmentin / Lisinopril / Metoprolol Attending:[**First Name3 (LF) 8263**] Chief Complaint: GIB Major Surgical or Invasive Procedure: none History of Present Illness: This is a 49 y.o female with h.o HTN, ESRD on recent PD, sarcoid, chronic pancreatitis, HL, epilepsy, anemia and angioectasias of the stomach/colon who presents with fever/chills to 101.6 last night, decreased po intake, R.shoulder pain since insertion of tunneled HD catheter yesterday-uncomplicated per pt, supposed to start HD tomorrow, generalized weakness/aching, SOB x3months with acute worsening over last day, cough over last few weeks with yellow phlegm with acute worsening over last few days, orthopnea, +dry heaves over last few months. Pt also reports L.lower back/tightness/pressure without radiation or paresthesias. Pt states she has had this for months but also acutely worsening over the last day. However, pt denies sick contacts,headache/LH/dizziness/blurred vision, rhinorrhea, ST, CP, palpitations, abd pain/n/v/d/c/melena/brbpr, dysuria/ hematuria (makes urine), joint pain, skin rash, paresthesias. . In the [**Name (NI) **], pt found to have HCT drop, 27 on [**11-16**] and 16.3 on admit. quaiac + brown stool. GI aware, recommends transfusion and possible scope in AM. S/P 2 units PRBCs/pantoprazole. Renal aware, did not want CTA, recommended v/q scan. For suspected infection, pt given vanco/levoquin. Most recent vitals Tm 100.4, BP 134/79, HR 90 (105 max), sat 100% on RA. . Currently, pt reports, soreness at R.tunneled HD, weakness, L.lower back pain. . Past Medical History: HIT HTN ESRD on PD, now HD sarcoid epilepsy chronic pancreatitis HL secondary hyperparathyroidism HL anemia angioectasias of the stomach and colon. . Social History: Lives at home with husband. 4 children, 3 grandchildren. She does not smoke, use alcohol or drugs. She is a previous substance abuse counselor. She is currently on medical disability due to her multiple medical illnesses. Family History: father-kidney failure 70 mother-HTN, breast ca, dx 68 uncle-kidney resection Physical Exam: On presentation: vitals: Tmax 100.4 BP 148/87, HR 89, RR 22, sat 93% RA GEN: sitting in bed, appears stated age, NAD, appears lethargic, but arousable and answering questions appropriately. HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, dry MM, OP Clear NECK: supple, ex JV distended, JVP to thyroid cartilage, no LAD chest:b/l ae +bibasilar crackles, no w/r heart:s1s2 rrr 4/6 systolic flow murmur throughout precordium abd: +well healed midline surgical scar, +PD catheter LLQ, +bs, soft, NT, ND, no masses. ext: no c/c/trace pitting edema 2+pulses. neuro:aaox3, cn2-12 intact, non-focal skin:dry, without rashes. . Pertinent Results: [**2184-12-8**] 10:10AM WBC-5.6 RBC-1.97*# HGB-5.5*# HCT-17.4*# MCV-89 MCH-28.1 MCHC-31.7 RDW-17.5* [**2184-12-8**] 10:10AM NEUTS-84.0* LYMPHS-10.7* MONOS-3.6 EOS-1.2 BASOS-0.5 [**2184-12-8**] 10:10AM PLT COUNT-319 . [**2184-12-8**] 10:10AM PT-14.6* PTT-32.3 INR(PT)-1.3* . [**2184-12-8**] 10:10AM GLUCOSE-107* UREA N-64* CREAT-12.5*# SODIUM-135 POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-20* ANION GAP-24* [**2184-12-8**] 10:14AM LACTATE-2.8* . [**2184-12-8**] 11:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2184-12-8**] 11:00AM URINE RBC-0-2 WBC-[**3-31**] BACTERIA-NONE YEAST-NONE EPI-0 . [**2184-12-8**] 12:15PM HGB-5.1* HCT-16.3* [**2184-12-9**] 12:01AM BLOOD WBC-4.4 RBC-2.59*# Hgb-7.5*# Hct-22.7*# MCV-88 MCH-28.9 MCHC-33.0 RDW-16.2* Plt Ct-213 [**2184-12-9**] 03:34AM BLOOD WBC-4.9 RBC-3.07* Hgb-9.1* Hct-26.6* MCV-87 MCH-29.7 MCHC-34.4 RDW-17.0* Plt Ct-215 [**2184-12-9**] 03:36PM BLOOD Hct-28.7* [**2184-12-9**] 08:21PM BLOOD Hct-29.1* [**2184-12-10**] 03:59AM BLOOD WBC-5.1 RBC-2.82* Hgb-8.2* Hct-24.2* MCV-86 MCH-29.1 MCHC-33.9 RDW-17.1* Plt Ct-217 [**2184-12-10**] 05:30PM BLOOD Hct-31.4*# . [**2184-12-8**] CXR: No pneumothorax. Stable cardiomegaly, right pleural effusion and background pulmonary parenchymal changes of sarcoidosis. . [**2184-12-8**] LENIs: No evidence of DVT. . [**2184-12-9**] CT Chest: 1. No evidence of mediastinal hematoma. 2. Small, likely partially loculated right pleural effusion, without evidence of hemorrhagic component. 3. Focal superior segment right lower lobe opacity, which may be due to atelectasis, aspiration, or early infectious pneumonia. 4. Slight increase in right pericardial lymph nodes with otherwise unchanged lymphadenopathy. Widespread pulmonary changes of sarcoidosis are unchanged. . [**2184-12-9**] CT Abd/Pelv: Brief Hospital Course: # Anemia - Pt's baseline HCt appears to be 26-30. Arrived at ED with Hct of 16.3. Likely secondary to bleeding, could be a slow GIB given h.o angioectasias and guaiac +stool. CT CHEST/Abd/Pelv ruled out intrathoracic/abdominal bleeding and confimend HD tunnel line in place. GI deferred scope as this was likely a slow bleed. She received HD x2 with 3 L take off each time and total of 3 U PRBC given. Addtionally DDAVP was given for uremic platlets. Her Hct bumped appropriately. . # Fever/chills - Likely related to infection. Patient complained of mild dry cough prior to admission. CT chest with ? early pna. Abx were peeled off, but it was decided that she should complete a course of Levofloxacin for ? PNA vs Bronchitis. . #SOB - was a first thought be a combination of PNA, fluid overload and sarcoid flare. Treated with Levofloxacin for PNA, HD for pulm edema. Pulm was consuted. Her shortness of breath was thought to be secondary to pulmonary hypertension of unclear etiology. She had had a VQ scan earlier this year which was negative for PE and thus pulmonary thought that it was less likely to be secondary to this. Her oxygen level decreased to 82% on RA after walking the entire loop of the nursing station. Her oxygen level was titrated and she required 6L with amublation to maintain an oxygen saturation of 92%. She was started on sildenafil 25 mg tid after HD which she tolerated well. On discharge home she was switched to revatio with strict instructions to monitor her blood pressure prior to taking it and to hold this medication prior to dialysis. She has selected to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of pulmonary. . #ESRD - Pt formerly on PD and HD started the second day of admission. She underwent HD daily to attain euvolemia. Towards the end the patient weight 127 lbs which she claimed was close to her dry weight of 126 lbs. She was continued on sevelemer and a renal diet. . # RUE/Breast swelling: was though to be from obstruction of SVC [**2-28**] to RIJ HD catheter placement. Her breast swelling improved slightly with daily HD but it was still present at discharge. A right upper extremity US was negative for DVT. She knows that she must discuss this with her NP[**MD Number(3) 18184**] appointment on [**12-27**] to faciliate further evaluation such as a mammogram and an ultrasound. Of note we avoided additional studies involving contrast as the patient has some renal function left which is critical for her to be able to eventually return to peritoneal dialysis. . # Medication reconciliation: Upon performing medication reconciliation prior to d/c it was observed that her ursodiol had been held. Careful review of the chart was unrevealing apart from a transaminits but per micromedix ursodiol does not cause increased liver function tests. I discussed this in detail with her and she will discuss this with her NP and gastroenterologist on [**12-27**] and [**12-28**]. . #HTN - initially held antihypertensives and restarted them as needed. . # Epilepsy - Continued home lamictal, lorazepam prn. . # FEN: renal diet. . # Access-2 PIVs, HD catheter . # PPx:PPI, bowel reg, spirometry, venodynes, NO HEPARIN . # Code:full discussed and confirmed with patient. . Dispo: Discharged home at her request with services: HHA, PT, [**Name (NI) 269**]. Medications on Admission: albuterol 1-2 puffs q6hrs lasix 40mg, 2.5tabs [**Hospital1 **] hydroxyzine 25mg [**Hospital1 **] lamotrigine 200mg [**Hospital1 **] lorazepam 0.5mg QHSprn seizure losartan 50mg, 3 tabs [**Hospital1 **] moxifloxacin 400mg daily for 7 days [**12-6**] nifedepine 60mg SR [**Hospital1 **] protonix 40mg daily sevelamer 800mg, 3 tabs, TID urodiol 300mg TID colace 100mg daily Discharge Medications: 1. Oxygen 2-4L continuous, pulse dose for portability. 2. Revatio 20 mg Tablet Sig: One (1) Tablet PO three times a day: Please check your blood pressure prior to taking this medication and hold it for a blood pressure < 110. . Disp:*60 Tablet(s)* Refills:*2* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Losartan 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Tablet Sustained Release(s) 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] [**Location (un) 269**] Discharge Diagnosis: Primary diagnosis: Pulmonary Hypertension Right ventricle dilatation Angioectasias of the colon Secondary Diagnoses: HIT - Heparin Induced Thrombocytopenia Hypertension End Stage Renal Disease Sarcoid Epilepsy Chronic pancreatitis Secondary hyperparathyroidism Anemia Angioectasias of the stomach and colon. End Stage Renal Disease Discharge Condition: Good, ambulating without difficulty. Discharge Instructions: You were admitted with fevers, anemia, cough and shortness of breath. You were seen by the pulmonologist/lung doctors who determined that your symptoms were consistent with worsening pulmonary hypertension of unclear origin. Given that you were started on revatio three times per day which you tolerated well while in the hospital. Please check your blood pressure prior to taking it and don't take it if the the top number is <110. Please hold it prior to dialysis. If you experience fevers, chills, nausea, vomiting, shortness of breath, chest pain, abdominal pain or other symptoms that concern you please seek urgent medical attention. When you walk around, your oxygen level is low. Please use 6L of oxygen when you walk around. Avoid flammatory substances when using oxygen. Your ursodiol was held while in the hospital for unclear reasons. Please dicuss re-starting it with your PCP and [**Name9 (PRE) 18306**] on [**12-27**] and [**12-28**]. Your liver function tests are elevated and thus we should clarify with them prior to re-starting this medication. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2184-12-27**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18307**], MD Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2184-12-28**] 11:30 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2185-1-4**] 8:40

[ "569.85", "611.72", "289.84", "585.6", "345.90", "416.0", "466.0", "403.91", "280.0", "577.1", "428.32", "486", "428.0", "537.83", "135" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

9637, 9714

4807, 8164

318, 324

10090, 10129

2926, 4784

11244, 11677

2174, 2253

8586, 9614

9735, 9735

8190, 8563

10153, 11221

2268, 2907

9852, 10069

275, 280

352, 1741

9754, 9831

1763, 1915

1931, 2158

5,604

132,833

15411

Discharge summary

report

Admission Date: [**2161-2-11**] Discharge Date: [**2161-2-27**] Date of Birth: [**2099-8-6**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old male with coronary artery disease (status post coronary artery bypass graft, status post myocardial infarction, status post coronary artery bypass graft in [**2153**]), end-stage renal disease (on hemodialysis), type 2 diabetes mellitus, and peripheral vascular disease who presented to Vascular Surgery on [**1-29**] with bilateral gangrenous feet status post bilateral iliac stents on [**2-7**] with a plan for bilateral below-knee amputations. The patient had intermittent ventricular tachycardia. Electrophysiology Service was consulted, and the patient was started on amiodarone. The patient was planned for catheterization on [**2-12**] before undergoing bilateral below-knee amputation. During the procedure for a stent to the saphenous vein graft to the posterior descending artery, the patient had an acute no reflow ST-elevation myocardial infarction with an inferior and posterior myocardial infarction. The patient was treated with medical management. Then, on [**2-15**], the patient had a hematocrit drop from 29 to 24. A computed tomography scan showed a right groin hematoma with questionable right hemothorax. The patient was subsequently transferred to the Coronary Care Unit. During his Coronary Care Unit stay, he had repeated episodes of ventricular tachycardia. Electrophysiology decided he was not a candidate for ablation or a pacer, and he was medically treated with amiodarone and mexiletine. PAST MEDICAL HISTORY: 1. Methicillin-resistant Staphylococcus aureus. 2. Coronary artery disease; status post myocardial infarction in [**2152**]. 3. Coronary artery bypass graft in [**2153**]; status post percutaneous transluminal coronary angioplasty of saphenous vein graft to right posterior descending artery in [**2159-8-19**]. 4. Congestive heart failure (with an ejection fraction of 30% to 35%) and moderate-to-severe mitral regurgitation, moderate pulmonary hypertension, akinesis of the basal, inferior, and lateral walls. 5. Type 2 diabetes mellitus. 6. Hypertension. 7. End-stage renal disease (on hemodialysis). 8. Gastroesophageal reflux disease. 9. Morbid obesity. PAST SURGICAL HISTORY: 1. Status post left common femoral artery to posterior tibial. 2. Coronary artery bypass graft times six in [**2153**]. 3. Left iliac to posterior tibial artery. 4. Status post angio with coronary angio ablation. ALLERGIES: ACE INHIBITOR (leads to nausea), NEURONTIN (leads to shakes), question of a NONSTEROIDAL ANTIINFLAMMATORY DRUGS allergy. MEDICATIONS ON ADMISSION: 1. Tylenol. 2. Allopurinol 100 mg once per day. 3. Aspirin 325 mg once per day. 4. Calcium acetate 667 mg three times per day. 5. Plavix 75 mg once per day. 6. Clonazepam 0.5 mg twice per day. 7. Regular insulin sliding-scale. 8. Levofloxacin. 9. Lorazepam 1 mg q.6h. 10. Flagyl 500 mg q.8h. 11. Metoprolol 25 mg three times per day. 12. Miconazole powder. 13. Nephrocaps 14. Pravastatin 20 mg once per day. PERTINENT RADIOLOGY/IMAGING: Echocardiogram showed congestive heart failure with an ejection fraction of 25% to 30%, severe 4+ mitral regurgitation, and 2+ tricuspid regurgitation. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 98, his heart rate was 62, his blood pressure was 83/25, his respiratory rate was 19, and 100% on 4 liters. In general, a morbidly obese male in no apparent distress. Alert and oriented times three. Skin revealed bilateral gangrenous toes in boots. Cool distal extremities. Signs of peripheral vascular disease. Head, eyes, ears, nose, and throat examination revealed the extraocular movements were intact. The pupils were equal, round, and reactive to light. Heart revealed a regular rate without murmurs. The lungs were clear to auscultation bilaterally. The abdomen was obese, soft, nontender, and nondistended. There were good bowel sounds. PERTINENT LABORATORY VALUES ON PRESENTATION: Most recent laboratories from [**2-27**] revealed his white blood cell count was 7.8, his hematocrit was 30.8, and his platelets were 119. Sodium was 138, potassium was 4.5, chloride was 96, bicarbonate was 31, blood urea nitrogen was 32, creatinine was 4.9, and blood glucose was 164. Calcium was 8.8, phosphate was 3.9, and magnesium was 2. BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. NONSUSTAINED VENTRICULAR TACHYCARDIA ISSUES: The patient was loaded with amiodarone and then placed on 400 amiodarone orally three times per day which he was to continue for four more days. He will then be switched to amiodarone 400 mg twice per day. He was also started on mexiletine 150 mg twice per day after lidocaine intravenous drip was found to be successful for reducing the amount of nonsustained ventricular tachycardia. The Electrophysiology Service felt that he was not a candidate for an implantable cardioverter-defibrillator or an ablation procedure and the he should be controlled medically with amiodarone and mexiletine. 2. PERIPHERAL VASCULAR DISEASE ISSUES: The patient was scheduled to undergo bilateral below-knee amputations for dry gangrene. This has been rescheduled because of the inferior myocardial infarction that the patient had. He was to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] (telephone number [**Telephone/Fax (1) 1393**]) by calling to schedule an appointment for three weeks. Prior to this appointment, the patient was to call the Radiology Department at [**Hospital1 69**] (telephone number [**Telephone/Fax (1) 44714**]) to schedule an aortogram and lower extremity arteriogram for evaluation prior to the bilateral below-knee amputations. This appointment for Radiology should attempted to be scheduled for next week. 3. INFERIOR MYOCARDIAL INFARCTION ISSUES: The patient was just to continue to be medically managed with aspirin and Plavix for his stent that he has received, pravastatin 20 mg twice per day. The patient had been on metoprolol 25 mg three times per day but was held and was not continued at this time for chronically low blood pressures of 80 to 90 but has hemodynamically stable and mentating fine during this admission. If his blood pressure starts to rise, we would recommend restarting his metoprolol at that time. 4. END-STAGE RENAL DISEASE ISSUES: The patient continued to have hemodialysis three times per week through his right fistula. He continued to take Nephrocaps and calcium acetate. 5. GOUT ISSUES: The patient continued to take allopurinol 100 mg once per day with no major problems. 6. ENDOCRINE ISSUES: The patient had a great reduction in his requirements for insulin while in the hospital because of a change in his diet. He was to be discharged on 15 units of Glargine and a Humalog sliding-scale. He normally had 60 units of Glargine at bedtime as an outpatient prior to this and took 12 units of Humalog with each meal. However, with the change in his diet he has needed less insulin. DISCHARGE STATUS: The patient to be discharged to a nursing facility. CONDITION AT DISCHARGE: The patient was able to feed himself but unable to walk or care for his activities of daily living. DISCHARGE DIAGNOSES: 1. Nonsustained ventricular tachycardia. 2. Inferior myocardial infarction. 3. Diabetes mellitus. 4. Peripheral vascular disease. 5. Dry gangrene. MEDICATIONS ON DISCHARGE: 1. Allopurinol 100 mg once per day. 2. Calcium acetate 667 mg three times per day (with meals). 3. Miconazole powder as needed. 4. Aspirin 325 mg once per day. 5. Plavix 75 mg once per day. 6. Trazodone 100 mg at hour of sleep. 7. Pravastatin 20 mg once per day. 8. Clonazepam 0.5 mg twice per day as needed (for anxiety). 9. Protonix 40 mg once per day. 10. Percocet 5/325-mg tablets one to two tablets q.4-6h. as needed (for pain). 11. Senna one tablet twice per day. 12. Amiodarone 400 mg three times per day times four days; please then switch his amiodarone to 400 mg twice per day. 13. Mexiletine 150 mg twice per day. 14. Multivitamin one tablet once per day. 15. Glargine insulin 15 units at bedtime. 16. Humalog sliding-scale. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] in the Vascular Surgery Department (telephone number [**Telephone/Fax (1) 1393**]) by calling for an appointment in three weeks. 2. The patient was instructed to call Radiology (telephone number [**Telephone/Fax (1) 44714**]) to schedule an aortogram and lower extremity arteriogram next week; to be performed prior to his appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] for evaluation of his lower extremity vasculature. Dictated By:[**Name8 (MD) 26705**] MEDQUIST36 D: [**2161-2-27**] 11:30 T: [**2161-2-27**] 12:36 JOB#: [**Job Number 44715**]

[ "427.1", "998.12", "414.02", "428.0", "440.24", "682.6", "410.31", "585", "997.1" ]

icd9cm

[ [ [] ] ]

[ "99.29", "39.90", "36.06", "93.90", "36.01", "37.22", "99.69", "99.04", "88.57", "99.07", "88.56", "39.95", "39.50" ]

icd9pcs

[ [ [] ] ]

7349, 7502

7529, 8290

2714, 4448

8323, 9050

2335, 2687

4482, 7212

7227, 7328

164, 1621

1643, 2312

5,191

138,987

630

Discharge summary

report

Admission Date: [**2165-3-31**] Discharge Date: [**2165-4-13**] Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1283**] Chief Complaint: worsening shortness of breath, dyspnea on exertion and edema Major Surgical or Invasive Procedure: s/p AVR(27mmCE pericardial), MV repair s/p tracheostomy History of Present Illness: Mr. [**Known lastname 1662**] has had a long standing murmur, had done well until 1 year PTA when he began developing SOB, DOE, orthopnea and pedal edema. Past Medical History: 1:aortic stenosis 2:mitral regurgitation 3:atrial fibrillation 4:s/p pacemaker insertion 5:h/o endocarditis 6:HTN 7:BPH 8:s/p R THR 9:s/p L TKR Pertinent Results: [**2165-4-12**] 02:15AM BLOOD WBC-10.5 RBC-3.30* Hgb-9.8* Hct-30.6* MCV-93 MCH-29.8 MCHC-32.1 RDW-13.4 Plt Ct-234 [**2165-4-12**] 02:15AM BLOOD Plt Ct-234 [**2165-4-12**] 02:15AM BLOOD PT-12.9 PTT-26.6 INR(PT)-1.1 [**2165-4-12**] 02:15AM BLOOD Glucose-110* UreaN-48* Creat-1.2 Na-133 Cl-88* HCO3-40* [**2165-4-12**] 11:25AM BLOOD Type-ART pO2-81* pCO2-59* pH-7.44 calHCO3-41* Base XS-12 Brief Hospital Course: Mr. [**Known lastname 1662**] was admitted to [**Hospital1 18**] [**3-31**] for pre operative anticoagulation. He was taken to the operating room on [**4-2**] with Dr. [**Last Name (STitle) **] for an AVR/MV repair. He tolerated the procedure well and was transferred to the ICU. He was weaned and extubated from mechanical ventilation on POD#1. He became oliguric despite adequate cardiac output and normal creatinine. He was started on dopamine and Natrecor. He was also noted to have worsening oxygenation and increased work of breathing. He was started on BiPAP with good results. He underwent a renal ultrasound which showed no hydronephrosis. He was given aggressive diuretic therapy which resulted in adequate urine output. His creatinine only minimally rose to 1.3 and he gradually required only minimal diuretics for adequate urine output. His respiratory status continued to be problem[**Name (NI) 115**] and he required BiPAP for several days. An ENT consult was obtained to rule out upper airway edema. A bedside fiberoptic exam showed an very large uvula and no airway edema. It was thought that the uvula was causing airway obstruction worsened by fluid overload and the decision was made to place a tracheostomy. He underwent tracheostomy on [**4-9**] with a #8 per fit trach placed without difficulty. He was weaned from the ventilator over the next day and was placed on trach mask with Passey Muir valve on [**4-11**]. An attempt to rest the patient on the ventilator made him uncomfortable and he requested to not be put back on. His arterial blood gasses showed adequate oxygenation and balanced acid base status. He was started on Coumadin after his tracheostomy for his atrial fibrillation and is cleared for discharge to rehab on [**4-12**] Medications on Admission: coumadin hytrin 2mg po qd lasix 80mg po qd MVI folate Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 11. Hytrin 2 mg Capsule Sig: One (1) Capsule PO once a day. 12. Coumadin 1 mg Tablet Sig: as directed Tablet PO once a day: goal INR 2.0-2.5. 13. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. 14. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 15. Folic Acid 400 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: aortic stenosis/mitral regurgitation s/p AVR/MV repair chronic atrial fibrillation s/p tracheostomy for enlarged uvula causing airway obstruction h/o PPM h/o endocarditis HTN BPH Discharge Condition: good Discharge Instructions: you may wash your incision with mild soap and water do not apply lotions, creams, ointments or powders to your incisions do not lift anything heavier than 10 pounds for 1 month do not drive for 1 month Followup Instructions: follow up with Dr. [**Last Name (STitle) **] in [**4-19**] weeks follow up with Dr. [**Last Name (STitle) 4829**] in [**3-21**] weeks follow up with you cardiologist Dr. [**Last Name (STitle) 4830**] in [**3-21**] weeks Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] for tracheostomy follow up upon discharge from rehab Completed by:[**2165-4-12**]

[ "997.3", "518.5", "427.31", "396.2", "401.9", "397.0", "V43.65", "507.0", "278.00", "V43.64", "V45.01" ]

icd9cm

[ [ [] ] ]

[ "96.05", "39.61", "93.90", "31.1", "35.12", "00.13", "35.21", "38.91", "96.6", "33.23", "96.72" ]

icd9pcs

[ [ [] ] ]

4325, 4404

1135, 2918

295, 353

4627, 4633

724, 1112

4884, 5264

3023, 4302

4425, 4606

2944, 3000

4657, 4861

195, 257

381, 537

559, 705

9,782

133,080

24441

Discharge summary

report

Admission Date: [**2120-4-11**] Discharge Date: [**2120-4-21**] Date of Birth: [**2041-5-28**] Sex: F Service: MEDICINE Allergies: Penicillins / Strawberry Attending:[**First Name3 (LF) 1642**] Chief Complaint: Unresponsive Major Surgical or Invasive Procedure: None History of Present Illness: 78 yo F with h/o paranoid schizophrenia, depression, CVA, hypothyroidism, spinal stenosis, h/o recent sepsis attributed to PNA presenting with unresponsiveness and acute respiratory distress in her NH. Per report, the patient was alert but nonverbal in the AM, and able to take breakfast and fluids well without signs of pain. At 12:45 PM, she vomited dark brown food, was noted to be quite diaphoretic, unreponsive with O2sat 73% non RA, 90% on 3L, T 101.4 and BP 70/40. At baseline, the patient can write, talk and walk on a walker. On admission to the ED, the patient's sats improved to 89% with deep suctioning. The patient is DNR/DNI, but her daughter who was not her HCP was unaware of her DNI wishes, and asked her to be intubated at that time. She was intubated in the ED and started on a sepsis protocol. She was given 5 L of fluid in the ED and a central line was placed. Her CVP was 17 after 4 L. She remained hypotensive and was started on levophed with improvement in her BP. A UA in the ED showed mod leukocyte esterase, + nitrites, > 50 WBC, many bacteria, [**11-4**] RBCs and 30 protein. She was given albuterol and atrovent nebs, vancomycin and ceftazidime, dexamethasone 10 mg x 1. Past Medical History: 1. CVA 2. GERD 3. Post herpetic neuralgia - Chronic pain began in [**11/2118**] following an episode of herpes zoster. 4. Polymyositis diagnosed in [**2113**]. 5. Hypothyroidism status post thyroidectomy 12 years ago for goiter. 6. Stress fracture, left thigh (femur). 7. Spinal stenosis. 8. Basal cell carcinoma. 9. Recurrent falls. 10. Paranoid schizophrenia, last hospitalization two years ago. 11. Depression. 12. Cholecystectomy. 13. Pneumonia. 14. urine incontince Social History: Lived in nursing home. Recently moved to [**Hospital3 **] facility. No history of smoking, alcohol, or recreational drug use. Walks with a walker. Independent in some activities of daily living, like toileting, feeding, walking, using telephone, etc. Needs assistance or is dependent on rest. Has 3 involved daughters. Family History: NC Physical Exam: T 97.5 BP 111/47 HR 62 RR 16 O2sats 100% on 600/16/5/0.6 Gen: Obese woman lying in bed intubated in NAD HEENT: PERRL Lungs: crackles on R side from chest Heart: RRR, nl s1, s2, no m/g/r Abd: BS+, soft, NT, ND Ext: [**12-18**]+ edema L > R Neuro: sedated Pertinent Results: AP CXR: No evidence of CHF or acute infiltrates. Resolution of left lower lobe infiltrate, which was present on the preceding examination of [**2120-1-30**]. EKG: 1400 - sinus tachy at 140, LAD, ST depressions in V5-V6, borderline long [**Year (4 digits) 5937**], poor R wave progression 1800 - NSR, slight LAD, poor R wave progression, borderline long [**Last Name (LF) 5937**], [**First Name3 (LF) **] depressions no longer present TTE [**1-22**]: Conclusions: 1. The left atrium is mildly dilated. The left atrium is elongated. The right atrium is moderately dilated. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 3.The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. 4.The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. 5. Moderate to severe [3+] tricuspid regurgitation is seen. 6.There is moderate pulmonary artery systolic hypertension. 25 to 50 mm Hg (nl <= 25 mm Hg 7.There is no pericardial effusion. Brief Hospital Course: 78 yo W with MMP p/w unreponsiveness and respiratory distress likely secondary to urosepsis and ? aspiration. . # Altered MS/Unresponsiveness - thought to be [**1-18**] E coli UTI, bacteremia and Sepsis, resolved with treatment of bacteremia. . # Sepsis - likely [**1-18**] to UTI and E coli bacteremia. Pt. was admitted to the ICU and initially resuscitated with pressors and IVF. Pt. was initially started on broad spectrum antibiotics with vanco, ceftazadime, flagyl and ampicillin as well as acyclovir for herpes to cover for meningitis, however when blood and urine cultures grew E coli antibiotics were narrowed to Ceftriaxone, to finish 2 week course on [**2120-4-24**]. Received 5 days of stress dose steroids for a failed [**Last Name (un) 104**] stim test (11.3 -> 10.9 -> 11.8). Respiratory status and BP improved, and pt. was extubated and weaned from pressors, and transferred to the floor for further care. Pt. continued to do well on the floor, breathing comfortably on RA with no further hypotension. Pt. was discharged on PO Keflex to finish the two week course. . # Elevated troponin: Patient found with marginally elevated troponins most likely secondary to hypotension with demand ischemia. Patient with recent TTE which showed significant valvular dz but otherwise normal wall motion and EF. - cardiac enzymes flat - continued on ASA - Lipid profile from [**1-22**] unremarkable with HDL of 65 and LDL of 75 - no need for statin - could consider outpatient stress test. . # Hypoxia: Thought to be secondary to sepsis with respiratory failure. Intubated for poor mental status and inability to protect airway. Extubated without complication on [**4-12**], no signs of respiratoy distress on the floor. . #. Chronic pain. Patient had b/l leg pain before admission as well as pain in side from post-herpetic neuralgia. She has spinal stenosis and is being scheduled for evaluation by her outpatient doctor. She had been having deterioration in her functional status before being admitted. - Restarted Neurontin (dose decreased [**1-18**] sedation), Lidoderm patch, added Oxycodone PRN with good pain control . # Hypothyroidism: Continued home Levothyroxine, TSH normal . # Paranoid Schizophrenia: Continued home Geodon . # Polymyositis: Stress dose steroids -> changed to home doses of Prednisone (7.5/2.5) prior to discharge. ## Communications: Dtr [**Doctor Last Name **] - HCP [**0-0-**] w [**Telephone/Fax (1) 61840**], [**Doctor First Name 7346**] [**Telephone/Fax (3) 61841**] cell, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 61839**] . Medications on Admission: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Ziprasidone HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO at bedtime: for a total of 1200 mg at night. 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 16. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 18. Risedronate 35 mg Tablet Sig: One (1) Tablet PO qSunday. 19. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 20. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 21. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 22. Insulin Regular Human 100 unit/mL Solution Sig: 1-20 units Injection ASDIR (AS DIRECTED): per insulin sliding scale. Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Risedronate 35 mg Tablet Sig: One (1) Tablet PO once a week. 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO QAM. 8. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 11. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 14. Ziprasidone HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 3 days. 16. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 17. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: UTI with Sepsis Paranoid Schizophrenia Depression GERD Hypothyroidism s/p Thyroidectomy Post-Herpetic Neuralgia Polymyositis Discharge Condition: Improved- no fevers for several days Discharge Instructions: Please call your doctor or go to the ER if you have any fevers, chills, pain with urination, abdominal pain, urinary urgency, chest pain, shortness of breath, or any other symptoms that concern you. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] at [**Hospital1 599**] (office phone # [**Telephone/Fax (1) 719**] with any questions) Completed by:[**2120-4-21**]

[ "995.92", "584.9", "710.4", "785.52", "518.81", "599.0", "053.19", "244.9", "285.9", "295.30", "041.4", "038.42" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10259, 10331

4101, 6723

298, 304

10500, 10539

2687, 4078

10786, 10956

2393, 2397

8765, 10236

10352, 10479

6749, 8742

10563, 10763

2412, 2668

246, 260

332, 1545

1567, 2040

2056, 2377

45,647

100,166

2995

Discharge summary

report

Admission Date: [**2200-2-24**] Discharge Date: [**2200-3-4**] Date of Birth: [**2123-2-5**] Sex: F Service: CARDIOTHORACIC Allergies: Nitroglycerin / Penicillins / Amoxicillin / Norvasc / Celecoxib / Adhesive Tape / Lovenox Attending:[**First Name3 (LF) 922**] Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: [**2200-2-25**] - Coronary artery bypass grafting to three vessels. (Saphenous vein graft->Diagonal artery, first obtuse marginal artery and second obtuse marginal artery. [**2200-2-24**] - left heart Catheterization,coronary angiogram History of Present Illness: This 77 year old white female has known coronary artery disease, having undergone stenting of the LAD and circumflex vessels in the past. She presented with recurrent angina elsewhere and ruled in for a non ST myocardial infaction with Troponin of 1.19. She was transferred here and underwent catheterization on [**2-25**]. Catheterization revealed osteal circumflex and subtotal in stent circumflex stenosis. LV function has been shown to be ~55%. She was referred for surgical revascularization. Past Medical History: hypertension hyperlipidemia noninsulin dependent Diabetes mellitus Moderate aortic stenosis Chronic atrial fibrillation Congestive heart failure in past Coronary artery disease with percutaneous interventions in past Anxiety Cerbrovascular disease-60-70% bilateral carotid arteries H/O breast cancer, s/p right lumpectomy and radiation H/O cervical cancer, s/p hysterectomy and radiation appendectomy cholecystectomy H/O multinodular goiter S/P removal of a pylonidal cyst S/P bilateral carpal tunnel surgery S/P bone spur removal Osteoarthritis coccyx ulcer - stage IV Social History: The patient currently lives alone. Her husband has alzheimer's disease and lives in a care facility. She has one son who is handicapped and a grandson. She quit smoking 35 years ago; previously 4 ppd. She does not drink alcohol or use ilicit drugs. Family History: Family history negative for premature coronary artery disease or sudden death. Mother died of complications from alcoholism. Father died of pneumonia. Grandmother died of colon cancer. Physical Exam: Admission: VS - 97.3, 100/74, 16, 95%RA Gen: WDWN elderly female in NAD. Oriented x3. Mood, affect appropriate. Patient lying supine post-cath. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple without lymphadenopathy. CV: Irregularly irregular, normal S1, S2. [**3-31**] holosystolic murmur loudest at the LUSB that radiates to both carotids. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi anteriorly. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: Brown skin changes around left lower leg. No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ Left: Carotid 2+ Femoral 2+ DP 2+ Pertinent Results: [**2200-2-24**] 04:45PM GLUCOSE-113* UREA N-11 CREAT-0.5 SODIUM-139 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-27 ANION GAP-11 [**2200-2-24**] 04:45PM ALT(SGPT)-18 AST(SGOT)-36 CK(CPK)-166* ALK PHOS-58 AMYLASE-16 TOT BILI-0.8 [**2200-2-24**] 04:45PM cTropnT-0.22* [**2200-2-24**] 04:45PM WBC-6.2 RBC-2.99* HGB-9.9* HCT-28.6* MCV-96 MCH-33.1* MCHC-34.6 RDW-14.7 [**2200-2-24**] 04:45PM WBC-6.2 RBC-2.99* HGB-9.9* HCT-28.6* MCV-96 MCH-33.1* MCHC-34.6 RDW-14.7 [**2200-2-24**] 04:45PM PT-17.2* PTT-31.9 INR(PT)-1.6* [**2200-2-24**] Cardiac Catheterization 1. Coronary angiography in this right dominant system revealed three vessel coronary artery disease. The LMCA had no angiographycally apparent coronary artery disease. The LAD was non-obstructed. The D1 had an ostial 80% lesion. The LCx had a subtotally occluded in-stent restenosis in the mid stent at the ostium of the vessel. The RCA was small caliber, with a 70% lesion proximally. 2. Resting hemodynamics revealed elevated left sided filling pressures with LVEDP of 20 mmHg. There was normal systemic arterial systolic and diastolic pressure with SBP of 109 mmHg and DBP of 72 mmHg. 3. There was a peak to peak transaortic gradient of 5 mmHg 4. Left ventriculography was not performed. [**2200-2-25**] ECHO The left atrium is mildly dilated. The left atrium is elongated. The right atrium is moderately dilated. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-27**]+) 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 to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2199-10-19**], the severity of mitral and tricuspid regurgitation has increased. Estimated pulmonary artery pressures are higher. Aortic stenosis is mild in severity. [**2200-3-2**] 06:13AM BLOOD WBC-9.7 RBC-3.01* Hgb-9.6* Hct-27.8* MCV-93 MCH-32.0 MCHC-34.6 RDW-16.0* Plt Ct-121* [**2200-3-3**] 05:04AM BLOOD PT-20.6* INR(PT)-1.9* [**2200-3-2**] 06:13AM BLOOD PT-19.8* PTT-30.8 INR(PT)-1.9* [**2200-3-1**] 05:30PM BLOOD PT-22.3* INR(PT)-2.1* [**2200-3-1**] 03:45AM BLOOD PT-20.0* PTT-35.0 INR(PT)-1.9* [**2200-2-28**] 02:10AM BLOOD PT-16.6* PTT-32.6 INR(PT)-1.5* [**2200-2-27**] 12:58AM BLOOD PT-16.3* PTT-31.4 INR(PT)-1.5* [**2200-2-26**] 03:09PM BLOOD PT-17.8* PTT-40.7* INR(PT)-1.6* [**2200-2-26**] 01:55PM BLOOD PT-18.0* PTT-34.4 INR(PT)-1.6* [**2200-2-26**] 02:20AM BLOOD PT-17.0* PTT-53.2* INR(PT)-1.5* [**2200-2-25**] 05:19PM BLOOD PT-16.8* PTT-80.5* INR(PT)-1.5* [**2200-2-25**] 05:10AM BLOOD PT-18.5* PTT-59.1* INR(PT)-1.7* [**2200-3-3**] 05:04AM BLOOD UreaN-22* Creat-0.6 Na-129* K-4.0 Brief Hospital Course: Ms. [**Known lastname 14330**] was admitted to the [**Hospital1 18**] on [**2200-2-24**] for a cardiac catheterization and further management of her myocardial infarction. A cardiac catheterization revealed two vessel disease with severe instent restenosis of her circumflex artery. Given the severity of her disease and the fact that she refused to take plavix, surgical revascularization was decided upon. Ms. [**Known lastname 14330**] was worked-up in the usual preoperative manner including a carotid ultrasound which showed mild right and moderate left internal carotid artery stenosis. Heparin was continued and she remained without chest pain. The wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] for assistance with her coccyx ulcer and appropriate dressings and barrier creams were applied. On [**2200-2-26**], Ms. [**Known lastname 14330**] was taken to the Operating Room where she underwent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. Over the next several hours, she awoke neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. Diuresis towards her preoperative weight was begun. The coccyx wound is being treated with Aquacel AG daily. Surgical wounds are clean and dry. Pacing wires and CTs were removed according to protocol. Bactroban was administered for MRSA positive nasal swab. Lopressor and digoxin were given and advanced for rate control of her chronic atrial fibrillation and diuretics were continued, to be so until she achieves her preoperative weight. STOP [**3-3**] Medications on Admission: ativan 3 HS, atenolol 25, lipitor 80, ASA 325, digoxin 0.125, lisinopril 40, colace, coumadin 2.5, januvia 100, magnesium oxide 400, lasix 40 and KCl 10 every other day, MVI Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Digoxin 250 mcg Tablet Sig: [**12-27**] alter w/ 1 tab Tablet PO EVERY OTHER DAY (Every Other Day). 11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 12. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. Warfarin 1 mg Tablet Sig: to be dosed per INR Tablet PO DAILY (Daily): Goal INR [**1-28**] INR 2.6 on [**3-4**]- no coumadin given. 14. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection Q12H (every 12 hours). 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass Hyperlipidemia Hypertension Atrial fibrillation non insulin dependent Diabetes mellitus Anxiety s/p Myocardial infarction Peripheral vascular disease Cerebrovascular disease Multinodular goiter Osteoarthritis h/o Cervical cancer Discharge Condition: deconditioned 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 from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 8725**] Please follow-up with Dr. [**Last Name (STitle) 1057**] in [**1-29**] weeks. [**Telephone/Fax (1) 14331**] Please call for appointments Completed by:[**2200-3-4**]

[ "272.4", "250.00", "427.31", "E878.8", "707.03", "428.0", "401.9", "996.72", "424.1", "E849.7", "443.9", "715.90", "428.32", "410.71", "707.24", "414.01", "458.29" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.22", "36.13", "88.53", "39.61" ]

icd9pcs

[ [ [] ] ]

9838, 9910

6467, 8148

375, 613

10234, 10250

3172, 6444

11049, 11406

2019, 2208

8373, 9815

9931, 10213

8175, 8350

10274, 11026

2223, 3153

314, 337

641, 1143

1165, 1737

1753, 2003

20,426

158,539

7323

Discharge summary

report

Admission Date: [**2161-6-8**] Discharge Date: [**2161-6-25**] Date of Birth: [**2091-5-12**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5266**] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: 1. PICC line placement History of Present Illness: Mrs. [**Known lastname 6314**] is a 70 yo female with MMP, including CHF with EF 30-35%,including PEG tube for achalasia & esophagitis, osteoporosis c/b compression fractures, and pituitary adenoma s/p radiation (last treatment [**2161-5-26**]) who presented from rehab w/ lethargy and fatigue. Patient is a poor historian and is only oriented to person and place. Complains only of back pain which she reports having for months. Denies CP, SOB, cough, abd pain, N/V, diarrhea, BRBPR, dizziness. Per written records & pt's brother report, patient had MI on [**5-27**] with a CK-MB of 7.[**Street Address(2) 27038**] elevations in V1-V3 per record but no labs or EKGs sent from rehab. Per rehab records, patient was on fluid restriction x24 hours on [**6-4**], then given lasix 100mg IV BID which was decreased to daily and was continued on fluid restriction of 1 liter. . In the ED, T 97.8, HR 94, BP 94/64 RR 24 96 % RA. She received 1 liter NS and levofloxacin 500 mg IV x1. . On the wards, pt found to have UTI (though UA notable only for [**3-16**] RBC & postive nitrites, only 0-2WBC). Urine cx growing Klebsiella & other unidentified gram (-) rod. She was tx'd w/ levo. Her SBP trended down from 90s-110s to 80s. Was initially responsive to IVF then non-responsive to it. She received >3.3: (was 2.5L (+)) over 24hr. She had low grade fevers ~99.8 and was reportedly more tired appearing, "less perky." Abx broadened to ceftaz & vanc. Again, pt w/o complaints. Reports feeling like usual self. Past Medical History: 1. Coronary artery disease with history of V. fib arrest, S/P LAD stent and repeat cath in [**10/2159**] The LAD had patent stnets with 50-60% proximal moderate instent restenosis. and Left ventriculography demonstrated extensive anteroapical and inferoapical akinesis and aneurysm with a contrast calculated ejection fraction of 26%. There was no mitral regurgitation. 2. CHF - EF 30-35% in [**2159**]. 3. Osteoporosis - early menopause, no history of hip fractures but verterbral compression fractures noted earlier this month. 4. Depression 5. History of colonic AVM and anemia of chronic blood loss 6. S/P Appendectomy 7. Hypertension 8. H/o achalasia, peptic stricture at EG junction 9. h/o TAH and bilateral oopherectomy in her 30s 10. Admission [**3-18**] for melena found to have Dilation at the lower third of the esophagus Grade 4 esophagitis in the lower third of the esophagus 11. s/p G tube placement 12. Per written records patient had MI on [**5-27**] with a CK-MB of 7.[**Street Address(2) 27039**] elevations in V1-V3 per record but no labs or EKGs sent Social History: Soc: Patient lives with her brother and sister-in-law. She has 60 pack-year tobacco history but quit 20 yrs ago; denies EtoH and drug use Family History: FHx - multiple members in the family with who has had early TAH and bilateral oopherectomy Physical Exam: T: 99.8 BP: 90/50 P: 88 RR: 18 O2 sats: 100 % on 2L Gen: cachetic appearing elderly female in NAD HEENT: MM mildly dry, OP clear Neck: no Cervical LAD, no JVD CV: RR, no m/g/r Resp: decreased BS w/ bibasilar crackles R>L Abd: G tube in place, site c/d/i; hypoactive BS, soft, NT/ND Back: lidoderm patch in place, mild tendernness to palpation of mid back, kyphotic GU: foley in place Ext: no edema, no calf tenderness, 2+ rad pulses b/l; PICC in L arm Neuro: Oriented to person and hospital but not date. Mild L facial droop. CN II-XII grossly intact, strength in b/l UE and LE [**4-16**] and symmetric, sensation to light touch intact Pertinent Results: [**2161-6-17**] 05:50AM BLOOD WBC-12.9* RBC-3.41* Hgb-9.2* Hct-27.2* MCV-80* MCH-26.8* MCHC-33.6 RDW-21.2* Plt Ct-321 [**2161-6-12**] 05:07AM BLOOD Neuts-93.2* Bands-0 Lymphs-3.9* Monos-2.7 Eos-0.1 Baso-0.1 [**2161-6-12**] 05:07AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL Macrocy-NORMAL Microcy-2+ Polychr-1+ Stipple-2+ [**2161-6-17**] 05:50AM BLOOD Plt Ct-321 [**2161-6-17**] 05:50AM BLOOD Glucose-93 UreaN-15 Creat-0.4 Na-135 K-4.4 Cl-105 HCO3-22 AnGap-12 [**2161-6-16**] 04:17PM BLOOD CK(CPK)-59 [**2161-6-16**] 04:17PM BLOOD CK-MB-NotDone cTropnT-0.13* [**2161-6-16**] 02:52AM BLOOD Calcium-8.1* Phos-1.4* Mg-2.0 [**2161-6-17**] 05:50AM BLOOD Vanco-10.0 [**2161-6-14**] 01:05AM BLOOD Lactate-1.0 Brief Hospital Course: 70 yo female with CAD, CHF, achalasia w/ PEG tube, pituitary adenoma s/p recent XRT, s/p klebsiella and steotrophomonas UTI and GPC bacteremia, flash pulmonary edema, probable ACS event, and L facial droop c/w ischemic stroke. . On the wards, pt found to have UTI (though UA notable only for [**3-16**] RBC & postive nitrites, only 0-2WBC). Urine cx grew pansensitive Klebsiella & Stenotrophomonas sensitive to Bactrim. She was tx'd w/ levo. Her SBP trended down from 90s-110s to 80s which was initially responsive to IVF and then unresponsive. She received >3.3L IVF in 24 hours (was 2.5L (+)). She had low grade fevers ~99.8 and was reportedly more tired appearing, "less perky" but was without complaints. Abx broadened to ceftaz & vanc. Given concern for potential early urosepsis patient was transferred to the MICU for further management on [**2161-6-12**]. In the MICU, blood cultures from [**6-12**] grew out pansensitive enterococcus as did her PICC tip. Source of her bacteremia unclear. She was continued on vanco, ceftaz, and flagyl (? aspiration on CTA chest) as well as Bactrim for stenotrophomonas. She had intermittent hypoxia thought to be due to CHF and pulm edema which was responsive to prn lasix. Also received short course of CPAP. Also intermittent hypotension responsive to IVF and holding of BP meds. Ddx sepsis vs. cardiogenic shock. On [**6-14**], patient had an episode of increased RR, increased O2 requirement, hypertensive requiring NTG gtt, lasix, lopressor, and morphine. EKG showed new TWI in inferior and precordial leads. CEs showed elevation w/ TnT peak of 0.15 (on [**6-15**], and [**6-16**]) as well as CK peak of 204 ([**6-14**]) and MB of 17 ([**6-14**]). Treated with asa/plavix, heparin given h/o GI bleeding and Hct drop. Received 1 unit PRBCs on [**6-15**] for Hct 21 w/ guiaic positive stools. At approximately the same time, patient developed a new L facial droop. Cardiology was consulted for NSTEMI and recommended medical management. Repeat TTE showd worsening LVEF . Neuro was consulted for L facial droop. CT head was negative for bleed. Carotid u/s negative for stenosis. MRI has not yet been obtained. Neuro attributed to toxic metabolic derangements vs. watershed infarct but no further intervention entertained. Most recently, has had intermittent sinus tachycardia. Today [**6-17**], received 20 mg IV lasix w/ brisk diuresis leading to tachycardia to 120s (baseline has been 90s-100s) which resolved back to baseline w/ 250 cc NS. Also attempted to increase beta blocker but systolic BPs dropped to 90s which returned to the 100s with IVF. Back pain has also [**Last Name 19301**] problem throughout admission on multiple pain medications and lidocaine patch. Currently, patient w/o complaint. Denies back pain, chest pain, SOB, abdominal pain, N/V, diarrhea. Breathing comfortably. . # Hypotension: baseline SBPs have been in 80s-100s. Pt's MS reportedly at baseline right now. DDx includes sepsis, cardiogenic hypotension. More likely cardiogenic given severely depressed EF. Patient currently afebrile with fluctuating but currently improving Completed 7 day course of ceftaz/bactrim for UTI. Hct stable following PRBC transfusion so less likely bleeding. Also unlikely adrenal insufficiency given random [**Last Name (un) 104**] of 21 ([**6-9**]). She was continued on antibiotics for her enterococcus bacteremia. She was started on low dose captopril, 3.125 mg QID which was decreased to TID due to more frequent low BPs in the 80s. However, she tolerated the TID dosing with BPs continuing in the 90s-100s without change in mentation. . # NSTEMI: cardiology consulted and recommended medical management. She was continued on asa, plavix, beta blocker, statin. She had no further evidence of ischemia following event and remained stable throughout remainder of course. . # CHF: EF <20% on TTE [**6-15**] with HK and akinetic walls. Anterior LV aneurysm as well. Tenuous volume status intermittently requiring lasix and IVF to manage hypotension in the ICU. Upon arrival to the floor, patient's volume status remained stable and only intermittently required small NS boluses for poor po intake and low SBPs into 80s (although always asymptomatic). Digoxin was started following drop in EF post NSTEMI. Low dose ace inhibitor started as described above. She was otherwise continued on her low dose beta blocker. She remained tachycardic in the low 100s. However, this was presumed necessary to augment her cardiac output given her poor stroke volume so there was no increase in her beta blocker dose made. She should follow up with her outpatient cardiologist as scheduled and may benefit from evaluation by EP for potential AICD placement. It was noted that she could benefit from anticoagulation given her LC aneurysm but given her history of GI bleed and guiaic positive stools in house, this intervention was not pursued. She was continued on a full dose aspirin. . # Left facial droop: New as of [**6-14**] AM. Concerning given hypotension on previous day. CT head and carotids negative. Per Neuro, likely toxic metabolic vs. watershed infarct. MRI showed R frontal lobe punctate lesions the chronicity of which could not be determined. It was thought that these could potentially be acute, but as above, GI bleeding precluded anticoagulation and she was already on antiplatelet therapy. She was therefore continued on her aspirin and plavix without further intervention. Her facial droop slowly improved over the course of admission and her Neuro exam otherwise remained unchanged. . # UTI: discharged on ciprofloxacin for 2 days to complete a 7 day course. . # Anemia- Chronic Fe deficicient anemia, likely from chronic GIB. HCT slowly trended downward over admission. Received 1 unit PRBCs. No active bleeding currently on asa, plavix but did continue to be intermittently guiaic positive. She was transfused 1 additional unit of PRBCs on the floor and following, Hct remained stable. She was continued on PPI and iron supplements throughout. . # Back pain: Chronic [**2-13**] to vertebral compression fractures. She was continued on standing tylenol and lidocaine patch with oxycodone prn with reasonable control of her pain. Her fentanyl patch was dc'ed during admission due to her hypotension. . # Lethargy and fatigue: Likely multifactorial with combination of pain medication, metabolic derangements including hyponatremia and infection with UTI/bactermia. Back to baseline after the above interventions. . # depression: No active issues. She was continued on her mirtazipine and Cymbalta. . # Pituitary Adenoma- completed radiation on [**5-26**]. No focal deficits. [**Month (only) 116**] be contributing to hyponatremia w/ potential adrenal abnormalies although random cortisol normal. Neuro exam was unchanged except for facial droop as above and there were no other significant changes noted on MRI. She should follow up with Dr. [**Last Name (STitle) 724**] as an outpatient. . # PPx- SC heparin, PPI, fall precautions, bowel regimen . # FEN: cont tubefeeds. Diet advanced without evidence of aspiration despite achalasia. . # Code- DNR/DNI . # Contact: Brother [**Name (NI) **] [**Name (NI) 27040**] (h) [**Telephone/Fax (1) **] (c) [**Telephone/Fax (1) 27041**] Medications on Admission: Remeron 7.5 mg Po QHS Zofran 4 mg IV Q6H Nitro paste 1inch Q6H, hold for SBP<90 Senna 2 tabs per Gtube [**Hospital1 **] Colace 100 mg GT TID Fentanyl patch 100 mg TP Q72 hours Simvastatin 40 mg po QD Ferrous sulfate 325 mg po QD Reglans 10 mg via GT QD Fragmin 5000 units sc Q12H Plavix 75 mg PO QD Lopressor 12.5 mg via GT TOD Cymbalta 30 mg via GT QD Aldactone 50 mg via GT [**Hospital1 **] (increased from 25 mg on [**6-5**]) Lidoderm patch to upper middle back Q12H on and off Potassium 20 [**Female First Name (un) **] via GT [**Hospital1 **] Zaroxalyn 2.5 mg via G tube Qdaily Perative 50 cc hr 7pm-7am and oerative 40 cc/hr 7am-7pm Discharge Medications: 1. Mirtazapine 15 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime). 2. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 300 mg/5 mL Liquid [**Hospital1 **]: Three Hundred (300) mg PO DAILY (Daily). 4. Metoclopramide 5 mg/5 mL Solution [**Hospital1 **]: Ten (10) mg PO TID (3 times a day). 5. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO QD (). 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: One (1) Adhesive Patch, Medicated Topical Q12H (every 12 hours): to be worn for 12 hours every 24 hours. 8. Therapeutic Multivitamin Liquid [**Hospital1 **]: Five (5) ML PO DAILY (Daily). 9. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 10. Zinc Sulfate 220 (50) mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY (Daily) for 14 days. 11. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 12. Acetaminophen 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every 6 hours). 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 14. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 15. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000) units Injection TID (3 times a day). 16. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash at PEG site. 17. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO Q 12H (Every 12 Hours). 18. Digoxin 125 mcg Tablet [**Hospital1 **]: 0.0625 mg PO DAILY (Daily). 19. Ondansetron 4 mg IV Q8H:PRN 20. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 21. Colace 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day. 22. Senna 8.6 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day. 23. Captopril 12.5 mg Tablet [**Hospital1 **]: 0.25 Tablet PO TID (3 times a day). 24. Ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **] Discharge Diagnosis: Primary: 1. Urinary tract infection 2. bacteremia 3. NSTEMI 4. Congestive Heart Failure 5. anemia Secondary: 1. coronary artery disease 2. pituitary adenoma 3. achalasia 4. hypertension 5. compression fractures Discharge Condition: Vitals stable. Afebrile. Discharge Instructions: You were admitted to the hospital for fatigue. You were found to have a urinary tract infection as well as a blood stream infection that were treated with antibiotics. You also had a small heart attack during your admission which was treated with medications. Please continue to take all medications as prescribed. Note that your Nitropaste, aldactone, and potassium have been stopped. Your fentanyl patch has been replaced with Tylenol and oxycodone as needed to help prevent low blood pressures. You have also been started on lansoprazole, aspirin, digoxin, and captopril. Please follow up as listed below. Please call your doctor or return to the hospital if you experience chest pain, shortness of breath, fevers, chills, abdominal pain, or any other concerns. Followup Instructions: Please call your Primary Care Provider to schedule [**Name Initial (PRE) **] follow up appointment after discharge from rehab. Phone: [**Telephone/Fax (1) 1247**] Please keep all other follow up appointments: Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2161-6-29**] 1:55 Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2161-6-29**] 3:00

