ChanBeDu/relevant_section_length · Datasets at Hugging Face

55,046

103,032

42844

Discharge summary

report

Admission Date: [**2163-12-6**] Discharge Date: [**2163-12-30**] Date of Birth: [**2078-5-30**] Sex: F Service: MEDICINE Allergies: Penicillins / Latex / lisinopril / levothyroxine sodium Attending:[**First Name3 (LF) 13685**] Chief Complaint: Leg swelling Major Surgical or Invasive Procedure: None History of Present Illness: 85F history of aortic aneurysm s/p repair, diastolic CHF, Afib, severe aortic regurgitation, and multiple recent admissions for CHF exacerbation and pneumonia, presenting with bilateral lower extremity swelling. Says her leg swelling has been persistent for the past month despite hospital admission and diuresis with IV lasix. She is on home torsemide increased on [**2163-12-5**] to 30 mg daily from 20 mg. No shortness of breath, chest pain, palpitation, fevers, chills, cough, URI symptoms, changes in diet or salt intake, medication noncompliance, nausea, vomiting. Of note, patient had multiple readmissions, 3 at [**Hospital1 5109**] and 2 at [**Hospital6 **] over the past 3 months per patient's report. At [**Last Name (un) 1724**] admission on [**2163-9-27**], she was treated with doxycycline and uptitrated her home Lasix to 120 mg daily. Patient reports hospital admissions for 7 days at [**Hospital3 **] in early [**11/2163**] for CHF exacerbation, pneumonia, and LLE cellulitis for which she is on a course of Clindamycin (exact timecourse is unclear, will obtain OSH records). At baseline, patient is on home O2 2L which she wears all the time. Denies CP, SOB, lightheadedness at home. Sleeps on 2 pillows, denies PND. Mobility limited by leg swelling and pain. In the ED, initial VS: 96.3 77 98/65 20 95% 4L Nasal Cannula. Labs notable for Cr of 1.7 ([**12-2**]: cr 1.28). EKG showed A. fib at 67, QTC 478, and nonspecific ST changes. CXR concerning for RLL inflitrate c/f CAP. Per ED report, assessed to be volume overloaded on exam. Patient was given ASA 325 and Levofloxacin 750 mg IV. VS prior to transfer: 97 76 107/58 16 98% room 4LNC (wears 02 4lnc at home). ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: ?????? Aortic Aneurysm, Thoracic s/p open heart surgery and repair ?????? Aortic valve insufficiency ?????? COPD (chronic obstructive pulmonary disease) ANEMIA ?????? HYPERCHOLESTEROLEMIA ?????? HYPERTENSION - ESSENTIAL, BENIGN ?????? HYPOTHYROIDISM ?????? LOW BACK PAIN ?????? ATRIAL FIBRILLATION ?????? HEART FAILURE - DIASTOLIC, CHRONIC ?????? MYOCARDIAL INFARCT - INFERIOR, UNSPEC CARE ?????? LOW BACK PAIN ?????? GASTRITIS - ACUTE ?????? DIVERTICULITIS ?????? THORACIC BACK PAIN Social History: Lives in same house as son in [**Name (NI) 4444**], MA. Worked as elderly caretaker until last year. Able to perform ADLs well, feels like memory has declined over past few years. Smoking - Quit 40 yrs ago, previously [**1-9**] ppd Alcohol - None currently, used to have occasional wine. Illicits - None. Family History: Family history positive for "heart disease." Physical Exam: ADMISSION PHYSICAL EXAM: VS - 97.0 96.2 108/68 72 18 99%2L GENERAL - Elderly-appearing woman in NAD, comfortable, pleasant HEENT - MMM, OP clear NECK - Supple, JVD at 15cm, no carotid bruits LUNGS - Mild crackles at the bases bilaterally, no r/rh/wh, decreased air movement, resp unlabored, no accessory muscle use HEART - Irregular rhythm, loud S2, RV heave, no MRG ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - 2+ to 3+ pitting edema bilaterally to mid-thigh, chronic venous stasis changes on left ankle, warm and well perfused, tender to palpation throughout, DP and PT pulses intact, no cellulitis noted on LEs. SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact. DISCHARGE PHYSICAL EXAM: VS: Afebrile, BP 80/50-110/60 50-72 94%2L GENERAL: Elderly-appearing woman in NAD, comfortable, pleasant NECK: Supple, JVD at 15cm with markedly dilated peripheral neck veins LUNGS: Crackles at the bases bilaterally, with decreased air movement throughout, respirations unlabored HEART: Irregular rhythm, at times bradycardic, loud S2, RV heave ABDOMEN: NABS, slightly protuberant with mild diffuse tenderness throughout, without rebound or guarding EXTREMITIES - 2+ to 3+ pitting edema bilaterally to mid-thigh, chronic venous stasis changes on left ankle, warm and well perfused, mildly tender to palpation throughout Pertinent Results: ADMISSION LABS: [**2163-12-6**] 03:00PM GLUCOSE-91 UREA N-50* CREAT-1.7* SODIUM-134 POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-31 ANION GAP-11 [**2163-12-6**] 03:00PM WBC-5.2 RBC-3.35* HGB-9.9* HCT-30.9* MCV-92 MCH-29.5 MCHC-32.0 RDW-18.2* [**2163-12-6**] 03:00PM NEUTS-64.7 LYMPHS-23.0 MONOS-9.2 EOS-2.2 BASOS-0.9 [**2163-12-6**] 03:00PM PLT COUNT-154 [**2163-12-6**] 03:00PM PT-15.8* PTT-43.1* INR(PT)-1.5* [**2163-12-6**] 03:00PM proBNP-6945* [**2163-12-6**] 03:00PM cTropnT-<0.01 DISCHARGE LABS: [**2163-12-28**] 04:16AM BLOOD WBC-6.7 RBC-2.93* Hgb-8.6* Hct-27.3* MCV-93 MCH-29.4 MCHC-31.5 RDW-18.0* Plt Ct-173 [**2163-12-27**] 02:58AM BLOOD PT-14.1* PTT-36.9* INR(PT)-1.3* [**2163-12-28**] 04:16AM BLOOD Glucose-97 UreaN-71* Creat-3.0* Na-128* K-4.7 Cl-84* HCO3-33* AnGap-16 [**2163-12-24**] 08:25AM BLOOD ALT-14 AST-29 LD(LDH)-303* AlkPhos-120* TotBili-0.8 [**2163-12-23**] 03:50PM BLOOD proBNP-7498* [**2163-12-28**] 04:16AM BLOOD Calcium-8.9 Phos-9.2* Mg-3.0* STUDIES: CXR [**2163-12-6**] IMPRESSION: 1. Opacity in the right lower lobe consistent with pneumonia or aspiration. 2. Emphysema 2. Severe cardiomegaly with mild interstitial edema. EKG [**2163-12-6**] Afib at 67, diffuse TWI, no ST changes, normal axis CXR [**2163-12-8**] 1. Minimally increased right lower lobe opacity, either representing aspiration or pneumonia. 2. Cardiomegaly with unchanged mild interstitial edema. KUB [**2163-12-18**] AP supine and left decubitus views of the abdomen show that the gut is fluid filled and not demonstrably distended. There is no free intraperitoneal gas. ECHO [**2163-12-27**]: The left atrium is moderately dilated. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thickness and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is markedly dilated with moderate global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trace aortic regurgitation is seen. Moderate (2+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Dilated and hypokinetic right ventricle. Severe functional tricuspid regurgitation. Small left ventricle with normal global and regional systolic function. Normally-functioning aortic valve bioprosthesis. Moderate mitral regurgitation. ECG [**2163-12-28**]: Sinus bradycardia, rate 54. Sinus bradycardia persists. There is low voltage throughout raising question of hypothyroidism. Otherwise, tracing is unchanged. Brief Hospital Course: 85F with history of aortic aneurysm s/p repair, diastolic CHF, Afib, severe aortic regurgitation, and multiple recent admissions for CHF exacerbations and pneumonia, presenting with bilateral lower extremity swelling and dyspnea. #. Acute on chronic diastolic congestion heart failure: She presented with substantial peripheral edema, JVD, and hepatomegaly felt to be severe right-sided heart failure from severe tricuspid regurgitation. Also has some moderate to severe MR felt to be contributing to her dyspnea. She has had multiple recent admissions for her difficult to control CHF. Denies any chest pain or palpitations during this admission, but did have waxing and [**Doctor Last Name 688**] shortness of breath. She was aggressively diuresed on a lasix drip (sometimes with metolazone augmentation) with some improvement in her symptoms. She was transitioned once to oral torsemide but began to gain weight again and was placed back on a lasix drip. However, eventually her urine output downtrended despite a lack of improvement in her dyspnea and she became oliguric with rising creatinine. She still had evidence of profound volume overload at that time. she was evaluated by cardiac surgery regarding her severe TR but was not deemed to be a surgical candidate. She was transferred to the CCU in the setting of hypotension and oliguria, where she was continued on a lasix drip without improvement in her symptoms or urine output. A meeting with the family and patient was held, and she decided to transition to comfort measures only and decided to be DNR/DNI. She is being discharged to home on hospice. #. Acute Kidney Injury: She had admission Cr of 1.7 which fluctuated during her hospital course. This is above her baseline of around 1.3 and was felt to be prerenal in the setting of CHF with poor forward flow. Her creatinine initially improved with diuresis but her diuresis limit was reached and she became oliguric. Her creatinine remained elevated around 3.0 at the time of discharge. #. Clostridium difficile colitis: She had been treated with clindamycin at an OSH for possible cellulitis of the legs. She became delirious on [**12-17**] with fevers and increased stool output, and was found to be C.diff positive. She was started on PO vancomycin on [**12-18**] for a fourteen day course. She remained afebrile, without leukocytosis and with KUB showing no signs of colonic dilatation, just stool. Her diarrhea and abdominal cramping were improving at the time of discharge. She will continue PO vancomyin q6h until [**2163-12-31**]. #. History of deep vein thrombosis: She has a history of recent DVT that was complicated by GI bleed so was discharged from OSH without anticoagulation. Repeat LENIs normal on [**2163-12-7**]. Despite her history of DVT and CHADS2 score of 3, anticoagulation was held due to her history of multiple GI bleeds in the past. She will not be anticoagulated at discharge. #. GI Bleed: She was guaiac positive, with occasional dark stools but stable Hct. OSH endoscopies this year/late last year have shown duodenal AVMs and moderate gastritis. She was started on IV PPI but as patient's Hct remained stable, she was switched back to her home dose PPI. Heparin SC was decreased in dose initially, and discontinued after she was made CMO. #. Thrombocytopenia: She was noted to have downtrending platelets during this admission with nadir of 103. Patient with intermittent dried blood in nose from nasal cannula and with one episode of hemoptysis. Platelet count rebounded and was back to the normal range at the time of discharge. It was not felt to be associated with heparin use. #. COPD: She was maintained on her home oxygen at 2L NC. Patient continued on her home regimen, which will be continued for comfort after discharge. #. Back pain: She had continued chronic right-sided back spasms that were controlled with her home regimen of Vicodin and Fentanyl patch. #. Atrial fibrillation: She has been previously on coumadin which was held permanently due to recurrent GI bleeds. Despite CHADS2 score of 3, we continued no anticoagulation and she will not be anticoagulated at discharge. She was rate controlled on metoprolol for much of her admission, which was stopped in the ICU for bradycardia to the 40's. HR at the time of discharge was about 60. #. HTN: Systolic blood pressures ran in 90's-100's for most of her admission which is at her baseline. We monitored pressures closely in setting of diuresis and held metoprolol for SBP <100's. She did have episodes of hypotension in the setting of worsening renal function necessitating CCU transfer for 2 days. At discharge, metoprolol has been discontinued due to low blood pressures and heart rates. #. HLD: Continued Simvastatin during admission, this was stopped at discharge because she is CMO. #. Hypothyroidism: Continued Levothyroxine. #. Code status and goals of care: She was admitted as full code, which was transitioned to DNR/DNI while she was in the CCU. After she failed medical therapy with IV diuretics and was determined not to be a surgical candidate, a family meeting was held. She was transitioned to CMO and was discharged to home with hospice. TRANSITIONAL ISSUES: - Sent home with hospice, goals of care are to focus on comfort Medications on Admission: Budesonide-Formoterol (SYMBICORT) 80-4.5 mcg/Actuation Inhalation HFA Aerosol Inhaler take 1 puff twice per day Torsemide 30 mg Oral Tablet Take 1 tablet daily or as directed Clindamycin HCl 150 mg Oral Capsule Take 2 capsules 3 times a day 10 days Fentanyl 25 mcg/hr Transdermal Patch 72 hr apply 1 patch every 72hrs Hydrocodone-Acetaminophen (VICODIN) 5-500 mg Oral Tablet 1 tab qid prn Simvastatin 40 mg Oral Tablet Take 1 tablet every evening for cholesterol Levothyroxine 200 mcg Oral Tablet 1 tab daily Omeprazole (PRILOSEC) 20 mg Oral Capsule, Delayed Release(E.C.) 1po qd Nitroglycerin 0.4 mg Sublingual Tablet, Sublingual 1 tablet sublingually every 5 minutes as needed for chest pain Metoprolol Succinate 25 mg Oral Tablet Extended Release 24 hr 1 tab daily Polyethylene Glycol 3350 17 gram/dose Oral Powder 17gm in liquid daily Senna 187 mg Oral Tablet take 1-2 tablets daily as needed Ferrous Sulfate 325 mg (65 mg Iron) Oral Tablet take two times daily Docusate Sodium 100 mg Oral Capsule Take [**1-9**] capsules daily as needed; available over the counter CALCIUM CARBONATE-VITAMIN D3 600 MG, 1,500 MG,-400 UNIT CAP 600 mg(1,500mg) -400 unit Oral Cap Take 1 tablet twice daily; available over the counter Discharge Medications: 1. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Back pain. Disp:*120 Tablet(s)* Refills:*0* 3. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation twice a day. Disp:*1 inhaler* Refills:*2* 4. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. Disp:*30 patches* Refills:*2* 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN PAIN Q5MIN as needed for chest pain: Please take only up to 3 times. Disp:*15 Tablet, Sublingual(s)* Refills:*0* 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) unit PO DAILY (Daily) as needed for constipation. Disp:*30 units* Refills:*2* 8. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. Disp:*60 Tablet(s)* Refills:*2* 9. docusate sodium 100 mg Capsule Sig: [**1-9**] Capsules PO BID (2 times a day) as needed for Constipation. Disp:*60 Capsule(s)* Refills:*2* 10. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 days: Last dose on [**12-31**]. Disp:*8 Capsule(s)* Refills:*0* 11. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath. Disp:*120 nebs* Refills:*2* 12. torsemide 20 mg Tablet Sig: Four (4) Tablet PO once a day. Disp:*120 Tablet(s)* Refills:*2* 13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Disp:*3600 ML(s)* Refills:*3* 14. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. Disp:*120 Tablet, Chewable(s)* Refills:*2* 15. nystatin 100,000 unit/mL Suspension Sig: 5-10 MLs PO QID (4 times a day) as needed for thrush for 3 days. Disp:*1200 ML(s)* Refills:*2* 16. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-9**] Sprays Nasal QID (4 times a day) as needed for nasal congestion. Disp:*240 sprays* Refills:*2* 17. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp:*90 Tablet(s)* Refills:*2* 18. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*360 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Hospice of the [**Location (un) 1121**] Discharge Diagnosis: Primary Diagnosis: Acute on chronic diastolic congestive heart failure C.diff colitis Secondary Diagnosis: COPD HYPERCHOLESTEROLEMIA HYPERTENSION HYPOTHYROIDISM LOW BACK PAIN ATRIAL FIBRILLATION HISTORY OF GASTRITIS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 92530**], You were admitted to [**Hospital1 18**] for an exacerbation of congestive heart failure. You were given a medicine to help remove excess fluid from your body and your shortness of breath improved. You also acquired an infection called Clostridium difficile (also called C.diff), which is a bacteria that leads to inflammation of the gut and causes diarrhea. We will send you home with antibiotics to treat this infection. After discussion with you and your family, we have decided to focus on comfort measures after you return home. You will be seen by a home hospice service after discharge. The following changes were made to your medications: START vancomycin 125mg by mouth every six hours until [**12-31**] STOP clindamycin STOP simvastatin STOP metoprolol STOP ferrous sulfate (iron pills) INCREASE torsemide to 80mg daily Followup Instructions: Please follow-up with your hospice nurses for any questions or concerning symptoms.

[ "403.90", "285.9", "287.5", "492.8", "V49.86", "584.9", "724.2", "112.0", "338.29", "276.1", "428.0", "397.0", "V42.2", "788.5", "427.31", "272.0", "458.9", "424.0", "428.33", "244.9", "585.3", "008.45" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

16671, 16741

7545, 12766

331, 337

17002, 17002

4645, 4645

18072, 18159

3160, 3206

14122, 16648

16762, 16762

12878, 14099

17178, 18049

5153, 7522

3246, 3980

12787, 12852

279, 293

365, 2311

16870, 16981

4661, 5137

16781, 16849

17017, 17154

2333, 2820

2836, 3144

4005, 4626

25,225

112,902

3974

Discharge summary

report

Admission Date: [**2180-4-28**] Discharge Date: [**2180-5-18**] Date of Birth: [**2147-8-13**] Sex: F Service: MEDICINE Allergies: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril / Morphine / Cyclosporine / Neurontin / Heparin Agents / IV Dye, Iodine Containing Attending:[**First Name3 (LF) 2181**] Chief Complaint: Joint Pain, Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: 32 y/o F with SLE, ESRD s/p failed transplant on HD, cerebral hemorrhages with resultant seizure d/o, restrictive lung disease, who presents with SOB, generalized body/joint pains similar to those from her prior admission. Has been taking more than her prescribed home dose of dilaudid over the past few days. Went to HD yesterday. Pain improved with 1mg IV dilaudid x 1. Patient recently diagnosed with fibromyalgias on last admission and having pains in neck, arms, legs. Had full session of [**First Name3 (LF) 2286**] on Wed. . In the ED, initial VS: 99.0 100 138/97 18 100 Given dilaudid 1mg IV x 6 over 12 hours. Admitted for pain control and shortness of breath. Past Medical History: #. Systemic Lupus Erythematosus: diagnosed [**2166**] complicated by lupus nephritis, anemia, serositis and ascites, vascular stenosis resulting in facial edema and subclavian steal #. Pulmonary HTN #. ESRD s/p failed renal transplant in [**2174**] requiring explant -HD T/Th/Sat #. HTN #. GERD #. Multiple hospitalizations for line sepsis #. S/p R BKA for chronically infected non-healing fracture (R Tib-fib fracture in [**2176**]) #. H/o MSSA endocarditis c/b embolic stroke and resultant seizure disorder #. Seizure disorder- complication of embolic strokes from mitral valve endocarditis in [**2177**] #. H/o VSD s/p surgery at age 13 #. HTN #. ITP #. Sickle cell trait #. S/p left oophorectomy related to IUD associated infection, s/p TAH/RSO for right pelvic abscess #. Restrictive lung disease Social History: Lives at home with husband and 16 year old son. Denies any past history of smoking, alcohol or other drugs. Originally from [**Country **]. Used to work at [**Hospital1 18**] as a patient care technician, currently on disability. She has used a walker for about 2.5 years since amputation of her right foot. She lives in an apartment on the [**Location (un) 448**], has to climb about 15 stairs to get to the apartment. Family History: Brother with SLE and DM Physical Exam: Vitals - T: 97.3 (100.5) BP: 102/84 HR: 96 RR: 18 02 sat:92/RA GENERAL: thin African-American woman with round swollen-appearing faces in NAD and thin extremities. Alert and Oriented x3. Tearful. HEENT: NCAT. Sclera anicteric but injected bilaterally. Eyelids and lips largely swollen; lower lip angio-edema appearing but pt states it is chronic. EOMI. oropharynx clear. tongue is midline and not swollen. CARDIAC: RR, split S1, normal S2. no murmurs appreciated. CHEST: HD line tunneled in place right side, nontender at insertion site, dressing in place. LUNGS: Resp unlabored, no accessory muscle use. Crackles bilaterally. ABDOMEN: Soft, mildly distended, nontender currently. BACK: diffusely tender to palpation over muscles of lower, mid, and upper back and spine EXTREMITIES: No peripheral edema of lower extremities, very thin. Right arm with scar from old AV graft or fistula site. Right foot amputated. Left foot warm w good pulses. Knees and elbows not erythematous or swollen, not any warmer than rest of extremities; good range of motion, pain with motion. Elbows nontender, but knees tender to palpation. NEURO: [**4-12**] right hip flexor strength and [**3-13**] Left Hip Flexor strength. Left arm also with mildly decreased strength s/p stroke. SKIN: Dark oval-shaped macular spots 2-3cm in width on arms and legs. Pertinent Results: Admission Labs: [**2180-4-27**] 09:57PM BLOOD WBC-6.9 RBC-4.46 Hgb-12.8 Hct-41.2 MCV-93 MCH-28.7 MCHC-31.0 RDW-22.5* Plt Ct-111* [**2180-4-27**] 09:57PM BLOOD Neuts-60.4 Lymphs-33.3 Monos-3.4 Eos-2.1 Baso-0.8 [**2180-4-29**] 06:05PM BLOOD ESR-90* [**2180-4-27**] 09:57PM BLOOD Neuts-60.4 Lymphs-33.3 Monos-3.4 Eos-2.1 Baso-0.8 [**2180-4-27**] 09:57PM BLOOD Glucose-92 UreaN-28* Creat-7.1*# Na-133 K-3.9 Cl-92* HCO3-34* AnGap-11 [**2180-4-27**] 09:57PM BLOOD Calcium-7.4* Phos-2.4* Mg-2.6 [**2180-4-29**] 06:05PM BLOOD CRP-41.5* [**2180-4-28**] 12:45PM BLOOD C3-23* C4-8* CXR [**2180-4-28**]: 1. Confluent left lower lobe opacity, potentially due to pneumonia in the appropriate clinical setting. Lupus pneumonitis is an additional consideration, as well as atelectasis. 2. Interstitial edema. 3. Massive enlargement of central pulmonary arteries consistent with pulmonary arterial hypertension. Plain film L shoulder [**2180-4-29**]: FINDINGS: The alignment is normal without fracture or dislocation. Please note that these films were taken to assess the shoulder. The lung visualized in the image demonstrates increased lung markings and hazy vasculature that has probably increased compared to the study from the prior day. The study and the report were reviewed by the staff radiologist MRI L Shoulder [**2180-5-3**]: 1. Tendinopathy of supraspinatus and infraspinatus tendons without tear. 2. Mild glenohumeral and acromioclavicular joint degenerative change. 3. Slightly limited by patient motion. Portable AP chest [**2180-5-7**]: Single view of the chest demonstrates enlargement of the heart, prominent mediastinum, patchy multifocal airspace disease with underlying interstitial changes. There is a probable small left-sided pleural effusion. Right-sided [**Month/Day/Year 2286**] catheter is present. Interval worsening of the appearance of the chest since prior study from [**2180-4-28**]. Brief Hospital Course: #. Arthralgias/joint pain/left shoulder immobility: Initially there was concern that this pain may represent a lupus flare, versus continuing chronic pain. Serum C3, and C4 were low and rheumatology was consulted. Plaquenil was stopped, and she was treated with three days of prednisone 20mg PO daily. She did not have significant improvement with this regimen and she was put back on her home dose of 5mg PO daily. She had difficulty moving her left shoulder, but could mover her fingers and hand, and sensation and pulses remained intact. An MRI was performed of her left shoulder, which showed supraspinatus tendonitis. Her dose of dilaudid was decreased from 1mg IV q 2 hrs, to 8 mg PO q 4 hr over several days. She gradually complained of less pain and reported improved mobility of her shoulder. . #. Opacities on CXR. Patient presented with a complaint of shortness of breath and had a temperature of 100.3 on the day of admission. Chest x-ray showed new RLL opacity suggestive on PNA. She was treated with one day of vancomycin and meropenem for HCAP. She clinically improved and antibiotics were stopped. Repeat CXR showed improvement. However she began spiking fevers, a repeat CXR and CT scan were concerning for HAP, and the patient defervesed on broad spectrum abx. - complete 8 day course of Vancomycin and Ceftaz. . #. Face/neck swelling. Patient had notable facial and neck swelling, slightly more prominent on the left. Per prior notes, this appeared stable from prior admissions. Transplant surgery was consulted and recommended no further intervention. . #. ESRD - Transplant nephrology was consulted, and patient received hemodialysis on M/W/F. She was also treated wth epogen twice weekly, nephrocaps and calcium acetate. She was noted to have low serum calcium, and her calcinet was stopped. A [**Year (4 digits) 2286**] session was stopped early on [**2180-5-5**], due to seizures and hypotension. She received and extra [**Date Range 2286**] session on [**2180-5-6**]. She tolerated [**Date Range 2286**] well thereafter with BP support from midodrine. . # Seizure disorder - Patient was continued on her current doses of topamax 100mg PO every day, with the dose given after [**Date Range 2286**] on [**Date Range 2286**] days, and keppra 500mg PO bid on non [**Date Range 2286**] days, and 1000mg PO daily on [**Date Range 2286**] days given AFTER [**Date Range 2286**]. Patient was noted to have short period of myoclonic jerking and unresponsiveness while at hemodialysis on [**2180-5-6**]. [**Date Range **] session was stopped, and she was given her anti-epileptics. Her serum calcium was noted to be low, and she was repleted 4g of calcium gluconate. Her outpatient neruologist was contact[**Name (NI) **] ([**Name (NI) **]/[**Doctor Last Name **]), who recommended a 24 hour video EEG. This was performed and showed no epileptiform activity. . # Hypotension - Patient blood pressure baseline is 90s/60s. Several times her dilaudid was held for SBP < 90. At [**Doctor Last Name 2286**] on [**2180-5-6**] her blood pressure decreased to 70s/50s and [**Date Range 2286**] was stopped. On the morning on [**2180-5-8**], she was noted to be somnolent and persistently hypotensive in the 70s/50s. She was bolused 1 liter of NS and her pressure increased to 80s/50s. She was tranferred to the intensive care unit for further management. In the ICU, the patient's pressures remained stable. She was started on Midodrine 10mg TID. TSH and Cortisol were WNL. She was started on Vancomycin on [**2180-5-7**], which was to be d/c'd if the BCx remained negative for 48hrs. She was called out the next morning to the floor. Midodrine was continued. . # Stage II decubitis ulcer: Ulcer was present on admission, and was treated with standard wound care measures. . # Constipation: Patient was consistently constipated. She was treated with a progressively more aggressive bowel regimen. . # CODE: FULL . #. Vaginal bleeding - Pt is s/p TAH, but has recent vaginal bleed. Patient needs outpatient follow-up with her gynecologist. Medications on Admission: - Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QMOWEFR (Monday -Wednesday-Friday) -- immediately after [**Date Range 2286**]. - Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID ON SAT/SUN/TUES/THURS - Topiramate 100 mg Tablet Sig: One (1) Tablet PO (After HD on [**Date Range 2286**] days). - Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). - Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). - Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). - B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). - Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. - Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. - Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). - Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). - Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. - Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). - HYDROXYCHLOROQUINE - 200 mg Tablet - 1 Tablet(s) by mouth twice a day - Epo-alfa at HD . Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO MWF (Monday-Wednesday-Friday): Take AFTER [**Date Range 2286**]. Disp:*30 Tablet(s)* Refills:*2* 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): take like this on NON-HD days, i.e. SA-[**Doctor First Name **]-TU-TH. Disp:*30 Tablet(s)* Refills:*2* 3. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*180 Capsule(s)* Refills:*2* 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 capsules* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for consitpation. Disp:*60 Tablet(s)* Refills:*0* 9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-11**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. Disp:*1 dropette* Refills:*3* 10. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 11. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:*90 Tablet, Chewable(s)* Refills:*2* 14. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 16. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO TID (3 times a day) as needed for constipation. Disp:*30 packet* Refills:*0* 17. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 18. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol). 19. Ceftazidime 1 gram Recon Soln Sig: One (1) Gram Injection QHD (each hemodialysis). 20. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 21. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 22. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Location (un) 86**] Center for Rehab & Sub-Acute Care - [**Location (un) 2312**] Discharge Diagnosis: Joint Pain Health Care Associated Pneumonia Lupus 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 for worsening pain and shortness of breath. An x-ray of your chest and shoulder were performed. The chest x-ray showed evidence of possible pneumonia which was confirmed on CT and you are currently being treated for this. The shoulder x-ray did not show a fracture. Fluid removed from your knee showed neither inflamation nor infection. You were initially treated with antibiotics for the possible pneumonia, but these were stopped as your breathing improved. Hemodialysis was performed on schedule. Rheumatology saw you and did not think your pain was related to a lupus flare. Pain management was consulted and recommended you start an new medication, lyrica. Your pain was otherwise controlled with the medication dilaudid. Your pain gradually improved and your dose of dilaudid was decreased. Psychiatry saw you while you were here, and recommended you start the anti-depressant medication cymbalta. During [**Location (un) 2286**] you had a seizure. You were placed an video electroencephalography (EEG) monitoring for one day, and no further seizures were observed. Your antiseizures were continued. Your stay was complicated by low blood pressures which were treated with the medication midodrine. Please note the following changes in your medications: You were started on topamax 100mg every evening You were started on duloxetine 60mg daily You were started on artificial tears as needed for dry eyes You were started on Lyrica(pregabalin) 75mg twice per day for pain You were started on calcium supplements (calcium carbonate) 500mg three times per day You were started on miralax which you can take upto three packets per day as needed for constipation. You were started on bisacodyl suppositories which you may use as needed up to twice per day for constipation Dr. [**Last Name (STitle) **] will attempt to get you a prior authorization for lidoderm patches. . Your hydroxychloroquine was stopped. Please review all change in your medications with your primary care doctor. It is very important that you only take all medications as prescribed. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: RHEUMATOLOGY When: WEDNESDAY [**2180-5-24**] at 9:30 AM With: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Unit Name **] [**Location (un) 861**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE Department: NEUROLOGY When: MONDAY [**2180-5-22**] at 4:00 PM With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name 5284**] [**Telephone/Fax (1) 5285**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: THURSDAY [**2180-5-18**] at 10:10 AM With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2180-5-18**]

[ "486", "427.31", "V45.11", "276.6", "707.22", "276.1", "287.5", "458.9", "V45.89", "401.9", "V42.0", "282.5", "416.8", "530.81", "564.00", "296.20", "459.2", "726.10", "435.2", "707.03", "438.89", "582.81", "780.39", "710.0", "585.6", "275.2", "338.29", "285.9", "517.8", "276.52", "719.46", "276.7", "V49.75", "275.41" ]

icd9cm

[ [ [] ] ]

[ "81.91", "39.95" ]

icd9pcs

[ [ [] ] ]

13829, 13939

5747, 9819

432, 439

14033, 14033

3811, 3811

16415, 17384

2420, 2445

11041, 13806

13960, 14012

9845, 11018

14209, 16392

2460, 3792

361, 394

467, 1138

3827, 5724

14048, 14185

1160, 1964

1980, 2404

24,718

130,322

1474+55288

Discharge summary

report+addendum

Admission Date: [**2178-2-25**] Discharge Date: [**2178-3-7**] Date of Birth: [**2100-5-11**] Sex: M Service: ACOVE MEDICINE ADMITTING DIAGNOSIS: Shortness of breath. HISTORY OF THE PRESENT ILLNESS: The patient is a 77-year-old man with a long history of intermittent lower GI bleed believed secondary to diverticulosis and hemorrhoids (as seen on colonoscopy in [**2177-4-2**]) who had been having some rectal bleeding. His hematocrit dropped to 27. He then received 2 units of packed red blood cells at his rehabilitation facility on the day of admission. At this time, he was noted to become more dyspneic. The patient was given Lasix, however, did not respond. He was, therefore, sent to the Emergency Department. In the Emergency Department, an initial ABG was 7.23/80/49. There was a trial of noninvasive positive pressure ventilation but the patient did not improve. Therefore, he was intubated. A chest x-ray taken at this time showed congestive heart failure with a right lower lobe effusion. The patient was suctioned and this revealed thick pus. In the Emergency Department, the patient was given ceftriaxone 1 gram and azithromycin 1 gram. He was also given 15 mg of Kayexalate for a potassium of 5.5 in the setting of acute renal failure with a BUN of 55 and creatinine of 2.3 up from a baseline of 1.2. A subclavian line was placed in the Emergency Department. After intubation, the patient's blood pressure dropped briefly to a systolic of 70s. It increased with 100 cc bolus of normal saline. The patient was admitted to the ICU for further management. The patient also received 120 mg of Lasix IV in the Emergency Department. PAST MEDICAL HISTORY: 1. Type 2 diabetes. 2. Hypertension. 3. Diverticulosis and grade III hemorrhoids causing a chronic lower GI bleed with the patient intermittently requiring transfusion. 4. Congestive heart failure with diastolic dysfunction. An echocardiogram in [**2177-5-3**] showed an ejection fraction of greater than 5%, trace aortic regurgitation, trace mitral regurgitation, trivial tricuspid regurgitation. 5. Paroxysmal atrial fibrillation, status post DCCV in [**2177-5-3**]. 6. Stress MIBI in [**2177-7-3**] showed a reversible inferior wall defect, inferior wall hypokinesis. 7. Spinal stenosis, status post laminectomy in [**2177-7-3**]. 8. Right hip fracture, status post ORIF in [**2177-12-3**]. 9. TIAs in [**2169**] and [**2177-3-3**] leading to garbled speech. 10. Prostate cancer, status post radiation therapy in [**2170**]. 11. Status post appendectomy complicated by peritonitis in [**2140**]. 12. COPD with most recent pulmonary function tests in [**2168**] showing an FEV1 of 50% of predicted and FVC 63% of predicted and FEV1 to FVC ratio 80% of predicted. 13. Melanoma, status post excision. 14. Radiation proctitis. MEDICATIONS ON ADMISSION: 1. Amiodarone 200 mg p.o. q.d. 2. Lasix 40 mg p.o. q.d. 3. Verapamil CR 180 mg p.o. q.d. 4. Moexipril 7.5 mg q.a.m., 11.25 mg q.p.m. 5. Cilium one packet p.o. q.d. 6. Zoloft 75 mg p.o. q.d. 7. Lovenox 30 mg subcutaneously q. 12 hours. 8. Regular insulin sliding scale. 9. Tylenol 975 mg p.o. b.i.d. 10. Vitamin C 500 mg p.o. b.i.d. 11. Multivitamin. 12. Melatonin 1 mg p.o. q.h.s. 13. Glyburide 2.5 mg p.o. q.d. 14. Niferex 150 mg p.o. b.i.d. 15. Vioxx 25 mg p.o. q.d. 16. Senna two tablets p.o. q.h.s. 17. Atenolol 37.5 mg p.o. q.d. 18. Sublingual nitroglycerin p.r.n. 19. Milk of magnesia p.r.n. 20. Dulcolax p.r.n. 21. Anusol one per rectum b.i.d. 22. Colace 100 mg p.o. b.i.d. ALLERGIES: The patient has no known drug allergies. However, Percocet and codeine cause delirium and confusion. SOCIAL HISTORY: The patient was working part-time as an accountant up until his hip fracture in [**2177-12-3**]. He has a 70 pack year history of smoking and quit in [**2141**]. The patient rarely drinks alcohol. He is married. His health care proxy is his son in-law, [**Name (NI) **] [**Last Name (NamePattern1) 8732**], phone number [**Telephone/Fax (1) 8733**]. He currently was at rehabilitation at [**Hospital1 5595**] and his family is looking into long-term care options as his mobility is severely limited since his hip fracture. FAMILY HISTORY: Positive for myocardial infarction. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 95.2, blood pressure 133/45, heart rate 50, respiratory rate 22, saturating 60% on room air. The patient was then intubated and had a blood pressure of 111/49, heart rate 55, respiratory rate 12, saturating 100% on AC 500 times 12 with a PEEP of 5. General: The patient was sedated and intubated. He responded only to pain. HEENT: The pupils were 2 mm and reactive bilaterally. The head was normocephalic, atraumatic. JVD 10 cm at 30 degrees. The tympanic membranes were normal. There was no lymphadenopathy in the head or neck. Pulmonary: Coarse bronchial breath sounds and rhonchi scattered bilaterally. Heart: The heart rate was bradycardiac. The rate was regular. There was a summation gallop. There were no murmurs. Abdomen: Soft, nontender, nondistended. Bowel sounds were present. There was ecchymoses bilaterally in the lower quadrants likely from Lovenox. Extremities: There was 2+ pitting edema. There was no clubbing or cyanosis. The dorsalis pedis pulses were 2+ bilaterally. The patient had a sacral decubitus ulcer. The right hip surgical scar was well healed. LABORATORY DATA: White count 15.9, hematocrit 40.0, platelets 218,000. Sodium 139, potassium 5.5, chloride 98, bicarbonate 30, BUN 55, creatinine 2.3, glucose 108. PT 13.1, INR 1.1, PTT 32.4. The urinalysis showed a small amount of blood, 30 protein, negative glucose, negative ketones, negative leukocyte esterase, negative nitrates. The pH was 5.0. There were [**2-4**] red blood cells, 0 white blood cells, and occasional bacteria. An EKG showed sinus bradycardia at 50 beats per minute. There was left axis deviation. There was a possible old MI with Q in V1. There was T wave flattening in III and aVF. There was a prolonged QT interval of 500. There were U waves in the precordium. Chest x-ray showed bilateral patchy opacities with a right pleural effusion with the diagnosis of congestive heart failure versus multifocal pneumonia. HOSPITAL COURSE: 1. PULMONARY: The patient was initially intubated and transferred to the ICU. His respiratory failure was felt to be multifactorial. However, pneumonia seemed most likely. The patient was also noted to have impaired pulmonary function at baseline secondary to COPD. The patient was initially started on vancomycin, ceftriaxone and azithromycin for treatment of pneumonia. Sputum culture eventually grew out MRSA. The patient's effusion was not amenable to tap. It was evaluated by ultrasound and felt to be nontappable. Therefore, the patient did not have a thoracentesis. The patient was maintained on intubation and ventilation. He was also maintained on inhalers for his COPD. The patient was extubated on [**2178-2-27**] and did well from a pulmonary point of view. He was called out to the floor on [**2178-2-28**]. That evening, the patient was given his evening medications and was noted to aspirate. The patient desatted to the 60s on a nonrebreather mask. He became unresponsive. The patient was then intubated for likely aspiration and transferred back to the ICU. The patient was maintained on his antibiotics. He did well in the ICU from a pulmonary point of view and was then extubated on [**2178-3-3**]. He was transferred to the floor on [**2178-3-4**]. The patient's mental status was noted to be quite changed after his second extubation. He failed a swallow study and was kept n.p.o. He seemed to be doing well from a pulmonary point of view. However, the patient, after much discussion with his family, was made DNR/DNI. He was then found deceased in the early morning of [**2178-3-7**]. It is thought that he may have passed away from a pulmonary event. 2. RENAL: The patient was noted to be in acute renal failure on admission. This was felt to be secondary to overdiuresis. The patient was given IV normal saline and his renal function improved somewhat. By the time that he was called out to the floor, the patient's creatinine was down to his baseline of 0.8. However, when the patient was intubated a second time, his blood pressure dropped again to the 60s to 70s and he transiently required dopamine. After that, the patient's renal function worsened. This was felt to be secondary to ATN from hypotension. His creatinine continued to climb up to as high as 1.7 on the day of his death. 3. ATRIAL FIBRILLATION: The patient came in in sinus rhythm. He intermittently went into atrial fibrillation while in the ICU. However, the patient then spontaneously converted to sinus rhythm. The patient was maintained on Amiodarone and it was felt that as he had returned to sinus rhythm that he did not require anticoagulation. 4. GASTROINTESTINAL: The patient has a long history of GI bleeding. This was not a factor during this admission. The patient's crits were followed q.d. and remained relatively stable in the mid 30s. 5. DIABETES: The patient has a history of type 2 diabetes. He was maintained on a regular insulin sliding scale. The patient was unable to take p.o. He was not kept on his oral hypoglycemics. 6. NEUROLOGY: After his first extubation, the patient appeared to be doing well from a neurological point of view. He was somewhat confused but was able to converse normally. However, after his second extubation, the patient's mental status was significantly worse. He was not oriented to place, time, or person. He was unable to converse and was very agitated. This may have been secondary to hypoxia at the time of his second intubation. 7. NUTRITION: The patient was maintained on tube feeds while in the ICU and intubated. After his second transfer to the floor, the patient's mental status was such that he was unable to take p.o. The patient failed a bedside swallow evaluation and was not oriented enough to undergo a video swallow study. After much discussion with the patient's wife as well as his health care proxy, his son in-law, [**Name (NI) **] [**Last Name (NamePattern1) 8732**], the family decided against placement of a PEG tube. The family at that time wished to maintain the patient on IV fluids for hydration and to see if his mental status improved. At that time, the family made the patient DNR/DNI. The patient then passed away before any final decisions could be made about his nutrition. 8. PROPHYLAXIS: The patient was maintained on either a proton pump inhibitor or an H2 blocker throughout his stay in the hospital. The patient was not on subcutaneous heparin prophylactically as he was HIT antibody positive. He was maintained on pneumoboots throughout his stay in the hospital. 9. CODE STATUS: The patient was initially a full code. However, after his second transfer to the floor and his worsened mental status, the family made the decision to have the patient made DNR/DNI. The patient was then found deceased on the floor the next day and was not coded. DISCHARGE DIAGNOSIS: 1. Methicillin-resistant Staphylococcus aureus pneumonia complicated by respiratory arrest. 2. Aspiration leading to respiratory arrest. 3. Pleural effusions. 4. Acute renal failure secondary to dehydration. 5. Acute renal failure secondary to acute tubular necrosis, secondary to hypotension. 6. Confusion, likely secondary to hypoxic brain injury. 7. Atrial fibrillation. 8. Type 2 diabetes. 9. Hypertension. 10. History of gastrointestinal bleed secondary to diverticulosis and grade III hemorrhoids. 11. Congestive heart failure with diastolic dysfunction. 12. Spinal stenosis, status post laminectomy. 13. Right hip fracture, status post open reduction and internal fixation. 14. History of transient ischemic attacks in [**2169**] and [**2176**]. 15. Prostate cancer, status post radiation therapy. 16. Status post appendectomy complicated by peritonitis in [**2140**]. 17. Chronic obstructive pulmonary disease. 18. Melanoma, status post excision. 19. Radiation proctitis. DISCHARGE: The patient was pronounced dead at 3:20 a.m. on [**2178-3-7**]. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 910**] Dictated By:[**Last Name (NamePattern1) 222**] MEDQUIST36 D: [**2178-3-16**] 10:22 T: [**2178-3-16**] 12:13 JOB#: [**Job Number 8734**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 1169**] Admission Date: [**2178-2-25**] Discharge Date: [**2178-3-8**] Date of Birth: [**2100-5-11**] Sex: M Service: ACOVE ADDENDUM: This is an Addendum to the Discharge Summary covering the admission from [**2178-2-25**] until [**2178-3-8**]. The patient died on [**2178-3-8**]. The previous Discharge Summary improperly stated the date of death as [**2178-3-7**]. [**Name6 (MD) 116**] [**Name8 (MD) 117**], M.D. [**MD Number(1) 118**] Dictated By:[**Last Name (NamePattern1) 1170**] MEDQUIST36 D: [**2178-5-21**] 15:52 T: [**2178-5-21**] 15:54 JOB#: [**Job Number 1171**]