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icd9cm

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icd9pcs

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Discharge summary

report+addendum

Admission Date: [**2155-3-14**] Discharge Date: [**2155-3-17**] Date of Birth: [**2103-7-30**] Sex: M Service: MEDICINE Allergies: Labetalol Hcl / Penicillins / Vicodin / Motrin / Ultram Attending:[**First Name3 (LF) 3624**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 51y/o gentleman with h/o renal Tx [**2149**], DM2, CAD, HTN, poly subs abuse, chronic pancreatitis recent admitted last week with abdominal pain presents with presents with dyspnea of 3 days duration with a productive cough. In the ER he was tachypneic to 22-30s, O2 sat 90 on RA. He was given multiple nebulizer treatments, but ultimately was admitted to the MICU for respiratory distress. ECG unchanged, CXR PA and LAT with no evidence of PNA. Given vanco/levo then received solumedrol 125mg IV. He also received 2 liters of NS. In ICU he was started on broad spectrum ABX for immunocopromised state. He was continued on Nebs, solumedrol and given lasix which helped him diurese to -1.3L. On the following day, viral screen returned positive for RSV (likely from grand child) and abx were stopped/transitioned to PO prednisone. His dyspnea improved and he is satting well on 3L nasal canula. Additionally, his FSBG was very elevated in the setting of steriods and he briefly required an insulin gtt. Once on the floor, he was transitioned back to Novolin 70/30 (NPH/Regular) with an increase in his home dosing to 24units QAM and 28units QPM. Past Medical History: - End-stage renal disease secondary to hypertension s/p transplant [**1-/2150**] - Hepatitis C - from transfusion after MVA in [**2134**]. - MVA - [**2134**] with chronic LLE neuralgia, chronic L otalgia since MVA - Diabetes mellitus - History of motor vehicle accident with right tibia fracture, head injury, exploratory laparotomy and tracheostomy - History of diastolic CHF EF > 55% echo [**2-7**] - CAD, Cath [**2149**] 2VD, chest pain - last admitted in [**12-9**]: Persantine stress: Normal myocardial perfusion. Unchanged dilated left ventricular cavity and unchanged decreased EF of 43%. - History chronic pain medication use and polysubstance abuse (last urine tox [**10-8**] positive for cocaine) - Nephrolithiasis - Gout - h/o HSV Social History: Pt smokes 5cigs/day. Has history of 35yr at 1/2ppd. Denies EtOH use. Patient denies recent drug use, cocaine 6mo ago, and heroin 4wks ago. States he lives with his wife. [**Name (NI) **] new sexual partners. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Vitals: T: BP: 174/82 P: 87 R: 22 O2: 94% on 4L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Diminished breath sounds throughout, but no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, 2/6 SEM at LUSB Abdomen: Large mid-line scar from prior ex-lap, soft, TTP at RLQ, non-distended, bowel sounds present, no rebound tenderness or guarding, Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, large scars from MVA on RLE. Pertinent Results: LABS: [**2155-3-14**] 09:25AM GLUCOSE-188* UREA N-25* CREAT-2.7* SODIUM-138 POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-23 ANION GAP-12 [**2155-3-14**] 09:25AM WBC-5.0 RBC-5.22 HGB-15.5 HCT-49.8 MCV-96 MCH-29.7 MCHC-31.1 RDW-13.5 [**2155-3-14**] 09:25AM NEUTS-78* BANDS-0 LYMPHS-12* MONOS-7 EOS-1 BASOS-0 ATYPS-2* METAS-0 MYELOS-0 [**2155-3-14**] 09:25AM ALT(SGPT)-15 AST(SGOT)-24 LD(LDH)-171 CK(CPK)-85 ALK PHOS-73 TOT BILI-0.6 [**2155-3-14**] 09:25AM LIPASE-69* [**2155-3-14**] 10:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG [**2155-3-14**] 09:25AM PLT SMR-NORMAL PLT COUNT-154 CXR PA and LAT: IMPRESSION: No acute intrathoracic process. . EKG: NSR, rate 77, Leftward axis, LVH by aVL criteria, ST elevations in V1-V3 with depressions and TWI in V5-V6 all likely from LVH. Unchanged from prior . ECHO [**1-/2153**]: The left atrium is moderately dilated. The estimated right atrial pressure is 0-5 mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve is bicuspid. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild to moderate ([**2-1**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2147-7-6**], the previously described wall motion abnormality is not detected. Brief Hospital Course: Mr. [**Known lastname 6164**] is a 51 y/o gentleman with h/o ESRD s/p renal transplant, DM, and polysubstance abuse who presented with worsening dyspnea secondary to RSV infection. 1. Dyspnea: Patient presented with acute respiratory decompensation and wheezing and was found to be RSV positive. He was admitted to the MICU for management, where he responded well to nebulizer treatments and was started on IV solumedrol followed by oral prednisone. He also responded well to some diuresis with furosemide while in the ICU. On discharge, he was continued on an oral prednisone taper and was provided a prescription for Combivent MDI. 2. Mild Volume Overload: Patient has a history of diastolic CHF (EF>55%) and became volume overloaded while in the MICU, with a BNP elevated to 872. He responed well to furosemide and was without signs of volume overload at the time of discharge. 3. DM Type 2: Patient is on 70/30 insulin regimen at home, with 20 units in the AM and 24 units in the PM. Given his current prednisone treatment and elevated FSBG into the 200s, his regimen was increased to 24 QAM and 28 QPM while on prednisone, with instructions to resume his home dosing upon completion of his prednisone taper. 4. HTN: Mr. [**Known lastname 6164**] was continued on his home regimen including amlodipine, clonidine, metoprolol. 5. Renal Transplant: Followed by renal transplant team while in hospital. Continue on his immunosuppression with Tacrolimus and CellCept. 6. Abdominal pain: Recent kidney stone diagnosed, but continued on opioid pain management during hospitalization. 7. h/o Polysubstance Abuse: Urine tox from [**2-9**] positive for cocaine. Was participating in a methadone program but stopped going about one month prior to admission. Medications on Admission: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO three times a day. 3. Fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day. 4. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Novolin 70/30 100 unit/mL (70-30) Suspension Sig: see below Subcutaneous once a day: 20 units in AM and 24 units in PM. 15. Percocet 5-325 mg Tablet Sig: Two (2) Tablet PO every [**5-6**] hours for 1 weeks. Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO once a day. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. 10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 11. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO three times a day. 12. Novolin 70/30 100 unit/mL (70-30) Suspension Sig: 24 units in the morning, 28 units at dinner time Subcutaneous QAM and QPM: Return to regular home dosing 20 units in the morning, 24 units at dinner time upon completion of your prednisone. 13. Prednisone 10 mg Tablet Sig: Take 4 tabs x2 days, then 2 tabs x2 days, then 1 tab x2 days, then STOP Tablet PO once a day. Disp:*14 Tablet(s)* Refills:*0* 14. Percocet 5-325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain for 1 weeks. Disp:*20 Tablet(s)* Refills:*0* 15. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 MDI* Refills:*0* 16. Outpatient Lab Work Serum prograf level. Fax results to [**Hospital1 18**] Renal [**Hospital 1326**] Clinic, Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 28646**]. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: RSV respiratory tract infection Secondary Diagnosis: ESRD s/p transplant in [**2150**], on immunosuppression Diabetes Mellitus, type 2 Diastolic CHF (EF>55%) Nephrolithiasis Gout Primary Diagnosis: RSV respiratory tract infection Secondary Diagnosis: ESRD s/p transplant in [**2150**], on immunosuppression Diabetes Mellitus, type 2 Diastolic CHF (EF>55%) Nephrolithiasis Gout Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted to the hospital do to your shortness of breath and productive cough, likely a result of a viral infection called RSV. You were treated with nebulizers and corticosteroids and your symptoms resolved. We ask that you continue your corticosteroid (prednisone) treatment at home as described below. Also, please weigh yourself every morning, and [**Name6 (MD) 138**] your MD if your weight goes up more than 3 lbs. Please continue all of your previous medication with the following additions: Prednisone 40mg PO daily for 2 days ([**3-17**], [**3-18**]), then Prednisone 20mg PO daily for 2 days ([**3-19**], [**3-20**]), then Prednisone 10mg PO daily for 3 days ([**3-21**] - [**3-23**]), then Prednisone 5mg PO daily for 3 days ([**3-24**] - [**3-26**]). Albuterol inhaler Ipratroprium inhaler Bactrim 1 tab daily 1. You were admitted to the hospital for shortness of breath and cough, which was due to a viral infection called RSV. You were treated with nebulizers and corticosteroids and your symptoms resolved. We ask that you continue your corticosteroid (prednisone) treatment at home as described below. 2. Your fludrocortisone was stopped during your admission. The following adjustments were also made to your medications: Prednisone 40mg PO daily for 2 days ([**3-17**] - [**3-18**]), then Prednisone 20mg PO daily for 2 days ([**3-19**] - [**3-20**]), then Prednisone 10mg PO daily for 2 days ([**3-21**] - [**3-22**]), then STOP. Combivent inhaler Bactrim 1 tab daily Insulin 70/30 24 units in the morning, 28 units at dinner time (you should go back to your regular home dosing of 20 units in the morning and 24 units at dinner time after completing your prednisone) 3. It is very important that you make all of your doctors [**Name5 (PTitle) 4314**]. Followup Instructions: Please follow-up with the renal transplant clinic. You can schedule an appointment with Dr. [**Last Name (STitle) 2106**] by calling ([**Telephone/Fax (1) 10248**]. Follow-up with your PCP [**Last Name (NamePattern4) **] 1 week. You can schedule an appointment by calling [**Telephone/Fax (1) 3581**]. Please follow-up in the renal transplant clinic in 1 week to have your Prograf level checked. Do not take your Prograf dose the morning before having your levels drawn. Please follow-up with the renal transplant clinic in [**2-1**] months. You can reach Dr.[**Doctor Last Name **] office by calling ([**Telephone/Fax (1) 3618**] to schedule an appointment. Follow-up with your PCP at [**Name9 (PRE) **] in 1 week. You can schedule an appointment by calling [**Telephone/Fax (1) 3581**]. [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**] Completed by:[**2155-3-18**] Name: [**Known lastname 749**],[**Known firstname 1096**] Unit No: [**Numeric Identifier 5540**] Admission Date: [**2155-3-14**] Discharge Date: [**2155-3-17**] Date of Birth: [**2103-7-30**] Sex: M Service: MEDICINE Allergies: Labetalol Hcl / Penicillins / Vicodin / Motrin / Ultram Attending:[**First Name3 (LF) 2670**] Addendum: This admission was for pneumonia with COPD exacerbation. Also, patient had an exacerbation of diastolic CHF, acute. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Discharge Disposition: Home [**First Name4 (NamePattern1) 460**] [**Last Name (NamePattern1) 461**] MD [**MD Number(1) 2671**] Completed by:[**0-0-0**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13854, 14013

4939, 6712

324, 331

10340, 10340

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161,013

2585

Discharge summary

report

Admission Date: [**2192-4-14**] Discharge Date: [**2192-5-4**] Date of Birth: [**2123-8-14**] Sex: M Service: MEDICINE Allergies: Penicillins / Norvasc / Nifedipine / Atenolol / Codeine Attending:[**First Name3 (LF) 905**] Chief Complaint: Neck pain Major Surgical or Invasive Procedure: [**2192-4-14**]: 1. Anterior fusion exploration. 2. Removal of instrumentation. 3. Incision and drainage. . [**2192-4-14**]: 1. Total laminectomy C 4,5,6. 2. Incision and drainage . [**2192-4-15**]: 1. Vertebrectomy of C4. 2. Instrumentation C3-C5. 3. Cage placement C4. 4. Incision and drainage. 5. Bone graft. . [**2192-4-24**]: G-tube placement via interventional radiology History of Present Illness: Mr. [**Known lastname 13060**] is a 68 year old man with history of cervical spondylysis and disc degeneration who underwent C4-C7 discectomies and C4-C7 spinal stabilization on [**2192-2-13**]. His post-operative course was complicated by fever and leukocytosis on [**2-23**]; a urine culture grew E. coli, and an infected PIV site grew MSSA; he was started on Cipro and Vanco on [**2-23**] and then was transitioned to Levofloxicin for 7 day course on [**2-28**]. He initially did well after discharge, but for the past 5-6 weeks he has been complaining of neck pain and restricted movement. His symptoms have worsened over the past ~ 10 days, with difficulty swallowing, decreased PO intake, rigors and possibly fevers. On [**4-13**] his symptoms worsened further, with [**10-13**] pain and inability to move his right side. He was referred to the emergency room early in the morning on [**4-14**] where an MRI revealed an epidural abscess from C2-C4, with spinal cord compression. Past Medical History: - Cervical spondylosis/disc degeneration - Obstructive sleep apnea (not on CPAP) - History of partial empty sella syndrome - Hypertension - Dyslipidemia - Seasonal asthma - Migraine headaches - Back pain, L5-S1 disc disease - Hypothyroidism - Ischemic colitis - Hemochromatosis - Retinal detachment [**2191**] - EtOH withdrawal/DT's . PSH: - Carpal tunnel repair 20 yr ago - liver bx - [**2191-7-6**] Left shoulder arthroscopic subacromial decompression. - Arthroscopic rotator cuff repair. - [**2192-2-13**] Anterior cervical diskectomy C4-C5, C5-C6 and C6-C7. Fusion C4-C7. Anterior instrumentation C4-C7. Structural allograft. Social History: Lives with wife in [**Name (NI) **]. No recent travel. Pet cat at home. Previously worked as a school bus driver. Active in the community, and with gardening and carpentry. Family History: Non-contributory. His mother died from complications from a cerebrovascular accident. His father died from "old age." He has a sister with diabetes, another sister with MS, and a 62-year-old brother who died from a myocardial infarction. Physical Exam: On presentation (per ortho-spine attending): Elderly white man in obvious distress. HEENT: limited ROM of head and neck secondary to pain. Right leg [**3-8**] IR/ER of hip, [**2-9**] knee flex/ext, ankle 0/5 DF/PF. FHL, [**Last Name (un) 938**]. Left [**5-8**] deltoid/biceps/tricepts/wrist ext/flex, finger flex/ext. Left leg [**4-8**] hip flex, knee flex/ext, ankle DF/PF On transfer to medicine service... VITALS: Tm 99.7F, Tc 99.7F, BP 140/90 (140-185/72-118), HR 104, Sat 94-97% GENERAL: C-collar in place, no acute distress HEENT: EOMI, PERRL, OP clear without lesions NECK: Unable to examine because of neck brace CARD: RRR, normal S1/S2, no m/r/g RESP: Course rhonchi bilaterally ABD: Soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly BACK: No spinal tenderness below cervical region EXT: No clubbing/cyanosis/edema, 2+ DP pulses NEURO: CN II-XII (grossly; difficult to perform full exam given limited patient cooperation), A&O x 0, Strength 3-/5 in right upper and right lower extremity, full on left. Unable to test for sensory deficits, gait not tested. PSYCH: Mumbles, inappropriate affect Pertinent Results: [**2192-4-14**] ECG: Baseline artifact. Rhythm is probably an ectopic atrial rhythm, although this cannot be confirmed on the basis of this study. Otherwise, normal tracing. Compared to the previous tracing of [**2192-2-14**] poor R wave progression is not seen on the current tracing. . [**2192-4-14**] CT Head: No acute intracranial process. If there is further clinical concern for acute stroke, an MR is more sensitive. . [**2192-4-14**] CXR: No acute cardiopulmonary process. . [**2192-4-14**] MR [**First Name (Titles) 11598**] [**Last Name (Titles) 1093**]: 1. Fluid collection in the epidural space from C2 to C4 level with compression of the spinal cord. The fluid collection could represent an epidural abscess or hematoma. Contrast gadolinium-enhanced MRI can help for further assessment. 2. Spinal cord edema at C2 level. 3. Prevertebral soft tissue swelling, which could be due to combination of abscess or hematoma or inflammatory changes. Again, contrast-enhanced MRI can help for further assessment. 4. Low signal is identified on T1-weighted images in the T1 vertebra which could be due to marrow edema. . [**2192-4-14**] Spine film: 1) Status post laminectomy, with marked prominence of soft tissues both anterior and posterior to the cervical spine, with small locules of air as described. 2) Alignment from C1 through C6 is preserved, without listhesis. 3) The cortical surfaces of the C4, C5, and C6 levels are not well demonstrated in part this likely relates to degenerative changes. However, review of prior studies suggests that there has been prior instrumentation and intervertebral fusion devices at these levels and this may represent residua from that. Possibility of superimposed osteolysis due to infection cannot be excluded. . [**2192-4-15**] Tissue: Intervertebral disc, C3-C4, excision: Fibrocartilage and bone with acute inflammation and fibrin, consistent with abscess formation. . [**2192-4-15**] CXR: ET tube tip is 5.6 cm above the carina. There is mild cardiomegaly. Aside from atelectasis in the right base the lungs are clear. There is pneumothorax. Small right pleural effusion is unchanged. . [**2192-4-15**] C-spine MRI: Progression of abnormality since the cervical spine MR of [**2192-4-14**]. Markedly increased spinal cord edema. Enlarged anterior epidural fluid collection. Increased abnormal signal in the C7-T1 intervertebral disc, worrisome for discitis. Extensive epidural and leptomeningeal enhancement compatible with epidural abscess as well as meningitis. . [**2192-4-16**] CXR: Small left pleural effusion and pulmonary and mediastinal vascular congestion suggest volume overload and/or cardiac decompensation, increased since [**4-15**]. ET tube in standard placement. No pneumothorax. Heart size normal, unchanged. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10752**] paged to report these findings at the time of dictation. . [**2192-4-16**] Left upper extremity ultrasound: No left upper extremity DVT. . [**2192-4-17**] CXR: In comparison with study of [**4-16**], the hemidiaphragm on the left is more sharply seen, suggesting some decrease in the left pleural effusion. However, some of this difference may reflect the semi-erect position of the patient. Again, there is no evidence of acute focal pneumonia. Endotracheal tube remains in place. . [**2192-4-18**] CT Head: 1. No acute intracranial process. 2. New opacification of the ethmoidal sinus and sphenoid sinuses and decreased opacification of the mastoid air cells. Correlate clinically. This may relate to intubation. . [**2192-4-18**] CT C-spine: 1. Extensive post-surgical changes as described above with no findings to suggest hardware failure status post recent corpectomy with C3-C5 anterior fusion. 2. Marked continued swelling involving the retropharyngeal/prevertebral soft tissues. Air pocket with simple-appearing fluid collection noted adjacent to the right hyoid, also likely postoperative. 3. Poor visualization of remaining epidural phlegmon/fluid collection which is better depicted on recently performed [**2192-4-17**], C-spine MRI. . [**2192-4-18**] CT L-spine: 1. No definite findings of infection identified. Equivocal small epidural hematoma noted at the L4-L5 interspace likely in conjunction with regions of ligamentum flavum hypertrophy at this level. Mild inflammatory changes are noted around the L5 and L3 spinous processes. This should be correlated with the site of recent lumbar puncture. 2. Small bilateral pleural effusions with adjacent compressive atelectasis. Please note, if further evaluation of the spine and epidural spaces is desired, dedicated MRI could be obtained. . [**2192-4-20**] CXR: The ET tube tip is 2.5 cm above the carina. The NG tube tip passes below the diaphragm terminating in the stomach. The left subclavian line tip is in mid SVC. There is no significant change compared to the prior study in bibasal opacities consistent at least partially with atelectasis and bilateral pleural effusion. The patient is in mild pulmonary edema. No pneumothorax is demonstrated. . [**2192-4-22**] CXR: ET tube tip is 4.7 cm above the carina. Left lower lobe aeration has markedly improved. Right lower lobe atelectasis is persistent. Small bilateral pleural effusions are stable. Mild cardiomegaly is unchanged. Left subclavian catheter remains in place. NG tube tip is out of view below the diaphragm. IMPRESSION: Almost complete resolution of left lower lobe atelectasis. . [**2192-4-24**] CXR: As compared to the previous examination, the patient has been extubated and the nasogastric tube has been removed. The left-sided central venous access line remains in place. Persistent pre-existing right-sided basal atelectasis, otherwise, the lung parenchyma is clear, there is no evidence of focal parenchymal opacities suggesting pneumonia. No pleural effusions, no pneumothorax. . [**2192-4-24**] CT Abd/Pelvis without contrast: No interposed loops of large bowel between the stomach and the anterior abdominal wall. The top portion of the stomach and the body and antrum is covered by the liver, although the more inferior aspects are not. The patient proceeded to the interventional radiology suite, for percutaneous gastrostomy placement. . [**2192-4-28**] CXR: There is an unchanged left sided central venous catheter. There is a right upper abdomen pigtail catheter. Lungs are grossly clear without evidence for overt pulmonary edema, pleural effusions, or focal consolidation. Cardiac silhouette and mediastinum is normal. There are no pneumothoraces identified. The feeding tube has been removed in the interim. . [**2192-4-29**] AXR: A pigtail catheter is seen across the abdominal midline. There is an unremarkable bowel gas pattern with air and stool seen throughout colon. No dilated loops of small bowel are seen. There are no signs for free intra-abdominal air. . [**2192-4-30**] CXR: 1. Newly placed right central venous access line ascending into the right internal jugular vein. 2. Interval development of bilateral basilar opacities which may indicate aspiration or atelectasis. Findings were discussed with the IV nurse at the time of interpretation on [**2192-4-30**]. . [**2192-4-30**] CXR: Existing PICC line repositioned, now with tip in the SVC. PICC line is ready to use. . [**2192-5-1**] MRI C-spine: Persistent extensive inflammatory changes after repeated anterior and posterior decompression and fusion. However, the intensity of enhancement, the size of epidural fluid collections, the spinal cord edema, and prevertebral fluid and enhancement have all improved dramatically since the examination of [**2192-4-17**]. . [**2192-5-2**] MRI Head: 1. Little change to region of old left basal ganglia hemorrhage. No evidence of acute intracranial hemorrhage, masses, or infarction. 2. Sinus disease. 3. Mild cerebral atrophy. . [**2192-5-2**] RUQ Ultrasound: Limited visualization of the left lobe of the liver. Otherwise, unremarkable examination. . [**2192-5-3**] Video Swallow: (prelim) continued silent aspiration, keep patient NPO. Brief Hospital Course: BRIEF HOSPITAL COURSE ON SURGERY: Mr. [**Known lastname 13060**] is a 68 year old man with history of cervical spondylysis and disc degeneration who underwent C4-C7 discectomies and C4-C7 spinal stabilization on [**2192-2-13**]. His post-operative course was complicated by fever and leukocytosis on [**2-23**]; a urine culture grew E. coli, and an infected PIV site grew MSSA; he was started on Cipro and Vanco on [**2-23**] and then was transitioned to Levofloxicin for 7 day course on [**2-28**]. He initially did well after discharge, but for the past [**5-9**] weeks he has been complaining of neck pain and restricted movement. His symptoms have worsened over the past ~ 10 days, with difficulty swallowing, decreased PO intake, rigors and possibly fevers. On [**4-13**] his symptoms worsened further, with [**10-13**] pain and inability to move his right side. He was referred to the emergency room early in the morning on [**4-14**] where an MRI revealed an epidural abscess from C2-C4, with spinal cord compression. He underwent anterior and posterior approach removal of hardware and evacuation of epidural abscess with a posterior laminectomy to decompress. Post-operatively he developed right sided hemiparesis and went back for repeat operation on [**4-15**] after repeat imaging showed increase in size of the epidural abscess. He had a C4 vertebrectomy and incision of C3-C4 disk, with placement of anterior hardware for cervical spine instability. He was initially started on vancomycin, ceftazidime, and metronidazole (on [**2192-4-14**]) for broad empiric coverage. Blood and wound cultures from admission and the OR grew MSSA. Antibiotic coverage was switched to cefazolin once the Staph aureus was identified as MSSA. A repeat MRI was performed [**4-17**] with continued expansion of the epidural abscess and leptomeningeal enhancement. An LP was performed on [**4-17**] concerning for meningitis with high protein (590), low glucose (34), 33 WBC, but negative gram stain and culture. He was started on meropenem, and vancomycin was re-added on [**4-19**]. He was found to be C. diff positive on [**4-19**], and PO vancomycin was initiated. He was extubated on [**4-23**]. On [**4-24**] a percutanous gastrostomy tube was placed in IR (given concern for aspiration). He was transferred out of the ICU to the surgical floor, seen by medicine for altered mental status, and transferred to the medicine service. BRIEF HOSPITAL COURSE, BY PROBLEM, WHILE ON MEDICINE SERVICE: Mr. [**Known lastname 13060**] is a 68yM with history of cervical spondylitis s/p C4-C7 discectomies and C4-C7 spinal stabilization on [**2192-2-13**] complicated by epidural abscess s/p evacuation and hardware removal on [**4-14**], growing MSSA, elevated WBC/protein in CSF concerning for meningitis, now extubated and transferred to the medical service for altered mental status/confusion. #) Altered mental status. All altering medications (benzodiazepenes, narcotics) were held, and his infection was treated as below. His mental status continues slowly to improve, with waxing and [**Doctor Last Name 688**] and occasional nighttime agitation. His mental status was thought likely to be multifactorial from infection, medications, ICU/hospital stay, and chronic sleep deprivation. His chemistries were initially notable for hypernatremia, which was corrected with free water repletion; at the time of discharge, they are within normal limits. He is not uremic; his transaminases were mildly elevated (thought secondary to meropenem, which was discontinued on [**5-2**], RUQ ultrasound negative). Cultures and other infectious workup unrevealing. MRI head showed no structural abnormalities or evidence of septic infarct. Pain was treated with standing acetaminophen (500-1000mg Q6H), and tramadol was added when his medication improved. He was started on low dose quetiapine for sleep and agitation. #) Epidural abscess/likely meningitis. Vancomycin was continued (through [**6-8**]), meropenem finished [**5-2**]. CT C-spine showed extensive inflammatory changes, but improved appearance overall. Follow up with Dr. [**Last Name (STitle) 363**] in two weeks; he should continue to wear cervical collar until then. #) Elevated white blood cell count. Unclear source, but resolved; known C. diff positive, but with benign abdominal exam. Has been afebrile since [**4-30**]. His respiratory status will need to be monitored (concern for aspiration; aspiration precautions and NPO until speech and swallow clears him). All surveillance cultures have been negative to date. #) C. difficile infection. Diagnosed as above during course on surgical service. Stable, with benign abdominal exam; abdominal x-ray showed no dilatation. Continue PO vancomycin; will need to continue 5 days past finishing IV vancomycin (until finished with IV antibiotics). #) Risk for aspiration. Given posterior oropharyngeal swelling, has silent aspiration. Appreciate speech & swallow recommendations. Video swallow will need to be repeated PRN so that if needed, can starting taking PO. #) Transaminitis. Thought mildly elevated secondary to meropenem. RUQ ultrasound was unrevealing for cause. Downtrending at the time of admission. #) Hypertension. Continue metoprolol, lisinopril, HCTZ (started this admission) at maximum doses; increased diltiazem to 90mg QID (although doubt much help with blood pressure). Blood pressures improved on current regimen. Allergy to amlodipine (leg swelling, sexual dysfunction). #) Dyslipidemia. Held statin for now given elevated transaminases. #) Hypothyroidism. Continued levothyroxine. #) F/E/N. Continue NPO and continue tube feeds. Monitor/replete electrolytes. #) Prophylaxis. Heparin SubQ, bowel regimen PRN given diarrhea, famotidine. Insulin sliding scale while on tube feeds. #) Communication. With patient's wife [**Name (NI) **]. [**Name2 (NI) **] [**Telephone/Fax (1) 13061**], Cell [**Telephone/Fax (1) 13062**]. #) Access. PICC placed; CVL from course on surgery was pulled. #) Code Status. Full code, confirmed with wife. Medications on Admission: (Per OMR) - Alprazole 0.25mg TID PRN - Butalbital-Acetaminophen-Caff [Fioricet], 325 mg-40 mg-50 mg Tablet [**1-6**] Tablet(s) by mouth q4-6 PRN - CPAP Device - Zyrtec 10mg tablet daily PRN itching - Clonazepam 0.5mg TID PRN muscle spasm - Colchicine 0.6 mg Tablet. Q1H until symptoms abate or diarrhea, max of 8 tabs per attack - Diltiazem HCl, 90 mg Capsule, Sust. Release 12 hr; 1 Capsule(s) by mouth once a day - Duloxetine 20mg [**Hospital1 **] - Fluticasone 50mcg spray [**Hospital1 **] - Indomethacin 25mg TID PRN - Lisinopril 40mg daily - Oxycodone 5mg Q4-6H PRN - Ranitidine 150mg [**Hospital1 **] - Sildenafil 50mg PRN - Simvastatin 40mg daily - Synthroid 100mcg daily - Testosterone 5mg/24h Patch Q24H Discharge Medications: 1. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 2. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous Q 12H (Every 12 Hours): FOR A TOTAL OF 750MG Q12H. 3. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Docusate Sodium 50 mg/5 mL Liquid Sig: [**5-13**] mL PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection [**Hospital1 **] (2 times a day). 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection Injection ASDIR (AS DIRECTED): According to sliding scale (Attached). 15. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours: Standing Tylenol for pain control. 16. Ultram 50 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Epidural abscess, MSSA C. difficile infection Aspiration Delirium Discharge Condition: Stable vital signs, neurologic exam as documented in the discharge summary Discharge Instructions: You were admitted with neurologic deficits and were found to have an epidural abscess, which was treated neurosurgically by Dr. [**Last Name (STitle) 363**]. You are being treated with a total of 6 weeks of intravenous antibiotics for this infection. Your post-operative course was complicated by C. difficile infection, for which you are taking oral antibiotics. In addition, because of the swelling around the site of the spinal infection, you have difficulty swallowing, for which a tube was inserted directly into your stomach. As the swelling improvees, and as you continue your rehab, this tube will likely be able to be removed and you will be able to eat on your own. . Please keep all of your follow up appointments and take all of your medications as prescribed. If you develop any shortness of breath, high fever, worsening pain, worsening neurologic deficits, chest pain, or other concerning symptoms, please seek medical attention immediately. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3573**] Date/Time:[**2192-5-18**] 10:00 Provider: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2192-5-24**] 10:30 Provider: [**Name10 (NameIs) 454**],TWO [**Name10 (NameIs) 454**] Date/Time:[**2192-7-25**] 8:30 Provider: [**Name10 (NameIs) 6122**] WEST OUTPATIENT RADIOLOGY Phone:[**Telephone/Fax (1) 8243**] Date/Time:[**2192-7-25**] 10:00 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

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icd9cm

[ [ [] ] ]

[ "03.09", "43.11", "80.51", "81.32", "03.02", "03.31", "96.6", "03.4", "81.62", "77.99", "84.51" ]

icd9pcs

[ [ [] ] ]

20378, 20448

12069, 18163

324, 702

20557, 20633

3985, 4289

21638, 22263

2576, 2818

18927, 20355

20469, 20536

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20657, 21615

2833, 3966

275, 286

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70,652

174,509

27787

Discharge summary

report

Admission Date: [**2150-9-8**] Discharge Date: [**2150-9-11**] Date of Birth: [**2096-12-6**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: none History of Present Illness: History taken with use of Spanish interpretor. The patient is a 53 y/o F with a PMH of fibromyalgia and hypertension presenting with chest discomfort, shortness of breath and hypotension. The patient reports that she began to feel increasingly unwell yesterday when she noted increased fatigue and did not leave her home. Today she noted dyspnea and dizziness while walking with her daughter. She had to stop frequently to catch her breath while walking home and had difficulty ambulating up stairs. She also reports difficulty swallowing secondary to throat tightness, with dysphagia to hard solid foods for one month. She has had symptoms like this before, last time one week ago. She sleeps on four pillows nightly due to difficulty breathing. Denies PND. She called EMS for transport to the ED. On arrival to the ED she complaints of [**10-24**] chest pain with associated diaphoresis and shortness of breath. . In the ED, initial vitals: T 99.6, HR 89, BP 106/60, 98% RA. She was given zofran 2mg IV, ntg sl, tylenol 1000 mg, ketorolac 30mg IV. EMS had been concerned about ECG and code STEMI was called. On arrival to ED, ECG was not felt to be consistent with acute ischemia. She underwent a FAST scan which was negative for pericardial effusion. CTA negative for PE or dissection. Her BP dropped to 80s after reciept of SL NTG. She was given 2L NS without response in BP. Her BP improved to 90s after 3rd L NS. She reported continued chest discomfort [**7-24**], which was reproducible upon palpation of the sternum. . On arrival to the MICU, the patient complains of continued discomfort in her chest and throat. Past Medical History: GERD. Bilateral carpal tunnel syndrome. Hypertension Lumbosacral radiculopathy. Depression. Fibromyalgia. . SURGICAL HISTORY Carpal tunnel release. Cholecystectomy. Laser surgery on the right eye. Social History: She is a widow, her husband was alcoholic and committed suicide three years ago. She lives with youngest daughter. The patient is currently unemployed after being laid off from a foods service job 6 weeks ago. Habits: Current tobacco use with 5 cig/daily. No EtOH or IVDU. Family History: Mother died with liver disease. Father died at 45 with a heart attack. One brother died with renal failure. Physical Exam: PHYSICAL EXAM ON ADMISSION: Vitals: T 97.3, BP 87/51, RR 16, O2 100% 2L GEN: alert, oriented X3, NAD HEENT: MMM, OP clear, patchy alopecia. CV: RRR, nl s1/s2, no MRG, palpable, reproducible tenderness along sternum, pulses palp 2+ radial, PT/DP RESP: CTAB, no WRR ABD: soft, NT/ND, NABS. Tendeness at epigastrium. EXT: no edema . PHYSICAL EXAM AT DISCHARGE: Vitals: T 97.9, BP 138/86, RR 18, pulse 77, O2 97%RA GEN: alert, oriented X3, NAD HEENT: MMM CV: RRR, nl s1/s2, no MRG, pulses palp 2+ radial, PT/DP RESP: CTAB, no WRR ABD: soft, NT/ND, NABS EXT: no edema Pertinent Results: LABORATORY RESULTS: . [**2150-9-8**] 12:00PM BLOOD WBC-6.0 RBC-3.81* Hgb-10.8* Hct-33.1* MCV-87 MCH-28.4 MCHC-32.7 RDW-14.2 Plt Ct-306 [**2150-9-8**] 10:04PM BLOOD Hct-30.7* [**2150-9-9**] 05:10AM BLOOD WBC-3.9* RBC-3.48* Hgb-9.4* Hct-30.8* MCV-88 MCH-27.1 MCHC-30.7* RDW-13.5 Plt Ct-236 [**2150-9-10**] 05:00AM BLOOD WBC-4.2 RBC-3.67* Hgb-10.1* Hct-31.7* MCV-87 MCH-27.6 MCHC-31.9 RDW-13.5 Plt Ct-250 [**2150-9-11**] 05:25AM BLOOD WBC-4.7 RBC-3.63* Hgb-10.0* Hct-31.1* MCV-86 MCH-27.7 MCHC-32.3 RDW-13.6 Plt Ct-247 [**2150-9-8**] 12:00PM BLOOD PT-12.0 PTT-26.2 INR(PT)-1.0 [**2150-9-8**] 12:00PM BLOOD Fibrino-229 [**2150-9-8**] 12:00PM BLOOD UreaN-10 Creat-0.9 [**2150-9-9**] 05:10AM BLOOD Glucose-94 UreaN-8 Creat-0.7 Na-136 K-4.7 Cl-107 HCO3-21* AnGap-13 [**2150-9-10**] 05:00AM BLOOD Glucose-129* UreaN-9 Creat-0.7 Na-140 K-4.2 Cl-106 HCO3-27 AnGap-11 [**2150-9-11**] 05:25AM BLOOD Glucose-124* UreaN-9 Creat-0.7 Na-141 K-3.7 Cl-103 HCO3-31 AnGap-11 [**2150-9-8**] 12:00PM BLOOD CK(CPK)-130 [**2150-9-8**] 07:12PM BLOOD ALT-29 AST-26 CK(CPK)-109 AlkPhos-52 TotBili-0.2 [**2150-9-9**] 05:10AM BLOOD ALT-32 AST-34 CK(CPK)-103 AlkPhos-52 TotBili-0.2 [**2150-9-8**] 12:00PM BLOOD Lipase-30 [**2150-9-8**] 07:12PM BLOOD CK-MB-3 cTropnT-<0.01 [**2150-9-9**] 05:10AM BLOOD CK-MB-3 cTropnT-<0.01 [**2150-9-10**] 05:00AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.0 [**2150-9-11**] 05:25AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.9 [**2150-9-9**] 05:10AM BLOOD Cortsol-0.6* [**2150-9-10**] 05:21AM BLOOD Cortsol-6.0 [**2150-9-10**] 05:58AM BLOOD Cortsol-13.9 [**2150-9-10**] 06:58AM BLOOD Cortsol-17.8 [**2150-9-11**] 05:25AM BLOOD Cortsol-5.1 [**2150-9-8**] 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2150-9-8**] 10:55PM BLOOD Type-[**Last Name (un) **] pO2-169* pCO2-41 pH-7.36 calTCO2-24 Base XS--1 Comment-GREEN TOP [**2150-9-8**] 12:16PM BLOOD Glucose-113* Lactate-2.7* Na-136 K-4.3 Cl-101 calHCO3-24 [**2150-9-8**] 10:55PM BLOOD Lactate-1.2 [**2150-9-10**] 05:21AM BLOOD ACTH - FROZEN-PND . [**2150-9-8**] 2:20 pm URINE CULTURE (Final [**2150-9-9**]): NO GROWTH. [**2150-9-8**]: Blood Culture: No growth [**2150-9-9**]: Blood Culture: No growth . STUDIES: . EKG [**2150-9-8**]: Tracing #1: Sinus rhythm. ST-T wave configuration suggests early repolarization pattern but clinical correlation is suggested. Compared to the previous tracing of [**2150-4-29**] no significant change. EKG [**2150-9-8**]: Tracing #2: Sinus rhythm. ST-T wave configuration suggests early repolarization pattern but clinical correlation is suggested. Compared to the previous tracing of same date no significant change. EKG [**2150-9-8**]: Tracing #3: Sinus rhythm. ST-T wave configuration suggests early repolarization pattern but clinical correlation is suggested. Compared to the previous tracing of same date no significant change. EKG [**2150-9-8**]: Tracing #4: Sinus rhythm. ST-T wave configuration suggests early repolarization pattern but clinical correlation is suggested. Compared to the previous tracing of same date no significant change. CXR [**2150-9-8**]: IMPRESSION: There is no evidence of pneumonia or CHF. There is no pneumothorax or pleural effusion. The heart is mildly enlarged. The aorta is tortuous. There is no definite acute displaced fracture. . CTA [**2150-9-8**]: IMPRESSION: Limited study due to technique. No definite pulmonary embolism within the main, primary, lobar or large segmental branches of the pulmonary artery. Cardiomegaly. Incidentally noted aberrant right subclavian artery. . CT HEAD [**2150-9-8**]: IMPRESSION: No definite acute intracranial abnormality. . UGI AIR w/o KUB: [**2150-9-10**]: IMPRESSION: IMPRESSION: Small amount of penetration into the vestibule. No aspiration into the airway. Prominent cricopharyngeus impression with free passage of a barium tablet. Brief Hospital Course: 53 y/o F with a PMH of fibromyalgia and hypertension presenting with chest discomfort, shortness of breath, admitted for hypotension. . # HYPOTENSION: SBP 106 at ED triage, dropped to 80s after nitro SL, and stable in 100-110s after 3L IVF. SBP in 100-110s is likely relative hypotension given her h/o HTN. However, she remains well-perfused on exam, with Cr and lactate within normal limits. . Unclear etiology. Initial concern for ACS, aortic dissection, or PE, but CE negative and stable, ECG unchanged from prior, and CTA negative. Arm pain could represent atypical CP, but likely MSK/fibromyalgia since it is exacerbated with movement and consistent with past arm pain. Volume depletion is possible but pt does not seem overtly volume down on exam or labs. Some improvement in ED with 2.6L of IVF but little change with final 500cc in MICU followed by autodiuresis, which indicates adequate fluid status but persistent relative hypotension. Minimal evidence of significant infection-- no fever, tachycardia. WBC down and lymphocytosis on [**9-9**], so viral infection is possible. However, vasodilation due to infection is unlikely since she does not meet SIRS criteria aside from WBC. BCx and UCx pending. Abx held give lack of evidence of infection. Blood loss possible given GERD symptoms and Hct down from 39.1 on [**6-23**] from 39.1 to 33 at admission and to 30.7 on [**9-9**]. Thus, GI bleed in setting of gastritis is possible, but she denies changes to bowel movement, guaiac was negative,and Hct has stabilized. Medication effect from metoprolol and lisinopril less likely since patient was adamant about adhering to the prescribed doses. Nitroglycerin effect unlikely to cause prolonged hypotension. Adrenal insufficiency is possible given hypotension and borderline low sodium. Random cortisol level was low but pt responded appropriately to cosyntropin stimulation test. Outpatient hypertensives were held. Pt then became hypertensive and her metoprolol was restarted at low dose and pt monitored. Blood pressures remained stable and at discharge was 138/86. . # Chest Discomfort: Likely due to GERD given ascending retrosternal burn, throat pain/tightness c/w prior experiences with GERD. GI cocktail with some effect. +/-MSK or costochondritis, especially given arm pain this AM. As noted, cardiac etiology less likely given unchanged EKG and negative CE. However, other cardiac etiologies including unstable angina, coronary vasospasm. Should follow up with outpatient cardiologist to see if catheterization is planned. A pharmacologic sestamibi stress test or similar CVD work up may be warranted given recent increase in health care visits/hospitalizations associated with chest pain. Significant anxiety given loss of job could exacerbate chest pain and cause sensation of SOB, throat tightness, weakness. Dysphagia to hard solids with history of GERD is suspicious for esophageal stricture/adhesion or esophageal spasm. Barium swallow was performed showing no obstruction or esophageal pathology. PPI and GI cocktail prn started and patient discharged on famotidine 10mg tablet [**Hospital1 **]. . # ANEMIA: Hct down from 39.1 on [**6-23**] to 33 at admission and to 30.7 on [**9-9**], then stable at 30.8. No clinical signs of poor perfusion, Cr stable. However, history of GERD could be associated with GI bleed in the setting of gastritis, although guaiac was negative and she denies changes to BM per above. Hemolysis less likely given normal tbili. . # ANXIETY/DEPRESSION: Worse in past 6 months following loss of her job, with worsening insomnia, headaches and anxious mood (per daughter, patient does not endorse) in the last month. No outpatient anxiolytics. Will likely defer to outpatient care providers, but would consider outpatient start of SSRI. . # FIBROMYALGIA: Continued gabapentin and nortriptyline . # FEN - regular diet, replete lytes PRN . # Ppx - heparin sc, pneumoboots . # ACCESS - PIV X2 . # DISPO - Home Medications on Admission: Fluticasone 50 mcg Spray, 2 puff daily Gabapentin 300 mg Capsule TID Lisinopril 10 mg Tablet daily Metoprolol Tartrate 25 mg Tablet [**Hospital1 **] Nitroglycerin 0.3 mg Tablet, Sublingual PRN Nortriptyline 50 mg Capsule QHS Tramadol 50 mg Tablet one or two Tablet(s) by mouth daily as needed Aspirin 325 mg Tablet daily Loratadine 10 mg Tablet daily Nicotine 7 mg/24 hour Patch 24 hr Discharge Medications: 1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO once a day as needed for pain. 4. Famotidine 10 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Nortriptyline 50 mg Capsule Sig: One (1) Capsule PO at bedtime. 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: active GERD Discharge Condition: stable Discharge Instructions: You were admitted to the hospital because of chest discomfort and a low blood pressure. Your chest discomfort is most likely due to your GERD and less likely due to a [**Last Name **] problem. It is recommended that you follow up with your cardiologist to confirm this. Your blood pressure normalized after we withheld your medications and gave you fluids and can be restarted. Famotidine was added to your home medications and is to be taken twice a day. The rest of your home medications can be continued as outpatient. Please keep your scheduled appointments or contact the provider [**Name9 (PRE) 67751**] you need to reschedule. Please contact the hospital or your doctor if you should experience a fever of greater than 101, shortness of breath or chest pain. Followup Instructions: Please contact the provider if you should need to reschedule/cancel any of your appointments. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2150-10-1**] 3:20 Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4012**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2150-10-30**] 2:40 Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2150-11-6**] 1:00 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 16624**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2150-10-12**] 2:00 Completed by:[**2150-9-11**]

[ "729.1", "530.81", "458.9", "300.00", "786.59", "311", "401.9", "285.9", "250.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12087, 12093

7064, 11020

325, 332

12149, 12158

3222, 7041

12976, 13735

2512, 2623

11458, 12064

12114, 12128

11046, 11435

12182, 12953

2638, 2652

2996, 3203

274, 287

360, 1984

2666, 2982

2006, 2205

2221, 2496

14,141

109,881

29924

Discharge summary

report

Admission Date: [**2201-1-27**] Discharge Date: [**2201-1-31**] Date of Birth: [**2143-3-12**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: HEMOPTYSIS Major Surgical or Invasive Procedure: [**2202-1-27**] Emergent MVRepair with 27 mm [**Company **] duran ring and resection P2 leaflet. History of Present Illness: 57 yo M with recently discovered heart murmur. Echo showed MR and cardiac MRI showed severe MR [**First Name (Titles) **] [**Last Name (Titles) 61102**] forward EF. He presented to the ED at MWMC a few weeks PTA with hemoptysis and was worked up for pulmonary problems. Outpatient Cath at MWMC the day of admission showed severe MR [**First Name (Titles) 151**] [**Last Name (Titles) **] leaflet and ruptured chordae. He became hypotensive and hypoxic. He was intubated and transferred to [**Hospital1 18**] for emergent surgery. Past Medical History: MR [**First Name (Titles) **] [**Last Name (Titles) 71504**] anal fissure repair Social History: married, lives with wife smokes cigars 2 etoh/week works as electrician Physical Exam: intubated, in NAD opens eyes to command, MAE well bibasilar crackles RRR holosystolic murmur Abd benign Extrem warm, no edema Rt groin dressing C/D/I Brief Hospital Course: He was taken emergently to the operating room on [**2201-1-27**] where he underwent an emergent MV repair. He was transferred to the ICU in critical but stable condition. He was extubated on POD #1, weaned from his vasoactive drips and transferred to the floor on POD #1. He was started on a beta blocker and diuretic. He has done well with ambulation, and has remained hemodynamically stable. He is ready to be discharged home on POD #4. Medications on Admission: asa, vitamin E, piroxicam, SBE proph Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*060 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO twice a day for 5 days. Disp:*20 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of greater [**Location (un) **] Discharge Diagnosis: MR [**First Name (Titles) 151**] [**Last Name (Titles) **] leaflet/ruptured chordae MR [**First Name (Titles) 20441**] [**Last Name (Titles) 71504**] anal fissure repair Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. No heavy lifting (>10 pounds) or driving until follow up with surgeon. Shower, no baths, no lotions, creams or powders to incisions. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (Prefixes) **] 4 weeks Dr. [**Last Name (STitle) 8049**] 2 weeks Dr. [**Last Name (STitle) 32255**] 2 weeks Completed by:[**2201-1-31**]

[ "429.5", "424.0", "428.0", "715.98" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.12" ]

icd9pcs

[ [ [] ] ]

2918, 2984

1374, 1815

332, 431

3198, 3206

1902, 2895

3005, 3177

1841, 1879

3230, 3481

3532, 3688

1200, 1351

282, 294

459, 992

1014, 1096

1112, 1185

5,466

108,815

16119+16120

Discharge summary

report+report

Admission Date: [**2130-2-27**] Discharge Date: [**2130-3-6**] Date of Birth: [**2088-2-10**] Sex: M Service: [**Location (un) **] CHIEF COMPLAINT: Aspiration status post electroconvulsive shock therapy. HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old male who underwent ECT shock therapy for depression for the first time on [**2-28**]. Following ECT, the patient had an episode of vomiting a small amount of bilious material. His oxygen saturation decreased to the 80s. He woke up diaphoretic, complaining of shortness of breath and chest pain. EKG disclosed sinus tachycardia. His blood pressure was stable. He was administered Lopressor and heart rate decreased to the 100-110 range. He was sent to the Emergency Department where he was found to have an oxygen saturation of 66% with an arterial blood gas that was 7.33/45/26. The patient was intubated for hypoxic respiratory failure. He subsequently developed tachycardia to the 170s and his systolic blood pressure declined to 85/40. The patient's blood pressure improved with decreasing his sedation (propofol) but he had a persistent narrow complex tachycardia. Rate did not decrease with administration of adenosine. The patient was shocked with 100 joules x 2 yet heart rate remained in the 130s. In the Emergency Department the patient was given doses of Levophed and Flagyl. He was sent to the medical intensive care unit for further treatment. PAST MEDICAL HISTORY: 1. Depression since [**2113**]. 2. History of pneumothorax. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: 1. Wellbutrin 150 b.i.d. 2. Klonopin 1 b.i.d. 3. Remeron 15 h.s. SOCIAL HISTORY: Tobacco one pack per day, occasional marijuana use. The patient is married and has two daughters ages 8 and 11. FAMILY HISTORY: Depression and bipolar disease. PHYSICAL EXAMINATION: In general he was a young male lying in bed in no apparent distress. Vital signs in the Emergency Department were temperature 97.2, heart rate 130, blood pressure 133/79, respiratory rate 30, oxygen saturation 89-92% on 15 liters of oxygen by face mask. On the floor his temperature was 100.2, heart rate 115, blood pressure 101/55, respiratory rate 31, oxygen saturation 100% on assist-controlled ventilation 750 x 18, FIO2 50%, PEEP 5. HEENT: Normocephalic, atraumatic, pinpoint symmetric pupils, endotracheal tube in place. Neck: No cervical lymphadenopathy, no thyromegaly. Chest: Coarse breath sounds throughout. Heart: Tachycardic, no murmurs, gallops, or rubs. Abdomen: Midline scar, diminished bowel sounds, nondistended. Extremities: No cyanosis, clubbing or edema. LABORATORY DATA: White count 7.5, hematocrit 30.5, platelet count 187. There were 64% neutrophils, 20% bands, 15% lymphocytes. Chemistries: Sodium 150, potassium 2.5, chloride 122, bicarbonate 19, BUN 15, creatinine 0.6, glucose 75, calcium 4.9, magnesium 1.1, phosphorous 2.8. Urinalysis was yellow, notable for [**3-15**] red blood cells, 0-2 white blood cells, few bacteria, no yeast. Chest x-ray: 1. Collapse of left lower lobe. 2. Minimal patchy right basilar opacity possibly due to aspiration. 3. Emphysema. EKG: Atrial tachycardia versus atrial fibrillation/flutter versus AVNRT 116-170s, no ST segment changes. IMPRESSION: This was a 42-year-old male with depression status post ECT complicated by vomiting, aspiration and hypoxia requiring intubation. Narrow complex tachycardia likely secondary to catecholemine surge following this episode. Arrhythmia likely exacerbated by electrolytes abnormalities. HOSPITAL COURSE: 1. Pulmonary: The patient required intubation due to hypoxic respiratory failure presumed secondary to aspiration and obstruction of airways. Review of chest x-ray disclosed bibasilar infiltrates and left lower lobe collapse. Left lower lobe collapse further investigated by chest CT likely represents bullous disease. There was no evidence of pulmonary embolus. The patient was maintained on the ventilator. He was administered clindamycin to cover for aspiration pneumonia. He underwent chest physical therapy. He was successfully extubated on [**3-2**]. On transfer to the floor he continued to undergo chest physical therapy and suctioning. 2. Infectious disease: As noted above the patient was started on a course of clindamycin for aspiration pneumonia. On [**3-4**] his antibiotics were changed to levofloxacin and Flagyl. The patient was to complete a 14-day course of antibiotics. 3. Cardiology: A. Rhythm: As noted above on admission the patient had a supraventricular tachycardia thought to be due to catecholemine surge/hypoxia. Cardiology consultation was obtained. Electrolytes were repleted. TSH was found to be within normal limits. The patient's heart rate improved during his hospital stay. The patient has been started on diltiazem. B. Ischemia: The patient's cardiac enzymes were cycled. He ruled out for myocardial infarction. He is to be started on aspirin. 4. Psychiatry: Consult service followed the patient during his hospital stay. His outpatient psychiatrist is Dr. [**Last Name (STitle) 46087**]. Following extubation the patient was accompanied by a sitter at all times since he expressed suicidal ideation. He was maintained on Klonopin. His other antidepressants were withheld. He was administered Seroquel p.r.n. anxiety. Further management of the patient's depression will occur in the inpatient setting. 5. GI: The patient was maintained on Pepcid during his hospital stay. 6. Prophylaxis: The patient was maintained on subcutaneous heparin during his hospital stay. 7. Nutrition: The patient was administered a regular diet. DISCHARGE CONDITION: Good. DISCHARGE STATUS: The patient is to be discharged for inpatient psychiatric hospitalization for management of his depression. DISCHARGE DIAGNOSES: 1. Depression. 2. Aspiration. 3. Hypotension. 4. Respiratory failure. 5. Supraventricular tachycardia. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Diltiazem 120 mg p.o. q.d. 3. Clonazepam 1 mg p.o. b.i.d. 4. Albuterol inhaler p.r.n. 5. Levofloxacin 500 mg p.o. q.d. for seven more days to complete a 14-day course. 6. Flagyl 500 mg p.o. t.i.d. for seven days to complete a 14-day course. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-ADP Dictated By:[**Name6 (MD) 36873**] MEDQUIST36 D: [**2130-3-6**] 13:29 T: [**2130-3-6**] 13:49 JOB#: [**Job Number 7862**] Admission Date: [**2130-2-27**] Discharge Date: [**2130-3-6**] Date of Birth: [**2088-2-10**] Sex: M Service: [**Location (un) **] CHIEF COMPLAINT: Aspiration status post electroconvulsive shock therapy. HISTORY OF PRESENT ILLNESS: The patient is a 42-year-old male who underwent ECT shock therapy for depression for the first time on [**2-28**]. Following ECT, the patient had an episode of vomiting a small amount of bilious material. His oxygen saturation decreased to the 80s. He woke up diaphoretic, complaining of shortness of breath and chest pain. EKG disclosed sinus tachycardia. His blood pressure was stable. He was administered Lopressor and heart rate decreased to the 100-110 range. He was sent to the Emergency Department where he was found to have an oxygen saturation of 66% with an arterial blood gas that was 7.33/45/26. The patient was intubated for hypoxic respiratory failure. He subsequently developed tachycardia to the 170s and his systolic blood pressure declined to 85/40. The patient's blood pressure improved with decreasing his sedation (propofol) but he had a persistent narrow complex tachycardia. Rate did not decrease with administration of adenosine. The patient was shocked with 100 joules x 2 yet heart rate remained in the 130s. In the Emergency Department the patient was given doses of Levophed and Flagyl. He was sent to the medical intensive care unit for further treatment. PAST MEDICAL HISTORY: 1. Depression since [**2113**]. 2. History of pneumothorax. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: 1. Wellbutrin 150 b.i.d. 2. Klonopin 1 b.i.d. 3. Remeron 15 h.s. SOCIAL HISTORY: Tobacco one pack per day, occasional marijuana use. The patient is married and has two daughters ages 8 and 11. FAMILY HISTORY: Depression and bipolar disease. PHYSICAL EXAMINATION: In general he was a young male lying in bed in no apparent distress. Vital signs in the Emergency Department were temperature 97.2, heart rate 130, blood pressure 133/79, respiratory rate 30, oxygen saturation 89-92% on 15 liters of oxygen by face mask. On the floor his temperature was 100.2, heart rate 115, blood pressure 101/55, respiratory rate 31, oxygen saturation 100% on assist-controlled ventilation 750 x 18, FIO2 50%, PEEP 5. HEENT: Normocephalic, atraumatic, pinpoint symmetric pupils, endotracheal tube in place. Neck: No cervical lymphadenopathy, no thyromegaly. Chest: Coarse breath sounds throughout. Heart: Tachycardic, no murmurs, gallops, or rubs. Abdomen: Midline scar, diminished bowel sounds, nondistended. Extremities: No cyanosis, clubbing or edema. LABORATORY DATA: White count 7.5, hematocrit 30.5, platelet count 187. There were 64% neutrophils, 20% bands, 15% lymphocytes. Chemistries: Sodium 150, potassium 2.5, chloride 122, bicarbonate 19, BUN 15, creatinine 0.6, glucose 75, calcium 4.9, magnesium 1.1, phosphorous 2.8. Urinalysis was yellow, notable for [**3-15**] red blood cells, 0-2 white blood cells, few bacteria, no yeast. Chest x-ray: 1. Collapse of left lower lobe. 2. Minimal patchy right basilar opacity possibly due to aspiration. 3. Emphysema. EKG: Atrial tachycardia versus atrial fibrillation/flutter versus AVNRT 116-170s, no ST segment changes. IMPRESSION: This was a 42-year-old male with depression status post ECT complicated by vomiting, aspiration and hypoxia requiring intubation. Narrow complex tachycardia likely secondary to catecholemine surge following this episode. Arrhythmia likely exacerbated by electrolytes abnormalities. HOSPITAL COURSE: 1. Pulmonary: The patient required intubation due to hypoxic respiratory failure presumed secondary to aspiration and obstruction of airways. Review of chest x-ray disclosed bibasilar infiltrates and left lower lobe collapse. Left lower lobe collapse further investigated by chest CT likely represents bullous disease. There was no evidence of pulmonary embolus. The patient was maintained on the ventilator. He was administered clindamycin to cover for aspiration pneumonia. He underwent chest physical therapy. He was successfully extubated on [**3-2**]. On transfer to the floor he continued to undergo chest physical therapy and suctioning. 2. Infectious disease: As noted above the patient was started on a course of clindamycin for aspiration pneumonia. On [**3-4**] his antibiotics were changed to levofloxacin and Flagyl. The patient was to complete a 14-day course of antibiotics. 3. Cardiology: A. Rhythm: As noted above on admission the patient had a supraventricular tachycardia thought to be due to catecholemine surge/hypoxia. Cardiology consultation was obtained. Electrolytes were repleted. TSH was found to be within normal limits. The patient's heart rate improved during his hospital stay. The patient has been started on diltiazem. B. Ischemia: The patient's cardiac enzymes were cycled. He ruled out for myocardial infarction. He is to be started on aspirin. 4. Psychiatry: Consult service followed the patient during his hospital stay. His outpatient psychiatrist is Dr. [**Last Name (STitle) 46087**]. Following extubation the patient was accompanied by a sitter at all times since he expressed suicidal ideation. He was maintained on Klonopin. His other antidepressants were withheld. He was administered Seroquel p.r.n. anxiety. Further management of the patient's depression will occur in the inpatient setting. 5. GI: The patient was maintained on Pepcid during his hospital stay. 6. Prophylaxis: The patient was maintained on subcutaneous heparin during his hospital stay. 7. Nutrition: The patient was administered a regular diet. DISCHARGE CONDITION: Good. DISCHARGE STATUS: The patient is to be discharged for inpatient psychiatric hospitalization for management of his depression. DISCHARGE DIAGNOSES: 1. Depression. 2. Aspiration. 3. Hypotension. 4. Respiratory failure. 5. Supraventricular tachycardia. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Diltiazem 120 mg p.o. q.d. 3. Clonazepam 1 mg p.o. b.i.d. 4. Albuterol inhaler p.r.n. 5. Levofloxacin 500 mg p.o. q.d. for seven more days to complete a 14-day course. 6. Flagyl 500 mg p.o. t.i.d. for seven days to complete a 14-day course. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-ADP Dictated By:[**Name6 (MD) 36873**] MEDQUIST36 D: [**2130-3-6**] 13:29 T: [**2130-3-6**] 13:49 JOB#: [**Job Number 7862**]