[ "707.0", "493.20", "584.9", "428.0", "707.14", "427.31", "263.9", "507.0", "428.33" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4231, 4289

11223, 13273

2863, 3668

6301, 11202

4304, 6283

164, 1679

1701, 2837

3685, 4214

7,251

196,370

6208

Discharge summary

report

Admission Date: [**2151-2-21**] Discharge Date: [**2151-2-27**] Date of Birth: [**2093-8-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: SOB and asymptomatic NSVT Major Surgical or Invasive Procedure: [**2151-2-26**] ICD placement. History of Present Illness: 57 F w/ hx CABG (emergent in [**2139**] w/ VG's to OM and LAD), stenting of SVG to LAD in [**2141**] who presented [**1-13**] w/ acute STEMI ([**Doctor First Name **] was SVG - LAD that was stented). Her course was complicated by severe cardiogenic shock requiring IABP and triple pressors. Her LCx was found to have successive 90% stenosis proximally and distally that were unsuccessfully attempted to be intervened on. ECHO showed severe LV dysfunction w/ 3+MR, extensive apical akinesis and mural thrombus. Over the course of 1 month, her pressors and IABP were weaned and she eventually tolerated low dose ACE and BB. EP was consulted for ICD placement and recommended future LV systolic function reassessment. She was discharged on lisinopril 5mg, toprol XL 12.5mg, furosemide 40mg. She was euvolemic at discharge. She was also discharged on coumadin for mural thrombus. She was d/c'd to rehab. . At rehab, pt has been noting intermittent SSCP ~5min [**5-23**] X per day. She has also been noting increased SOB. She has been taking her meds and per pt, eating low sodium diet. Today, [**2151-2-21**], she was found to have 2 runs of 20 beats of NSVT (assymptomatic). She was sent to [**Hospital1 18**]. . In the ED, she was afebrile, HR 93, BP 96/48, 98%4LNC. She was given lasix 100mg IV and transferred to CCU for goal directed therapy. Past Medical History: -[**Last Name (un) 24206**] [**Last Name (un) 24206**] syndrome -CVA in [**2122**] and [**2132**] with mild dysphagia -seizure disorder -CAD s/p emergent CABG (SVG to LAD, SVG to OM) after failed PTCA (attempted to LAD; LMCA occlusion) [**2139**]; stenting of SVG to LAD in [**2141**] -Aorto-bifemoral bypass -GI bleed Social History: She worked as a secretary but hasn't for some time due to health problems. Lives with her husband in [**Name (NI) **], daughter nearby. She had been smoking 1 pack per week. Rare etoh. Family History: Father died of an MI at 78, mother healthy. Physical Exam: Vitals- HR 104, BP 125/65, AC 500x30/5/100% General- NAD HEENT- pupils dilated and fixed, ETT, OGT Neck- R carotid pulse 1+, L carotid pulse diminished Pulm- coarse breath sounds b/l CV- tachycardic but regular, Abd- +BS, soft, ND Extrem- no LE edema, feet cool, slow cap refill Neuro- sedated, spontaneously moving all 4 extremities, ?withdraws to nailbed pressure, RUE +3 DTRs, LUE/[**Name2 (NI) **]/LLE +2 DTRs Pertinent Results: EKG [**2151-2-21**]: 9bpm, sinus rhythm. Left atrial abnormality. Low limb lead voltage. Prior anterior myocardial infarction. Compared to the previous tracing of [**2151-2-9**] the T waves are less inverted in the anterolateral leads and ventricular [**Date Range 24207**] is abasent. Otherwise, no diagnostic interval change. CXR [**2151-2-21**]: 1. Diffuse interstitial abnormality, which raises the possibility of a more chronic process such as hemosiderosis resulting from pulmonary edema. A PA and lateral study may be of value. 2. New small bilateral pleural effusion. CXR [**2151-2-26**]: A right chest wall single lead pacemaker/ defibrillator is in appropriate position. The proximal electrode is adjacent to the SVC. There is no pneumothorax. The cardiac silhouette is upper limits of normal, but stable. The mediastinal and hilar contours are within normal limits. The patient is status post sternotomy and CABG. A diffuse interstitial abnormality is unchanged since multiple prior exams. There are no focal consolidations, and no effusion. IMPRESSION: Status post right chest wall single lead pacemaker/defibrillator without pneumothorax. ECHO dyssynchrony study: LV systolic function appears depressed with apical and lateral hypokinesis (regional motion not fully assesed; focused views only). Tissue synchronization imaging demonstrates significant left ventricular dyssynchrony with the lateral wall contracting 105 ms later than the septum. The aortic pre-ejection time is normal at 42 (nl <140ms). The delay between left ventricular and right ventricular ejection is 14 (nl <40ms). The left ventricle is dyssnchronous with global synchrony ([**Doctor Last Name **]) index of 52 ms (nl <=33ms). CXR [**2151-2-27**]: There has been no interval change in the position of the single-lead AICD. Mediastinotomy wires are seen. There is again noted prominence of the interstitial markings bilaterally. Underlying pulmonary edema cannot be excluded, however, these findings are stable when compared to multiple prior radiographs. No pleural effusions are seen. Labs: [**2151-2-21**] 04:30PM BLOOD WBC-8.7 RBC-3.62* Hgb-11.4* Hct-33.9* MCV-94 MCH-31.7 MCHC-33.7 RDW-17.9* Plt Ct-256 [**2151-2-21**] 04:30PM BLOOD PT-43.8* PTT-31.0 INR(PT)-5.0* [**2151-2-27**] 09:15AM BLOOD PT-18.4* PTT-27.2 INR(PT)-1.7* [**2151-2-21**] 04:30PM BLOOD Glucose-113* UreaN-35* Creat-1.2* Na-132* K-4.7 Cl-95* HCO3-25 AnGap-17 [**2151-2-27**] 09:15AM BLOOD Glucose-94 UreaN-21* Creat-0.8 Na-132* K-3.8 Cl-91* HCO3-33* AnGap-12 [**2151-2-21**] 04:30PM BLOOD ALT-25 AST-20 LD(LDH)-422* CK(CPK)-54 AlkPhos-79 TotBili-0.4 [**2151-2-23**] 04:33AM BLOOD ALT-25 AST-17 LD(LDH)-347* AlkPhos-75 TotBili-0.8 [**2151-2-22**] 05:51AM BLOOD CK(CPK)-52 [**2151-2-21**] 04:30PM BLOOD CK-MB-5 cTropnT-.19* proBNP-[**Numeric Identifier 24212**]* [**2151-2-22**] 05:51AM BLOOD CK-MB-NotDone cTropnT-0.16* [**2151-2-21**] 04:30PM BLOOD Albumin-3.6 Calcium-9.3 Phos-4.8* Mg-2.7* [**2151-2-27**] 09:15AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.0 [**2151-2-26**] 09:08PM BLOOD Digoxin-0.6* [**2151-2-21**] 06:00PM BLOOD Lactate-1.5 K-4.9 Brief Hospital Course: A/P: 57 F w/ [**Last Name (un) **] [**Last Name (un) **], PVD, CAD s/p CABG ('[**39**]), massive STEMI [**12-23**] c/b cardiogenic shock now w/ runs of ASx NSVT. . 1. Pump: a. She has class 4 HF, EF 10-15%. On admission, she appeared mildly volume overloaded and responded well to diuretics. Her BP continued to run low sBP 70s-100s throughout the hospital course likely secondary to her low ejection fraction although she was mentating well. Her ACEi dose was initially held but restarted at a lower dose once her BP tolerated. She was also on digoxin and received Lasix as needed for volume overload. A dyssynchrony study was performed which showed left ventricular dyssynchrony with the lateral wall contracting 105 ms later than the septum. EP was contact[**Name (NI) **] given her low EF for consideration for ICD placement. An AICD was placed without complication. b. Mural thrombus on previous TTE and severe apical akinesis. Initially Coumadin was held because the INR was supratherapeutic. Heparin IV was started to bridge INR in preparation for ICD placement. Coumadin was restarted post procedure. . 2. Ischemia: CAD: Pt w/ CABG (VG's to LAD and OM in [**2139**]), PCI of OM-LAD '[**41**] and PCI of acute MI (VG to LAD) [**12-23**]. She still has very tight consecutive 90% lesions in prox and mid LCx w/ occluded VG-OM. Cardiac enzymes were negative and EKG without changes. She was continued on aspirin, plavix, beta blocker, statin. Her ACEi was initially held but restarted at a lower dose once her BP tolerated. . 3. Rhythm: She was mostly in normal sinus rhythm although she had several asymptomatic runs of NSVT. She was treated with beta blockers. Electrolytes were repleted as needed An AICD was placed without complication. She will follow up with EP and the device clinic. . 4. Pressure ulcer: She has a coccyx pressure ulcer that was seen by the wound nurses and appropriate wound care was administered. The patient was also encouraged to change positions every [**1-19**] hours. . 5. Nausea: The patient had an episode of nausea with emesis and diarrhea. She remained afebrile and no elevated WBC. Stool cultures were negative. This was likely a brief episode of viral gastroenteritis and symptoms resolved. . 6. [**Last Name (un) 24206**] [**Last Name (un) 24206**]: h/o CVA [**2114**] and [**2124**]. No evidence of acute CVA. . 7. FEN: Low sodium, cardiac diet. Fluid restriction 1L per day. . 8. PPx: PPI. Anticoagulated. . 9. FULL CODE Medications on Admission: ASA Lipitor Metoprolol Lisinopril Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: 0.5 Tablet Sustained Release 24HR 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. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 9. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing, dyspnea. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 16. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1) unit Intravenous Q8H (every 8 hours) as needed. 17. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Two (2) units Injection Q6H (every 6 hours) as needed for nausea. 18. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 2 days. 19. Lasix 80 mg Tablet Sig: One (1) Tablet PO qdaily prn as needed for leg swelling. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary diagnosis: NSVT s/p ICD placement Systolic congestive heart failure. . Secondary diagnosis [**Last Name (un) 24206**] [**Last Name (un) 24206**] syndrome, cerebrovascular accident, seizure disorder, coronary artery disease, peripheral vascular disease Discharge Condition: Stable. Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please notify your doctors if [**Name5 (PTitle) **] experience fevers, chills, shortness of breath, cough, chest pain, chest pressure, leg swelling, dizziness, light headedness, abdominal pain, nausea, vomitting, or if your ICD fires or any symptoms that concern you. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1L per day Followup Instructions: Please follow-up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] in heart failure clinic on [**2151-3-24**] at 9:40am. Please call if questions: [**Telephone/Fax (1) 4451**]. . Please follow-up in device clinic for your new pacer on [**3-5**], [**2151**] at 1:00pm. Please call if questions: [**Telephone/Fax (1) 59**]. . Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2151-3-17**] at 10:45am, please call if questions: [**Telephone/Fax (1) 41**].

[ "428.0", "V45.81", "414.8", "429.79", "437.5", "428.22", "427.1", "V45.82", "414.01", "707.03" ]

icd9cm

[ [ [] ] ]

[ "37.94" ]

icd9pcs

[ [ [] ] ]

10315, 10385

5954, 8453

340, 373

10689, 10699

2815, 5931

11232, 11767

2319, 2364

8538, 10292

10406, 10406

8479, 8515

10723, 11209

2379, 2796

275, 302

401, 1757

10425, 10668

1779, 2100

2116, 2303

14,452

186,134

28416

Discharge summary

report

Admission Date: [**2185-9-12**] Discharge Date: [**2185-9-17**] Date of Birth: [**2141-7-28**] Sex: F Service: MEDICINE Allergies: Augmentin / Biaxin / Sulfa (Sulfonamides) / Naprosyn / Motrin Attending:[**First Name3 (LF) 613**] Chief Complaint: Obstructed kidney stone Major Surgical or Invasive Procedure: Nephrostomy History of Present Illness: HPI: Pt is a 44 yo female with PMHx of allergic fungal sinusitis, who presents from OSH with obstructed kidney stone. Pt, who has no history of stones, says that Friday [**2185-9-9**] she started to have pain on the right side. She is unable to describe it saying that it was "constant and hurt." The next day, she continued to have the pain which was worse and a [**6-30**]. She also had subjective fevers, but did not take her temperature. Yesterday, she went to OSH ED ([**Hospital3 **] Hospital). She was found to have a WBC of 22.7, 89% neutrophils. U/a was WBC >50, +LE,. A transabdominal u/s done for RUQ pain showed normal kidneys and no hydronephrosis. There was an 8.9 x 6.3 mm gallstone without evidence of pericholecystic fluid and no evidence of choledocholithiasis (free fluid in morrisons pouch). She was discharged home on levaquin. . Pt again presented to OSH ED ~3 am this am as pain was worse and she was lightheaded. Pt noted to be tachycardic to 118, hypotensive to 81/55, and temp to 99.9. CT abd/pelvis showed a 5 mm calculus in the right proximal ureter 5 cm below ureteropelvic junction with mild right hydronephrosis and right renal perinephric stranding. There was also a 1 mm non-obstructing left ureter calculus. Pt was transferred to [**Hospital1 **] this am for further management and likely IR procedure. . VS on arrival to [**Hospital1 18**] were: T: 104.6, HR: 127; BP: 138/75; RR: 25. She was given 1 g tylenol, 1 g vancomycin, 500 mg IV levaquin, 2 mg IV morphine, solumedrol 125 mg IV x 1, motrin 600 mg po. She was noted to develop an arm rash and eyelid edema when she got the levaquin and morphine. She was given 25 mg po benadryl. Currently pt denies any pain. No dysuria or hematuria per pt. No N/V. . Past Medical History: Past Medical History: Allergic fungal sinusitis- s/p multiple surgeries since [**2171**] Asthma Colonoscopy- done for screening showed polyps Uterine fibroids s/p surgery Social History: Owns plumbing and heating company with husband. [**Name (NI) **] children. No smoking. Social beer. No drugs. Family History: F: melanoma; M: CAD; kidney stone. No other renal problems in family. Physical Exam: VS: T: 98.4; BP: 91/53; HR:85; RR: 16; O2: 97 RA Gen: Laying in bed speaking in full sentences in NAD HEENT: Puffy eyelids. PERRLA; EOMI; sclera anicteric; OP clear. No pettechiae. Neck: No LAD. CV: RRR S1S2. No M/R/G Lungs: CTA b/l with good air entry Abd: NABS. +suprapubic tenderness. +RUQ pain without rebound. + right CVA/flank pain. Back: No spinal, paraspinal tenderness. CVA/flank as above Ext: No edema. DP 2+ Neuro: CN II-CII tested and intact. Skin: puffy eyelids slightly erythematous. Scattered papules left hand, right leg. . Pertinent Results: [**2185-9-12**] 08:29PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.033 [**2185-9-12**] 08:29PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2185-9-12**] 08:29PM URINE RBC-[**4-30**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [**2185-9-12**] 06:30PM GLUCOSE-137* UREA N-8 CREAT-0.9 SODIUM-141 POTASSIUM-4.8 CHLORIDE-116* TOTAL CO2-16* ANION GAP-14 [**2185-9-12**] 06:30PM CALCIUM-6.4* PHOSPHATE-2.3* MAGNESIUM-1.8 [**2185-9-12**] 06:30PM WBC-10.3 RBC-3.45* HGB-10.8* HCT-31.2* MCV-91 MCH-31.4 MCHC-34.7 RDW-13.0 [**2185-9-12**] 06:30PM PLT COUNT-214 [**2185-9-12**] 11:37AM PT-13.5* PTT-32.6 INR(PT)-1.2* [**2185-9-12**] 09:02AM LACTATE-1.7 [**2185-9-12**] 09:00AM GLUCOSE-102 UREA N-9 CREAT-1.1 SODIUM-131* POTASSIUM-5.7* CHLORIDE-103 TOTAL CO2-20* ANION GAP-14 [**2185-9-12**] 09:00AM ALT(SGPT)-21 AST(SGOT)-75* ALK PHOS-53 AMYLASE-66 TOT BILI-0.3 [**2185-9-12**] 09:00AM LIPASE-51 [**2185-9-12**] 09:00AM WBC-15.7* RBC-4.27 HGB-12.9 HCT-39.1 MCV-92 MCH-30.3 MCHC-33.1 RDW-13.0 [**2185-9-12**] 09:00AM NEUTS-80* BANDS-6* LYMPHS-9* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2185-9-12**] 09:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [**2185-9-12**] 09:00AM PLT SMR-NORMAL PLT COUNT-250 Brief Hospital Course: Pt is a 44 yo female with chronic sinusitis who presents with an obstructed kidney stone. 1. Obstructed kidney stone- with impaction and superimposed infection. u/a, ucx taken at OSH, none here. At OSH, growing >100,000 pan sensitive E.Coli. UCx negative at [**Hospital1 18**]. -Pt is allergic to PCN (augmentin). Treated with gentamicin - had nephrostomy with tube placement. kidney abscess improved on repeat CT. Evaluated by ID consult, sent home on Ciprofloxacin 500 Q12 for 14days. Will need follow up CT scan before seeing urology as outpatient. 2. Pain control- ? allergy with morphine. Dilaudid IV prn. . 3. Rash- scattered papules on arm and swollen eyelids. Unclear if from levaquin or morphine. Will also need to look and see when she got the motrin. -benadryl prn; Famotidine [**Hospital1 **]. On steroids (see below) . 4. Chronic steroid use- On steroids as outpatient. prednisone 10mg QOD . 5. Acute renal failure- Creatinine was 1.4 at OSH now 1.1. Likely [**12-23**] post renal obstruction. . 6. Chronic sinusitis- continue home regimen of once tolerating POs and will continue nasal sprays. . Medications on Admission: Medications: Prednisone 10 mg qod Fexofenadine Albuterol prn- ~1x/day Flovent 110 mcg, qday Nasonex Singulair qday Discharge Medications: 1. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for rash. 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QOD (). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 1. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for rash. 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QOD (). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 12. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks: Continue until you have blood checked with your primary care physician and are instructed further. Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 13. Outpatient Lab Work Patient will require once weekly Chemistry-7 profile performed until appointment with Primary Care Physician Discharge Disposition: Home Discharge Diagnosis: Primary - Kidney abscess - nephrolithiasis . Secondary - Asthma Discharge Condition: Good. Patient is afebrile, hemodynamically stable, O2 sats > 95% on RA Discharge Instructions: 1. Please take all medications as prescribed . 2. Please keep all outpatient appointments . 3. Please return to the hospital immediately or seek medical attention for symptoms of fevers/chills, dizziness, shortness of breath or any other concerning symptom. Followup Instructions: 1. You should be seen by your primary care physician within one week for follow up visit and to have potassium levels monitored. PLease call your PCPs office to schedule this appointment. . 2. Please call Dr. [**Last Name (STitle) 3748**] from the division of Urology at([**Telephone/Fax (1) 39050**] to schedule an outpatient appointment. You will need to be seen in approximately three weeks time. At this office visit your nephrostomy tube will be removed. Also, a follow-up CT scan has been ordered for you. Please call the radiology department at [**Telephone/Fax (1) 327**] on Monday to schedule an appointment for the study. The CT scan should be done in 2 weeks (before you see urology) [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2185-9-17**]

[ "995.91", "590.10", "038.42", "591", "584.9", "E935.6", "693.0", "592.1", "493.90", "592.0", "V58.65", "473.9" ]

icd9cm

[ [ [] ] ]

[ "55.03" ]

icd9pcs

[ [ [] ] ]

8179, 8185

4517, 5630

346, 360

8293, 8366

3120, 4494

8672, 9519

2473, 2545

5796, 8156

8206, 8272

5656, 5773

8390, 8649

2560, 3101

282, 308

388, 2134

2178, 2329

2345, 2457

1,472

161,232

47160

Discharge summary

report

Admission Date: [**2107-9-26**] Discharge Date: [**2107-10-3**] Date of Birth: [**2027-2-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6565**] Chief Complaint: Fatigue, DOE Major Surgical or Invasive Procedure: Thoracentesis History of Present Illness: Mr. [**Known lastname 99932**] is an 80 year old male with history of prostatic adenocarcinom s/p radiation in [**2097**], adrenal mass (presumed angiomyolipoma) recently increased in size, MGUS, gastric polyps, mitral regurgitation, and atrial fibrillation s/p CVA x 2 on coumadin, who presented to the ED on the day of admission with c/o fatigue and dyspnea on exertion x 1 week. He says that he was in his usual state of health prior to this, but noted the gradual onset of dyspnea with things he could normally do more easily, such as walking up the stairs. He denies any orthopnea or PND. He has chronic LLE edema from [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] cyst. Denies fevers/chills. No melena, hematochezia, or hematemesis. No lightheadedness, dizziness, or vision changes. Of note, he has had about a 20 pound weight loss over the last few months. Denies bone pain, denies night sweats. His medical history is notable for prostatic adenocarcinoma treated with radiation in [**2097**]. His PSA nadired at 0.6 in [**2099**], but has been rising since, with a doubling time of about 2 years. He recently had a bone scan that was negative. Additionally, he has had a known L adrenal mass since as far back as [**2100**], with radiologic features c/w angiomyolipoma. Recently, however, on a CT scan from [**6-8**] the mass had been found to increase to 12 cm in largest dimension as compared to 6 cm in [**10-7**]. An MRI of the abdomen in [**8-8**] was consistent with hemorrhage into an angiomyolipoma, however a CT of the abdomen just 2 weeks later demonstrated an increase in size to 18 cm, with concern for transformation to carcinoma. Also demonstrated on this CT were new scattered non-calcified b/l pulmonary nodules < 5 mm in diameter. A repeat abdominal MRI done at the end of [**Month (only) 205**] confirmed the marked increase in size of the adrenal mass, additionally demonstrating at least 4 new focal liver lesions ranging in size from 6-8 mm. On arrival to the ED on the day of admission, his vitals were 97.8, HR 72, BP 157/65, RR 26, 95% RA. He appeared comfortable. His labs were notable for a hct of 26, down from 33 on [**8-17**], as well as a mild leukocytosis of 14. His INR was 2.3 (on coumadin). An EKG showed AF, with mild T wave flattening and ?low voltage in limb leads. He had a CT of the abdomen which revealed interval development of large bilateral pleural effusions with adjacent compressive atelectasis, the overall appearance and bilateral nature of which was felt to be most c/w failure; interval development and increase in size of numerous pulmonary nodules, as well as a slight interval increase in the previously described large left adrenal mass. An NG lavage was negative, though he was guaiac positive. He was transfused 1 U PRBCs, 2 U FFP, and given 40 mg IV lasix x 1 prior to transfer to the [**Hospital Unit Name 153**]. Past Medical History: 1) Chronic arthritis 2) Adenocarcinoma of the prostate in [**2097**], s/p radiation. Adrenal myelolipoma, first noted on CT in [**2100**], relatively stable in size until large increase from [**2104**] to [**2106**]. See above. 3) Non-insulin dependent diabetes with peripheral neuropathy 4) Atrial fibrillation on coumadin 5) CVA x 2 6) Monoclonal gammopathy of unknown significance 7) Mitral regurgitation: Last echo [**12-9**] showed EF 55%, moderately dilated RA and LA, 1+ MR, [**2-6**]+ TR, and moderate pulmonary systolic hypertension. 8) Gastric polyps: Seen on EGD [**7-10**] with the appearance of recent bleeding. Biopsy c/w hyperplastic polyps. Social History: Lives alone in an apartment in [**Location (un) **]. Able to ambulate on his own. Doesn't get any home services, takes all of his medications on his own. Used to smoke but quit 50 years ago. Used to drink socially, not much anymore. Family History: Mother died of breast ca at 80. Otherwise no known cancer history. Physical Exam: VS: 98.7, 66, 171/84, RR 24, 97% on 2L via NC Gen: Cachectic caucasian male appearing slightly tachypneic with some accessory muscle use, but otherwise comfortable and conversant. Skin: Prominent seborrheic keratoses over majority of skin surface. HEENT: Anicteric sclerae, moist MM. Neck: JVP at approx 10 cm, no bruits. Cor: RR, normal rate, no m/r/g. Lungs: Decreased breath sounds and dullness to percussion at both bases, mild rales just above dullness b/l. Abd: NABS, NT. Large firm nodular mass palpated in LUQ extending to umbilicus. Liver edge palpable 2 cm below the costal margin, though edge sharp and surface smooth. Extr: Trace edema of LLE to knee. Pertinent Results: . . . . . . . . . . . . . . . [**2107-9-26**] CT ABDOMEN/PELVIS, IMPRESSION: 1. Interval development of large bilateral pleural effusions with adjacent compressive atelectasis. The overall appearance and bilateral effusions is most suggestive of failure. 2. Interval development and increase in size of numerous pulmonary nodules. The differential includes metastatic disease, although the rapidity of the change compared to the prior study makes this unusual, and infectious etiologies, particularly given the surrounding ground glass. 3. Slight interval increase in the previously described large left adrenal mass, as discussed previously. The overall stability of the configuration and lack of a large change in mass makes this unlikely to account for a large hematocrit drop. [**9-26**] CXR PA and lat: IMPRESSION: CHF. Increased opacity in the left lower lobe could be atelectasis or pneumonia. Brief Hospital Course: 80 yo M with history of prostatic adenocarcinoma s/p radiation in [**2097**], adrenal mass (presumed angiomyolipoma) recently demonstrating signs of malignant conversion, MGUS, mitral regurgitation, and atrial fibrillation s/p CVA x 2 on coumadin, who presented to the ED on the day of admission with fatigue and DOE, found to have new large pleural effusions, increased pulmonary nodules, mild leukocytosis, large hematocrit drop, and guaiac positive stools. 1. Lung/liver nodules: preliminary cytology from pleural fluid with some atypical cells. Final report revealing mesothelial cells, blood and no evidence of malignant cells. However, it is still possible that malignant cells were present considering that there was no other evidence of infection in tap. However, did have elevated WBC but also had urosepsis. 2. Dyspnea: Dyspnea worsened with re accumulation of pleural effusions but also with increased size of nodules. Preliminary cytology from thoracentesis results with atypical cells. CTA no PE. Bedside echo no tamponade. Had worsening respiratory distress on [**2107-10-3**]/ Oxygen saturations began dropping on non-rebreather. Patient was asked if he wished to be intubated and said that he did not want this or any other drastic measures taken. His family was called and agreed with the patient's wishes. He was made comfortable with morphine and expired on [**2107-10-3**]. His family was offered an autopsy but declined. Medications on Admission: Moexipril 50 mg qday Prilosex 20 mg PO BID Procardia XL 90 mg PO Qday Glucotrol XL 10 mg Qday Glucophage 100 mg PO TID Zocor 30 mg PO Qday Coumadin 3mg/2mg Discharge Disposition: Expired Discharge Diagnosis: Expired secondary to respiratory failure Discharge Condition: Expired Discharge Instructions: No autopsy done as refused by family. Followup Instructions: none [**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]

[ "428.0", "790.7", "V12.59", "280.0", "599.0", "427.31", "250.60", "197.0", "197.7", "397.0", "194.0", "263.9", "357.2", "V10.46", "424.0", "V58.61", "197.2" ]

icd9cm

[ [ [] ] ]

[ "34.91", "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

7607, 7616

5950, 7401

328, 343

7700, 7709

5022, 5927

7795, 7928

4246, 4315

7637, 7679

7427, 7584

7733, 7772

4330, 5003

276, 290

371, 3293

3315, 3977

3993, 4230

47,404

102,142

39436

Discharge summary

report

Admission Date: [**2107-9-27**] Discharge Date: [**2107-10-18**] Date of Birth: [**2047-5-25**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2836**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2107-9-28**]: Placement of bilateral chest tube. [**2107-10-13**]: PICC line placement History of Present Illness: Ms. [**Known lastname 87141**] is a 60 y/o woman no known PMH who is transferred from an OSH with presumed gallstone pancreatitis, increasing leukocytosis, and fevers. On [**9-20**] she presented to [**Hospital3 628**] with a 1-day history of epigastric transitioning to RUQ abdominal pain, non-bilious emesis, and night sweats. Laboratory evaluation was notable for WBC 13.9, Hct 48.9, lipase 10,000, TBili 1.06, alkaline phosphatase, 115, ALT 115, AST 94. A RUQ ultrasound was reported to show gallbladder wall edema with presence of gallstones and CBD measuring 5mm with no evidence of intraductal dilatation. She was admitted to the ICU, given fluid resuscitation, started on Unasyn. She remained hemodynamically stable and her amylase/lipase continued to trend down. She then developed persistent tachycardia which was treated with metoprolol. She spiked a fever to 101.8 and began wheezing on hospital day 3, and a chest x-ray showed bilateral pleural effusions. The effusions were felt to be secondary to significant fluid rehydration. With aggressive pulmonary toilet, she improved clinically. An MRI was obtained on [**9-25**] which reported a hemorrhagic pancreatitis with a component of necrosis, severe inflammatory changes, significant retroperitoneal fluid/ascites, and a distended, fluid-filled gallbladder. MRCP showed no stone in the CBD. She remained hemodynamically stable but was later found to have a R subclavian vein thrombus related to her CVL, which was subsequently replaced. On [**9-26**] she developed worsening wheezing and became tachypneic with RR 30-40s. Her WBC count bumped to 21.4, however, her amylase and lipase continued to decrease (57, 193). A CT abdomen was performed and reported to show extensive necrosis of the pancreas with a likely hemorrhagic component, as well as cholecystitis. There was also reported to be a questionable area of splenic vein compression due to inflammation. In addition to her pleural effusions, a LLL opacification was identified, atelectasis vs. consolidation. Due to concern for fatigue from her persistent tachypnea, Ms. [**Known lastname 87141**] was intubated [**9-26**] PM. Due to concern for worsening infection, bilateral pleural effusions, and an uncertain source of leukocytosis, the patient was transferred to [**Hospital1 18**] for further evaluation and management. Past Medical History: Questionable history of asthma associated with URIs. Hx of fibroid removal, appendectomy. Social History: Denied alcohol, tobacco, or illicit drug use. Family History: Significant for mesothelioma in her father. Physical Exam: Physical Exam on Admission: Temp: 99.9 HR: 95 BP: 106/60 RR: 31 O2 Sat: 100% Vent: CMV 100%, 422 x 14, PEEP 5 GEN: Intubated, sedated. Obeys commands. NG tube. HEENT: PERRL. Scleral icterus. Moist mucous membranes. NECK: No JVD appreciated. RES: Mildly coarse breath sounds in setting of ventilator. Decreased at bases. CV: RRR. No m/r/g appreciated. GI: Soft. Obese. Some distension likely. No arousal when abdomen palpated to indicate pain. EXT: Warm, well-perfused. 1+ pitting edema b/l LEs. Cap refill <2 sec. On Discharge: VS: 100, 91, 137/86, 18, 96% RA Gen: NAD CV: RRR, no m/r/g Lungs: Decreased on bases Abd: Soft, obese. Slightly distended, minimal tenderness on palpation in epigastric region Extr: Warm, 1+ pitted b/l edema. Pertinent Results: [**2107-9-27**] 10:46PM TYPE-ART PO2-220* PCO2-31* PH-7.50* TOTAL CO2-25 BASE XS-2 [**2107-9-27**] 10:46PM LACTATE-1.7 [**2107-9-27**] 10:46PM freeCa-1.07* [**2107-9-27**] 09:41PM GLUCOSE-178* UREA N-23* CREAT-1.0 SODIUM-141 POTASSIUM-3.4 CHLORIDE-107 TOTAL CO2-23 ANION GAP-14 [**2107-9-27**] 09:41PM estGFR-Using this [**2107-9-27**] 09:41PM ALT(SGPT)-25 AST(SGOT)-33 LD(LDH)-615* ALK PHOS-111* AMYLASE-97 TOT BILI-0.9 [**2107-9-27**] 09:41PM LIPASE-42 [**2107-9-27**] 09:41PM ALBUMIN-2.5* CALCIUM-7.9* PHOSPHATE-3.9 MAGNESIUM-2.1 [**2107-9-27**] 09:41PM WBC-21.9* RBC-2.89* HGB-8.5* HCT-24.8* MCV-86 MCH-29.2 MCHC-34.1 RDW-15.2 [**2107-9-27**] 09:41PM PLT COUNT-365 [**2107-9-27**] 09:41PM PT-15.4* PTT-32.7 INR(PT)-1.3* [**2107-10-11**] 07:15AM BLOOD WBC-9.7# RBC-3.63*# Hgb-10.7*# Hct-32.1*# MCV-88 MCH-29.4 MCHC-33.2 RDW-17.2* Plt Ct-659* [**2107-10-18**] 04:52AM BLOOD Glucose-113* UreaN-12 Creat-0.8 Na-139 K-3.9 Cl-107 HCO3-24 AnGap-12 [**2107-10-17**] 06:40AM BLOOD Amylase-395* [**2107-10-17**] 06:40AM BLOOD Lipase-138* [**2107-9-27**] 11:53 pm BLOOD CULTURE Source: Line-new aline. **FINAL REPORT [**2107-10-4**]** Blood Culture, Routine (Final [**2107-10-4**]): NO GROWTH. [**2107-9-28**] 12:28 am URINE Source: Catheter. **FINAL REPORT [**2107-9-29**]** URINE CULTURE (Final [**2107-9-29**]): NO GROWTH. [**2107-9-28**] 4:25 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2107-10-7**]** GRAM STAIN (Final [**2107-9-28**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2107-10-7**]): RARE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. RARE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S [**2107-9-29**] 1:46 am PLEURAL FLUID RIGHT CHEST TUBE. **FINAL REPORT [**2107-10-5**]** GRAM STAIN (Final [**2107-9-29**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2107-10-2**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2107-10-5**]): NO GROWTH. [**2107-10-7**] 1:30 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2107-10-8**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2107-10-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). RADIOLOGY: [**2107-9-28**] CHEST PORT: IMPRESSION: 1. Small bilateral pleural effusions. 2. Bibasilar opacities, likely atelectasis, pleural fluid or infection, if clinically appropriate. [**2107-10-3**] CHEST PORT: FINDINGS: Bilateral chest tubes are again visualized. No pneumothorax is identified. The endotracheal tube has been removed. The left IJ line tip is in the SVC. Feeding tube tip is off the film, at least in the stomach, volume loss in the right lower lung has increased slightly and there is persistent plate-like atelectasis in the left lower lung. [**2107-10-5**] CHEST PA/LAT: There are persistent low lung volumes. There is mild-to-moderate bilateral pleural effusion, larger on the left side, associated with adjacent atelectasis. The upper lungs are clear. There are no new lung abnormalities. Left IJ catheter and Dobbhoff tube are in place in standard position. There is no pneumothorax. [**2107-10-13**] CHEST PA/LAT: IMPRESSION: Mild increase in bilateral pleural effusions, left greater than right. Dobbhoff tube tip now in fundus of stomach. [**2107-10-13**] CT ABd: IMPRESSION: 1. Large pancreatic pseudocyst essentially replaces pancreatic parenchyma with no identifiable parenchyma remain. 2. Non-visualization of splenic vein concerning for splenic vein thrombosis. 3. Persistently distended gallbladder; gallstones are better visualized in prior study. 4. Reactive bilateral left greater than right pleural effusions with associated compressive atelectasis, reaching subsegmental level on the right and segmental on the left. 5. Dobbhoff tube coiled with tip terminating in stomach. Brief Hospital Course: Ms. [**Known lastname 87141**] was initially sedated and intubated in the ICU. She continued to have fevers in the ICU, spiking to 102.3. Blood cultures taken remained negative. Sputum culture grew MSSA. B/l chest tubes were placed for pleural effusions, with the L>R and increased WBC counts. She was gradually weaned from ventilation and extubated on [**2107-10-2**], started on post-pyloric tube feeds and transferred to the floor. She was started on diuresis with IV Lasix to assist in removing excessive water. On [**2107-10-3**], with minimal chest tube output, her chest tubes were removed. Ms. [**Known lastname 87142**] amylase/lipase trended down to near-normal limits by her arrival to [**Hospital1 18**] but then started to increase again a few days post-admission to peak on [**10-12**] (677 amylase peaked on [**10-13**]; lipase peaked to 294 on [**10-7**]) to trend downwards on discharge (amylase/lipase 395/138). CT Abd/Pelvis on [**2107-10-13**] showed large pancreatic pseudocyst essentially replacing the entire pancreas with minimal normal pancreatic parenchyma. GI: On the floor, Ms. [**Known lastname 87141**] was advanced to sips then to clear liquids for a diet along with tube feeds. She had a few small episodes of emesis and was changed back to NPO status on [**2107-10-4**] until [**2107-10-10**] when she was readvanced from NPO to sips to clears which she tolerated well. She was tolerating clears well at time of discharge. On [**2107-10-15**] her tube feeds were stopped and she was transitioned to TPN for the duration of her hospitalization. ID: Ms. [**Known lastname 87141**] continued to spike low grade temperatures when on the floor. She was initially on multiple broad spectrum antibiotics (vanc/levo/flagyl). This was narrowed to nafcillin given the sputum culture and was dc'd after completion of the abx course on [**2107-10-11**]. All cultures except for the sputum culture (MSSA) were negative. Repeat CXRs late in the course of her hospitalization showed improvement in the pleural effusions and no signs of pneumonia. Pulm: On admission patient was found to have large bilateral pulmonary effusions. Bilateral chest tubes were placed in ICU, patient had daily chest x-rays to assess her pulmonary status. Effusions got better with chest tubes and lasix IV. On [**2107-10-3**] both chest tubes were removed. Patient was treated with IV Lasix for fluid overload, and she was weaned from supplemental O2. Currently, patient on room air, denies DOE, last CT ([**10-13**]) showed small b/l effusions. Heme: Ms. [**Known lastname 87141**] was thought to have acute on chronic anemia. Her Hct was stable in the in the mid 20s throughout her hospitalization. She was transfused on [**10-10**] for a Hct of 24. It responded appropriately and stayed in the high 20s upon discharge. Renal: Ms. [**Known lastname 87142**] renal function was normal throughout her stay with creatinine at baseline and remaining at 0.8 on discharge. She was diuresed extensively during her stay, especially in the week prior to discharge and was at her dry weight prior to discharge. She was discharged on [**2107-10-18**], at the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating clear liquid diet, ambulating with minimal assist, voiding without assistance, and pain was well controlled. The patient was evaluated by Physical therapy and recommended to be discharged in Rehab to continue PT. The patient was discharged in Rehab in stable condition, she will continue TPN until her f/u appointment with Dr. [**First Name (STitle) **]. Medications on Admission: None Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q12H (every 12 hours) as needed for constipation. 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas pains. 9. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 10. Dextrose 50% in Water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. 11. Famotidine(PF) in [**Doctor First Name **] (Iso-os) 20 mg/50 mL Piggyback Sig: One (1) Intravenous Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: 1. Gallstone pancreatitis 2. Pancreatic pseudocyst 3. Bilateral pleural effusion 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: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2107-10-28**] 9:30 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]. You will have an abdominal CT scan prior you appointment with Dr. [**First Name (STitle) **], Dr.[**Name (NI) 5067**] office will inform you about time of the CT scan. Completed by:[**2107-10-18**]

[ "577.0", "285.9", "482.41", "574.20", "041.11", "577.2", "288.60", "518.81", "511.9" ]

icd9cm

[ [ [] ] ]

[ "99.15", "96.6", "38.93", "96.72", "34.04" ]

icd9pcs

[ [ [] ] ]

13577, 13643

8660, 12294

330, 422

13768, 13768

3829, 8637

15334, 15744

3001, 3047

12350, 13554

13664, 13747

12320, 12327

13951, 15311

3062, 3076

3600, 3810

276, 292

450, 2807

3090, 3586

13783, 13927

2829, 2921

2937, 2985

12,547

125,356

25726+57465

Discharge summary

report+addendum

Admission Date: [**2140-8-17**] Discharge Date: [**2140-8-29**] Date of Birth: [**2085-3-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2880**] Chief Complaint: Witnessed Public Fall Major Surgical or Invasive Procedure: Coronary catheterization - no intervention, 3VD Hip fracture repair - no complications History of Present Illness: HPI: The pt. is a 55 year-old male with a history of coronary artery disease and diabetes mellitus who presented after being found down by EMS. At the time of my encounter, the pt was intubated and sedated and thus the history is per the record. On arrival to the ED, the pt. stated that he bent over to get his wallet and could not get up. He denied losing consciousness. EMS was called at 1331, arrived at 1337, departed at 1339 and arrived at hospital at 1352. It is presumed he was not down for long as he was in a populated area, town square, and EMS was called immediately. Per EMS notes, he was alert and oriented x3, found supine on the ground, denied all complaints. EMS report noted slurred speech, right sided gaze preference, weakness on the left side. Per EMS record, the pt's fingerstick glucose was 163, Pupils 4mm bilaterally. Pt arrived at [**Hospital1 18**] and a "code stroke" was called at 1402. Patient seen immediately by ED neuro resident. Patient was found awake, alert, fluent, denying anything is the matter, was noted to have right gaze preference, left sided hemiparesis (held both UE to gravity x 10 seconds, held left LE to gravity x 4 seconds then fell), left sensory neglect, left field cut vs. neglect. NIHSS of 10 on arrival. Fingerstick glucose was 161 in the ED. The pt was taken for head CT, which was negative for bleed. The patient denied history of GI bleed, MVA or trauma, recent MI, h/o stroke or seizures, recent surgery, brain tumor, aneurysms. SBP was 171/110 thus intravenous t- PA was given. Stated weight of 240 pounds, thus patient was bolused with 9mg t- PA at 1433, and remaining 81mg infused over the next hour. After t- PA was given, patient's status worsened, with less verbal output, inability to raise left side to gravity (was able to previously). Repeat head CT showed no bleed. Later, patient began having periods of apnea, became cyanotic, using accessory muscles to breathe, thus patient intubated and sedated at 1515. . ROS: Pt denies F/C/N/V/diarrhea/LOC/LH/sz/pain or other symptoms prior to his episode on the day of admission. Endorses 2 pillow orthopnea, intermittenly PND, leg claudication, DOE. Not on Home O2. Past Medical History: DM2 - oral antihyperglycemics since [**2136**] CAD s/p MI x 2 in [**2136**] - cath w/o stents - and MI in [**2138**] Non-specific "poikiloderma" in past ? Nephrotic syndrome in past ? H/O drug abuse . MEDS: -aspirin -he takes an oral hypoglycemic medication but was unsure of which ALL: NKDA Social History: SH: Smoker for 25 yrs ppd. Quit 4 yrs ago. EtOH [**1-17**] drinks/month. Denies current illicits. Denies any IVDU, admits to cocaine, mescaline, marijuana use during 20's and 30's. Family History: FH: Father died - cancer. Mother died ulcer perforation. Mat GF and Maternal Aunt - MI. Physical Exam: Vitals: T: 98F P: 60 R: 16 BP: 150/68 SaO2: 100% 0.4FiO2 General: Lying in bed, intubated and sedated. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs with rales at bases Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. Neurologic: -mental status: Sedated. -cranial nerves: PERRL 3 to 2mm and brisk. Facial musculature appears symmetric. -motor: normal bulk, tone throughout. No adventitious movements noted. [**Name8 (MD) **] RN, pt was thrashing all extremities symmetrically earlier when taken off sedation for previous examiner. -DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally. Plantar response was extensor on left, flexor on right. Pertinent Results: Laboratory data: 6.7> <319 44.8 PT: 13.0 PTT: 23.4 INR: 1.1 [**Age over 90 **]|105|13 /174 4.0| 22|1.3\ CK: 168 MB: 7 Trop-*T*: 0.07 EKG: incomplete LBBB, TWI flattening V4-V6 CT head: There is a small lacunar infarction in the right basal ganglia which appears old and there is a tiny area of decreased attenuation in the right parietal white matter, also with the appearance of an old infarction. There are no areas of cortical attenuation abnormality or gyral edema to suggest acute cortical infarction. The ventricles are not dilated. There is no shift of intracranial structures. No acute intracranial hemorrhage is seen. The visualized paranasal sinuses and mastoids are clear. The skull has a normal appearance. IMPRESSION: An acute infarction is not identified, however, MRI with diffusion-weighted imaging would be a more sensitive study for evaluation if this is suspected. There is no acute intracranial hemorrhage. . . . MRI/MRA ([**2140-8-19**]) FINDINGS BRAIN MRI: Diffusion images demonstrate slow diffusion in the right insular cortex extending to the right basal ganglia and corona radiata region indicative of acute infarct. Small areas of acute infarct also seen in the posterior aspect of the right sylvian fissure along the right temporal cortex and in the right frontal cortical region. These findings indicate acute infarcts in the distribution of the right middle cerebral artery. Additionally, a small area of slow diffusion is identified at the left parietal convexity region. This most likely represents a small area of acute infarct in the left parietal cortex. There is no mass effect or midline shift seen. Mild prominence of ventricles and sulci noted. Following gadolinium, no evidence of abnormal enhancement seen. No evidence of acute or chronic blood products are identified. IMPRESSION: Acute infarcts in the distribution of right middle cerebral artery, predominantly involving the insular cortex and subcortical region of the corona radiata and basal ganglia. Small infarcts in the right temporal and frontal region are also noted. A small infarct is seen in the left parietal cortical region. No enhancing lesions are identified. MRA OF THE HEAD: The head MRA demonstrates normal flow signal within the arteries of anterior and posterior circulation. No evidence of vascular occlusion or stenosis is seen. IMPRESSION: Normal MRA of the head. . ECHO [**2140-8-19**]: Conclusions: The left atrium is dilated. The right atrium is moderately dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers (however cannot exclude and views were suboptimal). Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed. Resting regional wall motion abnormalities include inferior/inferolateral hypokinesis/akinesis, severe septal hypokinesis and probable apical hypokinesis with moderate to severe hypokinesis elsewhere. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. The aortic root is mildly dilated. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a very small pericardial effusion. Electronically signed by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD on [**2140-8-18**] 13:27. . Hip Film [**2140-8-18**] IMPRESSION: Minimally displaced left subcapital femoral neck fracture. Better evaluation could be provided using LAO or RPO views of the left hip. . CXR [**2140-8-19**]: IMPRESSION: 1. ET tube at the thoracic inlet, about 8 cm from the carina. This should be pushed in at least 2-3 cm. 2. Improving pulmonary edema. These findings were communicated to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].. . CT abdomen [**2140-8-17**]: IMPRESSION: 1. No abnormal high-attenuating fluid collections to indicate hematoma are identified. 2. Moderate-sized bilateral pleural effusions with reactive atelectasis. Increased septal lines and ground-glass opacities consistent with pulmonary edema. 3. Anasarca. . . CATH [**2140-8-23**] FINAL DIAGNOSIS: 1. Severe three vessel coronary artery disease. 2. Mild aortic stenosis. 3. Depressed ventricular systolic function. 4. Severe pulmonary arterial hypertension. 5. Elevated right and left heart filling pressures. 6. Successful deployment of Perclose device to close right common femoral arteriotomy site. LMCA is short with dual ostia. The proximal LAD had an 80% stenosis along with serial 40% stenoses in the mid and distal LAD with mild luminal irregularities throughout. The first Septal branch has a 70% ostial stenosis. The D1 is small and the D2 is also small, but occluded, filling via left to left collaterals. The LCx has an 80% ostial stenosis with 50% proximal stenosis and mild diffuse diaseas throughout its course about the AV groove. The OM1 is small with 70% ostial stenosis and diffuse disease. The OM2 is small and has mild luminal irregularities. The L-PDA and L-PL have only mild luminal irregularities. The RCA is a small, non-dominant vessel with diffuse disease including a 95% stenosis in the middle segment. Resting hemodynamics from right and left heart catheterization demonstrated moderately elevated right (RVEDP=23mmHg) and left (LVEDP=28mmHg, PCWP=23mmHg) heart filling pressures. There was severe pulmonary arterial hypertension (86/40 mmHg). There was also moderate systemic arterial hypertension (170/80mmHg). Brief Hospital Course: BRIEF OVERVIEW: The pt is a 55 year old man with vascular risk factors that include diabetes mellitus, CAD, former smoking, who presented with acute onset of right gaze reference, left hemiparesis, left sensory neglect and visual neglect vs hemianopsia (NIHSS 10). The etiology of his stroke his most certainly embolic, either from cardiac, aortic or carotid source. He is S/P t-PA at 2:33pm as patient denied any contraindications and CT negative for bleed. Patient's condition then worsened after t-PA (increased weakness, less responsive), repeat head CT neg. Respiratory compromise ensued, thus intubated in the ED. Respiratory compromise was likely due to acute pulmonary edema in the setting of elevated blood pressure. The pt was quickly extubated and transfered out of the unit to the neurology service. Deficit was greatly reduced and only a L pronator drift remained. Hip films were taken due to pain and an externally rotated hip. Echo showed a low EF with hypokinesis as reported above. Cardiac enzymes were positive but trending down. The pt was transfered to the [**Hospital Unit Name 196**] service for further w/[**Location 64117**] and CHF. The pt was grossly volume overloaded. He was diuresed aggressively in hopes of stabilization for hip surgery. His goal diuresis was -3L per day, which was acheived with 80IV lasix [**Hospital1 **]. Prior to hip surgery he had a coronary catheterization to help risk stratify and intervene if possible. However, he was found to have 3VD and was thought to need CABG in future. No intervention was done. The pt then went to hip surgery on [**8-25**]. The hip was fixed under local anesthetic and the pt did well. He was sent to the floor on lovenox (1 mo therapy) and with PT - he participated and did well. Endocrine was c/s'd due to an increased PTH found during w/u for pathalogic fracture. The pt did not have elevated Ca, but was thought to have his blood ca controlled due to lasix therapy. There was no current intervention necessary, but he was scheduled for f/u with endocrine for further w/u and ? parathyroid scan and/or dexa bone scan. The pt continued to diurese well, participate in PT and have a good post-op recovery. HOSPITAL COURSE BY SYSTEM: 1. Stroke: The pt was brought in to the hospital after a fall. CT was negative for bleed and stroke score was high (as above). He was treated with t-PA for a stroke thought to be located in the MCA territory on the right. He was admitted to the neuro ICU and initially his symptoms did not respond. He became SOB and was intubated for what was thought to be pulmonary edema. He was extubated quickly and was noted to have had nearly complete resolution of his symptoms (except a persistent L pronator drift). MRI showed multiple areas of stroke on R and a few small areas on L. He was started on a w/u for cardiac causes of the stroke. He was found to be positive for amphetamine on his tox screen. Echo showed no PFO and a subsequent echo with ventricular contrast showed no itraventricular clot. The pt had no elevated homocysteine level. His carotids were clean. It was thought that the stroke was due to amphetamine use. The pt was tx to the [**Hospital Unit Name 196**] service and followed by neurology. For the first week, the pt's bp was kept at a goal of 130-140. Subsequently the goal was lowered to 110-130. He was to be maintained on aggrenox and asa indefinitely. . 2. Respiratory distress: Patient was intubated likely due to acute pulmonary edema, was diuresed, and was quickly extubated. . 3. DM: The pt was managed on a sliding scale of regular insulin for a number of days. After tx to the cardiology service, the pt was started on standing [**Hospital1 **] NPH and humalog sliding scale. The endocrine service helped determine an appropriate scale after some difficulty maximizing therapy. . 4. Elevated creatinine: The patient presented with an elevated creatinine which was thought to be due to forward flow due to overload state in a patient with systolic dysfunction. Diuresis was initiated on presentation and increased on transfer to the [**Hospital Unit Name 196**] service. His diuresis was with 80mg Lasix IV BID with a goal of [**2-18**] Liters negative per day. He maintained a good diuresis and a fluid restriction of 1.5L throughout the remaineder of his hospital course. His creatinine decreased as low as 1.4 but rebounded to 1.5. This was thought to represent a signal that he was nearing a euvolemic state. His baseline elevated creatinine is roughly 1.3-1.5 and is thought to be due to his HTN and DM. . 5. Hip Fracture: The pt was found on presentation to have a L hip fracture. However, initially he was unable to withstand surgery. After managing his strokes with tPA and his pulmonary edema with short intubation, and after diuresing aggressively, he had a cath showing severe 3VD. He was thought to have a high risk of coronary complications with the hip fracture, however the only option for changing his risk was CABG, which is known to increase risk if done in proximity to a non-coronary surgery. The hip repair, therefore, was done under local anesthetic on [**8-25**] without any complication. Both prior to and after the surgery, the pt's pain was managed with oral medications; though he was offered IV pain medication, he refused. After surgery he was put on a partial wt bear protocol with daily PT and did very well. He began to transfer and ambulate with a walker well. He was to be maintained on lovenox 40 qd for 30 days. . 6. Hyperparathyroidism: Given a fall from a stand with hip fracture, w/u was intiated for osteoporosis. SPEP and UPEP were negative, cortisol was normal, calcium and ionized calcium were normal. However PTH was elevated at 105. Endocrine was consulted and suggested that the pt had hyperparathyroidism with normalization of the PTH due to aggressive diuresis with lasix. It was suggested that he would need careful monitoring of his calcium after diuresis was decreased. He was not thought to be a clearcut surgery candidate but he would likely need a dexa bone scan and perhaps a parathyroid scan in the future. . 7. CHF: The pt presented in florid heart failure. His EF was 25-30% on echo (as above), and he had global hypokinesis. He had an NSTEMI on presentation with CE's trending down. He has a history of 2 MI's in the past. He was aggressively diuresed over his course here with improved physical exam, less sob/doe, decreased edema. He was to be continued on a lower dose of PO lasix in the future. He was fluid restricted to 1.5L. He diuresed well without an appreciable increase in his creatinine. He should F/U here and will need to continue diuresis, fluid restriction, salt restriction, and daily weights. The patient had daily runs of NSVT on tele that were asymptomatic and lasted 3-7 beats. He will likely need evaluation for implantation of an ICD after recovery from his CABG in the future (post-MI with EF of 25%). . 8. HTN: The pt was continued on BB, ACEI, and lasix to control his BP. Cath showed severely elevated R pressures, so his goal BP was temporarily decreased. Good diuresis allowed us to bring his goal SBP back to 130-140. The pt was maintained at this level without difficulty. . 9. MI: The pt had a bump in troponins (see above) representing an NSTEMI. He has had 2MI's previously. He has risks of smoking, age, HTN, DM, hypercholesterolemia. His echo showed hypokinesis. Cath prior to surgery showed diffuse 3VD and elevated right sided pressures and a low EF. He will need CABG in the future. This surgery will not be done until recovery from Hip surgery is complete. 10. FEN: The pt has 1.5l fluid restriction. Lytes should be monitored closely after discharge for hypercalcemia, hypokalemia, and creatinine. He should eat a heart healthy, diabetic, low salt diet. 11. Dispo: Discharged in good condition to rehabilitation. Medications on Admission: Medications verified by [**Hospital1 2025**] records, and Dr. [**First Name (STitle) **], PCP's letter on [**2139-12-3**]: ASA 325 Lipitor 20 Spironolactone 25 QD Digoxin 125 mcg qd Zestril 80 mg QD Lasix 80 mg QAM 40 mg QPM Glucophage 500 [**Hospital1 **] Glyburide 2.5 mg [**Hospital1 **] Atenolol 75 mg QD Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. 2. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO TID (3 times a day) as needed. 8. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for to legs and arms for 2 weeks. 9. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR Sig: One (1) Cap PO BID (2 times a day). 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 26 days. 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for BP < 110 or pulse < 60. 13. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours): This can be titrated down over the next weeks as the pt has less pain. 15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 16. Lasix 40 mg Tablet Sig: Two (2) Tablet PO twice a day. 17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous twice a day: qam and qhs. 18. Insulin Lispro (Human) 100 unit/mL Solution Sig: as per sliding scal Subcutaneous qachs: Fingerstick qid - please see attached sliding scale for instructions. Discharge Disposition: Extended Care Facility: [**Hospital 4199**] Hospital TCU - [**Location (un) 2251**] Discharge Diagnosis: Multiple Strokes NSTEMI Hip fracture Hyperparathyroidism CHF with systolic dysfunction Non-sustained Ventricular Tachycardia Discharge Condition: Stable Discharge Instructions: You have been diagnosed with a myocardial infarction (MI), multiple strokes, and a hip fracture. You have a condition that may cause your bones to be weak and more likely to break with trauma. . Your hip repair went well and you have done well with physical therapy. You will continue to have physical therapy over the upcoming weeks. . You will need a cardiac bypass surgery in the future because a coronary catheterization showed extensive narrowing of your coronary arteries. You will need to follow up to plan for this surgery. Your follow up will be in approximately a month. . Your stroke was treated and your symptoms have resolved. You should follow up with neurology as an outpatient. . You have been seen by the endocrinology service and found to have a high blood calcium. You will need to follow up with them - this may be the condition that causes your bones to be more fragile. . Follow up instructions: CT surgery for CABG planning appt w/in one month: ([**Telephone/Fax (1) 4044**] Cardiology (Dr. [**Last Name (STitle) 73**] within one month: ([**Telephone/Fax (1) 12468**] Neurology for stroke follow up in two months: ([**Telephone/Fax (1) 2528**] Endocrinology for hyperparathyroidism within 2 months: ([**Telephone/Fax (1) 27739**] Primary Care Physician: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] - [**Telephone/Fax (1) 64118**] Follow-up appointment should be in 2 weeks Followup Instructions: CT surgery for CABG planning appt w/in one month: ([**Telephone/Fax (1) 4044**] Cardiology (Dr. [**Last Name (STitle) 73**] within one month: ([**Telephone/Fax (1) 12468**] Neurology for stroke follow up in two months: ([**Telephone/Fax (1) 2528**] Endocrinology for hyperparathyroidism within 2 months: ([**Telephone/Fax (1) 27739**] Primary Care Physician: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] - [**Telephone/Fax (1) 64118**] Follow-up appointment should be in 2 weeks [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**] Completed by:[**2140-8-29**] Name: [**Last Name (LF) 11369**],[**Known firstname **] Unit No: [**Numeric Identifier 11370**] Admission Date: [**2140-8-17**] Discharge Date: [**2140-8-29**] Date of Birth: [**2085-3-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3188**] Addendum: Note: Pt also instructed to F/U with Ortho 2 weeks after discharge at the following phone number: [**Telephone/Fax (1) 809**] Discharge Disposition: Extended Care Facility: [**Hospital 11371**] Hospital TCU - [**Location (un) **] [**First Name11 (Name Pattern1) 1332**] [**Last Name (NamePattern1) 3189**] MD, [**MD Number(3) 3190**] Completed by:[**2140-8-29**]

[ "305.70", "250.40", "403.90", "427.1", "110.4", "428.31", "E888.9", "252.00", "416.8", "410.71", "414.01", "425.4", "412", "820.09", "424.1", "518.81", "434.11", "692.9" ]

icd9cm

[ [ [] ] ]

[ "88.56", "96.71", "99.10", "79.35", "96.04", "37.23" ]

icd9pcs

[ [ [] ] ]

23280, 23525

10087, 12297

337, 426

20605, 20613

4259, 4452

22083, 23257

3172, 3262

18388, 20327

20457, 20584

18053, 18365

8718, 10064

20637, 22060

12324, 18027

3836, 4240

3277, 3792

276, 299

454, 2640

4461, 6445

6462, 8701

3807, 3817

2662, 2957

2973, 3156

30,217

115,766

31615+57755

Discharge summary

report+addendum

Admission Date: [**2133-9-7**] Discharge Date: [**2133-9-14**] Date of Birth: [**2058-3-25**] Sex: F Service: ORTHOPAEDICS Allergies: Demerol / Epinephrine / Fosamax / Latex / Dilaudid Attending:[**First Name3 (LF) 3190**] Chief Complaint: Back and leg pain Major Surgical or Invasive Procedure: Anterior fusion [**9-7**] T11-L1 Posterior fusion T4-L5 History of Present Illness: Ms. [**Name14 (STitle) **] has a long history of back and leg pain. She has attempted conservative therapy including physical therapy and has failed. She now presents for surgical intervention. Past Medical History: Multiple compression fractures, not surgical candidate b/l hip and ankle ulcers Chronic diarrhea Colonic polyps Hx of GIB [**3-7**] ulcers HTN Fibromyalgia Hypothyroidism Glaucoma Cataracts "Irregular heartbeat" h/o benign fallopian tumor, removed [**2085**] SBO [**3-7**] adhesions [**2117**] IBS Gastritis Social History: Was living at [**Doctor Last Name **], now in rehab after recent hospitalization. Smoked for 50 years, currently smoking 3 cigaretts/day. Denies alcohol/illicit drug use. Family History: [**Name (NI) 74312**] [**Name (NI) 74313**] Physical Exam: A&O X 3; NAD RRR CTA B Abd soft NT/ND BUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes symmetric at biceps, triceps and brachioradialis BLE- good strength at hip flexion/extension, knee flexion/extension, decreased strength ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation diminished; - clonus, reflexes symmetric at quads and Achilles Pertinent Results: [**2133-9-14**] 09:30AM BLOOD WBC-8.9 RBC-3.71* Hgb-11.3* Hct-32.9* MCV-89 MCH-30.4 MCHC-34.3 RDW-14.5 Plt Ct-284 [**2133-9-13**] 09:30AM BLOOD WBC-11.9* RBC-3.99* Hgb-12.2 Hct-35.0* MCV-88 MCH-30.5 MCHC-34.8 RDW-14.6 Plt Ct-218# [**2133-9-11**] 02:48AM BLOOD WBC-10.0 RBC-3.50* Hgb-10.9* Hct-30.9* MCV-88 MCH-31.1 MCHC-35.3* RDW-15.0 Plt Ct-99*# [**2133-9-10**] 02:11AM BLOOD WBC-8.2 RBC-3.61* Hgb-11.1* Hct-31.5* MCV-87 MCH-30.7 MCHC-35.2* RDW-15.2 Plt Ct-58* [**2133-9-14**] 09:30AM BLOOD Glucose-175* UreaN-9 Creat-0.3* Na-135 K-3.4 Cl-99 HCO3-26 AnGap-13 [**2133-9-13**] 09:30AM BLOOD Glucose-200* UreaN-6 Creat-0.4 Na-135 K-3.3 Cl-99 HCO3-26 AnGap-13 [**2133-9-11**] 02:48AM BLOOD Glucose-99 UreaN-6 Creat-0.4 Na-139 K-3.6 Cl-102 HCO3-32 AnGap-9 Brief Hospital Course: Ms. [**Known lastname 33172**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a thoracolumbar fusion. She was informed and consented and elected to proceed. Please see Operative Note for procedure in detail. Post-operatively she was given antibiotics and pain medication. She was transfer3d to the T/SICU for blood loss anemia and neuro checks. She was extubated POD 2 and had no further difficulty. A hemovac drain was placed intra-operatively and this was removed POD 3. Her bladder catheter was removed POD 3 and her diet was advanced without difficulty. She was able to work with physical therapy for strength and balance. She was discharged in good condition and will follow up in the Orthopaedic Spine clinic. Medications on Admission: Protonix 40mg', Levoxyl 100mcg', lovastatin 20mg', clonazepam 2mg', zyprexa 10mg', Amitryptilne 50mg', Asacol 800mg''', Lidoderm patch, Fentanyl patch 100mcg q72, Celebrex 200mg" Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed. 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 8. Olanzapine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 11. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for insomnia. 15. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for HTN. 18. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Thoracic kyphosis Post-op anemia Discharge Condition: Good Discharge Instructions: Please continue to take your pain medication with an over the counter laxative. Call the clinic should you experience any redness, swelling or discharge at the incision site. Call the clinic if you experience a temperature greater than 101 degrees. Do not smoke. Do not lifting anything greater than a gallon of milk. Call the clinic for any additional concerns. Physical Therapy: Activity: Out of bed w/ assist Thoracic lumbar spine: when OOB Treatments Frequency: Please continue to change the dressings daily with dry, sterile gauze. Followup Instructions: Please follow up in the Orthopaedic Spine clinic during your previously scheduled appointments. Call [**Telephone/Fax (1) 11061**] to confirm your post-operative appointments. Completed by:[**2133-9-14**] Name: [**Known lastname 12268**],[**Known firstname 1940**] M. Unit No: [**Numeric Identifier 12269**] Admission Date: [**2133-9-7**] Discharge Date: [**2133-9-14**] Date of Birth: [**2058-3-25**] Sex: F Service: ORTHOPAEDICS Allergies: Demerol / Epinephrine / Fosamax / Latex / Dilaudid Attending:[**First Name3 (LF) 1740**] Addendum: stage I pressure ulcer on the sacrum/coccyx. Discharge Disposition: Extended Care Facility: [**Hospital6 41**] - [**Location (un) 42**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1743**] MD [**MD Number(1) 1744**] Completed by:[**2133-10-2**]

[ "733.13", "998.2", "729.1", "721.42", "244.9", "285.1", "V85.0", "564.1", "512.1", "401.9", "733.00", "707.03", "305.1", "287.5", "737.10", "E878.1", "E870.0" ]

icd9cm

[ [ [] ] ]

[ "81.04", "84.52", "81.64", "99.05", "77.99", "81.62", "77.89", "03.59", "99.04", "77.79", "84.51", "03.09", "81.05", "81.65" ]

icd9pcs

[ [ [] ] ]

6690, 6917

2516, 3301

332, 390

5417, 5424

1740, 2493

6019, 6667

1153, 1199

3530, 5247

5361, 5396

3327, 3507

5448, 5816

1214, 1721

5834, 5902

5924, 5996

275, 294

418, 616

638, 948

964, 1137

67,164

145,530

34526

Discharge summary

report

Admission Date: [**2168-1-10**] Discharge Date: [**2168-1-13**] Date of Birth: [**2105-2-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1253**] Chief Complaint: status-post fall, subarachnoid hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 1140**] is a 62 year old male with a history of recently diagnosed Inclusion Body Myositis, longstanding HTN, and fatty liver disease who presented to [**Hospital1 18**] after a fall at home with resultant head injury. According to his family, and wife who witnessed the event, the patient fell down 5 stairs at home after reportedly dropping his cane and stumbling. Patient does not have recollection of the events. He was found at the base of the stairs, and did have loss of consciousness for a brief period of time. Once he awoke, he was disoriented according to his wife and per reports he was stating Nixon was the president and the year was [**2067**]. At baseline, mental status is not impaired, but does has some baseline muscle weakness. EMS tansported patient to [**Hospital1 18**]. . In the ED, vitals included temp :97.8F, BP 158/90, HR 71, RR20, and oxygen saturation of 100% on room air. Labs were remarkable for normal CBC and electrolytes with the exception of elevated BUN to 33 and chloride of 109. Cardiac enzymes elevated, CK 370, MB 48, MBI 13%. Trop 0.28. Coagulation studies were normal. U/A unremarkable. CK significantly improved from last check in [**7-/2167**] when it was 3882. CK-MB and Troponin were never checked in the past. ALT elevated and AST within normal limits. LDH elevated. LFTs are improved from recent records. ECG was reportedly unchanged from prior from [**2167-11-26**] at NEBH with ST depressions and TWI inferiorly. A non-contrast CT head showed small SAH in frontal areas without mass effect. Neurosurgery evaluated the patient in the emergency room and felt the Neurological exam was without cranial nerve deficits or focal motor/sensory findings. However, as above, he was disoriented which is a change from his baseline, and was therefore admitted to MICU for close monitoring. . Upon arrival to ICU, he was no longer disoriented and stated he was feeling much better. He is still unclear of the details of how he fell and had some memory deficits. His last memory was being brought to the hospital in the ambulance. On ROS, he noted mild headache, but denied vision changes. He had no speech problems, no new numbness or weakness. He notes some mild neck pain but after removal of cervical collar, he had no change in pain with full active ROM or posterior cervical spine palpation. He also denied chest pain, SOB, nausea, vomiting, abdominal pain, diarrhea, or constipation. No new muscle aches. Denied fevers, chills, cough. A repeat head CT 12 hours after the first showed no interval change in his small frontal lobe region SAH. Cardiac enzymes were trended and did not increase markedly; his ECG was stable and a TTE showed no focal wall motion abnormalities. He was restarted on Prednisone for his Inclusion Body Myositis. Mental status and vital signs all remained stable/normal, and he was transferred to the regular medical floor where he continued to deny confusion, chest pain, dyspnea, headaches, visual changes, photophobia, or neck stiffness. He did, however, endorse proximal muscle weakness, but says this is no different from his "usual" muscle problems. On the medical floor the patient appeared to be in no acute distress and mentation at basline (A&Ox3). Temp 98.3F, BP 126/80s, HR 60s, RR 18, and oxygen saturation 98% room air. Morning fasting FSG on [**1-12**] was slightly elevated at 163. Past Medical History: - Inclusion Body Myositis ; walks with a cane at baseline - Hypertension - Hyperlipidemia - Fatty Liver Disease / chronic transaminitis; preserved synthetic function; (elevated IgG, iron studies normal, [**Last Name (un) **] Ab neg, AMA, anti-sm AB neg) - Osteoarthritis - h/o Gastritis - Obesity - Venous insufficiency Social History: Former heavy equipment operator now on disbility due to muscle weakness. Lives in [**Location 686**] with wife. 3 sons. Daughter passed away. Former heavy EtOH, none in several years. Former cigar smoker, [**1-28**]/day. Denies any illicit drug use/IVDU. . Family History: Father has DM2, passed away from complications of diabetes, patient uncertain of specific details. No known autoimmune diseases in family per patient. Physical Exam: Physical Examination: Tc 96.8 Tmax 98.9 BP 116/83 (110-155/61-86) HR 75 RR 13 Sat 99% on room air General: well-appearing obese man lying comfortably in bed HEENT: no scleral icterus or conjunctival erythema Neck: supple, no cervical/supraclavicular lymphadenopathy, JVP 6 cm Chest: trace bibasilar rales, otherwise clear to auscultation throughout with no wheezes, rales, or ronchi CV: regular rate and rhythm, normal s1/s2, no murmurs/rubs Abdomen: soft, nontender, nondistended, normal bowel sounds, no HSM/masses Extremities: trace ankle edema, 2+ PT pulses Skin: no rashes or jaundice MS/Neuro: alert, appropriate, oriented x3; CN 2-12 intact with 3 mm equally reactive pupils; 3/5 strength in bilateral deltoids, hip flexors, and spine flexors; 5/5 strength in bilateral biceps, triceps, interossei, hip extensors. [**6-1**] knee flexors and [**5-2**] knee strength with extension, ankle dorsi-/plantar flexors [**5-2**] bilaterally. Achilles and left DTR patellar responses diminished with 1+, right patellar response 2+ DTR. Pertinent Results: ADMISSION LABS: [**2168-1-10**] 11:30AM NEUTS-71.6* LYMPHS-19.1 MONOS-7.1 EOS-1.8 BASOS-0.4 [**2168-1-10**] 11:30AM WBC-8.2# RBC-6.59* HGB-14.5 HCT-44.7 MCV-68* MCH-22.1* MCHC-32.6 RDW-16.7*, PLT COUNT-234, [**2168-1-10**] 11:30AM ALBUMIN-3.8 [**2168-1-10**] 11:30AM ALT(SGPT)-46* AST(SGOT)-21 LD(LDH)-267* CK(CPK)-370* ALK PHOS-56 TOT BILI-0.3 [**2168-1-10**] 01:53PM PT-12.4 PTT-21.1* INR(PT)-1.0 [**2168-1-10**] 06:53PM WBC-11.6* RBC-6.29* HGB-14.0 HCT-42.0 MCV-67* MCH-22.3* MCHC-33.4 RDW-16.8* [**2168-1-10**] 06:53PM ALT(SGPT)-42* AST(SGOT)-20 LD(LDH)-274* CK(CPK)-337* ALK PHOS-41 TOT BILI-0.5 [**2168-1-10**] 06:53PM GLUCOSE-129* UREA N-27* CREAT-0.5 SODIUM-144 POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-24 ANION GAP-14 . CARDIAC ENZYMES: [**2168-1-10**] 11:30AM CK-MB-48* MB INDX-13.0* [**2168-1-10**] 11:30AM BLOOD cTropnT-0.28* [**2168-1-10**] 06:53PM BLOOD CK-MB-33* MB Indx-9.8* cTropnT-0.40* [**2168-1-11**] 02:12AM BLOOD CK-MB-29* MB Indx-7.9* cTropnT-0.43* [**2168-1-12**] 06:50AM BLOOD CK-MB-27* MB Indx-9.4* cTropnT-0.36* [**2168-1-12**] 06:50AM BLOOD CK(CPK)-288* [**2168-1-11**] 02:12AM BLOOD 250 CK(CPK) [**2168-1-10**] 06:53PM BLOOD CK(CPK)-337* [**2168-1-10**] 11:30AM BLOOD CK(CPK)-370* . URINE STUDIES: [**2168-1-10**] 03:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG [**2168-1-10**] 03:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 . ADDITIONAL STUDIES: ECG ([**2168-1-10**]):Sinus rhythm at 65 bpm, normal axis, normal intervals, LVH, biphasic T-waves in lateral leads. . [**2168-1-10**] EKG /repeat: Rate 70s, Sinus rhythm. Left ventricular hypertrophy with secondary repolarization changes . TTE ([**2168-1-11**]): The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Aortic valve sclerosis. . Head CT w/o contrast ([**2168-1-11**]): Again seen are several foci of linear increased attenuation within the superior frontal lobes bilaterally, consistent with known subarachnoid hemorrhage, without increase in extent. There is no acute intraparenchymal hemorrhage or intraventricular extension. There is no mass effect, shift of normally midline structures or hydrocephalus. The density values of the brain parenchyma are within normal limits. Imaged paranasal sinuses and mastoid air cells are well aerated. There are no fractures. . Head CT w/o contrast ([**2168-1-10**]): A few foci of linear increased areas of attenuation within the superior frontal lobes bilaterally is compatible with subarachnoid hemorrhage. No intra-parenchymal or ventricular hemorrhage is noted. There is no shift of normally midline structures, hydrocephalus, or major vascular territorial infarction. The density values of the brain parenchyma appear maintained. A small calcification is noted in the region of the right basal ganglia. Calcification of the cavernous portions of the carotid arteries bilaterally is evident. A small subgaleal hematoma overlying the right frontoparietal bone is evident (2:20). Otherwise, the soft tissues and osseous structures appear unremarkable. The visualized paranasal sinuses and mastoid air cells appear well aerated. . CT C-spine ([**2168-1-10**]): There is no prevertebral soft tissue swelling or acute fracture involving the cervical spine. Reversal of the normal cervical lordosis is evident. Multilevel degenerative changes are noted including prominent anterior osteophytes extending off of the C5 and C6 vertebral bodies. There are moderate areas of canal narrowing at the C5-6 and C6-7 levels secondary to thickening of the posterior longitudinal ligament and small osteophytes. Moderate areas of neural foraminal narrowing are noted at the right C2-3 level, bilaterally at the C3-4 and C6-7 levels and on the right at the C4-5 level. Diffuse, extensive facet arthropathy is present. The visualized outline of the thecal sac appears intact. Please note, CT is unable to provide intrathecal detail comparable to MRI. Biapical scarring is evident. Otherwise, the visualized lung apices are clear. Note is made of a few calcifications within the region of the tonsils bilaterally. . LS spine AP/lat ([**2168-1-10**]): Lumbar lordosis is preserved. Vertebral body heights are preserved, without evidence for compression fracture. There is no spondylolisthesis. There are multilevel degenerative changes of the thoracolumbar spine with marginal osteophytes seen, with a prominent osteophyte at L5-S1. Limited views of the sacroiliac joints and bilateral hips are unremarkable. Bowel gas pattern is within normal limits. . DISCHARGE LABS: [**2168-1-13**] 07:50AM BLOOD WBC-7.3 RBC-6.36* Hgb-14.4 Hct-42.3 MCV-67* MCH-22.6* MCHC-34.0 RDW-16.5* Plt Ct-193 [**2168-1-13**] 07:50AM BLOOD Plt Ct-193 [**2168-1-13**] 07:50AM BLOOD Glucose-131* UreaN-20 Creat-0.6 Na-138 K-4.4 Cl-102 HCO3-30 AnGap-10 Brief Hospital Course: In summary, Mr. [**Known lastname 1140**] is a 62 year old man with recently diagnosed Inclusion Body Myositis, fatty liver disease, and hypertension who was admitted after a fall down several stairs and note of a new acute, stable subarachnoid hemorrhage within the superior frontal lobes bilaterally on CT imaging. . # Subarachnoid Hemorrhage: On initial imaging with CT Head , Mr. [**Known lastname 1140**] had bilateral frontal subarachnoid hemorrhage noted which was attributed to his recent trauma and fall down his stairs. No midline shifts noted and there was no extension or change on repeat CT imaging on hospital day #2. Of note, Mr. [**Known lastname 1140**] also had a small right superior parietal, stable subgaleal hematoma noted on imaging. Despite questionable loss of consciousness at the scene of the fall, he was responsive en route to the hospital with EMS and upon arrival to the [**Hospital1 18**] ED. The patient was seen by the neurosurgery service in the emergency room and neurological exam was not acutely concerning for any expansive pathology or frank motor/sensory deficits. Despite, some mild confusion and initial disorientation in the ED, by the time of transfer from the ED to the MICU the patient was reportedly at his baseline mental status per MICU team. Per neurosurgery's advice, he was continued on 500mg [**Hospital1 **] levetiracetam for seizure prophylaxis and set up for followup with the neurosurgery service in 1 month's time, with a repeat head CT arranged. Per neurosurgery, the patient was restarted on a lower dose of aspirin, at 81mg daily for primary cardiac prevention. Given his SAH, his blood pressure was monitored closely during his hospital course, with goal range of 130-160s systolic range. Daily neurology exams remained unchanged, with no new deficits. Hematocrits were stable. He was continued on his daily Hydrochlorahiazide with PRN Hydralazine given. He continued to maintain steady blood pressures which were mainly normotensive to slightly hypertensive in the 140s and 150s range. Calcium channel blockers for post SAH vasospasm were not added, given the limited benefits in traumatic,acute SAH cases. After transfer to the general medical floor, he stated his headaches had largely resolved and he was much more alert and oriented (fully: accurate MS with person/place/date/time questioning). He was discharged with instructions to continue his daily Keppra for seizure prevention until he followed up for repeat head CT and his follow-up with Dr. [**Last Name (STitle) 548**] in the neurosurgery clinic on [**2168-2-16**]. . # Fall: On detailed questioning, it appears that the patient's underlying Inclusion Body Myositis played a major role in his fall. He was placed on fall precautions during his hospital stay until it was clear that he could stand and ambulate well with the help of a walker/cane. During his hospitalization, he was seen by physical therapy for ongoing rehabilitation and evaluation. It was felt that he would greatly benefit from home PT so there services were arranged through VNA services. An acute coronary event was explored initially, but the patient denied any recent chest pains, shortness of breath or anginal complaints and his EKG was unchanged from prior records. The varying elevations in his CK-MB, total CK level, and his troponin were attributed to his known myositis condition. Of note, secondary to his [**Company 378**], his CK-MBs back in [**2167-10-28**] were in the 210-216 range and his [**2167-7-28**] CPK rose to a peak of 11,473. Moreover, these CK/Troponin abnormalities were stable and trended down slightly prior to discharge, and were felt to have no association with a true acute cardiac issue given the [**Company 378**] history and his asymptomatic clinical cardiac correlation. A TTE was also done and showed LVEF 55% , mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. It seems more likely that his mechanical fall precipitated SAH and not vice versa as patient denies having any significant disorientation in hours or days preceding his fall. No other recent headaches, traumas or head injuries prior to this fall. Orthostatic measurements on the medical floor were within normal ranges/ negative so there was unlikely to be an autonomic or orthostatic component involved. . # Inclusion Body Myositis: Per patient he was started on Prednisone by his neurologist from NEBH (Dr. [**Last Name (STitle) 79312**] several months ago. He was again restarted on Prednisone by MICU team soon after admission. He had positive [**Doctor First Name **] in [**2167-7-28**] and CPK of [**Numeric Identifier **] in [**2167-10-28**] with positive Aldolase on [**2167-11-13**] of 23.1 but Anti-[**Doctor First Name **] 1 and mitochondrial Abs negative. CK-MBs back in [**2167-10-28**] were in the 210-216 range. Per Dr. [**Last Name (STitle) 79312**], Mr. [**Known lastname 1140**] underwent muscle biopsy last month and samples were anlayzed in the neuro-pathology department at [**Hospital1 3372**] (by [**Doctor First Name 79313**] [**Name6 (MD) **] [**Name8 (MD) **], MD). Biopsy results revealed classic rimmed vacuoles and histopathology consistent with Inclusion Body Myositis. Clinically, the patient's weakened knee extension, wrist flexion and decreased lower extremity DTRs are pertinent [**Company 378**] findings. The plan at discharge was for Mr. [**Known lastname 1140**] to continue his immunosuppressive therapy with an increased a.m. Prednisone dose of 40mg (from prior 20mg each morning), to be followed by his usual 20mg p.m. dose. He was set up with home physical therapy and a follow-up appointment was set up with his neurologist as well. It was ultimately felt that his progressive weakness played a large role in his recent fall down the stairs and his newly diagnosed head trauma. Thus, compliance with his prednisone and daily strengthening exercises were emphasized. . # Elevated cardiac enzymes: As noted above this was attributed to myositis condition and did not represent an NSTEMI. CKs and CK-MBs have been chronically elevated for months. Troponin elevation may also be related to myositis issues, particularly troponin T levels which were noted as high during this hospital course with troponin trending from initial .20-->.40-->.36. at discharge. Several EKGs were analyzed and felt to stable in comparison to his prior recorded EKGs. . # Hypertension: He was continued on his usual daily dose of HCTZ and hydralazine was added as needed to maintain SBPs in the 130-160s range roughly. His blood pressure stabilized to the 130-140 systolic ranges. . # Hyperlipidemia: Patient has known history of hyperlipidemia. In [**2167-7-28**]: lipid profile showed TC 210, LDL 144, HDL 42, TG 122. He is presumably not on a statin due to his underlying [**Company 378**]/myositis, however, the patient is a poor historian regaring these specific details so this is somewhat unclear. [**Name2 (NI) **] was placed on a cardiac healthy diet and he was essentially ruled out for ACS/MI as above. Daily ASA was continued but decreased to 81mg daily given his distant history of gastritis and new SAH. He will plan to follow-up with his outpatient cardiologist after discharge, Dr. [**Last Name (STitle) **]. . #Hyperglycemia: Mr. [**Known lastname 1140**] had some high FSG levels in the 150-200 range in the [**Last Name (un) 44550**] and some high post-prandial levels as well which was felt to be secondary to his Prednisone therapy. While inpatient he had q.i.d fingersticks and he was continued on a sliding scaled insulin regimen. The patient was encouraged to follow-up with his PCP and neurologist regarding ongoing DM-2 monitoring and sugar control given that he has a pertinent positive family history of DM-2 and will likely require long term Prednisone for his [**Company 378**] / myositis immunosuppression therapy. . # Fatty liver disease: This is a stable, chronic issue for Mr. [**Known lastname 1140**]. He had no new dramatic shifts in his LFTs during this hospital stay. He will continue to follow-up with Dr.[**Last Name (STitle) 696**] as an outpatient. The patient's NEBH records were researched and trended and he has a long history of transaminitis. . # Fluids, Electrolytes and Nutriiton: The patient was continued on a cardiac healthy diet which he tolerated well; good appetite. Electrolytes were monitored daily and repleted as needed. . # Prophylaxis: -He was given pneumoboots and Heparin SC for DVT prevention -Acetominophen was given PRN for pain control/muscles aches, as well as prednisone . #Code Status/Communication: Communication occurred directly with the patient on a daily basis and he was maintained as a full code status for the entirety of his hospital stay. Medications on Admission: -Aspirin 325 mg daily -HCTZ 25mg daily -Vitamin B12 -Calcium -Vitamin D -Prednisone [**Hospital1 **], 20mg every morning and every night Discharge Medications: 1. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 weeks. Disp:*56 Tablet(s)* Refills:*1* 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Fish Oil Oral 5. Os-Cal 500 + D Oral 6. Cyanocobalamin Oral 7. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for 2 weeks: Please take 40mg every morning, discuss any changes with your neurologist . 8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks: take 20mg every night as directed, follow-up with your neurologist regarding any changes . Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Weakness Subarachnoid Hemorrhage . Secondary: Inclusion Body Myositis Hypertension Fatty Liver Disease Discharge Condition: Good. At time of discharge the patient had stable vital signs and had no pain complaints. Discharge Instructions: It was a pleasure taking care of you here at [**Hospital1 771**] ([**Hospital1 18**]). . You were admitted after having a fall down several stairs. You briefly lost consciousness and you were brought by ambulance to the emergency room. Imaging studies showed that you had a small bleed in your brain called a subarachnoid hemorrhage. The neurosurgery service was called and felt that the bleed was small and did not require any surgical intervention. . Please follow-up with your Neurologist, Neurosurgeon and Primary Care doctors [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below. . You will continue to receive home physical therapy through VNA. . Medication Instructions: . In terms of medications, your neurologist would like you to take 40mg Prednisone in the morning and 20mg at night. You will discuss ongoing Prednisone schedule at your follow-up later this month. . Continue taking 81mg aspirin daily. . Please continue to take Keppra 500mg twice daily for seizure prevention. You will discuss ongoing need for therapy beyond 1 month with your Neurologist and Neurosurgeon at upcoming follow-up. . Otherwise, continue your usual home doses of your other medications as taken prior to this hospital admission. . If you have any headaches, vision changes, confusion, seizures, dizziness,numbness, new onset weakness, or any other health concerns please return to the emergency room or contact your primary care physician. Followup Instructions: You are scheduled for a follow-up head CT scan on Tuesday, [**2168-2-16**] at 10:30am in the [**Hospital Unit Name 1825**] at [**Hospital1 18**] on the [**Location (un) **]. Following that appointment for your head CT you are set up for a follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 548**] at 10:30am in the Spine Center, [**Hospital Ward Name 23**] Building, [**Location (un) **]. (on same date: [**2168-2-16**], Tuesday). Dr.[**Name (NI) 2845**] phone #[**Telephone/Fax (1) 78519**]. . Please follow-up with Dr. [**Last Name (STitle) 79312**] at [**Hospital6 2910**] on [**1-19**] at 1:45pm. Office phone # [**Telephone/Fax (1) 79314**] . Lastly, please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13983**] on [**1-18**] at 11am in [**Location (un) 30625**] office. Office phone # [**Telephone/Fax (1) 13987**] Completed by:[**2168-1-22**]