[ "E879.3", "296.30", "276.9", "458.9", "997.3", "518.81", "427.89", "507.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "94.27" ]

icd9pcs

[ [ [] ] ]

12240, 12375

8330, 8363

12396, 12500

12523, 13009

10122, 12218

8386, 10104

6676, 6733

6762, 7962

7985, 8182

8199, 8313

29,859

115,645

31834

Discharge summary

report

Admission Date: [**2111-10-16**] Discharge Date: [**2111-10-24**] Date of Birth: [**2043-12-14**] Sex: F Service: SURGERY Allergies: Heparin Agents Attending:[**First Name3 (LF) 1556**] Chief Complaint: hematemesis, bright red blood per rectum Major Surgical or Invasive Procedure: blood transfuions History of Present Illness: The patient is a 67 year-old female with coronary artery disease, history of MI, end stage renal disease on hemodialysis, diabetes mellitus, hypertension and known duodenal and gastric antral ulcers transferred from the Emergency Department of [**Hospital 1562**] Hospital for an upper GI bleed. She was admitted [**10-7**] - [**2111-10-10**] for an upper GI bleed. On the day of this current admission, she felt weak, had a non-bloody bowel movement, and went to the [**Hospital1 1562**] ED where she developed massive melena and hematochezia (1 liter). She received packed red blood cells at [**Hospital 1562**] Hospital (conflicting reports of how many - mostly likely 2) and was transferred via med flight to [**Hospital1 **] emergency department. Past Medical History: Past Medical History: - Diabetes mellitus - End stage renal disease on hemodiaylsis - hypertension - coronary [**Last Name (un) **] disease - peptic ulcer disease - congestive heart failure - diverticulitis Past surgical history: - appendectomy - cholecystectomy - c-section Physical Exam: (per surgery resident in the ED on admisson) VS HR 62 BP 120/74 intubated NG tube - frank blood Heart regular rate and rhythm Chest clear Abd obese, soft, non-distended Frank blood per rectum Pertinent Results: On admission: Hematocrit 28.0 (range 27.4 - 37.3) WBC 10.6 INR 1.4 PTT 34.1 CK 29 Trop 0.06 Electrolytes K 5.2, Creatinine 6.7, UreaN 34, Glucose 174 (others WNL) ABG 7.45/185/43/31 Angiography ([**10-16**]) No active contrast extravasation in the stomach or duodenum. Occlusion of SMA and proximal portion of the splenic artery and right hepatic artery. CXR ([**10-16**]) The ET tube tip terminates in the origin of the right main bronchus. The position was corrected and was demonstrated on the subsequent chest radiographs from 4:00 a.m. in the morning. The NG tube is coiled in the stomach with its tip most likely terminating in the mid or distal position of the stomach, not included on the field of view. There is new left lower lobe opacity which may represent either atelectasis or aspiration. No evidence of congestive heart failure is present. CXR ([**10-16**]) The patient is after median sternotomy and CABG. At least one of the mid sternal sutures is broken. The cardiac silhouette is mildly enlarged. The aorta is calcified. The right lung is essentially clear. The linear opacities in the mid area of the left lung most likely represent atelectasis. There is no sizable right pleural effusion. A left pleural effusion cannot be excluded due to the fact that the left costophrenic angle was not included in the field of view. EKG ([**10-16**]) normal sinus rhythm CXR([**10-17**]) Endotracheal tube remains in standard position, but nasogastric tube has been removed. Cardiomediastinal contours are stable in appearance. Worsening opacity in the left retrocardiac region probably represents a combination of atelectasis and effusion. Right lung is grossly clear except for minimal discoid atelectasis in the perihilar region. Echocardiography: Mild symmetric left ventricular hypertrophy with normal cavity sizes and regional/global biventricular systolic function. Mild pulmonary artery systolic hypertension. CXR (PICC placement): Interval improvement of aeration as noted above. The tip of the right subclavian line is in the right subclavian vein and requires advancement for standard positioning. Brief Hospital Course: *) GI bleed: The patient was intubated in the emergency department for airway protection given hematemesis. She had been transfused with packed red blood cells at the outside hospital (unclear number, likely 2) and on arrival her systolic blood pressure was in the 70s with a hematocrit of 28. She was transfued 4 units of packed red blood cells in the [**Hospital1 18**] emergency department with recovery of systolic blood pressure to the 120s. An initial EGD performed on [**10-16**] (night of admission) showed clot throughout the stomach and the scope could not be passed through the pylorus given that the clot covered the channel. An angiography demonstrated no active bleeding, as well as occlusions in the superior mesenteric artery and splenic artery, both which reconstituted. The patient was admitted to the surgical ICU. A second look EGD demonstrated a 1cm ulcer with a clean base in the antrum with evidence of recent bleeding which was treated with bicap and 4cc of epinephrine. Multiple shallow ulcers in the duodenum were treated with bicap. The plan, given high estimated risk of rebleed, was for angiography with attention to the left gastric artery. The patient had hematocrit checked every 8 hours. Between [**10-16**] and [**10-18**], the patient received a total of 12 units of packed red blood cells and 3 units of platelets with hematocrit ranging between 27.4 and 37.3. Since the last transfusion, her hematocrit has been stable between 27.4 and 31.0. Once she was taking clears, the patient was started on treatment for H. pylori: proton pump inhibitor (to be taken indefinitely), clarithromycin and amoxicillin (renally dosed - to be taken for a total of 2 weeks). The patient was extubated on [**10-17**] and did well from a respiratory standpoint for the rest of her admission. She was transfered from the intensive care unit to the floor on the evening of [**10-20**]. Her hematocrit remained stable, as did her vital signs for the rest of her admission. *) End stage renal disease: the patient was dialyzed on [**9-24**], [**10-20**], [**10-21**], [**10-23**]. *) FEN: The patient was advanced to sips then clears on [**10-20**], to full liquids on [**10-21**] and then to a regular, soft, diabetic diet on [**10-22**] which she tolerated well. She did complain of some loose/watery bowel movements on [**10-21**] that were light-medium brown with no blood. Stool was sent for C. difficile assay. The diarrhea resolved on the night of [**10-21**]. On dishcharge on hospital day #9, the patient's vital signs were stable, she was afebrile and she was able to tolerate a regular diet and ambulate well. She will follow up with her regular gastroenterologist and is aware that Dr. [**Last Name (STitle) **] is available should she have any problems or questions. Medications on Admission: Lantus Humalog Nephrocap Toprol Diovan Vytorin Phoslo Felodipine Amoxicillin Clarithromycin Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*5* 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO once a day. 4. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO QTUTHSASU (). 5. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Clarithromycin 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 7. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours) for 10 days. Disp:*20 Capsule(s)* Refills:*0* 8. Lantus 100 unit/mL Solution Sig: Sixty (60) Units Subcutaneous at bedtime. 9. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous sliding scale. 10. PhosLo 667 mg Tablet Sig: One (1) Tablet PO once a day. 11. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day. 12. Outpatient Physical Therapy Patient needs physical therapy for significant deconditioning after long hospitalization 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day). Disp:*qs qs* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: upper GI bleed Discharge Condition: stable Discharge Instructions: Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] > 101.5, severe pain, dizziness or lightheadedness, fainting, bleeding from the rectum or bloody/black bowel movements, vomiting blood, nausea or vomiting, or any other questions or concerns. Followup Instructions: Please follow up with your regular gastroenterologist. If needed, you can contact Dr.[**Name (NI) **] office at ([**Telephone/Fax (1) 2047**]

[ "285.1", "403.91", "531.40", "V45.1", "428.0", "250.00", "585.6", "041.86", "V45.81", "532.60", "518.89", "414.00" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "39.95", "44.13", "99.04", "99.07", "44.43" ]

icd9pcs

[ [ [] ] ]

8037, 8043

3795, 6610

318, 337

8102, 8111

1647, 1647

8428, 8574

6752, 8014

8064, 8081

6636, 6729

8135, 8405

1374, 1420

1435, 1628

238, 280

365, 1121

1661, 3772

1165, 1351

53,543

162,987

10225

Discharge summary

report

Admission Date: [**2114-7-9**] Discharge Date: [**2114-7-12**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: Fever and jaundice Major Surgical or Invasive Procedure: Endoscopic Retrograde Cholangiopancreatography (ERCP) [**7-10**] History of Present Illness: [**Age over 90 **] y.o. male with h/o chronic kidney disease, hypertension, mitral regurgitation and colon ca s/p resection who was recently admitted for painless jaundice from [**Date range (1) **] and underwent an ERCP with CBD [**Date range (1) **] placement with recent pathology consistent with adenocarcinoma who presented to [**Hospital1 **] [**Location (un) 620**] with fever and jaundice from his nursing home. At [**Location (un) 620**], T 99.7 with SBP 96/37 and HR 73. There he had a WBC of 13.8, cre 2.3, Alk P 438, ALT 69, AST 50, T bili 7.8, amylase 52 and lipase 242. He received 1 liter IVF, unasyn 1.5 g x 1 and had an abdominal CT which revealed biliary dilitation to sugesting possible obstruction of the [**Last Name (LF) **], [**First Name3 (LF) **] he was sent to [**Hospital1 18**] for ERCP. Past Medical History: Hypertension VVI ppm [**2-17**] Mobitz II Atrial fibrillation macular degeneration, legally blind cataracts h/o colon CA s/p resection 3 years ago hyperlipidemia CAD Chronic kidney disease, baseline cr 1.9. Anemia of chronic disease on epo Dementia CHF Venous insufficiency gout Mitral regurgitation h/o digoxin toxicity multiple falls Social History: Previously independent in [**Hospital3 **] with wife, but currently in [**Name (NI) 1501**] s/p recent hospitalization. Uses rolling wakler at baseline. Family History: The patient's mother had a stroke and his father had a myocardial infarction. Physical Exam: Admission Exam: ============== VITAL SIGNS: T 98.1, HR 111/48 hr 65 R 18 97% RA GEN: NAD, skin with diffuse jaundice HEENT: EOMI, MMM but tongue mildly dry, + scleral icteris PUL: CTA B/L no w/w/r CV: RR, nl S1, S2, no m/g/r ABD: +BS, minimally distended, but soft, non-tender EXT: 1+ pitting edema bilaterally left slightly more than right NEURO: Alert, oriented to person, says he is "at the [**Last Name (un) 4068**]" Skin: jaundice, LE venous stasis changes Discharge Exam: =============== VITAL SIGNS: 98.1 [**12/2072**] 60 18 98%RA BM [**7-12**] Pain 0/10 GEN: Elderly male, sitting in chair. NAD. Smiling and interactive, but more tired than last week. Far less jaundice than previous admission. RESP: CTA but diminished at bilateral bases, no wheezes, no crackles, no rhonchi, fair air exchange throughout. Dry cough. COR: RRR, no mumurs, no gallops, no rubs. ABD: + BS, soft, nondistended, nontender, no masses, no guarding. PULSES: 2+ radial bil, 2+ PT/DP bilaterally. Warm. EXT: No edema, no cyanosis, brownish disoloration above ankles L>R. SKIN : No wounds. Scattered rash to back. NEURO: Alert to person and place and [**Month (only) **]. Pleasant and engaging. Pertinent Results: Admission Labs: ============== [**2114-7-10**] BLOOD WBC-13.8* RBC-2.85* Hgb-9.4* Hct-28.6* MCV-101* MCH-33.0* MCHC-32.8 RDW-18.1* Plt Ct-166 [**2114-7-10**] BLOOD Glucose-107* UreaN-66* Creat-2.0* Na-134 K-4.7 Cl-109* HCO3-16* AnGap-14 [**2114-7-10**] BLOOD ALT-54* AST-50* LD(LDH)-151 AlkPhos-401* Amylase-54 TotBili-9.2* [**2114-7-10**] BLOOD PT-16.3* PTT-32.2 INR(PT)-1.4* [**2114-7-10**] URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-SM Urobilinogen-2* pH-5.0 Leuks-TR ERCP [**7-10**]: ========= Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Previously inserted plastic [**Month/Year (2) **] was noted at the major papilla. The [**Month/Year (2) **] looked blocked as no bile was draining. Cannulation: The previously inserted plastic [**Month/Year (2) **] was removed with a snare. Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique. Biliary Tree: Cholangiogram revealed a malignant looking distal CBD stricture with grossly dilated proximal bile duct. Procedures: A small sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A 6cm covered wall [**Month/Year (2) **] biliary [**Month/Year (2) **] was placed successfully. Good drainage noted Impression: Previously inserted plastic [**Month/Year (2) **] was noted at the major papilla. The [**Month/Year (2) **] looked blocked as no bile was draining. This [**Month/Year (2) **] was removed. Cholangiogram revealed a malignant looking distal CBD stricture with grossly dilated proximal bile duct. Sphincterotomy performed. A 6cm covered wall [**Month/Year (2) **] [REF 6971 / LOT [**Numeric Identifier 34089**]] biliary [**Numeric Identifier **] was placed successfully. Good drainage noted Micro: ====== [**2114-7-11**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2114-7-11**] BLOOD CULTURE Blood Culture, Routine-PENDING Discharge Labs: ================== [**2114-7-12**] 06:15AM BLOOD WBC-9.0 RBC-2.61* Hgb-8.3* Hct-26.3* MCV-101* MCH-31.8 MCHC-31.5 RDW-18.1* Plt Ct-191 [**2114-7-12**] 06:15AM BLOOD Glucose-106* UreaN-51* Creat-1.6* Na-134 K-4.0 Cl-109* HCO3-17* AnGap-12 [**2114-7-12**] 06:15AM BLOOD TotBili-5.7* [**2114-7-12**] 06:15AM BLOOD Calcium-7.7* Phos-2.4* Mg-1.8 Brief Hospital Course: Patient brought to the [**Hospital Unit Name 153**] from [**Hospital1 **] due to fever and jaundice, with CBD dilatation around a previously placed CBD [**Hospital1 **] and was to be scheduled for an ERCP. Previous pathology report revealed an adenocarcinoma of the bile duct; in [**Hospital Unit Name 153**], patient received unasyn, fluids, and was sent for another ERCP before transfer to the floor. 1. Biliary obstruction with sepsis Fever at [**Location (un) **] with ecoli in blood cultures at [**Hospital1 **] [**Location (un) 620**]. He received Unasyn for bacteremia which was changed to ceftriaxone [**7-11**] based on sensitivities. He continued to do well clinically without fever and decreasing WBC (max 13.8 at [**Hospital1 18**]). Cytology from ERCP last week with adenocarcinoma. S/P ERCP [**7-10**] with change to metal [**Month/Year (2) **]. Total bili trending down. Tolerating regular diet. Jaundice markedly improved from previous admission. Family meeting with patient and secondary health care proxy and friend [**Name (NI) **] [**Name (NI) 34090**]. Given his advanced age and comorbidities, treatment options for adenocarcinoma are limited and we recommend hospice care - the data compiled here are most consistent with cholangiocarcinoma, however, pancreatic adenocarcinoma is also a possibility. As he has severe CKD and other co-morbidities, he is not a surgical candidate given this and his age. He would be very unlikely to survive surgery. Further diagnostic workup was not pursued as it would not alter the treatment options. His CKD also precludes the use of chemotherapy. After a long discussion with his health care proxy, a palliative approach was decided on, at our recommendation. - Will need to complete a total 14 day course of antibiotics for sepsis, last dose of cefuroxime and flagyl [**2114-7-23**]. - Regular low fat diet. 2. Hypertension Well controlled while hospitalized. He was maintained on metoprolol 12.5 [**Hospital1 **] and prazosin was held. - On discharge will change to atenolol and restart prazosin. - Monitor BP. 3. Atrial fibrillation PPM in place for second degree heart block. Continued on beta blocker with heart rates 70s. Off digoxin related to recent toxicity, no coumadin per PCP because of falls. Avoid ASA for 7 days r/t ERCP. 4. Acute on chronic kidney disease stage IV BUN/Cr down to 1.6 on discharge, baseline levels around 1.9 - Renally dose medications. 5. Dementia Stable, no evidence of delirium at this time. Continue non-pharmacological reorientation strategies including alteration of sleep/wake cycle, activity, nutrition/hydration. - Avoid sedating medications. - Give patient time to respond, consider hearing loss when communicating. Also legally blind. 6. Anemia Continue folate for macrocytic anemia. Was on Procrit at [**Location (un) 34091**], he did not receive this while hospitalized. Due per their records [**2114-7-19**]. 7. Hyperlipidemia Zocor and allopurinol were held given elevated liver enzymes. 8. Chronic systolic heart failure Furosemide was held during admission because of limited oral intake after ERCP. Lung sounds were slightly diminished on day of discharge. - Restart furosemide at [**Hospital1 1501**] and monitor fluid volume status, hypotension. - ACE currently on hold to slightly titrate back as BP allows as outpatient. Medications on Admission: 1. Pantoprazole 40 mg PO Q24H 2. Hexavitamin 1 Cap PO DAILY 3. Metoprolol Succinate 50 mg PO DAILY 4. Prazosin 1 mg [**Last Name (un) **] PO BID 5. Ferrous Sulfate 325 mg PO BID 6. Folic Acid 1 mg PO DAILY 7. Furosemide 20 mg PO DAILY Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Cefuroxime Axetil 250 mg Tablet Sig: One (1) Tablet PO twice a day for 11 days. 5. Prazosin 1 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 11 days. 8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day: Hold for SBP <100. Discharge Disposition: Extended Care Facility: [**Location (un) **] - [**Location (un) 620**] Discharge Diagnosis: Primary diagnosis: 1. Adenocarcinoma 2. Transaminitis 3. Biliary duct dilitation 4. Leukocytosis Seconday diagosis: 1. Chronic kidney disease 2. Hypertension 3. BPH 4. Dementia 5. Hyperlipidemia 6. Coronary artery disease 7. Diastolic heart failure with MR 8. Gout 9. Venous insufficiency 10. VVI ppm [**2-17**] Mobitz II 11. Atrial fibrillation 12. macular degeneration, legally blind 13. cataracts 14. h/o colon CA s/p resection 3 years ago Discharge Condition: Stable. Tolerating regular diet. Denies pain or nausea. Out of bed to chair. Discharge Instructions: You were admitted with fever and increased jaundice. You had a repeat ERCP procedure [**7-10**] to have the biliary [**Month/Year (2) **] replaced to a metal [**Month/Year (2) **]. You will need to take antibiotics for bacteria in your blood for a total of 14 days, the last dose of this will be [**2114-7-23**]. Call your primary care doctor to come back to the hospital if you develop worsening fevers greater than 101. If you have pain, nausea, or shortness of breath you can call the hospice team. Followup Instructions: Please follow up with your primary care [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) **] within one week of discharge. [**Telephone/Fax (1) 19980**] Completed by:[**2114-7-12**]

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icd9cm

[ [ [] ] ]

[ "97.05", "51.85" ]

icd9pcs

[ [ [] ] ]

9780, 9853

5464, 8818

280, 347

10340, 10422

3039, 3039

10976, 11212

1740, 1820

9104, 9757

9874, 9874

8844, 9081

10446, 10953

5099, 5441

1835, 2299

2315, 3020

222, 242

375, 1192

3055, 5083

9893, 10319

1214, 1552

1568, 1724

1,541

100,705

4640

Discharge summary

report

Admission Date: [**2104-8-15**] Discharge Date: [**2104-9-9**] Service: VSURG Allergies: Penicillins / Cephalosporins / Carbapenem / Aztreonam Attending:[**First Name3 (LF) 1781**] Chief Complaint: Fevers and confusion, new Major Surgical or Invasive Procedure: Right foot debridment [**2104-8-27**] History of Present Illness: Patient recently discharged form our hospital areturn to ER with fever,chill and confusion. Vascular consulted during ER evaluation. Patient now admitted to vascular service for continued care(.Note on physical exam in ER. rt. leg cellulitis and foot color changes.Patient's PCP and vascular [**Name9 (PRE) 19670**] opted for conserative treatment. He was started on Ceftriaxone and flagyl ) Past Medical History: Diabetes type one, insulin dependant COPD CAD, s/p MI [**2094**] pneumonia, recent treated PVD esophgitis hypercholestremia history of CVA right sided s/p CABGsx4 s/p rt. toe amputations #3&4 Social History: not avaible Family History: unknown Physical Exam: Vital signs: 100.7-89-16 92/52 oxygen saturation on 6liter/nasal cannula 98% General: oriented x2. No acute distress Heart: irregular irregular rythmn Lungs: corase crackles LLL ABD: bengin EXT: right foot: large dorsal foot ersovie ulcer, not gangrenous with erthyema, warm to palpation and toe blanching Pulses: radial and femoral pulses palpable bilaterally, popliteal biphasic signal bilaterally. right pedal pulses moophasic signal. Left pedal pulses biphasic signal. Neuro Ox2, grossly intact Pertinent Results: [**2104-8-14**] 10:21PM LACTATE-2.0 [**2104-8-14**] 10:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2104-8-14**] 10:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2104-8-14**] 10:10PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 [**2104-8-14**] 10:00PM GLUCOSE-65* UREA N-19 CREAT-0.7 SODIUM-137 POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-32* ANION GAP-12 [**2104-8-14**] 10:00PM CK(CPK)-26* [**2104-8-14**] 10:00PM CK-MB-2 cTropnT-<0.01 [**2104-8-14**] 10:00PM WBC-20.0* RBC-4.19* HGB-13.1* HCT-38.4*# MCV-92 MCH-31.2 MCHC-34.0 RDW-13.8 [**2104-8-14**] 10:00PM NEUTS-83.3* LYMPHS-10.9* MONOS-5.4 EOS-0.3 BASOS-0.2 [**2104-8-14**] 10:00PM PLT COUNT-228 [**2104-8-14**] 10:00PM PT-12.5 PTT-30.1 INR(PT)-1.0 Brief Hospital Course: [**2104-8-15**] admitted vascular surgical service.right foot infection continued on Cefriaxone and flagyl.Now with fever of 102.5 and mental status changes in last twentfour hours. admitting chest xray left lower pneumonia antibiotics were changed to vancomycin,levofloxcin and flagyl IV. The night of admission patient became more confused, hypoglycemic with ? seizures VS. rigors and hypotension. He was transfered to ICU for hemodynamic monitering. right internal jugular line was placed withut pneumo thorax.Patient blood pressure responded to 2 liters of fluid bolus. Patient remained with low grade fever 100.5 but was hemodynamically stable. Total WBC 21.A D10 IV drip was instuted for his hypoglycemia. [**2104-8-16**] [**Last Name (un) **] service was consulted for glycemic control.Podiatry recommended continued current managment. Consider radical soft tissue debridment of right foot. [**2104-8-17**] patient 's WBC showed improvement. 14.4 Digoxin level was 0.6 and his digoxin was restarted.Blood cultures positive gram positive cocci.along with wound culture. cardology consulted. P mibi recommended 7/26/04abnormal P mibi. Echo obtained to asses left ventricular function.EF 30% with multiple reginol wall motion abnormalities.Patient at considerable cardiac risk. This was discussed with Dr. [**Last Name (STitle) **] by DR. [**Last Name (STitle) **] [**Name (STitle) 19671**] consultant. [**2104-8-19**] transfered to VICU [**2104-8-25**] angiogram with angioplasty and stenting of right TPT. [**2104-8-27**] debridment of right TMa VAC dressing application. [**2104-8-28**] urine c/s and urinalysis sent for mucous in urine. urinalysis was positive. Foley was removed. patient continued on antibiocs. wound c/s and bone c/s postive for MRSA. [**2104-9-2**] right TMA. Infectious disease consulted. Lenght of antibiotic for MRSA six weeks since bone culture positive. [**2104-9-3**] inital dressing removed. skin edges well approximated. no erythema.no drainage. ambulation strict nonweight bearing. Seen by physical theraphy who recommends rehab at discharge prior returning home. [**Last Name (un) **] continued to follow patient and adjust insluin dosing. [**2104-9-5**] levofloxcin discontinued. [**9-6**] flagyl dicontinued anerobic cultures no growth. [**2104-9-9**] PICC line placed. wbc 10.0 bun/cr. 18/0.6. 8/.17/04 discharged afebrile and stable Medications on Admission: medrol 4mgm qd surfate 240mgm qbid magoxide 400mgm [**Hospital1 **] insulin Humelin N 100 u [**Hospital1 **] insulin Humellin R [**Hospital1 **] pravachol 40mgm HS rinitidine 150mgm [**Hospital1 **] ASA 81 mgm qd lanoxin 125mgm qd atrovent MDI prn enalapril 5mgm dq fosmax 70mgm q week combivent MDI Flovent MDI Imdur 20mgm qd lasix 20mgm qd Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-25**] Puffs Inhalation Q6H (every 6 hours) as needed. 3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Methylprednisolone 4 mg Tablet Sig: One (1) Tablet PO QD (once a day). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-25**] Sprays Nasal QID (4 times a day) as needed. 10. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 11. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal QD (once a day) as needed. 14. Sodium Chloride 0.9% Flush 3 ml IV QD:PRN Peripheral IV - Inspect site every shift 15. Vancomycin HCl 1000 mg IV Q18H Previously approved by ID. 16. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous at bedtime. 17. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: Humalog breakfast/dinner: glucose < 80/ no insulin glucose 81-120/3u glucose 121-160/5u glucose 161-200/10u glucose 201-240/12u glucose 241-280/14u glucoses 281-320/16u glucose 321-360/18u glucose 361-400/20u glucose > 400/ [**Name8 (MD) 138**] MD. Lunch: glucoses <160/ no insulin glucoses 161-200/2u glucose 201-240/6u glucose 241-280/8u glucose 281-320/10u glucose 321-360/12u glucose 361-400/14u HS: glucoses<240/no insulin glucose 241-280/2u glucose 281-320/4u glucose 321-360/6u glucose 361-400/8u glucose > 400 [**Name8 (MD) 138**] MD. . Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: osteomylitis rt. foot s/p Right TMA MRSA wound infection Discharge Condition: stable Discharge Instructions: Moniter ESR while on antibiotics. trough level q week. contiune antibiotic for 6 weeks from [**2104-9-2**] finger glucoses qid Followup Instructions: 2 weeks Dr.[**Last Name (STitle) **]. call for appointment. [**Telephone/Fax (1) 1784**] Completed by:[**2104-9-9**]

[ "682.6", "707.15", "599.0", "428.0", "486", "440.24", "995.91", "038.11", "496" ]

icd9cm

[ [ [] ] ]

[ "39.50", "38.93", "88.48", "84.11", "93.57", "84.12", "83.39" ]

icd9pcs

[ [ [] ] ]

7222, 7294

2394, 4776

283, 322

7394, 7402

1548, 2371

7577, 7696

1004, 1013

5170, 7199

7315, 7373

4802, 5147

7426, 7554

1028, 1529

218, 245

350, 743

765, 959

975, 988

58,296

159,974

2031

Discharge summary

report

Admission Date: [**2183-11-25**] Discharge Date: [**2183-12-1**] Service: MEDICINE Allergies: Lisinopril / Plaquenil / Haldol Attending:[**First Name3 (LF) 7299**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 88 yo F w/ mild dementia at baseline, RA, HTN, anemia, CRI, last [**Hospital1 18**] admission ([**Date range (1) 11130**]) for AMS empirically treated for HAP and meningitis with vanc, cefepime, ampicillin, acylcovir x14 days, hospitalization c/b NMS [**2-25**] haldol she received in ED on that presentation, who presents with dyspnea. At baseline she is alert, conversant, uses an electric wheelchair. She has no baseline dementia and is primarily independent in ADS. . Per nursing home records, patient awoke short of breath and not feeling well. VS initially notable for O2 Sat 50%, increased to to 72% on 4L nasal cannuala. She was transferred to [**Hospital1 18**] ED. In the ED, initial VS 97.3 103 117/72 32 90% 8L NRB. She was intubated for hypoxia. She denied chest pain, cough, sputum, and fevers in the ED. Exam notable for dyspnea, and was guaic negative. CXR w/o effusion, consolidation, or pneumothorax. She had a CTA that showed bilateral segmental and subsegmental pulmonary emboli w/ small LLL peripheral wedged opacity, which could represent pulmonary infarct, and evidence of R heart strain. Labs notable for Trop 0.12, Cr 1.4, BNP 154, WBC 14.4, Hgb 10.7, INR 1.1. On the [**Hospital1 **], her ABG was 7.28, 53, 326. She received ASA 600mg, Albuterol/Ipratropium nebs, started on Heparin gtt, and Fent/Midaz for sedation. She was planned to go to the [**Hospital Unit Name 153**], but her SBP briefly dropped into the 80s. There was consideration of lysis, so she was changed to a West bed. However, with decreasing of her sedation, her SBP came up into the low 100s. She also received 4 L NS. She never received pressors or a central line. Family has not been contact[**Name (NI) **]. [**Name2 (NI) 5442**] settings prior to transfer: AC 500/18, PEEP 5, 100% FiO2. Past Medical History: 1. Erosive RA - previously on plaquenil (off >10 years). Also h/o chronic NSAID use. No DMARDs or biologics in the past per rheum note 04/[**2183**]. On prednisone 10mg daily (likely started 04/[**2183**]). 2. Aortic insufficiency (1+ on echo in [**2176**]) 3. HTN 4. Anemia - previous labs c/w anemia of chronic inflammation, also h/o B12 deficiency 5. CRI (baseline Cr around 1.4-1.5) 6. Hyperlipidemia 7. Vitiligo (secondary to plaquenil use) 8. Hx of esophageal tear [**2178**] 9. Positive PPD in past, per PCP no [**Name Initial (PRE) **]/o INH treatment Social History: Originally from [**Country **]. Currently in nursing home facility ([**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]). Has one sister, who lives out of state. No children. Tobacco: no smoking history per medical records. No EtOH or illicit drug use. Family History: none relavent to this presentation Physical Exam: General: intubated, sedated, not resposive to voice HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: clear anteriorly CV: regular, no murmurs appreciated Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, R knee valgus deformity Skin: patchy vitiligo Pertinent Results: [**2183-11-25**] 01:47PM WBC-11.0 RBC-3.59* HGB-9.6* HCT-30.2* MCV-84 MCH-26.8* MCHC-31.7 RDW-16.1* [**2183-11-25**] 12:02PM TYPE-ART PO2-106* PCO2-51* PH-7.27* TOTAL CO2-24 BASE XS--3 [**2183-11-25**] 06:15AM GLUCOSE-148* UREA N-27* CREAT-1.4* SODIUM-138 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16 CXR [**11-25**]: No definite evidence of acute cardiopulmonary process. CTA Chest [**2183-11-25**] - 1. Occlusive and nonocclusive lobar, segmental and subsegmental bilateral pulmonary emboli involving bilateral upper and lower lobes, with significant clot burden and possible right heart strain. 2. Left lower lobe small peripheral opacity likely represents a pulmonary infarct. 3. Stable right apical pulmonary scarring with calcifications, likely prior granulomatous disease. Bilaterl Lower Extremity U/S [**2183-11-27**] - 1. Occlusive DVT in the right superficial femoral and popliteal vein, but not involving the common femoral vein. 2. No left lower extremity DVT. Brief Hospital Course: 88 year-old woman presents with bilateral pulmonary emboli with evidence of right heart strain. # Pulmonary emboli: Patient markedly hypoxic with evidence of R heart strain on CTA secondary to multiple pulmonary emboli. Briefly hypotensive in the ED. On arrival to the ICU, she was hemodynamically stable with SBP >100. Pt was treated with heparin gtt and her FiO2 was quickly weaned to 40%. Given absence of hemodynamic instability and stable oxygenation, lysis was not performed. TTE with bubble study was done and showed patent foramen ovale. Lower extremity ultrasound showed a persistent right-sided DVT. Patient was transferred to the floor, started on warfarin and continued on heparin until INR > 2.0 Patient was weaned from oxygen and was chest pain free by the time of discharge. INR will need to be checked q48 hours after discharge until stable warfarin dose determined. Warfarin needs to be continued for at least 3 months, at which time decision can be made by primary care physician regarding risks/benefits of continuing anticoagulation in Mrs. [**Known lastname 805**]. # Rheumatoid arthritis: On 10 mg prednisone at home. Likely has some adrenal insufficiency related to that. Given borderline hypotension and chronic prednisone use, pt was given stress dose steroids on presentation to the ICU. She was tapered back to maintenance dose of prednisone (10 mg daily) prior to discharge. # Urinary Tract Infection: Patient had a foley catheter in place during admission which was removed but she was noted to have a positive UA. Pt was started on empiric Cipro 500 mg daily for a five day course and Urine Cx was pending at the time of discharge. She will need a follow up CBC [**12-4**] to confirm resolution of mild leukocytosis. Final Urine Cx revealed mixed flora. Medications on Admission: Acetaminophen prn Amlodipine 5 mg daily Bisacodyl 10 mg prn Prednisone 10 mg daily Mirtazapine 15 mg daily Tramadol 25 mg q8h Discharge Medications: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 5. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: 7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: Pulmonary Embolism Deep Vein Thrombosis Right Ventricular Hypokinesis Patent Foramen Ovale Secondary Diagnosis: Rheumatoid Arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with shortness of breath. You were found to have blood clots in your lungs. You temporarily required a machine to help you breath while you were started on blood thinners. You improved very quickly. You were also found to have a blood clot in your right leg. You will need to take blood thinners (a pill) after discharge to help treat your blood clots. You are being treated for a UTI - you will need to continue medication for 4 days after discharge to complete your antibiotic course. Followup Instructions: Please follow-up with your PCP after discharge from the rehabilitation center.

[ "272.4", "403.90", "714.0", "V12.42", "429.9", "518.81", "585.9", "415.19", "599.0", "288.60", "745.5", "453.40" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

6945, 7035

4433, 6237

248, 254

7213, 7213

3416, 4410

7940, 8022

2955, 2991

6414, 6922

7056, 7148

6263, 6391

7389, 7917

3006, 3397

201, 210

282, 2071

7169, 7192

7228, 7365

2093, 2654

2670, 2939

11,285

174,354

5979

Discharge summary

report

Admission Date: [**2163-10-19**] Discharge Date: [**2163-10-20**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: 81 yo m w/ low grade BCL s/p multiple cycles of ritaxin. c/o fatigue, seen in Dr.[**Initials (NamePattern4) 10560**] [**Last Name (NamePattern4) **] found to be anemic. BmBx revealed Hodgkins On day of admission, while receiving bleomycin developed chills, t t0 104, w/ sao2 to 88%. Rec'd demerol and benadryl and taken to ED where he was febrile to 105, rigoring, and rec'd ativanx3, started on cefepime. ROS positive for cough x2wks, no sob. Also chills/ night sweats. Past Medical History: prostate ca, s/p radiation htn gout tia BCL Hodgkins Social History: Lives w/ wife Family History: NC Physical Exam: 104.5, p 110, bp 152/59, r 20-24, sao2 96% minimally responsive, localizes pain PERRLA. Moist MMM No JVD Regular, tachycardic, S1, S2. No m/r/g LCA b/l +bs. soft. nt. nd. no le edema Pertinent Results: [**2163-10-19**] 05:20PM BLOOD WBC-1.0* RBC-3.87* Hgb-10.3* Hct-31.6* MCV-82 MCH-26.6* MCHC-32.5 RDW-18.5* Plt Ct-83* [**2163-10-19**] 05:20PM BLOOD PT-14.5* PTT-29.8 INR(PT)-1.3 [**2163-10-19**] 05:20PM BLOOD Gran Ct-790* [**2163-10-19**] 05:20PM BLOOD Calcium-8.2* Phos-2.8 Mg-1.8 [**2163-10-19**] 05:32PM BLOOD Lactate-2.8* CXR: No evidence of pneumonia. Brief Hospital Course: 81yo m w/ hodgkins lymphoma, who developed f/rigors in the setting of bleomycin infusion. 1) fever- Pt became afebrile soon after transfer to the MICU. By the morning after admission he felt well and had no complaints. At this point his standing tylenol was discontinued and he did not spike. Onc agreed with our assessment that his syndrome was due to bleomycin toxicity. Pt felt stable for discharge. 2) [**Name (NI) 12329**] Pt continued on dilt. BP was stable. 3) Prostatitis - pt continued on his cipro. 3) Px: pneumoboots, GI until taking p.o. 4) Glucose: stable on QID finger sticks. 5) T/L/D- PIV 6) Full code Medications on Admission: Cipro Allopurinol Dilt Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Diltiazem HCl 60 mg Capsule, Sust. Release 12HR Sig: One (1) Capsule, Sust. Release 12HR PO once a day. Disp:*30 Capsule, Sust. Release 12HR(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Bleomycin reaction Discharge Condition: stable, afebrile, and on room air Discharge Instructions: follow up with your oncologists as scheduled continue all of your current medications as listed in the discharge paperwork. Please call Dr [**Last Name (STitle) **] or go to the Emergency room if you have fever, chills, lightheadedness, or trouble breathing. Followup Instructions: Provider: [**Name10 (NameIs) **] FELT, RN Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-10-21**] 10:30 Provider: [**Name10 (NameIs) 17515**] CHAIR 2D Date/Time:[**2163-10-21**] 10:30 Provider: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-10-26**] 1:30 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "E933.1", "274.9", "780.6", "601.9", "202.80", "401.9", "V10.46" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2615, 2621

1517, 2149

275, 282

2684, 2719

1133, 1494

3026, 3599

910, 914

2222, 2592

2642, 2663

2175, 2199

2743, 3003

929, 1114

232, 237

310, 787

809, 863

879, 894

29,861

151,810

4276

Discharge summary

report

Admission Date: [**2133-9-12**] Discharge Date: [**2133-9-15**] Date of Birth: [**2064-2-24**] Sex: F Service: SURGERY Allergies: Streptomycin / Versed / Fentanyl Attending:[**First Name3 (LF) 974**] Chief Complaint: right lower quadrant abdomen pain Major Surgical or Invasive Procedure: [**2133-9-12**]: s/p laparoscopic appendectomy History of Present Illness: 69 year-old female, arrives to Emergency Dept c/o right lower quadranct pain, for one day duration. She describes the pain as sharp, sudden onset, rates pain [**10-14**] to [**7-14**], constant, non-radiating. She has never had this pain before. She has been able to tolerate normal diet. Denies recent trauma or illness. Positive chills. Patient denies chest pain, shortness of breath, nausea, vomiting and diarrhea Past Medical History: 1. CAD 2. Diastolic CHF 3. Pulmonary HTN 4. Atrial fibrillation 5. DM II 6. OSA 7. Hypothyroidism 8. Anemia with B12 and iron deficiency 9. HTN 10. Thrombocytopenia 11. Anxiety 12. Depression 13. Peripheral neuropathy 14. h/o falls 15. Ascites, unclear duration - extensive w/u with SAAG reportedly 2.4 at FH 1 month ago, attributed to right heart failure, reportedly awaiting transjugular bx at [**Hospital1 112**] 16. s/p asystolic arrest at elective EGD after receiving Versed and fentanyl 17. CRI (baseline 1.0-1.4) 18. Back pain Social History: Armenian, speaks russian and is able to understand english minimally. Lives with husband. [**Name (NI) **] [**Name2 (NI) **], etoh, gets around on wheelchair Family History: noncontributory Physical Exam: VS: 97.3, 83, 116/51, 19, 99RA Gen: slightly distress, appears uncomfortable CV: normal S1, prominent S2 Chest: CTAB anteriorly ABD: RLQ tenderness, soft, nondistended, +psoas sign (mild) Ext: warm, well perfused Pertinent Results: Admission Labs -------------- [**2133-9-12**] 10:15PM POTASSIUM-3.6 [**2133-9-12**] 10:15PM CK(CPK)-73 [**2133-9-12**] 10:15PM CK-MB-NotDone cTropnT-<0.01 [**2133-9-12**] 10:15PM PHOSPHATE-3.3 MAGNESIUM-2.0 [**2133-9-12**] 10:15PM TYPE-ART TEMP-36.3 RATES-14/ TIDAL VOL-500 PEEP-5 O2-100 PO2-269* PCO2-39 PH-7.47* TOTAL CO2-29 BASE XS-5 AADO2-424 REQ O2-72 INTUBATED-INTUBATED VENT-CONTROLLED [**2133-9-12**] 10:15PM LACTATE-0.8 [**2133-9-12**] 10:15PM freeCa-1.07* [**2133-9-12**] 10:15PM HCT-25.4* [**2133-9-12**] 10:15PM PT-17.9* PTT-28.8 INR(PT)-1.7* [**2133-9-12**] 08:43PM GLUCOSE-97 LACTATE-0.7 NA+-136 K+-4.0 CL--103 TCO2-29 [**2133-9-12**] 08:43PM HGB-9.5* calcHCT-29 O2 SAT-99 [**2133-9-12**] 08:43PM freeCa-1.07* [**2133-9-12**] 01:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2133-9-12**] 10:53AM GLUCOSE-270* LACTATE-1.2 K+-4.7 [**2133-9-12**] 10:45AM ALT(SGPT)-19 AST(SGOT)-23 ALK PHOS-51 AMYLASE-85 TOT BILI-0.6 [**2133-9-12**] 10:45AM LIPASE-49 [**2133-9-12**] 10:45AM WBC-8.5 RBC-3.34* HGB-10.0* HCT-29.8* MCV-89 MCH-29.9 MCHC-33.5 RDW-15.0 [**2133-9-12**] 10:45AM NEUTS-78.2* LYMPHS-17.2* MONOS-3.7 EOS-0.7 BASOS-0.1 [**2133-9-12**] 10:45AM PLT COUNT-134* [**2133-9-12**] 10:45AM PT-28.6* PTT-31.4 INR(PT)-3.0* . Radiology studies ----------------- [**2133-9-12**] 12:16 PM ~CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST 69 year old woman with rlq abd pain & tenderness IMPRESSION: 1. Acute uncomplicated appendicitis. 2. Cholelithiasis. . Discharge Labs ------------- [**2133-9-15**] 06:45AM BLOOD WBC-7.5 RBC-2.93* Hgb-8.9* Hct-25.7* MCV-88 MCH-30.3 MCHC-34.6 RDW-14.8 Plt Ct-147* [**2133-9-12**] 10:45AM BLOOD Neuts-78.2* Lymphs-17.2* Monos-3.7 Eos-0.7 Baso-0.1 [**2133-9-15**] 06:45AM BLOOD Plt Ct-147* [**2133-9-15**] 06:45AM BLOOD PT-14.4* PTT-23.8 INR(PT)-1.3* [**2133-9-15**] 06:45AM BLOOD Glucose-102 UreaN-44* Creat-1.4* Na-143 K-4.0 Cl-105 HCO3-30 AnGap-12 [**2133-9-14**] 06:05AM BLOOD CK(CPK)-52 [**2133-9-14**] 06:05AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2133-9-13**] 10:02PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2133-9-13**] 08:13AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2133-9-13**] 03:03AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2133-9-15**] 06:45AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.3 . Coagulation Labs ---------------- [**2133-9-15**] 06:45AM BLOOD PT-14.4* PTT-23.8 INR(PT)-1.3* [**2133-9-14**] 02:40AM BLOOD PT-16.5* PTT-26.3 INR(PT)-1.5* [**2133-9-13**] 08:13AM BLOOD PT-18.4* PTT-25.9 INR(PT)-1.7* [**2133-9-13**] 03:03AM BLOOD PT-18.6* PTT-27.2 INR(PT)-1.8* [**2133-9-12**] 10:15PM BLOOD PT-17.9* PTT-28.8 INR(PT)-1.7* [**2133-9-12**] 10:45AM BLOOD PT-28.6* PTT-31.4 INR(PT)-3.0* Brief Hospital Course: GI: Admitted to Dr.[**Name (NI) 18535**] [**Name (STitle) 4869**] on [**2133-9-12**] for right lower quadrant pain. Abdominal CT demonstrated an inflamed but non-ruptured appendix. The pt was taken to the OR after INR was reversed with FFP, and a laparoscopic appendectomy was performed without complications. On POD2, diet was advanced without event and by POD3 the pt was tolerating a regular diet without nausea or vomiting; in addition, she was passing flatus and having bowel movements. CV: Post-operatively, the pt remained intubated for respiratory failure/congestive heart failure due to afib with a rapid ventricular response. The pt was diuresed overnight and weaned from the ventilator the following morning in the ICU. Cardiac workup revealed non-diagnostic ST and T wave changes on EKG and troponin was 0.02 the following morning. Cardiac consult was obtained and determined that the pt had a leak in setting of demand ischemia due to the rapid ventricular rate. In the ICU, rate was controlled with a diltiazem drip, which was weaned over the first day and the pt was transitioned to beta-blockade with good rate control. On the floor, the cardiology service recommended starting diltiazem PO and this was done upon discharge, POD3. ID: Pt was febrile on admission, but postoperatively was afebrile. WBC on admission were 13.6, maximizing at 16.0 on POD1. By POD3, WBCs were 7.5. The pt was given antibiotics in the perioperative period, but these were not continued in the ICU or on the floor. Medications on Admission: Lantus insulin Lasix 40mg daily Synthroid 88mg daily Lisinopril 10mg daily Tricor 145mg daily Protonix 40mg po daily Lipitor 10 mg daily Amitriptoline (patient unaware of dose) Glipizide 5mg po daily Coumadin 5mg fri/sat 7.5mg sun-thursday Senna Folate Thiamine Tylenol Discharge Medications: 1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 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). Disp:*60 Capsule(s)* Refills:*2* 7. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*60 Capsule, Sustained Release(s)* Refills:*2* 8. Lantus Subcutaneous 9. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*60 Tablet(s)* Refills:*2* 10. Glipizide Oral 11. Amitriptyline Oral Discharge Disposition: Home Discharge Diagnosis: appendicitis, non-perforated Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs different form normal. Adhere to 2 gm sodium diet. If you develop fever >101.3, abdominal pain or distention, nausea or vomiting, or any other symptom concerning to you please call [**Hospital1 18**]. Take medications as prescribed by your physician. Followup Instructions: Please follow up in [**2133-11-25**] with Dr. [**Last Name (STitle) 171**] Cardiology. Please see Dr. [**Last Name (STitle) **] on [**2133-9-25**] @ 1115am in the [**Hospital **] Medical Office Building for [**Hospital **] hospital follow-up. Please follow up with your PCP on [**Name9 (PRE) 2974**], [**2133-9-18**] @345pm with Dr. [**Last Name (STitle) 12981**]. At this appointment they will check your electrolytes and INR. At this time a decision to start you lasix will be made and your coumadin dose with be determined.