[ "571.8", "E880.9", "293.0", "459.81", "851.82", "729.1", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

20822, 20879

11138, 17125

357, 364

21035, 21127

5641, 5641

22618, 23567

4419, 4572

20137, 20799

20900, 21014

19976, 20114

21151, 21815

10859, 11115

4587, 4587

4609, 5622

17142, 19950

276, 319

392, 3783

5657, 6383

21840, 22595

3805, 4128

4144, 4403

30,911

131,215

44821

Discharge summary

report

Admission Date: [**2123-5-21**] Discharge Date: [**2123-5-26**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7223**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Left Heart Catheterization with Successful PTCA of the LCX/OM2 History of Present Illness: The patient is a [**Age over 90 **] y/o male w/ hx of CAD s/ BMS x 3 ('[**22**]), sev AS, s/d CHF, HTN presents with complaints of chest pain. Patient admitted in [**11-19**] w/ complaints appearing to be unstable angina. Had dynamic EKG changes with ST depressions in the precordial leads. Underwent cardiac catheterization, w/ BMS to OM2, D1, LCx. Had peak troponin of 0.33 at that time. Patient has had two admissions since of similiar complaints of chest pain, and reportedly dynamic EKG changes, and was treated with medical manegment after ruling out by cardiac enzymes. The patient describes daily chest pain, but does not describe associated activity as an inciting factor. He says that he tries to avoid taking nitro. On the day prior to presentation he was walking when he began to feel [**10-22**] substernal chest tightness without radiation for 5-10 minutes. It was relieved by taking nitro. Again this morning, patient had a second episode of chest pain. He was in the shower with onset of [**10-22**] squeezing chest pressure without radiation. Chest pain again was relieved by SLNG. These past episodes are similar to daily chest discomfort, but more severe. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. *** Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . . In the ED, initial vitals were T: 100.1 HR: 80 BP: 150/64 RR: 18 O2Sat: 99% on 2L. Patient had a further episode of chest pain, was given SLNG x 1, with resolution of chest pain. Patient noted to have ST segment depressions in anterolateral and anterior leads. He was started on a heparin and nitro drip, and and was admitted for further evaluation and management. . . On arrival to the floor, patient's T 98.6, BP 137/61 P 80 O2 100 % on 2L. He was friendly and cooperative throughout interview and denied any chest discomfort. Nitro and heparin were discontinued, explained below in assesment and plan. Patient then began to experience [**2125-4-16**] chest discomfort. Became tachycardic and uncomfortable with a decreas of sats from 99 to 93% on 2L with new crackles on exam b/l [**1-13**] way up lung fields. Patient was given 1mg IV morphine, 1 SLNG, 20mg IV lasix with complete resolution of symptoms. Past Medical History: --Coronary Artery Disease - s/p BMS to OM2, D1, LCX ([**2122-11-16**]) for unstable angina with TWI in V2-V4 --CHF, systolic EF 40% and [**Month/Day/Year 7216**] dysfunction with sever LVH --Valvular disease - moderate aortic stenosis, mild to moderate aortic and mitral regurgitation, ?bicuspid congenital valves --HTN --COPD --Gout --DJD - bilateral knee pain --h/o chronic pyelonephritis --s/p bladder stone removal --Colon cancer Social History: Social history is significant for occasional cigarrettes socially 20 years ago. He drinks about 1 glass of wine or alcoholic drink /week. He is from [**Country 532**] and worked as a general surgeon in [**Location (un) 4551**]. He retired at age 63 due to his hand tremor. He has been widowed for 8 years and lives alone in [**Location (un) **]. He has children in the area who are helpful. . Family History: There is no family history of premature coronary artery disease or sudden death. . Physical Exam: Vitals: T 98.6 BP 150/72 P 100 O2 94% @L Gen: elderly male in NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No signs of conjunctivitis. Neck: JVP 8cm. Heart: PMI 5th ICS & MCL, no thrills/heaves, RRR, normal S1, S2. Midpeaking III/VI murmur best heard at along left SB. Lungs: CTAB. Abd: Soft, slightly distended, non-tender Ext: WWP, no edema, DP 2+ b/l. Neuro: Follows commands, Spontaneously moves all 4 extremities Pertinent Results: [**2123-5-21**] 11:50AM BLOOD WBC-9.1 RBC-3.12*# Hgb-7.9*# Hct-26.1* MCV-84 MCH-25.1* MCHC-30.1* RDW-15.9* Plt Ct-205 [**2123-5-21**] 11:50AM BLOOD Neuts-76.6* Lymphs-17.0* Monos-4.7 Eos-1.6 Baso-0.1 [**2123-5-21**] 11:50AM BLOOD PT-12.5 PTT-26.0 INR(PT)-1.1 [**2123-5-21**] 11:50AM BLOOD Glucose-106* UreaN-23* Creat-0.9 Na-143 K-4.2 Cl-108 HCO3-30 AnGap-9 [**2123-5-21**] 11:50AM BLOOD cTropnT-0.02* [**2123-5-21**] 11:50AM BLOOD CK(CPK)-49 [**2123-5-21**] 11:50AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.0 [**2123-5-26**] 07:45AM BLOOD WBC-8.1 RBC-4.06* Hgb-10.9* Hct-33.6* MCV-83 MCH-26.9* MCHC-32.4 RDW-15.9* Plt Ct-203 [**2123-5-21**] 11:50AM BLOOD WBC-9.1 RBC-3.12*# Hgb-7.9*# Hct-26.1* MCV-84 MCH-25.1* MCHC-30.1* RDW-15.9* Plt Ct-205 [**2123-5-21**] 11:50AM BLOOD CK(CPK)-49 [**2123-5-22**] 06:50AM BLOOD CK(CPK)-147 [**2123-5-24**] 06:34PM BLOOD CK(CPK)-33* [**2123-5-21**] 11:50AM BLOOD cTropnT-0.02* [**2123-5-24**] 06:21AM BLOOD CK-MB-NotDone cTropnT-0.49* [**2123-5-24**] 11:54AM BLOOD Type-ART O2 Flow-2 pO2-79* pCO2-44 pH-7.46* calTCO2-32* Base XS-6 Intubat-NOT INTUBA Comment-NC CXR [**2123-5-21**]: FINDINGS: Bedside AP examination labeled "up at 12:00 p.m.", is compared with study dated [**2123-3-16**]. Though the lung volumes appear larger, there is diffuse interstitial prominence with [**Last Name (un) 16765**] B-lines and pulmonary vascular congestion, as well as stable cardiomegaly. There is no overt edema or pleural effusion. No focal consolidation is seen. There are atherosclerotic changes involving the thoracic aorta. IMPRESSION: Interstitial edema, new since [**2123-3-16**]. TTE [**3-20**]: The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. There is severe symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with inferior akinesis and inferior septal/inferior lateral hypokiensis. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate to severe aortic valve stenosis (area 0.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild to moderate regional LV dysfunction. Moderate to severe aortic stenosis and mild aortic regurgitation. Mild to moderate mitral regurgitation. Dilated thoracic aorta. Cardiac Cath: COMMENTS: 1. Selective coronary angiography of this right-dominant system demosntrated two vessel coronary artery disease. The LMCA had 40% proximal and 30% distal stenosis. The LAD was a moderately calcified vessel. The 30% proximal LAD lucency seen on prior angiogram was unchanged. A 70% calcific mid LAD lesion was noted at the D1 origin. The D1, which was stented in [**2122-11-12**] with a BMS, was stump-occluded without antegrade flow. The D1 post the occluded stent filled via right- to-left collaterals. The proximal LCX had 50% in-stent restenosis extending into the stented OM2 branch. The OM2 had 65% in-stent restenosis at the proximal segment of the stent and 60% at the distal end of the stent. The AV groov LCX was diffusely diseased with 80% stenosis in a small lower pole of OM2. The RCA is a large caliber dominant vessel with diffuse mild plaquing and focal heavy calcification. The flow within the RCA system was rather slow consistent with microvascular dysfunction. The RCA system gave collaterals to the occluded D1. 2. Resting hemodynamic assessment revealed a 12 point step-up from the SVC to the PA. A full saturation run was performed (see table above) and The findings were consistent with a possible small left-to-right intracardiac shunt at the upper chamber (RA) level. Systemic arterial pressure was normal (134/46 mmHg) and the pulmonary arterial pressure was mildly elevated (39/12 mmHg). The mean pulmonary capillary wedge pressure was mildly elevated (11 mmHg). 3. The aortic valve was not crossed based on the primary service's request. Hence, left ventriculography was deferred. 4. Successful PTCA of the ISRS of the LCX and OM2 with a 2.75 x 15 mm and a 3.0 x 12 mm balloons. Final angiography revealed a 20% residual stenosis in the stents, no dissection and TIMI III flow (See PTCA comments) FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Mild pulmonary arterial hypertension and mildly elevated PCWP. 3. Step up O2 saturation from 53% in the SVC to 65% in thebpulmonary artery suggestive of a possible left-to-right shunt on the RA level. 4. Successful PTCA of the LCX/OM2. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Systemic arterial systolic hypertension. 3. Successful stenting of the OM2, LCX and D1 with bare metal stents Brief Hospital Course: #. CAD: The patient has a history of pronounced CAD status post BMS x 3. Patient presented with complaints of chest pain, similar to prior MI. Has had two subsequent admission for similar complaints, with negative rule outs. ST segment depressions noted on EKG seem to be similar multiple baseline EKGs in OMR, but degree of ST depressions seems to deponstrate a dynamic component with correlates with the patients complaint of chest pain. Was unclear if respresented ischemia from ACS vs. repolarization abnormalties vs subendocardial ischemia with severe AS and LV thickness. Hct drop of 10 pts from baseline was thought to be exacerbating factor. Patients chest pain persisted, despite transfusion. Heparin was initally held due to concern of GI bleeding, but with persisent chest pain and rising of troponins to peak of 0.49, patient was transfered to the CCU for monitored heparinization. He underwent cardiac cath with PTCA of the LCX/OM2. He was chest pain free following cath, with trending down of CK to baseline and resolution of EKG changes. He was discharged on aspirin, metoprolol, lipitor, and plavix. . #. Pump: The patient has known valvular disease with mod-sev AS, mod AR/MR [**First Name (Titles) **] [**Last Name (Titles) 7216**] and systolic HF. Had appeared euvolemic on intial presentation, and did not endorse symptoms of heart failure. During admission patient became SOB in setting of chest pain with fall in O2 sats and new pulmonary edema on CXR. Symptoms improved with morphine, lasix, and SLNG. In setting of severe AS, patient may have had increased stiffness in setting of ischemia. [**Month (only) 116**] also have had been overloaded with increased pre-load after discontinuing nitro gtt. Patient had no further episodes during hospitalization. . #. Rhythm: NSR, maintain on telemetry . # GI Bleed: The patient presented with a hct 10 pt lower since [**Month (only) **] with history of colon CA and guaic positive stool. No hx of melena or hematochezia. Decision was made to transfer patient to CCU for monitored heparinization. Patient was transfused and responded appropriatly. Endoscopy was deffered until stable from a cardiac view point, and patinet scheduled to follow up with Dr. [**Last Name (STitle) **] upon discharge. . #. Hypertension: continued metoprolol and amplodipine for afterload reduction. . # FULL CODE Medications on Admission: 1. Aspirin 325 mg Tablet PO DAILY 2. Clopidogrel 75 mg Tablet DAILY 3. Allopurinol 150 mg Tablet PO once a day. 4. Atorvastatin 40 mg PO DAILY 5. Amlodipine 2.5 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Ferrous Sulfate 325 mg Tablet PO DAILY 8. Ranitidine HCl 300 mg Capsule PO daily 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release PO once a day 10. Colchicine 0.6 mg One (1) Tablet PO BID as needed for pain: take regularly for gout pain. 11. Toprol XL 25 mg PO once a day Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 doses. Disp:*5 Tablet(s)* Refills:*0* 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for angina: If chest pain does not resolve after 3 doses five minute apart call your PCP [**Last Name (NamePattern4) **] 911. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for gouty pain. 11. Outpatient Lab Work Hct, K, BUN, Creat, Call results to Dr. [**Last Name (STitle) **] 617=[**Telephone/Fax (1) **] 12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 13. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: family care extended Discharge Diagnosis: Primary Diagnosis: NSTEMI Acute on Chronic [**Telephone/Fax (1) **] Congestive Heart Failure GI Bleed with anemia Secondary Diagnosis: Coronary artery disease Severe Aortic Stenosis Goutty Attack Hyptertension Mild pulmonary arterial hypertension Discharge Condition: Stable Discharge Instructions: You are being discharged from the hospital after admission for chest pain. You were found to have a small heart attack. You had a cardiac catheterization with balloon angioplasty of the left circumflex and OM1 arteries. You also had mild pulmonary hypertension and acute [**Telephone/Fax (1) 7216**] heart failure that improved with diuresis. You had pseudomonas in your urine and have been on a 7 day course of Ciprofloxacin. Please continue to take your Plavix every day without missing a day. Consult your cardiologist before stopping the medication. Your Imdur has been stopped and Lisinopril has been started. You should take a proton pump inhibitor twice daily. You should weigh yourself every day and report a weight gain of more than 3 pounds in 1 day or 6 pounds in 3 days to Dr. [**Last Name (STitle) **]. If you develop chest pain, shortness of breath, palpitations, light headedness, or any other concerning symptoms, you should call your PCP or go to the emergency room. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) **] of Gastroenterology on [**6-17**] at 11:30am. You have an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2123-6-9**] 3:40 You have an appointment with [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 4200**], M.D. Date/Time:[**2123-6-17**] 8:20

[ "599.0", "274.0", "396.2", "V10.05", "E849.8", "410.71", "416.8", "041.7", "E879.0", "414.01", "280.0", "401.9", "428.0", "996.72", "496", "578.1", "428.43" ]

icd9cm

[ [ [] ] ]

[ "00.66", "99.04", "37.23", "00.40", "88.56" ]

icd9pcs

[ [ [] ] ]

13892, 13943

9618, 12000

273, 338

14235, 14244

4456, 9127

15280, 15697

3886, 3971

12539, 13869

13964, 13964

12026, 12516

9441, 9595

14268, 15257

3986, 4437

223, 235

366, 2996

14100, 14214

13983, 14079

3018, 3454

3470, 3870

6,626

163,468

10335

Discharge summary

report

Admission Date: [**2143-6-28**] Discharge Date: [**2143-7-3**] Date of Birth: [**2067-3-30**] Sex: F Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old woman with a history of pancreatic CA who woke up in her usual state of health at approximately 6:30 this morning to get in the shower. She was sitting on a stool and went in to reach for the shower knob when she slipped off the stool and onto her left knee. She did not hit her head, and there was no loss of consciousness. When she got back onto the stool she had a funny feeling that she finds difficult to describe, and then afterwards noted that she had numbness in the right upper extremity from the elbow down and could not move her right upper extremity at all. She reports she yelled for help, as her grandson lives upstairs, and did not find any difficulties vocalizing. She did not note any slurred speech or trouble finding words. She also did not note any leg weakness or difficulty walking to the door. She eventually alerted her grandson who found the patient with symptoms largely resolved. The patient was taken to the emergency room where a head CT revealed a subacute left frontal parietal subdural hematoma. The patient was evaluated by neurosurgery PAST MEDICAL HISTORY: The patient has a past medical history of pancreatic CA, hypertension, depression. MEDICATIONS ON ADMISSION: Chemotherapy once every 1 to 2 weeks, Paxil, and sliding-scale insulin. ALLERGIES: MORPHINE and CODEINE. PHYSICAL EXAMINATION ON ADMISSION: The patient is afebrile, blood pressure is 142/78, pulse is 80, respiratory rate is 18, saturations of 98% on room air. In general, an elderly woman in no acute distress. HEENT reveals anicteric, OP's clear. The neck is supple. No LAD. No carotid bruits. No thyromegaly. Cardiovascular reveals a regular rate and rhythm. No murmurs, rubs, or gallops. Respiratory reveals clear to auscultation bilaterally. The abdomen reveals positive bowel sounds, soft, nontender, and nondistended. No masses. The extremities reveal no clubbing, cyanosis, or edema. Mental status reveals awake, alert, and oriented x 3. Interactive, appropriate, following commands, spelling "world" backwards, names months of the year backwards. Memory is [**4-11**] immediately without prompting in 5 minutes. Speech is fluent. No evidence of neglect with visual tactile stimulation. No apraxia. Cranial nerves are intact. Her strength is [**6-13**] in biceps, triceps, and grasp bilaterally. On her right side she is 5- in the biceps and finger flexion. On her lower extremities she is [**6-13**] in all muscle groups. Her reflexes are 2 on the right side. Her right-sided reflexes are somewhat more brisk; biceps are 3, brachioradialis are 3. She did have 7 to 8 beats of clonus on the right and 5 to 6 beats of clonus on the left. Sensation was intact to light touch, temperature, vibration, and position sense. The patient's coordination was intact with no nystagmus. Gait was not tested. RADIOLOGIC STUDIES: The patient had a head CT that just showed the left frontal parietal subdural hematoma which did not require surgical intervention. HOSPITAL COURSE: Neurology evaluated the patient for a question of seizure versus TIA. A MRI/MRA was done on the patient which was essentially negative. The patient's symptoms were completely resolved by the time she came to the emergency room. She had recurrence while in house. The patient was seen by physical therapy and occupational therapy and found to be safe for discharge to home, and no further treatment was recommended; although monitoring her blood pressure and continuing her on Keppra until followup was recommended. She was discharged on Keppra. MEDICATIONS ON DISCHARGE: Paroxetine 20 mg p.o. daily, Keppra 500 mg p.o. b.i.d., Humalog insulin 7 units subcutaneously twice a day, Lantus 15 units subcutaneously at bedtime. CONDITION ON DISCHARGE: The patient's condition was stable at the time of discharge. DISCHARGE FOLLOWUP: She will follow up with Dr. [**Last Name (STitle) 739**] in 4 weeks for a repeat head CT at this time. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2143-7-4**] 14:20:32 T: [**2143-7-5**] 09:48:12 Job#: [**Job Number 34318**]

[ "250.00", "780.39", "157.8", "435.9", "401.9", "530.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3752, 3904

1399, 1528

3179, 3725

4012, 4378

164, 1265

1543, 3161

1288, 1372

3929, 3991

19,781

114,730

3040+55436

Discharge summary

report+addendum

Admission Date: [**2186-1-22**] Discharge Date: [**2186-1-29**] Service: MEDICINE This is an incomplete discharge summary, please see discharge addendum for completion of the [**Hospital 228**] hospital course, discharge diagnoses and discharge medications. HISTORY OF PRESENT ILLNESS: The patient is an 80 year-old female with a past medical history significant for chronic diarrhea since colon resection for a colon cancer in [**2179**] with a resultant chronic hypokalemia and hypocalcemia for which she is on oral supplementation. She has multiple histories to [**Hospital3 **] in the past for metabolic abnormalities, which required intravenous supplementation. She now presents with complaints of intermittent nausea, vomiting, diarrhea for at least one week. She admits to discontinuing her potassium and calcium supplements approximately one and a half weeks ago, because of gastrointestinal upset. Her daughter reports that this probably is a form of secondary gain since the patient cares for her demented husband. She denies any fevers or chills, headache, chest pain, shortness of breath, abdominal pain, urinary symptoms. She also complains of weakness and decreased oral intake with a weight loss over the last two years. On admission in the Emergency Room the patient was found to be severely hypokalemic with a potassium of 1.6, calcium 5.2, magnesium level of 0.6, bicarbonate level of 12, and an anion gap of 21. The patient received 1 liter of normal saline, potassium chloride intravenous 40 milliequivalents, 2 grams of calcium gluconate intravenous and 2 grams of magnesium sulfate intravenous. Central access was obtained. PAST MEDICAL HISTORY: 1. Breast cancer in [**2173**]. 2. Colon cancer in [**2179**] status post resection with resultant chronic diarrhea since the surgery. 3. Diverticulitis. 4. Hypothyroidism. ALLERGIES: Penicillin, morphine sulfate. MEDICATIONS: 1. Synthroid 150 micrograms po q day. 2. Potassium 8 milliequivalents two tabs b.i.d. 3. Calcium supplementation. 4. Multivitamin. SOCIAL HISTORY: No tobacco, no alcohol use. The patient lives and cares for her demented husband. PHYSICAL EXAMINATION: In general, the patient was conversing well in no acute distress, alert and awake. Temperature 97.1. Heart rate 90. Blood pressure 133/79. Respiratory rate 18. Oxygen saturation 94% on room air. HEENT pupils are equal, round and reactive to light. Extraocular movements intact. Normocephalic, atraumatic. Cardiovascular irregularly irregular, normal S1 and S2 without murmurs, rubs or gallops. Lungs clear to auscultation bilaterally. Abdomen soft, nontender, nondistended. Normoactive bowel sounds. Extremities no clubbing, cyanosis or edema. Neurological alert and oriented times three with cranial nerves II through XII intact. Strength 4 out of 5 in upper and lower extremities. LABORATORY: White blood cell count 15.5 with a differential of 91 neutrophils, 4 bands, 4 lymphocytes, 1 monocytes, 0 eosinophils. Hematocrit 37.0, platelets 396, sodium 140, potassium 1.2, chloride 107, bicarbonate of 12, BUN 75, creatinine 9.6, glucose 102. Calcium 5.2 with a free calcium of 0.93 with phosphorus of 6.0, magnesium of 0.6. TSH 11, albumin 3.3. Urinalysis yellow, clear, no leukocyte esterase or nitrates, large blood, 30 protein, 0 to 2 red blood cells, 0 to 2 white blood cells, moderate bacteria, 0 to 2 epithelial cells. Urine creatinine 61, urine sodium 47, FENA 5.28%. Spun urine revealed muddy brown casts. Arterial blood gas 7.19, 24, 150. Renal ultrasound small kidneys without evidence of hydronephrosis. Head CT no evidence of intracranial hemorrhage. Chest x-ray no congestive heart failure, no pneumonia or fusions, moderate cardiomegaly. Electrocardiogram normal sinus rhythm at 91 beats per minute with frequent premature ventricular contractions, left axis deviation, normal intervals, nonspecific ST and T wave changes, QT interval was noted to be 438. HOSPITAL COURSE: 1. Renal: The patient's profound electrolyte abnormalities were likely secondary to the patient's not taking her oral supplementation as well as severe volume depletion. The evidence of muddy brown casts as well as elevated BUN and creatinine indicated that the patient had acute tubular necrosis, which was likely secondary to hypovolemia and poor renal perfusion. The patient was also noted to have a primary metabolic acidosis secondary to her diarrhea and her renal failure with a compensatory respiratory alkalosis. The renal team was consulted and repletion of potassium, calcium and magnesium was initially performed intravenously in the Medical Intensive Care Unit. The patient was also started on bicarbonate repletion once her potassium was above 3.0. The patient was also given gentle intravenous fluids and on [**2186-1-25**] the patient was transferred from the Medical Intensive Care Unit to the medicine team. At that time the patient was started on oral potassium supplements, Tums for calcium supplementation and oral sodium bicarb tablets. By this time the patient did not require any standing magnesium supplementation and was only repleted on a prn basis. The patient's BUN and creatinine continued to improve during her hospital stay with her BUN and creatinine at the time of this dictation being 44 and 6.0 respectively. At this time there is no indication for hemodialysis, however, the Renal Service is following and assessing this decision on a daily basis. In addition, the patient had a good urine output during her hospital course. 2. Gastrointestinal: The patient was noted to have an elevated amylase and lipase level of amylase levels in the 200s and lipase level in the 600s on [**2186-1-24**]. It was thought that this chemical pancreatitis was probably secondary to volume depletion and poor perfusion of the pancrease. The patient did not clinically have any signs of pancreatitis such as nausea, vomiting, abdominal pain when the pancreatitis was discovered by elevated amylase and lipase levels. The patient was placed on a low fat diet. Enzymes were followed and there was no treatment indicated at this time since the pancreatitis was likely secondary from ischemia from hypotension and hyperperfusion. The GI Service was consulted for the patient's chronic diarrhea, which is likely multifactorial. Possible causes included lactose intolerance as well as a short colon. There possibly is a malabsorption element as well. Stool studies were sent, which did not reveal an infectious etiology nor was there any evidence to suggest inflammatory bowel disease. Currently a stool fat is pending at this time as well as stool electrolytes and osms. Metamucil as well as Lomotil was added to help with the diarrhea. In addition, a right upper quadrant ultrasound was obtained to further evaluate the patient's pancreatitis, which was completely unremarkable. 3. Hematology: The patient's hematocrit was noted to be 21 to 22 upon transfer from the Medical Intensive Care Unit. The patient's stools were guaiaced and were negative. The patient's iron studies were consistent with anemia of chronic disease. It was thought that the patient's anemia was likely secondary to her acute renal failure. As a result the patient was transfused 2 units of packed red blood cells with appropriate increase in her hematocrit to 30 to 31. In addition, the patient was started on Epogen 3000 units subQ b.i.d. This is an incomplete discharge summary. Please see discharge addendums for completion of the [**Hospital 228**] hospital course, discharge diagnoses and discharge medications. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) 14486**] MEDQUIST36 D: [**2186-1-29**] 04:27 T: [**2186-2-1**] 09:22 JOB#: [**Job Number 14487**] Name: [**Known lastname 2280**], [**Known firstname 2281**] Unit No: [**Numeric Identifier 2282**] Admission Date: [**2186-1-22**] Discharge Date: [**2186-2-1**] Date of Birth: [**2105-8-13**] Sex: F Service: [**Location (un) 571**] ADDENDUM: 1. RENAL: The patient's renal function continued to improve throughout the remainder of the hospitalization with adequate urine output and a creatinine at the time of discharge of 3.9, BUN 28. The patient was deemed volume replete with adequate oral intake. However, the patient continued to require electrolyte repletion for continued GI losses. The Renal Service recommended continued monitoring of the patient's creatinine as an outpatient with recommended follow-up with Outpatient Renal in two to three weeks time if the creatinine had not normalized by that time. 2. HEMATOLOGY: The patient underwent a workup for anemia and was found to have anemia of chronic disease, likely secondary to renal dysfunction. The patient was continued on Epogen 3,000 units q. Monday and Friday and maintained a stable hematocrit in the 30-32 range. There was no evidence of blood loss or further need for transfusion. 3. GASTROINTESTINAL: The patient continued with chronic diarrhea; however, with the addition of bulk-forming agents and the initiation of a lactose/fat-free diet, the patient's diarrhea frequency decreased and the stools were reportedly more formed. The diarrhea was felt likely secondary to short gut and lactose intolerance. A family meeting was held with discussion regarding factors that may have contributed to the patient's current hospitalization including family stressors and discordance. The importance of the [**Hospital 1325**] medical compliance was strongly reinforced. DISCHARGE CONDITION: Good. DIAGNOSIS ON DISCHARGE: 1. Chronic diarrhea secondary to right hemicolectomy ([**2179**]). 2. History of colon cancer, status post right hemicolectomy ([**2179**]). 3. Chronic hypokalemia and hypocalcemia. 4. Acute renal failure secondary to acute tubular necrosis. 5. Status post breast cancer. 6. Hypothyroidism. 7. Diverticulosis. MEDICATIONS ON DISCHARGE: 1. Synthroid 150 micrograms p.o. q.d. 2. Epogen 3,000 units subcutaneously q. Monday and Friday. 3. Potassium chloride 60 mEq p.o. b.i.d. 4. Magnesium oxide 400 mg p.o. q.d. 5. Calcium carbonate 1,000 mg p.o. b.i.d. 6. Metamucil one packet b.i.d. 7. Sodium bicarbonate 13 mg p.o. b.i.d. (to be discontinued at the resolution of renal failure). 8. Protonix 40 mg p.o. q.d. DISCHARGE INSTRUCTIONS: The patient was discharged to home with home services for medication teaching and reinforcement of compliance. The patient also will be followed with frequent blood draws in the short-term to continue to monitor the patient's electrolytes, renal function, and hematocrit. The patient was instructed to follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2283**], on [**2186-2-10**] at 2:00 p.m., Dr. [**First Name4 (NamePattern1) 255**] [**Last Name (NamePattern1) **] (Renal) on [**2186-2-14**] at 3:30 p.m., and Dr. [**Last Name (STitle) 2284**] (GI) on [**2186-2-22**] at 1:00 p.m. [**Name6 (MD) **] [**Last Name (NamePattern4) 424**], M.D. [**MD Number(1) 425**] Dictated By:[**Name8 (MD) 2285**] MEDQUIST36 D: [**2186-2-12**] 04:07 T: [**2186-2-12**] 16:32 JOB#: [**Job Number 2286**]

[ "275.41", "V10.3", "577.0", "244.9", "276.5", "276.2", "V10.05", "276.8", "584.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9715, 9732

10090, 10471

4000, 9693

10496, 11372

2185, 3982

9746, 10064

297, 1666

1688, 2061

2078, 2162

54,757

112,220

42445+42446+58526+58529

Discharge summary

report+report+addendum+addendum

Admission Date: [**2186-3-24**] Discharge Date: [**2186-6-1**] Date of Birth: [**2145-4-18**] Sex: M Service: SURGERY Allergies: Latex Attending:[**First Name3 (LF) 14255**] Chief Complaint: cholangiocarcinoma Major Surgical or Invasive Procedure: 1. R hepatic lobectomy and pancreaticoduodenectomy ([**2186-3-24**]-[**Location (un) **]), 2. ex-lap, drainage of RUQ abscess, and redo pancreaticojejunostomy ([**2186-4-8**]-[**Location (un) **]), 3. ex-lap, washout for bleeding ([**2186-4-14**]-[**Location (un) **]), 4. abd washout, temporary closure ([**2186-4-16**]-[**Location (un) **]), 5. ex-lap, washout, attempted closure ([**2186-4-19**]-[**Location (un) **]), 6. abd washout and closure ([**2186-4-25**]-[**Location (un) **]) Thoracentesis [**2186-4-21**], [**2186-4-28**] Picc placed [**2186-4-4**], removed [**2186-5-30**] History of Present Illness: 40-year-old Italian male who presents with a segment VIII hepatic lesion. [**Known firstname 91899**] was initially diagnosed with his bile duct stricture in [**2183**]. He has undergone multiple brushings and biopsies of this lesion, which were all consistent with a benign stricture. He has had a number of stents placed in the bile duct and eventually these were removed. He was doing well until he was seen at the [**Hospital 8**] Hospital by Dr. [**Last Name (STitle) 2161**] and [**Last Name (STitle) 1834**] a CT scan, which demonstrated what appeared to be metastasis in the right lobe of the liver. He has no significant past medical history. Past Medical History: None Social History: He is currently employed as a construction worker working full time. He divides his time between [**State 108**] and [**Location (un) 86**]. He notes that he has a glass of wine or beer a couple of times a week, approximately 10 cigarettes per day and he has quit approximately three years ago. No drugs, no marijuana. Family History: Non-contributory Physical Exam: discharge PE 98.5 92 100/64 18 A&O, anicteric decreased breath sounds R lower half rrr abd soft/non-tender, capped Roux tube, 2 JP drains with greenish fluid, L side of incision with 2x2 damp to dry NS dressing ext trace edema right ankle roux capped JP #1 15ml/day JP #2 20ml/day BM x2 [**5-31**] Pertinent Results: [**2186-6-1**] 05:55AM BLOOD WBC-9.8 RBC-2.96* Hgb-8.9* Hct-27.4* MCV-92 MCH-30.1 MCHC-32.5 RDW-14.6 Plt Ct-365 [**2186-5-29**] 03:46AM BLOOD PT-13.8* PTT-28.9 INR(PT)-1.3* [**2186-5-29**] 03:46AM BLOOD Glucose-116* UreaN-11 Creat-0.6 Na-132* K-3.9 Cl-98 HCO3-28 AnGap-10 [**2186-6-1**] 05:55AM BLOOD Glucose-116* UreaN-10 Creat-0.6 Na-130* K-4.0 Cl-96 HCO3-29 AnGap-9 [**2186-5-22**] 05:50AM BLOOD ALT-37 AST-36 AlkPhos-215* TotBili-1.1 [**2186-5-29**] 03:46AM BLOOD ALT-30 AST-35 AlkPhos-242* TotBili-0.6 [**2186-6-1**] 05:55AM BLOOD ALT-33 AST-41* AlkPhos-270* TotBili-0.6 [**2186-4-28**] 01:13AM BLOOD Lipase-36 [**2186-6-1**] 05:55AM BLOOD Albumin-2.7* Calcium-8.3* Phos-4.6* Mg-1.8 [**2186-5-9**] 05:32AM BLOOD calTIBC-213* TRF-164* [**2186-5-8**] 05:08AM BLOOD Triglyc-111 [**2186-5-21**] 5:46 pm PLEURAL FLUID PLEURAL FLUID . **FINAL REPORT [**2186-5-27**]** GRAM STAIN (Final [**2186-5-22**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 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 [**2186-5-24**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2186-5-27**]): NO GROWTH. [**2186-4-7**] 4:20 am BLOOD CULTURE **FINAL REPORT [**2186-4-15**]** Blood Culture, Routine (Final [**2186-4-14**]): PREVOTELLA SPECIES. BETA LACTAMASE NEGATIVE. Anaerobic Bottle Gram Stain (Final [**2186-4-9**]): Reported to and read back by DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 1650, [**2186-4-9**]. GRAM NEGATIVE ROD(S). Brief Hospital Course: On [**2186-3-24**], Mr. [**Known lastname 91900**] [**Last Name (Titles) 1834**] right hepatic lobectomy and Whipple procedure for distal cholangiocarcinoma with metastasis to the right lobe of the liver. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], co-surgeon Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **]. He was intubated and sedated postoperatively for a prolonged period due to revision of pancreaticojejunostomy, drainage of right upper quadrant abscess and redo of pancreaticojejunostomy on [**4-8**] for pancreaticojejunostomy dehiscence. He had open abdomen and need for repeated abdominal washouts. SICU course was prolonged. He was successfully extubated after repeated operations on [**4-22**]. Despite his prolonged intubation, he was oriented to time and place post extubation. Following repeated surgeries, he was persistently tachycardic. CTA was performed on [**2186-3-27**] and was negative for pulmonary embolus, but did show a subdiaphragmatic fluid collection. He remained on pressor support (neo,vasopressin from [**Date range (1) 89937**]). Octreotide was also started due to continued bleeding after initial OR on [**4-8**]. Cardiac echo was performed [**2186-4-10**] which revealed normal biventricular cavity sizes with preserved regional and hyperdynamic global biventricular systolic function. No valvular pathology or pathologic flow identified. On [**4-8**], (postop day 15), he continued to drain bile from his JP drains. He was taken back to the OR for concern of anastomotic leak from his pancreaticojejunostomy. He continued to have a dropping hematocrit on [**4-14**] and returned to to OR on [**4-14**] for abdominal washout, however no source of bleeding was determined. Despite this the patient continued to have a transfusion requirement. had a persistent transfusion requirement and returned again to the OR for abdominal washout later that day. In total, between [**4-8**] and [**4-16**] he received 23 Units of PRBC, 16U of FFP. He again returned to the OR on [**4-14**] for abdominal washout. Abdomen was left open. Following diuresis with a Lasix drip the patient subsequently returned to the OR [**4-25**] for closure. Please refer to operative reports for details. Thoracentesis was done on [**4-21**] and [**4-28**] for 1200 cc and 1000 cc respectively. Respiratory status subsequently improved and patient had decreased oxygen requirement. Thoracentesis was again performed on [**5-16**] for large pleural effusion. Pleural fluid culture isolated pan sensitive E.coli. IV Ciprofloxacin was administered for 15 days. CXR demonstrated apical pneumothorax. Reaccumulation of the pleural effusion occurred necessitating repeat thoracentesis with pigtail drain placement was done on [**5-21**] yielding one liter of exudate. TPA instillation was attempted, however, pigtail catheter became dislodge. Culture of this fluid demonstrated 4+PMN, but was negative for microorganisms. Given concern for empyema, a thoracic consult was obtained on [**5-25**]. After review of CXRs , no further intervention was recommended as the thoracic surgery service thought the effusion was most likely reactive from the subdiaphragmatic collection. Notation of an 8-mm right upper lobe nodule was made and attention on followup scans for surveillance for metastasis was recommended. He was weaned off oxygen and O2 saturations were greater than 93%. CXR on [**5-29**] showed slightly decreased loculated right pleural effusion since the prior study still involving the major fissure and still with multiple air-fluid levels consistent with air loculations. No pneumothorax was noted. There was a small left pleural effusion. He was maintained on total parenteral nutrition throughout most of his hospital course. On postop day 32, a post-pyloric feeding tube was placed and tube feedings were started and successfully advanced to goal rate. Throughout hospital stay, regular insulin was given per sliding scale. From [**Date range (1) 91901**] while critically ill he remained on an insulin gtt which was subsequently weaned off. He passed a bedside swallow and was subsequently advance to clears and then regular diet. Otolaryngology was consulted for weak, hoarse voice. It was felt that prolonged and repeated intubations were likely the cause and that granulomatous changes would resolve over time. PPI therapy was recommended and administered (Protonix [**Hospital1 **]). Hoarseness and projection improved. Creatinine remained stable at ~1.0. He tolerated diuresis with a Lasix drip until successful closure of abdomen on [**4-25**]. While on Lasix drip, urine output remained excellent 100-400 cc/hr with urine output of >4-6L/day. Following abdominal washout on [**2186-4-8**] he was placed on broad spectrum antibiotics including vanc/zosyn and fluconazole. Blood cultures returned on [**4-7**] positive for Prevotella species, but surveillance cultures remained negative since this blood culture. On [**2186-4-20**] his PICC line was removed and his CVL was replaced for concern of rising leukocytosis to 14. PICC line culture was negative. Central line was eventually removed and another PICC line was placed ([**5-6**]/)into left upper arm. This line was used for TPN/antibiotics/blood draws. On [**5-30**], this line was removed as IV antibiotic course (Ciprofloxacin)was stopped on [**5-31**]. Give protracted hospital course, he was very depressed. Social work and pastoral care supported. Remeron was started on [**5-11**] at 7.5mg then increased to 15mg on [**5-25**]. Mood, energy level and sleep pattern improved. LFTs slowly improved with values approaching normal limits with the exception of alk phos which remained in the low to mid 200s. Ursodiol was continued. He continued to have anemia with stable hematocrit of 25. Physical therapy worked with him throughout this hospital stay. He became more independent with ambulation and ADLs as his condition improved. He had been very debilitated, tachycardic and with O2 requirement. Rehab was recommended. Rehab screen was done per case management and [**Hospital3 **] in [**Hospital1 8**] offered a bed on [**6-1**]. He will transfer there today. Medications on Admission: none Discharge Medications: 1. DiphenhydrAMINE 25 mg PO HS:PRN insomnia 2. Docusate Sodium 100 mg PO BID 3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain 4. Mirtazapine 15 mg PO HS 5. Octreotide Acetate 100 mcg SC Q8H 6. Ondansetron 4 mg IV Q8H:PRN nausea 7. Pantoprazole 40 mg PO Q12H 8. Ursodiol 300 mg PO BID Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Cholangiocarcinoma pancreaticojejeunostomy dehiscence right pleural effusion prevotella bacteremia [**2186-4-7**] Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You will be transferring to [**Hospital3 **] in [**Hospital1 8**]. Please call Drs.[**First Name (STitle) **] and [**Doctor Last Name **] office if you have any of the following: temperature of 101 or greater, chills, nausea, vomiting, jaundice, increased abdominal pain, drain output stops or increases significantly or changes in color/odor, constipation or diarrhea or if feeding tube clogs. You may shower. Followup Instructions: Follow up will be with Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **] on [**2186-6-15**] at 1:15 PM at [**Hospital **] Medical Office Building, [**Location (un) **], [**Last Name (NamePattern1) **]. [**Location (un) 86**], [**Numeric Identifier **] Completed by:[**2186-6-1**] Admission Date: [**2186-6-7**] Discharge Date: [**2186-6-20**] Date of Birth: [**2145-4-18**] Sex: M Service: SURGERY Allergies: Latex Attending:[**First Name3 (LF) 14255**] Chief Complaint: fevers, bacteremia Major Surgical or Invasive Procedure: picc line placement [**2186-6-9**] History of Present Illness: 41M well known to the West 1 service who was discharged to rehab one week ago after a 10-week admission. His hospital course is well documented in his discharge summary dated [**2094-5-31**]. In brief, he has cholangiocarcinoma and [**Month/Day/Year 1834**] resection followed by several more operations to repair anastamoses and drain fluid collections. On discharge to rehab last week, he was tolerating tube feeds, off antibiotics, with two JP drains in place in his abdomen. Over the weekend, he was not tolerating tube feeds well so the rate was decreased. Despite decreasing the rate, he had intermittent emesis. Two days ago, routine labs at [**Hospital3 **] showed an elevated WBC of 14.3 (9.8 last week) and blood cultures were drawn showing 1 of 4 bottles with gram + cocci. He was started on vancomycin. The WBC was 12.8 the following day. Yesterday, he had a fever to 101.2 and was broadened with meropenem. A direct admission to [**Hospital Ward Name 121**] 10 was arranged. On arrival to [**Hospital Ward Name 121**] 10, he is in good spirits. He states his only symptom in nausea and is frustrated he is not tolerating tube feeds well. Otherwise states he feels well and has been making good progress since discharge a week ago. ROS: (+) per HPI (-) Denies pain, chills, night sweats, unexplained weight loss, fatigue/malaise/lethargy, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, hematemesis, bloating, cramping, melena, BRBPR, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: None Social History: He is currently employed as a construction worker working full time. He divides his time between [**State 108**] and [**Location (un) 86**]. He notes that he has a glass of wine or beer a couple of times a week, approximately 10 cigarettes per day and he has quit approximately three years ago. No drugs, no marijuana. Family History: Non-contributory Physical Exam: Vitals: T 99.5 P 105 BP 105/75 RR 18 95 RA 74.8 kg GEN: A&O, NAD, pleasant HEENT: No scleral icterus, mucus membranes moist CV: RRR, no r/m/g PULM: decreased breath sounds R base, mild rales bilaterally ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses. JPx2 in position, draining thin tan-colored fluid Ext: No LE edema, LE warm and well perfused Laboratory: CBC - 12.1 > 29.3 < 329 PT: 14.7 PTT: 23.8 INR: 1.4 131 96 11 --------------< 105 3.6 25 0.9 Ca: 8.5 Mg: 1.7 P: 4.2 AST: 32 ALT: 30 AP: 293 Tbili: 0.8 Alb: 2.5 Lip: 143 (elevated from baseline lipase) Imaging: CT torso (wet read): R parapneum eff slightly bigger, abdomen/pelvis grossly unchanged from prior, no new collection Pertinent Results: [**2186-6-8**] URINE URINE CULTURE-FINAL INPATIENT (<10,000 org) [**2186-6-8**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2186-6-8**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2186-6-7**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2186-6-7**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2186-6-7**] URINE URINE CULTURE-FINAL Negative. INPATIENT [**2186-6-7**] 11:25PM URINE RBC->182* WBC-19* Bacteri-FEW Yeast-NONE Epi-0 [**2186-6-8**] 01:57PM URINE RBC->182* WBC-14* Bacteri-FEW Yeast-NONE Epi-0 [**2186-6-7**] 11:25PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-SM [**2186-6-8**] 01:57PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM [**2186-6-9**] Urine cytology: pending [**2186-6-7**] 09:20PM BLOOD WBC-12.1* RBC-3.31* Hgb-9.4* Hct-29.3* MCV-89 MCH-28.4 MCHC-32.1 RDW-14.0 Plt Ct-329 [**2186-6-19**] 03:48AM BLOOD WBC-7.9 RBC-2.96* Hgb-8.6* Hct-26.1* MCV-88 MCH-29.1 MCHC-33.0 RDW-14.2 Plt Ct-258 [**2186-6-19**] 03:48AM BLOOD PT-14.1* PTT-29.2 INR(PT)-1.3* [**2186-6-7**] 09:20PM BLOOD Glucose-105* UreaN-11 Creat-0.9 Na-131* K-3.6 Cl-96 HCO3-25 AnGap-14 [**2186-6-19**] 03:48AM BLOOD Glucose-118* UreaN-8 Creat-1.0 Na-138 K-3.3 Cl-103 HCO3-29 AnGap-9 [**2186-6-7**] 09:20PM BLOOD ALT-30 AST-32 AlkPhos-293* Amylase-182* TotBili-0.8 [**2186-6-19**] 03:48AM BLOOD ALT-14 AST-19 AlkPhos-214* TotBili-0.4 [**2186-6-19**] 03:48AM BLOOD Calcium-8.5 Phos-4.4 Mg-1.8 Brief Hospital Course: 41 y.o. male with complicated post-operative course following resection of cholangiocarcinoma. He was readmitted with bacteremia and nausea to the West 1 Surgery Service under Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **]. He was pan-cultured and started on IV Vancomycin. UA was notable for hematuria. Urine culture was negative. Surveillance blood cultures were done and remained negative. Blood cultures from [**6-5**] from [**Hospital3 **] were positive for pan-sensitive Enterococcus Faecalis. Vancomycin IV was switched to Unasyn. The plan was to treat with Ampicillin for 2 weeks from [**6-9**] until [**6-23**]. Torso CT demonstrated slightly smaller air and fluid containing subphrenic collection. This collection was not drained as this required crossing thru the liver to target the collection. Air within this collection suggested communication with the colon. Perigastric fluid collection was stable. Left pelvic fluid collection was slightly smaller. There was a new 1.2 cm hypodense lesion within the left lobe of the liver concerning for metastatic disease or possible abscess. There was a nonspecific perigastric nodule which may represent omental implant or fat necrosis. Bilateral pleural effusions were noted with left slightly larger than right. 8mm right upper lobe pulmonary nodule was stable, but will require f/u CT scan to monitor for changes. [**Hospital 91902**] hospital course was notable for stable vital signs. JP drain outputs averaged 10-20cc (brown/cloudy) for #1 drain and 55-70cc (brown cloudy) for #2. Abdominal incision had scant amount of drainage at midline area. Dry gauze dressing was applied. LFTs remained stable. Post pyloric tube feeds were continued. Nutrition assessment by dietician noted that his caloric requirements were higher than what he had been receiving via the feeding tube. Tube feedings were switched to Isosource at 80cc/h cycled over 18 hours. However, he did not tolerate this rate. Even with decreased rate, he experienced indigestion and nausea with vomiting. Formula was switched to Replete. However, this was not well tolerated either. Oral kcal intake averaged ~ 1100kcals per day with approximately 32grams protein. Eventually, formula was switched to Vivonex with advancement to goal of 80cc/hr (continuous). He tolerated this well. Pancrealipase was also started at 3 times per day. Recommendations from dietician were to increase continuous Vivonex to 90cc/hr continuous to meet his caloric needs (2200 kcal per day-this is low end of patients requirement). He continued to have sensation with swallowing that fluid was stuck in back of throat. ENT was reconsulted and noted resolution of previous granulomatous changes from post intubation that was noted in early [**Month (only) 116**]. A speech and swallow eval was obtained. He was able to swallow without signs or symptoms of aspiration. Recommendations were to continue thin liquids and solids. Medications were ok to be swallowed whole. During this hospital stay, it was also noted that he had micro-hematuria. Urine cultures were negative. Urine cytology was sent demonstrating atypical urothelial cells, present singly and in few clusters. Urology was consulted and recommendation was made for outpatient cystoscopy was made. Appointment still needs to be scheduled. He was ambulating independently. Plans were to return to [**Hospital3 **]. A bed was available and he transferred there on [**6-20**]. He will f/u with his surgeon, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital 7302**] (Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 91903**] Monday [**2186-6-26**] at 09:00, [**Street Address(2) 64224**], [**Location (un) 583**] (building next to [**Hospital6 **]) (fax: [**Telephone/Fax (1) 91904**]). Medications on Admission: Meds at Rehab: vancomycin 1', meropenem, mirtazapine 15qhs, nystatin 10''', pantoprazole 40", ursodiol 300", tylenol prn, benadryl qhs, colace 100", glycerin PR', dilaudid 2 prn, zofran 4 prn Allergies: latex Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN discomfort 2. Ampicillin 2 g IV Q4H via picc until [**6-23**] 3. Docusate Sodium 100 mg PO BID 4. Mirtazapine 15 mg PO HS 5. Ondansetron 4-8 mg IV Q8H:PRN nausea 6. Pantoprazole 40 mg PO Q12H 7. Ursodiol 300 mg PO BID 8. Pancrelipase 5000 1 CAP PO TID W/MEALS 9. Outpatient Lab Work Twice Weekly stat labs on Monday and Thursday for cbc, chem 10, ast, alt, alk phos, tbili and albumin. Fax to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Bacteremia, enterococcus faecium [**2186-6-5**] h/o whipple Malnutrition RUL lung nodule Microscopic hematuria Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -you will be transferring back to [**Hospital1 **] in [**Hospital1 8**] Please call Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office [**Telephone/Fax (1) 91903**] if you have any of the following: temperature of 101 or greater, chills, nausea, vomiting, inability to tolerate food or fluid, increased abdominal pain or abdominal distension, jaundice, increase drain output, constipation/diarrhea or incision open area appears red or has drainage. -IV ampicillin will continue until [**6-23**] via the PICC line. -Feeding tube formula was switched to Vivonex an elemental formula for easier digestion. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 91903**] [**2186-6-26**] at 09:00, [**Street Address(2) 91905**], [**Location (un) 583**] (building next to [**Hospital3 2005**] Hospital) (fax: [**Telephone/Fax (1) 91904**]) -Schedule f/u with Urologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] [**Telephone/Fax (1) 3752**] for cystoscopy for hematuria in next few weeks Completed by:[**2186-6-20**] Name: [**Known lastname 14453**],[**Known firstname 14454**] Unit No: [**Numeric Identifier 14455**] Admission Date: [**2186-3-24**] Discharge Date: [**2186-6-1**] Date of Birth: [**2145-4-18**] Sex: M Service: SURGERY Allergies: Latex Attending:[**First Name3 (LF) 2214**] Addendum: Please note, at time of discharge, attending coverage had changed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 15**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2216**] MD [**MD Number(2) 2217**] Completed by:[**2186-6-12**] Name: [**Known lastname 14453**],[**Known firstname 14454**] Unit No: [**Numeric Identifier 14455**] Admission Date: [**2186-6-7**] Discharge Date: [**2186-6-20**] Date of Birth: [**2145-4-18**] Sex: M Service: SURGERY Allergies: Latex Attending:[**First Name3 (LF) 2214**] Addendum: Urology f/u appointment scheduled: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3843**], MD (Urology) Phone:[**Telephone/Fax (1) 14464**] Date/Time:[**2186-7-25**] 2:00..initial visit with possible cystoscopy. [**Hospital1 8**], [**Hospital Ward Name 600**], [**Hospital Ward Name **] Building, [**Location (un) 1826**], [**Location (un) 14465**], [**Location (un) 42**] Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 15**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2216**] MD [**MD Number(2) 2217**] Completed by:[**2186-6-20**]

[ "793.11", "V85.1", "995.92", "156.1", "599.72", "790.7", "276.69", "E878.8", "785.52", "997.49", "998.12", "155.1", "511.9", "579.3", "998.09", "998.11", "567.22", "998.59", "041.04", "038.9", "197.7", "276.7", "787.01", "510.9" ]

icd9cm

[ [ [] ] ]

[ "33.24", "51.94", "38.97", "34.04", "99.15", "54.61", "96.72", "52.7", "54.12", "50.3", "34.91", "54.19", "96.6", "87.54" ]

icd9pcs

[ [ [] ] ]

24281, 24510

16539, 20438

12088, 12125

21458, 21458

14979, 16516

22262, 23261

14162, 14180

20699, 21210

21325, 21437

20464, 20676

21609, 22239

14195, 14960

12029, 12050

12153, 13778

21473, 21585

13800, 13806

13822, 14146

18,429

109,865

29468

Discharge summary

report

Admission Date: [**2138-11-20**] Discharge Date: [**2138-11-29**] Date of Birth: [**2065-11-30**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3507**] Chief Complaint: fevers and mental status change Major Surgical or Invasive Procedure: pleural tap History of Present Illness: 72 yo Mandarin speaking female with metastic breast CA who had a hip fx 2 months ago with a prolonged hospital course and long recovery at rehab, presents with MS [**First Name (Titles) 767**] [**Last Name (Titles) 1501**] on [**2138-11-20**]. She also complained of sharp right sided chest pain. . Her temp in ED was 102. She received 1L NS, tylenol, vancomycin, ceftrioxone, [**Date Range **], lopressor and plavix. She was aditted to [**Hospital1 1516**] for rule out MI and fevers. Past Medical History: -- R. breast cancer s/p mastectomy no chemotx / radiation[according to records from [**Hospital1 **]--pt had 1.9cm infiltrating, poorly differentiated ductal carcinoma; 8 axillary nodes (-). ER/PR negative & HER-2/Neu 3+. Pt reportedly lost to follow-up after mastectomy - 10 years ago per notes. Chest CT from [**2138-10-14**] shows "extenisive tumor mass involving the right anterior chest wall & ribs...there appears to be increase in the extent of . The lesion extends from the level of the aortic arch caudally to the inferior costal margin." ] -- s/p excisional bx of right neck lymph node [**10-3**] (for purpose of assessing recurrance of breast CA via tumor markers -- Stage 4 sacral decubitus ulcer -- Osteoarthritis (according to son) -- Anemia NOS -- Pulmonary nodule (6mm) seen on [**10-3**] CT, unchanged from prior scan -- Calcified lung granuloma (? remote h/o TB) --- choledolithiasis - 3 months ago @ MWH, had subsequent sphintorectomy and biliary duct stenting placed with improvement in n/v -> subsequent functional decline with overall weakness leading to R hip Fx after a fall at home. --- R hip replacement - 6 weeks ago - s/p ORIF, subsequent care at [**Hospital1 **] --- SI/attempt [**1-30**] to hip fx and associated pain Social History: Pt moved from [**Country 651**] to US 10yrs ago to live w/ her son & his children. She has served as primary care giver for them. Has two sons in [**Name (NI) 651**]. Hopes to move back one day. Family History: NC Physical Exam: Vitals: T: 97.4 BP:84/51 P:89 R:12 SaO2: 98% 2L General: appropriate, answering question in chinese, cachetic woman. HEENT: NC/AT, temporal wasting, anicteric, dry MM, clear OP without lesions. Neck: no JVD, flat neck veins Pulmonary: Lungs CTA bilaterally; Cardiac: RRR, nl. distant HS; S1S2, no M/R/G noted Abdomen: + BS x 4 quadrants, soft, NT/ND, no masses or guarding Rectal: Guiac positive in ED. Large area of skin breakdown with necrotic area, exposed bone, area ~ 5 cm diameter with minimal surrounding erythema. Extremities: No edema, no cyanosis. Skin: no rashes or lesions noted, no extremity skin breakdown Pertinent Results: CXR [**2138-11-20**]: Right lower lobe pneumonia with a small parapneumonic effusion. . EGK [**11-20**]: 99bpm Sinus rhythm. Low limb lead voltage. There is diffuse slight ST segment elevation. . TTE: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Moderate tricuspid regurgitation. . MR head: Moderate brain atrophy. No enhancing brain lesions to indicate metastatic disease. . MR [**Name13 (STitle) **]: 1. There is no spinal cord compression. 2. There are STIR and T1 hyperintense lesions in C7 and T2 most consistent with hemangiomas. . MR [**Name13 (STitle) 2854**]: There is no evidence of metastatic disease to the thoracic spine or thoracic spinal cord compression. . MR [**Name13 (STitle) **]: 1. No lesion is seen that suggests a lumbar spine metastasis. 2. There is moderate degenerative stenosis at L4-5 where there is grade 1 spondylolisthesis and posterior element hypertrophy. . CT chest, Abd, pelvis: 1. Large right breast/anterior chest wall soft tissue mass, measuring approximately 7.4 cm in size, eroded the adjacent sternum. Associated right lateral chest wall 1.2 cm subcutaneous deposit. Moderate-sized layering right pleural effusion with three right upper lobe/right middle lobe nodules. No primary lung mass identified. No additional osseous metastatic lesions seen. 2. Calcified lung nodule with associated multiple calcified mediastinal nodes suggest prior tuberculosis exposure. 3. Pneumobilia with distended intra- and extra-hepatic biliary ducts. No hepatic metastases visualized. 4. Large right sacral decubitus ulcer extending to the sacrum/coccyx, chronic osteomyelitis cannot be excluded. 5. Right total hip replacement without evidence for loosening. No acute fracture or dislocation. . Pleural fluid Cytology: PND . Bone scan: Patchy uptake involving the anterior right ribs and sternum correlates with right chest wall osseous tumor invasion on CT scan. Uptake around the trochanteric portion of the right hip prosthesis may relate to surgery, but if there had been a pathologic fracture initially, residual osseous tumor cannot be excluded. Brief Hospital Course: 72 YO mandarin speaking woman with metastatic breast cancer and recent hospitalization for hip fracture, state IV ulcer, and recent suicide attempt who presents with fevers, N/V and found to have pneumonia, UTI, bacteremia, Stage IV decubitus ulcer, pleural effusion. . # Fever: Has multiple sources of infection including RLL PNA treated with a course of azithromycin and at time of discharge no cough or sputum production, lungs are clear. UTI with enterococcus, Strep milleri bacteremia. At time of discharge, she was afebrile, normal WBC count. Stage IV decubitus ulcer dressing changes and family teaching. Will complete a 14 day course of antibiotics with moxifloxacin per ID recommendations. Pleural effusion was tapped and showed exudate negative for bacterial culture. AFB stain was negative. Cytology is pending at the time of discharge. It is thought the pleural effusion is most likely associated with her malignancy but await cytology results. . # ID: During her hospitalization, the infectious disease service was concerned about active tuberculosis. Her pleural effusion was negative for AFB stain. Pulmonary does not believe that further evaluation is needed. Infectious disease and infection control have cleared patient for active TB; she does not need to wear mask at home OR have contact TB precautions when hospitalized (unless she develops new symptoms suspicious for TB) at which point this will need to be reevaluated. . # HYPOTENSION: Likely [**1-30**] [**Month/Day (2) **] dose. She only had low grade temperatures and her lactate was normal which argues against sepsis. However, she currently has multiple infections and a dramatic stage IV decubitus ulcer which puts her at high risk for sepsis. She responded to IVF and is currently at her low-normal baseline. (Her son reports that her SBP runs between 100-105.) . # MS CHANGE: She is back to baseline currently, confirmed with son. This was likely from her multiple infections. MRI head was negative for metastatic disease . # ANEMIA: She had a HCT drop from 27 to 22 and responded to 32 after 1u of pRBC. She denies blood in stool but was guaiac + is ED. She has iron panel suggesting anemia of chronic disease. She takes iron at home. She was continued on iron and her HCT was monitored and PPI continued. At the time of discharge her HCT was stable in the mid 30s. . # CARDIAC: She has small (if even present) ST elevations in II, II, AVF and no old EKGs to compare. Cardiology saw patient in ED and recommended [**Last Name (LF) 30474**], [**First Name3 (LF) **] and plavix. Three sets of cardiac markers were unremarkable. The family refused cath. [**First Name3 (LF) **] and plavix discontinue. [**First Name3 (LF) **] discontinued [**1-30**] hypotension. Echo showed normal L and R ventricular function with moderate TR. . # BREAST CA: She has metastatic disease to chest wall and ribs. MRI is negative for mets to brain. She received mastectomy in the past but has never received chemo or radiation per OSH records. Of note, her decline in the past 7 weeks is quite dramatic. Per family, she was cooking and cleaning 7 weeks ago and now she cannot walk and has urinary incontinence. MRI of spine was negative for evidence of cord compression. CT showed large right breast/anterior chest wall soft tissue mass, eroded the adjacent sternum. Associated right lateral chest wall 1.2 cm subcutaneous deposit. Moderate-sized layering right pleural effusion with three right upper lobe/right middle lobe nodules. No primary lung mass identified. No additional osseous metastatic lesions seen. Pleural effusion tapped and cytology is pending. Pain control provided. Lymph node cytology obtained from OSH revealing metastatic disease. . # CODE STATUS: At time of discharge, patient is DNR/DNI. The status has been changed throughout the hospitalization to await family arrival from [**Country 651**]. Currently DNR/DNI per patient and family. Medications on Admission: Pantoprazole 40 mg qd remeron 7.5 mg po qd Fragmin 2500U qd iron Discharge Medications: 1. Hospital Bed Needs hospital bed, this is a medical necessity. 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain: [**Month (only) 116**] cause drowsiness. . Disp:*30 Tablet(s)* Refills:*1* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QDAY (): Apply to hip. Leave for 12 hours, then take off for 12 hours. . Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 8. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). Disp:*1 bottle* Refills:*2* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for loose stools. Disp:*60 Tablet(s)* Refills:*2* 10. Moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days: Begin on [**11-30**]. . Disp:*5 Tablet(s)* Refills:*0* 11. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 12. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea: Take as needed for nausea. Disp:*100 Tablet(s)* Refills:*2* 13. Sterile Gauze Bandage Sig: As Directed Topical twice a day: 4x4 size Wound care as directed. Disp:*2 boxes* Refills:*2* 14. Aquacel Hydrofiber Dressing Bandage Sig: As directed Topical twice a day: 4x4 size Wound care as directed. Disp:*2 boxes* Refills:*2* 15. Aloe Vesta 2-n-1 Protective Ointment Sig: As directed Topical twice a day: Wound care as directed. Disp:*1 Tube* Refills:*2* 16. Normal saline Normal saline for wound irrigation 17. Dressing Sponges Bandage Sig: As directed. Topical twice a day: Wound care as directed. Disp:*2 Boxes* Refills:*2* 18. Medfix Tape Sig: As directed Topical twice a day: Wound care as directed. Disp:*2 Rolls* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (un) 2646**] Discharge Diagnosis: PRIMARY DIAGNOSIS: UTI Bacteremia-S. milleri Metastatic breast cancer Stage 4 sacral decubitus ulcer . SECONDARY DIAGNOSIS: Osteoarthritis Anemia NOS Pulmonary nodule, per report unchanged from prior exam Calcified lung granuloma Sphintorectomy and biliary duct stenting Suicide ideation/attempt Discharge Condition: Stable, afebrile, respiratory status stable Discharge Instructions: Please take all medication as prescribed. . If you develop a fever, cough, night sweats, or weight loss, or any other symptoms that care concerning to you, call you primary care doctor. . Continue to eat and drink as tolerated. Ensure Plus is a good supplement that you should drink three times daily as tolerated. Followup Instructions: Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) **], phone: [**Telephone/Fax (1) 70737**] . Follow up pleural fluid cytology with your primary care physician.

[ "276.1", "V10.3", "198.89", "V12.01", "311", "401.9", "458.29", "293.0", "198.5", "196.0", "707.03", "276.7", "599.0", "V43.64", "518.89", "197.0", "486", "285.29", "790.7" ]

icd9cm

[ [ [] ] ]

[ "34.91", "99.04", "86.28" ]

icd9pcs

[ [ [] ] ]

12256, 12312

5824, 9782

350, 364

12652, 12698

3044, 5801

13063, 13278

2383, 2387

9897, 12233

12333, 12333

9808, 9874

12722, 13040

2402, 3025

279, 312

392, 883

12457, 12631

12352, 12436

905, 2155

2171, 2367

24,953

193,521

16635

Discharge summary

report

Admission Date: [**2192-7-20**] Discharge Date: [**2192-8-15**] Date of Birth: [**2135-6-9**] Sex: M Service: SURGERY Allergies: Avapro / Norvasc / Penicillins / Paxil / Fluvoxamine Maleate Attending:[**First Name3 (LF) 6346**] Chief Complaint: Anastamotic leak Major Surgical or Invasive Procedure: PICC line placement, central venous line placement History of Present Illness: Pt is a 57 y/o male who is transferred to [**Hospital1 18**] from an OSH for anasatmotic leak s/p lap-assisted sigmoid colectomy, followed by a washout procedure with end colostomy and drain placement. He is being amintained on an amiodarone drip, and is presenting intubated. Past Medical History: hypertension, alcoholism, cirrhosis, obesity, anxiety, leg cramps. Social History: Pt is a current smoker of unknown duration and quantity. He has quit alcohol many years ago, but is an alcoholic. Family History: [**Name (NI) 1094**] mother also had colon cancer. Physical Exam: HR 94 BP 141/64 saO2 99% CMV 650X16 5 40% [**Pager number 47125**] gen: intubated, and sedated pulm: breath sounds decreased at the bases CV: irregularly irregular Abd: obese, soft, eccymotic lower abdmmonal wall, ostomy pink with a possiblity of epiploic or mesenteric fat visualized, midline surgical incision with two JP drains ext: 2+ edema of b/l lower extremities, dorsalis pedis and posterior tibial pulses present b/l Pertinent Results: [**2192-7-20**] 10:57PM TYPE-ART PO2-113* PCO2-35 PH-7.37 TOTAL CO2-21 BASE XS--3 [**2192-7-20**] 10:57PM LACTATE-2.1* [**2192-7-20**] 10:44PM GLUCOSE-128* UREA N-57* CREAT-1.4* SODIUM-144 POTASSIUM-5.6* CHLORIDE-116* TOTAL CO2-18* ANION GAP-16 [**2192-7-20**] 10:44PM ALT(SGPT)-66* AST(SGOT)-285* ALK PHOS-61 AMYLASE-21 TOT BILI-5.2* [**2192-7-20**] 10:44PM LIPASE-23 [**2192-7-20**] 10:44PM ALBUMIN-1.8* CALCIUM-7.8* PHOSPHATE-2.8 MAGNESIUM-2.4 [**2192-7-20**] 10:44PM WBC-9.8 RBC-3.25* HGB-10.2*# HCT-30.5*# MCV-94 MCH-31.3# MCHC-33.5 RDW-18.7* [**2192-7-20**] 10:44PM PLT COUNT-180 [**2192-7-20**] 10:44PM PT-13.8* PTT-26.1 INR(PT)-1.3 Brief Hospital Course: Pt was admitted, stabilized, and taken to the SICU. He was started on daptomycin, meropenem, and fluconazole. Cultures were sent and he was monitored for progression of his infection. On HD5 VRE was isolated from his wound cultures, ID was consulted and his fluconazole was changed to micafungin. Cardiology also was consulted and his a-flutter/fib was rate controlled with beta blockade. Pt continued to spike fevers, and on HD 6 a fluid collection was noted on CT that was then drained by IR. This did not solve the problem, and ultimately a combination of Micafungin, Meropenem, Linezolid along, with ongoing drainage of the wound. Pt progressively improved and was able to be extubated, ambulate, and tolerate PO intake. He is now being sustained on the above antibiotic combination, and his wound is granulating in. Medications on Admission: Atenolol, lisinopril, quinine, aspirin, KCl, Diazepam, Ambien Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for groin. Disp:*qs 1 month * Refills:*0* 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. Disp:*qs 1 month ML(s)* Refills:*0* 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H prn as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 4. Micafungin 50 mg Recon Soln Sig: One (1) Recon Soln Intravenous q day (). Disp:*qs 1 month Recon Soln(s)* Refills:*0* 5. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed. Disp:*qs 1 month * Refills:*0* 6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. Disp:*qs 1 month * Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours). Disp:*270 Tablet(s)* Refills:*2* 8. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 9. 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* 10. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 11. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). Disp:*qs 1 month * Refills:*2* 12. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 13. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*2* 14. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours). Disp:*qs 1 month Recon Soln(s)* Refills:*0* 15. Linezolid 600 mg/300 mL Parenteral Solution Sig: One (1) Intravenous Q12H (every 12 hours). Disp:*qs 1 month * Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: anastamotic leak, sepsis, abdominal abcess Discharge Condition: stable Discharge Instructions: Please take antibiotics and other medications as prescribed. If you develop fevers, chills, nausea, vomiting, redness around your wounds or opaque discharge from your wounds please call the office or return to the hospital. Please do not lift any heavy objects for six weeks. You may shower, but please pat your wounds dry. Followup Instructions: Upon discharge, please call to make an appointment to see Dr. [**First Name (STitle) 2819**] in the third week of [**Month (only) **]. His office number is [**Telephone/Fax (1) 2998**]. Completed by:[**2192-8-15**]

[ "576.8", "E942.0", "401.9", "790.92", "427.31", "782.4", "305.1", "427.32", "348.30", "995.92", "303.93", "571.2", "278.00", "567.2", "789.5", "998.59", "790.4", "112.89", "041.04", "V10.05", "575.8", "V44.3", "038.9" ]

icd9cm

[ [ [] ] ]

[ "38.91", "00.14", "99.15", "96.72", "38.93", "54.91" ]

icd9pcs

[ [ [] ] ]