[ "518.81", "V58.61", "585.9", "428.0", "250.00", "428.33", "403.90", "300.4", "427.31", "327.23", "416.8", "496", "244.9", "281.1", "356.9", "540.9" ]

icd9cm

[ [ [] ] ]

[ "99.07", "47.01" ]

icd9pcs

[ [ [] ] ]

7347, 7353

4583, 6104

325, 374

7426, 7435

1834, 4560

7808, 8340

1569, 1586

6424, 7324

7374, 7405

6130, 6401

7459, 7785

1601, 1815

252, 287

402, 820

842, 1377

1393, 1553

43,731

190,000

42690

Discharge summary

report

Admission Date: [**2191-2-21**] Discharge Date: [**2191-2-24**] Date of Birth: [**2149-3-1**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 3298**] Chief Complaint: chest pain, dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 41 yo male w/ h/o squamous cell cancer involving right jaw s/p resection and remission p/w saddle pulmonary embolism. One week PTA pt was found to have left lower extremity dvt involving the greater saphenous vein. He was not anticoagulated at that time. Three days prior to admission, he began to have upper abdominal or lower chest pain. Earlier today, he presented to an OSH with chest pain and dyspnea. He was found to have a saddle pulmonary embolism, started on iv heparin gtt, and transferred to [**Hospital1 18**] ED for further managment. Also at the OSH, a triple lumen CVC was placed via IR guidance. He was bolused heparin and started on gtt. Guaiac reportedly negative. Reportedly had Troponin I 0.52. In the ED, initial VS were: 97.4 90 105/79 16 98%. He was given dilaudid 10mg iv once, heparin gtt was continued, Transfer vitals were 97.4 98 105/79 18 93-94%on RA. In the MICU, he continued to have dull chest pian in his mid to left chest. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -MRSA right jaw infection with fistula -SCC with right jaw involvement s/p resection. Diagnosed in [**2184**] and had several attempts at resection with positive margins and radiation. It recurred in [**2189**] when he had a right mandibular resection with fibular reconstruction. -superficial clot in L saphenous vein -HCV diagnosed 13 years ago s/p attempted pegylated interferon and ribavarin rx which was discontinued [**1-17**] for intractable n/v -history of polysubstance abuse including injection of heroin (last [**2178**]) and snorting cocaine Social History: Formerly worked in construction. - Tobacco: 26 pk yr history, quit 5 yrs ago - Alcohol: none - Illicits: h/o heroin and cocaine, last use [**2178**] Family History: No history of thromboembolic disease Physical Exam: Vitals: T:98 BP:87 P:119/77 R:15 O2:95% RA General: Alert, significant scarring of the right face with distortion of mouth. oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD, R CVL 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, healed scars from prior surgeries 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. Pertinent Results: [**2191-2-21**] 10:56PM PT-14.1* PTT-137.8* INR(PT)-1.3* [**2191-2-21**] 09:39PM COMMENTS-GREEN [**2191-2-21**] 09:39PM GLUCOSE-100 LACTATE-1.3 K+-3.6 [**2191-2-21**] 09:35PM GLUCOSE-105* UREA N-15 CREAT-0.7 SODIUM-136 POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14 [**2191-2-21**] 09:35PM estGFR-Using this [**2191-2-21**] 09:35PM proBNP-2457* [**2191-2-21**] 09:35PM WBC-5.9 RBC-4.32* HGB-13.6* HCT-39.1* MCV-91 MCH-31.4 MCHC-34.7 RDW-16.4* [**2191-2-21**] 09:35PM NEUTS-36.7* LYMPHS-53.7* MONOS-8.1 EOS-0.7 BASOS-0.9 [**2191-2-21**] 09:35PM PLT COUNT-105* [**2191-2-21**] 09:35PM [**Name (NI) 8255**] TO PTT-UNABLE TO INR(PT)-UNABLE TO . Labs from OSH: WBC 5.5 HGB14.3 HCT 42.4 Plt 101 . Troponin I 0.52 . Na 134 K 3.8 Cl 101 CO2 24 BUN 17 Creatinine 0.8 Cal 8.9 Albumin 3.7 Alk Phos 89 T.Bili 0.8 AST 24 ALT 18 . [**2191-2-24**] 09:30AM BLOOD WBC-4.3 RBC-3.99* Hgb-12.5* Hct-36.0* MCV-90 MCH-31.3 MCHC-34.6 RDW-16.3* Plt Ct-145* [**2191-2-24**] 09:30AM BLOOD Plt Ct-145* [**2191-2-24**] 09:30AM BLOOD Glucose-127* UreaN-10 Creat-0.7 Na-135 K-3.6 Cl-99 HCO3-28 AnGap-12 [**2191-2-24**] 09:30AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.2 [**2191-2-21**] 09:35PM BLOOD proBNP-2457* [**2191-2-21**] 09:35PM BLOOD cTropnT-0.06* cta chest osh ([**Hospital3 **]) extensive bilateral pulmonary emboli, incluing a saddle embolus at main pulmonary artery bifurcation. Predominate clot burden is within the lower segmental and subsegmental branches. EKG: sinus 99bpm, na, ni; no lad, right heart strain indicated by twi in v1-v3. q1s3t3 ECHO: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is mildly dilated with severe global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The mitral valve leaflets are mildly thickened. Mild to moderate ([**2-7**]+) mitral regurgitation is seen. There is at least mild pulmonary artery systolic hypertension. There is no pericardial effusion. RUQ U/S: Technically limited study due to extensive overlying bowel gas. Bilateral LENI: Partially occlusive deep venous thrombosis of the left deep femoral and popliteal veins. CT Head: Normal study. Brief Hospital Course: 41 yo male w/ h/o squamous cell cancer involving right jaw s/p resection and remission p/w saddle pulmonary embolism and LLE DVT. #Saddle Pulmonary Embolism: Causes included immobility and malignancy. There was no acute indication for thrombolysis. The patient had signs of right heart [**Last Name (un) **] on EKG and mild troponin increase. He was howeever hemodynamically stable and was able to walk for 5 min without oxygen desaturation or tachycardia. Heparin drip was started and hew as transitioned to lovenox. Echo revealed right heart strain but not failure. During his hospitalization he was evaluated with head CT to rule out intracranial metastases given history of squamous cell cancer given initiation of anticoagulation. A brief malignancy workup was initiated given with RUQ ultrasound to evaluate for liver mets which was a limited study and liver could not be properly evaluated. AFP was 2.0. He understands that a full malignancy workup will need to be completed as outpatient, notably follow up with his ENT as scheduled for his squamous cell carcinoma. He will require a repeat ECHO in six weeks to ensure improvement of right heart function. Lovenox was chosen as method of anticoagulation due to concern for recurrent nausea and vomiting as well as possible further treatment for HCV and unknown status of malignancy. He was discharged with an rx for 10 day supply and an additional 30 day supply which could be obtained after processing of prior authorization which was completed by medical team. Lastly, his nausea and vomiting which had been thought too be secondary to his Hep C medications continued through his hospitalization. There was some thought that this was related to constipation. Though evaluation with EGD and other means should be strongly considered if symptoms don't resolve in the 1-2 weeks. His symptoms temporarily did subside after bowel movement on day of discharge and he was tolerating a regular diet. He was continued on his chronic pain medications and zoloft. TRANSITIONAL ISSUES: - malignancy workup including ENT follow up - ensure pt taking lovenox and is covered by mass health - is no resolution of nausea/vomiting, this will require further workup - repeat echocardiogram in 6 weeks. Medications on Admission: methadone 20mg qid oxycodone 20mg qid prn pain zoloft 100mg daily telapravir pegasys-ribavarin Discharge Medications: 1. methadone 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 2. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 3. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours): to be picked up at CVS [**Hospital1 92282**]. Disp:*20 syringes* Refills:*0* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): stool softener. 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): mild laxative. 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: pulmonary embolus nausea/vomiting. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to care for you during your hospitalization. You were admitted for treatment of a deep vein thrombosis and pulmonary embolus. Your EKG and ECHO showed signs of strain on the right heart. You should repeat the echocardiogram in 6 weeks to ensure improvement. You are being treated with enoxaparin 120mg every 12 hours. It is ESSENTIAL you continue taking this medication as prescribed. A 10 day supply of lovenox will can be obtained at [**Hospital1 45674**] in the galleria building. A prescription for an additional 30 day supply is being provided which can be obtained at [**Company 4916**] on [**Location (un) **] St in [**Hospital1 487**]. If you have any difficulty obtaining this medication please contact Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 3633**] or your primary care doctor. During your hospitalization you were also having nausea and vomiting. If these symptms are to continue, you will need further evaluation by Dr. [**Last Name (STitle) 16254**]. Please make sure you follow up with your oncologist for evaluation of your squamous cell cancer. Medication changes during this hospitalization: Start Lovenox 120mg every 12 hours for 6 months Followup Instructions: Location: GREATER [**Hospital1 **] FAMILY HEALTH CENTER Address: [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 66038**] Phone: [**Telephone/Fax (1) 63099**] Appointment: MONDAY [**2-28**] ANY TIME BETWEEN THE HOURS OF 8:30AM-8:30PM **You can go to your healthcare center on Monday to the walk in center for follow up care to check on your anti-coagulation treatment.** Completed by:[**2191-2-27**]

[ "070.70", "453.40", "415.19", "V10.81", "787.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8834, 8840

5752, 7780

325, 331

8919, 8919

3344, 5705

10296, 10711

2550, 2588

8158, 8811

8861, 8898

8038, 8135

9070, 10273

2603, 3325

7801, 8012

1339, 1787

265, 287

359, 1320

5714, 5729

8934, 9046

1809, 2365

2381, 2534

64,597

153,266

39976

Discharge summary

report

Admission Date: [**2176-11-7**] Discharge Date: [**2176-11-12**] Date of Birth: [**2150-11-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 13256**] Chief Complaint: abdominal pain and vomiting x2 days Reason for MICU admission: hepatic failure from presumed Tylenol OD Major Surgical or Invasive Procedure: None History of Present Illness: patient is a 25-year-old woman with history of psychiatric illness and ?prior suicide attempts (per mother) who was transferred to [**Hospital1 18**] after being found to have transaminases upwards of [**Numeric Identifier 961**] after reported Tylenol ingestion. Per patient (and corroborated by mother), patient reported taking a "fistful" of tylenol two days prior to admission for headache. She denies any suicide attempt or recent life-altering events, but per her mother she has many psychiatric problems and mother suspects a suicide attempt. The patient reports persistent nausea and emesis for the past two days and inability to take anything by mouth. She denies any bowel movements for the past two days and reports that she has been urinating but that it's been very dark. She reports some moderate abdominal pain and chest pain as well, but denies any shortness of breath. On evaluation patient answers with mostly one word answers and she trails off mid-sentence several times. Over the phone the mother also told us that [**Name (NI) 87933**] tried to run away 3 months ago. She also endorsed history of prior suicide attempts. . At [**Hospital6 204**], patient was found to have an AST >[**Numeric Identifier 961**], ALT >1000, lipase of 538, K 2.9, Cl 93. Patient was given an acetylcysteine bolus, and started on a drip. She was then transferred to [**Hospital1 18**] for work-up for possible liver transplant. . In the ED, initial vital signs were: 97.7, 60, 109/54, 16, 100%RA. Patient was continued on NAC 6.25 mg/kg/hr. Tox, liver and transplant surgery were consulted. An EKG was done and demonstrated sinus rythm, QRS normal, QTc 480. Labs notable for ALT [**Numeric Identifier 3301**] and AST [**Numeric Identifier 961**], TBili 5.5 and INR 2.7. Renal function was normal, with potassium of 2.7. CBC was within normal limits. Tylenol level was undetectable (three days post-ingestion), and other urine toxicology was negative. In addition to the NAC, she was given several liters of normal saline and her potassium was repleted. . On the floor, her vitals were stable and she was satting well. She reported abdominal pain and mild nausea. Past Medical History: ? depression Social History: she reports living at home with mother. Denies any significant other. States that she does nothing for work or school. Both patient and mother endorses that [**Name (NI) 87933**] drinks alcohol (variable amounts, [**Known firstname 87933**] stated last drink was 4 days ago - 1 drink) and smokes cigarettes. No other clear illicit drug use. Family History: cardiac History in the family. Physical Exam: Vitals: T:100.1 BP:108/62 P:50s R:12 O2:100% RA GEN: dishevelled, alert and interactive, no asterixis. Oriented to hospital, city, year. HEENT: positive for scleral icterus, mucus membranes moist, but lips are cracked and dry. CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, TTP in epigastrium with no rebound or guarding and hypoactive bowel soundsExt: No LE edema, LE warm and well perfused Pertinent Results: 1. Labs on admission: [**2176-11-7**] 01:10AM BLOOD WBC-10.7 RBC-4.60 Hgb-13.9 Hct-39.2 MCV-85 MCH-30.3 MCHC-35.6* RDW-13.4 Plt Ct-184 [**2176-11-7**] 01:10AM BLOOD Neuts-91.8* Lymphs-4.8* Monos-2.1 Eos-0.7 Baso-0.6 [**2176-11-7**] 01:10AM BLOOD PT-27.7* PTT-32.3 INR(PT)-2.7* [**2176-11-7**] 01:10AM BLOOD Glucose-157* UreaN-19 Creat-0.5 Na-135 K-2.7* Cl-93* HCO3-30 AnGap-15 [**2176-11-7**] 01:10AM BLOOD ALT-[**Numeric Identifier 87934**]* AST-[**Numeric Identifier **]* AlkPhos-58 TotBili-5.5* [**2176-11-7**] 01:10AM BLOOD Lipase-124* [**2176-11-7**] 04:40AM BLOOD Albumin-3.6 Calcium-7.4* Phos-1.5* Mg-2.2 [**2176-11-8**] 04:00AM BLOOD Hapto-<5* [**2176-11-7**] 01:10AM BLOOD Ammonia-55 [**2176-11-7**] 04:40AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2176-11-7**] 01:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2176-11-7**] 04:40AM BLOOD HCV Ab-NEGATIVE [**2176-11-7**] 08:03AM BLOOD Lactate-2.5* K-3.1* . 2. Labs on discharge: [**2176-11-12**] 05:27AM BLOOD WBC-8.5 RBC-3.15* Hgb-9.6* Hct-28.2* MCV-90 MCH-30.5 MCHC-34.1 RDW-16.1* Plt Ct-208 [**2176-11-12**] 05:27AM BLOOD Neuts-59.2 Lymphs-31.9 Monos-5.7 Eos-2.5 Baso-0.8 [**2176-11-12**] 05:27AM BLOOD PT-12.5 PTT-27.8 INR(PT)-1.1 [**2176-11-12**] 05:27AM BLOOD Glucose-88 UreaN-10 Creat-0.6 Na-135 K-4.7 Cl-102 HCO3-26 AnGap-12 [**2176-11-12**] 05:27AM BLOOD ALT-1525* AST-82* AlkPhos-72 Amylase-174* TotBili-0.9 [**2176-11-12**] 05:27AM BLOOD Lipase-205* [**2176-11-12**] 05:27AM BLOOD Calcium-8.9 Phos-4.4# Mg-2.1 . 3. Diagnostics: CXR [**2176-11-7**]: IMPRESSION: No acute cardiopulmonary process. KUB [**2176-11-8**]: IMPRESSION: No evidence for ileus or obstruction. . Pending Studies at the time of discharge: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 32883**] Ceruloplasmin Urine 24 hour Copper level [**Last Name (NamePattern1) 32883**] Hepatitis A IgM Brief Hospital Course: Ms. [**Known lastname **] is a 25-year-old woman with PMH of possible depression with psychotic features, and no other known PMHx, who was admitted with transaminitis [**2-20**] to Tylenol overdose. # Transaminitis/Liver failure - Likely [**2-20**] to Tylenol overdose with no h/o co-ingestion. Pt admitted to suicide attempt. Pt was treated with NAC infusion which was stopped after LFTs trended down. Hepatitis A positive, vaccinated against Hep B, HCV negative, CMV IgG positive but IgM negative. Studies for [**Doctor First Name **] were sent and are pending at the time of discharge. A 24 hour urine was collected to test copper levels for wilson's disease and this was pending at the time of overdose. At the time of discharge, ALT was 1525 and AST was 82. INR was 1.1. These were trending down each day and do not need to be checked daily. They can be checked in 1 week. She was discharged to a psychiatric facility for ongoing psychiatric care. . # Psych: Pt was evaluated by Psychiatry. Because this was a suicide attempt, the patient is not allowed to refuse treatments. Medical issues were cleared and she was placed in a psychiatric facility. . #Electrolyte disturbances: Ms. [**Known lastname **] had low PO4, K+ and Ca of unclear etiology, which were repleted in the MICU. . # Anemia: Her hematocrit trended down from 40.8 to 28.2. She remained stable for 5 days prior to discharge and hematocrit at discharge was 28.2. Her low blood counts were likely due to acute illness and bone marrow suppression as well as her liver injury. This is expected to recover and she can have a CBC checked in 1 week to follow-up. . # Elevated lipase: Pt with lipase that trended up to [**2170**]. Can be related to Tylenol overdose, but may also have component of pancreatitis given epigastric abdominal pain and nausea. This improved on discharge with a lipase of 206. She tolerated a regular diet without abdominal pain on discharge and this does not need to be rechecked. . # Nausea - Was considered secondary to liver failure or NAC. She was managed with zofran IV PRN. This improved on discharge. . She should follow-up with her primary care physician and psychiatry team on discharge. . Pending labs at the time of discharge: [**Doctor First Name **] Urine Copper level Hepatitis A IgM Please check a CBC, electrolytes and LFTs in 1 week. Medications on Admission: None Discharge Medications: None Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4 [**Hospital1 18**] Discharge Diagnosis: Acute liver failure from acetaminophen overdose Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname **], you were admitted to the [**Hospital1 1170**] because you took too many tylenol pills, which resulted in severe liver damage. You were first admitted to the intensive care unit where you were treated with IV fluids and medications to protect your liver. Gradually, your liver began to recover. Your blood count also dropped, but you never required any blood transfusions. The psychiatrists evaluated you, and given the seriousness of your suicide attempt, they have recommended an inpatient psychiatric stay. . We did not make any changes to your medications. . Please follow up with your primary care physician after discharge. Followup Instructions: Please make a follow-up appointment within 1 week of discharge with your primary care physician. Completed by:[**2176-11-12**]

[ "570", "E950.0", "V62.84", "276.2", "296.90", "781.0", "965.4", "285.9", "790.5", "787.02", "286.9", "790.4" ]

icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

7902, 7966

5461, 7818

422, 428

8058, 8058

3528, 3536

8889, 9018

3031, 3063

7873, 7879

7987, 8037

7844, 7850

8209, 8866

3078, 3509

279, 384

4530, 5438

456, 2621

3550, 4511

8073, 8185

2643, 2657

2673, 3015

57,968

179,996

12829

Discharge summary

report

Admission Date: [**2167-11-17**] Discharge Date: [**2167-11-28**] Date of Birth: [**2082-6-2**] Sex: F Service: MEDICINE Allergies: Cephalexin / vancomycin / IV Dye, Iodine Containing Contrast Media / Penicillins / Tylenol Attending:[**First Name3 (LF) 594**] Chief Complaint: hip fracture Major Surgical or Invasive Procedure: closed reduction of left femur fracture and open reduction and internal fixation of right supracondylar periprosthetic femur fracture History of Present Illness: closed reduction of left femur fracture and open reduction and internal fixation of right supracondylar periprosthetic femur fracture Past Medical History: b/l knee prosthesis rheumatoid arthritis a.fib anxiety Social History: Lives in a nursing Family History: NC Physical Exam: ADMISSION EXAM VS: 98.7 110 134/74 20 98% AOx1 tenderness to palpation above the knees bilaterally. legs are angulated to the right below the knees. pt unable to cooperate w/ sensory exam. no palpable pulses, PT pulses are dopplerable, unable to doppler DP pulses. Pertinent Results: ADMISSION LABS [**2167-11-17**] 12:45PM BLOOD WBC-12.4* RBC-2.79* Hgb-9.0* Hct-25.6* MCV-92 MCH-32.2* MCHC-35.0 RDW-13.4 Plt Ct-101* [**2167-11-17**] 12:45PM BLOOD Neuts-90.7* Lymphs-5.7* Monos-3.2 Eos-0.4 Baso-0.1 [**2167-11-17**] 08:20PM BLOOD PT-13.3 PTT-24.6 INR(PT)-1.1 [**2167-11-17**] 12:45PM BLOOD Plt Ct-101* [**2167-11-17**] 12:45PM BLOOD Glucose-123* UreaN-21* Creat-1.1 Na-136 K-3.9 Cl-106 HCO3-18* AnGap-16 [**2167-11-18**] 01:21AM BLOOD ALT-24 AST-35 LD(LDH)-264* AlkPhos-48 TotBili-0.8 [**2167-11-17**] 08:20PM BLOOD Calcium-7.5* Phos-4.4 Mg-1.7 [**2167-11-17**] 01:05PM BLOOD Glucose-124* Lactate-1.7 Na-136 K-3.8 Cl-108 calHCO3-21 PERTINENT LABS [**2167-11-21**] 02:14AM BLOOD WBC-14.0*# RBC-2.87* Hgb-9.2* Hct-25.7* MCV-90 MCH-32.1* MCHC-35.9* RDW-14.6 Plt Ct-214# [**2167-11-23**] 12:57AM BLOOD WBC-13.4* RBC-2.88* Hgb-8.8* Hct-25.7* MCV-89 MCH-30.7 MCHC-34.4 RDW-15.1 Plt Ct-189 [**2167-11-26**] 06:10PM BLOOD WBC-25.7*# RBC-1.76*# Hgb-5.7*# Hct-18.0*# MCV-102*# MCH-32.1* MCHC-31.4 RDW-14.3 Plt Ct-183 [**2167-11-26**] 07:58PM BLOOD WBC-32.4* RBC-3.48*# Hgb-10.9*# Hct-32.4*# MCV-93# MCH-31.4 MCHC-33.7 RDW-13.7 Plt Ct-132* [**2167-11-27**] 04:15AM BLOOD WBC-34.3* RBC-4.07* Hgb-12.3 Hct-36.3 MCV-89 MCH-30.3 MCHC-33.9 RDW-14.0 Plt Ct-100* [**2167-11-28**] 01:51AM BLOOD WBC-29.4* RBC-3.99* Hgb-11.8* Hct-37.9# MCV-95 MCH-29.6 MCHC-31.2 RDW-14.0 Plt Ct-44*# [**2167-11-26**] 06:10PM BLOOD Neuts-96* Bands-0 Lymphs-3* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2* [**2167-11-26**] 07:58PM BLOOD PT-20.5* PTT-60.8* INR(PT)-1.9* [**2167-11-27**] 04:15AM BLOOD PT-17.6* PTT-34.0 INR(PT)-1.6* [**2167-11-28**] 01:51AM BLOOD PT-32.6* PTT-52.5* INR(PT)-3.2* [**2167-11-24**] 06:10PM BLOOD Glucose-121* UreaN-29* Creat-0.6 Na-144 K-4.3 Cl-111* HCO3-25 AnGap-12 [**2167-11-26**] 06:10PM BLOOD Glucose-357* UreaN-30* Creat-0.8 Na-146* K-6.1* Cl-117* HCO3-7* AnGap-28* [**2167-11-27**] 03:07PM BLOOD Glucose-157* UreaN-48* Creat-1.5* Na-143 K-5.0 Cl-113* HCO3-13* AnGap-22* [**2167-11-28**] 01:51AM BLOOD Glucose-97 UreaN-53* Creat-1.8* Na-142 K-6.5* Cl-109* HCO3-<5* [**2167-11-18**] 02:05PM BLOOD ALT-20 AST-21 LD(LDH)-168 AlkPhos-36 TotBili-0.4 DirBili-0.2 IndBili-0.2 [**2167-11-26**] 06:10PM BLOOD ALT-1438* AST-901* LD(LDH)-2430* CK(CPK)-277* AlkPhos-47 Amylase-295* TotBili-1.0 [**2167-11-27**] 04:15AM BLOOD ALT-2858* AST-3167* CK(CPK)-2069* AlkPhos-69 TotBili-1.4 [**2167-11-28**] 01:51AM BLOOD ALT-6510* AST-6971* CK(CPK)-2655* AlkPhos-93 TotBili-2.1* [**2167-11-27**] 07:06AM BLOOD Type-ART Temp-36.8 Rates-/31 PEEP-5 FiO2-40 pO2-83* pCO2-21* pH-7.53* calTCO2-18* Base XS--2 Intubat-INTUBATED [**2167-11-28**] 02:26AM BLOOD Type-ART Temp-35.7 Rates-14/19 Tidal V-460 PEEP-5 FiO2-40 pO2-86 pCO2-13* pH-7.19* calTCO2-5* Base XS--20 Intubat-INTUBATED [**2167-11-17**] 01:05PM BLOOD Glucose-124* Lactate-1.7 Na-136 K-3.8 Cl-108 calHCO3-21 [**2167-11-26**] 05:15PM BLOOD Glucose-399* Lactate-13.2* Na-136 K-6.0* Cl-116* [**2167-11-20**] 01:51AM BLOOD Lactate-1.6 [**2167-11-27**] 02:03AM BLOOD Lactate-5.0* [**2167-11-28**] 02:26AM BLOOD Lactate-15.2* . PERTINENT STUDIES # Pelvis X-ray ([**11-19**]) IMPRESSION: 1. No displaced fracture on this single AP view of the pelvis. 2. Focal lucent and sclerotic lesion in right proximal femur, not fully characterized, ? fibrous dysplasia, intraosseous lipoma, or bone infarct. If clinically indicated, followup radiograph in six months could help to establish expected stability. . Brief Hospital Course: 85 year old F w/ h/o dementia, RA, afib, transferred from OSH with bilateral supracondylar femur fracture on [**11-17**]. On [**11-17**], patient presented to ED and received intravenous pain medication carefully. The patient also received steroids because she has been on steroids recently. Her lactate was normal. She was admitted to the orthopedic surgery service. Her blood pressure was stable in the emergency department. She was ordered for 1U PRBCs at 3pm given crit drop 31->26. Orthopaedics team ordered that patient to be NPO, added her on to OR schedule, placed in bilateral knee immobilizers, finalized consent with daughter, b/l ORIF, ordered preop labs/EKG/CXR, and continue macrobid for UTI. She was taken to the OR with Orthopaedics for fixation of her bilateral distal femur fractures. She was brought to the operating room, was given general anesthesia placed in the supine position on her stretcher. There was much difficulty with getting access to her and anesthesia had to place a central line in the subclavian area. Her pulse was quite rapid and there was difficulty controlling her blood pressure and difficulty establishing good access. She was given a unit of blood, but given her labile pressures and tachycardia, decision was made to hold off on the open treatment. At this point, Ortho team elected to hold both femur fractures reduced with traction and knee immobilizers were placed. Plan was to bring her back to the intensive care unit for supportive care and consider fixation in the future. The patient was taken to the TSICU floor for close observation and care under sedation and intubated. On [**11-18**], the patient was transfused 1u pRBC for HCT drop from 29.4 to 23.2 in TSICU. She was made NPO overnight for planned procedure on [**11-9**]. A surface echo was ordered to evaluate cardiac function in setting of recent hypotension (SBP 50) and tachycardia (HR 160) showing Relatively small left ventricle with hyperdynamic systolic function; Mild mitral regurgitation; Borderline dilation of the right ventricle with moderate tricuspid regurgitation. An US of gallbladder was ordered showing Cholelithiasis with no son[**Name (NI) 493**] signs of cholecystitis and No biliary dilatation seen. On [**11-19**], the patient went to the OR and underwent an attempted open reduction and internal fixation of left periprosthetic supracondylar femur fracture (aborted), closed reduction of left femur fracture, open reduction and internal fixation of right supracondylar periprosthetic femur fracture. Given comminution of the lateral aspect of the femur, intraoperative consultation was obtained with one of our arthroplastic specialists, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5322**]. After formal consultation over the telephone, we discussed the options including supplementary fixation with bone cement, the option for a revision left total knee in the form of a distal femoral replacement, provisional stabilization with an external fixator versus closed reduction. After consultation with Dr. [**Last Name (STitle) 5322**], we elected to proceed with a closed reduction of the left femur. She was provisionally going to return to the operating room in the next 48 to 72 hours with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5322**] for possible distal femoral replacement, revision left total knee arthroplasty. On [**11-20**], blood culture results came back positive (from [**11-17**] show enterococcus, gram(-) rods, gram(+) cocci). Urine cultures were also positive ([**11-17**] shows gram(-) rods). On [**11-22**], results finalized with positive cultures showing enterococcus, moragnella morganii, coag neg staph. Antibiotics continued appropriately with Meropenem. On [**11-26**] pt was called out to regular floor. In the afternoon, pt was found unresponsive, with PEA arrest. A code was called. Pt was intubated. CPR was given for 5 mins, 1 mg epi and stress dose hydrocortisol were given. Pulse was palpated afterwards without defibrillation. Pt was emergently transferred to MICU. Central access was established, and pt was initially pressors. Post-code labs were consistent with acute shock liver and myocardial injury post arrest. She was supported with pressor and mechanical ventilation. However, no meaningful return of neurological function was observed - she had roving eyes without any evidence of higher cortical function during her ICU stay post-arrest, concerning for significant hypoxemia brain injury. On [**2078-11-26**], she manifested a progressive elevation in her lactate, increasing pressor requirements, and evidence of evolving multiorgan failure. Given her lack of neurological function and her overall dire clinical course, her family was notified, came in and during a family meeting the consensus decision was made to transition to CMO. Ventilator support was withdrawn on [**11-28**]. Pt expired at 10:22 AM on [**2167-11-28**] with her family at the bedside. Autopsy was declined. Medications on Admission: MVI daily vitamin D 1000U daily aspirin 325mg daily omeprazole 20mg daily lisinopril 5mg daily loperamide 2mg PO PRN natural tears 1gtt OU [**Hospital1 **] furosemide 40mg daily prednisone 20mg daily imdur 30mg daily diltiazem 180mg daily melatonin 3mg QHS PRN lexapro 20mg daily xanax 0.25mg [**Hospital1 **] duoneb 1 INH PRN milk of magnesia 10 mL PO daily senna 1 tab PO daily maalox 1ml PO daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: femoral fracture Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

[ "276.2", "V49.86", "293.0", "821.23", "790.92", "998.09", "300.00", "E884.2", "996.74", "041.6", "458.29", "599.0", "453.82", "E849.7", "041.04", "570", "401.9", "V43.65", "998.11", "E934.2", "276.69", "276.3", "790.7", "427.31", "E938.4", "427.5", "V64.1", "714.0", "285.1", "518.81", "276.52", "041.19" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "96.04", "80.16", "99.60", "00.14", "79.35", "38.97", "79.05" ]

icd9pcs

[ [ [] ] ]

10101, 10110

4576, 9621

364, 499

10170, 10179

1098, 4553

10232, 10239

793, 797

10072, 10078

10131, 10149

9647, 10049

10203, 10209

812, 1079

312, 326

527, 662

684, 741

757, 777

13,033

139,630

43033

Discharge summary

report

Admission Date: [**2186-6-11**] Discharge Date: [**2186-6-15**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Hypertension. Major Surgical or Invasive Procedure: None. History of Present Illness: 38 M, well-known to this institution, with DM1 c/b autonomic neuropathy, gastroparesis, and multiple admissions for hypertensive urgency. Last hospitalized from [**Date range (1) 25243**], now presenting with the same. . States that his abdominal pain began yesterday. Characteristically similar to his usual abdominal pain. He was otherwise able to take his medications the day prior to admission. Underwent dialysis as scheduled the day prior to admission. Today, had worsening of his symptoms accompanied by nause and vomiting. Denies chest pressure, headache, or SOB. . In the ED, BP 262/164. Received IV dilaudid and ativan, started on labetalol and nitroglycerin gtts. Admitted to MICU for further management. 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. Lives with his [**Hospital1 **] mother and their three children Family History: His father recently 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: Vitals - T 96.8, BP 218/138, HR 81, RR 17, O2 sat 100% RA, wt 71.9 kg General - young male, sleeping, but easily arousable to voice; no acute distress HEENT - PERRL, EOMI, OP clr, MM sl dry, no LAD CV - RRR, [**4-18**] syst mur at base Chest - CTAB; R POC and R tunneled HD line c/d/i Abdomen - NABS, soft, NT/ND, no g/r Extremities - no edema; L AVF clotted Neuro - A&O x 3 Pertinent Results: Labwork on admission: [**2186-6-11**] 09:40AM WBC-5.9 RBC-5.06 HGB-13.3* HCT-42.3 MCV-84 MCH-26.3* MCHC-31.5 RDW-19.0* [**2186-6-11**] 09:40AM PLT COUNT-233 [**2186-6-11**] 09:40AM NEUTS-53.8 LYMPHS-30.4 MONOS-8.7 EOS-6.2* BASOS-0.9 [**2186-6-11**] 09:40AM GLUCOSE-285* UREA N-36* CREAT-7.8*# SODIUM-140 POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-26 ANION GAP-20 [**2186-6-11**] 09:40AM CK(CPK)-89 . ECG Study Date of [**2186-6-11**] 11:16:08 AM Sinus rhythm Since previous tracing of [**2186-6-4**], ST-T wave abnormalities more marked Clinical correlation is suggested . ECG Study Date of [**2186-6-14**] 6:06:54 AM Sinus rhythm. Consider left ventricular hypertrophy. ST-T wave configuration suggest in part, early repolarization pattern. Clinical correlation is suggested. Since the previous tracing of [**2186-6-11**] further ST-T wave changes are present. . [**2186-6-11**] 09:40AM BLOOD CK(CPK)-89 [**2186-6-12**] 04:49AM BLOOD CK(CPK)-41 [**2186-6-11**] 09:40AM BLOOD CK-MB-NotDone cTropnT-0.27* [**2186-6-12**] 04:49AM BLOOD CK-MB-NotDone cTropnT-0.29* . Labwork on discharge: [**2186-6-15**] 04:28AM BLOOD WBC-9.9# RBC-4.96 Hgb-13.0* Hct-42.1 MCV-85 MCH-26.3* MCHC-31.0 RDW-18.3* Plt Ct-267 [**2186-6-15**] 03:29PM BLOOD Glucose-235* UreaN-22* Creat-6.0*# Na-134 K-4.6 Cl-97 HCO3-28 AnGap-14 [**2186-6-15**] 03:29PM BLOOD Calcium-8.7 Phos-4.6*# Mg-1.9 Brief Hospital Course: In brief, the patient is a 38M with DM1 with complications of ESRD on HD, autonomic dysfunction, gastroparesis who is presenting with hypertensive urgency. . 1. Hypertensive urgency: The patient has had multiple admissions for hypertensive urgency with exacerbations of gastroparesis and inability to take his oral anti-hypertensives. There was no evidence of acute end-organ damage from the hypertension. He was admitted to the ICU for stabilization and labetalol gtt. The patient's blood pressures were within normal range when the patient's abdominal pain was controlled and he was able to take his home antihypertensives. The patient was started on lisinopril 5 mg daily for improved blood pressure control. The patient's potassium was stable prior to discharge. . 2. Nausea, vomiting, abdominal pain: Consistent with the patient's prior exacerbations of diabetic gastroparesis. The patient was continued on his outpatient reglan when able to take oral medications. . 3. Diabetes mellitus, type 1: The patient has a history of labile blood sugars. He remained on his home dose of NPH 3 units twice daily with Humalog sliding scale. . 4. ESRD on HD: The patient was followed by the Dialysis team. He was continued on his usual dialysis schedule and received dialysis the day of discharge. The patient was continued on calcium acetate. Sevelamer was added to the patient's regimen. The patient's electrolytes were within normal limits prior to discharge. The patient's coumadin for history of clotted left AVF was supratherapetic on admission, but coumadin was restarted prior to discharge. The patient will have his INR checked at dialysis per usual. . 5. History of esophageal erosion: The patient was continued on protonix. . Disposition: Home Medications on Admission: 1. Clonidine 0.3 mg/24 hr Patch QSAT 2. Aspirin 81 mg PO DAILY 3. Metoclopramide 10 mg PO QIDACHS 4. Clonidine 0.2 mg PO TID 5. Nifedipine 30 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Calcium Acetate 667 mg PO TID W/MEALS 8. Senna 8.6 mg Tablet PO BID 9. Metoprolol Tartrate 75 mg PO TID 10. Warfarin 1.5 mg PO at bedtime 11. Pantoprazole 40 mg PO once a day 12. NPH 3 units twice a day Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Hypertensive urgency 2. Diabetic gastroparesis . Secondary: 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 Discharge Condition: Afebrile, normotensive, tolerating PO. Discharge Instructions: You were admitted with hypertension, abdominal pain, nausea, and vomiting. This was likely due to your diabetic gastroparesis. Your blood pressure and abdominal pain are now improved and you are able to take oral medications. You should continue to follow with dialysis per your usual schedule Tuesday, Thursday, and Saturday. . Please contact a physician if you experience fevers, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, inability to take your medications, or any other concerning symptoms. . Please take your medications as prescribed. - You were started on lisinopril 5 mg daily for your blood pressure. - You were started on sevelamer 800 mg three times daily with meals for your kidney failure. - You should have your INR checked with dialysis per usual. - No other changes were made to your medications. . Please keep your follow-up appointments as below. Followup Instructions: Follow-up with your primary care physician: [**Name Initial (NameIs) 2169**]: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2186-6-21**] 11:00 . You should have your INR checked with dialysis per usual.

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

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

6201, 6207

4007, 5757

329, 337

7088, 7129

2616, 2624

8074, 8371

2034, 2205

6228, 7067

5783, 6178

7153, 8051

2220, 2597

3707, 3984

276, 291

365, 1082

2638, 3693

1104, 1870

1886, 2018

23,031

184,185

43744

Discharge summary

report

Admission Date: [**2144-1-6**] Discharge Date: [**2144-1-19**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 86 year old gentleman transferred from the VA for complaints of shortness of breath and worsening fatigue over the past few months. No syncope. Chest x-ray showed CHF. A subsequent echo showed an aortic valve gradient. Cardiac cath showed no CAD, but severe valvular aortic stenosis with mild aortic regurgitation. At the same time chest CT showed extensive consolidation of the bases of the lungs without calcifications and a nodule in the right mid-chest. The diagnosis of aspiration pneumonia with lung CA was made. A CT guided biopsy of the right lower lobe was done with the complaint of right pneumothorax. This was all at the outside hospital. Aspirate smear showed a few clusters of cells and cytologic dysplasia favor reactive versus degenerative changes. Patient was admitted to [**Hospital1 18**] for AVR and question of open lung biopsy for definite diagnosis to rule out lung cancer and was transferred here. PAST MEDICAL HISTORY: Significant for GERD, anemia, status post TURP, BPH, aortic stenosis, intention tremor. MEDICATIONS ON ADMISSION: Iron, primidone, aspirin, oxybutynin, Protonix, ascorbic acid, vitamin E, vitamin B, Lopressor 25 b.i.d., Colace. PHYSICAL EXAMINATION: Pulsatile exam showed that he had warm feet and palpable popliteals, dopplerable DPs and PTs. No evidence of ischemia. HOSPITAL COURSE: Plastic surgery was consulted and patient was taken to the operating room on [**1-8**] for a VATS procedure which subsequently showed no evidence of cancer, most likely fibrotic changes. Patient was then transferred to the floor with chest tubes which were discontinued after the VATS without incident. Infectious disease was consulted because patient spiked a fever. Workup revealed that patient most likely had noninfectious etiology most likely related to postoperative atelectasis. Levaquin was started empirically which had a complete course. After the concurrence with ID that patient had no ongoing infectious issues, patient was taken to the operating room on [**2144-1-14**] for CABG times one and AVR with tissue valve. The patient tolerated the procedure well. Postoperatively patient had increased bleeding because of a fractured sternum. Blood products and FFP were administered to which patient responded well. Patient stayed in the ICU for two days after which he was transferred out to the floor. His chest tubes were discontinued. His wires were discontinued. He did well. P.T. worked with him. He ambulated well. He returned to his preoperative weight and Lasix was discontinued. Beta blockade was continued. Patient is being discharged home on [**2144-1-19**]. His sternum is stable. His incisions are clean and dry, both leg and chest. He is taking Colace 100 mg p.o. b.i.d., primidone 50 mg p.o. b.i.d., Oxybutynin 5 mg p.o. t.i.d., Protonix 40 mg p.o. once a day, morphine sulfate as needed, metoprolol 50 mg p.o. b.i.d., aspirin once a day. Patient is going home with prescriptions for Lopressor 50 b.i.d., Colace 100 mg p.o. b.i.d., Percocet 50 tablets of 325 mg/5 mg apiece. He will go home with prescriptions for aspirin and Colace as mentioned previously. Patient will resume his other preoperative medications. He is doing well. He will follow up with Dr. [**Last Name (STitle) 70**], who performed the case, in about four weeks. He will follow up with his PCP. [**Name10 (NameIs) **] is afebrile with vital signs stable. He is going to go home with VNA for wound care and safety checks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2144-1-19**] 09:28 T: [**2144-1-19**] 09:35 JOB#: [**Job Number 94015**]

[ "518.0", "414.01", "285.9", "424.1", "530.81", "515", "998.11", "511.8", "997.3" ]

icd9cm

[ [ [] ] ]

[ "36.11", "35.21", "34.24", "88.72", "34.51", "39.61", "34.09" ]

icd9pcs

[ [ [] ] ]

1202, 1317

1479, 3914

1340, 1461

112, 1063

1086, 1175

30,059

198,497

33030

Discharge summary

report

Unit No: [**Numeric Identifier 76812**] Admission Date: [**2182-1-17**] Discharge Date: [**2182-4-26**] Date of Birth: [**2182-1-17**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname **] #2 was born at 27 and 1/7 weeks gestation with a birth weight of 979 gm. This pregnancy was complicated by dichorionic-diamniotic spontaneous twin gestation. The mother was 27-year-old, G1 P0- 2 with the following prenatal labs. Blood type AB+, antibody negative, RPR nonreactive, rubella-immune, hepatitis B surface antigen negative and GBS was unknown at the time of delivery. This pregnancy was complicated by premature preterm rupture of membranes on the day prior to delivery. Mom did receive betamethasone x1 prior to delivery. Mom had progressive labor and the infants were born by emergent C- section because of breech gestation during one of the twins. The Apgar score of this twin, twin #2 or [**Known lastname **] [**Known lastname **] was 8 at one minute and 9 at five minutes of life. The patient's initial birth weight was 979 gm which was equal to the 25th- 50th percentile. The head circumference was equal to 26.5 cm which was equal to the 50th-75th percentile, and the birth length was 36 cm which equaled to the 50th percentile. This patient was intubated in the delivery room and was brought up to the NICU for further care. Of note, this patient was discharged home at 41 and 4/7 weeks gestation. This was equal to day of life 99 on the day of discharge. PHYSICAL EXAM AT DISCHARGE: The weight at discharge was 3.75 kg which was equal to the 75th-90th percentile for post menstrual age. The discharge head circumference was 37 cm which was equal to greater than 90th percentile and the length was equal to 49.5 cm which was equal to the 50th-75th percentile for post menstrual age. Generally: This patient is alert and well appearing during physical exam. The HEENT exam is significant for extraocular movements intact with a red reflex present bilaterally. The anterior fontanelle is open, soft and flat. The ears are normal set in rotation. The palate is intact and this patient has no significant dysmorphic features noted. Neck was supple during the exam. The respiratory exam was consistent with clear breath sounds bilaterally with good aeration. The heart exam was normal S1, S2 with no murmur appreciated. The femoral pulses were equal bilaterally. The abdomen exam is consistent with a nondistended, nontender abdomen with no masses palpable. The patient does have a small, approximately 0.5 cm scar in the right upper quadrant of the abdomen which is the location of a chest tube placed for pneumothorax. This lesion is well healed. The GU exam is consistent with bilateral palpable testicles and bilateral hydroceles. This patient does have approximately 1.5 cm linear scars located at the proximal portion of the inguinal canals bilaterally. These scars are covered with Steri-Strips and appear pink and well perfused with no significant erythema or pus. The penis is circumcised. The hip exam reveals no clicks or clunks. The anus is patent. There is no sacral pits or tuft noted. The extremities are warm and well perfused and moving symmetrically. The neurologic exam demonstrates a normal tone and suck for post menstrual age and a normal Morrow reflex. The infant does attempt to lift his head on ventral suspension. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: This patient was initially placed on high frequency ventilation until day of life 7. This patient did receive surfactant x2 for surfactant deficiency. This patient was transferred from high frequency to conventional ventilation on day of life 7 and remained on conventional ventilation until day of life 11. This patient was then weaned to CPAP until day of life 54. This patient was then weaned to nasal cannula until day of life 69. The patient remained in room air from day of life 69 until day of life 99 at discharge. This patient also had a presumed pulmonary hemorrhage due to bloody secretions that were obtained from the endotracheal tube on day of life [**6-9**]. The patient had no significant hemodynamic compromise from these secretions. This patient did have a right-sided pneumothorax that was noted in the 1st week of life and a chest tube was placed. This patient also had apnea of prematurity and was placed on caffeine. The patient's caffeine was discontinued on day of life 64 which was equal to 36 and 1/7 weeks post menstrual age. The patient had no significant apnea or bradycardia events for at least five days prior to discharge. Cardiovascular: This patient did have a patent ductus arteriosus and was treated with indomethacin for 2 courses. Echocardiograms were performed on [**1-20**] and [**2182-1-29**]. The most recent echocardiogram on [**1-28**] revealed no patent ductus arteriosus, a PFO and a left-sided peripheral pulmonic stenosis. The patient had normal structure and biventricular function at that time. Fluids, electrolytes and nutrition: This patient was placed on total parenteral nutrition for the first 2 weeks of life. Feedings were not started until day of life 13 because the patient was receiving indomethacin for the patent ductus arteriosus as previously mentioned. Full feedings were achieved by day of life 19. The maximum kilocalories that this patient received was 30 calories per ounce with Beneprotein. This patient will be discharged home on 20 calories per ounce Enfamil AR or breast milk. Gastroenterology: It was noted in the last month of this hospitalization that this patient had spitting and associated apneic events related to these spit-ups. Due to these clinical findings a clinical diagnosis of reflux was made. The infant was clinically managed first with Enfamil AR and the infant did show clinical improvement with the Enfamil AR. Two days prior to discharge this patient had blood-streaked spit-up x1. This event occurred after the patient breast fed. It is not clear if this patient had bloody spit-up related to problems with mom's breast milk or if the patient had true esophagitis. The NICU team started this patient on a 7-day course of ranitidine for possible esophagitis. The dosing of this is 10 mg b.i.d. for 7 days. It is recommended that this patient complete a 7-day course at this dose and then the pediatrician consider a maintenance dose of ranitidine for reflux. There have been no additional episodes of blood streaked emesis. This patient will be discharged home with Enfamil AR with a few feedings with breast milk when available. We have noticed that breast milk helps regulate his stooling patterns which were infrequenct or hard in consistency when given an all formula diet. Therefore, we recommend that the patient be discharged home with a combination of Enfamil AR 20 K-calorie per ounce formula, as well as breast milk 2-3 bottles per day. GU: This patient did have bilateral hernias noted in the last 2-3 weeks prior to discharge. This patient had a bilateral hernia repair performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of [**Hospital3 18242**] [**Location (un) 86**] on [**2182-4-17**]. This patient did have some apnea events after the anesthesia, but remained stable for approximately a week prior to discharge. The incision sites looked goog prior to discharge. Of note, this patient does have bilateral hydroceles in addition to the bilateral hernias. A circumcision was performed after the surgery. Infectious disease: This patient was initially treated with ampicillin and gentamicin for 14 days at birth. Ampicillin and gentamicin were started due to concerns for sepsis related to mom's premature rupture of membranes and delivery. A lumbar puncture revealed increased white blood cell count and left shift and for a 14-day course. On day of life 48 which was equal to [**2182-3-6**] the patient had a cluster of apnea and bradycardia events. A blood culture was performed and group B Streptococcus was obtained. The patient was initially started on vancomycin and gentamicin and when sensitivities returned the patient was transitioned to penicillin to treat the group B Strep bacteremia. The patient completed a 14-day course of antibiotics for the group B Strep bacteremia. A followup blood culture on [**3-7**], as well as lumbar puncture revealed no group B Strep. Breast milk was cultured as a possibility for the etiology of the group B Strep and revealed mixed flora, but no significant group B Strep. It was thought that this patient's group B Strep bacteremia was due to a late onset sepsis. Hematology: This patient did receive blood transfusions x2 in the first 2 weeks of life. One of the blood transfusions was received after the blood-tinged secretions from the endotracheal tube were found as previously mentioned. This patient received no FFP for coagulopathy. This patient had anemia of prematurity and was treated during the hospitalization with iron and vitamin E. The most recent hematocrit performed prior to discharge on [**4-4**] was 30.4 with a reticulocyte count of 2.2%. This patient will be discharged home with supplemental iron sulfate of 2 mg of elemental sulfate per kg per day. Endocrine: This patient had 2 abnormal newborn screens with low T4 levels. On [**2182-2-11**] TFTs were checked and the patient had normal levels. Of note, followup newborn screens were also normal. This likely represented transient hypothyroxinemia of prematurity. Neurology: This patient had several head ultrasounds to screen bleeding related to prematurity. This patient had a normal head ultrasound performed on [**2182-1-18**] which was equal to day of life 1. A head ultrasound on [**1-22**] revealed a right germinal matrix hemorrhage. A head ultrasound on [**2182-1-29**] revealed a right germinal matrix hemorrhage and slightly increased ventricular sizes. Followup on [**2-7**] revealed normal ventricular sizes and resolving right germinal matrix hemorrhage. The most recent head ultrasound was performed on [**2182-4-17**] and was normal with no evidence of periventricular leukomalacia or germinal matrix hemorrhages. This patient had a hearing screen that was performed prior to discharge and the patient passed. The patient also had ophthalmology screening for retinopathy of prematurity. This patient was followed several times during the hospitalization and the most recent exam was performed on [**2182-4-25**]. At this time the patient had a ROP exam consistent with immature retina in zone 3 in the right eye and stage 1 zone 3 ROP in th e left eye. It is recommended that this patient followup in 2 weeks with the ophthalmologist as an outpatient. Psychosocial: The [**Hospital1 69**] social worker was involved with this family. The social worker identified no significant psychosocial problems with this family. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Home. NAME OF PRIMARY CARE PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD. The address is [**Hospital 76813**], [**Location (un) 76808**], [**Hospital1 392**], [**Numeric Identifier 76809**]. CARE/RECOMMENDATIONS: Feedings: Enfamil AR 20 K-calories per ounce and breast milk 20 K- calories per ounce. It is recommended that this patient take at least 2-3 bottles a day of breast milk to prevent constipation that may be caused by Enfamil AR. Medications at discharge: 1. Ferrous sulfate (concentration 25 mg/mL) 0.4 mL PO daily (=2 mg of elemental iron/kg/day) 2. Ranitidine 10 mg p.o. b.i.d. x5 days to complete a 7-day course at this dose. Ranitidine: We recommended this patient complete a 7-day course of ranitidine at a dose of 10 mg p.o. b.i.d. which is equivalent to approximately 5 mg/kg/day to treat possible esophagitis. After this is completed, we recommend starting ranitidine at a dose for treatment of gastroesophageal reflux (recommended 2 mg/k/dose PO q8 hours). Car seat positioning screening was performed prior to discharge and this patient has passed. State newborn screening was performed during this hospitalization. This patient had initial abnormal newborn screens with low T4 levels on [**1-22**] and [**2182-1-31**]. Followup newborn screens performed on [**2-28**] and [**2182-3-6**] were both normal. Immunizations received during this hospitalization include hepatitis B vaccine on [**2182-2-17**] and Pediarix, Hib, pneumococcal 7-valent conjugate vaccine on [**2182-3-24**]. This patient also had Synagis vaccine performed on [**2182-4-15**]. Immunizations recommended: Synagis RSV prophylaxis should be considered from [**Month (only) **]-[**Month (only) 958**] for infants who meet any of the following 4 criteria: 1. Born less than or equal to 32 weeks. 2. Born between 32-35 and 0/7 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings. 3. Chronic lung disease. 4. Hemodynamically significant congenital heart disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age, and for the first 24 months of a child's life immunization against influenza is recommended for household contacts and out of home caregivers. This infant has not received the Rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks, but fewer than 12 weeks of age. FOLLOWUP APPOINTMENTS SCHEDULED/RECOMMENDED: 1. Followup appointment with primary care pediatrician on Monday [**2182-4-29**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. 2. Ophthalmology is recommended at 2 weeks after discharge to screen for retinopathy of prematurity. 3. One-month followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for postoperative evaluation of bilateral hernia repair. DISCHARGE DIAGNOSES: 1. Premature birth at 27 and 1/7 weeks gestation 2. Dichorionic-diamniotic twin gestation 3. Respiratory distress syndrome, resolved 4. Pulmonary hemorrhage, resolved 5. Right pneumothorax, resolved 6. Chronic lung disease 7. Apnea of prematurity, resolved 8. Presumed sepsis, resolved 9. Group B Strep bacteremia, resolved 10. Patent ductus arteriosus, status post indomethacin treatment, resolved 11. Bilateral inguinal hernias status post repair 12. Anemia of prematurity 13. Retinopathy of prematurity 14. Right germinal matrix hemorrhage, resolved 15. Gastroesophageal reflux [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**] Dictated By:[**Last Name (NamePattern4) 76810**] MEDQUIST36 D: [**2182-4-25**] 14:34:30 T: [**2182-4-25**] 15:59:07 Job#: [**Job Number 76814**]

[ "243", "765.24", "V05.3", "V45.89", "772.11", "747.0", "770.2", "782.3", "V31.01", "771.81", "752.51", "745.5", "770.3", "362.21", "765.13", "276.2", "530.81", "550.92", "769", "747.3", "776.6", "761.7", "778.6", "770.81", "041.02", "774.2" ]

icd9cm

[ [ [] ] ]

[ "99.29", "03.31", "34.04", "96.72", "99.83", "93.90", "96.04", "96.6", "99.55", "38.91", "34.91", "38.92", "38.93" ]

icd9pcs

[ [ [] ] ]

10906, 11403

14134, 14981

3420, 10848

11420, 12615

12642, 14113

189, 1513

10873, 10882

28,944

105,451

51366

Discharge summary

report

Admission Date: [**2143-7-18**] Discharge Date: [**2143-7-26**] Date of Birth: [**2098-12-27**] Sex: M Service: SURGERY Allergies: Ciprofloxacin / Hydralazine Attending:[**First Name3 (LF) 668**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: [**2143-7-21**]: renal transplant nephrectomy History of Present Illness: This is a 42 year old M with past medical history significant for ESRD s/p LRRT in [**2134**] c/b rejection now on HD with malignant hypertension and likely PRES who presents with hypertensive urgency. The patient reports that he had been feeling well since his discharge from [**Hospital1 18**] in [**Month (only) 205**] of this year, though he notes that his blood pressure has been persistently elevated to around 150s-160s/90s-100s. He presented to see his transplant nephrologist this morning and developed acute onset of posterior headache with visual changes which consisted of floaters in his peripheral vision and the visualization of streaks of color. He also notes that he felt tremulous at the time and as if he might pass out, but this quickly passed. He therefore presented to the ED for further evaluation. . The patient has a history of malignant hypertension and was admitted in [**Month (only) 116**] of this year with a hypertensive emergency at which time he had a seizure and a small SAH. He was then admitted again in [**Month (only) 205**] with headaches and vision changes and a SBP up to 200s. At that time, his antihypertensive regiemen was increased and he has tolerated this regimen. . In the ED, initial VS: T 98.8 HR 69 BP 167/106 16 99% on RA. He received 1L NS, morphine 4mg IV x1 and tylenol 650 mg PO x1 with modest improvement in symptoms. . At this time, patient feels much improved. Denies any visual changes, states headache is less than a [**1-20**] and does not want further medication at this time. Otherwise, ROS negative for fevers, chills, nightsweats, chest pain, shortness of breath, cough, abdominal pain, nausea, vomiting, diarrhea, melena, hematochezia, hematemesis, dysuria. No paresthesias or weakness. Pertinent positives as above. Past Medical History: - ESRD secondary to chronic ureterovesical junction obstruction leading to bilateral hydronephrosis, on hemodialysis - S/p living-related renal transplant [**2134**] ([**Name (NI) 106515**] brother), failed, now on hemodialysis since [**12-18**] - Malignant hypertension - PRES - s/p SAH - Gout - Peptic Ulcer disease - Bladder neck stricture - Atypical chest pain Social History: 40py, quit 2 yrs ago. No EtOH or other drugs. Lives in apartment building with his wheelchair-bound wife where he works as superintendent. Family History: Father had MI mid 50s. No DM. Brother had cancer of jaw which was resected. Physical Exam: VS: T 98.5 BP 158/98 P 77 RR 22 98% RA GEN: Well-appearing, comfortable in bed, talkative and in NAD HEENT: NCAT, EOMI, PERRL, oropharynx clear and without erythema or exudate NECK: Supple, no appreciable JVD CV: RRR, normal S1S2, no murmurs, rubs or gallops PULM: CTAB, no w/r/r, good air movement bilaterally ABD: Soft, NTND, normoactive bowel sounds, no organomegaly, multiple well-healed incisions EXT: Warm and well perfused, full and symmetric distal pulses, no pedal edema, two hyperpigmented papules on plantar surface of left foot NEURO: AAOx3, responds appropriately to questions, CN 2-12 grossly intact, full strength in bilateral upper extremity extensors, wrists, fingers, and lower extremities, downgoing toes bilaterally Pertinent Results: On Admission: . IMAGING: . CT HEAD W/O CONTRAST Interval resolution of subarachnoid hemorrhage seen within the parieto-occipital lobes in [**2143-5-5**]. No acute intracranial hemorrhage. Aerosolized secretions within the sphenoid sinus. . CXR [**2143-7-20**] - PA and lateral views of the chest are obtained. A right IJ dialysis catheter is noted with its tip at the cavoatrial junction. Lungs are clear bilaterally without evidence of pneumonia or CHF. Cardiomediastinal silhouette is normal. There is no pleural effusion or pneumothorax. Osseous structures appear intact. . On Admission: [**2143-7-18**] WBC-5.0 RBC-4.52* Hgb-13.3* Hct-42.1 MCV-93 MCH-29.3 MCHC-31.5 RDW-14.3 Plt Ct-153 PT-13.7* PTT-41.3* INR(PT)-1.2* Glucose-83 UreaN-37* Creat-6.9*# Na-140 K-5.6* Cl-101 HCO3-26 AnGap-19 ALT-6 AST-18 CK(CPK)-217* AlkPhos-53 TotBili-0.4 Calcium-9.2 Phos-6.9* Mg-2.3 . On Discharge [**2143-7-26**] WBC-5.0 RBC-3.55* Hgb-10.4* Hct-32.1* MCV-90 MCH-29.3 MCHC-32.4 RDW-14.5 Plt Ct-224 Glucose-91 UreaN-26* Creat-10.3* Na-141 K-4.0 Cl-101 HCO3-26 AnGap-18 Calcium-9.8 Phos-5.7*# Mg-2.1 [**2143-7-23**] TSH-0.79 [**2143-7-23**] T4-8.0 [**2143-7-26**] 05:20AM BLOOD Brief Hospital Course: 44 year old M with history of ESRD s/p failed transplant on HD who presents with headache and hypertension. . # Headache: Per the patient, it is similar to the headache he had from his prior SAH in [**Month (only) 116**]. This, however, resolved much more quickly and he currently has no other symptoms. Has been improved with tylenol and one dose of morphine in the ED. No other focal neurologic findings. Most likely due to hypertension. As no focal neurologic deficits, no clear indication for MRI or further imaging as no evidence of bleed on CT non-contrast. # Malignant hypertension/h/o PRES: Has been admitted in the past with hypertensive emergency and seizures. Concern for PRES syndrome based on MRI done in [**Month (only) 116**] (was also on tacrolimus/cyclosporine in the past). Also concern that patient may have malignant hypertension as a result of failed renal transplant. Previous work up for renal transplant artery stenosis which was negative. Renin/[**Male First Name (un) 2083**] levels drawn in [**Month (only) 205**] showed low renin and aldosteron within normal range. #Patient underwent transplant nephrectomy on [**7-21**] with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The transplant kidney was satisfactorily removed and he was extubated and transferred to the PACU in stable condition. . # ESRD on HD s/p failed transplant: Patient underwent HD on [**2143-7-19**], and then per M-W-F outpatient schedule. In the post op period he progressed nicely. He was maintained on many different classes of antihypertensives with reasonable control. When he missed some doses due to HD on [**7-24**] he remained with elevated BP requiring IV Lopressor. He is being discharged on a new BP med regimen . Medications on Admission: Lisinopril 40 [**Hospital1 **] Valsartan 160 [**Hospital1 **] Bactrim 80-400 mg qday Cellcept 1 gram [**Hospital1 **] Sevelamer 800 mg tid Clonidine patch 0.3 mg/24 hours - 1 patch q week Carvedilol 50 mg [**Hospital1 **] Protonix 20 mg q day Hydralazine 50 mg q 6 hours Nifedipine 30 mg q day Nephrocaps 1 mg q day Discharge Medications: 1. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for pruritis, dryness, pain. 5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSUN (every Sunday). 6. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 9. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 11. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 12. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 13. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: (1) Posterior reversible encephalopathy syndrome (PRES) (2) End stage renal disease, on hemodialysis (3) S/p renal transplant now s/p transplant nephrectomy Secondary Diagnoses: (1) Malignant hypertension Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital with headache and vision changes that were likely related to your prior diagnosis of PRES syndrome. Please continue to monitor your blood pressure at home as you have been doing, keep a copy and bring to clinic visits. Call your doctor at [**Telephone/Fax (1) 673**] if BP routinely goes high (above 180 for the systolic pressure), if you have dizziness or headaches. Please continue your normal dialysis schedule. Continue food, fluid and medication recomendations per your kidney doctors [**First Name (Titles) 7219**] [**Last Name (Titles) **] heavy lifting, nothing more than a gallon of milk Do not drive if taking narcotic pain medication Monitor incision for redness, drainage or bleeding Followup Instructions: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2143-8-1**] 8:00 [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2143-8-6**] 2:40 Completed by:[**2143-7-26**]

[ "348.39", "585.6", "274.9", "276.7", "403.01", "593.4", "996.81", "E878.0" ]

icd9cm

[ [ [] ] ]

[ "39.95", "55.53" ]

icd9pcs

[ [ [] ] ]