5006, 5078

2134, 2962

336, 389

5165, 5174

1452, 2111

5548, 5765

934, 986

3075, 4983

5099, 5144

2988, 3052

5198, 5525

1001, 1433

280, 298

417, 696

718, 786

802, 918

6,863

171,986

16374+16375+56754

Discharge summary

report+report+addendum

Admission Date: [**2170-1-12**] Discharge Date: [**2170-1-26**] Date of Birth: [**2100-10-23**] Sex: M Service: [**Hospital **] [**Hospital Ward Name 46602**] CHIEF COMPLAINT: Hematemesis HISTORY OF PRESENT ILLNESS: This is a 69 year old semi-retired male orthopedic surgeon with a history of peptic ulcer disease, alcoholic cirrhosis and hepatic encephalopathy with a [**2169-12-24**] admission for an upper gastrointestinal bleed for Grade 3 esophageal varix banded on [**2170-1-3**] and discharged that month with subsequent banding as an outpatient in [**Month (only) 956**]. On this particular visit the patient had two episodes of hematemesis on the night of admission with accompanying dizziness, lightheadedness and diaphoresis but no complaints of abdominal pain, shortness of breath and cough, no bright red blood per rectum and no loss of consciousness. Emergency Medical Services were called and they estimated his blood loss approximately 1 liter. Blood pressure at the time was 53/33 and heartrate was 60. He was given Octreotide 15 mcg bolus and given Trippa 25 mcg/hr. He was admitted to the Medicine Intensive Care Unit on [**2170-1-12**]. Esophagogastroduodenoscopy was performed that day and showed presence of esophageal varices. The procedure was complicated by active bleeding into intubation. Transfusion of four units of packed red blood cells. Central line was placed. Emergent transjugular intrahepatic portocaval shunt was performed because of continued gastrointestinal bleed. Systolic blood pressure was in the 60s to 70s and also he had failed attempt at [**Last Name (un) **] tube placement on [**2170-1-13**]. The patient will need 26 units of packed red blood cells on [**1-17**]. By [**1-14**], he received one additional unit of packed red blood cells and gastrointestinal bleed had stabilized with hematocrit in the 26 to 29% range. On [**1-15**], he underwent a paracentesis for ascites, approximately 2.5 liters was aspirated. At that time he was also able to be transferred to the floor on [**2170-1-18**]. On transfer to the floor vital signs were as follows - Temperature 98.4, blood pressure 112/72, heartrate 90, respirations 24 and oxygen saturation 94% on 2 liters. On presentation he was well with no jaundice noted in no apparent distress. Mucous membranes were moist. Extraocular movements intact. Lungs were bilaterally clear. Cardiovascular, regular rate and rhythm, no murmurs, rubs or gallops. Abdomen was distended and soft. There was, however, presence of fluid wave on percussion, nontender, liver is not palpable. Extremities notable for 5+ bilateral and there was 3+ lower extremity edema. Dorsalis pedis pulses were palpable. Radial pulses were 1+. Hematocrit at the time he was transferred to the floor was 30. BUN and creatinine were 21/0.5 respectively. At this point the [**Hospital 228**] hospital course was that of management for evaluation for getting the patient on the transplant liver list. Work included the bone densitometry which was normal and also the patient was scheduled for pulmonary function tests which were still pending. The patient had an abdominal computerized tomography scan to evaluate his liver. A questionable liver mass was found but follow up on magnetic resonance imaging scan revealed only presence of the hepatic cyst. Also found on the ultrasound evaluation was the patient's proximal portion of the transjugular intrahepatic portocaval shunt was not in adequate position and so Interventional Radiology went in again to place a stent within the stent, proximal portion, to link that part of the catheter. At this point, the patient is being screened now and being evaluated by physical therapy and will be evaluated by occupational therapy for placement either in a rehabilitation center or home with rehabilitation services. Plan to discharge most likely will be [**2170-1-26**]. DISCHARGE MEDICATIONS: To be added as an addendum. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 13467**] Dictated By:[**Last Name (NamePattern1) 31134**] MEDQUIST36 D: [**2170-1-25**] 16:52 T: [**2170-1-25**] 17:50 JOB#: [**Job Number 46603**] Admission Date: [**2170-1-12**] Discharge Date: [**2170-1-29**] Date of Birth: [**2100-10-23**] Sex: M Service: ADDENDUM DISCHARGE INSTRUCTIONS: The Spironolactone should be changed from 200 mg in the morning, 100 mg in the evening to just 400 mg p.o. q.d. In addition, diet on discharge will be 1.5 g sodium with Boost with each meal. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ACD Dictated By:[**Doctor Last Name 46604**] MEDQUIST36 D: [**2170-1-29**] 10:47 T: [**2170-1-29**] 10:47 JOB#: [**Job Number 46605**] Name: [**Known lastname 8559**], [**Known firstname 140**] JR Unit [**Name2 (NI) **]: [**Numeric Identifier 8560**] Admission Date: [**2170-1-12**] Discharge Date: 03/08/0303 Date of Birth: [**2100-10-23**] Sex: M Service: ADDENDUM: The plan is to see the patient to rehabilitation, short term, before return home. DISCHARGE DIAGNOSES: 1. Cirrhosis. 2. Upper gastrointestinal bleed. MEDICATIONS ON DISCHARGE: 1. Lasix 120 mg p.o. daily. 2. Spironolactone 200 mg q.a.m. and 100 mg p.o. q.p.m. 3. Lactulose 30 ml four times a day. 4. Protonix 40 mg p.o. once daily. 5. Folate 1 mg p.o. once daily. 6. Multivitamin one capsule p.o. once daily. 7. Thiamine 100 mg p.o. once daily. 8. Levofloxacin 500 mg p.o. once daily times seven days. Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2170-1-27**] 02:09 T: [**2170-1-27**] 14:58 JOB#: [**Job Number 8561**]

[ "571.2", "799.4", "518.82", "578.0", "428.0", "572.3", "280.0", "456.20", "789.5" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "96.6", "45.13", "39.1", "54.91", "42.33" ]

icd9pcs

[ [ [] ] ]

5212, 5262

3957, 4397

5288, 5767

4422, 5191

198, 211

240, 3933

70,111

157,037

52033

Discharge summary

report

Admission Date: [**2119-4-28**] Discharge Date: [**2119-5-7**] Date of Birth: [**2033-4-8**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (un) 32349**] Chief Complaint: Black Stools Major Surgical or Invasive Procedure: EGD History of Present Illness: 85-year-old female with a history of mechanical/porcine AVR on coumadin, hypertension who presented to the ED with 2 black stools on Wednesday and Friday. She also reported increasing fatigue over the past 2 days. She denies any BRBPR, nausea, vomiting, dizziness, syncope, lightheadedness, palpitations, chest pain SOB, headache, recent NSAID use. She reports some mild suprapubic discomfort. There have been no changes in her usual bowel consistency. . In the ED, initial vs were: 97.4 70 133/47 16 100% RA. Initial Hct was 26, then 24 and INR 2.2. She did report on the initial ED history some sporadic upper left sided chest pain lasting several seconds, although upon further question, she has intermitting gas pains relieved with flatus. She was evaluated by GI, who recommended scope when INR < 2 if safe based on valve. She was started on a PPI gtt, started blood transfusion with plan was for a total of two units of PRBC's, was given 1L NS. She apparently did not receive any blood in the ED due to difficulty cross match. Her EKG was NSR at 65 bpm, with LAD and an old LBBB. She has remained hemodynamically stable, however since her INR is unable to be reversed due to her St. Jude's valve, and her 10 point HCT she will be admitted to the ICU for possible EGD over the weekend. VS on transfer were: Afebrile 63 100/70 100% 2L. . On the floor initial VS were, 97 155/52 76 97% RA. Past Medical History: 1. Depression/anxiety. 2. Hypertension. 3. Hyperlipidemia. 4. Aortic stenosis. 5. Macular degeneration. 6. Cataracts. 7. Hearing loss. 8. Hypothyroidism. 9. Vitamin D deficiency. 10. Chronic constipation 11. History of falls in the setting of benzodiazepine use. 12. Ruptured epidural benign inclusion cyst. PAST SURGICAL HISTORY: 1. St. [**Male First Name (un) 1525**] Aortic valve replacement [**2097**], on anticoagulation. 2. Carpal tunnel surgery [**2117-11-26**] in [**Country **]. Social History: Ms. [**Known lastname 46253**] was born in [**Location (un) 686**] and finished [**Location (un) 686**] High School. She did not attend college. She went to work right after high school. She married, her husband died in [**2104**]. She has three children, Mark, [**Doctor First Name **] and [**Doctor First Name **]. [**Doctor First Name **] and [**Doctor First Name **] both live in [**Country **]. Mark is an internist in [**State 20651**]. She does not smoke. She does not drink alcohol. She did exercise while she was in [**Country **], but since she just returned, she has not had time to do this. Lives alone, independent in ADLs. - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Family History: Maternal: Cardiac disease Father: Unknown Brother: Leukemia Sister: Unknown cancer Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97 155/52 76 97% 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 Mechanical 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 Vitals: Tm-97.9, Tc-96.0, BP-118/70(110-140/60-70), HR:64(60-80), RR:20, O2 sat: 98% RA GEN: Comfortable in bed, NAD HEENT: Atraumatic, normocephalic, MMM, No scleral icterus, Oropharynx clear NECK: No thyromegaly, no lyphmadenopathy CV: Regular rate, nl rhythm, regular S1, mechanical S2, no rubs/gallops PULM: clear bilaterally, nl respiratory effort, no crackles, wheezes, ABD: Soft, +BS, NT/ND, no rebound or guarding EXT: No edema/cyanosis, warm and well perfused. Dorsal part of left wrist non-tender to palpation Neuro: Alert and oriented, CN II-XII grossly intact, [**3-30**] strength, sensation nl. Pertinent Results: ADMISSION LABS: . [**2119-4-28**] 11:40AM BLOOD WBC-7.6 RBC-3.21*# Hgb-8.5*# Hct-26.0*# MCV-81* MCH-26.5* MCHC-32.8 RDW-15.0 Plt Ct-263 [**2119-4-28**] 02:50PM BLOOD WBC-7.1 RBC-2.99* Hgb-8.4* Hct-24.6* MCV-82 MCH-27.9 MCHC-34.1 RDW-15.3 Plt Ct-236 [**2119-4-28**] 11:40AM BLOOD PT-23.8* INR(PT)-2.2* [**2119-4-28**] 02:50PM BLOOD Glucose-119* UreaN-27* Creat-0.9 Na-140 K-4.2 Cl-103 HCO3-27 AnGap-14 [**2119-4-29**] 04:06AM BLOOD CK-MB-5 cTropnT-0.01 [**2119-4-28**] 02:50PM BLOOD Calcium-9.5 Phos-3.1 Mg-2.2 [**2119-4-28**] 03:15PM BLOOD Hgb-8.3* calcHCT-25 [**2119-4-30**] 08:20AM BLOOD WBC-8.5 RBC-3.63* Hgb-10.5* Hct-30.8* MCV-85 MCH-29.0 MCHC-34.2 RDW-15.9* Plt Ct-276 [**2119-5-1**] 04:40PM BLOOD WBC-6.4 RBC-3.49* Hgb-10.1* Hct-29.1* MCV-83 MCH-28.8 MCHC-34.6 RDW-16.1* Plt Ct-229 [**2119-5-3**] 06:56AM BLOOD WBC-7.4 RBC-3.39* Hgb-9.6* Hct-29.0* MCV-86 MCH-28.5 MCHC-33.2 RDW-15.8* Plt Ct-241 [**2119-5-4**] 06:00AM BLOOD WBC-6.3 RBC-3.29* Hgb-9.3* Hct-28.1* MCV-85 MCH-28.1 MCHC-33.0 RDW-15.6* Plt Ct-237 [**2119-5-4**] 08:20PM BLOOD WBC-6.4 RBC-3.49* Hgb-9.8* Hct-30.1* MCV-86 MCH-28.1 MCHC-32.7 RDW-15.5 Plt Ct-268 [**2119-5-6**] 05:50AM BLOOD WBC-5.0 RBC-3.41* Hgb-9.8* Hct-29.2* MCV-86 MCH-28.6 MCHC-33.4 RDW-15.7* Plt Ct-296 [**2119-5-7**] 06:15AM BLOOD WBC-5.3 RBC-3.58* Hgb-10.2* Hct-30.2* MCV-85 MCH-28.5 MCHC-33.7 RDW-15.7* Plt Ct-315 [**2119-5-3**] 06:56AM BLOOD Neuts-75.3* Lymphs-16.9* Monos-5.5 Eos-2.1 Baso-0.3 [**2119-5-2**] 06:31AM BLOOD PT-15.9* PTT-150* INR(PT)-1.4* [**2119-5-3**] 06:56AM BLOOD PT-15.1* PTT-71.7* INR(PT)-1.3* [**2119-5-4**] 08:20PM BLOOD PT-15.1* PTT-31.8 INR(PT)-1.3* [**2119-5-5**] 10:10AM BLOOD PT-16.8* PTT-34.1 INR(PT)-1.5* [**2119-5-6**] 05:50AM BLOOD PT-19.4* PTT-34.8 INR(PT)-1.8* [**2119-5-7**] 06:15AM BLOOD PT-21.2* PTT-34.4 INR(PT)-2.0* [**2119-5-1**] 04:40PM BLOOD Glucose-89 UreaN-11 Creat-0.9 Na-142 K-3.8 Cl-107 HCO3-27 AnGap-12 [**2119-5-3**] 06:56AM BLOOD Glucose-128* UreaN-10 Creat-0.9 Na-141 K-4.3 Cl-106 HCO3-25 AnGap-14 [**2119-5-6**] 05:50AM BLOOD Glucose-126* UreaN-20 Creat-0.8 Na-140 K-4.5 Cl-106 HCO3-24 AnGap-15 [**2119-5-7**] 06:15AM BLOOD Glucose-120* UreaN-25* Creat-0.9 Na-140 K-4.1 Cl-104 HCO3-25 AnGap-15 Brief Hospital Course: #.GIB:. She presented with melena and HCT drop an. EGD revealed multiple non-bleeding erosions in antrum, non-bleeding ulcer in pyloric channel. Erythema & congestion of duodenal bulb compartible w/ mild bulbar duodenitis. Tested positive for H. pylori so was started on clarithromycin and amoxicillin. She was started on pantoprazole 40 [**Hospital1 **]. Pt. remained afebrile, no leukocytosis, no tenderness on exam. Hct remained stable over hospital stay although was guaiac positive and discharge Hct was 30.2. She will follow-up with outpatient GI to (1) repeat EGD to document healing ulcers (2) urea breath test to confirm treatment of H.Pylori. . #.ANTI-COAGULATION FOR MECHANICAL VALVE: On coumadin (home dose: 5mg M/W/F; 7.5 t/th/sat/sun) for anti-coagulation 2/2 to St. Jude's valve in [**2094**] which was found to have pannus growth on prior echo leading to a higher risk of emboli if subtherapeutic. Coumadin was stopped prior to EGD but was restarted with heparin drip to bridge then enoxaparin bridge until INR was within goal of [**12-28**].5 (confirmed with Dr. [**Last Name (STitle) **],cardiologist. Coumadin dose was up-titrated to 10mg twice during the bridge. Discharge INR is 2 but patient should follow-up with primary care doctor (gerontology) in the next few days to monitor IR/coagulation factors since clarithromycin interracts with coumadin metabolism. . #LEFT WRIST PAIN: Worsened left wrist pain from her fall in [**Country **] a month prior to hospital admission. Thought likely to be infiltrating IVs. Plain films of the wrist was negative for any fractures. Managed with ice packs/1000 Tylenol [**Hospital1 **] and elevation and is currently not symptomatic on exam. . #.HYPERTENSION:Enalapril and lasix were held prior to EGD to confirm source of UGIB causing a rise in her BPs to 180 SBP but BPs trended down to normal and was stable as her home medications were restarted. . #.DEPRESSION/DEMENTIA: Stable over the course of the stay and she continued her home medications- effexor/aricept. . #.HYPERLIPIDEMIA: Stable and continue home meds-simvastatin. . #.HYPERTHYROIDISM: Stable and continued home levothyroxine. Medications on Admission: Donepezil 5 mg PO QD Enalapril Maleate 10 mg PO BID Furosemide 40mg PO TID Levothyroxine 25 mcg PO QD Simvastatin 40 mg PO QD Venfalxaine 37.5 mg Ext Release 24 hr - 2 (Two) Warfarin 5 mg Tablet PO 3QWk Cholecalciferol (VITAMIN D3) - 1,000 unit Tablet PO QD Lactobacillus Acidophilus 1 capsule PO QD Discharge Medications: 1. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 3. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 6. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 8. amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day for 5 days. Disp:*22 Tablet(s)* Refills:*0* 9. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*11 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: GI bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 46253**]: It was a pleasure taking care of you at [**Hospital1 18**]. Initially, you were admitted to the medical intensive care unit for treatment of a gastrointestinal bleed. A endoscopy showed: Ulcer in the pyloric channel, erosions in the antrum, erythema and congestion in the duodenal bulb compatible with mild bulbar duodenitis You were treated with acid reducing medications and blood transfusions. You were transferred to the medical floor, where your blood counts (hematocrit) remained stable. Your coumadin was stopped for prior to the endoscopy and was restarted after that exam. You were on heparin for anti-coagulation then as your coumadin was restarted. Continuous heparin drip was later changed to enoxaparin as bridge since that required less blood draws. Your INR recovered to 2.0 at discharge which is within your goal of [**12-28**].5 as confirmed with Dr. [**Last Name (STitle) **], your cardiologist. You also tested positive for the bacteria, H.Pylori, known to cause gastric/duodenal erosions. You were therefore, started on anti-biotics (clarithromycin and amoxicillin) to treat the infection- you should continue taking the anti-biotics at home as instructed. You should follow-up with the gastroenterologists for a urea breath test to confirm that the antibiotics fully cleared the H. Pylori infection. Followup Instructions: Please follow-up with the providers below: . 1. Gerontology: Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 64426**] ([**Telephone/Fax (1) 719**]), your gerontolist on the [**Location (un) **] of the LM [**Hospital Unit Name **] at the [**Hospital Ward Name 517**] on WEDNESDAY [**2119-5-10**] at 2:30 PM . 2. Gastroenterology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 463**]) at the Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] of the [**Hospital Ward Name 516**] on WEDNESDAY [**2119-5-24**] at 1 PM Dr. [**Last Name (STitle) **] will do a repeat EGD to document healing of the gastric/duodenal ulcers seen on your inpatient EDG. She will also, do a urea breath test to confirm adequate treatment of your H. Pylor infection.

[ "999.9", "272.4", "E879.8", "300.4", "564.00", "244.9", "578.1", "V58.61", "366.9", "V42.2", "V15.88", "268.9", "401.9", "041.86", "531.90", "535.60", "362.50", "790.01", "389.9" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

9925, 9983

6509, 8665

314, 319

10036, 10036

4298, 4298

11570, 12448

3014, 3099

9019, 9902

10004, 10015

8691, 8996

10187, 11547

2117, 2277

3139, 4279

262, 276

347, 1752

4314, 6486

10051, 10163

1774, 2094

2293, 2998

74,046

104,759

35659

Discharge summary

report

Admission Date: [**2122-4-15**] Discharge Date: [**2122-4-21**] Date of Birth: [**2066-9-18**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Tetracycline Analogues / Demerol / Phenergan Attending:[**First Name3 (LF) 281**] Chief Complaint: Malignant central airway obstruction. Major Surgical or Invasive Procedure: [**2122-4-20**]: Flexible bronchoscopy Therapeutic debridement of necrotic material.Therapeutic aspiration of secretions. [**2122-4-17**]: Flexible bronchoscopy with tumor debridement [**2122-4-17**]: Bronchoscopy [**2122-4-15**]: Flexible bronchoscopy. PDT activation. [**2122-4-13**]: Flexible bronchoscopy. Endobronchial biopsy, left upper lobe, right main stem. History of Present Illness: Dr. [**Known lastname 1968**] is a 55-year-old woman with metastatic breast cancer who has failed multiple treatment therapy regimens. She was recently admitted to [**Hospital3 **] from [**2122-2-4**] to [**2122-2-7**] for chief complaint of central airway obstruction and acute dyspnea. She underwent rigid bronchoscopy and tumor debridement of the left upper lobe and balloon dilatation of the left upper lobe and left lower lobe. She was discharged to home after a few days and since her rigid bronchoscopy she reports significant improvement in her dyspnea. She does have persistent cough. The only thigh that makes her cough better is Tessalon 200 mg t.i.d. to q.i.d. She denies any significant sputum or hemoptysis. She has had no fevers, chills, or night sweats. She was recently diagnosed with metastatic involvement of the left eye and she is planning for radiation therapy soon. She self weaned her prednisone to 15 mg daily. She Underwent flex bronch [**2122-4-13**] which showed Necrotic debris right main stem, left upper lobe which likely represents tumor involvement verus infection. Accordingly, she was injected with photofrin in the same day. Patient is admitted for PDT activation. Past Medical History: 1) Breath cancer (metastatic): - Dx [**6-/2119**]: stage IIA. underwent lumpectomy and chemotherapy. - Recur [**2-21**]: Bilateral mastectomy and chemotherapy. - Recur [**5-23**] ( Mediastinal then metastatic) S/P XRT and chemotherapy ( currently cycle 2 of adriamycin and cisplatinum) 2) Papillary thyroid carcinoma S/P total thyroidectomy and radioactive iodine. 3) H/O multinodular goiter 4) H/O tracheostomy at the age of 4 for H.flu epiglottitis. 5) H/O febrile neutropenia 6) H/O severe sinusitis. 7) Peripheral neuropathy Social History: Tobacco: no Alcohol: social Divorced. Has 2 sons Occupation: Physician Family History: Breath cancer in her aunt Thyroid disease in her mother side Physical Exam: VS: T: 97.0 HR: 103 SR BP: 116/51 Sats: 96% 3L General: breath well in no apparent distress Card; RRR Resp: coarse breath sounds with scattered expiratory wheezes GI: benign Extr: warm Incision: abominal incision with sutures, site clean mild erythema Neuro: non-focal Pertinent Results: [**2122-4-20**] WBC-7.4 RBC-3.37* Hgb-11.0* Hct-35.1* Plt Ct-237 [**2122-4-19**] WBC-8.7 RBC-3.22* Hgb-10.8* Hct-33.2* Plt Ct-229 [**2122-4-17**] WBC-9.7 RBC-3.18* Hgb-11.0* Hct-32.8* Plt Ct-256 [**2122-4-20**] Glucose-90 UreaN-13 Creat-0.5 Na-140 K-3.5 Cl-99 HCO3-28 [**2122-4-19**] Glucose-90 UreaN-12 Creat-0.5 Na-136 K-4.1 Cl-102 HCO3-25 [**2122-4-18**] Glucose-107* UreaN-9 Creat-0.5 Na-139 K-3.7 Cl-105 HCO3-25 [**2122-4-21**] proBNP-695* CXR: [**2122-4-21**]: the last study, the patient was extubated and the Dobbhoff tube was removed. Multifocal opacity overall slightly decreased. Small pleural effusions are unchanged. Left rib fracture is stable, could be pathological in the clinical context. Clips in the right axillary region and the left paramediastinal region are unchanged. There is no other change. [**2122-4-17**] Endotracheal tube in standard position. Feeding tube as described. Rapidly evolving widespread air space opacities, which could be due to a combination of pulmonary infection and pulmonary edema superimposed upon underlying pulmonary metastatic disease. ARDS is an additional consideration. Seventh left lateral rib fracture, potentially pathologic fracture in the setting of known breast cancer. Echo: [**2122-4-20**] Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Compared with the prior study (images reviewed of [**2122-4-16**], the pericardial effusion is now apparent, but is very small. [**2122-4-16**] Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Brief Hospital Course: Mrs. [**Known lastname 1968**] was admitted on [**2122-4-15**] for PDT activation. She was transferred to the floor overnight for observation. She gradually deveoped respiratory distress and was transferred to the SICU for aggressive pulmonary toilet and nebulizers. Her respiratory distress increased and was taken to the operating room and bronchscopy showed complete LMS obstruction and 80% RMS obstruction and mechanical tumor debridement was done. She transferred back to the SICU intubated. On [**2122-4-17**] she was taken back to the operating room for further mechanical debridement. She had a flexible bronchoscopy on [**2122-4-18**] which revealed a patent airway. She was extubated. She was hypotensive and tachycardic overnight requiring pressors. Cardiology was consulted and an echocardiogram showed new wall motion abnormalities. The cardiac enzymes were negative. She slowly improved. Her oxygen requirements returned to her baseline. She transferred to the floor on [**2122-4-20**]. She had a repeat echocardiogram shoed good LV systolic function EF 55% no wall abnormality. Small pericardial effusion. A flexible bronchoscopy was done and further debulking on tumor was done with therapeutic aspiration of secretions. Overnight she did well and was discharged to home on [**2122-4-21**]. Medications on Admission: 1. Singulair 10 mg daily. 2. Prednisone 15 mg. 3. Albuterol/saline nebs. She states that the saline nebs more frequently work better than the albuterol. 4. Levaquin, taking for the last 10 days. 5. Flagyl, taking for the last 10 days. 6. Synthroid 175 mcg. 7. Nexium 40 mg b.i.d. 8. Zantac 150 mg b.i.d. 9. Mylanta. 10. Tessalon 200 mg t.i.d. to q.i.d. 11. Lidoderm topical. 12. Ativan p.r.n. Discharge Medications: 1. Benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-16**] Drops Ophthalmic PRN (as needed) as needed for eye irritation. 9. Ipratropium Bromide 0.02 % Solution Sig: Three (3) ML Inhalation Q4H (every 4 hours) as needed for wheeze. Disp:*500 vial* Refills:*0* 10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:*400 ML(s)* Refills:*0* 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 13. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: Three (3) ML Inhalation q6h (). Disp:*360 ML(s)* Refills:*2* 14. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 11786**] Homecare Discharge Diagnosis: Metastatic breast cancer with malignant airway obstruction, status post photodynamic therapy. Discharge Condition: stable Discharge Instructions: Call Dr. [**Last Name (STitle) **] office [**Telephone/Fax (1) 48380**] if experience; -Increased shortness of breath or cough -Remain out of direct sunlight Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] as needed Follow-up with your Pulmonologist [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**] Completed by:[**2122-4-21**]

[ "285.9", "V10.3", "276.52", "491.20", "197.0", "244.0", "V10.87", "530.81", "486", "198.4", "356.9" ]

icd9cm

[ [ [] ] ]

[ "33.22", "32.01" ]

icd9pcs

[ [ [] ] ]

8331, 8391

5096, 6421

363, 731

8529, 8538

3003, 5073

8745, 8956

2633, 2696

6878, 8308

8412, 8508

6447, 6855

8562, 8722

2711, 2984

285, 325

759, 1973

1995, 2526

2542, 2617

55,219

183,127

39051

Discharge summary

report

Admission Date: [**2132-6-13**] Discharge Date: [**2132-7-1**] Date of Birth: [**2065-1-30**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 5790**] Chief Complaint: Tracheobronchomalacia and lung nodules. Major Surgical or Invasive Procedure: [**2132-6-13**] - Flexible bronchoscopy with bronchoalveolar lavage, right upper lobe wedge resection and tracheoplasty with mesh, left main stem bronchus bronchoplasty with mesh, right main stem bronchus and bronchus intermedius bronchoplasty with mesh. Flexible bronchoscopy with biopsy. [**2132-6-15**] and [**2132-6-23**] - bronchoscopy [**2132-6-15**] and [**2132-6-19**] - intubation [**2132-6-24**]: 8-0 Portex tracheostomy tube and 20-French Ponsky peg tube placement. Central venous and arterial lines for access History of Present Illness: 67M with history of recurrent infections, shortness of breath, COPD exacerbations; hospitalized three times over the last five years- usually requiring antibiotics and steroids. He has a 150 pack year history of smoking but quit 2 years ago. He was diagnosed with tracheobronchomalacia on bronchoscopy [**2132-3-25**]. He had positive response to Y-stenting, therefore presented for tracheobronchoplasty. Past Medical History: -COPD -DM II -GERD -Obstructive sleep apnea- did not tolerate bipap so he has been on 2L NC at night x 2 years. Social History: Married with 4 children. Lives in [**Location 15852**]. Smoking 150pk year hx. Quit 2 years ago. No ETOH, no drugs. Exposure to asbestos. Retired autobody worker. Family History: father who died of CAD. no other contributory history. Physical Exam: T: 98.0 HR: 87 SR BP: 111/60 Sats: 95% TC .5% General: sitting at side of bed no apparent distress HEENT: normocephalic, mucus membranes moist Neck: Trach in place no erythema or discharge Card: RRR normal S1,S2 Resp: decreased breath sounds with scattered rhonchi GI: bowel sounds positive, PEG in place no signs of infection Extr: warm no edema Neuro: Awake, Alert & Oriented. Moves all extremities Pertinent Results: [**2132-7-1**] WBC-14.0* RBC-3.74* Hgb-9.8* Hct-31.4 Plt Ct-536* [**2132-6-30**] WBC-12.9* RBC-3.44* Hgb-9.4* Hct-29.4 Plt Ct-417 [**2132-6-28**] WBC-20.3* RBC-3.68* Hgb-9.9* Hct-31.3 Plt Ct-490* [**2132-6-26**] WBC-19.2* RBC-3.54* Hgb-9.6* Hct-30.2 Plt Ct-515* [**2132-6-23**] WBC-15.9* RBC-3.58* Hgb-9.6* Hct-31.0 Plt Ct-706* [**2132-6-13**] WBC-39.0*# RBC-4.15* Hgb-11.1* Hct-35.9 Plt Ct-713* [**2132-6-13**] WBC-31.1* RBC-4.09* Hgb-11.0* Hct-35.2 Plt Ct-663* [**2132-6-15**] WBC-17.7* RBC-3.34* Hgb-8.5* Hct-27.8 Plt Ct-566* [**2132-7-1**] Glucose-148* UreaN-14 Creat-0.6 Na-139 K-4.1 Cl-98 HCO3-36 [**2132-6-30**] Glucose-146* UreaN-13 Creat-0.4* Na-140 K-3.9 Cl-101 HCO3-35 [**2132-6-13**] Glucose-163* UreaN-16 Creat-0.9 Na-137 K-6.1* Cl-101 HCO3-27 [**2132-6-13**] Glucose-115* UreaN-15 Creat-0.9 Na-137 K-6.7* Cl-100 HCO3-32 [**2132-7-1**] Calcium-9.1 Phos-3.9 Mg-1.9 [**2132-6-29**] freeCa-1.14 [**2132-6-26**] freeCa-1.13 Cultures: [**2132-6-15**] SPUTUM FINAL REPORT [**2132-6-29**]** GRAM STAIN (Final [**2132-6-15**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2132-6-18**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S LEGIONELLA CULTURE (Final [**2132-6-22**]): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Final [**2132-6-29**]): NO FUNGUS [**2132-6-13**] TISSUE LEVEL 7 LYMPH NODE. No Growth [**2132-6-27**] Urine No growth Blood x 6 No growth CXR: [**2132-6-30**]: The tracheostomy is at the midline, approximately 8 cm above the carina. The heart size and the mediastinal contours are stable, unremarkable. The mediastinum continues to be shifted to the right with no appreciable change since the prior study. Post-surgical changes in the right upper lung is stable. Right basal consolidation has slightly improved, but there is minimal worsening of the right upper lobe, the left lung is essentially clear. There is no pleural effusion or pneumothorax. Chest CT [**2132-6-23**]; IMPRESSION: 1. No evidence of pulmonary embolism. 2. Bilateral lower lobe patchy airspace opacities suspicious for aspiration and/or pneumonia. 3. Cholelithiasis. 4. Right greater than left small pleural effusions. Echocardiogram [**2132-6-16**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size is normal with borderline normal free wall function. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. Brief Hospital Course: Mr [**Known lastname **] was admitted to the Thoracic Surgery service on [**2132-6-13**] after undergoing tracheobronchoplasty by Dr. [**Last Name (STitle) **]. Please see operative note for details. There were no complications to the surgery. He was transferred to the SICU for further managment and care. He remained intubated and was extubated POD1. However, due to respiratory distress, he was re-intubated later that evening. Patient failed another extubation trial and eventually required a tracheostomy on [**2132-6-24**]. We also placed a gastrostomy tube percutaeously as well for feeding. His hospital course can be summarized by the following review of systems: Neuro: The patient received an epidural with good effect and adequate pain control. The epidural removed on [**2132-6-15**] bc of fevers. He was then transitioned off propfol to precedex for anxiolytic wean. Patient was experiencing a paradoxical effect with precedex. He was effectively transitioned to dilaudid. He will be discharged on percocet and ativan for agitation. Both medications working with good effect. No other neurological issues. CV: Patient experienced post-operative atrial fibrillation with tachycardia. Beta-blocker used with good effect. Briefly, esmolol was used but later transitioned to a lopressor regimen. TTE performed showed EF 55% and no other abnormalities. Remained in NSR during rest of his hospitalization Pulmonary: The patient had bronchoscopy on [**2132-6-15**] and was then started on broad spectrum antibiotics. Cultures grew pseudomonas, and on 5.26 his regimine kept Zosyn and added Cipro. He was extubated but failed after struggling most of the day on [**2132-6-19**] despite aggressive pulmonary toilet, bronchodilators and IV solumedrol. Trach mask trials were started [**2132-6-25**] during the day requiring CPAP 5/5 50% at night with oxygen saturations of 97%. Speech and Swallow was consulted for PMV which he tolerated. Please see note. GI/GU/FEN: Post-operatively, the patient was started on tube feedings due to inability to wean from the ventilator. He was seen by Speech and Swallow who deemed him safe for Regular Diabetic Diet with thin liquids. ID: He had a persistent elevated WBC. Was pan cultured with no growth except the sputum culture which grew pseudomonas. Vancomycin and zosyn started on [**2132-6-15**] post bronch, and vanco switched to cipro [**2132-6-18**] sensitive to pseudomonas completed a 14 day course. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: HCT remained stable 31-35. IV Access: PICC line was placed [**2132-6-19**] and removed [**2132-7-1**]. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: advair 250/50 inhaled [**Hospital1 **] ventolin prn mucinex 1200mg po bid metformin 1000mg po bid glyburide 2mg po bid omeprazole 20 mg po daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush . 3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation QID (4 times a day). 5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheeze. 6. Insulin Glargine 100 unit/mL Solution Sig: Seventy (70) units Subcutaneous qhs (). 7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) SQ Injection TID (3 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation. 13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for prn insomnia. 14. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) puff Inhalation once a day. 15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 16. Humalog insulin sliding scale 0-70 mg/dL Proceed with hypoglycemia protocol 71-150 mg/dL 0 Units 151-200 mg/dL 2 Units 201-250 mg/dL 4 Units 251-300 mg/dL 6 Units 301-350 mg/dL 8 Units 351-400 mg/dL 10 Units > 400 mg/dL Notify M.D. 17. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation Q4H (every 4 hours) as needed for sob, wheezing. 19. Ipratropium Bromide 0.02 % Solution Sig: Three (3) mL Inhalation Q4H (every 4 hours) as needed for sob, wheezing. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Tracheobronchomalacia -COPD -DM II -GERD -Obstructive sleep apnea- did not tolerate bipap so he has been on 2L NC at night x 2 years. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or sputum production Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 2348**] Tuesday [**7-22**] at 9:30 in the [**Hospital Ward Name 121**] Building Chest Disease Center [**Hospital1 **] I Chest X-ray [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology Depart 30 minutes before your appointment Completed by:[**2132-7-1**]

[ "E878.8", "V15.82", "276.7", "250.00", "V15.84", "482.1", "327.23", "574.20", "728.88", "427.31", "518.5", "519.19", "112.0", "V58.67", "530.81", "511.9", "997.1", "276.2" ]

icd9cm

[ [ [] ] ]

[ "31.79", "96.04", "96.72", "40.3", "43.11", "38.91", "31.1", "96.6", "33.24", "38.93", "33.22", "33.48", "32.29" ]

icd9pcs

[ [ [] ] ]