8128, 8134

4771, 6526

308, 356

8403, 8412

3582, 3582

9191, 9476

2733, 2810

6893, 8105

8155, 8332

6552, 6870

8436, 9168

2825, 3563

8353, 8382

248, 270

384, 2170

4174, 4748

2192, 2559

2575, 2717

56,651

105,954

34543

Discharge summary

report

Admission Date: [**2147-10-12**] Discharge Date: [**2147-10-29**] Date of Birth: [**2079-6-24**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: On admission: Mr [**Known lastname 79336**] states that he experienced two to three months of abdominal discomfort, which grew in severity and became more constant. He had a simultaneous loss of appetite, although he denies nausea or emesis. Major Surgical or Invasive Procedure: [**2147-10-12**] - s/p subtotal gastrectomy w/Bilroth II reconstruction, transverse colectomy, feeding J tube placement History of Present Illness: On [**9-6**], the patient underwent a barium upper GI series. This study demonstrated a large ulcerated mass associated with the greater curve of the stomach in the distal portion. On [**9-8**], upper endoscopy was performed, with the finding of a large ulcerated antral mass. Upon biopsy, he has been considered to have an invasive adenocarcinoma of the signet ring type. On [**9-13**], a CT scan of the torso was obtained. He was described as having a 4-mm right pulmonary lobe nodule. There was a 6-mm hypodense lesion in segment III of the liver. A 7.5 cm mass was seen in association with the greater curve of the stomach within the antrum. There did appear to be some stranding or nodularity in the greater omentum extending towards the transverse colon, although there was no clear-cut involvement of the transverse colon. There did not appear to be any significant retroperitoneal adenopathy. Past Medical History: HTN Hypercholesterolemia Arthritis Social History: Mr [**Known lastname 79336**] is a 68-year-old retired factory worker from the food industry He has a history of heavy cigarette smoking, one pack per day for 25 years, stopping in [**2146-10-24**]. Family History: The family history is significant for a brain tumor in his mother. [**Name (NI) **] believes that his brother died at age 12 from leukemia but he was uncertain. Physical Exam: Deceased Pertinent Results: SPECIMEN SUBMITTED: gastrectomy with tranverse colon. Procedure date Tissue received Report Date Diagnosed by [**2147-10-12**] [**2147-10-13**] [**2147-10-19**] DR. [**Last Name (STitle) **]. FU/mb???????????? Previous biopsies: [**-8/3468**] Slides referred for consultation. DIAGNOSIS: Stomach and transverse colon, subtotal gastrectomy and segmental colectomy: 1. Gastric adenocarcinoma, intestinal type with focal signet ring cell features. See synoptic report. 2. Segment of colon with serositis and focal adhesion, no malignancy identified. Stomach: Resection Synopsis MACROSCOPIC Specimen Type: Partial gastrectomy: distal. Tumor Site: Body, antrum. Tumor configuration: Ulcerating. Tumor Size Greatest dimension: 8.2 cm. Additional dimensions: 8.1 cm x 3.5 cm. MICROSCOPIC Histologic Type: Adenocarcinoma, intestinal type with focal signet ring cell features. Histologic Grade: G3: Poorly differentiated. Primary Tumor: pT3: Tumor penetrates serosa (visceral peritoneum) without invasion of adjacent structures. Regional Lymph Nodes: pN1: Metastasis in 1 to 6 perigastric lymph nodes. Lymph Nodes Number examined: 13. Number involved: 4. Distant metastasis: pMX: Cannot be assessed. Margins Proximal margin: Uninvolved by invasive carcinoma. Distal margin: Uninvolved by invasive carcinoma. Omental (radial) margins Lesser omental margin: Uninvolved by invasive carcinoma. Greater omental margin: Uninvolved by invasive carcinoma. Distance from closest margin: 29 mm. Specified margin: Proximal. Lymphatic (Small Vessel) Invasion: Present. Venous (Large vessel) invasion: Present. Perineural invasion: Absent. Additional Pathologic Findings: Chronic active gastritis with intestinal metaplasia. Bacilli forms consistent with H. pylori are present. Clinical: 68 year old man with diagnosis of gastric adenocarcinoma. Upper GI series demonstrating a large ulcerative mass of the distal stomach, along the greater curvature. Follow-up biopsy demonstrating invasive signet-ring cell adenocarcinoma. Brief Hospital Course: The patient underwent the above procedure on [**10-12**]. He tolerated the procedure well and was transferred to the surgical floor, with a foley catheter in place, NG tube in place, J tube to gravity, PCA for pain control, his diet remained NPO, IVF for hydration. He received 3 doses of peri-operative antibiotics. [**10-14**] - Tube feeds were started at 1/2 strength at 10cc/hour, NGT discontinued [**10-16**] - transferred to the ICU for tachycardia, oxygen desaturations. CTA performed showing no pulmonary embolism. ECHO performed showing moderate symmetric left ventricular hypertrophy with global normal systolic function and mildly dilated right ventricle with mild hypokinesis. [**10-17**] - respiratory status was stable. Had bilious emesis twice and began burping. Tube feeds were held and pt was made NPO. [**10-18**]- TPN started, NPO continued. UGI study showed ileus. [**10-19**] - Transferred to the surgical floor, continued NPO, TPN, NGT and foley catheter in place, TF at 20 cc/hr [**10-20**] - transferred to the TSICU for continued respiratory distress, transfused one unit RBC [**10-21**] - Zosyn started for blood cultures positive for GNR, central line removed [**10-22**] - central line replaced, vancomycin started [**10-23**] - CT guided drainage of right and left abdominal fluid collections, drains left in place to gravity, flagyl added [**10-24**] - cont TPN, TF at full strength at 60, started fluconazole for yeast in left abdminal drain, transfused 2 units RBC [**10-25**] - Dr [**Last Name (STitle) 519**] recommended possible re-exploration for a presumed abscess. He indicated to the family that there was no evidence of any actual anastamotic dehischence from any of the imaging studies. However, after extensive discussions, per the patient and family requests, the patient was made comfort measures only. All antibiotics, tube feeds, and extraneous means of support were removed. The patient was transferred to the surgical floor [**10-26**] - Palliative Care consulted. Adjustments made to pain medication regimen. [**10-29**] - Pt expires at 12:20 PM. Immediate cause of death is respiratory arrest Medications on Admission: Benicar 20/12.5 mg once daily ranitidine 150 mg once daily simvastatin 20 mg once daily aspirin 325 mg once daily Darvocet p.r.n. for abdominal discomfort Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Signet-ring cell gastric cancer invading trans colon Discharge Condition: Deceased Discharge Instructions: n/a Followup Instructions: N/A [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

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icd9cm

[ [ [] ] ]

[ "99.04", "46.39", "96.6", "99.15", "43.7", "54.91", "45.74" ]

icd9pcs

[ [ [] ] ]

6636, 6645

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32391

Discharge summary

report

Admission Date: [**2181-4-18**] Discharge Date: [**2181-4-28**] Date of Birth: [**2150-6-8**] Sex: M Service: MEDICINE Allergies: Allopurinol / Bleomycin Attending:[**First Name3 (LF) 3967**] Chief Complaint: fever Major Surgical or Invasive Procedure: Central Venous Line placement History of Present Illness: 30 YO M with classic HL, nodular sclerosis type C1D11 ABVD. The patient reports feeling ok until the day prior to presentation aside from an intensely pruritic rash which developed shortly after completion of chemotherapy. On the day prior to presentation, he developed a fever to 102.7 at home. He had associated chills but no oral pain, URI sx, no SOB, no abdominal pain or diarrhea, no dysuria. Upon arrival to the ED, VS were: 103.3 140 95/49 20 100% RA; he was triggered for HR 140. Exam was notable for non-focal exam aside from pruritic, diffuse rash which the patient reports he gets with therapy. Labs were notable for WBC 2.7 12% bands, hyperseg polys and dohle bodies), Na 125, and lactate 2.7. U/A was negative for infection. Blood cultures were sent. CXR was reportedly negative for infection. He was given vanc and cefepime as well as tylenol and IVFs. The fellow was called and agreed with vanc/cefepime. VS prior to transfer were: 98.9, 119, 103/53, 14, 1002L. Upon arrival to the floor, the patient complains of shaking. He is quite hungry. He reports recent constipation relieved by a bowel regimen. Past Medical History: ONC History: The patient reports that he had a [**1-25**] month history where he had noticed a "lump" on his left anterior chest, which had eventually grown in size and he also notes one a one and half to two-month history of pruritus. A biopsy of a left supraclavicular node was done on [**3-15**] which revealed evidence of classical Hodgkin's Lymphoma, nodular sclerosis subtype. Outside labs from [**3-6**] revealed a normal albumin, a wbc of 13.98 and hgb of 11.8. He had a chest x-ray on [**3-12**] as part of a preop testing before his lymph node biopsy which revealed Central adenopathy is predominantly in a pre- and paratracheal planes, extending from the neck to the upper mediastinum, as well as both internal mammary chains, probably not involving the lower poles of the hila. PET scan on [**4-4**] revealed numerous FDG-avid nodules throughout the anterior chest wall along with extensive FDG-avid cervical, hilar, mediastinal, and axillary lymphadenopathy. There was an indeterminate FDG-avid lesion in the right lobe of the liver. Attention to this region on followup studies is recommended. He had no evidence of bone marrow involvement. C1 ABVD [**2181-4-9**] Social History: The patient has never smoked, does not drink alcohol, no history of IV drug use. The patient has been married for eight years. He has no children. He is a minister. He does note that he does have some exposures to paint chemicals. He works with car dealerships and does on occasion paint cars, notes that he used to do window tinting back in [**Country 4194**]. He has been here from [**Country 4194**] for about eight years. He has two brothers. Family History: There is no known history of any blood disorders or blood cancers. Exposure risks, chemicals in terms of painting the cars, which he has been doing for the past three years. Physical Exam: Admission Exam: VS: 99.1 100/60 121 18 100% 2L GENERAL: Non-toxic although tired appearing, rigoring; diffuse indurated warm, red maculopapular rash in all areas that patient is able to reach (sparing of the mid-back) with scattered pinpoint areas of skin breakdown and scabbing HEENT: Oropharynx is clear without any erythema, lesions, or thrush. CHEST: clear to auscultation, anterior chest wall mass HEART: Tachy, Regular rhythm, S1, S2, and no clicks, murmurs, or rubs. ABDOMEN: Normal bowel sounds, soft, nontender, nondistended, without palpable hepatosplenomegaly. EXTREMITIES: 2+ nonpitting edema SKIN: as above Pertinent Results: ADMISSION LABS: [**2181-4-17**] 09:15AM WBC-7.0 RBC-4.77 HGB-13.0* HCT-39.2* MCV-82 MCH-27.3 MCHC-33.2 RDW-12.5 [**2181-4-17**] 09:15AM NEUTS-89* BANDS-2 LYMPHS-7* MONOS-0 EOS-2 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2181-4-17**] 09:15AM TOT PROT-6.2* ALBUMIN-3.4* GLOBULIN-2.8 CALCIUM-8.7 PHOSPHATE-4.0 MAGNESIUM-2.2 [**2181-4-17**] 09:15AM ALT(SGPT)-18 AST(SGOT)-13 LD(LDH)-264* ALK PHOS-56 TOT BILI-0.5 [**2181-4-17**] 09:15AM UREA N-14 CREAT-1.1 SODIUM-130* POTASSIUM-4.6 CHLORIDE-92* TOTAL CO2-30 ANION GAP-13 [**2181-4-18**] 09:00PM WBC-2.7*# RBC-4.35* HGB-12.0* HCT-34.2* MCV-79* MCH-27.5 MCHC-34.9 RDW-13.3 [**2181-4-18**] 09:00PM NEUTS-57 BANDS-12* LYMPHS-16* MONOS-0 EOS-8* BASOS-0 ATYPS-6* METAS-0 MYELOS-0 PLASMA-1* [**2181-4-18**] 09:00PM ALT(SGPT)-19 AST(SGOT)-21 LD(LDH)-320* ALK PHOS-43 TOT BILI-0.4 [**2181-4-18**] 09:00PM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-1.9 URIC ACID-2.4* [**2181-4-18**] 09:15PM LACTATE-2.7* . DISCHARGE LABS: CBC: 22.6/28.4/409; 73N 6Band 9L 9Meta INR 1.1 PT 13.0 PTT 22.9 Chem7: 137/4.4/102/27/26/0.7/102 ALT 67 AST 15 LDH 575 AP 80 TBil 0.3 Alb 3.0 Ca 8.5 Phos 4.9 Mg 2.3 . MICROBIOLOGY: Strongyloides Antibody, IgG ([**Doctor First Name **]) Strongyloides IgG <1.00 ASPERGILLUS ANTIGEN 0.2 Fungitell (tm) Assay for (1,3)-B-D-Glucans : <31 (Reference Negative Less than 60 pg/mL) COMPLEMENT, TOTAL (CH50) 34 31-60 U/mL PATHOLOGY: Skin Biospy: Perivascular and dermal mixed inflammatory infiltrate with focal pigment incontinence, consistent with a medication reaction, see note. Note: The sections show perivascular and dermal lympho-histiocytic infiltrate with numerous neutrophils and eosinophils. Focal dyskeratosis is noted, and mild pigment incontinence is present. Overall, the findings are consistent with a reaction to chemotherapeutic agents, and compatible with early/inflammatory phase of flagellate erythema (due to bleomycin). No fungi are seen in PAS - reacted sections. The tissue Gram stain is negative. The findings were communicated with Dr. [**Last Name (STitle) **] [**Female First Name (un) **] on [**2181-4-20**]. Clinical: Specimen submitted: right abdomen. Rule out flagellate erythema. 30 year old male with newly diagnosed Hodgkin's lymphoma. Status post ABVD TX (includes bleomycin) who presents with several days history of intensely pruritic eruption, neck down which is strikingly flagellate appearing deep erythematous papules and plaque. No mucosal involvement. Patient febrile with elevated eos plus neutropenic. Gross: The specimen is received in one formalin-filled container, labeled with the patient's name, "[**Known lastname 59139**], [**Known firstname 75634**]", and the medical record number. The specimen consists of a single 0.4 x 0.4 cm circular portion of tan-white skin excised to a depth of 0.5 cm. The specimen is hair bearing. There is also pink and red discoloration on the skin surface. The specimen is black-inked at the resection margin, bisected and entirely submitted in cassette A. IMAGING: [**4-18**] CXR: IMPRESSION: Mediastinal widening relates to the patient's known history of lymphoma. No acute pneumonia. [**4-19**] ECHO: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. There is mild posterior leaflet mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. No vegetations seen but suboptimal study [**4-23**] CXR: FINDINGS: In comparison with study of [**4-22**], the right IJ catheter remains in place with the tip in the mid portion of the SVC. No change in the appearance of the heart and lungs. Prominence of the superior mediastinum consistent with adenopathy is again seen. Brief Hospital Course: 30yo M h/o Hodgkin's Disease on ABVD c1d13 on day of admission who presented w rash, febrile neutropenia, and was intially treated in the ICU for hypotension to SBP 80s and poor peripheral access. CVL was placed in R IJ; blood pressures resolved to 90s with fluid resuscitation and remained stable afterwards. . Patient's exam was notable for pruritic, erythematous rash over extremities and trunk. He was evaluted by Dermatology with biopsy taken. Biopsy confirmed that this flagellate erythema, thought to be either [**1-24**] bleomycin vs hypersensitivity reaction to allopurinol. Pruritus responded well to prednisone and hydroxyzine; PO prednisone was changed to IV steroids for most of the hospitalization of of concern for poor absorption. . Patient was initially covered with cefepime/vanco in setting of febrile neutropenia. ANC recovered with neupogen and patient was continued on vancomycin for skin flora coverage. Neupogen was stopped after ANC recovered. WBC did continue to trend upwards to 70s in setting of steroids and previous neupogen but again trended down prior to discharge. No infectious source was isolated, and his hypotension and fevers were attributed to allergic reaction. Antibiotics were finally stopped. . After the patient was transferred out of the ICU, he remained stable and was given a second course of chemo; on [**2181-4-26**] he received AVD (Bleomycin was held given above reaction.) He tolerated this well. His LFTs did transiently increased to ALT 95 the day following chemo, but this trended down to 65 the following day. . On discharge, he was kept on 40mg daily Prednisone with no plans to taper given continued active disease. Ranitidine was added given steroids. He will followup in [**Hospital **] clinic and [**Hospital 2652**] clinic in a few days. . PENDING: Of note, if patient remains on long term steroids for this reaction he will require PCP prophylaxis, Calcium, Vitamin D as well as close followup with a PCP. Medications on Admission: patient unsure of his meds...taken from recent clinic note. ALLOPURINOL - 300 mg Tablet - 1 Tablet(s) by mouth once a day APREPITANT [EMEND] - 80 mg Capsule - 1 Capsule(s) by mouth on days 2 and 3 of chemotherapy HYDROXYZINE HCL - 25 mg Tablet - 1 Tablet(s) by mouth q6-8h as needed for itch LACTULOSE - 10 gram/15 mL Solution - 15-30 ml by mouth q6-8hrs as needed for constipation dispense 300ml ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth every eight (8) hours as needed for nausea PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth q6-8h as needed for nausea Discharge Medications: 1. Zofran 8 mg Tablet Sig: One (1) Tablet PO TID; prn as needed for nausea. 2. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO q6-8h; prn as needed for nausea. 3. lactulose 10 gram/15 mL Solution Sig: Two (2) PO q4-6h; prn as needed for constipation. 4. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO q6-8h;prn. 5. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) Topical every 6-8 hours as needed for itching. Disp:*1 bottle* Refills:*0* 6. mupirocin calcium 2 % Cream Sig: One (1) Topical [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*0* 7. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 8. prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hodgkin's Disease Drug Reaction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 59139**], You were admitted to the hospital with a serious drug reaction that resulted in a rash and low blood pressure. We think that this was a reaction to Bleomycin which was one of your chemotherapy medications. It is also possible that this was an allergy to allopurinol so we stopped this as well. . While you were here, we gave you the second cycle of your chemotherapy, but did not give you the Bleomycin component. . We made the following changes to your medications: STOP taking Allopurinol Start taking Famotidine Please continue to take Prednisone 40 mg daily for now. You can use Sarna lotion and Mupirocin lotion for your legs for itching or irritation. You can take Benadryl or Claritin over the counter if you need for itching at home. . Please go to the followup appointments below. Followup Instructions: Appointment with Dr. [**Last Name (STitle) 3759**] on Tuesday, [**5-1**] at 11AM. He will take out your stitches at that time. Appointment with [**Hospital 2652**] Clinic. They will call you to set this up with Dr. [**Last Name (STitle) **]. If you do not hear from them, you can call them at [**Telephone/Fax (1) 1971**]. [**Name6 (MD) **] [**Last Name (NamePattern4) 3974**] MD, [**MD Number(3) 3975**]

[ "780.61", "276.1", "273.8", "458.29", "288.03", "285.22", "201.50", "E930.7", "693.0", "458.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "86.11", "99.25" ]

icd9pcs

[ [ [] ] ]

11484, 11490

8080, 10054

289, 321

11566, 11566

4004, 4004

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3162, 3339

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11511, 11545

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244, 251

349, 1470

4020, 4956

11581, 11693

1492, 2675

2691, 3146

76,457

123,511

9111

Discharge summary

report

Admission Date: [**2196-9-26**] Discharge Date: [**2196-10-4**] Date of Birth: [**2113-3-12**] Sex: F Service: CARDIOTHORACIC Allergies: Crestor / Iodine-Iodine Containing Attending:[**First Name3 (LF) 922**] Chief Complaint: Worsening shortness of breath. Major Surgical or Invasive Procedure: [**2196-9-27**] TAVI CoreValve/ partial sternotomy ( [**Company 1543**] 26 mm) [**2196-9-30**] Re-exploration for bleeding History of Present Illness: The patient is an 83-year-old woman with known aortic stenosis. She was evaluated in [**2192**] by Dr. [**Last Name (STitle) **] for consideration of aortic valve replacement. At that time, he felt that she was not very symptomatic and that she had an extremely calcified aorta and that surgery was deferred due to prohibitively high risk. The patient was minimally symptomatic at that time with the exception of one isolated event. She returned to [**Hospital1 69**] six weeks ago with worsening shortness of breath, lightheadedness with exertion, and requiring two to three pills to sleep at night as well as a 10-lb weight loss over the last two months. She now is being referred for consideration of percutaneous aortic valve replacement. Her [**State 531**] Heart Association Heart Failure Class is 2. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABGx3 : [**2184**] MI x1 in [**2155**] and [**2184**] 3. OTHER PAST MEDICAL HISTORY: Aortic stenosis with [**Location (un) 109**] 0.6cm2 Hypothyrpodosm Dyslipidemia A fib on BB for rate control,not on anticoagulation HTN GERD Osteoarthritis S/P Right THR [**5-11**] s/p hysterectomy s/p cataract removal Social History: Pt lives with husband and both children are deceased. Denies smoking, drugs. Drinks 1.5oz scotch daily. Family History: Daughter died of MI at 34 yo. Uncle with 7 [**Name2 (NI) **] but alive in his 90s. Sister with CABG in her 60s. Mom with MI at 78, dad at 45. Physical Exam: Physical Examination shows a well-developed and well-nourished woman appearing her stated age. Her heart rate is 55 and irregular. Blood pressure is 160/80. Respiratory rate is 20. Height is 61 inches. Weight is 97 pounds. Skin is pale, warm, and dry with fair turgor with no lesions. HEENT, normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is within normal limits except that she is edentulous. Neck is supple without lymphadenopathy, thyromegaly, or bruits. Chest is clear to auscultation bilaterally. Cardiac exam shows III/VI late peaking systolic murmur heard best at the right parasternal border. Abdomen is soft, nontender, and nondistended. Bowel sounds are present. Extremities show trace right lower extremity pedal edema. Neuro exam is nonfocal. Gait is steady. Pulses are 2+ throughout including bounding pedal pulses Pertinent Results: [**2196-10-4**] 05:45AM BLOOD WBC-6.1 RBC-4.39 Hgb-13.5 Hct-39.2 MCV-89 MCH-30.8 MCHC-34.5 RDW-14.8 Plt Ct-131* [**2196-10-3**] 05:30AM BLOOD WBC-5.7 RBC-4.25 Hgb-12.8 Hct-36.8 MCV-87 MCH-30.1 MCHC-34.7 RDW-14.6 Plt Ct-129* [**2196-10-2**] 01:19AM BLOOD WBC-5.6 RBC-4.29 Hgb-12.9# Hct-36.5 MCV-85 MCH-30.1 MCHC-35.3* RDW-14.6 Plt Ct-154 [**2196-10-4**] 05:45AM BLOOD UreaN-12 Creat-0.6 Na-136 K-3.7 Cl-99 HCO3-30 AnGap-11 [**2196-10-3**] 05:30AM BLOOD Glucose-83 UreaN-12 Creat-0.6 Na-136 K-3.4 Cl-97 HCO3-32 AnGap-10 [**2196-10-2**] 01:19AM BLOOD Glucose-103* UreaN-12 Creat-0.6 Na-135 K-3.8 Cl-94* HCO3-34* AnGap-11 [**2196-10-1**] 02:58AM BLOOD Glucose-113* UreaN-18 Creat-0.7 Na-133 K-4.7 Cl-98 HCO3-30 AnGap-10 TTE [**9-28**] The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is moderately dilated. An aortic CoreValve prosthesis is present. The transaortic gradient is normal for this prosthesis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. No mitral regurgitation is seen. There is at least mild-to-moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional function. Well-seated Corevalve prosthesis with normal gradient and no regurgitation. Mild to moderate pulmonary hypertension. The severity of mitral regurgitation is reduced (but not well seen on current study) TTE [**10-4**] LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC diameter (<=2.1cm) with >50% decrease with sniff (estimated RA pressure (0-5 mmHg). LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). No resting LVOT gradient. RIGHT VENTRICLE: RV not well seen. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Normal aortic arch diameter. AORTIC VALVE: Aortic valve homograft (AVR). Thickened AVR leaflets. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Mild functional MS due to MAC. Physiologic MR (within normal limits). [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. Conclusions The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy. 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 normal (LVEF>55%). The ascending aorta is mildly dilated. The aortic valve appears to be a homograft. The prosthetic aortic valve leaflets are thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is a very small (~5 mm) mobile structure attached/adjacent to the anterior mitral leaflet that may represent a loose chord. There is mild functional mitral stenosis (mean gradient 3 mmHg) due to mitral annular calcification. Physiologic mitral regurgitation is seen (within normal limits). [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2196-9-28**], findings are similar. The mobile structure associated with the anterior mitral leaflet is better visualized in the current study. Brief Hospital Course: 83-year-old woman with known aortic stenosis. She was evaluated in [**2192**] by Dr. [**Last Name (STitle) **] for consideration of aortic valve replacement. At that time, he felt that she was not very symptomatic and that she had an extremely calcified aorta and that surgery was deferred due to prohibitively high risk. The patient was minimally symptomatic at that time with the exception of one isolated event. She recently returned to [**Hospital1 1170**] with worsening shortness of breath, lightheadedness with exertion, requiring two to three pills to sleep at night as well as a 10-lb weight loss over the last two months. She was evaluated for consideration of percutaneous aortic valve replacement. Her [**State 531**] Heart Association Heart Failure Class was 2. Since she had severe peripheral vascular disease and an abdominal aortic aneurysm and very small subclavian arteries, she was deemed appropriate for alternative access. Alternative access in her case was chosen as direct aortic through an upper mini sternotomy approach. On [**9-27**] she was taken to the operating room and underwent a Transaortic [**Company 1543**] CoreValve placement using upper mini sternotomy and axillary artery cutdown and introduction of vascular access sheath aortography and right heart catheterization and left heart catheterization, balloon aortic valvuloplasty. See operative note for full details. Initially the patient did well - she was extubated and chest tubes were removed on POD 2. POD 3 she complained of some pain and had a hematocrit drop of 28->24. She initially responded to transfusion appropriately. A chest x-ray showed a new fluid collection in the right hemithorax, close to where the chest tube inserted into the chest wall. A CT scan was done after appropriately pretreating her for her intravenous contrast allergy which showed that there was a copious amount of clot in the right hemithorax and the mediastinum superiorly with a question of extravasation right around the sternum on the right side. She was taken back to the operating room and underwent a mediastinal re-exploration and repair of bleeding right internal mammary artery and vein. There was a copious amount of clotted blood in the right hemithorax as well as non clotted blood. She once once again transferred to the CVICU in stable condition after evacuation. She was extubated later that day without incidence and remained hemodynamically stable on no pressors. Her chest tubes were once again removed and she was transferred to the floor. Pacing wires were removed on POD 3 per cardiac surgery protocol. Plavix was started per corevalve protocol. She had an echocardiogram on [**10-4**] which showed left atrium normal in size. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size normal. Overall left ventricular systolic function normal (LVEF>55%). The ascending aorta mildly dilated. The prosthetic aortic valve leaflets are thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is a very small (~5 mm) mobile structure attached/adjacent to the anterior mitral leaflet that may represent a loose chord. There is mild functional mitral stenosis (mean gradient 3 mmHg) due to mitral annular calcification. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. There was a trivial/physiologic pericardial effusion. Compared with the prior study of [**2196-9-28**] findings were similar. The mobile structure associated with the anterior mitral leaflet were better visualized in the [**2196-10-4**] study. On POD 7 she was ambulating in the [**Doctor Last Name **] without difficulty, tolerating a full po diet and her incisions were healing well. It was felt she was safe for discharge home with visitng nurse services. All appropriate follow up appointments were made. [**Doctor Last Name **] on Admission: [**Doctor Last Name **]: Lipitor 80 mg tablet one p.o. daily, Lasix 20 mg tablet one p.o. daily, Levothyroxine 88 mcg tablet one p.o. daily, Metoprolol Tartrate 50 mg tablet one p.o. b.i.d., Nifedipine XL 60 mg tablet one p.o. daily, Ascorbic Acid 500 mg tablet one p.o. daily, Aspirin 81 mg tablet one p.o. daily, Vitamin D3 1000 unit capsule one p.o. daily, Coenzyme Q10 30 mg capsule one p.o. daily, and Multivitamin one p.o. daily. Allergies: Crestor which causes myalgias and contrast dye which causes the room to spin. Discharge [**Doctor Last Name **]: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*1* 4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Tablet(s) 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Aortic stenosis Coronary artery disease Status post previous coronary artery bypass grafting x3 in [**2184**] non-ST-elevation myocardial infarction in [**2196-5-4**] Calcified aorta Hypertension dyslipidemia Myocardial infarction in [**2155**], [**2184**], and in [**2194-6-4**] Hypothyroidism Paroxysmal atrial fibrillation not on anticoagulation gastroesophageal reflux disease osteoarthritis Abdominal aortic aneurysm. Status post coronary artery bypass grafting in [**2184**] by Dr. [**Last Name (STitle) 1774**], status post right total hip replacement in [**2193-5-5**] status post hysterectomy status post cataract removal Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage + Sternal Click - sternum stable Trace Edema Discharge Instructions: Please shower daily including washing puncture sites in groins with mild soap, no baths or swimming for 1 week until groin sites are healed. Please NO lotions, cream, powder, or ointments to puncture sites in your groins Your [**Year (4 digits) 4982**]: Following TAVI, you will be taking anti-platelet [**Year (4 digits) 4982**] as prescribed by your doctor. [**First Name (Titles) **] [**Last Name (Titles) 4982**] could include aspirin, clopidrogel (Plavix), Coumadin, or a combination. You will remain on these for at least 3 months after your procedure. Please take the dose recommended by your doctor. You should not stop these [**Last Name (Titles) 4982**] unless instructed to do so by your cardiologist. You may experience shortness of breath as you recover. Your doctor may adjust your water pills (diuretics) to improve your shortness of breath. 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, will be discussed at follow up appointment No lifting or pulling more than 10 pounds for 1 week, and then continue to take it easy for 1 month Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call Integrated Aortic valve clinic in cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**] or the NP[**Telephone/Fax (1) 31409**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2196-11-7**] 2:00 Cardiologist:[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2196-11-17**] 4:00 pm ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2196-10-31**] 11:00 Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 8725**] **Please call Integrated Aortic valve clinic in cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**] or the NP[**Telephone/Fax (1) 31409**]. Answering service will contact on call person during off hours** Completed by:[**2196-10-4**]

[ "401.9", "428.32", "244.9", "440.0", "V17.3", "414.02", "V81.2", "V43.65", "530.81", "440.20", "441.4", "427.31", "424.1", "272.4", "V14.8", "715.90", "998.11", "412", "790.01", "428.0", "V70.7" ]

icd9cm

[ [ [] ] ]

[ "88.42", "38.97", "37.23", "39.64", "39.32", "39.31", "35.05" ]

icd9pcs

[ [ [] ] ]

13182, 13237

7197, 11187

332, 459

13912, 14116

2956, 7174

15628, 16491

1839, 1983

13258, 13891

14140, 15605

1998, 2937

1394, 1450

261, 294

487, 1300

11201, 13159

1481, 1701

1322, 1374

1717, 1823

21,992

102,789

2878

Discharge summary

report

Admission Date: [**2126-4-4**] Discharge Date: [**2126-4-13**] Date of Birth: [**2064-8-9**] Sex: M Service: cardiac surgery HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old gentleman with a past medical history of coronary artery disease status post cardiac catheterization and stenting in [**2123**] who presents with substernal chest pain on exertion. His symptoms began the evening of presentation when he was walking. He described the chest pressure as 7 on a scale of 1 to 10. He reportedly lightheadedness with chest pressure. The pain continued despite rest and he was brought to the ED where his symptoms resolved with sublingual nitroglycerin times two. He denied any radiation, shortness of breath, diaphoresis, nausea or vomiting with this exertional angina. He reports that his exertional angina began a few weeks ago but normally is relieved by rest. He underwent exercise test on [**6-5**] which was negative to [**Doctor First Name **] 83 without symptoms or EKG changes and with a MIBI that was completely normal, no longer revealing mild inferior re-perfusing defect that was present on his prior study. PAST MEDICAL HISTORY: 1. Sleep apnea. 2. GERD. 3. Hypercholesterolemia. 4. Coronary artery disease status post cath and stenting. MEDICATIONS: 1. Lopressor 50 milligrams po bid. 2. Aspirin 325 milligrams po q day. 3. Lipitor 10 milligrams po q day. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: Negative except for HPI. SOCIAL HISTORY: A 30 pack year history of tobacco use. A history of alcoholism but absent for the past six years. PHYSICAL EXAMINATION: He is afebrile. Pulse of 92. Blood pressure 168/94, respiratory rate 15, saturation 97% on four liters. Generally he is alert and oriented times 3 in no acute distress. HEENT - pupils are equal, round and reactive to light. Extraocular muscles are intact. Moist mucous membranes. No LED. Supple neck, no JVD. Cardiovascular - S1, S2 regular rate and rhythm. Pulmonary - mild bibasilar crackles. Abdomen - nontender, nondistended, soft, obese, reducible umbilical hernia. Extremities - 1+ pedal edema bilaterally. Neuro - cranial nerves II through XII are intact. Groin - no bruits bilaterally. LABORATORY DATA: EKG shows normal sinus rhythm with an axis of -30 degrees, normal interval except for prolonged PR interval, left atrial enlargement. Labs - white count 8.2, crit 39, platelet count 228,000. Chem 7 140, 3.6, 103, 26, 20, 1.1 and 107. HOSPITAL COURSE: The patient was admitted on [**2126-4-4**] and underwent cardiac catheterization which showed significant distal left main coronary artery stenosis extending into the proximal LAD and a very high grade mid LAD stenosis. The patient was placed on a Heparin drip and aspirin. The cardiothoracic surgery service was consulted on [**4-5**] regarding surgical correction of these lesions. The patient was scheduled for Monday, [**4-8**]. The patient underwent a three vessel CABG on [**2126-4-8**] with saphenous vein graft to the distal LAD, LIMA to mid LAD and radial artery to RM 1. The patient did well postoperatively and was transferred to the CSRU. The patient was placed on Imdur on postoperative day one. The patient's mediastinal tubes were removed on postoperative day one. The patient was transferred to the floor on the evening of postoperative day one. On postoperative day two the patient continued to do well and his pleural chest tubes were removed. On postoperative day three the patient had his wires removed. The patient's Lopressor was increased to 25 milligrams po bid. On postoperative day four the patient continued to do well and was ambulating at a level V with physical therapy. The patient was discharged to home on postoperative day five in good condition on the following medications: DISCHARGE MEDICATIONS: 1. Lopressor 50 milligrams po bid. 2. Lasix 20 milligrams po bid times seven days. 3. Lipitor 10 milligrams po q day. 4. Isosorbide Mononitrate 60 milligrams po q day. 5. Prilosec 20 milligrams po q day. 6. Percocet 5/325 one to two tablets four to six hours prn. 7. Aspirin 325 milligrams po q day. 8. KCL 20 milliequivalents po bid times seven days. 9. Colace 100 milligrams po bid. DISCHARGE DIAGNOSIS: 1. Status post CABG times three vessels with LIMA, Radical artery and saphenous vein on [**2126-4-8**]. DISCHARGE STATUS: Good condition. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 6067**] MEDQUIST36 D: [**2126-4-12**] 13:11 T: [**2126-4-12**] 13:36 JOB#: [**Job Number 13958**]

[ "272.0", "780.57", "V45.82", "530.81", "414.01", "411.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

3857, 4252

4273, 4694

2513, 3834

1636, 2495

1469, 1495

175, 1154

1176, 1449

1513, 1613

69,023

124,839

39035

Discharge summary

report

Admission Date: [**2120-5-3**] Discharge Date: [**2120-5-9**] Service: NEUROLOGY Allergies: Lasix / Motrin Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: aphasia, R. hemiparesis Major Surgical or Invasive Procedure: IV TPA infusion History of Present Illness: The patient is an 86 year old right handed Albanian speaking woman with a history of CHF, paroxysmal atrial fibrillation not on Coumadin, and kidney cyst s/p removal who presents with acute onset aphasia and right sided weakness for whom neurology was called for a CODE STROKE. The history is taken initially from the patient's daughter-in-law, [**Name (NI) **]. At 3:30 pm today, the patient went to take a nap, but prior to that was [**Location (un) 1131**] the newspaper and crocheting without difficulty. She woke up from the nap at 4:00-4:10 pm, as her daughter was calling her on the phone. She grabbed the phone with her left hand, but was unable to speak at all. Her daughter-in-law also noted that she had increased work of breathing, and her face was white/yellow. She did not notice any unilateral weakness or facial asymmetry, but the patient could not walked. EMS was called, and FSBG in the field was 180. She was taken to [**Hospital1 18**] for further evaluation. At [**Hospital1 18**], a CODE STROKE was called at 17:19, and neurology was at the bedside at 17:22. She was found to be in atrial fibrillation with RVR. NIHSS 14. Head CT showed a hyperdense left MCA and early loss of the left insular ribbon. IV tPA was given at 18:21, at which time her bp was 136/96. Of note, at 7:00 pm (when the rest of the patient's family arrived), they mention that the patient had similar symptoms 5 years ago, but the symptoms were not as intense. (It should be noted that on initial history, her daughter-in-law did not say that she had ever had symptoms like this before). She had aphasia x30-45 minutes and generalized weakness (not unilateral) for which she was evaluated at [**Hospital1 2177**] with CT head and MRI head. Per her family, she was given antibiotics for a lung infection at that time. She was started on Coumadin at that time, and took it for 2 months but then refused further doses. At 7:00 pm, her sister also reported that the patient may have been complaining of right leg weakness vs. pain since 1:00 pm today; however, other family members think she was complaining of generalized weakness. Otherwise, she has complained of generalized weakness x1 week, pain in her right leg x1 week, and has been having trouble breathing. She has not had fevers/chills or cough/colds. Past Medical History: CHF Paroxysmal atrial fibrillation not on Coumadin Kidney cyst s/p removal s/p cholecystectomy 2-3 years ago Diverticulitis She has no history of stroke, seizure, CAD, hypertension, hyperlipidemia. She reportedly had elevated blood glucose a few years ago for which she was treated with medications, but they were since discontinued after she developed hypoglycemia. She gets most of her care at [**Hospital1 112**] and [**Location (un) 20026**] Hospital. Social History: The patient is originally from [**Country 38213**], and came to the US 10 years ago. She is a former director of a high school in [**Country 38213**]. She is independent at baseline. She lives at home with her son, daughter-in-law [**Doctor First Name **], and their children. Her HCP is her daughter [**Name (NI) 15139**]. She denies cigarette, EtOH, or illicit drug use. Family History: Her brother died of a stroke in his 70s. Physical Exam: VS: temp 97.5, HR 106, bp 143/99, RR 22, SaO2 100% on NRB Gen: Awake, alert, audible crackles HEENT: Sclerae anicteric, no conjunctival injection CV: Tachycardic, irregularly irregular heart rate, Nl S1, S2, no murmurs, rubs, or gallops Chest: Bibasilar crackles, no wheezes or rhonchi Abd: Quiet BS, soft, ND abdomen Neurologic examination: Mental status: Awake and alert, follows commands to squeeze left hand but does not follow command to close eyes. Does not say her name, the month, or her age. Occasionally makes a grunting sound, but no word production. Cranial Nerves: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. No gaze preference. Does not reliably blink to threat bilaterally or follow commands for EOM. Initial had minor flattening of the right NLF (but would not follow command to smile), 30 minutes later had a right UMN facial droop. Tongue midline. Motor: Normal tone bilaterally in UE and LE. No observed myoclonus or tremor. Keeps left arm briefly off the bed, and keeps left leg off the bed x5 seconds. Keeps right forearm lifted against gravity, but does not lift the deltoid. Only has a flicker of contraction of the right leg, but does withdraw the right leg to nailbed pressure. Sensation: Does not cooperate with pinprick testing. Reflexes: Trace and symmetric in triceps. 0 and symmetric in biceps, brachio-radialis, knees, and ankles. Toe upgoing on the right and downgoing on the left. Coordination: Unable to test NIHSS Score: 1a. LOC: 0 1b. LOC Questions: 2 1c. Commands: 1 (squeezes hand on the left, does not close eyes) 2. Best Gaze: 0 3. Visual Fields: X (inconsistently blinks to threat) 4. Facial Palsy: 1 (initially 1 on the right, but later into the exam became a 2 for a right UMN facial paralysis) 5. Motor Arm: 2 on the right 6. Motor Leg: 3 on the right 7. Limb Ataxia: X 8. Sensory: X (pinprick tested, but she is not able to say if she feels it) 9. Best Language: 3 10. Dysarthria: 2 11. Extinction/Neglect: X NIHSS Score Total: 14 Pertinent Results: Admit Labs: 143 104 58 169 -------------< 4.4 28 1.9 CK: 73 MB: Not done Trop-T: <0.01 Ca: 9.2 Mg: 2.3 P: 3.3 Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative 13.9 83 7.7>---------<336 42.8 PT: 11.8 PTT: 23.2 INR: 1.0 IMAGING: CT Head (our read): Possible hyperdense left MCA, early loss of the left insular ribbon CXR (PRELIM): prominent right paratracheal opacity could be due to enlarged thyroid, although other mediastinal mass is not excluded. recommend comparison with any prior studies if available, o/w nonemergent u/s or chest CT. bilat pleural eff with overlying atelect/consol. Brief Hospital Course: Attending A/P: Acute L-MCA infarction, likely cardioembolic in setting of AF, s/p iv tPA. Repeat exam shows minimal improvement. Repeat head CT shows a large evolving left hemispheric infarction but no significant bleeding. Continue ICU monitoring for now. Will hold off on CTA because of renal failure. Check carotid dopplers. Hold off on antipaletelst, anticoagulants for now. D/C iv pressors. Monitor I/O closely. Swallow eval. Family counseled about patient's condition at bedside; questions answered. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Hospital Course: Mrs. [**Known lastname 86555**] had no improvement following tPA. She continued with full aphasia, as judged by her family members (speaks only Albanian). Her attention and interaction improved somewhat over the first four days of her hospitalization, but she never displayed clear attempt to communicate or evidence of understanding. On [**2120-5-8**], a family meeting was held, with the patient's two daughters ([**Name (NI) 15139**], the HCP, was present), the attending physician (Dr. [**First Name (STitle) **], and the resident physician (Dr. [**Last Name (STitle) **] in attenance. The daughters stated that Mrs. [**Known lastname 86555**] had explicitly stated on multiple occasions that she would not want to survive by artificial support. She stated that she would not want further surgeries and would not want to be intubated. We weaned her to comfort measures only, withdrawing medications and tube feeds. She expired the following evening. Medications on Admission: Medications: Verapamil 240 mg SA daily Gabapentin 100 mg qhs Edecrin 25 mg [**Hospital1 **] (loop diuretic) ASA 81 mg daily She does not take Coumadin currently. Allergies: Lasix-> ? reaction, Motrin->stomach Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: L. middle cerebral artery embolic stroke Discharge Condition: Expired Discharge Instructions: You were admitted for evaluation of right sided weakness and inability to speak, and were found to have had a L. sided stroke. This left you with aphasia and right sided hemiparesis (the inability to speak or understand language, and weakness of the right side). Unfortunately, these symptoms did not improve with the most aggressive form of therapy, and failed to show improvement during your time in the hospital. Followup Instructions: None Completed by:[**2120-5-10**]

[ "434.11", "428.0", "428.30", "V45.88", "585.9", "584.9", "427.31", "342.90", "784.3" ]

icd9cm

[ [ [] ] ]

[ "99.10" ]

icd9pcs

[ [ [] ] ]

8094, 8103

6231, 6823

253, 270

8188, 8198

5579, 6208

8664, 8700

3496, 3538

8065, 8071

8124, 8167

7830, 8042

6841, 7804

8222, 8641

3553, 3872

190, 215

298, 2606

4133, 5560

3911, 4117

3896, 3896

2628, 3087

3103, 3480

55,543

192,206

52249

Discharge summary

report

Admission Date: [**2140-9-26**] Discharge Date: [**2140-10-7**] Date of Birth: [**2060-8-26**] Sex: M Service: NEUROLOGY Allergies: Niacin / Penicillins Attending:[**First Name3 (LF) 65686**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: Central Line Placement History of Present Illness: Note: All of the following history obtained from ED physicians and medical records. 80yo M with h/o indwelling foley and right frontal lobe glioblastoma multiforme, WHO grade IV on brain biopsy with hemiparesis being treated with shortened course of radiotherapy with concurrent Temodar by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**] in Neurology, presented from NH to ED with fevers and AMS. Per report of his nursing facility he had become more somnolent and altered, no change in his baseline deficits. While at the rehab facility he has had a foley in place. . In the ED, initial vs were: T 97.8 108 155/103 18 98. He was A&O x 1, looked dry on exam Patient was given vanc and gent due to his penicillin allergy for a presumed UTI, tylenol, and dexamethasone for his refractory hypotension, due to concern that since he had previously been on steroids the persistent hypotension after 4LNS could be due to adrenal insufficiency. His BP remained low in spite of the steroids and IVF, so he had a right IJ placed, and was started on noriepinephrine. His foley was replaced in the [**Last Name (LF) **], [**First Name3 (LF) **] EKG showed lateral ST depressions, a CXR with no acute process and had a head CT with interval improvement, and felt that there was no intervention needed from their service at this time. Prior to transfer from the ER he was started on levophed at 0.03, and VS prior to transfer were: 102, 88/47, 26, 93% on 4LNC. . On the floor, initial VS were: 97.4, 111, 119/64, 25, 94% on 4LNC. He currently is denying any pain, is complaining of some shortness of breath that is worsened with lying flat, but denies any CP, abdominal pain, n/v/d, fever/chills. . Review of systems: (+) Per HPI (-) Denies fever. Denies headache. Denies chest pain. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Past Medical History: HTN, Triple bypass x2 at [**Hospital1 2025**] ( date unknown) Cardiac stents "[**2090**] or [**2100**]" PNA Colon polyps idiopathis bowel incontinence ( has worn a diaper for the past 15 years) Social History: He is married and lives with his wife in [**Name (NI) 3146**], MA. He has no children, his wife has a daughter from her previous marriage. He is retired, used to work for an oil company, unloading tanker ships. Family History: He had three brothers and four sisters, only one of sister is alive, the other died in their 70s and 80s. His parents died in their 50s, his father had COPD, and his mother had cancer, he does not know more details. Physical Exam: ADMISSION PHYSICAL EXAM General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM Tm/Tc 98.5/96.5 BP 136/54 (116-136/40-62) P 70 (57-70) R 18 Sat 94%RA I/O: 24h: 1315/1600 Physical exam: GEN: No acute distress, arousable and answers questions. AAOx2 HEENT: Mucous membranes moist, no lesions noted NECK: No cervical LAD. CV: Regular rate and rhythm, no murmurs, rubs or [**Last Name (un) 549**] PULM: Clear to auscultation bilaterally, no wheezes, rales or rhonchi. ABD: Soft, tender in epigastric and periumbilical regions, non distended, bowel sounds present. No rebound or guarding, no organomegaly. EXTR: No edema, 2+ Dorsalis pedis and radial pulses bilaterally. SKIN: Vesicular rash noted on right flank from midline of abdomen to center of back. Pertinent Results: CT head [**9-26**]- FINDINGS: Since the prior CT, there has been significant resolution of the biopsy-related hemorrhage within the right basal ganglia/insular mass. There is now a slightly hyperdense appearance to the periphery of this mass which measures 2.0 x 2.3 cm and is seen on series 2, image 19. Associated vasogenic edema is noted though there is no significant mass effect or shift of midline structures. There is no new hemorrhage. The known additional masses (right temporal lobe and right thalamic lesions) as seen on MR are not clearly seen on this study. Periventricular white matter hypodensity suggests chronic small vessel ischemic disease. The sinuses and air cells are well pneumatized. The osseous structures again demonstrate a right-sided burr hole. There is no associated soft tissue emphysema or fluid collection. The dense calcification at the left quadrigeminal cistern appears unchanged. [**2140-9-26**] 04:35PM GLUCOSE-158* UREA N-33* CREAT-0.9 SODIUM-137 POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-20* ANION GAP-17 [**2140-9-26**] 04:35PM CK(CPK)-612* [**2140-9-26**] 04:35PM CK-MB-57* MB INDX-9.3* cTropnT-0.26* [**2140-9-26**] 04:35PM CALCIUM-7.5* PHOSPHATE-4.0 MAGNESIUM-2.0 [**2140-9-26**] 09:02AM LACTATE-2.2* [**2140-9-26**] 08:45AM GLUCOSE-85 UREA N-47* CREAT-1.1 SODIUM-138 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-26 ANION GAP-18 [**2140-9-26**] 08:45AM estGFR-Using this [**2140-9-26**] 08:45AM CK(CPK)-268 [**2140-9-26**] 08:45AM CK-MB-2 cTropnT-<0.01 [**2140-9-26**] 08:45AM CALCIUM-9.5 PHOSPHATE-3.0 MAGNESIUM-2.4 [**2140-9-26**] 08:45AM WBC-29.1*# RBC-5.97 HGB-17.1 HCT-50.1 MCV-84 MCH-28.6 MCHC-34.1 RDW-14.6 [**2140-9-26**] 08:45AM NEUTS-90* BANDS-3 LYMPHS-3* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2140-9-26**] 08:45AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2140-9-26**] 08:45AM PLT SMR-LOW PLT COUNT-137* [**2140-9-26**] 08:45AM PT-15.2* PTT-36.3* INR(PT)-1.3* [**2140-9-26**] 08:45AM URINE COLOR-[**Location (un) **] APPEAR-Cloudy SP [**Last Name (un) 155**]-1.025 [**2140-9-26**] 08:45AM URINE BLOOD-LG NITRITE-POS PROTEIN-150 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2140-9-26**] 08:45AM URINE RBC->50 WBC-[**7-14**]* BACTERIA-MANY YEAST-NONE EPI-0-2 [**2140-10-4**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2140-10-3**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2140-9-30**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2140-9-30**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Anaerobic Bottle Gram Stain-FINAL INPATIENT [**2140-9-29**] URINE URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA} INPATIENT [**2140-9-28**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2140-9-28**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2140-9-27**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2140-9-27**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2140-9-26**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2140-9-26**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **] [**2140-9-26**] BLOOD CULTURE Blood Culture, Routine-FINAL {PSEUDOMONAS AERUGINOSA}; Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **] [**2140-9-26**] BLOOD CULTURE Blood Culture, Routine-FINAL Brief Hospital Course: 80yo M with h/o glioblastoma multiforme admitted with AMS and fever likely [**3-8**] urosepsis now c/b NSTEMI, on ASA, Atorvastatin, plavix, and heparin gtt. # Goals of care/GBM: Followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**] in radiation oncology and Dr. [**Last Name (STitle) 724**] (neuro-oncology) and is on dexamethasone as an outpatient. We continued dexamethasone during his stay. Patient felt to be too poor a performance status for chemotherapy. Given overall prognosis, patient was changed to DNR/I, via talks with Dr. [**Last Name (STitle) 6570**], with plan to initiate hospice care. # Infection/Hypotension: given grossly positive U/A, likely urosepsis causing change in his mental status, baseline mental status not clear, however is alert and interactive, oriented X [**2-6**]. The fact that his CT and neuro exam per neurosurgery is not concerning are both reassuring. Pt is on vancomycin and gentamicin given possible anaphylactic reaction to penicillin. Blood culture and urine culture grew pseudomonas. Patient was also found to have findings suspicious for pneumonia on chest x-ray. Pt was weaned off levophed. He received a total of 10 days antibiotics for treatment, which were discontinued upon discharge. # NSTEMI: Pt had a concerning EKG with ST depressions with positive cardiac enzymes that have continued to climb. Pt was on aspirin, atorvastatin, plavix, and heparin gtt (heparin gtt for 48 hrs) with PTT goal of 50-80. Echo showed EF of 40%, moderate septal hypokinesis, mild anterior wall and apical hypokinesis, mild aortic stenosis and mitral regurgitation. He was started on 6.25 mg of metoprolol tartrate PO BID. # Shingles: On day of discharge, patient noted to have zoster rash on right flank. He was started on valacylovir for a planned 10 day course. # Hyponatremia: Given that pt seemed hypervolemic/euvolemic on exam, possibly [**3-8**] SIADH given GBM. However, could be an early salt wasting syndrome, or developing congestive heart failure, although echocardiogram findings argued against that. Patient also has possible hypothyroidism. We empirically started 1.5 liter free water restriction, which was liberalized when goals of care were changed. # Thrombocytopenia: last documented platelet count was 30 two days before discharge, and dropped during the admission. Due to this, aspirin and heparin were held to prevent bleeding. The cause of thrombocytopenia was unknown. Of note, patients platelets are noted to clump when drawn, and need to be drawn in a yellow tube. Medications on Admission: Medications - Prescription DEXAMETHASONE - 4 mg Tablet three times a day HEPARIN (PORCINE) - 5,000unit/mL - SQ three times a day LEVETIRACETAM - 500 mg Tablet -2 Tablet(s) by mouth twice a day LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth twice a day OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth twice a day SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth at bedtime TEMOZOLOMIDE [TEMODAR] - 140 mg Capsule - 1 Capsule(s) by mouth daily Take 150 mg daily, ONE 140 mg capsule and TWO 5 mg capsules during radiation treatment every day (75 mg/m2 177 lbs, 69 in, 1.97 m2) TEMOZOLOMIDE [TEMODAR] - 5 mg Capsule - 2 Capsule(s) by mouth daily Take 150 mg daily, ONE 140 mg capsule and TWO 5 mg capsules during radiation treatment every day (75 mg/m2 177 lbs, 69 in, 1.97 m2) Medications - OTC CALCIUM CARBONATE - (Prescribed by Other Provider) - 500 mg (1,250 mg) Tablet - 1 Tablet(s) by mouth three times a day DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg Capsule - 2 Capsule(s) by mouth once a day LIPASE-LACTASE-AMYLASE [TRI-ZYME] - (Prescribed by Other Provider) - 150 mg-100 mg-60 mg Capsule - 1 Capsule(s) by mouth three times a day SENNA - 2 Capsule(s) by mouth at bedtime Discharge Medications: 1. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 2. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once 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. Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) for 10 days. 12. Morphine 2 mg/mL Syringe Sig: 1-2 mg Injection Q6H (every 6 hours) as needed for pain, diaphoresis. 13. Ondansetron 8 mg IV Q8H:PRN nausea 14. Prochlorperazine 10 mg IV Q6H:PRN nausea Discharge Disposition: Extended Care Facility: [**Hospital3 9475**] Care Center - [**Location (un) 3146**] Discharge Diagnosis: Pseudomonas sepsis Shingles NSTEMI Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You presented to the hospital with altered mental status. You were found to have a serious blood stream infection, pneumonia, a urinary infection and a small heat attack. You were also found to have an infection of the skin rash called Shingles. Your are being discharged back to your rehab facility, with plan to bridge to comfort measures. You are being continued on steroids. You may follow up with Dr. [**Last Name (STitle) 724**], your oncologist if you see fit. Followup Instructions: Department: NEUROLOGY When: MONDAY [**2140-10-17**] at 12:00 PM With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2147-3-4**] Discharge Date: [**2147-3-10**] Date of Birth: [**2101-6-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: Unresponsive ---> OSH acetaminophen intoxication Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 76719**] is a 45 year old man found unresponsive, admitted with acetaminophen overdose. . Per the wife's report, the patient has been dealing with pain over the last few days, related to prior hemorrhoids. From what she knows, he has been taking prescription pain medications (percocet). . On the evening prior to admission, he went to bed at 11pm; given that he is a chronic snorer, he sleeps in a separate room from his wife. At the time that he went to bed, the wife reports that he was snoring but that nothing was otherwise different. . On the morning of admission - at approximately 8:30am, the patient's wife found him still asleep, snoring and in a similar position. She tried to wake him, without success and called EMS. There was a bottle of ES Tylenol at the bedside with three tabs apparently missing. . At the OSH, initial BP 99/56, HR 118, RR 25 with an O2 sat of 71%. ABG was 7.18/47/61. Narcan was given without effect. His acetminophen level was found to be 186 and he was started on NAC (10 grams, then 3.5 grams IV). For hyperkalemia, he was given Calcium, insulin, dextrose, kayexalate. . When his respiratory status declined, he was intubated with reported aspiration; avelox and flagyl were given. . In the ED, BP 97/73, HR 94, RR 20, O2 99%. O2 saturation fell to low of 80%, although it is unclear in what context this occured. He recieved 2+ liters of fluid and made ~300cc of urine. Also received propofol gtt and three versed boluses, vancomycin 1gram and zosyn 4.5mg IV. NAC was started at 17mg/kg/hr. . Upon arrival to the ICU, the patient was intubated and not sedated. He appeared comfortable. When asked if he ingested >10 tabs of percocet or tylenol, he nods yes. When asked if he used or uses amphetamine, his answer is unclear, though he appears to say yes at one time. Past Medical History: 1. Hyperlipidemia 2. Hemorrhoids s/p surgery in [**Month (only) **], with continued pain and new incontinence 3. Anxiety 4. Chronic Diarrhea since hemorrhoid surgery 1 year ago. Social History: Grew up [**Location (un) 6409**], MA. Completed 10th grade. Works as maintenence supervisor at [**Location (un) 40029**] academy. Has 2 stepchildren and 4 grandchildren who live in the area. Does have h/o childhood sexual abuse by a priest starting at age 7 or 8 and continuing for [**4-5**] yrs. Court case completed 5 yrs ago and perpetrator is in prison. + flashbacks. Has smoked 1-2 packs per day since the age of 7, denies ETOH Family History: FAMILY HISTORY: Adopted. Physical Exam: vs - T 99.9, BP 121/76, HR 102. Vent: AC 550/16, PEEP 12, O2 95% on 0.70 FiO2 gen - Intubated. Asleep but arousable. No apparent distress. Mildly diapheretic. heent - No palor and no icterus. cv - Tachycardic. No murmurs. pulm - Coarse but without obvious crackles. No wheeze. abd - Soft and non-tender. Non palpable liver. post-appendectomy scar in RLQ ext - Cool but with positive pulses bilaterally. No edema. . On transfer to floor patient was alert, oriented, comfortable and appeared well. He was afebrile and had an oxygen saturation of 93% on room air. He occasionally had to interupt sentences to take breath but he reports this is baseline for him. CV: RRR nl s1 and s2 lungs: clear to auscultation bilaterally. no wheezes or crackles. Abd: BS+ nontender Peri-anal region: (after removal of fecal collection system) erythema in midline between anus and scrotum. no ulcerations or bleeding. no evidensce of fissures. some redness at site of flexi-seal system but no actual peri-anal lesions. several skin tags noted in gluteal region. extrem: no edema Pertinent Results: [**2147-3-4**] CXR: SUPINE CHEST: Cardiomediastinal silhouette is unremarkable. Pulmonary vascular congestion is noted with likely airspace opacity in the left mid- lung. There are no effusions. There is no pneumothorax. The proximal side port of a nasogastric tube is at the gastroesophageal junction. The tip of an endotracheal tube projects 4.4 cm above the carina. IMPRESSION: 1. Vascular congesion. 2. Apparent airspace opacity in the lingula, question aspiration related. 3. Nasogastric tube should be advanced for more optimal positioning. ETT tube in adequate position. [**3-6**] Liver/gallbladder u/s: ABDOMINAL ULTRASOUND: The liver shows no focal or textural abnormality. The gallbladder is normal without evidence of stone. There is no intra- or extra- hepatic biliary dilatation. The common bile duct measures 2 mm. The portal vein is patent with normal hepatopetal flow. Pancreas is obscured by bowel gas. A small right pleural effusion is present. The spleen is within normal limits. IMPRESSION: 1. Liver shows no focal or textural abnormality. 2. Small right pleural effusion. [**2147-3-6**] CTA Chest: IMPRESSION: 1) No pulmonary embolism. 2) Bilateral small-to-moderate pleural effusions with associated atelectasis. 3) Bibasilar consolidation, likely related to aspiration. 4) Perihilar ground-glass attenuation with smooth interlobular septal thickening likely relates to noncardiogenic pulmonary edema, given history of recent overdose. 5) Mild centrilobular emphysema. 6) Mediastinal lymphadenopathy, likely reactive. 7) Right lower lobe nodular opacities, likely inflammatory; however, followup CT recommended to ensure resolution. [**2147-3-6**] TTE: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). 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 ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No outflow tract obstruction, intracardiac shunt, or significant valvular disease seen. Normal global and regional biventricular systolic function. Mildly dilated thoracic aorta. [**2147-3-4**] 06:20PM BLOOD WBC-15.9* RBC-4.89 Hgb-14.2 Hct-44.8 MCV-92 MCH-29.1 MCHC-31.8 RDW-13.3 Plt Ct-176 [**2147-3-9**] 05:40AM BLOOD WBC-12.7* RBC-4.50* Hgb-13.1* Hct-38.6* MCV-86 MCH-29.1 MCHC-33.9 RDW-14.1 Plt Ct-236 [**2147-3-4**] 06:20PM BLOOD Neuts-77.7* Lymphs-19.1 Monos-2.8 Eos-0.2 Baso-0.1 [**2147-3-5**] 06:40PM BLOOD Neuts-83* Bands-3 Lymphs-7* Monos-6 Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2147-3-4**] 06:20PM BLOOD PT-19.2* PTT-40.2* INR(PT)-1.8* [**2147-3-6**] 04:13AM BLOOD PT-22.9* PTT-150* INR(PT)-2.2* [**2147-3-8**] 03:33AM BLOOD PT-15.0* PTT-32.8 INR(PT)-1.3* [**2147-3-4**] 06:20PM BLOOD Glucose-164* UreaN-17 Creat-1.6* Na-142 K-4.6 Cl-109* HCO3-20* AnGap-18 [**2147-3-9**] 05:40AM BLOOD Glucose-94 UreaN-8 Creat-0.7 Na-141 K-3.7 Cl-104 HCO3-27 AnGap-14 [**2147-3-4**] 06:20PM BLOOD ALT-45* AST-39 AlkPhos-49 TotBili-0.5 [**2147-3-6**] 05:15PM BLOOD ALT-143* AST-61* LD(LDH)-234 AlkPhos-61 Amylase-37 TotBili-0.8 [**2147-3-9**] 05:40AM BLOOD ALT-61* AST-27 AlkPhos-93 TotBili-0.7 [**2147-3-4**] 06:20PM BLOOD Lipase-18 [**2147-3-7**] 09:59AM BLOOD Lipase-9 [**2147-3-5**] 06:40PM BLOOD CK-MB-11* MB Indx-7.3* cTropnT-0.04* [**2147-3-6**] 12:56AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2147-3-6**] 11:41AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2147-3-5**] 04:30AM BLOOD Albumin-2.9* Calcium-7.6* Phos-2.4* Mg-1.5* [**2147-3-9**] 05:40AM BLOOD Calcium-7.7* Phos-2.3* Mg-2.0 [**2147-3-6**] 08:35PM BLOOD %HbA1c-5.6 [**2147-3-6**] 04:13AM BLOOD Triglyc-93 HDL-28 CHOL/HD-2.9 LDLcalc-33 [**2147-3-5**] 06:40PM BLOOD TSH-0.52 [**2147-3-4**] 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-71.6* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2147-3-5**] 04:30AM BLOOD Acetmnp-13.8 [**2147-3-5**] 12:19AM BLOOD Type-ART Tidal V-550 O2 Flow-70 pO2-105 pCO2-47* pH-7.22* calTCO2-20* Base XS--8 -ASSIST/CON Intubat-INTUBATED Vent-CONTROLLED [**2147-3-5**] 06:35PM BLOOD Type-ART pO2-94 pCO2-43 pH-7.34* calTCO2-24 Base XS--2 [**2147-3-4**] 06:37PM BLOOD Lactate-2.9* K-4.3 [**2147-3-5**] 06:35PM BLOOD Lactate-1.1 Brief Hospital Course: Initial presentation/ICU course: In brief, Mr. [**Known lastname 76719**] is a 45 yo with h/o depression/anxiety, chronic diarrhea and chronic pain [**3-4**] hemmorhoids who was transferred from OSH after being found unresponsive by wife after deliberate acetaminophen overdose. At the OSH, initial BP 99/56, HR 118, RR 25 with an O2 sat of 71%. ABG was 7.18/47/61. Narcan was given without effect. His acetaminophen level was found to be 186 and he was started on NAC (10 grams, then 3.5 grams IV) and treated for hyperkalemia. He was intubated with observed aspiration and transferred to [**Hospital1 18**] for further management. . Initially received vanco/zosyn and transitioned to levofloxacin for aspiration PNA. He was extubated [**3-5**], but continued to have enough of an o2 requirement that he was sent for CTA which was negative for PE, and ECHO to evaluate for CHF given pulmonary edema. ECHO was wnl. His o2 requirements have now been weaned to RA prior to transfer to floor. For acetaminophen toxicity, NAC was started at 17mg/kg/hr and continued until yesterday. His LFTs, which were essentially normal on admission peaked [**3-6**], ~ 48-72h after ingestion, have trended down. He has been followed by psychiatry service who favor inpatient psych admission once medically cleared. Of note pt. also had 1 episode of what was noted to be irregular SVT in context of albuterol administration and thought to be atrial fibrillation. Telemmetry has not shown any similar events since that time. . On arrival to floor, pt. stating he would like to go home when medically clear rather than to psych inpt. admission. Says that SI were worse in last month since starting chantix. Denies amphetamine use, though not vehemently. Denies use of [**Last Name (un) **], zyban, pseudephedrine, known to cause false positive amphetamine on tox screen. Says he has not had rectal pain since rectal tube placed and would like to have it continued. . Floor course/follow-up: # Acetaminophen intoxication: intentional, now LFTs improving, now off NAC. ARF resolved, with continued pulmonary edema likely [**3-4**] aspiration +/- pulmonary toxicity. LFTs trending down. He should have outpatient liver followup to confirm that liver function tests have normalized. . # aspiration pneumonia: Respiratory status has improved to baseline and he has finished course of levofloxacin x6 days. At discharge his O2 sat was 93-95% on room air and did not drop with ambulation. He reports having some baseline shortness of breath and felt that at time of discharge he had returned to his baseline level. He should discuss with his primary care physician if he should have a further evaluation for emphysema given his significant smoking history. . # suicide attempt: Patient denies suicidality currently however psychiatry feels he would benefit from inpatient psychiatry hospitalization. He denied SI and HI to medical team however he apparently did report suicidal intent earlier in his hospital course to psychiatry team. His psychotropic medications were stopped in consultation with the psychiatry service, in part due to concern over hepatic metabolism. He was written for PRN trazodone for sleep but did not need this medication regularly. These should be restarted under the direction of his inpatient and/or outpatient mental health providers. [**Name (NI) **] wife unhappy about inpatient psychiatric admission. It was explained to her that [**State 350**] law does allow a patient to be admitted if he is felt to be a danger to himself. . # chronic diarrhea and fecal urgency: started after hemorrhoid surgery and is perhaps due to impaired rectal tone. He was C.diff negative x2 and there was a very low suscpicion for infectious cause of diarrhea. We continued his home imodium prn but believe that this is more likely a surgical issue and that he should followup with his outpatient GI surgeon as well as a gastroenterologist. He was also provided with the number for the outpatient [**Hospital **] clinic at [**Hospital1 18**] in case he chooses to followup here (he and his wife wanted to discuss this). . #perineal irritation most likely chronic irritation from diarrhea. perineum irritated but no frank ulcers. Seen by wound care who recommended a cleanser and antibiotic cream to be used after bowel movements. Their recommendations were " Cleanse wrll after each BM with perineal cleansing foam and pat dry. Apply Critic Aid anti-fungal ointment to peri-anal skin after every 2nd - 3rd BM." Patient should continue this treatment until irritation is resolved. . # Afib with RVR: isolated event in context of intubation + albuterol. CHADS 0. no anticoagulation indicated. no further events once pulmonary issues had resolved. . # pulmonary nodules: seen on CT, likely due to inflammation from aspiration, but will need followup CT as outpatient to ensure resolution. PCP made aware of this issue by letter. Issue also discussed with patient. . # hypercholesterolemia: statin held initially given elevated LFTs, but restarted once near normal levels. . # Contact: Wife, [**Name (NI) **] [**Name (NI) 76719**] (c: [**Telephone/Fax (1) 76720**]) Medications on Admission: (pharmacy CVS in [**Hospital1 392**]; Phone #[**Telephone/Fax (1) 76721**]): 1. Percocet (filled [**1-17**] x 60 tabs) 2. Simvastatin 40mg daily (filled [**1-7**]) 3. Klonopin 0.5mg daily as needed (filled [**1-24**] x15) 4. Celexa 20mg daily (filled [**1-7**] x30) 5. Lomeramide 4mg PRN (filled [**1-23**] x 100 tabs) 6. Avelox 400mg x 10 days (filled [**2-2**]) 7. Z-pack (filled [**1-26**]) 8. Chantix 1mg [**Hospital1 **] [**1-20**] Discharge Medications: 1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for diarrhea. Discharge Disposition: Extended Care Facility: [**Hospital1 18**]- [**Hospital1 **] 4 Discharge Diagnosis: Primary: acetaminophen overdose Aspiration pneumonia depression with suicide attempt transient atrial fibrillation due to severe illness Chronic diarrhea due to rectal dysmotility Discharge Condition: Stable. O2 saturations 94-95% on room air, patient feels respirations at baseline. Patient denies active or passive suicidal ideation at present Discharge Instructions: You were admitted for an overdose of tylenol which was toxic to you liver and caused you to lose consciousness. The loss of consciousness was complicated by an aspiration pneumonia which required intubation and treatment in the intensive care unit. Your liver function numbers are improving but we believe you should see a gastroenterologist as an outpatient to followup regarding your liver function. You were seen by a psychiatrist because of this overdose. We believe that a stay in an inpatient psychiatry unit would benefit you. Please followup with your outpatient GI surgeon. You should also see the above gastroenterologist to discuss your chronic diarrhea which is likely due to a problem with rectal tone. The anal irritation you have is likely due to chronic irritation from stool. You were seen by a wound care specialist who recommended cleansers and an antibiotic cream which will help healing. You had a CT of the chest while you were here which showed some nodules in your lungs. While these are most likely due to your pneumonia, you should have a repeat CT scan checked in 6 months. Your PCP was made aware of this issue and can have the scan repeated. If you have the CT done outside of [**Hospital1 18**], you will need to obtain a copy of your current CT scan by calling ([**Telephone/Fax (1) 18969**] Followup Instructions: Please followup with your primary care doctor who can arrange a followup appointment with a gastroenterologist. Please followup with your outpatient colorectal surgeon at [**Hospital1 2025**]. If you feel that you would like a new primary care physician and to be seen at [**Hospital1 18**], please call ([**Telephone/Fax (1) 1921**]

[ "311", "276.7", "272.0", "584.9", "787.91", "965.4", "E950.0", "507.0", "300.00", "427.31" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

14656, 14721

8733, 13895

363, 369

14945, 15094

4022, 8710

16473, 16810

2911, 2921

14383, 14633

14742, 14924

13921, 14360

15118, 16450

2936, 4003

275, 325

397, 2226

2248, 2428

2444, 2879

21,015

195,987

6055

Discharge summary

report

Admission Date: [**2186-4-3**] Discharge Date: [**2186-4-14**] Date of Birth: [**2133-11-4**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2777**] Chief Complaint: Left lower extremity ischemia with rest pain and failed common femoral to anterior tibial artery bypass graft. Major Surgical or Invasive Procedure: [**2186-4-3**] - Redo - Left lower extremity femoral to anterior tibial artery bypass with right saphenous arm vein History of Present Illness: This is a 52-year-old male with a history of end-stage renal disease, status post kidney transplant, as well as severe peripheral arterial disease. He has a history of a right below-the-knee amputation and a left femoral to anterior tibial bypass, which has occluded, resulting in rest pain and limb threat. He was consented for a redo femoral endarterectomy and femoral to anterior tibial bypass with arm vein. Past Medical History: 1)CABG x 3 '[**75**] 2)Living related kidney transplant coplicated by wound exploration '[**75**] 4)Cadaveric pancreas transplant '[**77**] 5)L CEA '[**77**] ([**Doctor Last Name **]), 6)Right common femoral artery to above-knee popliteal artery bypass graft with 8 mm ringed PTFE '[**77**] 7)Right second toe amputation '[**77**] 8)Cataracts '[**78**] 9)R wrist '[**78**] 10)Left common femoral artery to above-knee popliteal artery bypass graft with 8-mm ringed PTFE '[**79**] 11)Repair of incisional hernia '[**81**] 12)L fem-AT bypass with PTFE graft [**12-27**] 13)Pancreas explant '[**82**] 14)Vitrectomy '[**73**] Social History: Tobacco - long term smoker, currently not using Alcohol - use on a social level Drugs - denies Family History: CAD. Physical Exam: On discharge 98.4 64 97/45 18 97ra NAD, A&Ox3 RRR CTAB Soft NT ND abd LLE trace edema, well healing incisions, no drainage, no erythema, Right arm well healed and approximated with steristrips Palp L thigh graft, Dopplerable L AT. Pertinent Results: Creatinine on DC 2.3 Brief Hospital Course: PT was admitted to the vascular surgery service post operatively. He was transfused 2 unit for HCT 22.9 with a post hct 24.7. He remained hemodynamically stable but c/oo of increasing hand pain overnight into the A.m. of POD1. The chronic pain service was consulted for further management given home narcotic use, and right arm pain. He was started on home meds, Dilaudid and methadone 5 mg. He was advanced to a regular diet. POD 3 patient diuresis was started with Lasix 20' IV, His home Lantus dosing was resumed. Cardiac enzymes were cycled for nausea, with ,CEs x 3. ambulation was encouraged. Patient made excellent urine throughout, but his Cr increase to 2-2.3. Renal transplant was following patient. Patient's tacrolimus was undetectable due to his home daily dose , thus recommendations were made to increased tacro to Tacro 5 Q12' patient refused this regimen but finally agreed to 3mg tacrolimus twice daily. Due to poor IV acces a L PICC line was placed. Throughout [**Date range (1) 23783**] patient was diereses 1-2L with close attention to his Creatinine. Per renal transplant his calcium channel blocker was held and his lisinopril decreased, His methadone was discontinued. His arm wound was noted to open slightly but this was easily approximated with steristrips. POD 10 he was transfused 2 units PRBC for drifting Hct 23.8 with appropriate response to 28.4. His potassium was also elevated to K 5.. He was given Kayexalate and calcium gluc with recheck rate 5.1. PT worked with the patient throughout POD 2-discharge and he was cleared for home. On [**4-14**] he was discharged to home. He will follow up with renal transplant in 2 weeks with a lab check [**2186-4-21**]. His volume status is euvolemic as judged by nephrology team. He will not be discharge on Lasix nor his amlodipine. Patient is using his wheelchair for mobility, eating a regular diet, pain controlled on po regimen of pain medication. His dc Cr was 2.3. his picc was dcd prior to leaving. Medications on Admission: atorvastatin 40 mg', amlodipine 10 mg', plavix 75 mg', gabapentin 900 mg''', Huamlog SSI, Lantus 28 units Q AM, 20 units Q PM'', metoprolol 100 mg'', oxycodone 5 mg PO Q4-6 PRN, paricalcitol 1 mcg', Prednisone 5 mg', ranitidine 150 mg', sertraline 50 mg', Tacrolimus 5 mg'', Asprin 325 mg' Discharge Medications: 1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 3. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lantus 100 unit/mL Solution Sig: One (1) 26U am / 20U PM Subcutaneous twice a day: Per PCP. 8. Humalog 100 unit/mL Solution Sig: One (1) SSI pewr PCP Subcutaneous three times a day: Dose per PCP. 9. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 13. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 14. Outpatient Lab Work Potassium, Creatinine and Tacrolimus level to be drawn [**First Name9 (NamePattern2) 5929**] [**2185-4-21**]. 15. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: left lower extremity ischemia ARF post opertive, creatinine on down trend coronary artery disease, renal transplant, peripheral vascular disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You will need to have your labs drawn on thursday [**4-21**]. Please bring prescription for lab drawing. Lower Extremity Bypass Surgery Discharge Instructions: What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**12-22**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2186-4-27**] 2:45 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2186-6-8**] 10:00 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Please call for follow up within 2-3 weeks - office aware. You will need labs drawn on [**Telephone/Fax (1) 5929**] lab drawing: tacro, Creatinine and K need to be drawn for Renal follow up Completed by:[**2186-4-14**]

[ "440.22", "250.61", "V42.83", "585.9", "V49.75", "V42.0", "338.18", "362.01", "V58.67", "V45.81", "327.23", "250.41", "250.51", "403.90", "412", "536.3", "E878.2", "584.9", "996.74" ]

icd9cm

[ [ [] ] ]

[ "38.16", "39.49", "00.41", "38.18" ]

icd9pcs

[ [ [] ] ]

5974, 5980

2077, 4078

414, 532

6170, 6170

2032, 2054

9232, 9859

1756, 1762

4418, 5951

6001, 6149

4104, 4395

6514, 8799

8825, 9209

1777, 2013

263, 376

560, 975

6185, 6329

997, 1625

1641, 1739

57,507

108,029

54976

Discharge summary

report

Admission Date: [**2117-7-12**] Discharge Date: [**2117-7-14**] Date of Birth: [**2087-7-16**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 25936**] Chief Complaint: syncope and chest pain Major Surgical or Invasive Procedure: [**2117-7-13**] Pericardiocentesis History of Present Illness: HISTORY OF PRESENTING ILLNESS: 29 yo M without cardiac history presents with retrosternal chest pain and syncope - 2 episodes in the last 5 days. First time pain occurred after dinner and pt describes this as a dull soreness extending from throat to mid chest, no radiation to arms, jaw, or back. Non exertional. Lasted about an hour though took advil. Current episode started 10 min after dinner consisting of steak, potatoes, fries and ginger ale - lasted all night despite taking Advil per pt, was worse when he was laying down flat and somewhat relieved when sitting up. No recent cough, diarrhea, fevers, vomiting, no viral symptoms. Also no history of arthritis or autoimmune disorders. Also had a syncopal event 3x in the past day. Each time he feels nauseous "out of the blue", and then passes out. Once was observed, in our ED and there were no tonic/clonic jerks, he did hit his right head. He regained consciousness as soon as he hit the ground, was pale and clammy with vitals of pulse 80 regular, BP 80/50. He was able to sit up and walked 8 paces to an exam table. He always returns to consciousness without biting tounge, B/B incontinence, or confusion. No headache or changes in vision. Seen at BIDN where EKG showed difuse STE, and formal echo showed moderate-sized pericardial effusion with some evidence of RV collapse by report. Initial vitals on transfer to [**Hospital1 18**] ED were: 99.5 101 110/64 18 98% RA. In our ED, he received IV fluids x 5 L, 2 x 325 mg ASA, oxygen 2L NC, maalox with decrease in chest discomfort (decreased with maalox and before ASA). His repeat BP was 120/60, pulse 78/min, stable, alert and oriented. . On arrival to the floor, patient is feeling well. He no longer has chest pain nor nausea/lightheadedness. He did go to the bathroom without lightheadedness also. No compliants. . REVIEW OF SYSTEMS On review of systems, he denies any prior history of stroke, TIA, pulmonary embolism, bleeding, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: none 3. OTHER PAST MEDICAL HISTORY: epididymitis opiate abuse (oxycodone) Social History: Works in construction. Lives with wife. -Tobacco history: 1 ppd x 11 years -ETOH: social, about 3x/week -Illicit drugs: was addicted to intranasal oxycodone, now on naltrexone maintenance and has been clean x 6 weeks Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T 99.0, BP 120s/80s, HR 90s, RR 10, O2 sat > 96% RA GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate. HEENT: Right temple with 4x4 cm hematoma, tender, no skin break. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of [**9-2**] cm. CARDIAC: RR, normal S1, split S2. No m/r/g. + S4 LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: no c/c/e SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: pulsus of 12 Right: radial 2+ PT 2+ Left: radial 2+ PT 2+ . DISCHARGE PHYSICAL EXAM VS afebrile, BP 120s/80s, HR 80s, saturations 100% RA exam unchanged except: JVD cannot be visualized at 45 degrees normal S1, S2 and no spliting of S2, S4 remains Pertinent Results: ADMISSION LABS: [**2117-7-12**] 03:40PM BLOOD WBC-17.1* RBC-5.02 Hgb-15.3 Hct-45.7 MCV-91 MCH-30.5 MCHC-33.6 RDW-12.7 Plt Ct-211 [**2117-7-12**] 03:40PM BLOOD Neuts-88.0* Lymphs-7.4* Monos-2.4 Eos-1.9 Baso-0.3 [**2117-7-12**] 03:40PM BLOOD PT-10.1 PTT-25.5 INR(PT)-0.9 [**2117-7-12**] 03:40PM BLOOD ESR-0 [**2117-7-12**] 03:40PM BLOOD Glucose-116* UreaN-16 Creat-0.9 Na-135 K-4.7 Cl-104 HCO3-23 AnGap-13 [**2117-7-12**] 03:40PM BLOOD cTropnT-<0.01 [**2117-7-13**] 05:28AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.2 [**2117-7-13**] 05:28AM BLOOD TSH-2.6 [**2117-7-12**] 03:40PM BLOOD CRP-13.4* [**2117-7-12**] 03:44PM BLOOD Lactate-1.6 [**2117-7-13**] 06:37AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 [**2117-7-13**] 06:37AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2117-7-13**] 06:37AM URINE RBC-0 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0 . Discharge Labs: [**2117-7-14**] 05:35AM BLOOD WBC-10.2 RBC-5.05 Hgb-15.5 Hct-44.0 MCV-87 MCH-30.8 MCHC-35.3* RDW-12.5 Plt Ct-199 [**2117-7-14**] 05:35AM BLOOD Glucose-88 UreaN-16 Creat-1.0 Na-140 K-3.6 Cl-106 HCO3-26 AnGap-12 [**2117-7-14**] 05:35AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.0 PERICARDIAL FLUID: [**2117-7-13**] 05:44PM OTHER BODY FLUID WBC-4778* RBC-2889* Polys-1* Lymphs-23* Monos-0 Eos-57* Macro-19* [**2117-7-13**] 05:44PM OTHER BODY FLUID TotProt-4.8 Glucose-81 LD(LDH)-320 Amylase-30 Albumin-3.6 . MICRO: [**2117-7-13**] 5:44 pm FLUID,OTHER PERICARDIAL FLUID. GRAM STAIN (Final [**2117-7-13**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary): ACID FAST SMEAR (Final [**2117-7-14**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): BLOOD CULTURE [**2117-7-12**] NO GROWTH TO DATE PERICARDIAL FLUID CULTURE [**2117-7-13**] NO GROWTH TO DATE PERICARDIAL FLUID CYTOLOGY [**2117-7-13**] PENDING [**2117-7-12**] ECHO: LEFT VENTRICLE: Overall normal LVEF (>55%). PERICARDIUM: Small to moderate pericardial effusion. Brief RA diastolic collapse. Significant, accentuated respiratory variation in mitral/tricuspid valve inflows, c/w impaired ventricular filling. GENERAL COMMENTS: Emergency study performed by the cardiology fellow on call. Results were reviewed with the Cardiology Fellow involved with the patient's care. Conclusions Overall left ventricular systolic function is normal (LVEF>55%). There is a small to moderate sized pericardial effusion. Focal right ventricular diastolic compression is seen in the subcostal view but is not present in the apical and parasternal views (this may represent focal/early tamponade). There is brief right atrial diastolic collapse. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. [**2117-7-13**] ECHO: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Normal mitral valve supporting structures. [**Male First Name (un) **] of the mitral chordae (normal variant). No resting LVOT gradient. No MS. Trivial MR. TRICUSPID VALVE: TVP. Normal tricuspid valve supporting structures. No TS. Physiologic TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: Moderate pericardial effusion. Effusion circumferential. No RA or RV diastolic collapse. Significant, accentuated respiratory variation in mitral/tricuspid valve inflows, c/w impaired ventricular filling. Conclusions The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 60%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Tricuspid valve prolapse is present. The estimated pulmonary artery systolic pressure is normal. There is a moderate sized pericardial effusion. The effusion appears circumferential. No right atrial or right ventricular diastolic collapse is seen. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling, although frank cardiac tamponade is not present. Compared with the findings of the prior study (images reviewed) of [**2117-7-12**], the findings are similar [**2117-7-14**] ECHO: This study was compared to the prior study of [**2117-7-13**]. LEFT VENTRICLE: Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: Normal aortic valve leaflets (3). TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal PA systolic pressure. PERICARDIUM: No pericardial effusion. Conclusions FOCUSED STUDY POST-PERICARDIOCENTESIS: Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2117-7-13**], left ventricular function appears more vigorous. CXR [**2117-7-14**]: previous images. There is no evidence of post-procedure pneumothorax. Cardiac silhouette is at the upper limits of normal or mildly enlarged. No definite vascular congestion or acute pneumonia. Brief Hospital Course: 29 yo M w/ no significant PMH presented with pleuritic chest pain and syncope (likely vasovagal) and was found to have a pericardial effusion with a Pulsus of 12 and early tamponade physiology on TTE who underwent successful pericardiocentesis with improved chest pressure. #Pericardial effusion- etiology is unclear. Cytology is still pending. Given that the most common cause is pericarditis, he was started on colchicine and ibuprofen in house and will continue these as an outpatient. He has multiple labs on the pericardial fluid still pending at the time of discharge. As he had a significant effusion it was decided to drain it rather than monitor with serial TTE. He will require f/u with TTE with Dr. [**First Name (STitle) **] on [**8-2**]. He will continue on colchicine and ibuprofen until then, and will be directed by Dr. [**First Name (STitle) **] when to stop the colchicine. He was instructed what to look out for in terms of signs of tamponade or worsening effusion. -discharged on colchicine and ibuprofen -will f/u with Dr. [**First Name (STitle) **] of cardiology to determine course of treatment -Multiple pericarld fluid studies are still pending #Syncope- patient had syncope on admission and it was in teh setting of pain, and therefore likely due to a vasovagal event as opposed to his pericardial effusion. Follow-up needed for: 1.Pericardial fluid studies- to be followed up by Dr. [**First Name (STitle) **] 2. TTE will need to be performed to evaluate for resolution of the effusion Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Naloxone Dose is Unknown mg IM QMONTH Discharge Medications: 1. Ibuprofen 600 mg PO Q8H Take for 5 days, then take 200mg PO TID for 7 days RX *ibuprofen 600 mg TID and then [**Hospital1 **] Disp #*30 Tablet Refills:*0 2. Colchicine 0.6 mg PO DAILY RX *Colcrys 0.6 mg daily Disp #*30 Tablet Refills:*0 3. Naloxone 0 mg IM QMONTH Discharge Disposition: Home Discharge Diagnosis: Pericardial Effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 63724**], You were admitted to the hospital after you had passed out, and you were found to have a pericardial effusion (fluid within the sac surrounding your heart). You were monitored in the Cardiac intensive care unit and had this fluid drained. The exact cause of the increase in fluid is still not clear but likely was due to inflammation in the sac called the pericardium. We started you on two medications that you will need to continue as an outpatient to treat your pericarditis. Transitional Issues: Pending labs: Pericardial Fluid studies from [**2117-7-13**], including cytology Medications started: 1. Colchicine 0.6mg by mouth once a day to help with inflammation around the heart. You should continue this until your follow-up appointment with Dr. [**First Name (STitle) **] (cardiology) 2. Ibuprofen to help with inflammation around your heart. You should take 600 mg three times a day for 5 more days, then 200 mg three times a day for 1 week, and then you can stop. Medications changed/Stopped: None Follow-up needed for: 1. You should see a cardiologist as per below and will need a repeat echocardiogram (ultrasound of your heart). You should bring your medications to each appointment so your doctors [**Name5 (PTitle) **] update their records and adjust the doses as needed. It was a pleasure taking care of you in the hospital! Followup Instructions: Name:[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],MD Specialty: Primary Care Location: [**Hospital **] MEDICAL ASSOC- [**Location (un) **] Address: [**Location (un) 11898**], [**Location (un) **],[**Numeric Identifier 9310**] Phone: [**Telephone/Fax (1) 8506**] When: A message was left on the office voicemail that you need an appointment in the next week. You should be called at home with an appoinment. If you have not heard, please call above number for status. Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 83560**], MD Specialty: Cardiology Location: [**Hospital1 641**] Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 3883**] Phone: [**Telephone/Fax (1) 38275**] When: [**8-3**] at 10:40am

[ "272.4", "401.9", "423.9" ]

icd9cm

[ [ [] ] ]

[ "37.0" ]

icd9pcs

[ [ [] ] ]

12474, 12480

10469, 11993

328, 366

12545, 12545

4231, 4231

14108, 14908

3151, 3266

12182, 12451

12501, 12524

12019, 12159

12696, 13215

5160, 5864

3306, 4212

2823, 2828

6062, 10446

13236, 14085

266, 290

394, 2712

4247, 5144

5934, 6028

12560, 12672

2859, 2898

2734, 2802

2914, 3135

5897, 5897

66,298

152,072

46997

Discharge summary

report

Admission Date: [**2104-10-23**] [**Month/Day/Year **] Date: [**2104-10-23**] Service: CARDIOTHORACIC Allergies: unknown antibiotic Attending:[**First Name3 (LF) 165**] Chief Complaint: aortic disection Major Surgical or Invasive Procedure: s/p bilateral chest tube placement s/p L subclavian tripple lumen catheter placement History of Present Illness: Mr. [**Known lastname **] is an 88 year old man found down for unknown amount of time; he was awake, alert and oriented for EMS. He was given atropine 0.5 for bradycardia with a pulse. On arrival to the emergency department he was disoriented and agitated. He cardiopulmonary arrested and received 20 minutes of chest compressions without shocking. No breath sounds were heard so he was given bilateral needle decompressions and then bilateral chest tubes; right sided tube returned blood (probably secondary to a rib fracture from compressions). A 7.5 ETT tube was placed without premedication. Intubation was complicated, with oxygen saturation down to 65%, but never [**Doctor Last Name **]). EKG was nonischemic. Initial head CT was unremarkable. On assessment from the cardiac surgery team the patient began to have a violent tremor throughout his body every couple of minutes lasting for over thirty minutes. Sedation was discontinued to obtain neurological exam and neurology consult was called. Past Medical History: 1. Osteoarthritis s/p left hip replacement back in [**2101**]. 2. GERD 3. Retinal detachment s/p repair a few months ago 4. Hemorroids Social History: Lives alone in [**Hospital1 778**]. Endorses tobacco use in the distant past (quit ~[**2059**]) and rare EtOH use. Family History: Father-MI ~55. Mother passed away from an MI at the age of 86. GF had diabetes requiring amputation of distal leg. Brother had an aortic dissection. Physical Exam: Physical Exam Pulse: 60 Resp:18 O2 sat: 95%, intubated B/P Right: 112/56 General: Skin: Dry x[] intact [x] HEENT: pupils 3mm and non-reactive bilaterally Neck: in C collar Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [] large left inguinal hernia Extremities: Warm [x], well-perfused [x] Edema []none Varicosities: None [x] Neuro: UTA, sedated Pulses: Femoral Right: 1+ Left:1+ DP Right: 1+ Left:1+ PT [**Name (NI) 167**]: 1+ Left:1+ Radial Right: 1+ Left:1+ Pertinent Results: [**2104-10-23**] 08:02PM BLOOD WBC-11.8* RBC-2.75* Hgb-8.6* Hct-26.0* MCV-95 MCH-31.3 MCHC-33.1 RDW-15.2 Plt Ct-175 [**2104-10-23**] 03:55PM BLOOD WBC-17.0*# RBC-2.36* Hgb-7.6* Hct-23.8* MCV-101* MCH-32.1* MCHC-31.8 RDW-15.3 Plt Ct-219 [**2104-10-23**] 08:02PM BLOOD Neuts-54.5 Lymphs-41.0 Monos-3.9 Eos-0.2 Baso-0.4 [**2104-10-23**] 03:55PM BLOOD Neuts-40.7* Lymphs-56.1* Monos-2.6 Eos-0.2 Baso-0.5 [**2104-10-23**] 08:02PM BLOOD Plt Ct-175 [**2104-10-23**] 08:02PM BLOOD PT-16.6* PTT-37.0* INR(PT)-1.6* [**2104-10-23**] 03:55PM BLOOD Plt Ct-219 [**2104-10-23**] 03:55PM BLOOD PT-15.7* PTT-150* INR(PT)-1.5* [**2104-10-23**] 08:02PM BLOOD Glucose-197* UreaN-46* Creat-2.1* Na-131* K-5.8* Cl-100 HCO3-18* AnGap-19 [**2104-10-23**] 03:55PM BLOOD Creat-2.0*# [**2104-10-23**] 03:55PM BLOOD Glucose-176* UreaN-45* Creat-2.1*# Na-133 K-4.5 Cl-103 HCO3-11* AnGap-24* [**2104-10-23**] 08:02PM BLOOD LD(LDH)-1297* [**2104-10-23**] 03:55PM BLOOD CK(CPK)-492* [**2104-10-23**] 03:55PM BLOOD cTropnT-0.08* [**2104-10-23**] 08:02PM BLOOD Calcium-9.3 Phos-6.5* Mg-2.1 [**2104-10-23**] 03:55PM BLOOD Calcium-11.5* Phos-6.9*# Mg-2.4 [**2104-10-23**] 03:55PM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2104-10-23**] 10:30PM BLOOD Type-ART pO2-83* pCO2-50* pH-7.16* calTCO2-19* Base XS--10 [**2104-10-23**] 09:34PM BLOOD Type-ART pO2-77* pCO2-44 pH-7.26* calTCO2-21 Base XS--6 [**2104-10-23**] 09:05PM BLOOD Type-CENTRAL VE Comment-GREEN [**2104-10-23**] 08:16PM BLOOD Type-[**Last Name (un) **] pH-7.27* Comment-GREEN TOP [**2104-10-23**] 05:51PM BLOOD Type-ART Tidal V-540 FiO2-100 pO2-328* pCO2-28* pH-7.42 calTCO2-19* Base XS--4 Intubat-INTUBATED Vent-CONTROLLED [**2104-10-23**] 04:00PM BLOOD pH-7.06* Comment-GREEN [**2104-10-23**] 10:30PM BLOOD Glucose-76 Lactate-3.9* K-5.4* [**2104-10-23**] 09:34PM BLOOD Glucose-188* Lactate-2.8* K-5.4* [**2104-10-23**] 09:05PM BLOOD Glucose-173* Lactate-2.7* K-5.8* [**2104-10-23**] 04:00PM BLOOD Glucose-164* Lactate-7.0* Na-132* K-4.5 Cl-108 calHCO3-13* Brief Hospital Course: Mr. [**Known lastname **] was found down at home after an unknown period of time and was brought to the ED where he developed cardiac arrest, was intubated and had bilateral chest tubes placed. He had a CT scan of chest which showed type a aortic disection. An initial head CT was negative for significant intracranial pathology, but when the sedation was weaned to evaluate the patient's neurologic function he began to have seizure like activity. The patient was evaluated by neurology, the CT scan was repeated without change and the decision was made to perform an EEG to evaluate the seizure activity. The patient was brought to the ICU and was given blood transfusion for a dropping hematocrit, an arterial line was placed and patient was attached to a continuous EEG machine. The patients seizure activity became more frequent and lasting longer, without regaining consciousness. We were notified by neurology that the patient's EEG trace showed "burst supression" and the on call neurologist explained to the family that meant that Mr. [**Name14 (STitle) 99660**] had no chance of meaningful recovery. Dr. [**First Name (STitle) **] decided in light of the poor neurologic prognosis that the patient was not a surgical candidate and the family decided to withdraw care. The patient was extubated and expired at 2352 on [**10-23**] with the family at the bedside. Medications on Admission: unknown [**Month/Year (2) **] Medications: none [**Month/Year (2) **] Disposition: Expired [**Month/Year (2) **] Diagnosis: type A aortic disection s/p cardiac arrest [**Month/Year (2) **] Condition: expired [**Month/Year (2) **] Instructions: expired Followup Instructions: none [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2104-10-24**]

[ "530.81", "427.5", "443.22", "780.39", "443.23", "584.9", "441.01", "780.01", "V43.64", "V12.54", "285.9", "511.89" ]

icd9cm

[ [ [] ] ]

[ "96.71", "34.04", "38.93", "99.60", "96.04" ]

icd9pcs

[ [ [] ] ]

4534, 5914

262, 349

2473, 4511

6223, 6351

1696, 1847

5940, 6200

1862, 2454

206, 224

377, 1387

1409, 1546

1562, 1680

5,922

110,134

26570

Discharge summary

report

Admission Date: [**2142-11-1**] Discharge Date: [**2142-11-10**] Date of Birth: [**2081-4-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: palpitations and chest pain Major Surgical or Invasive Procedure: [**2142-11-5**] Coronary Artery Bypass Graft x3 (left internal mammary -> left anterior descending, saphenous vein graft -> diagonal, saphenous vein graft -> posterior descending artery) MAZE procedure, Removal of mass from pulmonic valve History of Present Illness: 61 year old man presented to [**First Name9 (NamePattern2) 65581**] [**Location (un) **] with palpitations and chest pain left sided, non-radiating, described as sharp in nature. He has history of this pain for years, always associated w/ exertion--shoveling, walking up inclines. On day of presentation to OSH, he developed pain on a 2 mile walk with wife. [**Name (NI) 1194**] resolved w/ rest. Recurred later in day, after eating & having BM. The pain escalated, worst ever. He noted his "heart racing." No SOB, diaphoresis, N/V, or pre-syncope. Went to [**Location (un) **] ED, where pain relieved w/ 2SL nitroglycerin. Pt found to be in AF w/ RVR, rate in the 140??????s. EKG anterolateral ST depression (per records). Transferred for cardiac catherization Past Medical History: Hypertension Hypercholesterolemia Paraxsymal Atrial Fibrillation Prostate cancer s/p prostatectomy & radiation Hx of fibroblastoma of pulmonic valve Varicose veins Social History: Married, lives with spouse, retired police officer (works some part-time); Remote h/o smoking, stopped over 25yrs ago, smoked 2-3cigs per day for ~20yrs; 2-3glasses of wine per night Family History: mother had CAD after age 65; father died at age 53 of AAA rupture Physical Exam: Admission VS--96.9, 106/70, (106-112/70-81), 92 (92-100), 18 Gen: well-nourished, well-appearing man, NAD Integumentary: no rashes, no cyanosis HEENT: PERRL, EOMI, MMM, OP clear, no LAD, no carotid bruits CV: RRR, Nml s1s2, no M/R/G Pulm: CTAB Abd: +BS, soft, NTND, No HSM Back: no CVA tenderness Ext: no edema, 2+ DP pulses; no femoral bruits, no groin hematoma Neuro: a&o3, no focal neuro deficts Discharge Vitals 98.1, 89 SR, 116/68, 20, RA sat 96% weight 86.6 Neuro: alert and oriented x3, MAE R=L strength Pulmonary: clear to ausculation bilaterally - decreased left base Cardiac: RRR, no murmur/rub/gallop Abdomen: soft, nontender, nondistended, + bowel sounds Extremeties warm +1 edema pulses +2 Incisions: Sternal midline healing no drainage, no erythema, sternum stable Left leg endovascular harvest steristrips, no drainage no erythema Pertinent Results: [**2142-11-8**] 06:20AM BLOOD WBC-9.3 RBC-3.25* Hgb-10.0* Hct-28.4* MCV-87 MCH-30.6 MCHC-35.1* RDW-14.9 Plt Ct-150 [**2142-11-1**] 10:15AM BLOOD WBC-5.1 RBC-5.07 Hgb-15.1 Hct-43.7 MCV-86 MCH-29.8 MCHC-34.5 RDW-13.3 Plt Ct-179 [**2142-11-9**] 06:10AM BLOOD PT-12.4 PTT-27.2 INR(PT)-1.1 [**2142-11-8**] 06:20AM BLOOD Plt Ct-150 [**2142-11-1**] 08:49AM BLOOD PT-12.4 INR(PT)-1.1 [**2142-11-1**] 10:15AM BLOOD Plt Ct-179 [**2142-11-8**] 06:20AM BLOOD Glucose-115* UreaN-12 Creat-0.8 Na-136 K-4.6 Cl-102 HCO3-27 AnGap-12 [**2142-11-1**] 10:15AM BLOOD Glucose-269* UreaN-16 Creat-0.9 Na-135 K-3.7 Cl-106 HCO3-20* AnGap-13 [**2142-11-1**] 10:15AM BLOOD ALT-22 AST-18 CK(CPK)-60 AlkPhos-57 Amylase-47 TotBili-1.2 [**2142-11-2**] 07:37AM BLOOD %HbA1c-5.5 [Hgb]-DONE [A1c]-DONE CHEST (PA & LAT) [**2142-11-9**] 8:55 AM CHEST (PA & LAT) Reason: pleural effusion/pneumothorax [**Hospital 93**] MEDICAL CONDITION: 61 year old man s/p CABG MAZE REASON FOR THIS EXAMINATION: pleural effusion/pneumothorax INDICATIONS: 61-year-old man status post CABG and maze. CHEST, PA AND LATERAL: Comparison is made to [**2142-11-7**]. The patient is status post coronary artery bypass graft surgery. The heart is mildly enlarged. Cardiac and mediastinal contours are unremarkable. There is a tiny right apical pneumothorax, and a probable tiny left apical pneumothorax, perhaps not discernable previously because of differences in technique. There is persistent volume loss at the left base with small effusions. Otherwise the lungs are clear. IMPRESSION: 1. Stable right apical pneumothorax. 2. Probable tiny left apical pneumothorax. 3. Stable volume loss at the left base. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**] DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**] Sinus rhythm. Early precordial QRS transition is non-specific. ST-T wave configuration suggests early repolarization pattern but clinical correlation is suggested. Since the previous tracing of [**2142-11-5**] sinus tachycardia and low T wave amplitude are now absent. TRACING #2 Read by: [**Last Name (LF) **],[**Known firstname 177**] W. Intervals Axes Rate PR QRS QT/QTc P QRS T 79 118 70 362/396.42 52 10 29 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. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions: PRE-BYPASS: The left atrium is normal in size. 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 thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. A homogenous echodensity of 1.5cm X 1cm is seen on the pulmonic valve c/w probable vegetation or mass is seen on the pulmonic valve. There is no pericardial effusion. POST_BYPASS: Preserved biventricular systolic function. Overall LVEF 60%. Trivial MR. The pulmonic valve is not visualized anymore after removal of the same by the surgeon. Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD on [**2142-11-5**] 16:26. [**Location (un) **] PHYSICIAN: Brief Hospital Course: Transferred from outside hospital and underwent cardiac catherization that revealed 3 vessel coronary artery disease. He was evaluated for cardiac surgery and underwent preoperative work up. On [**2142-11-5**] he was transferred to the operating room for coronary artery bypass graft surgery, MAZE procedure, and removal of mass from pulmonic valve. Please see operative report for further details. He was then transferred to the cardiac surgery recovery unit. In the first 24 hours he woke up neurologically intact and was extubated without difficulty. He was weaned from all vasoactive medications and was transferred to [**Hospital Ward Name **] 2 on post operative day 2. He continued to progress. He remains in normal sinus rhythm on beta blockers and amiodarone, and coumadin was started. Activity was increased and he continued to progress. On post operative day 5 he was ready for discharge home with VNA services. Plan for INR to be checked [**11-12**] with results to Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8430**] with goal INR 2-2.5. Medications on Admission: Meds at home: Lipitor 40mg Zetia 10mg Ecotrin Atenolol 25mg Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary Artery Disease Paraxysmal Atrial Fibrillation Hypertension Hyperlipidemia Prostate cancer s/p resection and chemotherapy Discharge Condition: good Discharge Instructions: [**Month (only) 116**] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Dr [**First Name (STitle) **] [**Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**Last Name (STitle) 5543**] in [**2-17**] weeks please call for appointment Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8430**] in 1 week ([**Telephone/Fax (1) 8431**]) please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3633**]) PT/INR to be checked [**11-12**] with result to Dr [**Last Name (STitle) 8430**] for further dosing Completed by:[**2142-11-10**]

[ "E879.8", "E849.5", "425.3", "E849.7", "996.74", "414.01", "427.31", "401.9", "E878.8", "V10.46", "272.4", "411.1", "512.1" ]

icd9cm

[ [ [] ] ]

[ "36.12", "36.15", "39.61", "37.33", "37.23", "88.56" ]

icd9pcs

[ [ [] ] ]

7825, 7874

6633, 7715

349, 590

8048, 8055

2752, 3621

8521, 9106

1791, 1859

3658, 3688

7895, 8027

7741, 7802

8079, 8498

1874, 2733

282, 311

3717, 6572

618, 1388

6610, 6610

1410, 1575

1591, 1775

45,226

112,787

49371

Discharge summary

report

Admission Date: [**2197-3-15**] Discharge Date: [**2197-3-16**] Date of Birth: [**2137-12-27**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2763**] Chief Complaint: Dark stools Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: 59 year old male with history of cirrhosis and hepatitis C on treatment with interferon and ribavirin with chief complaint 2-3 days of black stools. He had labs drawn in Dr.[**Name (NI) 948**] office on [**2197-3-13**] which revealed a HCT drop from 40.0 to 25.0. He reports a few episodes of "purple" from saturday night into sunday morning. He thinks this is from drinking a purple powerade mixed with his lactulose. . Of note his pegylated inteferon and ribavirin was stopped [**3-14**]. . In the ED, initial vs were: T 98.2 P 78 BP 131/68 R17 100% O2 sat. Patient refuesed NG lavage and was started on protonix gtt, octreotide gtt. He was also give ceftriaxone 1gm for SBP prophylaxis. . He also c/o feeling lightheaded with standing and feeling slightly SOB, pale, dry. Brown guaiac stool was found on rectal exam. He was typed and crossed for 4 units, which he will receive when it is available. IV access is bilateral 18g IVs. . Past Medical History: HCV cirrhosis history of elevated AFP history of varices Social History: lives in [**Hospital1 392**] with his fiance. He does not have any children. He has smoked a pack of cigarettes a day for 30 years, quit last month. He denies any alcohol in 20 years, but did drink heavily in the past. IVDU with no drugs in four years. Family History: the patient denies any known family history of liver disease or liver cancer. His mom had heart issues, but he does not know the details of this. His father had congestive heart failure. He has one brother who was diagnosed with colon cancer at age 56. There is no other significant family history Physical Exam: Vitals: T:99.6 BP:95/63 P:67 R:18 O2:100 % RA General: Alert, oriented, no acute distress HEENT: Pale conjunctiva and skin overal, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Pertinent Results: [**2197-3-15**] 11:20AM PT-15.4* INR(PT)-1.3* [**2197-3-15**] 11:20AM PLT COUNT-117* [**2197-3-15**] 11:20AM NEUTS-76.7* LYMPHS-17.7* MONOS-4.7 EOS-0.7 BASOS-0.2 [**2197-3-15**] 11:20AM WBC-5.8 RBC-2.22* HGB-8.0* HCT-24.6* MCV-111* MCH-36.2* MCHC-32.6 RDW-19.0* [**2197-3-15**] 11:20AM LIPASE-32 [**2197-3-15**] 11:20AM ALT(SGPT)-64* AST(SGOT)-124* [**2197-3-15**] 11:20AM GLUCOSE-93 UREA N-17 CREAT-0.8 SODIUM-138 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-12 [**2197-3-15**] 09:23PM HCT-26.4* Brief Hospital Course: Pt admitted [**3-15**] with dark stools. He recieved IV PPI and octreotide gtt and transfused 1 unit of PRBC. Endoscopy performed was unremarkable and pt's hematocrit was stable. He was dishcarged in stable condiation and will follow with Dr. [**Last Name (STitle) 497**]. [**Hospital **] hospital course and will follow up for repeat HCT to evaluate for continued bleeding as cause of anemia. Medications on Admission: furosemide 40 mg once a day, lactulose 30 mL TID, methadone 60 mg QD, nadolol 20 mg once a day, PegIntron 150 mcg injecting 0.4 mL once per week ribavirin 1000 mg daily ?stopped [**2197-3-14**], rifaximin 550 mg 1 by mouth twice a day, Zoloft 100 mg once a day, Aldactone 50 mg once a day, Boost twice a day, multivitamins simethicone. Discharge Medications: 1. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. lactulose 10 gram/15 mL Solution Sig: Thirty (30) milliliters PO three times a day. 3. methadone 10 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily). 4. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. rifaximin 550 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day. 7. Aldactone 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. multivitamin Tablet Sig: One (1) Tablet PO once a day. 9. Boost Liquid Oral 10. simethicone Oral Discharge Disposition: Home Discharge Diagnosis: 1. Anemia 2. Cirrhosis 3. Hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with anemia, or low blood counts, and dark stools. We were concerned that you might be bleeding from your gastrointestinal tract. You received blood transfusions and your blood counts improved. You underwent upper endoscopy which did not show any explanation for your low blood counts and no evidence of bleeding. It is very important you follow up tomorrow for a repeat check of your blood counts. . None of your medications were changed during this admission. You should continue to take all of your other medications as prescribed. Followup Instructions: Department: LIVER CENTER When: FRIDAY [**2197-3-17**] at 10:00 AM With: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 13146**] [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2197-3-16**]

[ "456.1", "070.54", "304.01", "311", "537.9", "571.5", "280.9" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

4478, 4484

3105, 3501

319, 348

4566, 4566

2563, 3082

5310, 5767

1695, 1998

3888, 4455

4505, 4545

3527, 3865

4717, 5287

2013, 2544

267, 281

376, 1323

4581, 4693

1345, 1404

1420, 1679

28,365

121,835

31708

Discharge summary

report

Admission Date: [**2190-1-5**] Discharge Date: [**2190-1-8**] Date of Birth: [**2140-8-7**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 5123**] Chief Complaint: hypovolemic hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 49 yo M w/ Hx of ETOH abuse, who was found down by EMS and brought to the [**Hospital1 18**] ED about 15:30, initially in yellow zone then noted to be hypotensive. Received 4L NS, and a banana bag through a femoral line and was briefly on levophed for SBPs 70s. In the ED he was afebrile, an EKG was checked and revealed a paced rhythym. CE's were trended and were negative. He says that he had been sober for several months up until the afternoon PTA when he fell off the wagon. He states that he drank just over a pint of Vodka "in one shot" and that this was his first drink since [**Month (only) 216**]. He says that he was in his usual state of health and did not have any F/C/NS, chest pain or bleeding. He does not elaborate on why he went back to drinking. Past Medical History: # HTN # Hypercholesterolemia # V-pacer for bradycardia (?sick sinus), AICD for HF # CAD s/p MI [**7-14**] "100% occlusion, no stents, ?appropriate for CABG # CHF with EF 15-20% # DM2 # BPH # Depression # Alcohol abuse Social History: # Personal: Homeless, living in a veterans' shelter. # Alcohol: Denies abuse. Unable to quantify the amount he drinks. Had been sober for several months until he drank a pint of vodka today. # Recreational drugs: Denies # Tobacco: ~1 PPD for unknown number of years. Family History: # Father: Unknown # Mother: [**Name (NI) **] cancer Physical Exam: Vitals: T:98.6 BP:132/90 P:108 R: SaO2:93 on 2L General: Remorsefuls, Awake, alert, NAD, thouth diaphoretic HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in OP Neck: supple, no significant JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales Cardiac: Tachycardic, quiet nl S1 S2, no murmurs, rubs or gallops Abdomen: Obese soft, NTND, normoactive bowel sounds, no masses or organomegaly noted Extremities: cool, no edema, 2+ radial, DP pulses b/l Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted Skin: no rashes or lesions noted. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves grossly intact Pertinent Results: [**2190-1-5**] 03:35PM PLT COUNT-222 [**2190-1-5**] 03:35PM NEUTS-62.3 LYMPHS-30.8 MONOS-3.6 EOS-2.4 BASOS-1.0 [**2190-1-5**] 03:35PM WBC-5.8 RBC-4.33* HGB-13.1* HCT-37.8* MCV-87# MCH-30.2 MCHC-34.5 RDW-15.1 [**2190-1-5**] 03:35PM ASA-NEG ETHANOL-293* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2190-1-5**] 03:35PM CK-MB-NotDone cTropnT-<0.01 [**2190-1-5**] 03:35PM ALT(SGPT)-31 AST(SGOT)-29 LD(LDH)-183 CK(CPK)-82 ALK PHOS-68 TOT BILI-0.3 [**2190-1-5**] 03:35PM estGFR-Using this [**2190-1-5**] 03:35PM GLUCOSE-223* UREA N-14 CREAT-1.0 SODIUM-140 POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-27 ANION GAP-18 [**2190-1-5**] 06:54PM LACTATE-3.6* [**2190-1-5**] 07:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2190-1-5**] 07:10PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2190-1-5**] 07:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2190-1-5**] 07:10PM URINE GR HOLD-HOLD [**2190-1-5**] 07:10PM URINE HOURS-RANDOM [**2190-1-5**] 07:10PM URINE HOURS-RANDOM [**2190-1-5**] 07:28PM PT-19.1* PTT-33.1 INR(PT)-1.7* [**2190-1-5**] 10:47PM O2 SAT-92 [**2190-1-5**] 10:47PM LACTATE-2.5* [**2190-1-5**] 10:47PM TYPE-MIX PH-7.33* COMMENTS-GREEN TOP [**2190-1-5**] 03:35PM BLOOD ALT-31 AST-29 LD(LDH)-183 CK(CPK)-82 AlkPhos-68 TotBili-0.3 [**2190-1-6**] 01:46AM BLOOD CK(CPK)-79 [**2190-1-7**] 06:20AM BLOOD CK(CPK)-69 [**2190-1-7**] 06:20AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2190-1-6**] 01:46AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2190-1-5**] 03:35PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2190-1-7**] 06:20AM BLOOD D-Dimer-<150 [**2190-1-7**] 06:20AM BLOOD calTIBC-308 VitB12-833 Folate-18.6 Ferritn-51 TRF-237 [**2190-1-5**] 03:35PM BLOOD ASA-NEG Ethanol-293* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: Hypotension: This was most likely [**3-9**] extreme hypovolemia in the setting of an alcohol binge cominbed with taking his home BP meds. He improved after 8 liters of IVF and an overnight stay in the MICU. There was concern for underlying infection in the MICU given that his Lactate was initially elevated however it trended down and he never manifested infection. Given his history of MI cardiac etiology was ruled out by his fluid responsiveness, EKG without ischemic changes, and negative CEs. His tachycardia abruptly improved on [**2190-1-7**] and his pressures stabilized in the low 110's. He eventually tolerated the readition of his home carvedilol. The rest of his home BP meds were held pending follow-up with Dr. [**Last Name (STitle) 74485**]. We would recomend maximizing his beta-blocker and ace inhibitor over smaller doses of ACE, Beta and Spi, but we leave this up to Dr. [**Last Name (STitle) 74485**]. ?increased work of breathing - On [**1-7**] Mr [**Known lastname **] complained of increased work of breathing and was noted to be diaphoretic. PE was ruled out given his low-probability (INR 1.8 and receiving sq heparin.), and his D-Dimer returned at <150. PNA was another concern though his very thorough PA/Lateral [**Location (un) 1131**] shows no signs of PNA. Flash pulmonary edema was also of concern though his exam and cxr were not concerning for this. His original MI presented partly as SOB however his cardiac enzymes remain flat and his EKG is unchanged. At this point anxiety was the most likely source for his symptomology and it had resolved by [**1-8**] . ETOH: He received a banana bag in the ED and apparently cleared mentally while there. He never required a single dose of ativan on his CIWA. He was initially resistant to seeing a social worker though did agree and is currently very motivated to stop drinking. . HCT DROP: A 6 point HCT drop was noted from admission and remained stable throughout the stay. This was likely dilutional given large volume fluid repletion. We also assessed his folate, B12, Iron and retics to expedite his outpatient work-up . CAD/CHF: He has had an MI diagnosed at [**Hospital1 3278**] [**7-14**] with reduced EF, and without revascularization. ACEI and spironolactone were held for hypotension. We did reintroduce his carvedilol and continued his home Simvastatin 40 and ASA. We continued his home warfarin for his history of ?LV thrombus. He will follow-up with Dr. [**Last Name (STitle) 74485**] shortly to restart these meds. . 6. DMII: Finger sticks were in the 200s here. We kept him on insulin sliding scale in house, and eventually restarted his glyburide. He can restart his metformin at home. Medications on Admission: Simvastatin 40mg daily Glyburide 5mg [**Hospital1 **] Paroxetine 60mg daily Warfarin 10mg daily Metformin 1g [**Hospital1 **] Furosemide 20mg daily Spironolactone 12.5mg daily Carvedilol 3.125mg [**Hospital1 **] Lisinopril 2.5mg daily Mg oxide 420mg TID MVI daily ASA 325mg daily Terazosin ? dose Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Paroxetine HCl 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Magnesium Oxide 420 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Hypovolemic Hypotension Discharge Condition: stable Discharge Instructions: You were admitted to the hospital for low blood pressure. This is because you drank alcohol, became dehydrated, and took your blood pressure meds. With holding of your meds and several liters of IV fluids your blood pressure returned to acceptable levels. We successfully restarted your home carvedilol. The following changes were made to your home medications: You should NOT take your: Furosemide Spironolactone lisinopril Terazosin until you discuss with Dr. [**Last Name (STitle) 74485**] at the causeway VA Please return to your local ED if you have fever greater 101, chest pain, SOB, DOE, or worsening of baseline dizziness with walking. Followup Instructions: Appointment #1 MD: Pharmacist Specialty: Pharmacy Date/ Time: [**2190-1-13**] 11:30am Location: 251 Causeway, [**Location (un) 86**] Phone number: 1-[**Telephone/Fax (1) 74486**] Special instructions for patient: The office will be contacting you with an appointment with Dr. [**Last Name (STitle) **]. In the mean time they booked an appointment with a pharmacist to review your medications. Completed by:[**2190-1-11**]