10928, 11002

5449, 6103

338, 863

11180, 11180

2128, 5426

11523, 11869

1631, 1688

8840, 10905

11023, 11159

8670, 8817

11331, 11500

1703, 2109

6123, 8644

258, 300

891, 1298

11195, 11307

1320, 1434

1450, 1615

12,736

159,404

28965

Discharge summary

report

Admission Date: [**2121-8-21**] Discharge Date: [**2121-8-27**] Date of Birth: [**2040-6-6**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 358**] Chief Complaint: syncope Major Surgical or Invasive Procedure: None. History of Present Illness: 81M PMH R CVA x2, laryngeal cancer s/p laryngectomy, question PAF who presented to OSH after syncope x 2 at home. The history was obtained from the patient and his domestic partner. The patient had two episodes of syncope the morning of admission following coughing episodes. The patient has had an increasing number of falls after coughing episodes and has been followed by his PCP. [**Name10 (NameIs) **] patient has had increased secretions over the past few months. The patient complains of preceding dizziness for > 5 seconds but denies palpitations, tongue biting, bladder or bowel incontinence. The patient was intially seen at [**Hospital **] Hospital, where CT head showed acute on chronic bilateral SDH. The patient's C-spine was cleared by report at the OSH. OSH labs were significant for minimally elevated CK 185 with negative troponin I and WBC 11.2 with 3% bandemia. The patient was a given tetanus booster and then transferred to [**Hospital1 18**] ED. . In the ED, VS 98.4 96 198/101 20 98%2L. The patient was seen by neurosurgery and plastic surgery. Repeat CT head showed acute on chronic bilateral subdural hemorrhages, likely subarachnoid but possibly intraparenchymal blood in the high right frontal lobe, and right orbital wall fractures. The patient's right orbital laceration was repaired. The decision was made to admit to medicine for monitoring of SDH and further syncope work-up. The patient was given morphine 2 mg IV x 2, labetolol 10 mg IV x 2, labetolol 100 mg PO x 1. . On arrival, the patient complained of mild right orbital pain. He denies focal neurologic symptoms, loss of vision, fevers, chills. Review of systems otherwise negative in detail. Past Medical History: 1. Cerebrovascular accidents [**2115**], [**2116**] with minimal left hand residual deficit; question now unused tracheostomy after CVA versus after laryngectomy 2. Laryngectomy for squamous cell laryngeal cancer in [**2105**] with neck dissection with [**Doctor Last Name **]-[**Doctor Last Name **] artificial larynx 3. Reported history of gastric cancer 4. Question paroxysmal atrial fibrillation from previous admission 5. Hypertension, not on home regimen Social History: Lives with domestic partner, no current tobacco use, no EtOH. Family History: nc Physical Exam: Vital signs: T 98.8 P 94 BP 145/75 RR 12 O2sat 97%RA General: Elderly gentleman in NAD HEENT: Sclera anicteric, repaired right orbital laceration, PERRL, EOMI, vision grossly intact, OP clear without lesions, MM dry Neck: Well-healed tracheostomy, yellow mucus production with speaking, no carotid bruits Heart: RRR, no MRG Lungs: Coarse BS anteriorally Abdomen: NABS, soft, NTND, no HSM Skin: No rashes Extrem: Warm and well-perfused, no C/C/E Neuro: AAOx3, cooperative with exam. Normal bulk and tone bilaterally. Strength full power [**4-5**] throughout. No pronator drift. Toes downgoing bilaterally. No abnormal movements, tremors. Pertinent Results: [**2121-8-21**] 12:45AM BLOOD WBC-11.8* RBC-4.23* Hgb-13.1* Hct-38.5* MCV-91# MCH-30.9 MCHC-33.9 RDW-13.3 Plt Ct-305 [**2121-8-27**] 05:45AM BLOOD WBC-7.5 RBC-3.79* Hgb-11.7* Hct-35.0* MCV-92 MCH-30.9 MCHC-33.5 RDW-13.3 Plt Ct-362 [**2121-8-27**] 05:45AM BLOOD WBC-7.5 RBC-3.79* Hgb-11.7* Hct-35.0* MCV-92 MCH-30.9 MCHC-33.5 RDW-13.3 Plt Ct-362 [**2121-8-21**] 12:45AM BLOOD PT-13.7* PTT-26.7 INR(PT)-1.2* [**2121-8-21**] 12:45AM BLOOD Glucose-140* UreaN-16 Creat-1.0 Na-139 K-4.5 Cl-102 HCO3-25 AnGap-17 [**2121-8-27**] 05:45AM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-138 K-4.3 Cl-100 HCO3-31 AnGap-11 [**2121-8-21**] 04:00PM BLOOD CK-MB-9 cTropnT-<0.01 [**2121-8-21**] 08:03AM BLOOD CK-MB-9 cTropnT-<0.01 [**2121-8-21**] 12:45AM BLOOD cTropnT-<0.01 [**2121-8-21**] 12:45AM BLOOD Calcium-8.9 Mg-1.8 [**2121-8-27**] 03:48PM BLOOD Type-ART pO2-65* pCO2-47* pH-7.43 calTCO2-32* Base XS-5 Intubat-NOT INTUBA [**2121-8-26**] 01:33PM BLOOD Type-ART pO2-63* pCO2-46* pH-7.42 calTCO2-31* Base XS-4 [**2121-8-27**] 03:48PM BLOOD Lactate-1.2 EKG: ST at 102. Axis +90, same as previous. Normal intervals. No ST-T changes. CT Orbit/Sella/IAC ([**8-20**]):IMPRESSION: 1. Minimally displaced fractures of the right superior and medial orbital wall with herniation of fat into the defects, but no evidence of muscular herniation at this time. No intracoronal abnormalities. No evidence of globe rupture. Soft tissue swelling over the right eye and face. Aid-fluid level in the right frontal air cell and opacification of multiple ethmoid air cells. 2. Middle ear opacification on the left with slight asymmetry of the nasopharynx, left more prominent than right. Direct visualization is recommended. CT Head w/o Contrast ([**8-20**]) 1. Acute on chronic bilateral subdural hemorrhages. 2. Likely subarachnoid but possibly intraparenchymal blood in the high right frontal lobe. 3. Right orbital wall fractures, which are detailed in the CT of the orbits done the same day. Carotid Series ([**8-21**]) IMPRESSION: Likely occlusion of right carotid system. On the left there is moderate plaque with a 40-59% carotid stenosis. Based on these findings _____ clinical correlation and CTA or MRA evaluation is warranted. Echo ([**8-21**]): Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis (LVEF = 45-50 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. CXR ([**8-25**]): FINDINGS: In comparison with the study of [**8-21**], there is little change. Bilateral apical pleural capping and elevation of the right hemidiaphragm is again seen. No evidence of acute pneumonia. Brief Hospital Course: # Acute on chronic SDH: CT head showed acute on chronic bilateral subdural hemorrhages. Likely subarachnoid but possibly intraparenchymal blood in the high right frontal lobe, Right orbital wall fractures, which are detailed in the CT of the orbits done the same day. Patient cleared by neurosurgery, initially admitted to MICU but transferred to floor. No concerning signs or symptoms on exam. Goal SBP for patient was 120-140 for permissive hypertension, yet patient was on Metoprolol 25 mg PO bid while in the hospital with SBP ranging from 120s-170s. The patient's Plavix was held for 1 week, and was restarted on [**8-28**]. No operative intervention advised, patient will follow-up in neurosurgery [**Month/Year (2) **] in one month with head CT. . # Orbital fractures: Patient seen by plastic surgery and laceration repaired. Ophthalmology consulted, no surgical intervention advised. Patient to complete 7 day course of Keflex. Sutures removed prior to discharge. . # Syncope: Likely situational syncope occuring in context of cough. Some concern for arrhythmia given the patient did not protect his face on falling. EKG unrevealing. Patient was monitored on telemetry during his stay on no concerning arrhythmia alarms. Patient at risk for seizures given prior CVA but no signs or symptoms of seizure activity. Unlikely TIA. Carotid ultrasound showed unchanged complete RCA stenosis, but no new pathology. . # Dyspnea: Patient with long-standing smoking history and 1-month history of cough. Patient with stoma secondary to laryngectomy. CXR showed apical pleural capping. Dyspnea improved with nebulizer treatments. Likely [**1-3**] underlying COPD, will need continued outpatient monitoring and PFTs. No focal consolidations seen on imaging. Nebulizer machine arranged for home treatments. . # ARF Patient dry on initial presentation, improved with hydration. Creatinine 0.9 on discharge. # HTN: The patient's goal SBP was 120-140 systolic. BB was discontinued in setting of likely underlying COPD. BP in 130s on discharge without pharmacotherapy. Patient will need close follow-up with outpatient PCP as scheduled. . # History of CVA: No acute issues. Outpatient secondary prevention with statin continued. . # PPx: While in-house, patient received pneumoboots and continued on home PPI . # FULL CODE Medications on Admission: Protonix 40 mg QD Plavix 75 mg QD Simvastatin 40 mg QD Seroquel 12.5 mg QD Fluoxetine 40 mg QD Levothyroxine 112 mcg QD Vitamin B 1000 mcg QD Folic acid 1 mg QD Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily): This is Vitamin B12. 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 8. Guaifenesin 600 mg Tablet Sustained Release Sig: [**12-3**] Tablet Sustained Releases PO BID (2 times a day): To help with your cough. . Disp:*56 Tablet Sustained Release(s)* Refills:*0* 9. Keflex 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours for 4 doses. Disp:*4 Tablet(s)* Refills:*0* 10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Nebulizers Device Sig: One (1) device Miscellaneous as directed. Disp:*1 device* Refills:*0* 13. Nebulizer Accessories Kit Sig: One (1) nebulizer kit Miscellaneous as directed. Disp:*1 kit* Refills:*0* 14. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) treatment Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*qs-1month trade size* Refills:*2* 15. Atrovent 0.02 % Solution Sig: One (1) treatment Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*qs-1month solution* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Acute on chronic subdural hemorrhages (bleeding) in the brain Right bony orbit fracure Syncope Discharge Condition: Stable. Lots of respiratory secretions, but no fevers or evidence of pneumonia. Some bruising on the face from the fall. Discharge Instructions: Please call your doctor or go to the emergency department if you develop a fever. You have a bleed in your head, which was stable when you were in the hospital and will be re-evaluated as an out-patient. You will probably have a minor headache. If this gets severely worse or you become very sleepy, please call you doctor or go to the emergency department. You also have a broken bone under your eye-- please be careful with this while it heals. If you have changes in your vision, please call the doctor. . Please take all of your medications as prescribed . Your Plavix was held in the hospital because of the bleed in your head. You will start taking the Plavix again on [**2121-8-28**]. . You were put on an antibiotic for your eye trauma (Cephalexin 500 mg by mouth every six hours). You should only take this until [**2121-8-28**] (your last dose will be on [**2121-8-28**]). Followup Instructions: (1) You have an appointment to see you primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1968**] on Monday [**2121-9-1**] at 2:00 pm. (2) You have an appointment to see the plastic surgery doctors in [**Name5 (PTitle) **] on Friday, [**9-5**] at 1:30 in the [**Hospital Ward Name 23**] building, [**Location (un) 470**], surgical specialties. (3) You have an appointment to see Dr. [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 699**] in ophthamology on [**2121-9-9**] at 1:30 pm in the [**Hospital Ward Name 23**] Center on the [**Location (un) 442**] ([**Telephone/Fax (1) 5120**]. . (4) You have a noncontrast head CT scheduled on [**9-17**] at 8:30 am at the [**Hospital Ward Name 23**] Clinical Center [**Location (un) **]. You may have nothing to eat or drink 3 hours before the procedure. . (5) You have an appointment with Dr. [**Last Name (STitle) 739**] in neurosurgery on [**9-17**] at 11:30 am. .

[ "584.9", "V10.21", "431", "496", "V44.0", "873.40", "401.9", "E885.9", "780.2", "802.8", "852.21" ]

icd9cm

[ [ [] ] ]

[ "86.59" ]

icd9pcs

[ [ [] ] ]

10590, 10639

6434, 8751

274, 282

10778, 10904

3253, 6411

11843, 12807

2576, 2580

8965, 10567

10660, 10757

8777, 8940

10928, 11820

2595, 3234

227, 236

310, 1996

2018, 2481

2497, 2560

44,385

107,623

54118

Discharge summary

report

Admission Date: [**2103-3-5**] Discharge Date: [**2103-3-12**] Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 13329**] Chief Complaint: Vomiting Major Surgical or Invasive Procedure: None History of Present Illness: This is a [**Age over 90 **]yo F with a history of dementia, COPD, and dysphagia, DNR/DNI, presented to the ED from nursing home with several episodes of bilious emesis earlier today. She had one episode where she was witnessed to be choking after emesis. She appeared pale and diaphoretic in some respiratory distress. Reportedly she had an O2 sat in the 60s at the nursing home, so was brought to the emergency department. . In the ED, initial vs were: T 101.8 P 100-110 BP 130/70 R 32 O2 sat 75% on RA-->92% on 4L. CT Abdomen/Pelvis was performed, which confirmed bibasilar opacities concerning for aspiration pneumonia, but no other abdominal pathology that would cause vomiting. Patient was given Zofran 4mg, Tylenol 650mg PR, Ativan 2mg IV, Zosyn and Vancomycin. She received 1L IV fluids. Vitals prior to transfer HR 94 BP 108/48 RR 26 92% NRB. On arrival to the floor, the patient was sedated. Past Medical History: dementia dysphagia pacer COPD asthma chronic UTI HTN angina HL s/p chole s/p appy esophageal diverticula Social History: She has been living in a nursing home for 3.5 years, before that she lived on her own in an apartment. She had an episode 6 or 7 years ago when she was attacked on the street by a mugger and (used to be a doctor) and she fell and hit her head, and after that, was never quite the same. She worked as a pulmonologist Family History: Non contributory in this [**Age over 90 **] yo woman Physical Exam: ADMISSION EXAM: Vitals: T: BP: 99/50 P: 85 R: 18 O2: 98% on NRB General: somulent, GCS 11, localize stimuli,inapropriate words opens eye to voice HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: course rhonchi and crackles throughout 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 EXAM: Vitals: 96.1 97(m) 176/100 (138-176/80-100) 73 (73-95) 20 90-95% RA General: Elderly woman, sleeping, but arousable Neck: supple, no LAD Lungs: clear anteriorly, coarse in bases CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2103-3-5**] 06:27PM BLOOD WBC-11.8*# RBC-4.97 Hgb-15.0 Hct-45.6 MCV-92 MCH-30.2 MCHC-32.9 RDW-14.7 Plt Ct-559* [**2103-3-6**] 07:35AM BLOOD WBC-27.5*# RBC-4.25 Hgb-13.3 Hct-40.1 MCV-94 MCH-31.3 MCHC-33.2 RDW-15.0 Plt Ct-467* [**2103-3-8**] 09:57AM BLOOD WBC-11.6* RBC-3.78* Hgb-11.6* Hct-35.6* MCV-94 MCH-30.6 MCHC-32.5 RDW-15.4 Plt Ct-471* [**2103-3-5**] 06:27PM BLOOD PT-13.1 PTT-23.3 INR(PT)-1.1 [**2103-3-8**] 09:57AM BLOOD Plt Ct-471* [**2103-3-5**] 06:27PM BLOOD Glucose-141* UreaN-26* Creat-1.2* Na-138 K-4.6 Cl-100 HCO3-26 AnGap-17 [**2103-3-8**] 09:57AM BLOOD Glucose-156* UreaN-14 Creat-1.1 Na-142 K-3.9 Cl-110* HCO3-25 AnGap-11 [**2103-3-6**] 07:35AM BLOOD ALT-29 AST-35 AlkPhos-116* TotBili-1.1 [**2103-3-8**] 10:39AM BLOOD Type-ART pO2-48* pCO2-52* pH-7.29* calTCO2-26 Base XS--1 Discharge Labs: [**2103-3-11**] 09:20AM BLOOD WBC-8.7 RBC-4.76 Hgb-14.4 Hct-42.6 MCV-89 MCH-30.2 MCHC-33.8 RDW-15.4 Plt Ct-621* [**2103-3-11**] 09:20AM BLOOD Glucose-129* UreaN-14 Creat-1.0 Na-138 K-3.2* Cl-97 HCO3-29 AnGap-15 [**2103-3-11**] 09:20AM BLOOD Calcium-10.0 Phos-1.1* Mg-1.8 Cultures: [**3-5**] Urine culture negative [**3-7**] and [**3-10**] C diff negative [**3-6**] Blood cultures- NGTD (pending on discharge) [**3-7**] Blood cultures pending Imaging: CT CHEST/ABDOMEN [**2103-3-5**]: 1. Bibasilar opacities, concerning for aspiration or pneumonia. 2. Descending and sigmoid colon diverticulosis without diverticulitis. No bowel obstruction. 3. Areas of lucency in the left iliac bone with suggestion of increased trabeculation could relate to Paget's disease, focal osteopenia, metastatic disease not entirely excluded. No cortical disruption seen. Focal area of lucency in the right sacrum, without definite cortical destruction, may relate to osteopenia, although underlying metastatic disease can not be entirely excluded. Consider further evaluation with bone scan. 4. 9 x 8 mm hypodense lesion in the pancreatic head, possible representing intraductal papillary mucinous neoplasm (IPMN). If clinically appropriate given patient age, MRCP for further evaluation. 5. 2 cm right ovarian hypodense lesion. If clinically warranted, pelvic US can be obtained for further characterization. CXR [**2103-3-5**]: Unchanged right middle lobe atelectatic changes, as noted on the prior CT, raising concern for underlying malignancy. There is an unchanged small left pleural effusion and bibasilar atelectasis. Cardiomediastinal silhouette and hila are stable. There is no pneumothorax. CXR [**2103-3-8**]: 1. Stable right base opacity and increasing left base opacity. Probable pneumonia with superimposed atelectasis or worsening infection. 2. Increasing mild vascular congestion. 3. Stable mild cardiomegaly. 4. Intact pacemaker leads in unchanged position. Brief Hospital Course: Ms. [**Last Name (Titles) 110916**] [**Age over 90 **] yo F with multiple medical problems who presented with vomiting, with subsequent hypoxia and respiratory distress, concerning for aspiration pneumonia. ACTIVE PROBLEMS: 1. ASPIRATION PNEUMONIA: She presented from her nursing home with significant emesis, and subsequently became febrile with oxygen desaturations to the 60s-70s on room air. Initial CXR and CT chest/abdomen both showed bilateral basilar opacities, which was felt to be consistent with an aspiration event. She was started on vancomycin with levaquin and cefepime dual therapy for additive GNR coverage, and her oxygen saturations slowly improved over her ICU stay. She did not require invasive ventilation or BIPAP during her hospitalization. Speech and swallow saw her, and recommended continuation of her previous nectar thickened liquids and pureed solids. She will completed 7 days of antibiotic treatment with vancomycin and cefepime on [**3-11**]. She was discharged with oxygen saturations in the low-mid 90s on room air. She had intermittent wheezing treated with nebs, steroids withheld due to agitation and deliriogenic effect. Her wheezing had largely resolved at the time of discharge. 2. DEMENTIA/DELIRIUM: Patient had initially been quite agitated with sundowning and insomnia. She was initially managed with haldol with poor effect. Geriatrics team was consulted and recommended use of home seroquel, which fostered significant improvement. Her nighttime dose was increased to 75mg Q5pm which prevented sundowning. She received intermittent 12.5mg prn doses which helped control intermittent agitation. She has baseline dementia, and this behavior is at her baseline. She also was continued on her aricept, celexa, and namenda. 3. GOALS OF CARE: Patient was DNR/DNI during hospital stay. Brief meeting was held to discuss avoidance of further hospitalization, though family was unprepared to make decision at the time. This will need to be addressed again in the future. 4. ACUTE RENAL FAILURE: Presented with a Cr 1.2. Unclear baseline, but she likely was slightly prerenal in the setting of vomiting and infection. Cr improved to 1.0 with fluids. 5. VOMITING: Nausea and vomiting had resolved at the time of admission. 6. Concern for underlying malignancy: Patient has history of lung nodule. CT abdomen shows lytic lesions of iliac bone, concerning for metastases. The family has decided not to pursue further work up. 7. H/o Angina: No active issues. Continued plavix, Simvastatin, Metoprolol. Pending on Discharge: [**3-7**] Blood Culture- NGTD Medications on Admission: 1. Colace 100 mg po bid 2. trazodone 50 mg po qhs 3. Acidophilus po bid 4. Aricept 10 mg po qhs 5. gabapentin 300 mg po qhs 6. acetaminophen 650 mg po tid 7. Spiriva 18 mcg inh daily 8. loratadine 10 mg po daily 9. Namenda 10 mg po daily 10. Plavix 75 mg po daily 11. simvastatin 20 mg po daily 12. metoprolol tartrate 25 mg po bid 13. Seroquel 50 mg po bid 14. Seroquel 12.5 mg po bid PRN agitation 15. DuoNeb inh q6h PRN SOB 16. Cranberry Concentrate Capsule Sig: One (1) Capsule PO once a day. 17. Prilosec 20 mg po dailyl 18. Celexa 15 mg po daily 19. Atrovent 2 puffs inh [**Hospital1 **] PRN SOB 20. Milk of Magnesia 30mL po q4h Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. quetiapine 25 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)): Liquid form is peferable if available. 4. quetiapine 50 mg Tablet Sig: One (1) Tablet PO qAM: Liquid form preferable if available. 5. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO twice a day as needed for agitation. 6. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 7. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP<100, HR<60. 10. memantine 5 mg Tablet Sig: Two (2) Tablet PO daily (). 11. citalopram 10 mg/5 mL Solution Sig: Fifteen (15) mg PO DAILY (Daily). 12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for constipation. 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 15. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 16. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) puff Inhalation once a day. 17. gabapentin 300 mg Capsule Sig: One (1) Capsule PO at bedtime. 18. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for fever or pain. 19. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Aspiration Pneumonia Agitation Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 110917**], It was a pleasure taking care of you in the hospital. You were admitted for aspiration pneumonia and treated with antibiotics in the medical ICU. You improved on antibiotics and were ready to go back to your nursing home. You were agitated during your stay and this was treated with Seroquel and Haldol. . We made the following changes to your medications: - Please increase your evening dose of seroquel to 75 mg Please continue to take your other medications as you were previously. We wish you a speedy recovery. Followup Instructions: Please followup with your PCP at your nursing home. Completed by:[**2103-3-12**]

[ "280.9", "413.9", "307.9", "V13.02", "794.9", "507.0", "401.9", "E942.6", "511.9", "787.20", "V12.51", "518.89", "518.82", "414.01", "793.7", "518.0", "293.0", "780.52", "493.20", "584.9", "V45.01", "787.01", "294.8", "272.0", "530.81", "V49.86", "458.29", "E939.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10585, 10655

5541, 8104

226, 232

10730, 10730

2731, 2731

11488, 11571

1645, 1700

8838, 10562

10676, 10709

8175, 8815

10907, 11274

3560, 5518

1715, 2262

2278, 2712

8118, 8149

11303, 11465

177, 188

260, 1164

2747, 3544

10745, 10883

1186, 1293

1309, 1628

31,869

108,701

52730

Discharge summary

report

Admission Date: [**2152-12-6**] Discharge Date: [**2152-12-11**] Date of Birth: [**2116-2-7**] Sex: M Service: MEDICINE Allergies: Penicillins / Aspirin / Milk / Morphine / Haldol / Ibuprofen Attending:[**First Name3 (LF) 2745**] Chief Complaint: clonidine overdose Major Surgical or Invasive Procedure: None History of Present Illness: 36M s/p Clonidine overdose. patient took ~30 pills of unknown dose and got onto ferry to [**Hospital3 **]. The patient was MedFlighted from [**Hospital3 **] to [**Hospital1 **] after alerting the crew that he overdosed and was subsequently found unresponsive. He reported that he took 30 Clonidine, 1 Soma, & 1 beer. . Patient was brought to the ED, Toxicology was consulted who suggested that he should be intubated for airway protection and his course should be that of hypertension followed by that of hypotension. Patient may also be bradycardic. . Patient was also given Charcoal in the ED and given atropine x1 for bradycardia. Past Medical History: DM2 asthma Depression Prior hx of SI Social History: recently broke up with fiance. Family History: unknown Physical Exam: Vitals - T:99.5 BP:154/120 HR:47 RR:23 02 sat:100 VENT SETTINGS: AC 525x16 1.0 PEEP% GENERAL: intubated and sedated SKIN: many scars on L forearm, warm and well perfused HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no mrg LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact . Pertinent Results: [**2152-12-6**] 09:48AM OSMOLAL-304 [**2152-12-6**] 09:48AM WBC-14.7* RBC-4.79 HGB-16.1 HCT-47.6 MCV-99* MCH-33.6* MCHC-33.8 RDW-14.0 [**2152-12-6**] 09:48AM PLT COUNT-304 [**2152-12-6**] 09:21AM TYPE-ART TEMP-37.2 RATES-16/4 TIDAL VOL-500 O2-60 PO2-137* PCO2-41 PH-7.39 TOTAL CO2-26 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED [**2152-12-6**] 09:21AM LACTATE-1.8 [**2152-12-6**] 06:17AM VoidSpec-SPECIMEN L [**2152-12-6**] 04:36AM GLUCOSE-171* UREA N-10 CREAT-0.8 SODIUM-144 POTASSIUM-4.4 CHLORIDE-111* TOTAL CO2-22 ANION GAP-15 [**2152-12-6**] 04:36AM estGFR-Using this [**2152-12-6**] 04:36AM ALT(SGPT)-36 AST(SGOT)-28 CK(CPK)-39 ALK PHOS-94 TOT BILI-0.5 [**2152-12-6**] 04:36AM LIPASE-21 [**2152-12-6**] 04:36AM cTropnT-<0.01 [**2152-12-6**] 04:36AM CK-MB-NotDone [**2152-12-6**] 04:36AM CALCIUM-8.4 MAGNESIUM-2.4 [**2152-12-6**] 04:36AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2152-12-6**] 04:32AM TYPE-[**Last Name (un) **] RATES-/14 TIDAL VOL-500 O2-100 PO2-71* PCO2-56* PH-7.26* TOTAL CO2-26 BASE XS--2 AADO2-595 REQ O2-96 -ASSIST/CON INTUBATED-INTUBATED CHEST (PORTABLE AP) [**2152-12-7**] 4:21 AM CHEST (PORTABLE AP) Reason: Please eval for interval change [**Hospital 93**] MEDICAL CONDITION: 36 year old man found unresponsive after drug ingestion. Intubated. REASON FOR THIS EXAMINATION: Please eval for interval change SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Patient found unresponsive after drug ingestion. Comparison is made to prior study performed a day earlier. Patient has been extubated. Cardiomediastinal contour is normal. There has been almost complete resolution of the opacities described in the left upper lobe and left lower lobe, a faint opacity remains in the left upper lobe, there is no pneumothorax or sizable pleural effusions. Note is made that the left lateral CP angle was not included on the film. CHEST (PORTABLE AP) [**2152-12-6**] 3:36 AM CHEST (PORTABLE AP) Reason: Evaluate ETT placement, evaluate for intrathoracic pathology [**Hospital 93**] MEDICAL CONDITION: 36 year old man found unresponsive after drug ingestion. Intubated en route to hospital. REASON FOR THIS EXAMINATION: Evaluate ETT placement, evaluate for intrathoracic pathology. HISTORY: Drug OD status post intubation. No prior comparison exams are available. SUPINE PORTABLE CHEST RADIOGRAPH FINDINGS: Ill-defined opacity is noted in the retrocardiac region, causing slight obscuration of the left hemidiaphragm, as well as the left upper lung zone. Remaining lungs appear clear with overall exam somewhat limited due to low lung volumes. The hilar contours appear slightly prominent, likely related to low lung volumes and bedside technique. No evidence of pneumothorax, pulmonary edema, or large effusion. Endotracheal tube terminates 4.5 cm from the carina and orogastric tube tip can be traced as distal as the gastroesophageal junction. IMPRESSION: 1. Retrocardiac consolidation with air bronchograms, and probable left upper zone opacity. Likely infectious, and aspiration-related. Radiographic followup is recommended. 2. Appropriately positioned endotracheal tube. Nasogastric tube appears to terminate at the GE junction. Advancement is recommended. Brief Hospital Course: . #Clonidine Overdose: Patient reportedly ingested 30-50 pills of Clonidine and 20 pills of SOMA. The patient was initially given Charcoal in the ED and received Atropine for bradycardia. He was intubated for airway protection. Clonidine overdose may cause hypertension and bradycardia followed by hypotension, thus an A-line was placed for BP monitoring. Poison control/toxicology was consulted. He had an episode of HTN and bradycardia thought to be secondary to rebound from teh Clonidine. He was given hydralazine for BP control given his reflex hypertension. Atropine was at the beside given his reflex bradycardia but was not used (HR was 30's to 40's initially). On day 2 in the MICU his BP normalized and his HR increased to the 50'[**05**] range. The patient was subsequently felt to be stable and transferred to the floor. On the floor, the patients vitals remained stable. A repeat EKG did not show any changes. No further intervention was needed at that point. . #Leukocytosis-Originally thought to be secondary to a stress reaction after the overdose. A CXR and U/A did not show any evidence of infection. WBC improved on its own. No further intervention taken. . #Suicide attempt/depression: Patient was evaluated by psychiatry and social work. A formal psychiatric diagnosis was not made and pharmacologic agents were not started given the above overdose. Pt had 2 Code purples on [**12-10**] for extreme agitation and violent behavior. He was upset because he was not allowed to smoke, and subsequently broke the end of the bed by kicing it as well as taking a butter knife and cutting up the mattress. He received PO Zyprexa and Ativan in response to this episode. In adiiton, after this initial incident, he was asked not to leave his room which further agitated him. He then threw the phone at the wall and was threatening to all those who came in the room. He broke a second bed by kicking the end off. Security was called during both incidents. After the 2nd incident, he was ordered for 24 hour security monitoring and started in Zyprexa 2.5mg TID per psychiatry recommendations. He was ordered for a safe tray, all objects were removed from his room that could be harmful, and he had zyprexa and ativan for any further agitation. Pt was discharged directly to an inpatient psychiatric unit for further care. Of note, just before time of discharge patient was found to be tachycardic to the 120s and pt was getting increasingly agitated and frustrated with staff and with discharge procedures. He subsequently attempted to punch a security officer. After discussing with psychiatry, patient calmed down and received PO zyprexa and Ativan before leaving. . #Asthma: Patient was continued on his home inhalers prn. . #HTN: Pt was taken off his home CLonidine medication given the overdose. His BP remained stable once on the floor. The medication was not resumed on discharge because it was felt medically unnecessary. . . #DM2: Patient was recently diagnosed with DM and is currently diet controlled at home. He was monitored with finger sticks QID and an insulin sliding scale was in place. He was maintained on a diabetic diet. ================================================ Medications on Admission: unknown but then patient told us after extubation: advair 500/50 singulari 10mg daily albuterol flovent clonidine 0.2mg [**Hospital1 **] prednisone 20mg daily soma lortab Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] PRN as needed for shortness of breath or wheezing. 2. Montelukast 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. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 5. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 6. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TWO times a day: per MOST RECENT [**Hospital1 18**] psychiatry service notes. Discharge Disposition: Extended Care Facility: [**Hospital 1680**] Hospital - [**Location (un) 538**] Discharge Diagnosis: Depression Suicide Attempt Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for overdosing on clonidine and soma in a suicide attempt. You were initially admitted to the intensive care unit for close monitoring. You were intubated initially monitor you closely but subsequently extubated. You were medically stable since then. You were evaluatd by psychiatry who feels you were still at risk for injuring yourself. They recommended further care at an inpatient psychiatric facility. You will be discharged to a facility for close monitoring. You were started on a medication called Protonix which is to help your reflux symptoms. You will need to take this everyday. Your Clonidine was held because your Blood pressure was stable during the hospital and there was concern that you could overdose again. Followup Instructions: Please follow up with with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 6585**](orthopedic NP) at [**Telephone/Fax (1) **] after discharge. You will need to follow up with psychiatry per their recommendations.

[ "530.81", "305.90", "401.9", "301.7", "427.89", "E849.9", "311", "968.0", "305.1", "972.6", "306.2", "250.00", "780.09", "E950.4", "307.9", "305.00", "493.90", "288.60" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

9194, 9275

5054, 8277

340, 347

9346, 9355

1764, 3001

10169, 10400

1136, 1145

8500, 9171

3862, 3951

9296, 9325

8303, 8477

9379, 10146

1160, 1745

282, 302

3980, 5031

375, 1011

1033, 1072

1088, 1120

67,862

159,958

37150

Discharge summary

report

Admission Date: [**2176-3-3**] Discharge Date: [**2176-3-8**] Date of Birth: [**2154-12-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1253**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: . HPI: 21 y/o with h/o asthma presents from Bounewood (for polysubstance abuse) with worsening shortness of breath starting [**2176-3-2**]. He is on proair and an undefined ? steroid inhaler at baseline. Reports increased proair use over the last few days. He claims compliance with steroid inhaler despite its abcense on his [**Hospital1 **] medication list. He reports sick contacts at [**Name2 (NI) 83698**] with rhinitis and dry cough over the last few days. Last exacerbation 3 months ago requiring hospitalization at [**Hospital **]. Treated with steroid taper. H/o approximately 3 hospitalizations over his life, denies intubation (despite ED report). Received neb x 2 at [**Hospital1 **] with Sat 93-99%, BP 110/70, HR 120-130s at [**Hospital1 **]. . On arrival at [**Hospital1 18**] VS 99.2, 127, 130/78, 100% on neb mask. He received combivent x 5, solumedrol 125mg, Mg 2gm, and benadryl 25mg IV. Peak flow increased from 275 to 320. Pt does not know his baseline peak flow. EKG with sinus tachycardia. COntinued expiratory wheezing and desating to 88% RA. CXR without infiltrate. PIV x [**Street Address(2) 8582**]. VS prior to transfer HR 131, 106/42, 94% on neb mask. Pt endorsed depression and suicidal ideation in the last few days. Last Etoh 3-4 days ago. This is the patients 3rd detox in [**2176**] at [**Hospital1 **] for heroin, benzos, and alcohol (also PCP and [**Name9 (PRE) 83699**] use). He was in "moderate" withdrawal on admisison to [**Hospital1 **], and started on Ativan and methadone detox protocols. He endorsed depression and recent SI. . On arrival his breathing is improved but continues to be labored. He continues of anxiety. Continued dry cough. No F/C . ROS: + for diarrhea in setting of detox. Otherwise negative . Past Medical History: - asthma with preivous hospitalization, +intubation; 4 wks ago @ [**Hospital3 **] - [**Hospital3 8372**] - ADHD - depression - multiple dual dx detoxes with poor results - curently admitted to [**Hospital1 **] ([**2176-2-29**]) for benzo depnedence, opaite dependence, and alcohol and cannibis use. Social History: Social History: Per [**Hospital1 **] H+P: just d/ced from Bourneweeod [**2176-2-13**], immediately resumed abuse using [**Name (NI) 3755**] (pt states 5mg daily, [**Name (NI) 83698**] estimated as 12 pills, up 25-30mg daily), drinking daily (1 pint vodka chronically), smoking PCP (per [**Hospital1 **], pt denies) and cannabis, .5gm of heroin. [**First Name4 (NamePattern1) 11560**] [**Last Name (NamePattern1) **] tox screen was negative for opiates but positive for benzos, cannabis, and PCP. [**Name10 (NameIs) 13802**] in [**Location 7661**]. On SSI, lives with father. Active tobacco use, [**1-21**] ppd for few years. . Family History: No known addiction or substance abuse. Asthma in Mother. . Family History: mother - anxiety, depression, [**Name (NI) 8372**] father - anxiety, depression, [**Name (NI) 8372**] other - GF - DM Physical Exam: Physical Exam: VS: Temp: BP: / HR: RR: O2sat GEN: yound, mildly tachypneic, NAD HEENT: PERRL, EOMI, anicteric, DMM, op without lesions, no jvd, RESP: Reduced air movement throughout, diffuse expiratory wheeze CV: tachy, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, mild epigastic tenderness without gaurding or rebound, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. . Pertinent Results: [**2176-3-3**] 03:37AM BLOOD WBC-13.5* RBC-5.44 Hgb-16.1 Hct-46.4 MCV-85 MCH-29.5 MCHC-34.6 RDW-13.3 Plt Ct-159 [**2176-3-6**] 01:50PM BLOOD WBC-8.6 RBC-5.23 Hgb-15.7 Hct-46.4 MCV-89 MCH-30.0 MCHC-33.8 RDW-12.9 Plt Ct-221 [**2176-3-5**] 06:14AM BLOOD Glucose-104* UreaN-16 Creat-0.9 Na-140 K-3.8 Cl-108 HCO3-22 AnGap-14 [**2176-3-3**] 03:37AM BLOOD ALT-35 AST-22 LD(LDH)-175 AlkPhos-103 TotBili-0.3 [**2176-3-5**] 06:14AM BLOOD Calcium-8.9 Phos-4.4# Mg-2.2 [**2176-3-3**] 04:54PM BLOOD D-Dimer-247 [**2176-3-3**] 03:37AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2176-3-3**] 12:38PM BLOOD Type-ART pO2-70* pCO2-24* pH-7.44 calTCO2-17* Base XS--5 [**2176-3-3**] 06:25AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010 [**2176-3-3**] 06:25AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2176-3-3**] 06:25AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . MICRO: [**2176-3-6**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2176-3-6**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2176-3-5**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2176-3-3**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT . [**2176-3-3**] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Anaerobic Bottle Gram Stain-FINAL INPATIENT . [**2176-3-4**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN TEST- {POSITIVE FOR INFLUENZA A VIRAL ANTIGEN} . [**2176-3-3**] MRSA SCREEN MRSA SCREEN-negative Brief Hospital Course: 21 y/o with history of polysubstance abuse with active withdrawl (heroin, benzos, alcohol), presented from detox with asthma exacerbation in the setting of influenza and active smoking. . #. Asthma exacerbation: On admission had significantly decreased BS and wheezing. Likely exacerbated by influenza. Had poisitve DFA for influenza A. It appears that he was not reliably using his asthma maintenance medications. Active smoking is also likely contributing to uncontrolled asthma. Patient was started on Tamiflu + Levofloxacin received 3 days of Levofloxacin, but this was discontinued at the time of transfer out of the ICU. He also was treated with steroids which were gradually tapered, Advair 250/50 [**Hospital1 **], and nebs. Lung auscultation much improved with this. He was gradually weaned off of oxygen, and at the time of discharge, his breathing was back to baseline. He was discharged on Prednisone 10 mg po q day, which he will receive for several more days. . #. Polysubstance abuse and ?withdrawal: Recent use of benzos and heroin, as well as heavy EtOH 4 days prior to admission. History of withdrawal but not seizures. Patient was quite agitated, diaphoretic, and tachycardic, with improvement after administration of clonidine. He was treated with clonidine and valium on a CIWA scale. At the time of discharge, it appeared that his [**Doctor Last Name **] on the CIWA scale was due to his baseline psychiatric issues and not active withdrawl. Social work/Addictions followed throughout the hospitalization. . #. CoNS bacteremia; probable contaminant: Blood culture [**3-3**] was positive for CoNS. Pt was covered with Vancomycin IV while awaiting results of surveillance blood cultures and cardiac echo. Cardiac echo was normal and without evidence of endocarditis. Surveillance blood cultures were drawn, and remain negative >48 hours. The positive blood culture was likely a contaminant. . #. Tachycardia: Sinus tach on EKG. Negative d-dimer decreases concern for PE. Suspect significant component due to patient's significant anxiety issues. Tachycardia resolves during periods of lower anxiety. . #. Depression/bipolar disorder/ Anxiety: Psychiatry was consulted and assisted in management of his anxiety and other psychiatric issues. Pt was treated as follows: - Gabapentin 600 mg PO/NG [**Hospital1 **] - Clonazepam 0.5 mg PO/NG TID - BuPROPion (Sustained Release) 150 mg PO BID - Quetiapine extended-release 200 mg PO HS - traZODONE 50 mg PO/NG HS:PRN insomnia Pt was covered with a CIWA scale during the admission for his history of alcohol and benzo abuse, however, I strongly suspect that his CIWA actually reflected pt's anxiety and NOT active withdrawl at the time of discharge. . FEN: IVF, lytes prn, regular diet . Access: PIV x 1 . PPx: heparin SC, BM regimen . Comm: HCP father, [**Name (NI) **] [**Telephone/Fax (1) 83700**]. [**Name2 (NI) 16001**] [**Name (NI) 83701**], mother [**Telephone/Fax (1) 83702**] . Code: confirmed full, consent completed . DISPO: Patient is now medically stable for discharge to psychiatric facility for ongoing treatment of his substance abuse. Pt would medically benefit from resuming his drug treatment program as soon as possible. Medications on Admission: Meds at home: Wellbutrin 200mg PO BID, clonidine 0.1 [**Hospital1 **], seroquel 200mg qhs, neurontin 600 TID . Meds on transfer: ativan 1mg PO q4h prn Bentyl 20mg PO q6h prn loperamide 2mg PO prn CLonidine 0.1mg PO q6h prn trazodone 50mg PO qhs prn mylanta 30ml q4h prn MOM 30ml PO qhs prn multivit 1 tab daily ibuprofen 400mg PO q4h prn chlorpormazine 50mg PO q6h prn albuterol MDI 1 puff q6h prn Nicotine gum 2mg q 1hr prn. Allergies: NKDA . Discharge Medications: 1. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 2. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for opiate withdrawal. 3. quetiapine 200 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO HS (at bedtime). 4. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 10. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. Discharge Disposition: Extended Care Facility: [**Hospital3 8063**] - [**Location (un) **] Discharge Diagnosis: # Asthma exacerbation # Influenza # Polysubstance abuse and withdrawal # CoNS bacteremia; probable contaminant # Depression/bipolar disorder/ Anxiety 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 a severe asthma exacerbation that was initially managed in the ICU. Your breathing was treated with steroids and nebulizers. You were found to have influenza, which was treated with Tamiflu. You also had withdrawl symptoms from your multiple drugs of abuse and alcohol. This was treated with medication as well. Psychiatry helped with treatment of your anxiety. It is very important that you take your medications as prescribed, as we discussed. Followup Instructions: Please follow up with your primary care provider [**Name Initial (PRE) 176**] 2 weeks. Please call to schedule an appointment.