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Discharge summary

report

Unit No: [**Numeric Identifier 99852**] Admission Date: [**2170-1-30**] Discharge Date: [**2170-2-13**] Sex: M Service: SURGERY This is a pleasant 82 year old male with a history of nephrolithiasis, hypertension, colonic polyps, adenocarcinoma who presented to the [**Hospital1 756**] emergency department on the seventeenth of [**2170-1-9**] complaining of chest pain which ruled out for a myocardial infarction overnight. He was discharged, but he was diagnosed eventually with pericarditis, and the chest pain eventually resolved. However, between the seventeenth and the 22nd presentation to the [**Hospital1 69**], he was seen by the primary care physician with some hypotension and was told to come to the emergency department for evaluation for potential tamponade. In the emergency department, an emergent echocardiogram was done which illustrated moderate pericardial effusion, no tamponade, a 1.5 cm effusion organized with fibrin stranding and organization. The patient was noted to have an hematocrit of 26.1 and was admitted for evaluation of his anemia and pericardial effusion. His past medical history includes nephrolithiasis, history of back surgery, anemia, squamous cell carcinoma removed from the ear, hypertension, history of a colonic polyp that was adenocarcinoma. His meds on admission included aspirin 325 mg p.o. daily, Lipitor 20 mg at bedtime and Diovan unknown dose. On presentation here, he was afebrile with vital signs stable. He appeared to be nontoxic and with no pertinent positives on physical examination. He was admitted to the medical service and evaluated for his anemia. He had a CTA that was done that illustrated no evidence of any mass, a question of a duodenal diverticulum on the CTA. Colonoscopy illustrated diverticulosis of the sigmoid, and upper EGD illustrated esophagitis and mild hiatal hernia in the gastric antrum. His EGD on the 25th illustrated a mild hiatal hernia and an ulcer in the distal bulb. The colonoscopy done on the same day, on the 25th, also illustrated diverticulosis of the sigmoid colon, but otherwise a normal colonoscopy. This gentleman had a repeat EGD done on the 27th. Upon examination, when they entered the duodenal bulb, a large, organized, maroon colored clot was seen, and a single acute ulcerated ulcer measuring 2.5 cm was seen, and in that base were two visible vessels, which were clipped during the procedure. The patient was transfused during this admission. During this admission, he received two units on the 23rd, and again an additional two units on the 25th, and an additional two units on the 27th, and he received an additional unit on the first. The patient was evaluated by the surgical service under the care of Dr. [**First Name (STitle) 2819**], and taken to the operating room on the 27th for an exploratory laparotomy, duodenal gastrotomy, and ulcer hemostasis with sutures and duodenal gastrotomy closure with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain placed on the 27th. The patient had no postoperative complications and was admitted to the surgical service postoperatively for routine postoperative care under the care of the blue surgical team with Dr. [**First Name (STitle) 2819**]. On postoperative day one, we monitored with serial hematocrits and a nasogastric tube was placed. The patient was monitored. On postoperative day three, the patient continue NPO, and he was followed in terms of his hematocrit and continue TPN and intravenous fluids. On postoperative day three, the patient was given TPN and was encouraged to ambulate and began to be evaluated by Physical Therapy. The patient underwent a water soluble contrast study on the fourth to evaluate for closure of the duodenum which was intact. The patient had an echocardiogram done on the fourth to evaluate further pericarditis, which appeared to resolve. He had an ejection fraction of 55 on the echocardiogram, with some noted mild dilation of the left atrium as well as some mildly thickened mitral valve leaflets. As mentioned previously, his gastroduodenal anastomosis was without any evidence of contrast extravasation. The antibiotics levofloxacin and Flagyl were discontinued on postoperative day seven, [**2170-2-11**]. The patient advanced to a regular diet after admitting to passing flatus. His TPN was stopped on the seventh, and the patient was encouraged to take p.o., which he did well. He had some ostomy output. Due to his home situation, which includes a wife with [**Name (NI) 5895**] and poor mobility at this time, it was felt that the patient should go to a rehabilitation center for encouragement and management, but at the time of discharge to the rehab center, the patient was tolerating a regular diet, urinating without difficulty and ambulating to a certain degree. His medications on discharge include Lopressor 50 mg p.o. b.i.d., which has been started during this admission, and Dilaudid 2 mg q 2 hours p.r.n. for pain, Colace 100 mg p.o. b.i.d. and Lipitor 25 mg p.o. at bedtime. The patient was not re- started on his Diovan, and he will follow up with his primary care physician within [**Name Initial (PRE) **] week to assess his high blood pressure and other management. He is to follow up with Dr. [**First Name (STitle) 2819**] in approximately two weeks. FINAL DIAGNOSES: 1. Exploratory laparotomy. 2. Duodenal gastrotomy with ulcer hemostasis and sutures and duodenal gastrotomy closure on [**2170-2-4**]. 3. Squamous cell cancer. 4. Hypertension. 5. Pericarditis. 6. Anemia. 7. Nephrolithiasis. The patient is to be discharged to rehab in good condition. At the center he will be getting rehab and wound assessment and further management. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 18475**] Dictated By:[**Doctor Last Name 22186**] MEDQUIST36 D: [**2170-2-13**] 11:54:08 T: [**2170-2-13**] 13:15:09 Job#: [**Job Number 99853**]

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42386

Discharge summary

report

Admission Date: [**2112-5-12**] Discharge Date: [**2112-6-15**] Date of Birth: [**2042-10-12**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 983**] Chief Complaint: Respiratory Distress, Hypotension Major Surgical or Invasive Procedure: Ultrasound guided Chest pigtail catheter placement Left video-assisted thoracoscopic decortication Dobhoff placement PICC line placement History of Present Illness: History of Present Illness: Mr. [**Known lastname 31**] is a 69 year old pleasant gentleman with COPD, atrial fibrillation on Coumadin, history of ischemic Right parietal stroke approximately 6 yrs ago resulting in seizure disorder, long history of EtOH abuse, and recent subdural hematoma resulting in a one-month long hospitalization at [**Hospital1 18**] with discharge on [**2112-4-7**] who presents in respiratory distress with appreciable Left sided pleural effusion on CXR. . Mr. [**Known lastname 31**] was discharged from [**Hospital1 18**] on [**2112-4-7**] following a one-month hospitalization for a subdural hematoma. Following discharge, the patient's son reports continuing mental status changes, characterized mainly by increased somnolence, while the patient reports chills for the past month and non-productive cough as well. Given his persistent mental status changes, his son brought him for a neurologic evaluation to [**Hospital1 18**]. Following the evaluation and head imaging, the patient developed sudden chest pain and SOB in the [**Hospital1 18**] east lobby and was subsequently taken to the ED. . In the ED, the patient's initial VS were: T: 99.6 HR: 113 BP: 110/65 RR: 16 O2Sat: 96% 4L NC. The patient did not endorse any chest pain or fevers, but continued to have SOB. A chest x-ray revealed a large left-sided pleural effusion, and the patient was administered 1L of NS, IV Azithromycin and Ceftraixone, and Tylenol. Interventional Pulmonary was consulted to drain the pleural fluid, and removed approximately 1.7L of pleural fluid through placement of a pigtail catheter. However, during the procedure, the patient became hypotensive with SBPs in the 80s, prompting his admission to the MICU. . On arrival to the MICU, the patient was in no acute distress, but appeared somewhat somnolent in response to questioning. His VS were: T: 98.4 HR: 96 BP: 98/57 RR: 33 O2Sat: 96% 2L NC. Past Medical History: 1) COPD 2) Atrial Fibrillation 3) Ischemic stroke - R parietal lobe (6 yrs ago per the patient) 4) Seizures - L hand rhythmic shaking, complex partial seizures 5) H/o EtOH abuse 6) Subdural hematoma Social History: Lives with wife in [**Name (NI) 1474**]. Retired exterminator. States drinks whiskey daily, but has been sober since [**Month (only) 404**]. Non-smoker. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98.7 BP: 92/50 P: 95 RR: 26 O2 Sat: 96 on 2L NC General: AOx2, No acute distress, Somnolent HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: Irregularly irregular, Distant Heart Sounds Lungs: Audible air movement in all lung fields, with diffuse crackles throughout, No egophony in the LL lobe Abdomen: Soft, NT, ND, +BS, no hepatosplenomegaly GU: + Foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Grossly intact . DISCHARGE PHYSICAL EXAM: VS - Tc 98.4 Tmax 99.5 HR 94 (80-90) BP 128/91 (110-120/70-90) RR 18 satting 96%RA GENERAL - well-appearing man in NAD, comfortable, appropriate, with dobhoff, in arm restraints HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, LUNGS - crackles at the bases bilaterally with weak inspiratory effort limited by patient's mental status. reduced air entry at left lung base HEART - PMI non-displaced, irregular rate, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - alert, oriented (self, place), conversant, able to move all extremities spontaneously, follows commands Pertinent Results: ADMISSION LABS: =============== [**2112-5-12**] 12:25PM BLOOD WBC-15.9*# RBC-4.08*# Hgb-11.8* Hct-39.6* MCV-97 MCH-28.9# MCHC-29.8* RDW-14.4 Plt Ct-681*# [**2112-5-12**] 01:34PM BLOOD Neuts-89.6* Lymphs-5.1* Monos-4.5 Eos-0.6 Baso-0.2 [**2112-5-12**] 12:25PM BLOOD Plt Ct-681*# [**2112-5-12**] 01:34PM BLOOD Glucose-108* UreaN-12 Creat-0.5 Na-135 K-4.5 Cl-95* HCO3-33* AnGap-12 [**2112-5-12**] 01:34PM BLOOD cTropnT-<0.01 proBNP-3166* [**2112-5-12**] 01:44PM BLOOD Lactate-2.0 [**2112-5-12**] 05:23PM BLOOD pH-7.12* Comment-PLEURAL [**2112-5-12**] 10:11PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.029 [**2112-5-12**] 10:11PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG [**2112-5-12**] 10:11PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 TransE-<1 [**2112-5-12**] 05:21PM PLEURAL TotProt-3.5 Glucose-55 LD(LDH)-412 [**2112-5-12**] 05:21PM PLEURAL WBC-6425* RBC-1475* Polys-72* Lymphs-10* Monos-15* Eos-3* NRBC-0 . DICHARGE LABS: ============== [**2112-6-15**] 05:22AM BLOOD WBC-6.6 RBC-2.62* Hgb-7.8* Hct-26.1* MCV-100* MCH-29.8 MCHC-29.9* RDW-22.3* Plt Ct-380 [**2112-6-15**] 05:22AM BLOOD Glucose-105* UreaN-17 Creat-1.0 Na-136 K-3.7 Cl-100 HCO3-33* AnGap-7* [**2112-6-15**] 05:22AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.1 . MICRO/PATH: =========== BLOOD CULTURE: [**5-12**] x 2: No growth [**5-14**] x 2: No growth . URINE: [**5-12**]: No growth [**5-14**]: No growth Urine Legionella Ag: Negative . PLEURAL FLUID: Pleural Fluid [**5-12**]: No growth Pleural Fluid [**5-16**]: Strep Anginosus (Milleri) Pleural Debris Tissue Cx [**5-16**]: Strep Anginosus (Milleri) BAL [**5-16**]: Commensal Flora Pleural Fluid [**5-18**]: No growth . MRSA Screen [**5-12**]: Negative . CYTOLOGY: PLEURAL FLUID Procedure Date of [**2112-5-12**] NEGATIVE FOR MALIGNANT CELLS. . Pathology of Pleural Debris [**2112-5-16**]: Granulation tissue and fibrinopurulent exudate; bacterial forms present. . IMAGING/STUDIES: ================ CHEST (PA & LAT) [**2112-5-12**]: IMPRESSION: Marked new opacification of the left mid to lower hemithorax with a lenticular shape which may potentially imply a large loculated pleural effusion in addition to parenchymal opacification. . Portable TTE [**2112-5-13**]: Pleural effusions are present. The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Overall left ventricular systolic function is normal (LVEF 65%). There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm. The right ventricular cavity is dilated with depressed free wall contractility. There is no aortic valve stenosis. No aortic regurgitation is seen. There is mild pulmonary artery systolic hypertension. The branch pulmonary arteries are dilated. There is no pericardial effusion. . CT CHEST W/O CONTRAST [**2112-5-13**]: IMPRESSION: Extensive highly loculated and only partially drained left pleural effusion. Small right pleural effusion. Extensive pulmonary emphysema with areas of non-characteristic scarring and atelectasis. Extensive coronary and aortic calcifications. Calcified gallstones, calcified upper abdominal vessels. . UNILAT UP EXT VEINS US RIGHT [**2112-5-18**]: IMPRESSION: No evidence of DVT in the right upper extremity. . Chest xrays, most recently: CHEST (PORTABLE AP) [**2112-6-10**]: IMPRESSION: 1. Dobbhoff feeding tube has its tip projecting over the expected location of the stomach. Right subclavian PICC line has its tip in the proximal SVC, unchanged. Bilateral airspace opacities, left greater than right with probable associated layering effusions are again seen. Two surgical clips are again identified at the left lung base. No overt pulmonary edema. The lung apices are not entirely included; therefore, evaluation for a pneumothorax is limited on this examination. Calcification of the aortic knob and descending aorta consistent with atherosclerosis. Overall, cardiac and mediastinal contours are stable. . CHEST (PORTABLE AP) [**2112-6-8**]: FINDINGS: As compared to the previous radiograph, there is no relevant change. The monitoring and support devices are in constant position. Unchanged size of the cardiac silhouette. Unchanged left and right pleural effusions, left more than right. Unchanged bilateral parenchymal opacities, left more than right. Unchanged mild-to-moderate retrocardiac atelectasis and right basal atelectasis. No parenchymal opacities have newly occurred. . Video swallow evaluation [**2112-5-23**]: FINDINGS: Barium passes freely from the oropharynx into the cervical esophagus without evidence of obstruction. Gross aspiration was witnessed with thin and nectar thick liquids. Moderate vallecular residue was noted with all consistencies of barium. For full details, please see the speech and language pathology report in the OMR. IMPRESSION: 1. Gross aspiration of thin and nectar thick liquids. 2. Moderate vallecular residue. . CT head without contrast [**2112-6-1**] FINDINGS: The previously described right frontal subdural collection is stable. There are no areas of acute intracranial hemorrhage. The previously described hypodensity involving the right temporoparietal region with associated encephalomalacia and ex vacuo dilatation of the right occipital [**Doctor Last Name 534**] persists. The visualized paranasal sinuses and mastoid air cells are clear. Calcified atherosclerotic disease is present in both cavernous portions of the internal carotid arteries. IMPRESSION: Stable right frontal subdural collection and right temporoparietal old infarct; no intracranial hemorrhage or CT evidence for acute CVA, although MR would be more sensitive in detecting such. . Video swallow evaluation [**2112-6-13**] SWALLOWING VIDEOFLUOROSCOPY: Oropharyngeal swallowing videofluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. Barium passed freely through the oropharynx without evidence of obstruction. There was penetration with nectars and thick liquids. The patient aspirated thin liquids. There is a swallow delay. IMPRESSION: Aspiration of thin liquids. SUMMARY: Mr. [**Known lastname 31**] presents with a mild progression of his dysphagia compared with video swallow performed [**2112-5-23**]. He continues to have intermittent aspiration of thin liquids, especially when clearing solid residue from the pharynx. His risk for aspiration of nectar-thick liquids is felt to be mildly increased compared to previous evaluation, and overall, there appears to be an increase in muscle weakness which is not unexpected as pt has been NPO since [**2112-5-16**]. Brief Hospital Course: Mr. [**Known lastname 31**] is a 69 year old gentleman with COPD, atrial fibrillation, history of ischemic right parietal stroke resulting in seizure disorder, long history of EtOH abuse, and recent subdural hematoma resulting in a one-month long hospitalization at [**Hospital1 18**] with discharge on [**2112-4-7**]. He re-presented to [**Hospital1 18**] on [**2112-5-12**] in respiratory distress secondary to a parapneumonic effusion. Hospital course was complicated by seizures, altered mental status, acute renal failure, ventricular tachycardia, and dysphagia. . ACTIVE DIAGNOSES: ================= . # Left-sided Parapneumonic Effusion: Likely secondary to aspiration pneumonia. He was initially hypotensive following a thoracentesis and required an ICU admission and pressor support. He was initially started on Vancomycin and Zosyn. Thoracic surgery was consulted given the complicated nature of his pleural effusion and he underwent VATS decortication and chest tube placement. He remained intubated following the OR and was extubated without complication. Pleural fluid and tissue cultures from the VATS grew Strep anginosus (Milleri) and cytology was negative for malignancy. Both chest tubes were removed three days after the patient was transferred to the medical floor. He was switched to vancomycin/flagyl, then vancomycin/cefepime, and finally just to zosyn. He completed a total of 21 days of antibiotics (end date [**2112-6-6**]). On exam he continues to have decreased air entry at the left lung base but has been saturating in the mid 90's on room air. . # Seizures: Patient has a history of seizures, likely secondary to prior right parietal stroke and alcohol abuse. He was initially on valproic acid and levetiracetam. He was noted to have 3 seizures on [**2112-5-26**]. After the seizures he had left-sided paralysis which was thought to be most likely [**Doctor Last Name 555**] paralysis, but in order to rule out stroke patient underwent a head CT, which was negative for new stroke or hemorrhage. He was started on phenytoin and continued on the valproic acid and levetiracetam and has remained seizure-free. Upon discharge he should continue valproic acid 750mg TID, levetiracetam 1500mg [**Hospital1 **], and phenytoin 100mg TID. . # Altered Mental Status: Likely secondary to underlying parapneumonic effusion/infection and seizures (treatment discussed above). His mental status has been gradually improving and he is currently A&Ox2-3. . # Code Blue for Hypoxemia/Unresonsiveness: Patient alarmed on tele for afib with RVR to the 140's, nurses found the patient unresponsive and per report his saturation was in the 50's. He was bag masked and became responsive almost instantaneously with sat of 99%. On transfer back to the MICU, patient underwent CT head which did not show progressive subdurals, and repeat infectious workup was unremarkable. Patient was evaluated by neurology team and EEG was reviewed but there was no evidence of seizures during that episode. Patient had gradual improvement of his mental status without evidence of seizures and was called back out to the floor for further management. . # Atrial Fibrillation/Ventricular tachycardia: On aspirin 325mg daily but not anticoagulated with warfarin given history of subdural hematoma. He had several episodes of asymptomatic sustatined ventricular tachycardia so cardiology was consulted and metoprolol tartrate was started which was uptitrated to 37.5mg TID. Afterward, his HR has been well controlled in the 80s-90s. . # Acute renal failure: Patient developed acute kidney injury with creatinine which peaked at 2.3 from baseline 0.5. Likely prerenal vs ATN in setting of hypotension. Urine sediment analysis revealed granular casts, UA reveals Trace protein, 11 Whites, 8 RBCs, Few Bacteria. FENA 1.2 and negative urine eos. Patient had anasarca from fluid rescusitation in the ICU and was thus diuresed with IV lasix with significant post-ATN diuresis. Creatinine gradually improved back to 1.0 upon discharge. . # Dysphagia: Longstanding issue, patient presented with poor nutritional status with albumin 1.9. Pneumonia suspected to be secondary to aspiration. He failed a video speech and swallow evaluation so an NG tube was placed and tube feeds were initiated. Repeat video swallow evaluation on [**2112-6-13**] showed worsening swallowing abilities and continued aspiration so the patient's family decided to keep the patient NPO and continue feeds via the dobhoff (see goals of care below). . # Goals of Care: Patient has had a complicated medical course as outlined above. After frequent meetings with his family including his health care proxy/son [**Name (NI) 37680**] [**Name (NI) 31**], the decision was made to change his status to DNR/DNI. On [**2112-6-14**] (after a second video swallow evaluation showed no improvement) another family meeting occurred in the presence of both sons. A decision was made to continue feeds via the dobhoff and keep him NPO in anticipation that Mr. [**Known lastname **] mental status will continue to improve. While he continues to be intermittently confused, he should remain in soft wrist restraints in order to keep him from pulling at the feeding tube. . CHRONIC DIAGNOSES: ================== . # H/O EtOH Abuse: The patient has a significant EtOH abuse history complicated by hospitalizations with delirium tremens. The patient endorses that he has not had a drink since [**Month (only) 404**] and was without any suicidal ideations or symptoms that could be explained by EtOH withdrawal but he seemed to have elements of dementia likely related to significant prior EtOH use. He was started on thiamine, folate, and a multivitamin. . TRANSITIONAL ISSUES: ==================== - Code status: DNR/DNI - Soft restraints while not observed since might pull the dobhoff tube - Tube feeding - Aspiration precaution - Mental status is partially oriented, most of the time AOx2, occasionally AOx3 Medications on Admission: 1) Valproic acid (as sodium salt) 250 MG/5 ML Solution 2) Levetiracetam 100 MG/ML Solution 3) Simvastatin 40 MG Tablet 4) Acetaminophen 325 MG Tablet PO Q6H PRN 5) Guaifenesin 100 MG/5 ML Syrup PO Q4H PRN for cough Discharge Medications: 1. valproic acid (as sodium salt) 250 mg/5 mL Solution [**Month (only) **]: Seven [**Age over 90 1230**]y (750) mg PO TID (3 times a day). 2. levetiracetam 100 mg/mL Solution [**Age over 90 **]: 1500 (1500) mg PO BID (2 times a day). 3. simvastatin 40 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily). 4. phenytoin 125 mg/5 mL Suspension [**Age over 90 **]: One Hundred (100) mg PO three times a day. 5. aspirin 325 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily). 6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 7. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO TID (3 times a day). 8. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every six (6) hours as needed for pain. 9. codeine-guaifenesin 10-100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB/Wheezing. 11. thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 12. folic acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 13. therapeutic multivitamin Liquid [**Last Name (STitle) **]: Five (5) ML PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: Seizures Altered mental status Ventricular Tachycardia Complicated Left Parapneumonic Effusion Aspiration Secondary Diagnoses: Anemia Subdural hematoma Atrial fibrillation Discharge Condition: Mental Status: level of orientation varies however coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr [**Known lastname 31**], . It was a great pleasure taking care of you as your doctor. As you know you were admitted to [**Hospital1 1170**] because of breathing difficulty. . The fluid around your left lung was drained and was found to be infected. A tube was placed to keep draining it out. Afterwards, a surgery was done to help reduce re-accumulation of the fluid. You received IV antibiotic called Zosyn for this infection. . Given your seizure activity, a new medication called dilantin was started. In the meantime, your brain electrical activity was monitored. The brain doctors were involved in the care provided to you and were following with us on daily basis. . While your heart was being monitored, you had a few episodes of fast heart beat in a rhythm called ventricular tachycardia. For this, a new medication was started called metoprolol as below. . You were disoriented during your stay and we had to utilize soft restraints at your hands to avoid self-pulling of tubes which you did a few times during your stay when there was no restraints. Also, restraints were required for your safety to avoid being out of bed and falling without prior notice. . You were provided nutrition through a tube from your nose down to your stomach. You were evaluated by speech and swallow team who found that you are aspirating. You were re-evaluated after improvement in your mental status and unfortunately found no significant change from prior. It was decided to discharge you from the hospital to a rehab and to continue to feed you through the feeding tube. You will be going to a rehab for further physical therapy and management. . We made the following changes in your medication list. - Please START phenytoin 100 mg three times daily - Please START Aspirin 325 mg daily - Please START metoprolol 37.5 mg three times daily - Please START lansoprazole oral disintegrating tablet 30mg daily - Please START thiamine 100 mg daily - Please START folic acid 1 mg daily - Please START multivitamins 1 tablet daily - Please CONTINUE valproic acid at 750 mg three times daily - Please CONTINUE levetiracetam at 1500 mg twice daily . Please continue the rest of your home medications the way you were taking them prior to admission. . Please follow with the appointment as illustrated below. . We wish you all the best at the rehab. Followup Instructions: Department: COGNITIVE NEUROLOGY UNIT When: MONDAY [**2112-7-4**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage . Department: RADIOLOGY When: WEDNESDAY [**2112-7-6**] at 10:00 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage . Department: NEUROSURGERY When: WEDNESDAY [**2112-7-6**] at 10:45 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report+addendum

Admission Date: [**2182-4-10**] Discharge Date: [**2182-4-15**] Date of Birth: [**2110-10-9**] Sex: M Service: MEDICINE Allergies: trazodone Attending:[**First Name3 (LF) 896**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 71 year-old male with a history of squamous cell carcinoma of lung [**2172**] s/p R VATs and RLL basilar segmentectomy, organizing pneumonitis and follicular bronchiolitis, COPD (FEV1 67%, on 4L NC at home) who presents from PCP office for respiratory distress. Patient reports that he stopped taking his medications approximately 1.5 months ago, including prednisone (10 mg daily) and multiple nebs and inhaled steroids (proair, spiriva, albuterol and advair). He stopped taking his medications because his prednisone has contribued to his back pain and compression fracturse. He states over the last 2 weeks he has been gradually increasingly short of breath. He denies cough, fevers, no sputum, no chills, chest pain. He went to his PCP today for her regularly [**Year (4 digits) 1988**] visit and was found to be hypoxic to 85% on 5 L and tachycardic. The patient normally wears approximately 4 L of oxygen at home as he has interstitial lung disease and is status post lung cancer. . Of note, whenever pt stops taking his steroids, he is hospitalized for hypoxemia. Per OMR, he had similar episode 2 years ago where he stopped his prednisone, O2 70s, admitted for 2 weeks to hospital and given steroids and trial of rituximab. . In the ED, initial VS were: 100.2 120 138/94 26 97% 15L Non-Rebreather, tachycardic. Mentating well. Tried 6L NC but triggered for O2 sat 84%. Then placed on non-rebreather and improved O2 sat to 96%. Given 2Mg, solumedrol 125mg, 500mg azithromycin, cefepime 2g, vancomycin, pantoprazole gtt, ipratropium neb, albuterol neb. Placed on BIPAP. CXR looks like worsening interstial lung disease. Trace guiac positive stool but HCT stable. EKG checked twice and was stable, showed: ST depressions in V4-V6, II. Given: 1L NS Access: 18g in R arm Labs: Lactate 1.7, trop<0.01, Na 139, K 3.6, Cl 101, HCO3 23, BUN 9, Cr 0.6, gluc 105. Ca 9.6, Mg 1.9, P 2.8. BNP 356. INR 1.1 ABG on BIPAP pH 7.44, CO2 31, O2 106, HCO3 22 Vitals prior to transfer: T-100.0, HR 127, RR 27, 93% on non rebreather, 96/55. . On arrival to the MICU, pt appeared comfortable on the BIPAP. No sputum, no cough, no fevers. Did endorse weight loss. In the MICU, patient was treated with Lasix 40 IV x1 and put out 550c. TTE showed normal EF 55%. He was also treated with solumedrol and then transitioned to prednisone 60mg and ipratropium nebs q6 standing. Bactrim prophylaxis was started. Attempted induced sputum, but failed. Antibiotics were deferred. Patient's respiratory status improved rapidly. . Prior to transfer to the floor, patient feels well. Denies sob, cough, chest pain. Feels that he is close to his basline respiratory wise. No abdominal pain. . Past Medical History: - Diffuse parenchymal lung disease-biopsy showed organizing pneumonitis and follicular bronchiolitis- [**2179**] bx showed follicular bronchiolitis. Trial of high dose steroids (pred 60mg daily) helped, then had hypoxemia to 70s when stopped. Had trial of rituximab infusion, both on [**2181-6-11**] and [**2181-6-26**] - H/o lung CA (scc): incidental nodule on cxr, s/p R VATS and RLL basilar segmentectomy on [**2172-3-23**], neg margins. f/b Dr. [**Last Name (STitle) 87213**], serial chest CT (stable 11mm RLL nodule and 6mm L hilar nodule) - COPD on 4L home O2 (FEV1 67%: Three hospitalization and ~ED vistis since [**2179**] for COPD exacerbation. No history of intubation or ICU stay. - Hypertension - Benign prostatic hypertrophy: Elev PSA : 7.1 ([**1-26**]) --> 9.5 ([**7-27**]). has been up to 11 in past ([**4-26**]). prostate bx neg x3. now on flomax, avodart - H/O colonic polyps : A-colon: [**2173**] scope sessile polyps, [**7-/2177**] repeat hyperplastic polyps. - Gout Social History: Patient reports being a county clerk and he retired during [**2160**]. Reports a 100 pack year history of smoking. Quit in [**2172**] after lung cancer discovered. Denies alcohol and drug use. Denies any recent sick contacts. Denies TB or asbestos exposure.No ETOH now. Family History: Brother had problem with SOB and required pacemaker placement. No family history of lung cancer or autoimmune diseases. Physical Exam: ADMISSION EXAM Vitals: T 97.6, HR 110, BP 135.77, 95% on BIPAP 5.5 40% FiO2, RR 19 General: Alert, oriented, no acute distress, chronically ill appearng male HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: sinus tachy, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: fine crackles bilaterally throughout, predominantly in bases Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: [**5-25**] stregnth throughout, A+Ox3 . DISCHARGE EXAM: Vitals: T 98.4 BP 122/71 HR 92-108 RR 12 O2 93% on 5L NC General: Alert, oriented, no acute distress, chronically ill appearng male HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: sinus tachy, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: fine crackles bilaterally throughout, predominantly in bases Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: [**5-25**] stregnth throughout, A+Ox3 Pertinent Results: Labs on Admission: [**2182-4-10**] 02:15PM WBC-15.7* RBC-5.34 HGB-16.1 HCT-49.1 MCV-92 MCH-30.1 MCHC-32.7 RDW-15.3 [**2182-4-10**] 02:15PM NEUTS-86.7* LYMPHS-6.4* MONOS-4.7 EOS-1.6 BASOS-0.6 [**2182-4-10**] 02:15PM PT-11.6 PTT-34.9 INR(PT)-1.1 [**2182-4-10**] 02:15PM GLUCOSE-105* UREA N-9 CREAT-0.6 SODIUM-139 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-23 ANION GAP-19 [**2182-4-10**] 02:15PM CALCIUM-9.6 PHOSPHATE-2.8 MAGNESIUM-1.9 [**2182-4-10**] 02:15PM proBNP-356* [**2182-4-10**] 02:15PM cTropnT-<0.01 [**2182-4-10**] 02:49PM LACTATE-1.7 . Discharge labs: WBC-10.3 RBC-4.88 Hgb-14.2 Hct-45.2 MCV-93 MCH-29.0 MCHC-31.3 RDW-15.7* Plt Ct-265 Glucose-76 UreaN-19 Creat-0.5 Na-142 K-4.1 Cl-106 HCO3-29 AnGap-11 . Imaging: CXR [**4-10**]: New moderate heterogeneous interstitial abnormality, for which interstitial pulmonary edema should be considered. Perhaps less likely, the appearance could reflect atypical infection in the appropriate setting. . EKG: sinus tachy HR 134, S1, QIII, PR<200, narrow QRS, nl axis, delayed R wave progression, New compared to prior: very mild ST depressions in V4, II. . Echo [**4-11**]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Doppler parameters are indeterminate for left ventricular diastolic function. The right ventricular cavity is mildly dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. IMPRESSION: Normal regional and global left ventricular systolic function. The right ventricle appears mildly dilated with borderline systolic function. Diastolic parameters are indeterminate. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [**2181-11-20**], heart rate has increased. Impaired relaxation was present on the prior but cannot be confirmed/excluded on the current study. . X ray T/L Spine [**4-11**]: No new compression fractures since the recent CT but the L3 Preliminary Reportcompression fracture has progressed with further height loss since the Preliminary Reportradiographs on [**2181-11-20**]. . Brief Hospital Course: 71 year-old male history of squamous cell carcinoma of lung [**2172**] s/p R VATs and RLL basilar segmentectomy, organizing pneumonitis and follicular bronchiolitis, COPD (FEV1 67%, on 4L NC at home) who presents from PCP office for respiratory distress in setting of medication non-compliance. # Respiratory Distress secondary to severe exacerbation of COPD: Has underlying COPD, organizing pneumonitis/follicular bronchiolitis using 4L NC at home. Patient's decompensation thought secondary to medication noncompliance for approximately 6 weeks, per patient report and given past similar presentations. Patient was treated with solumedrol 80 q8, BIPAP, inhalers initially in the MICU. He did not require intubation. Once stabilized, he was transferred to the floor on 60mg of oral prednisone daily. Per his outpatient pulmonologist, he was continued on this dose at the time of discahrge and will follow up with her in the next two weeks. He was back to his home 4L NC at the time of discharge. He was otherwise continued on fluticasone-salmeterol and tioptropium with as needed albuterol. Patient was also restarted on bactrim prophylaxis monday, wednesday, friday. # Back pain/Osteoporosis: Patient with known compression fracture and osteoporosis related to long term steroid use. T and L spine films with no new fractures. Patient was continued on vitamin D and calcium, and was started on alendronate 10mg po daily. He was continued on home tylenol and oxycodone for pain control. # Dark stools: Guaiac mildly positive, HCT stable throughout. Has history of gastritis likely [**2-21**] prednisone use. Continued omeprazole. # Urinary burning: UA negative, did not treat for cystitis. # BPH: Continued tamsulosin and finasteride. # Gout: Continued allopurinol 100mg daily. # Depression/Anxiety: Continued citalopram and mirtazapine. Held lorazepam given compromised respiratory status initially, but continued upon discharge. # GERD: Continued omeprazole. # Transitional issues: - discharged on 60mg po daily prednisone. Patient [**Month/Day (2) 1988**] for follow-up in [**Hospital 2182**] clinic on [**5-2**], but if possible should be seen by pulmonology sooner for tapering of prednisone. - blood cultures with no growth to date, but pending final at time of discharge - patient discharged with VNA services to assist with medication compliance Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] - (Not Taking as Prescribed) - 90 mcg HFA Aerosol Inhaler - two puffs(s) inhaled every 4-6 hours as needed for wheezing ALLOPURINOL - (Not Taking as Prescribed) - 100 mg Tablet - 1 Tablet(s) by mouth daily CITALOPRAM - (Not Taking as Prescribed) - 10 mg Tablet - one Tablet(s) by mouth at bedtime DUTASTERIDE [AVODART] - (Not Taking as Prescribed) - 0.5 mg Capsule - 1 Capsule(s) by mouth daily ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D2] - (Prescribed by Other Provider) (Not Taking as Prescribed) - 50,000 unit Capsule - 1 Capsule(s) by mouth weekly FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Dose adjustment - no new Rx) - 500 mcg-50 mcg/Dose Disk with Device - 1 puff(s) po twice a day Rinse mouth after use LORAZEPAM - 0.5 mg Tablet - 1 (One) Tablet(s) by mouth twice a day as needed METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day MIRTAZAPINE [REMERON] - (Not Taking as Prescribed) - 15 mg Tablet - 1 (One) Tablet(s) by mouth once a day OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day OXYCODONE - 5 mg Tablet - 1 (One) Tablet(s) by mouth every six (6) hours POTASSIUM CHLORIDE - (Not Taking as Prescribed) - 20 mEq Tablet, ER Particles/Crystals - 1 (One) Tablet(s) by mouth twice a day PREDNISONE - (Not Taking as Prescribed) - 10 mg Tablet - 1 Tablet(s) by mouth daily TAMSULOSIN - (Not Taking as Prescribed) - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth daily TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 1 puff inhaled daily Medications - OTC ACETAMINOPHEN [ACETAMINOPHEN EXTRA STRENGTH] - (Prescribed by Other Provider) - 500 mg Tablet - 2 (Two) Tablet(s) by mouth three times a day CALCIUM CARBONATE [CALTRATE 600] - (OTC) (Not Taking as Prescribed) - 600 mg (1,500 mg) Tablet - 2 Tablet(s) by mouth daily MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain POLYETHYLENE GLYCOL 3350 [MIRALAX] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO once a day. 4. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. alendronate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 7. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. calcium carbonate 600 mg (1,500 mg) Tablet Sig: Two (2) Tablet PO once a day. 11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for insomnia/anxiety. 13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 14. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 15. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8 HR PRN () as needed for pain. 17. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Disp:*90 Tablet(s)* Refills:*2* 18. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): continue until you see Dr. [**First Name (STitle) 437**]. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: # COPD exacerbation Secondary diagnosis: # Osteoporosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 4401**], You were admitted to the hospital with shortness of breath and low oxygen levels after discontinuing steroids. We treated you with steroids and you improved. On discharge, you should complete a steroid taper to your previous dose as per instructions below. Also, please follow up with your lung doctor. In regards to your back pain in the setting of compression fractures, we started you on a new medication called alendronate to help make your bones stronger. We also started a supplement of calcium and vitamin D. This will decrease your risk for further compression fractures. . We have made the following changes to your medications: - START prednisone 60mg by mouth daily until you see Dr. [**First Name (STitle) 437**] - START alendronate once daily - RE START bactrim, one pill on monday, wednesday and friday Please follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**] below. It was a pleasure taking care of you, and hope you continue to feel well! Followup Instructions: Department: [**Hospital **] MEDICAL GROUP When: MONDAY [**2182-4-22**] at 11:00 AM With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3879**] [**Telephone/Fax (1) 133**] Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**] Campus: OFF CAMPUS Best Parking: On Street Parking Department: PULMONARY FUNCTION LAB When: THURSDAY [**2182-5-2**] at 1:40 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: THURSDAY [**2182-5-2**] at 2:00 PM Department: MEDICAL SPECIALTIES When: THURSDAY [**2182-5-2**] at 2:00 PM With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage **This appointment is with a specialist who will focus directly on managing your COPD as you transition from the hospital to home. After this visit, you will be [**Hospital Ward Name 1988**] in the department as needed with either your regular pulmonologist or with a new one.** Name: [**Known lastname 2132**],[**Known firstname 63**] Unit No: [**Numeric Identifier 13809**] Admission Date: [**2182-4-10**] Discharge Date: [**2182-4-15**] Date of Birth: [**2110-10-9**] Sex: M Service: MEDICINE Allergies: trazodone Attending:[**First Name3 (LF) 3046**] Addendum: Left message for patient on home answering machien to clarify medication list. Potassium chloride, amlodipine and oxycodone accidentally left of discharge medication list. Instructed patient to continue these medications as prescribed prior to admission. Discharge Disposition: Home With Service Facility: [**Location (un) 42**] VNA [**First Name11 (Name Pattern1) 394**] [**Last Name (NamePattern4) 3047**] MD [**MD Number(2) 3048**] Completed by:[**2182-4-15**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

17736, 17953

8161, 10140

289, 296

14655, 14655

5652, 5657

15863, 17713

4316, 4437

12666, 14455

14556, 14556

10560, 12643

14805, 15455

6225, 8138

4452, 5048

5064, 5633

15484, 15840

230, 251

324, 2997

14617, 14634

14575, 14596

5672, 6209

14670, 14781

10163, 10534

3019, 4008

4024, 4300

79,699

171,493

39384

Discharge summary

report

Admission Date: [**2113-8-18**] Discharge Date: [**2113-9-15**] Date of Birth: [**2050-8-16**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: pneumonia, bronchus intermedius-neoesophageal fistula Major Surgical or Invasive Procedure: Flexible bronchoscopy with bronchoalveolar lavage and chest tube placement, metallic stent placement in the bronchus intermedius, Flexible bronchoscopy and stent revision, bronchoscopy, Right thoracotomy and repair of bronchoesophageal fistula using a pedicled latissimus dorsi flap, takedown of the gastric conduit and creation of the left cervical end esophagostomy (split fistula), Laparotomy, G-tube and J-tube placement, Flexible bronchoscopy and bronchoalveolar lavage, Percutaneous tracheostomy tube History of Present Illness: 63M with hx of esophageal CA s/p chemo/radiation, esophagectomy transferred from [**Hospital 1474**] Hospital after found to have severe PNA and a fistula from bronchus intermedius to neoesophagus through gastric conduit. Pt had recently been admitted in [**6-12**] for cardiac stenting for 100% stenosis of RCA using BMS. On [**7-17**], pt admitted to [**Hospital1 1474**] and underwent Right thoracotomy with esophagectomy and J-tube placement, complicated by SBO thought due to stricture at duodonal anastamosis. Patient went back to hospital on [**8-16**], found to have severe PNA and also went into rapid a-fib which was controlled with diltiazem drip. Patient had worsening respiratory status, and was intubated. After intubation, significant leak was discovered on vent, and on CT, patient was found to have broncho-neoesophageal fistula. Patient was then transferred to [**Hospital1 18**] for further management. On arrival, an a-line was placed and CVL was replaced. Thoracic srgery bronched the patient and found a 1 cm fistula at the bronchus intermedius. Prolonged intubation time, unable to wean from ventilator, required pressors on several occasions. Trach and PEG placed. Patiemt on ventilator and unable to wean. Family made patient DNR (no pressors) and then CMO, patient was taken off the ventilator and expired shortly thereafter. PCP and ME notified. Past Medical History: prostate CA, COPD, CAD s/p stenting, CHF (EF 40-45%, mild hypokinesia), ischemic cardiomyopathy (EF 40-45%, mild hypokinesia), OA, GERD, esophageal CA s/p chemo, radiation adn surgical resection PSH: radical prostatectomy, appendectomy, PEG placement, Social History: Lives with wife, who is primarily Portuguese speaking. Has son & daughter as well as grandchildren. Family is described by daughter as "close." His daughter is the HCP. Family History: No lung cancer or congenital lung diseases Physical Exam: T 96.2 HR 90 A.fib BP 106-110/50 RR 38 O2SAT 97% vent CMV/PSV 8, PEEP 0 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 [x] Abnormal findings: ETT tube in place. NGT in place. RESPIRATORY [ ] All findings normal [ ] CTA/P [ ] Excursion normal [ ] No fremitus [ ] No egophony [ ] No spine/CVAT [x] Abnormal findings: decreased breath sounds at lung bases, right greater than left. No wheezing, rhonchi or rales. CARDIOVASCULAR [ ] All findings normal [ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema [ ] Peripheral pulses nl [ ] No abd/carotid bruit [x] Abnormal findings: Irregularly irregular rhythm, Atrial fibrillation. No murmur, rubs or gallops. 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: TLD: L. PICC, R. IJ CVC, Foley, NGT, ETT #9.5 Pertinent Results: [**2113-8-18**] 11:42PM GLUCOSE-143* UREA N-10 CREAT-0.4* SODIUM-137 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-28 ANION GAP-8 [**2113-8-18**] 11:42PM estGFR-Using this [**2113-8-18**] 11:42PM CK(CPK)-27* [**2113-8-18**] 11:42PM CALCIUM-7.5* PHOSPHATE-3.3 MAGNESIUM-2.1 [**2113-8-18**] 11:42PM CK-MB-5 cTropnT-0.02* [**2113-8-18**] 11:42PM WBC-9.9 RBC-3.10* HGB-9.1* HCT-28.3* MCV-91 MCH-29.3 MCHC-32.0 RDW-17.0* [**2113-8-18**] 11:42PM NEUTS-92.5* LYMPHS-4.0* MONOS-3.2 EOS-0 BASOS-0.2 [**2113-8-18**] 11:42PM PLT COUNT-220 [**2113-8-18**] 11:42PM PT-13.4 PTT-37.7* INR(PT)-1.1 [**2113-8-18**] 11:35PM TYPE-ART TEMP-35.7 PO2-98 PCO2-60* PH-7.29* TOTAL CO2-30 BASE XS-0 INTUBATED-INTUBATED [**2113-8-18**] 11:35PM LACTATE-1.4 [**2113-8-18**] 11:35PM O2 SAT-97 [**2113-8-18**] 11:35PM freeCa-1.08* [**2113-8-22**] CXR x3 : Last one showed improved aeration of right upper lobe. [**2113-8-23**] ECG: Sinus rhythm with ventricular premature beats. Right bundle-branch block. Compared to the previous tracing of [**2113-8-19**] the findings are similar. Left atrial abnormality persists. [**2113-8-23**] CXR: Diminished aeration of the left lung and improved aeration of the right lung and decrease in size of right pleural effusion after repositionning of ETT in the trachea. Left perihilar consolidation or edema may have worsened. [**2113-8-23**] CXR: Bilateral widespread opacities, which could represent infection or aspiration overlying edema, remain unchanged in comparison to the prior radiograph. [**2113-8-23**] CXR:Bilateral widespread opacities, which could represent infection or aspiration overlying edema, remain unchanged in comparison to the prior radiograph. [**2113-8-24**] stomach path: Few areas of mucosal ischemia, with single ulcer involving muscularis propria, No carcinoma seen, Bronchoesophageal fistula. [**2113-8-24**] ECHO: Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%). The apex is hypkinetic. The right ventricular cavity is dilated with borderline normal free wall function. with focal hypokinesis of the apical free wall. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2113-8-22**], apical hypokinesis of the left and right ventricle is now seen. [**2113-8-24**] CXR: In comparison with the study of earlier in this date, there is little change. Multiple monitoring and support devices remain in place with no definite pneumothorax. Extensive bilateral pleural opacifications persist. [**2113-8-24**] CXR: In comparison with the study of earlier in this date, there is little change. Multiple monitoring and support devices remain in place with no definite pneumothorax. Extensive bilateral pleural opacifications persist. [**2113-8-25**] ECG: Sinus rhythm with frequent supraventricular premature beats including couplets. Right bundle-branch block. Compared to the previous tracing of [**2113-8-23**] no change except supraventricular premature beats are more frequent. [**2113-8-25**] CXR: In comparison with the study of [**8-24**], there is little overall change in the appearance of the extensive bilateral pulmonary opacifications. Monitoring and support devices remain in place. [**2113-8-26**] CXR: Compared to the study from the prior day, there is no significant interval change. [**2113-8-27**] CXR: Compared to the film from the prior day, there is no significant interval change. [**2113-8-28**] ECG: Atrial fibrillation with rapid ventricular response. Right bundle-branch block. Low limb lead voltage. Non-specific ST-T wave changes. Compared to the previous tracing of [**2113-8-25**] atrial fibrillation has appeared. [**2113-8-28**] CXR: In combination with findings of the CT of [**2113-8-19**], the observed lung abnormalties probably represent a combination of pulmonary edema and multifocal pneumonia. [**2113-8-28**] CXR: Following removal of right-sided chest tube, there is no visible right pneumothorax and no substantial change in a moderate-sized right pleural effusion. Remainder of the chest is also unchanged in appearance since the recent radiograph of a few hours earlier. [**2113-8-28**] CXR: Satisfactory appearances after insertion of new right chest drain with persistence of right apical pneumothorax, moderate right pleural effusion and associated atelectasis. The endotracheal tube is 7 cm from the carina which may is high-lying and could be advanced by approximately 3-4 cm, if clinically warranted. [**2113-8-28**] CXR: Satisfactory appearances after insertion of new right chest drain with persistence of right apical pneumothorax, moderate right pleural effusion and associated atelectasis. The endotracheal tube is 7 cm from the carina which may is high-lying and could be advanced by approximately 3-4 cm, if clinically warranted. [**2113-8-29**] BAL cytology: ATYPICAL. Many groups of bronchial epithelial cells, some with crowding and prominent nucleoli, favor reactive; pulmonary macrophages, neutrophils, and some squamous cells. [**2113-8-29**] CXR: Lower aspect of the chest and upper abdomen are excluded from the examination. Subcutaneous emphysema in the right chest wall has increased substantially over 12 hours. Moderate right pleural effusion may be slightly larger and moderate pulmonary edema has worsened. Right apical pleural tubes are unchanged in their respective positions, and there is no pneumothorax in the upper chest. [**2113-8-30**] CXR: BEF and new central line. Comparison is made with prior study performed 4 hours earlier. Right subclavian catheter tip is in the lower SVC. There is no evident pneumothorax. There are no interval changes. [**2113-8-31**] CXR: Cardiomediastinal contours are unchanged with cardiac size normal. Right IJ catheter tip is in the lower SVC. Left PICC tip is also in the lower SVC. There is no evident pneumothorax. Right subcutaneous emphysema is stable. Two right apical chest tubes remain in place. Right hydropneumothorax has minimally decreased in amount. Of note, the lateral aspect of the left hemithorax was not included on the film. Moderate pulmonary edema has minimally improved. Large air collection in the abdomen still is concerning for pneumoperitoneum. ET tube is in the standard position. Bibasilar opacities, left greater than right are unchanged, could be due to atelectasis, superimposed infection cannot be totally excluded. [**2113-9-1**] CXR: The ET tube tip is 5.5 cm above the carina. The right subclavian line is at the level of low SVC. The two right chest tubes are in unchanged location. Subcutaneous air as well as air within the pleural space are partially imaged. There is no change in multiple opacities, in particular involving the left perihilar and bibasal areas. The left PICC line tip is at the cavoatrial junction. [**2113-9-2**] CXR: New tracheostomy tube tip is 5 cm above the carina. Right subclavian catheter tip is in the mid-to-lower SVC. Right apical chest tubes remain in place. Right chest wall subcutaneous emphysema is stable. Left PICC remains in place. Pneumoperitoneum is unchanged. Bilateral pleural effusions, perihilar and bibasilar opacities right greater than left are unchanged. There is no evident pneumothorax. [**2113-9-2**] CT chest/abd/pelvis : Moderate-to-large layering L pleural effusion, worsened with loculations in superior posterior portion. Dense heterogeneous consolidations at b/l bases, with increasing heterogeneity concerning for necrosis. Multiple wedge perfusion anomalies of the kidneys, likely renal infarcts. [**2113-9-3**] CXR: There is a new apical chest tube. The aeration of the left lung has markedly improved. There is almost complete resolution of left pleural effusion. Cardiac size is normal. Medial right pneumothorax is stable. Cardiomediastinum is midline. Tracheostomy tube, two right apical chest tubes and a right subclavian catheter remain in place. Right chest wall subcutaneous emphysema is minimally improved. Right pleural effusion and right perihilar and lower lobe opacities are stable. There is no pneumothorax. Pneumoperitoneum is persistent. [**2113-9-4**] CXR : Worsening B pulmonary edema and pleural effusions. Atalectasis at bases has increased. Pneumomediastinum, previously seen and consistent with surgery. [**2113-9-5**] CXR : Unchanged extensive R lung opacities associated with pleural effusion. Left lung with reduction in pre-existing opacities. Persistent [**2113-9-7**] CXR: Pneumomediastinum, apparently new. Otherwise, unchanged exam from two days prior. Findings were discussed with [**First Name4 (NamePattern1) 1446**] [**Last Name (NamePattern1) **] at 1:30 pm. Recommendation was made to repeat study after removal of overlying external device on left upper chest. [**2113-9-7**] CXR: Radiographic suspicion for pneumomediastinum in this patient with history of tracheoesophageal fistula persists. If conclusive diagnosis is essential, one has to recommend a repeat chest CT. [**2113-9-13**] CXR: Two right-sided chest tubes remain in place, with persistent localized pneumothorax at the extreme right apex. Moderate right pleural effusion is unchanged, but small-to-moderate left pleural effusion has probably slightly increased in the interval. Cardiomediastinal contours are similar to prior study. Widespread heterogeneous opacities affecting the right lung more than the left have also worsened in the interval. In combination with findings from CT torso [**2112-9-2**], this is concerning for multifocal pneumonia. Brief Hospital Course: [**2113-8-19**]: Bronch: extravasated methylene blue in bronchioles, 1cm fistula at bronchus intermedius communicating with esophagus. [**2113-8-21**]: repeat bronch: size of fistula increased significantly and stent fell into the fistula tract. R thoracotomy latissimus flap to bronchus intermedius defect. Debridement/excision of necrotic anastamosis. Spit fistula creation. [**8-22**]: increasing hypercarbia. Multiple bronchs to try to remove plugging and help right lung re-expand. [**8-23**]: DLT switched to SL ETT over cook catheter due to difficulty ventilating/DLT kink; bronchoscopy/suction; improved ventilation [**8-23**]: Sustained SVT in 180-190s with hemodynamic instability. Shocked once, which converted him for approx 5 minutes. Given amiodarone 150 IV push x3, amio gtt with good effect. [**8-24**]: G-tube, J-tube placed. [**8-28**]: Intermittent a-fib with RVR improved briefly o/n [**8-28**] with amio bolus despite amiodarone infusion, converted back to a-fib with RVR without hemodynamic compromise. Lopressor 5mg IV x2 with rate control. [**2113-8-30**]: R subclavian line; RIJ removed, tip cultured [**2113-9-3**]: L Chest tube placed --> ~1L simple fluid [**2113-9-4**]: permissive hypercapnia, Afib controlled w/ dilt ggt and boluses [**2113-9-5**]: lasix gtt started, goal 2L/24 h. A flutter, hr 150-->metop, amio. Started on esmolol/amio gtt with improved hemodynamics. Fent/midaz increased with improved HR. [**2113-9-6**]: weaned sedation. PO amio. diuresis. Diamox started [**2113-9-7**]: failed PS trail. changed micafungin to fluc per cx results. stopped esmolol gtt, change to PO metop, kept PO amio. weaning neo. New pneumomediatinum seen on CXR. neg 3L/24h [**2113-9-8**]: lasix 20 [**Hospital1 **] [**2113-9-9**]: lasix 20 daily, switched midaz to haldol, family meeting [**2113-9-10**]: remained in NSR, went back onto versed, remained in NSR, did not require pressors [**2113-9-11**]: hypotension to 80s/40s, family declined pressor use, used IVF to return BP to normal range [**2113-9-12**]: Seen by palliative care, plan for family meeting [**2113-9-13**]: hypotensive, well controlled with IVF boluses as needed [**2113-9-14**]: Family does no want to make patient CMO but does not want to escalate care [**2113-9-15**]: increased output from split fistula, hypotensive to 72/45, given albumin and 1 L LR and fentanyl drip was decreased to 100, pressure was restored to normal range. Family made patient CMO, patient removed from vent, went into respiratory arrest, then cardiac arrest, then brain death. Medications on Admission: ASA 325 mg PO daily, Plavix 75 mg PO daily, Digoxin 0.25 mg Q6PM, Diltiazem 60 mg PO QID, Fentanyl 25 mcg, Ferrous sulfate 324 mg PO daily, Folic acid 1 mg PO daily, Gabapentin 600 mg PO daily, Magnesium oxide 400 mg PO daily, Metoclopramide 10 mg PO QAS, Metoprolol 25 mg PO daily, Omeprezole 20 mg PO BID, Oxycodone 15 mg PO Q12, Potassium chloride 40 mEq PO daily, Prednisone 20 mg PO QAM, Prochlorperazine 10 mg PO Q4, TPN Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: esophageal cancer, severe pneumonia, fistula from bronchus intermedius to neoesophagus through gastric conduit, SBO Discharge Condition: expired, respiratory and cardiac arrest, brain death Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2113-9-16**]

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icd9cm

[ [ [] ] ]

[ "43.89", "38.91", "96.6", "43.19", "46.39", "31.1", "96.72", "38.93", "42.11", "34.04", "33.24", "96.05", "33.42", "33.22", "99.15" ]

icd9pcs

[ [ [] ] ]

17827, 17836

14768, 17322

375, 884

17996, 18051

4957, 14745

18103, 18138

2770, 2815

17799, 17804

17857, 17975

17348, 17776

18075, 18080

2830, 4938

282, 337

913, 2290

2312, 2566

2582, 2754

616

101,515

7423

Discharge summary

report

Admission Date: [**2101-4-11**] Discharge Date: [**2101-4-17**] Date of Birth: [**2064-10-2**] Sex: M Service: [**Company 191**] CHIEF COMPLAINT: Fever and nausea. HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old male with human immunodeficiency virus who developed fever and nausea several days prior to admission. He denied any cough, abdominal pain, or diarrhea. He reports bouts of nausea and vomiting. Per the patient's partner, the patient will approximately four day prior to admission. He felt better the following, but then two days two days prior to admission had chills and "seemed off." He did not see Mr. [**Known lastname 27239**] until the morning of admission when Mr. [**Known lastname 27239**] seemed confused and was "talking gibberish." He was complaining of dizziness as well. Of note, two weeks prior to admission the patient was seen in the Emergency Room for rectal trauma related to anal intercourse and placed on ciprofloxacin. In the Emergency Department, the patient was given 2 g of ceftriaxone to cover for meningitis and a lumbar puncture was performed. PAST MEDICAL HISTORY: 1. Human immunodeficiency virus; with most recent CD4 count of 577 and undetectable viral load. 2. Hepatitis B with hepatitis B surface antigen positive. 3. History of syphilis; treated with penicillin in the past. 4. Irritable bowel syndrome. 5. History of perirectal abscess. MEDICATIONS ON ADMISSION: (Medications on admission included) 1. Trizivir 300/150 mg one tablet by mouth twice a day. 2. Ciprofloxacin 500 mg one tablet by mouth twice a day. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient lives at home with his male roommate. He occasionally smokes cigarettes. He denies any intravenous drugs or other drug use. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 100.9 to 101.7, heart rate was 90 to 100s, blood pressure was 130s to 150s/70s, saturating 95% on room air. In general, the patient was alert, pleasant, confused with word switching. Head, eyes, ears, nose, and throat showed sclerae were anicteric. The fundi was without palpal edema, exudate, or hemorrhage. The oropharynx was clear. The neck was supple. Kernig sign was negative. The lungs were clear to auscultation bilaterally. The heart had a regular rate and rhythm. Normal first heart sound and second heart sound. No murmurs. The abdomen was soft, nontender, and nondistended, with normal active bowel sounds. Extremities were without edema. Neurologically, the patient was alert. His speech showed multiple word-finding difficulties and switching words. Sounds like "gibberish" at times. He had normal muscle bulk. Strength was [**4-10**] in both the upper and lower extremities. Finger-to-nose was slow but normal. The toes were downgoing bilaterally. Cranial nerves II through XII were intact. PERTINENT LABORATORY DATA ON PRESENTATION: Sodium was 139, potassium was 4, chloride was 105, bicarbonate was 23, blood urea nitrogen was 15, creatinine was 1.1, blood glucose was 129. ALT was 11, AST was 15, alkaline phosphatase was 77, total bilirubin was 0.7, albumin was 4.4. White blood cell count was 4.5 (with 57% neutrophils, 28% lymphocytes, 7% monocytes, and 8% atypical cells), hematocrit was 42.1, with a mean cell volume of 104, platelets were 159. Lumbar puncture results showed the white count in tube #1 to be 81 with 24 red blood cells. In tube #4 the white count was 141 with 6 red blood cells, protein was 153, glucose was 69, and the Gram stain was pending. RADIOLOGY/IMAGING: A head CT showed no bleed and no midline shift. A KUB showed no free air. There was gas and stool throughout the colon. A chest x-ray showed a heart size within normal limits. There was no pneumonia, infiltrates, or effusions. ASSESSMENT AND PLAN: In summary, the patient is a 36-year-old male with human immunodeficiency virus presenting with fever and altered mental status. At the time of admission, the working differential diagnosis included meningitis, central nervous system inflammatory state, and vasculitis. HOSPITAL COURSE: The patient was admitted to the Medicine Service for further workup. The lumbar puncture results obtained at the time of admission eventually came back showing a Gram stain which showed no polys and no organisms. It was felt the findings were most consistent with viral meningitis; although, the patient was initially covered with vancomycin, ceftriaxone, and acyclovir pending culture results. Over the first 24 hours the patient had improvement of his mental status until early on [**4-13**], in the morning, when he had a seizure. His seizure was broken with Haldol and Ativan. Per Neurology recommendations, the patient was loaded on Dilantin and transferred to the Medical Intensive Care Unit for close observation. In the Intensive Care Unit, the patient was intubated for airway protection while a magnetic resonance imaging was performed. The magnetic resonance imaging was negative for any masses, hemorrhage, or meningeal enhancement. There was subtle increased T2 signal in the left semiovale felt to be consistent with his human immunodeficiency virus status. The magnetic resonance angiography was also negative. The patient was continued on acyclovir for a question of herpes simplex virus and doxycycline pending ehrlichiosis titers. An electroencephalogram was performed which was consistent with widespread encephalopathy. The patient stabilized and was quickly extubated. The Dilantin was then held in absence of any seizure focus on the electroencephalogram or recurrent seizures. Ceftriaxone, doxycycline, acyclovir were continued. Highly active antiretroviral therapy was held, per Infectious Disease recommendation. The patient was recatheterized in order to allow a cerebrospinal fluid to be sent off for all appropriate viral cultures, as the initial amount of cerebrospinal fluid was not sufficient. On [**4-15**], the patient was complaining of left shoulder pain and was found to have a left dislocated shoulder with fracture of the proximal humerus, felt to be secondary to the seizure episode. It was reduced by the Orthopaedic Service on [**4-15**]. The patient was transferred out from the Intensive Care Unit to the General Medicine Service on [**2101-4-15**]. NOTE: The rest of this Discharge Summary will be continued in system format. 1. INFECTIOUS DISEASE: The patient was closely followed by the Infectious Disease Service during this hospitalization given his human immunodeficiency virus disease. He was felt to have a viral meningitis; although, cultures never elucidated the exact cause of his meningitis. On [**2101-4-15**], ceftriaxone was stopped as there was a very low likelihood of bacterial meningitis. The patient was continued on acyclovir, despite the fact that his herpes simplex virus PCR eventually came back negative, as it was felt that there was not a sufficient sample to be sure that it was true result. In addition, a repeat fluid sent four days after treatment had begun was also felt not to be able to be trusted given that the patient was already on antiviral therapy. The patient continued to improve from an Infectious Disease standpoint after being transferred out to the general medical floor and remained afebrile with a normal mental status. A peripherally inserted central catheter line was placed on [**2101-4-15**] in order to continue with intravenous antibiotics at home. The patient's antiretrovirals were discontinued on [**2101-4-13**]; per the recommendations of the Infectious Disease team. The patient was to follow up the day following discharge to discuss with his primary Infectious Disease doctor (Dr. [**Last Name (STitle) 2148**] about restarting his antiretroviral therapy. 2. NEUROLOGY: The patient had no further seizures following the one prior to admission to the Medical Intensive Care Unit. Antiepileptic drugs were discontinued when he was transferred out the general medical floor, and the patient had no further seizure events. 3. MUSCULOSKELETAL: As previously stated, the patient suffered a left shoulder fracture/dislocation which was successfully reduced by the Orthopaedic team. The patient's arm was placed in a sling, and the patient was to follow up with Orthopaedics in 7 to 10 days until further followup. DISCHARGE DIAGNOSES: 1. Human immunodeficiency virus. 2. Viral meningeal encephalitis. 3. Left shoulder fracture/dislocation. 4. Thrush. MEDICATIONS ON DISCHARGE: 1. Acyclovir 700 mg intravenously q.8h. (times 14 days). 2. Doxycycline 100 mg p.o. b.i.d. (times 7 days). 3. Tylenol 650 mg p.o. q.6-8h. as needed. 4. Dulcolax one tablet p.o. b.i.d. as needed. 5. Nystatin swish-and-swallow 5 cc p.o. q.i.d. 6. Colace 100 mg p.o. b.i.d. 7. Percocet one to two tablets p.o. q.4-6h. as needed. 8. Trizivir one tablet p.o. b.i.d. (to begin after the patient follows up with Dr. [**Last Name (STitle) 2148**]. DISCHARGE FOLLOWUP: 1. The patient was to see Dr. [**Last Name (STitle) 2148**] in one to two weeks. 2. The patient was also to follow up in the [**Hospital 9696**] Clinic in 7 to 10 days. 3. He was to speak with Dr. [**Last Name (STitle) 2148**] the day following discharge in order to determine when to restart his Trizivir. Dictated By:[**Last Name (NamePattern1) 6859**] MEDQUIST36 D: [**2101-8-9**] 11:24 T: [**2101-8-15**] 00:41 JOB#: [**Job Number 27240**]

[ "780.39", "V08", "276.5", "812.00", "083.9", "070.32", "054.3", "831.00", "047.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "79.71", "03.31", "96.04" ]

icd9pcs

[ [ [] ] ]

8421, 8542

8568, 9017

1455, 1661

4146, 8400

164, 183

9037, 9497

212, 1122

1144, 1428

1678, 4127

66,555

124,440

14931

Discharge summary

report

Admission Date: [**2111-3-19**] Discharge Date: [**2111-3-27**] Date of Birth: [**2040-2-25**] Sex: M Service: UROLOGY Allergies: Iodine; Iodine Containing / Percocet / Hydroxychloroquine Attending:[**First Name3 (LF) 5272**] Chief Complaint: Left staghorn calculus Major Surgical or Invasive Procedure: 1. Left percutaneous nephrolithotomy - [**2111-3-19**] - Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 770**] 2. Selective angiography and embolization of bleeding renal vessels - [**2111-3-19**] - interventional radiology 3. Left antegrade nephrostogram - [**2111-3-23**] - interventional radiology 4. Downsizing of left percutaneous nephrostomy tube - [**2111-3-24**] - interventional radiology History of Present Illness: 70 M with a left staghorn calculus s/p an attempted left stent placement on [**2111-1-23**] in which a large amount of pus was encountered intraoperatively. The stent was aborted and the patient was sent to receive a percutaneous nephrostomy tube. He presents now for definitive treatment of his stone with PCNL. Past Medical History: PMH- liver dz --- PSH- knee, hernia, megaureter taper and reimplant Physical Exam: Sitting in bed comfortably, NAD Borderline tachy, regular CTAB Abd obese, S, NT, ND Percutaneous nephrostomy tubes x 2 capped. Urine clear yellow Pertinent Results: [**2111-3-24**] 07:00PM BLOOD WBC-9.6 RBC-2.91* Hgb-9.2* Hct-26.7* MCV-92 MCH-31.5 MCHC-34.4 RDW-15.2 Plt Ct-181 [**2111-3-24**] 07:05AM BLOOD Glucose-156* UreaN-27* Creat-1.3* Na-133 K-4.8 Cl-98 HCO3-29 AnGap-11 Brief Hospital Course: The patient was admitted to the Urology service after undergoing Left percutaneous nephrolithotomy. Please see the dictated operative note for details of the procedure. While in the post-anesthesia care unit, the drainage from the larger L PCN that was used during the procedure was draining fruit punch-colored urine with normal saline flowing through the smaller L PCN (patient had two sites of access in the left kidney). However, the drainage from the larger L PCN became suddenly more sanguinous and began extruding frank blood. The pt c/o dizziness, lightheadedness, and nausea. He was placed in trendelenburg position and was stabilized. Four units of emergency release pRBCs were transfused, and interventional radiology was consulted for angiography and possible embolization of potentially bleeding vessels. The patient remained hemodynamically stable, although he did have three hypotensive/pre-syncopal episodes while in the PACU. The patient underwent selective angiography and embolization of some bleeding arterioles in his L kidney, and was transferred to the [**Hospital Ward Name 332**] ICU post-procedurally. He received a total of six units of pRBCs during his hospitalization. On POD 2, his urine was clear, and he was transferred to the floor on a renacidin gtt to help clear out any residual stone fragments. The renacidin gtt was stopped in the evening of POD 3, and on POD 4 the pt underwent a L antegrade nephrostogram, which verified the correct positioning of his two L PCNs and verified flow down the L ureter and drainage of urine/contrast into the urinary bladder. there was mild stenosis in the distal ureter, but contrast did flow past the stricture. Both PCNs were then capped. His foley catheter was removed, and the pt voided clear yellow urine without difficulty. On POD 5, he again went to the IR suite for removal of his large 22 Fr council tip foley percutaneous nephrostomy tube. Slow venous bleeding was noted from the site of the tube, and a downsized percutaneous nephrostomy tube was placed through the access site to maintain access and hemostasis. On POD 7, the pt noted generalized discomfort that was relieved by opening his PCN to gravity drainage. He was transfused 2u pRBC for a hct of 24. He was discharged on POD 8 in stable condition, ambulating, and with pain controlled by PO pain meds on a regular diet. He will follow up with interventional radiology for PCN removal. Medications on Admission: 1. Simvastatin 20 mg PO daily 2. Lisinopril 10 mg PO daily 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. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Left staghorn calculus, left renal hemorrhage Discharge Condition: Stable Discharge Instructions: -You may shower but do not bathe, swim or immerse your incision. -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids. -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up. -Do not drive or drink alcohol while taking narcotics. -Resume all of your home medications, except hold NSAID (aspirin, advil, motrin, ibuprofin) until you see your urologist in follow-up. -Call your Urologist's office today to schedule a follow-up appointment in 3 weeks AND if you have any questions. -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest ER. Call Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 770**] to set up a follow-up appointment. Followup Instructions: Call Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 770**] to set up a follow-up appointment. Please also follow-up with interventional radiology ([**Telephone/Fax (1) 18969**] for nephrostomy tube removal Completed by:[**2111-3-27**]

[ "458.29", "998.11", "593.3", "592.0", "272.4", "426.3", "571.5", "285.1", "276.7", "276.1", "E878.8", "585.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.79", "87.75", "55.04", "88.45", "55.93" ]

icd9pcs

[ [ [] ] ]

4500, 4549

1616, 4064

340, 763

4639, 4648

1379, 1593

5528, 5787

4173, 4477

4570, 4618

4090, 4150

4672, 5505

1213, 1360

278, 302

791, 1107

1129, 1198

83,210

176,736

3595+55488

Discharge summary

report+addendum

Admission Date: [**2187-3-19**] Discharge Date: [**2187-3-31**] Date of Birth: [**2117-6-1**] Sex: M Service: ORTHOPAEDICS Allergies: Dilantin Kapseal Attending:[**First Name3 (LF) 11415**] Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: ORIF Right Anterior Column Fracture History of Present Illness: 69yom w/ETOH, chronic SDH and mult falls transferred from OSH after admission 4d prior for unwitnessed fall, sent to MICU for profound hypokalemia and ETOH withdrawal. c/o hip pain, found to have mult pelvic fx's. Transferred for ortho trauma higher level of care. Past Medical History: Medical Hx: EtOH Abuse c/b withdrawal seizures, Thrombocytopenia, Acne rosacea, Adenomatous polyps Surgical Hx: L hip replacement; Right inguinal hernia repair ([**10-27**], [**Doctor Last Name 519**]); appendectomy; Exploratory laparotomy, Lysis of adhesions, Small bowel resection; R cataract extraction ([**4-2**], Turon); Polypectomy Social History: Social Hx: has a girlfriend, has been at rehab facility after leg surgery. Patient has a daughter and sister who are involved with his care. History of ETOH abuse. Family History: NC Physical Exam: Admission Examination: PE: VSS, NAD, AOx3 BUE skin clean and intact No tenderness, deformity, erythema, edema, induration or ecchymosis Arms and forearms are soft No pain with passive motion R M U [**Month/Year (2) 2189**] EPL FPL EIP EDC FDP FDI fire 2+ radial pulses BLE skin clean and intact No tenderness, deformity, erythema, edema, induration or ecchymosis + pain with lateral compression of pelvis Thighs and legs are soft No pain with passive motion Saph Sural DPN SPN MPN LPN [**First Name9 (NamePattern2) 2189**] [**Last Name (un) 938**] FHL GS TA PP Fire 1+ PT and DP pulses Contralateral extremity examined with good range of motion, SILT, motors intact and no pain or edema Pertinent Results: [**2187-3-19**] 09:45PM GLUCOSE-96 UREA N-16 CREAT-0.8 SODIUM-136 POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-32 ANION GAP-11 [**2187-3-19**] 09:45PM estGFR-Using this [**2187-3-19**] 09:45PM CALCIUM-8.4 PHOSPHATE-3.2 MAGNESIUM-2.2 [**2187-3-19**] 09:45PM WBC-3.2* RBC-3.12* HGB-10.0* HCT-32.3* MCV-104*# MCH-32.2* MCHC-31.1# RDW-14.8 [**2187-3-19**] 09:45PM PLT COUNT-84* [**2187-3-19**] 09:45PM PT-12.2 PTT-22.6* INR(PT)-1.1 Brief Hospital Course: The patient was admitted to the Orthopaedic Trauma Service for repair of his right pelvic fracture. The patient was taken to the OR and underwent a complicated open reduction and internal fixation. Patient had extensive blood loss requiring 2 units of PRBCs during the surgery, in addition to FFP. The patient, however, tolerated the procedure without complications and was transferred to the PACU in stable condition, still intubated. He was extubated later on post-operative day zero without difficulty. Please see operative report for details. Post operatively pain was controlled with a PCA with a transition to PO pain meds once tolerating POs. On Post-operative day 1, patient's mental status deteriorated and patient became increasingly hypotensive despite 2 more units of PRBCs and fluid boluses. Patient underwent a head CT which showed a stable chronic subdural hematoma. His neurological exam improved, but later on POD1, he again became hypotensive. Repeat Hct showed decline and an abdominal CTA showed patient's pelvic hematoma increased in size with arterial bleeding. Patient was transferred to the surgical ICU and sent to Interventional Radiology for embolization of his right iliac vessels. Patient tolerated this procedure well and was transferred back to the SICU. Patient was weaned off of his sedation and extubated. Repeat hematocrit showed patient to have stabilized. Patient was transferred out of the SICU on Post-operative day 5 with stable hematocrit. He continued to require oxygen thought to be secondary to all of the blood products he recieved. He continued on his home lasix dose and was slowly diuresed. The patient had trouble swallowing with concern for aspiration. He was evaluated by the speech and swallow service who thought that patient was unsafe to take nutrition by mouth at this time. An NGT was inserted and patient began receiving tube feeding while in the ICU. On POD6, patient was re-evaluated by speech and swallow, and again was determined to be of great aspiration risk. He underwent a video assisted swallow study on POD7, at which point it was determined that he was not safe to take anything by mouth. Please see speech and swallow evaluation for further information. A Dobhoff NGT was placed on POD7 that patient tolerated well. A chest x-ray was done that showed that tube needed advancement. Tube was advanced an additional 5 cm to be in correct position. He will continue to get tube feeding per nutrition recommendations until he can be reassessed. Patient made steady progress with PT. Weight bearing status: touch-down weight bearing right lower extremity. The patient received peri-operative antibiotics as well as Lovenox for DVT prophylaxis. The incision was clean, dry, and intact without evidence of erythema or drainage; and the extremity was NVI distally throughout. The patient was discharged in stable condition with written instructions concerning precautionary instructions and the appropriate follow-up care. The patient will be continued on chemical DVT prophylaxis for 4 weeks post-operatively. All questions were answered prior to discharge and the patient expressed readiness for discharge. Medications on Admission: Keppra, Folic Acid, MVI, Thiamine, Metolazone, Lasix, Albuterol IH Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 3. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Syringe Subcutaneous QPM (once a day (in the evening)). 9. ipratropium bromide 0.02 % Solution Sig: One (1) Nebulizer Inhalation Q6H (every 6 hours). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Nebulizer Inhalation Q6H (every 6 hours) as needed for wheezing. 11. oxycodone 5 mg Tablet Sig: [**12-25**] to 2 Tablet PO Q3H (every 3 hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*0* 12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Right anterior column fracture 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: ******SIGNS OF INFECTION********** should experience severe pain, increased swelling, decreased sensation, difficulty with movement; fevers >101.5, chills, redness or drainage at the incision site; chest pain, shortness of breath or any other concerns. -Wound Care: You can get the wound wet/take a shower starting from 3 days post-op. No baths or swimming for at least 4 weeks. Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. No dressing is needed if wound continued to be non-draining. ******WEIGHT-BEARING******* ******MEDICATIONS*********** - Resume your pre-hospital medications. - You have been given medication for your pain control. Please do not operate heavy machinery or drink alcohol when taking this medication. As your pain improves please decrease the amount of pain medication. This medication can cause constipation, so you should drink 8-8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. -Medication refills cannot be written after 12 noon on Fridays. *****ANTICOAGULATION****** - Take Lovenox for DVT prophylaxis for 4 weeks post-operatively Followup Instructions: Please have your staples removed at your rehabilitation facility at post-operative day 14. Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks for evaluation. Call [**Telephone/Fax (1) 1228**] to schedule appointment upon discharge. Please follow up with your PCP regarding this admission and any new medications/refills. You will need a repeat speech and swallow video swallow study performed in approximately one week to reassess your ability to swallow. At that time the determination will need to be made whether or not you will be able to have your diet advanced. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**] Name: [**Known lastname 2575**],[**Known firstname **] Unit No: [**Numeric Identifier 2576**] Admission Date: [**2187-3-19**] Discharge Date: [**2187-3-31**] Date of Birth: [**2117-6-1**] Sex: M Service: MEDICINE Allergies: Dilantin Kapseal Attending:[**Doctor First Name 376**] Addendum: This is an addendum to a finalized Ortho D/C summary. Pertinent Results: Updated Lab Results ([**2187-3-28**] - [**2187-3-31**]): CBC: [**2187-3-28**] 05:28AM BLOOD WBC-6.2 RBC-2.84* Hgb-9.1* Hct-28.9* MCV-102* MCH-32.1* MCHC-31.6 RDW-17.6* Plt Ct-69* [**2187-3-29**] 05:28AM BLOOD WBC-3.7* RBC-2.89* Hgb-9.2* Hct-29.5* MCV-102* MCH-31.8 MCHC-31.2 RDW-17.4* Plt Ct-73* [**2187-3-30**] 05:07AM BLOOD WBC-3.3* RBC-2.84* Hgb-9.0* Hct-28.3* MCV-100* MCH-31.8 MCHC-31.9 RDW-16.3* Plt Ct-67* [**2187-3-31**] 06:10AM BLOOD WBC-3.2* RBC-3.02* Hgb-9.6* Hct-30.7* MCV-102* MCH-31.8 MCHC-31.3 RDW-16.7* Plt Ct-84* Coags: [**2187-3-28**] 01:00PM BLOOD PT-13.7* PTT-28.6 INR(PT)-1.3* [**2187-3-29**] 05:28AM BLOOD PT-14.1* PTT-28.5 INR(PT)-1.3* [**2187-3-29**] 05:28AM BLOOD Plt Ct-73* [**2187-3-30**] 05:07AM BLOOD PT-13.4* PTT-28.7 INR(PT)-1.2* [**2187-3-30**] 05:07AM BLOOD Plt Ct-67* [**2187-3-31**] 06:10AM BLOOD PT-12.4 PTT-28.7 INR(PT)-1.1 Lytes: [**2187-3-28**] 05:28AM BLOOD Glucose-116* UreaN-19 Creat-0.7 Na-146* K-3.3 Cl-106 HCO3-34* AnGap-9 [**2187-3-29**] 05:28AM BLOOD Glucose-92 UreaN-20 Creat-0.7 Na-146* K-3.6 Cl-108 HCO3-32 AnGap-10 [**2187-3-30**] 05:07AM BLOOD Glucose-93 UreaN-17 Creat-0.7 Na-139 K-3.5 Cl-103 HCO3-28 AnGap-12 [**2187-3-31**] 06:10AM BLOOD Glucose-92 UreaN-16 Creat-0.6 Na-138 K-3.3 Cl-102 HCO3-28 AnGap-11 LFTS: [**2187-3-29**] 05:28AM BLOOD ALT-103* AST-68* AlkPhos-134* TotBili-2.6* [**2187-3-30**] 05:07AM BLOOD ALT-82* AST-55* LD(LDH)-375* AlkPhos-144* Amylase-44 TotBili-2.4* DirBili-1.0* IndBili-1.4 [**2187-3-31**] 06:10AM BLOOD ALT-72* AST-55* AlkPhos-167* TotBili-2.2* [**2187-3-28**] 05:28AM BLOOD Phos-3.3 Mg-2.0 Lytes: [**2187-3-29**] 05:28AM BLOOD Albumin-2.9* Calcium-8.1* Phos-3.2 Mg-1.9 [**2187-3-30**] 05:07AM BLOOD Albumin-2.9* Calcium-7.9* Phos-2.9 Mg-2.0 [**2187-3-31**] 06:10AM BLOOD Albumin-2.9* Calcium-7.9* Phos-2.6* Mg-1.8 Brief Hospital Course: Patient was transferred to medical service on [**2187-3-28**] for evaluation of delirium. Head CT with no acute findings. Patient found to have UTI and his mental status improved with treament. Final sensativities showed the organism was sensative to bactrim and not ciprofloxacin so the antibiotics were changed on [**3-30**] and a 7 day treatment course should be continued until [**2187-4-6**]. He was also noted to have a transaminase and bilirubin elevation on [**2187-3-29**] and underwent a RUQ U/S which showed cholelithiasis without cholecystitis. ALT/AST/Tbili trended down over next 2 days, although Alk Phos remained very mildly elevated. Mr. [**Known lastname **] has had a similar situation happen in the past which was previously noted to somewhat normalize. Most likely this was either drug induced or his common bile duct was transiently obstructed with a gallstone which he then passed. Previously during the hospitalization he had failed a bedside and video speech and swallow study while delerious. When his delerium cleared a repeat speech and swallow study evaluated him and he pased with some difficulty. They cleared him for mechanical ground and nectar thick with all crushed meds. [ ] He will need f/u LFTs and CBC on [**2187-4-6**] to make sure his LFTs and CBC were not worsened by the addition of bactrim. Discharge Medications: Updated Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 7. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Syringe Subcutaneous QPM (once a day (in the evening)) for 3 months. Disp:*1 Syringe* Refills:*11* 8. oxycodone 5 mg Tablet Sig: [**12-25**] Tablet PO every eight (8) hours as needed for pain. Disp:*21 Tablet(s)* Refills:*0* 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. potassium chloride 20 mEq Packet Sig: One (1) PO once a day. 13. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 6 days. Disp:*12 Tablet(s)* Refills:*0* 15. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 16. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 inh* Refills:*3* Discharge Disposition: Extended Care Facility: [**Hospital3 2215**] - [**Location (un) 42**] Discharge Diagnosis: Primary: Right anterior column fracture Secondary: Urinary Tract infection Delerium Discharge Condition: Mental Status: Clear although intermittently confused about facts. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory Touch-down weight bearing right lower extremity. Supervised activity. - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure participating in your care at [**Hospital1 8**]. You were admitted to the hospital for repair of a hip fracture. This was done and you were also treated for a urinary tract infection. The [**Hospital1 8**] speech and swallow team evaluated you and felt it was safe for you to attempt eating and drinking on a restricted diet with all medications being crushed. You were discharge to a rehab facility for further rehabilitation. REGARDING YOUR MEDICATIONS... Medications STARTED that you should continue: - Enoxaparin 40mcg injections daily ongoing for DVT prophylaxis for 4 weeks after your surgery - stop on [**2187-4-24**] - Start Ipratropium bromide inhaler every 6 hrs as needed for wheezing or shortness of breath - Start bisacodyl 5mg tabs, 2 tabs every evening as needed for constipation - start oxycodone 2.5mg every 4-6hrs as needed for pain - start calcium carbonate 500mg twice each day - start Sulfamethoxazole/Trimethoprim (Bactrim) 1 double strength tab twice each day for 6 more days (last day [**2187-4-5**]) Medications STOPPED this admission: None Medication DOSES CHANGED that you should follow: - Increase Thiamine to 100mg by mouth daily from 50mg daily Otherwise, it is very important that you take all of your usual home medications as directed in your discharge paperwork. ******SIGNS OF INFECTION********** Please return to the emergency department or notify MD if you should experience severe pain, increased swelling, decreased sensation, difficulty with movement; fevers >101.5, chills, redness or drainage at the incision site; chest pain, shortness of breath or any other concerns. -Wound Care: You can get the wound wet/take a shower starting from 3 days post-op. No baths or swimming for at least 4 weeks. No dressing is needed if wound continued to be non-draining. ******WEIGHT-BEARING******* Touch down weight bearing right lower extremity ******MEDICATIONS*********** - Resume your pre-hospital medications. - You have been given medication for your pain control. Please do not operate heavy machinery or drink alcohol when taking this medication. As your pain improves please decrease the amount of pain medication. This medication can cause constipation, so you should drink 8-8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. -Medication refills cannot be written after 12 noon on Fridays. *****ANTICOAGULATION****** - Take Lovenox for DVT prophylaxis for 4 weeks post-operatively. Followup Instructions: Please have your staples removed at your rehabilitation facility at post-operative day 14 (surgery was [**2187-3-21**] so removal on [**2187-4-4**]). Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2577**] in 2 weeks for evaluation. Call [**Telephone/Fax (1) 809**] to schedule appointment upon discharge. After discharge from rehab, please follow up with your PCP regarding this admission and any new medications/refills. [**Name6 (MD) **] [**Last Name (NamePattern4) 377**] MD [**MD Number(2) 378**] Completed by:[**2187-4-1**]

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icd9cm

[ [ [] ] ]

[ "39.79", "88.49", "88.42", "99.29", "79.39", "96.6", "88.47" ]

icd9pcs

[ [ [] ] ]

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45,601

180,922

45444

Discharge summary

report

Admission Date: [**2106-5-12**] Discharge Date: [**2106-5-31**] Date of Birth: [**2025-2-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Nsaids / Percocet / Verapamil / Neurontin / Ultram / Mysoline / [**Doctor First Name **] / Codeine / Darvon Attending:[**First Name3 (LF) 9002**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: cardioversion, defibrillation History of Present Illness: 81 yo F with a history of CHF (EF 30%), afib on coumadin, s/p CABG presents with dyspnea. Last night she began feeling chest pain that felt "like a [**Doctor Last Name **] in my chest" and noticed her heart beating quickly. She felt short of breath, weak, nauseaous, with abdominal pain and "like I was dying". The chest pain and SOB continued overnight, but the patient is unclear when it started; she states she has had chest pain at baseline for months. The pt's nurse called her in the morning to check in and decided to call 911. EMS found pt hypotensive, with pulse in 170s, gave pt 150mg amiodarone and aspirin in the field. . In ED, initial vital signs were: 98.8 61/39, 168, 23, 100% on NRB. In ED appeared uncomfortable, minimally tender in the epigastrium, found to have maroon guaiac positive stools, 2+ non-pitting edema bilaterally. On EKG appeared to be in aflutter, given midazolam, cardioverted with 100J initially, then appeared to go into VTACH, defibrillated with 200J, converted to NSR. Labs significant for hypoperfusion, CXR appears to be c/w CHF, pulmonary edema. CTAb showed equivocal colitis. Covered with vanco/flagyl, got levoflox then developed a rash so levoflox was stopped. Got 150mg IV amiodarone after cardioversion, now on amiodarone gtt. Surgery consult for increased lactate. Cardiology, EP looked at EKG, rhythm strip, no reccommendations. On transfer, VS were 102/49, P 60, 19, 100% 3.5L. Now has 2 PIVs. Had gotten 1750 cc IVF, 200 cc in foley, prior to transfer. . On the floor, vitals HR 56, BP 86/47, SpO2 99% on 2L NC. Pt felt tired and had some continued chest pain. On ROS, the patient denied fever, cough, vomiting, melena, blood in stools. She did endorse weight loss over the past few months, anorexia X months, chronic LE edema, constipation (no BM X 5-6 days), a history of diarrhea with abdominal pain (unclear time course), and a feeling of increased pressure in her head. Most recent weights in clinic about 145 lb. In clinic [**4-29**] c/o decreased urination, not found to be volume overloaded on exam, BP 80/40 (near baseline per note). Was found to have elevated Cr and K from [**4-29**] labs, refused medical intervention and so was treated with stopping ACE-I and spironolactone and took kayexalate. . Pt had extensive discussion concerning code status with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] (see note in OMR). Briefly, pt has been DNR/DNI for years and expressed wish to be dead, wants to pass in her sleep. She clearly does not want any futile aggressive interventions (e.g. long term supportive care, or intervention if she is "very sick") but is equivocal about temporary less aggressive measures; she should remain DNR/DNI per her goals of care. Full ACLS resuscitation with CPR / intubation would not be consistent with her wishes. Past Medical History: #) Coronary artery disease: (followed by Dr. [**Last Name (STitle) **] -- [**1-/2090**] Wide Complex Tacchycardia, ep: inducable sustained monomorphic VT; most of arrythmia felt to be atrial fibrillation. On/off multiple antiarrhythmics. -- [**2-/2090**] Acute Lateral MI ([**Location (un) 7349**]). 100% ramus lesion, EF 45% mod MR, lateral hypokinesis -> treated medically. -- History of CHF ([**2090**]) requiring intubation, found to have found severe MR. -- [**2099**] Nuclear stress test with reversible defect but cath ok. -- [**11/2101**] had MVR (porcine), CABG LIMA-->RAMUS. Some complications including cardiogenic shock, prolonged on pump. -- [**2101**] EF 35-40%, well functinoing mitral valve. -- [**2102**] resumed coumadin, amio discontinued #) Pulmonary: History of COPD, pulmonary hypertension. Stopped smoking [**2091**]. #) Chronic renal insufficiency. Baseline creatinine approx 1.1. #) Left knee Pain, s/p TKR, now functionally impaired with dislocation after replacement. #) History of left hip replacement with revision [**2094**], [**2095**] #) Allergic Rhinitis. On fluticasone, atrovent. #) History of basal cell carcinoma. Lesion removed from nose [**2095**]. #) History of tremor. #) Osteoporosis. History of T6 compression fracture. Fosamax. #) History of headaches. #) History of low back pain. Rx neurontin, prozac. #) GERD. s/p hiatal hernia repair [**2070**]. Barrett's esophagus. #) History of abnormal mammogram, thought not to require biopsy. #) Chronic dizziness. #) History of mild anemia. #) History of TIA with atypical hand numbness. #) History of peripheral edema (presumed venous insufficiency +/- cardiac component) #) History of abnormal LFT's (?amio related) #) History of shoulder pain, moderate-severe OA, history bursitis #) History of hand pain #) Fibromyalgia #) Depression #) DNR/DNI status Social History: She was born in [**Location (un) 84482**], [**Country 3399**]. She denies tobacco (quit at the time of her open bypass surgery), alcohol, and other drugs. She has lived in both [**Country 2559**] and [**Country 6171**] prior to living in the United States ([**2063**]). She speaks several languages. Her medications are delivered to her from a local pharmacy. Family History: non-contributory Physical Exam: GENERAL: Some increased work of breathing. Looks stated age. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Very poor dentition without upper teeth. NECK: Supple with JVP to mandible. CARDIAC: PMI enlarged. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Some kyphosis. Resp were slightly labored, no accessory muscle use. Very poor air entry, with no breath sounds at bases. Wheezes and ronchi above. ABDOMEN: Slightly distended. No HSM. Mildly tender, particularly periumbilically. EXTREMITIES: Very severe lower extremity edema. Cool extremities. SKIN: Mild statis dermatitis, no ulcers, scars, or xanthomas. NEUROLOGIC: Alert and oriented to person and place. CNII - XII intact. Neurologically limited right leg movement since stroke after CABG, pain limited movement of left leg (s/p redone hip and 'dislocated' knee per patient). Pertinent Results: LABS ON ADMISSION: [**2106-5-12**] 11:00AM BLOOD WBC-10.5# RBC-4.18* Hgb-11.3* Hct-36.6 MCV-88 MCH-27.0 MCHC-30.8* RDW-15.2 Plt Ct-248 [**2106-5-12**] 11:00AM BLOOD Neuts-84.6* Lymphs-11.0* Monos-4.1 Eos-0.2 Baso-0.1 [**2106-5-12**] 11:00AM BLOOD PT-34.3* PTT-37.2* INR(PT)-3.5* [**2106-5-12**] 11:00AM BLOOD UreaN-54* Creat-3.2* Na-141 K-3.5 Cl-100 HCO3-15* AnGap-30* [**2106-5-12**] 11:00AM BLOOD ALT-199* AST-219* LD(LDH)-673* CK(CPK)-267* AlkPhos-106* TotBili-1.0 [**2106-5-12**] 11:00AM BLOOD Lipase-66* [**2106-5-12**] 11:00AM BLOOD CK-MB-24* MB Indx-9.0* [**2106-5-12**] 11:00AM BLOOD cTropnT-0.50* [**2106-5-12**] 11:00AM BLOOD Calcium-8.5 Phos-4.5 Mg-2.1 [**2106-5-12**] 05:59PM BLOOD calTIBC-289 Ferritn-1480* TRF-222 [**2106-5-12**] 11:09AM BLOOD Glucose-163* Lactate-7.1* Na-142 K-3.6 Cl-104 calHCO3-15* . IMAGING: . CT ABDOMEN: Metallic clips at the GE junction are again noted with extensive streak artifact which somewhat limits the evaluation of the adjacent anatomy. The non-contrast appearance of the liver is unremarkable. The gallbladder is surgically absent, with clips in the gallbladder fossa. There is dilation of the common bile duct which measures up to 23 mm in diameter, series 301B, image 19, which is increased from previous measurement of 18 mm at a similar level. Possibility of a retained stone cannot be excluded. Correlate clinically and if needed ultrasound may be obtained to further assess. The pancreas is atrophic. The spleen is grossly unremarkable along with both adrenal glands. The kidneys demonstrate no hydronephrosis or stones. The abdominal aorta contains atherosclerotic calcification and appears normal in course and caliber. There is an unremarkable appearance of the stomach and duodenum. . There is a fat-containing umbilical hernia, which appear stable. The hernia also contains a small amount of fluid, though there is no bowel entering the hernia. Haziness is seen along the inferior edge of the liver and along the right paracolic gutter, best seen on series 2, image 29 and 30, which is new and reflect the presence of mild colitis. Small bowel is unremarkable without evidence of ileus or obstruction. PELVIS: There is equivocal thickening along the transverse colon, which may reflect colitis. As mentioned above, there is mild stranding along the hepatic flexure, which could also reflect inflammation. There is no free air or evidence of abscess. Large amount of fecal loading of the rectum is noted. There is no evidence of diverticulitis. The appendix is not definitively identified, though there is no secondary sign of appendicitis. The uterus and adnexa appear unremarkable. Trace free fluid is seen in the deep pelvis. Urinary bladder contains a Foley catheter. Streak artifact from a left hip prosthesis limits evaluation through the pelvis. . BONES: Degenerative changes are noted in the included portion of the thoracolumbar spine with an S-shaped scoliosis. Hardware related to left hip arthroplasty is noted. . IMPRESSION: 1. Mild thickening along the transverse colon with associated stranding in the region of the hepatic flexure may represent colitis. Etiology could be inflammatory, infectious, or ischemic. 2. Post-cholecystectomy with increasing diameter of the common bile duct compared with prior exam. Recommend clinical correlation and if needed ultrasound may be obtained to further assess. 3. Moderate fecal loading of the rectum. 4. Fat and fluid-containing periumbilical hernia, stable. . . TRANSTHORACIC ECHO ([**2106-5-13**]): The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %) with apical akinesis. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] There is no ventricular septal defect. 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. A bioprosthetic mitral valve prosthesis is present. The transmitral gradient is normal for this prosthesis. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [**2105-6-12**], the mitral regurgitation may be increased (may have been underestimated due to shadowing), and the left ventricular ejection fraction is further reduced. . RENAL US: IMPRESSION: 1. No hydronephrosis. 2. Arterial and venous flow identified within the hilum of each kidney, but no further characterization can be made. . Heel x-ray: The patient is status post ORIF of distal fibular fracture, not fully evaluated on these views. Small inferior calcaneal spur is present. No fracture or dislocation is detected on the available views. No focal lytic or sclerotic lesion is identified. Brief Hospital Course: 81 y/o female with coronary artery disease, s/p CABG/MVR, atrial fibrillation on coumadin, CHF (EF 30%), COPD, and chronic renal insufficiency, admitted with dyspnea, found to have wide complex tachycardia s/p DCCV and amiodarone complicated by development of a different wide complex tachycardia for which she was defibrillated, subsequently transferred to CCU for volume overload/diuresis, now s/p -7L diuresis, with hospital course complicated by infection/septic shock. . INITIAL MEDICAL FLOOR COURSE: . # HYPOTENSION: most likely developed cardiogenic shock in the setting of tachyarrhythmia, however there also may be component of hypovolemia, given dehydration and nausea. She was given gentle IVF boluses to maintain good urine output. There was also some concern for a distributive process with elevated white count with evidence of colitis on imaging so she was started on broad spectrum antibiotics (Vanc, flagyl, ceftriaxone), which were discontinued when infectious etiology was felt to be unlikely. . # TACHYARRHYTHMIA: It was felt that she most likely was in SVT with aberrancy on initial presentation to the Emergency Department. When cardioversion was attempted she developed a wide complex tachycardia consistent with ventricular tachycardia, which broke with DCCV. She was started on an amiodarone drip. The cardiology service was consulted. Amiodarone was transitioned to PO on HD #2. . # COLITIS: Patient complained of abdominal pain, benign exam but questionable colitis on imaging. The general surgery service was consulted. She had an elevated lactate in the setting of renal failiure and shock, which could be due to ischemic colitis but also could be due to tachyarrhythmia. She was started on broad spectrum antibiotics, which were discontinued when abdominal exam improved and infectious etiology was felt to be unlikely. . # NSTEMI: Elevated cardiac biomarkers with anterior TWI on EKG likely demand ischemia in the setting of tachyarrhythmia. She was monitored on telemetry and continued on aspirin, statin. Etiology not felt to be ACS/UA/plaque rupture. . # sCHF: initially intravascularly volume depleted in the setting of her cardiogenic shock, with elevated lactate and hypotension. Subsequently volume overloaded and was eventually transitioned to CCU for diuresis (see below). Patient felt to be euvolemic (after 7L diuresis in the CCU). . # SUBACUTE RENAL FAILURE: likely from chronic CHF with intravascular depletion. On final days prior to passing away, patient developed ARF likely from infection/septic shock (see below). . # ELEVATED LFTs: Elevated LFTs in the setting of hypotension likely due to shock liver, which improved throughout hospital course. . # OBSTRUCTIVE LUNG DISEASE / ALLERGIC RHINITIS: patient met with the pulmonary team to optimize her regimen. She was started on fluticasone nasal spray as well as fluticasone inhalers. Advair was avoided given the salmeterol component. . # ANXIETY: continued on fluoxetine, and started on low dose ativan prn . CCU COURSE: . Patient was admitted to the CCU for failure to diurese on the cardiology floor on lasix gtt. The patient was started on milrinone, lasix gtt which was discontinued secondary to hypotension. Milrinone was switched to renally dosed dopamine with lasix gtt and metolazone and the patient started to produce urine. Patient's dyspnea and perepheral edema markedly improved and patient was 7 liters net negative during her length of stay in the CCU. The patient was then transitioned to PO torsemide 40mg PO BID plus metolazone 2.5mg PO Daily. . On the medical floor, tosemide was changed to 40 mg daily and metolazone was continued at 2.5 mg daily to maintain euvolemia. . SUBSEQUENT MEDICAL FLOOR COURSE/PALLIATIVE CARE/GOALS OF CARE: . # Infection/hypotension/SIRS/septic shock: on date of anticipated discharge, patient developed likely infection, with high grade fever to 102 degrees. Extensive conversations with patient and family took place, and empiric antibiotics were started. However, over the next 48 hours, patient's clinical course did not improve. No source of organism was identified, as blood culture, urine culture, and CXR were without overt source. Given patient's goals of care and after discussion with family and health care proxy, care was transitioned initially to "do not escalate care" and subsequently "comfort measures" when her condition did not improve. . # GOALS OF CARE: extensive conversations with patient, family, patient's primary care physician and palliative service took place during this admission. Patient was informed that her chronic medical conditions are end stage, including her end stage systolic heart failure. She has also become severely deconditioned after her ICU and subsequent CCU stay. Patient always stated her goals of care to be consistent with do not resuscitate/do not intubate, and subsequently, transitioned her care to do not escalate care, and finally, comfort measures when her clinical course precipitously declined from likely sepsis complicated by her underlying co-morbidities. She passed away with family at bedside on [**2106-5-31**] Medications on Admission: Albuterol Sulfate Atorvastatin [Lipitor] 40 mg DAILY Fluoxetine 40 mg every morning Fluticasone 50 mcg Spray, 2 sprays(s) Fluticasone 220 mcg 2 puffs inhaled twice daily Folic Acid 1 mg Tablet Furosemide [Lasix] 80 mg Tablet 2 Tablet(s) by mouth once daily dose Isosorbide Mononitrate [Imdur] 30 mg Tablet Sustained Release 24 hr Lisinopril 5 mg Tablet (stopped 3/19 per clinic note) Metoprolol Succinate 12.5 NITROGLYCERIN 300 MCG (1/200 GR) TABLET Oxybutynin Chloride 5 mg Tab,Sust Rel Osmotic Push 24hr Sodium Polystyrene Sulfonate [SPS] Spironolactone (stopped 3/19 per clinic note) Trazodone 300 qhs Warfarin 1 mg qd Acetaminophen [Tylenol Extra Strength] Aspirin 81 mg Tablet, Delayed Release (E.C.) COLACE 100MG Capsule Cromolyn 40 mg/mL Spray, Non-Aerosol Cyanocobalamin [Vitamin B-12] [**2096**] mcg Tablet Diphenhydramine HCl [Benadryl] 25 mg Capsule 2 Capsule(s) by mouth daily at bedtime (OTC) [**2104-7-1**] Sennosides [Ex-Lax (Sennosides)] Vitamin A-Vit C-Vit E-Zinc-Cu [Ocuvite PreserVision] Kayexelate per clinic note [**5-5**] Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: PRIMARY: 1. septic shock 2. cardiogenic shock 3. acute on chronic, end stage, systolic heart failure 4. acute renal failure . SECONDARY: 1. atrial fibrillation 2. asthma 3. dilated cardiomyopathy Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2106-5-31**]

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icd9cm

[ [ [] ] ]

[ "99.62", "38.93" ]

icd9pcs

[ [ [] ] ]

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11764, 16889

389, 420

18263, 18272

6553, 6558

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41372

Discharge summary

report

Admission Date: [**2135-1-11**] Discharge Date: [**2135-1-20**] Date of Birth: [**2080-6-21**] Sex: F Service: SURGERY Allergies: Penicillins / Epinephrine / aspirin / Benadryl / grapes / red peppers Attending:[**First Name3 (LF) 2836**] Chief Complaint: Gallstone pancreatitis and cholangitis Major Surgical or Invasive Procedure: [**2135-1-11**]: 1. Laparoscopic converted to open cholecystectomy with common bile duct exploration. 2. Intraoperative cholangiogram and T-tube placement. 3. Liver biopsy. History of Present Illness: The patient is a 54-years-old female with complicated psychiatric history. She has been under the care of Dr. [**Last Name (STitle) **] undergoing multiple ERCP and stent changes with a history of gallstone pancreatitis and cholangitis initially last spring. At that time, she had refused surgical intervention. She did state in [**2134-10-5**] that she would be interested in having her cholecystectomy, and she was then transferred to our service and prepared for surgery, but in the preoperative holding area again changed her mind, and thus was ultimately discharged home as she was no longer willing to undergo an ERCP either. In [**Month (only) 404**] [**2134**], patient returned back to Dr. [**First Name (STitle) **] office to discuss cholecystectomy again. All risks, benefits and possible outcomes were discussed with the patient, and she was scheduled for elective laparoscopic/open cholecystectomy on [**2135-1-11**]. Past Medical History: Fibromyalgia Chronic fatigue syndrome Depression Schizophrenia Gallstone pancreatitis/cholangitis [**3-16**] Cholelithiasis/choledocholithiasis Possible sleep apnea Past Surgical History: laparoscopic exploration Social History: Social History: Lives alone, denies tobacco, EtOH, drugs Family History: NO family history of gallstone disease Physical Exam: On Discharge: VS: 97.6, 87, 136/80, 12, 95% 3L NC GEN: NAD, AAO x 3, somnolent CV: RRR, no m/r/g RESP: Diminished bilaterally on bases R > L ABD: Obese. Right subcostal incision OTA with staples and c/d/i. Right T-tube capped, insertion site with dry dressing and c/d/i. EXTR: Warm, no c/c/e Pertinent Results: [**2135-1-13**] 06:40AM BLOOD WBC-16.4* RBC-3.96* Hgb-12.0 Hct-36.4 MCV-92 MCH-30.2 MCHC-32.9 RDW-13.9 Plt Ct-163 [**2135-1-17**] 03:40PM BLOOD ALT-100* AST-42* AlkPhos-164* TotBili-0.4 [**2135-1-13**] 06:40AM BLOOD Calcium-8.0* Phos-2.0*# Mg-2.6 Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 90063**],[**Known firstname 1521**] [**2080-6-21**] 54 Female [**Numeric Identifier 90064**] [**Numeric Identifier 90065**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 90066**]/mtd SPECIMEN SUBMITTED: Gallbladder, Bile duct stent, Common Duct Stones, Liver biopsy. Procedure date Tissue received Report Date Diagnosed by [**2135-1-11**] [**2135-1-11**] [**2135-1-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mrr?????? ************This report contains an addendum*********** DIAGNOSIS: I. Gallbladder (A): Acute and chronic cholecystitis. II. Bile duct stent: Gross examination performed. III. Common duct stones: Gross examination performed on mixed type calculi. IV. Liver, needle core biopsy (B): A. Severe mixed macro- and microvesicular steatosis with foci suspicious for ballooning degeneration. B. Single focus of portal non-necrotizing granulomatous inflammation; see note. C. Mild portal and lobular mixed inflammation including lymphocytes, eosinophils, and neutrophils. D. Trichrome stain demonstrates increased sinusoidal and portal fibrosis (Stage 2 fibrosis). E. Iron stain shows minimal stainable iron focally in foci of granulomatous inflammation. Note: Overall, the above histologic features in the liver support a chronic, active injury of a toxic/metabolic (fatty liver disease/steatohepatitis) etiology. The additional finding of a well-formed portal non-necrotizing granuloma raises the possibility of a a foreign body reaction (such as to intrahepatic calculi), a granulomatous drug reaction, or if clinically relevant, a systemic granulomatous disease such as sarcoidosis. Special stains to rule out infections with acid fast bacilli and fungal organisms, although uncommon in well-formed, non-necrotizing granulomas, are in progress and will be reported in an addendum. ADDENDUM: Special stains for fungal organisms (GMS) and acid fast bacilli (AFB) are negative with adequate controls. Addendum added by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/rna Date: [**2135-1-15**] Clinical: Cholelithiasis. Brief Hospital Course: The patient was admitted to the General Surgical Service for elective cholecystectomy. On [**2135-1-11**], the patient underwent laparoscopic converted to open cholecystectomy with common bile duct exploration, intraoperative cholangiogram and T-tube placement and liver biopsy, which went well without complication (reader referred to the Operative Note for details). After extubation in the PACU, patient was required 6L of supplemental O2 via face mask. She was monitored overnight in the PACU and was transferred on the floor in satisfactory condition. On the floor patient was NPO, on IV fluids, with a foley catheter, and IV Dilaudid for pain control. The patient was hemodynamically stable. Neuro: The patient has past PMH significant for schizophrenia and depression, her home medications were restarted on POD # 2. The patient more somnolent and less responsive in AMs, but returns to baseline AAO x 3 without difficulties. The patient received IV Dilaudid with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. Prior discharge, oral pain medication was discontinued. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient has a history of questionable sleep apnea. After she was extubated in the PACU, she was required supplemental O2 via face mask. On The floor, patient was continue to receive O2 via nasal cannula. Patient's blood gases revealed chronic hypercarbia, she refused to have CPAP overnight and was recommended to see her PCP to discuss possible OSA after discharge as outpatient. Prior discharge, patient's O2 requirements were weaned off during day time, she still requires 3 L NC overnight. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. Patient had increased LFTs post operatively secondary to liver biopsy. LFTs were monitored post op and LFTs started to downward on POD # 2, T-tube was capped on POD # 5. The foley catheter was discontinued at midnight of POD# 1. The patient subsequently voided without problem. ID: Wound was evaluated daily and no signs and symptoms of infections were noticed prior discharge. Staples will be removed during her follow up appointment with Dr. [**First Name (STitle) **]. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay. Physical and Occupational Therapy evaluated the patient and recommended to discharge her in Rehab. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with assist, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Clozaril 200qHS, Cal/Vit D 500-400', Dulcolax 5 PO prn, Senokot 2'' prn, Tylenol 650'''' prn, Zantac 150'prn Discharge Medications: 1. clozapine 200 mg Tablet Sig: One (1) Tablet PO at bedtime. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for fever or pain. 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 7. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every six (6) hours. 8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - [**Location (un) 14663**] Discharge Diagnosis: 1. Choledocholithiasis 2. Fatty liver disease 3. Acute and chronic cholecystitis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-14**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. . T-drain care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *If the drain is connected to a collection container, please note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Wash the area gently with warm, soapy water or 1/2 strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: Department: SURGICAL SPECIALTIES When: WEDNESDAY [**2135-1-26**] at 2:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 2998**] Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site . Please follow up with Dr. [**Last Name (STitle) 51969**] (PCP) in [**1-7**] weeks after discharge Completed by:[**2135-1-20**]

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icd9cm

[ [ [] ] ]

[ "51.41", "51.22", "50.12", "87.53", "51.98" ]

icd9pcs

[ [ [] ] ]

9055, 9138

4843, 8144

368, 543

9263, 9263

2202, 4820

11427, 11889

1834, 1874

8303, 9032

9159, 9242

8170, 8280

9450, 10031

10046, 11404

1716, 1743

1889, 1889

1903, 2183

290, 330

571, 1505

9278, 9426

1527, 1693

1775, 1818