[ "487.1", "493.92", "304.70", "314.01", "305.20", "305.1", "300.4", "305.00", "296.50" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10223, 10293

5434, 8645

307, 313

10487, 10487

3829, 5411

11150, 11280

3159, 3279

9139, 10200

10314, 10466

8671, 8782

10638, 11127

3309, 3810

264, 269

341, 2099

10502, 10614

2121, 2422

2454, 3066

8800, 9116

5,771

127,184

59

Discharge summary

report

Admission Date: [**2173-6-30**] Discharge Date: [**2173-7-15**] Date of Birth: [**2095-6-20**] Sex: M Service: SURGERY Allergies: Cozaar Attending:[**First Name3 (LF) 668**] Chief Complaint: nausea, vomiting Major Surgical or Invasive Procedure: [**2173-6-30**] ex lap, reduction of volvulus, enterotomy repair [**2173-7-13**] AVG thrombectomy History of Present Illness: 78 M presents with 24 hours of nausea, multiple bouts of emesis, and abdominal pain. Has thrown up non-stop overnight. Reports not passing gas today but has had loose stool. Denies fevers, chills, or any urinary sypmtoms. Past Medical History: - DM - HTN - Dyslipidemia - Laser surgery to both eyes - Bilateral cataracts - ESRD on dialysis MWF - Atrial flutter/atrial fibrillation s/p ablation. He is reportedly not on anticoagulation because of renal insufficiency and concern for high risk of bleeding. - s/p pacemaker placement with history of tachy-brady syndrome - Prostate cancer, diagnosed 12 years ago s/p orchietctomy and hormone therapy - Renal cell cancer, s/p right nephrectomy - Secondary hyperparathyroidism - Small bilateral pleural effusions noted on [**2172-1-17**] admission, no longer noted on recent chest x-ray from [**2172-9-24**] - Percutaneous thrombectomy of his left forearm AV graft, fistulogram, arteriogram, and a balloon angioplasty of multiple venous outflow stenoses and angioplasty of the arteriovenous graft anastomosis in [**2172-6-16**] -s/p surgical removal of upper GI obstruction per patient Social History: Retired foundry worker who lives at home in [**Location (un) 669**] with his wife. Stopped smoking cigarettes over 20 years ago, smoked intermittently for years before that, but has difficulty quantifying use. Has not had alcohol in over 20 years, drinking only socially prior to that time. Denies a history of drug use. Family History: Family History: States that his siblings are healthy, but unsure on health of other family members Physical Exam: 97.6 99/48 78 18 100% RA Awake, alert, oriented x 3, NAD NG tube in place PERRL, anicteric RRR CTAB Abdomen soft, distended, tender along midline incision and left side of the abdomen, hypoactive bowel sounds, + guarding LE warm, no edema Imaging: CT abd [**6-30**]: High grade SBO with dilated loops of small bowel up to 4.4cm with associated ascites. Two transition points seen in the mid abdomen involving proximal and distal jejenum likely secondary to large adhesions in this area CXR: negative Labs: WBC 13, Hct 46, Plts 260, PT 23.9, PTT 30.2, INR 2.3 Lactate 5.3 --> 4.3 after 2 L IVF Na 141, K 4.7, Cl 93, HCO3 22, BUN 54, Cr. 8.7 Pertinent Results: [**2173-7-15**] 04:50AM BLOOD WBC-7.4 RBC-2.87* Hgb-8.5* Hct-26.8* MCV-93 MCH-29.6 MCHC-31.7 RDW-16.4* Plt Ct-127* [**2173-7-15**] 04:50AM BLOOD PT-14.2* PTT-33.5 INR(PT)-1.2* [**2173-7-15**] 04:50AM BLOOD Glucose-91 UreaN-72* Creat-5.2*# Na-139 K-3.9 Cl-102 HCO3-27 AnGap-14 [**2173-7-4**] 07:20AM BLOOD ALT-17 AST-25 AlkPhos-59 TotBili-0.3 [**2173-7-15**] 04:50AM BLOOD Calcium-10.1 Phos-4.0# Mg-1.9 Brief Hospital Course: 78 M with ESRD on hemodialysis was admitted with high grade SBO seen on CT. CT showed dilated loops of small bowel measuring up to 4.4 cm. Moderate ascites was noted. Two transition points were seen in the mid abdomen involving the proximal and distal jejunum best seen on (2:49) likely secondary to multiple adhesions in this area. An NG tube was placed with 500 cc of feculent material suction out. IV recussitation was administered. Blood cultures were sent. He was taken to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who performed an exploratory lap with lysis of adhesions and reduction of internal volvulus for small bowel obstruction. He was given FFP for an inr of 2.3 (on coumadin for afib)and coumadin was held. Of note, he has a pacemaker. Please refer to Dr.[**Name (NI) 670**] operative note. Per OR note, the fascial incision was opened down to the pubic symphysis and almost to the xiphoid process. We took down some internal adhesions to the anterior abdominal wall. In doing this,a large serosal tear occurred which was repaired with a series of sutures. A large portion of the small bowel appeared gangrenous. The bowel was de-torsed. There was concern for the viability of the bowel and a second laparotomy was planned. He was temporarily closed. On [**7-1**], he was taken back to the OR where the bowel appeared viable and he was closed. Postop, he was sent to the SICU for management. He was kept NPO with an NG tube in place. CXR demonstrated a left lower lobe retrocardiac opacity was new. He continued on IV antibiotics. He was transferred out of the SICU on**** IV Cefepime,Flagyl and Vanco were administered from [**7-1**] thru [**7-3**]. WBC had been 13.6 on admission. This decreased to 5.5 by [**7-3**]. Blood cultures were negative and an MRSA screen was also negative. TPN was started on postop day 4 ([**7-3**])as he remained NPO for bowel rest and because he was sleepy. By [**7-7**], he was passing flatus and stool. The NG was removed. He continued to be lethargic. Speech and swallow evaluated on [**2173-7-8**] recommending the following: PO diet of thin liquids and soft solids. Select ONLY moist soft foods. Please cut food into small, manageable pieces. Pills whole or crushed with puree. 1:1 assistance with POs. Give POs only when most awake and alert. Maintain aspiration precautions. Q8 oral care. Diet was slowly advanced. TPN continued. PO intake was fair. KCAL counts were ordered and started on [**7-14**] to determine if TPN could be weaned off. Hemodialysis was continued via the LUE AVG. Until, [**7-7**] when his graft clotted and dialysis could not be performed. He was also noted to be tachypnic in afib. CXR demonstrated fluid overload. A temporary right groin line was placed and he was dialyzed for 3 liters. Afib converted to sinus rhythm. Of note, cardiac/antihypertensives were held when npo. Hematocrit was noted to have slowly trended down to 23. One unit of PRBC was administered and epogen was increased at dialysis. On [**2173-7-13**], a LUE AVG thrombectomy was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. There was a thrill/bruit and radial pulse. Of note, the preop cxr demonstrated improvement in left basilar opacity with minimal bibasilar atelectasis and small right pleural effusion. The left subclavian line was noted. On [**7-14**], hemodialysis was performed via the graft with good flows and 2.5 liters were removed. The temporary right groin dialysis line was removed without incident. PT evaluated and recommended rehab. He was screened by [**Hospital 671**] Rehab in [**Location (un) 86**] and was accepted there. Most of home meds were held during this hospital course. At time of discharge, amiodarone and lopressor 12.5 [**Hospital1 **], asa, coumadin 4mg qd, cinacalcet and zantac were resume. Hydralazine and nifedipine were held. These should be re-instituted as tolerated. Fosrenal should be resumed when dietary intake improved. Medications on Admission: coumadin [**3-22**], amiodarone 100', cinacalcet 30', hydralazine 25"', metoprolol 25", nifedipine 30', ranitidine 150", simvastatin 20', ASA 81, januvia 25", fosrenol 1000"' Discharge Medications: 1. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain . 2. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. 3. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day: check inr 3x/week goal 2-2.5. 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 7. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO once a day. 8. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day. 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold for sbp <110 or HR <60. 10. Outpatient Lab Work inr 3x a week on coumadin inr goal 2-2.5 Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: esrd small bowel obstruction clttted left avf malnutrition afib Discharge Condition: stable Discharge Instructions: You will be going to [**Hospital 671**] Rehab in [**Location (un) 86**]. Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, malfunction of left upper arm AVF Continue hemodialysis on Monday-Wednesday-Friday Continue calorie counts and stop TPN if adequate Followup Instructions: Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2173-7-22**] 3:10 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2173-12-22**] 2:30 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2173-12-22**] 3:00 Completed by:[**2173-7-15**]

[ "997.1", "V45.01", "585.6", "V10.46", "996.73", "403.91", "998.2", "560.2", "250.00", "560.81", "V10.52", "427.31", "285.9", "263.9" ]

icd9cm

[ [ [] ] ]

[ "54.59", "39.95", "39.49", "54.62", "38.93", "46.73", "46.81", "99.15" ]

icd9pcs

[ [ [] ] ]

8126, 8181

3115, 7123

283, 383

8289, 8298

2689, 3092

8658, 9093

1920, 2005

7349, 8103

8202, 8268

7149, 7326

8322, 8635

2020, 2670

226, 245

411, 635

657, 1547

1563, 1888

75,031

147,206

35392

Discharge summary

report

Admission Date: [**2198-3-28**] Discharge Date: [**2198-4-1**] Date of Birth: [**2132-10-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: Endotracheal intubation Aterial line placement Left internal jugular central venous line placement History of Present Illness: Mr. [**Known lastname 80664**] is a 65-year-old man with known alcoholic cirrhosis, DM, pneumonia who is transferred from [**Hospital6 5016**] for evaluation of hepatopulmonary syndrome. Admitted to the OSH on [**3-5**] with shortness of breath, he was initially treated with Levaquin and Cetriaxone along with steroids for COPD as this was felt to be most consistent with a COPD exacerbation. Given CT findings consistent with pulmonary fibrosis, thoracic surgery was consulted and on [**3-14**] a bronchoscopy with washings, RVATS RUL lung biopsy was performed. Per the OSH notes, he appeared to have respiratory failure on [**3-15**] with a PaO2 of 58. He was not intubated at this time. Worsening was felt to be due to CHF and hebwas diuresed with IV lasix. On [**3-18**] he was noted to have diarrhea. On [**3-19**] he underwent an echo that showed an LVEF of 64% with negative bubble study. On [**3-26**] a PICC line was placed. On [**3-27**] he appeared more confused. Transfer to [**Hospital1 18**] was arranged. Past Medical History: 1. Interstitial lung disease 2. Cirrhosis secondary to alcoholism - Ascites - Portal hypertension - History of GIB - Splenomegaly - Esophageal varices - History of hepatic encephalopathy 3. Diastolic heart failure 4. Diabetes 5. Portal hypertension 6. Polysubstance abuse Depression 7. COPD 8. Appendectomy Social History: Single, lives alone, retired bank examiner. Family History: DM in brother Physical Exam: VITALS: T: 98.4 BP: 95/48 P: 71 R: 23 18 O2: 88/ NRB GEN: Alert, oriented to self, tachypneic HEENT: Sclera anicteric, dry MM, oropharynx clear LUNGS: Poor effort. Decreased bilaterally. CV: Regular rate and rhythm. Systolic murmur at aortic site. Abdomen: Soft, non-tender. Questionable ascites. Unable to palpate hepatosplenomegaly EXT: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema, hairless legs SKIN: Ecchymoses throughout UE and chest Pertinent Results: Admission Labs: [**2198-3-28**] 01:14AM BLOOD WBC-13.2* RBC-2.64* Hgb-8.7* Hct-25.3* MCV-96 MCH-32.9* MCHC-34.2 RDW-15.8* Plt Ct-25* [**2198-3-28**] 01:14AM BLOOD Neuts-96.1* Lymphs-1.7* Monos-1.8* Eos-0.3 Baso-0.1 [**2198-3-28**] 01:14AM BLOOD PT-19.7* PTT-35.9* INR(PT)-1.8* [**2198-3-28**] 01:14AM BLOOD Ret Aut-6.6* [**2198-3-28**] 01:14AM BLOOD Glucose-110* UreaN-61* Creat-1.3* Na-132* K-5.3* Cl-103 HCO3-25 [**2198-3-28**] 01:14AM BLOOD ALT-65* AST-63* LD(LDH)-337* AlkPhos-89 Amylase-71 TotBili-4.4* [**2198-3-28**] 01:14AM BLOOD Albumin-2.2* Calcium-9.4 Phos-3.9 Mg-2.3 Iron-28* [**2198-3-28**] 01:14AM BLOOD calTIBC-261 VitB12-GREATER TH Folate-GREATER TH Ferritn-86 TRF-201 [**2198-3-28**] 01:28AM BLOOD Type-ART pO2-48* pCO2-29* pH-7.49* calTCO2-23 Base XS-0 [**2198-3-28**] 01:28AM BLOOD Lactate-2.3* [**2198-3-28**] 01:28AM BLOOD O2 Sat-82 [**2198-3-28**] 09:29AM BLOOD freeCa-1.34* [**2198-3-28**] 09:31AM URINE Hours-RANDOM UreaN-1221 Creat-51 Na-15 K-38 Cl-LESS THAN [**2198-3-29**] 09:48AM ASCITES WBC-15* RBC-158* Polys-56* Lymphs-22* Monos-5* Mesothe-6* Macroph-11* [**2198-3-29**] 09:48AM ASCITES TotPro-<0.2 Glucose-249 LD(LDH)-46 Amylase-60 Albumin-LESS THAN Triglyc-7 Additional Labs: [**2198-3-30**] 07:51AM BLOOD FDP-10-40* [**2198-3-30**] 07:51AM BLOOD Fibrino-164 [**2198-3-30**] 02:08PM BLOOD QG6PD-11.3 [**2198-3-30**] 07:51AM BLOOD Hapto-91 [**2198-4-1**] 03:27AM BLOOD Cortsol-6.9 [**2198-3-28**] 7:00 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2198-3-29**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2198-3-29**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [**2198-3-28**] 5:50 am MRSA SCREEN **FINAL REPORT [**2198-3-30**]** MRSA SCREEN (Final [**2198-3-30**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. [**2198-3-29**] 9:48 am PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT [**2198-4-4**]** GRAM STAIN (Final [**2198-3-29**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 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 [**2198-4-1**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2198-4-4**]): NO GROWTH. [**2198-3-29**] 2:50 pm STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2198-3-30**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2198-3-30**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Studies: [**2198-3-28**] ECG: Normal sinus rhythm. Normal tracing. No previous tracing available for comparison. [**2198-3-28**] ECHO: The left atrium is elongated. No thrombus/mass is seen in the body of the left atrium. A patent foramen ovale is present. A right-to-left shunt across the interatrial septum is seen at rest. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Patent foramen ovale. [**2198-3-28**] CXR - IMPRESSION: Retrocardiac opacity may represent pneumonia or atelectasis. Background interstitial lung disease. Small left pleural effusion. [**2198-3-28**] CXR - FINDINGS: In comparison with the earlier study of this date, there has been placement of an endotracheal tube that has its tip at the top of the clavicles, approximately 7 cm above the carina. The patient has taken a much better inspiration. Opacification persists in the left mid and lower lung zones. [**2198-3-28**] Abdominal ultrasound - IMPRESSION: 1. Limited study due to respiratory motion. Portal venous system appears patent with reversed flow. Hepatic arterial and hepatic venous systems are grossly patent. 2. Small amount of ascites. 3. Heterogeneous, coarsened liver echotexture, consistent with the patient's history of cirrhosis. 4. Cholelithiasis. [**2198-3-28**] CXR - FINDINGS: As compared to the previous radiograph, all monitoring and support devices are in unchanged position. In addition, a central venous access line has been inserted over the left internal jugular vein. The tip projects over the mid SVC. There is an increase of the retrocardiac opacity with air bronchograms, suggestive of atelectasis. Otherwise, no relevant changes. No pneumothorax. [**2198-3-29**] Peritoneal fluid cytology: NEGATIVE FOR MALIGNANT CELLS. Few reactive mesothelial cells with histiocytes, lymphocytes and neutrophils. [**2198-3-29**] Cardiac Cath - COMMENTS: 1. Resting hemodynamics demonstrated mildly elevated right-sided filling pressures with an RVEDP of 16 mmHg, mild pulmonary arterial hypertension with a PA pressure of 35/19 mmHg, and elevated left ventricular filling pressures with a mean PCWP of 20 mmHg. 2. Oximetry run did not demonstrate any evidence of left-to-right shunting. Assuming an oxygen consumption of 125 ml/min/m2, and assuming a pulmonary venous saturation of 98%, the calculated Qp was 8.0 L/min and Qs was 10.6 L/min. This would suggest mild right-to-left intracardiac shunting. However, inability to directly measure a PV saturation and the clinical suspicion for intrapulmonary shunting challenges these calculations. 3. High-output state suggestive of sepsis or systemic vasodilation of another etiology. FINAL DIAGNOSIS: 1. Biventricular diastolic dysfunction. 2. Mild pulmonary arterial hypertension. 3. High-output / low SVR shock. 4. No evidence of left-to-right shunt. 5. Possible mild right-to-left intracardiac shunting. [**2198-3-29**] CT head w/o contrast - CONCLUSION: No evidence of hemorrhage or infarction. No abnormal enhancement. [**2198-3-29**] CTA chest - IMPRESSION: 1. Suboptimal study. No central pulmonary embolism. If clinical suspicion of pulmonary embolism is high, a V/Q scan should be obtained. 2. Bibasilar consolidation, mostly on the left, could be due to multifocal pneumonia or aspiration. 3. Heterogeneous attenuation, could be due to air trapping. 4. Cirrhosis and ascites. 5. Coronary artery, aortic annulus, and aortic valve calcifications, of unknown hemodynamic significance. 6. Signs of anemia. [**2198-3-30**] Shunt study - IMPRESSION: Study is consistent with the presence of a right-to-left shunt. [**2198-3-30**] CT abdomen/pelvis w/o contrast - IMPRESSION: 1. No evidence for retroperitoneal or other hematoma. 2. Moderate simple abdominal and pelvic ascites. 3. Nodular liver consistent with cirrhosis. 4. Diffuse pancreatic calcifications with atrophy suggestive of chronic pancreatitis. 5. Bilateral avascular necrosis of the femoral heads without collapse. 6. Bibasilar consolidations concerning for aspiration pneumonia. 7. Nonobstructive renal calculi with bilateral renal cysts. 8. Cholelithiasis without cholecystitis. [**2198-3-31**] CXR - FINDINGS: Endotracheal tube terminates 6.4 cm above carina and could be advanced slightly for standard positioning. Other indwelling devices remain in standard position. Persistent mild fluid overload. Slight improvement in airspace consolidation in left lower lobe, possibly due to an infectious pneumonia. Persistent small left pleural effusion. [**2198-3-31**] CXR - Widespread pulmonary opacification developed in both lungs in addition to the previous consolidation in the left lower. Findings consistent with edema or hemorrhage in addition superimposed on left lower lobe pneumonia. Azygos engorgement and enlargement of the cardiac silhouette suggest a component of cardiac decompensation or volume overload but that may not explain all the new findings. ET tube tip at the thoracic inlet at least 6 cm from the carina, 2 cm above optimal placement. Nasogastric tube passes into the stomach and out of view. Left jugular and right PIC lines both end in the mid SVC. No pneumothorax. Pleural effusion if any is small. [**2198-4-1**] CXR - Generalized pulmonary opacification probably combination of edema and pneumonia, particularly in the left lower lobe has worsened since [**3-31**]. ET tube, nasogastric tube and left central and right PIC catheters in standard placements. Pleural effusion if any is minimal. Mild cardiomegaly is stable. Component of pulmonary hemorrhage cannot be excluded. No pneumothorax. [**2198-4-1**] CXR - Sequence of pulmonary abnormalities on chest radiographs since [**3-28**], suggests the development of pneumonia, particularly in left lower lobe, followed by evidence of volume overload and most recently worsening generalized pulmonary opacification which could be due to a combination of edema and hemorrhage, showing particular worsening over the past five hours. ET tube, nasogastric tube, left internal jugular and right PIC line ends in standard placements. Pleural effusion, if any, is small. No pneumothorax. Brief Hospital Course: Mr. [**Known lastname 80664**] is a 65 year old man with known alcoholic cirrhosis and COPD admitted to an OSH with SOB who was transferred for further evaluation of hypoxia. 1. Hypoxia / Respiratory Failure: The patient was intubated shortly after arrival due to hypoxia, altered mental status, and the need to safely perform multiple studies and procedures. Initially many possible explanations for hypoxia were entertained and likely several of them contributed to his presentation. The patient had a significant shunt with both a cardiac shunt (PFO seen on TTE and via right heart catheterization) as well as a pulmonary shunt (most likely hepatopulmonary syndrome as a consequence of his cirrhosis). The patient also had a LLL infiltrate on his admission CXR and was treated with vancomycin and zosyn for HAP following arrival for the duration of his MICU course. PE was also considered in the differential, however, heparin was held given concern for HIT. CTA showed no central large PE, but was a limited study. There was concern raised at the OSH for intrinsic lung disease and history of IPF, however, the patient's CXR did not show evidence of significant IPF. Biopsies from the OSH were unobtainable as they had been sent to [**State **] for further evaluation. Following intubation, O2 sats >90% were achieved by keeping MAPs > 70 with levophed and blood products. MAPs improved with platelets and FFP infusion, suggesting that shunting was playing a significant role. Oxygen saturations improved briefly, however, they could not be maintained, even with blood pressure support. On the day prior to the patient's death his oxygen sats dropped to the mid 80s on an FiO2 of 100%. Despite multiple attempts to improve sats overnight with ventilator changes, the patient desatted to the low 70s the following morning and pink, frothy fluid was aspirated from his ET tube. The patient subsequently became hypotensive and died shortly thereafter despite aggressive support with pressors and maximum ventilatory support. 2. Hypotension: The patient initially required levophed for blood pressure support and to help maintain O2 sats following admission and intubation. Levophed was eventually weaned off and the patient did not require any pressors for a few days. The patient subsequently became hypotensive the morning of his death. Despite aggressive resuscitation with fluids and 3 pressors (levophed, vasopressin, and neosynephrine) the patient remained hypotensive. He became bradycardic and had a cardiac arrest. CPR was not begun as it was felt to be medically futile given the severity of the patient's illness. 3. Thrombocytopenia: The patient was throbocytopenic on admission. He received 2 platelet transfusions prior to an abdominal paracentesis. The following day his platelets were 10. Aggressive platelet replacement was begun and continued over the next couple of days. Despite multiple units, his platelet count never increased. Hematology was consulted. They recommended continued platelet transfusion with ABO-matched platelets. They felt that some underlying consumptive process was responsible. The patient was HIT antibody negative both at this hospital and at the outside hospital. Peripheral smear was unremarkable and DIC labs were negative. The patient was already on steroids for COPD and hematology felt that ITP was unlikely. On [**3-30**] vancomycin was stopped, on [**3-31**] zosyn was stopped, and on [**3-31**] his PPI was changed to ranitidine in the event that the patient had thrombocytopenia as a result of a drug reaction. 4. Cirrhosis: Per the OSH notes, the patient had alcoholic cirrhosis. He had a low albumin and somewhat elevated INR as well as splenomegaly and thrombocytopenia. Hepatology was consulted. Given the patient's altered mental status, he was treated with lactulose and rifaximin for possible hepatic encephalopathy. The patient also underwent a diagnostic paracentesis without evidence of SBP. 5. Anemia: The patient was noted to be anemic. His anemia was likely multifactorial including marrow suppressions (EtOH), GIB (guaiac + at the OSH). His hematocrit was 42 on initial presentation to the OSH and between 38 and 40 until [**3-18**]. The precipitous drop prior to his transfer to [**Hospital1 18**] remained unclear. [**Name2 (NI) **] count was elevated (6.6), iron was low, B12 & folate were sufficient. DIC labs were negative and peripheral smear was not suggestive. 6. Altered mental status: The patient's altered mental status was most likely multifactorial with hyponatremia, hepatic encephalopathy, hypoxia, and infection all contributing. Treatment was directed at these primary causes. He had a head CT that was negative for any acute process. 7. Hyponatremia: The patient was hyponatremic on presentation. This problem resolved quickly following admission with fluid resuscitation. 8. Renal failure: The patient had a baseline creatinine at the OSH of ~1.0. His creatinine peaked at 1.4 shortly after admission and then trended back downward. The transient elevationwas likely secondary to a pre-renal state and GI bleeding. 9. Diarrhea: The patient was treated as C. Diff positive, despite being toxin negative at the OSH. He remained negative at [**Hospital1 18**] (x 2) and treatment for C. Diff was held. His diarrhea was most likely secondary to lactulose. 10. COPD: The patient was initially treated at the OSH as having a primary diagnosis of COPD. He was started on a steroid taper there and continued on a steroid taper following his transfer. He continued to receive bronchodilators while intubated. Medications on Admission: MEDICATIONS (home): 1. Atenolol 50 mg daily 2. Spironolactone 50 mg daily 3. Lasix 20 mg daily 4. Lactulose 30cc QID 5. Prednisone 10 mg daily 6. Glucophage 500 mg daily 7. Omeprazole 40 mg daily 8. Celexa 20 mg daily 9. Vit D 50,000 units of 15th of every month 10. Folate 1 mg daily 11. Vit B 100 mg daily 12. Spiriva 18 mcg 2 puffs daily 13. Albuterol 14. Atrovent . MEDICAIONS (transfer): 1. Atenolol 50mg daily 2. Vanc 1g IV daily 3. Vanc 250mg PO QID 4. Prednisone taper 5. Insulin Levemir 5U SC daily 6. Albuterol Neb 7. Percocet 2 tab PRN 8. Thiamine 100mg daily 9. MVI daily 10. Folate 1mg daily Discharge Medications: N/A patient deceased Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: 1. Respiratory failure 2. Patent foramen ovale 3. Hepatopulmonary syndrome 4. Pneumonia 5. Cirrhosis secondary to alcoholism 6. Anemia 7. Thrombocytopenia 8. Chronic obstructive pulmonary disease Secondary Diagnoses: 1. History of a gastrointestinal bleed 2. Diastolic heart failure 3. Diabetes Discharge Condition: Deceased Discharge Instructions: N/A patient deceased Followup Instructions: N/A patient deceased

[ "486", "518.4", "787.91", "250.00", "303.93", "287.5", "571.2", "572.3", "789.59", "707.22", "276.1", "785.59", "428.0", "285.1", "428.32", "456.21", "707.03", "585.9", "515", "572.8", "583.81", "286.7", "572.2", "518.84", "786.3", "745.5" ]

icd9cm

[ [ [] ] ]

[ "37.21", "96.71", "54.91", "96.6" ]

icd9pcs

[ [ [] ] ]

18447, 18456

12105, 16594

334, 434

18815, 18825

2415, 2415

18894, 18917

1902, 1917

18402, 18424

18477, 18693

17772, 18379

8643, 12082

18849, 18871

1932, 2396

18714, 18794

275, 296

462, 1493

2431, 8626

16609, 17746

1515, 1824

1840, 1886

27,677

167,794

44361

Discharge summary

report

Admission Date: [**2115-1-17**] Discharge Date: [**2115-1-25**] Date of Birth: [**2041-1-18**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2108**] Chief Complaint: Fever, cough, myalgias, vomiting and diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: 73-year-old man with history of CAD s/p CABG x3 in [**2097**], hypertension, type II diabetes c/b peripheral neuropathy and renal insufficiency (baseline creatinine 1.1-1.3), sCHF with ejection fraction of 30% on TTE [**2111**], and peripheral vascular disease who presented to the ED on night of [**1-16**] with two days of fever, cough, myalgias, vomiting and diarrhea. The patient reports that approximately two days ago both he and his wife acutely developed a febrile illness with nausea, diarrhea, vomiting, and cough. He continued to feel quite unwell during that time. He denies orthopnea but cannot sleep flat [**2-27**] spinal stenosis, chest pain, chest pressure, palpitations, LE edema, or urinary changes. His son came to visit him yesterday and he looked so sick he insisted he come to the ED. . In the emergency room, his initial vital signs were T 99.7, HR 79, BP 116/41, RR 24, satting 83% on RA (patient is not normally on oxygen at home). He was not endorsing weight gain in the ED. Labs were notable for white count of 8.2 with 75% neutrophils, no bands, hematocrit of 28.8 (at recent baseline), and platelet count of 85 (down from recent baseline in 200s). Electrolytes showed hyponatremia of 131, bicarb of 19 with AG of 13, and acute kidney injury with creatinine of 1.6 up from baseline 1.1-1.3. Patient underwent EKG that was reportedly without ischemic changes. CXR showed new right upper lobe density concerning for pneumonia. There was also comment on stable pulmonary vascular congestion with mild edema and a small left pleural effusion that was unchanged. He received ceftriaxone 1g IV and levofloxacine 750 mg IV as well as ASA 325, NTG 0.3 SL, and Tylenol 650 mg PO x1. He also received enoxaparin 75 mg SQ for possible PE. They attempted to wean patient off non-rebreather but could not. A fle swab was sent. Vitals at time of admission are satting 94% NRB, RR 24, HR 67, BP 125/44. For access he has 2-peripherals. Reportedly patient was breathing comfortably, and he was felt to be stable for transfer. Past Medical History: - CAD [**4-/2097**]: CABG x 3 (LIMA to LAD, SVG to PDA, SVG to Cx); Catheterization in [**2110**] revealed occluded SVGx2 and LIMA patent) - Chronic systolic CHF with EF 30% in [**2111**] - Hypertension - Type II Diabetes x 20 years, with peripheral neuropathy - Chronic renal insufficiency with baseline Cr 1.1 - Anemia - PVD - Benign ??????lump?????? removed from right foot - Osteoporosis - Questionable GERD - Hypothyroidism - S/p toe amputation for infected toe Social History: - Married with four children. - Alcohol: Denies - Tobacco: Denies Family History: - Mother: Angina in her 50??????s, died of MI at age 57. - Father: Stroke in his 50s. - Sister: CAD and DM. Physical Exam: On Admission: GEN: NAD on NRB VS: 97.3 67 126/64 18 94% on NRB HEENT: MMM, no OP lesions, JVP 12cm w accentuated Vwaves, neck is supple, no cervical, supraclavicular, or axillary LAD CV: RR, NL S1S2, low pitched III/VI holosystolic murmur loudest at the mid L sternal border without radiation to the carotids or axilla PULM: Bibasilar crackles, crackles in the R apex with R apical dullness to percussion ABD: BS+, soft, NTND, no masses or HSM, no stigmata of chronic liver disease LIMBS: No LE edema, no tremors or asterixis, no clubbing SKIN: No rashes or skin breakdown NEURO: CNII-XII nonfocal, strength 5/5 of the upper and lower extremities, reflexes 2+ of the upper and lower extremities, toes down bilaterally Pertinent Results: [**2115-1-17**] 10:15PM TYPE-ART TEMP-37.8 O2 FLOW-6 PO2-72* PCO2-30* PH-7.46* TOTAL CO2-22 BASE XS-0 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**] [**2115-1-17**] 09:26PM TYPE-[**Last Name (un) **] TEMP-37.8 O2 FLOW-6 PO2-47* PCO2-31* PH-7.44 TOTAL CO2-22 BASE XS--1 COMMENTS-NASAL [**Last Name (un) 154**] [**2115-1-17**] 09:26PM LACTATE-1.5 [**2115-1-17**] 09:26PM O2 SAT-80 [**2115-1-17**] 09:00PM URINE HOURS-RANDOM UREA N-1057 CREAT-102 SODIUM-<10 POTASSIUM-67 CHLORIDE-<10 [**2115-1-17**] 09:00PM URINE OSMOLAL-534 [**2115-1-17**] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2115-1-17**] 09:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2115-1-17**] 09:00PM URINE MUCOUS-RARE [**2115-1-17**] 04:48PM GLUCOSE-76 UREA N-47* CREAT-1.6* SODIUM-135 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-21* ANION GAP-15 [**2115-1-17**] 04:48PM CK(CPK)-889* [**2115-1-17**] 04:48PM CK-MB-16* MB INDX-1.8 cTropnT-0.33* [**2115-1-17**] 04:48PM CALCIUM-8.0* PHOSPHATE-2.3* MAGNESIUM-2.1 [**2115-1-17**] 04:48PM PT-15.1* PTT-150* INR(PT)-1.3* [**2115-1-17**] 11:11AM TYPE-ART PO2-74* PCO2-34* PH-7.43 TOTAL CO2-23 BASE XS-0 INTUBATED-NOT INTUBA [**2115-1-17**] 11:11AM LACTATE-0.9 [**2115-1-17**] 11:11AM O2 SAT-95 CARBOXYHB-0 [**2115-1-17**] 11:11AM freeCa-1.09* [**2115-1-17**] 10:49AM LACTATE-1.2 [**2115-1-17**] 10:49AM O2 SAT-77 [**2115-1-17**] 10:49AM freeCa-1.09* [**2115-1-17**] 07:51AM D-DIMER-819* [**2115-1-17**] 04:10AM COMMENTS-GREEN TOP [**2115-1-17**] 04:10AM LACTATE-2.5* [**2115-1-17**] 04:00AM GLUCOSE-276* UREA N-50* CREAT-1.6* SODIUM-131* POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-19* ANION GAP-17 [**2115-1-17**] 04:00AM estGFR-Using this [**2115-1-17**] 04:00AM ALT(SGPT)-24 AST(SGOT)-40 LD(LDH)-244 CK(CPK)-561* ALK PHOS-84 TOT BILI-0.5 [**2115-1-17**] 04:00AM cTropnT-0.05* [**2115-1-17**] 04:00AM CK-MB-5 proBNP-4412* [**2115-1-17**] 04:00AM CALCIUM-8.4 PHOSPHATE-3.2 MAGNESIUM-1.9 [**2115-1-17**] 04:00AM HAPTOGLOB-229* [**2115-1-17**] 04:00AM WBC-8.2# RBC-3.26* HGB-10.1* HCT-28.8* MCV-88 MCH-31.0 MCHC-35.0 RDW-13.0 [**2115-1-17**] 04:00AM NEUTS-74.7* LYMPHS-10.9* MONOS-13.5* EOS-0.5 BASOS-0.3 [**2115-1-17**] 04:00AM PLT COUNT-85*# [**2115-1-17**] 04:00AM PT-14.1* PTT-25.9 INR(PT)-1.2* [**2115-1-17**] 04:00AM FIBRINOGE-422* [**2115-1-17**] 04:00AM RET AUT-2.5 [**2115-1-24**] 06:50AM BLOOD WBC-6.7 RBC-3.20* Hgb-9.4* Hct-28.8* MCV-90 MCH-29.5 MCHC-32.8 RDW-13.0 Plt Ct-150 [**2115-1-25**] 05:45AM BLOOD Glucose-126* UreaN-24* Creat-1.2 Na-137 K-4.1 Cl-100 HCO3-31 AnGap-10 [**2115-1-22**] 06:12AM BLOOD calTIBC-190* Ferritn-499* TRF-146* [**2115-1-18**] 4:43 pm Rapid Respiratory Viral Screen & Culture Site: NASOPHARYNX SWABS RECEIVED. **FINAL REPORT [**2115-1-21**]** Respiratory Viral Culture (Final [**2115-1-21**]): 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 [**2115-1-19**]): 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. [**2115-1-18**] 1:49 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2115-1-24**]** Blood Culture, Routine (Final [**2115-1-24**]): NO GROWTH. [**2115-1-17**] 9:00 pm URINE **FINAL REPORT [**2115-1-18**]** Legionella Urinary Antigen (Final [**2115-1-18**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. [**2115-1-17**] 9:00 pm URINE **FINAL REPORT [**2115-1-18**]** URINE CULTURE (Final [**2115-1-18**]): NO GROWTH. [**2115-1-17**] 4:00 am BLOOD CULTURE # 1. **FINAL REPORT [**2115-1-23**]** Blood Culture, Routine (Final [**2115-1-23**]): NO GROWTH. [**2115-1-22**] chest ap: 1. Improved right mid lung consolidation, but increased right and new left upper lung consolidations. 2. Possible superimposed element of pulmonary edema. [**2115-1-17**] chest ap: 1. New right upper lobe density concerning for pneumonia. Followup radiographs are recommended following resolution of symptoms, as there is persistent, chronic prominence of the right hilum. 2. Stable pulmonary vascular congestion with mild edema. 3. Unchanged small left pleural effusion. ECHOCARDRIOGRAM (TRANSTHORACIC) [**2115-1-17**]: The left atrium is mildly dilated. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with akinesis/thinning of the inferior wall and hypokinesis of the inferior septum and inferolateral wall. The remaining segments contract normally (LVEF = 35 %). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral leaflets are mildly thickened. Mild to moderate ([**1-27**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction c/w CAD. Mild-moderate mitral regurgitation. Pulmonary artery systolic hypertension. Right ventricular cavity enlargement with preserved free wall motion. Increased PCWP. Compared with the prior study (images reviewed) of [**2112-12-26**], the severity of mitral regurgitation and the estimated pulmonary artery systolic pressure are now lower. The left ventricular cavity size is now smaller. The other findings are similar. Brief Hospital Course: 73M with history of CAD s/p CABG x3 in [**2097**], hypertension, type II diabetes c/b peripheral neuropathy and renal insufficiency (baseline creatinine 1.1-1.3), sCHF with ejection fraction of 30% on TTE [**2111**], and peripheral vascular disease who presented with new hypoxia, low grade fever, diarrhea and acute on chronic kidney injury and was also found to have NSTEMI. PNEUMONIA: the patient was treated with levofloxacin and flagyl for an 8 day cours,e his history was that of possible aspiration. Given his severe hypoxia he was treated in the ICU and eventually called out to the floor. Last dose of abx on [**2115-1-25**]. ACUTE ON CHRONIC SYSTOLIC CHF: he was treated with IV lasix and diuresed very well. His dry weight on discharge was 155.8. his ambulatory O2 sat was 95% on room air. he was cleared by PT. His echo did not reveal any significant changes from his prior. He was told to weigh himself daily and call his physician if he gains 3 pounds and he was also told to keep his sodium intkae to < 2 grams per day. His ACE was restarted at his home dose upon discharge, for benign hypertension he was continued on his home dose of norvasc and carvedilol as well. He was discharged on his home dose of lasix of 20mg po bid. NSTEMI VERSUS DEMAND ISCHEMIA: cardiology consulted inpatient, more likely to be demand ischemia, very mild troponin increase without a CKMB increase. His EF was unchanged and he had no new wall motion abnormalities. He was continued on aspirin, plavix and carvedilol and an ACEi. His lipitor 40mg po daily was increased to 80mg po daily, he should have a nuclear stress test as an outpatient per cardiology consult. This recommendation was emailed to his cardiologist Dr. [**Last Name (STitle) **] and discussed with the patient extensively. Acute kidney injury: Cr was 1.6 on admission from 1.1 to 1.2 baseline. FeNa of 0.1% on admission was consistent with pre-renal etiology, likely [**2-27**] to poor forward flow in the context of CHF exacerbation. Patient was treatred with diuresis with subsequent down trending of Cr. Home lisinopril was initally held pending resolution of renal failure, but was restarted upon discharge home. Thrombocytopenia: PLT count = 85, likely related to acute infection, this resolved with treatment of his pneumonia. Anemia: anemia of chronic disease. Patient has chronic normocytic anemia with past Hct ranging from 24 to 28. On this admission down trended from 28 on admission to 23 on day 4. Due to active ischemia received 1 unit of PRBC and bumped appropriately. He had no over bleeding, neg hemolytic indices and his Reticulocyte index was < 2% indicating hypoproliferation. Diabetes type II - home insulin was continued. Hypothyroidism: home levothyroxine 25 mcg daily was continued Medications on Admission: - Amlodipine 2.5 mg daily - Atorvastatin 40 mg daily - Carvedilol 25 mg [**Hospital1 **] - Clopidogrel 75 mg daily - Furosemide 20 mg [**Hospital1 **] - Insulin - Levothyroxine 25 mcg daily - Lisinopril 40 mg [**Hospital1 **] - Niacin 500 mg daily - Omeprazole 20 mg daily - KCl 10 mEq [**Hospital1 **] - Aspirin 325 mg daily Discharge Medications: 1. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. 6. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. 7. insulin lispro 100 unit/mL Solution Sig: per sliding scale units Subcutaneous four times a day: before meals and at bedtime. 8. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day. 10. niacin 500 mg Tablet Sig: One (1) Tablet PO once a day. 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. potassium chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO twice a day. 13. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Caregroup Discharge Diagnosis: Primary Diagnosis: Severe community acquired pneumonia, bacterial Acute on chronic systolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Dry weight 155.8 lbs, standing ambulatory O2 sat 95% on room air Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. your weight prior to discharge from the hospital (on [**2115-1-25**]) was 155.8 lbs. You were admitted with fluid in your lungs and pneumonia. You were treated with antibiotics and IV lasix. Please take your medications as prescribed and make your follow up appointments. MEDICATION CHANGES Please increase the dose of your LIPITOR (ATORVASTATIN) Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] J. Address: [**Apartment Address(1) 26992**], [**Hospital1 **],[**Numeric Identifier 26419**] Phone: [**Telephone/Fax (1) 16335**] Appt: [**1-29**] at 3pm Department: CARDIAC SERVICES When: WEDNESDAY [**2115-2-6**] at 11:00 AM With: [**Known firstname **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: VASCULAR SURGERY When: THURSDAY [**2115-3-7**] at 1 PM With: VASCULAR LAB [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: VASCULAR SURGERY When: THURSDAY [**2115-3-7**] at 1:50 PM With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "V45.81", "285.21", "276.1", "414.00", "486", "V45.02", "250.60", "443.9", "585.9", "287.5", "428.23", "403.90", "410.71", "244.9", "584.9", "V58.67", "518.81", "428.0", "733.00", "357.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14912, 14952

10665, 13455

350, 357

15102, 15102

3887, 10642

15783, 16826

3017, 3127

13832, 14889

14973, 14973

13481, 13809

15318, 15760

3142, 3142

265, 312

385, 2426

14992, 15081

3157, 3868

15117, 15294

2448, 2917

2933, 3001

3,042

113,262

22648

Discharge summary

report

Admission Date: [**2173-11-10**] Discharge Date: [**2173-11-19**] Date of Birth: [**2124-10-13**] Sex: M Service: CARDIOTHORACIC Allergies: Percocet / Quinine Attending:[**First Name3 (LF) 1505**] Chief Complaint: Increasing fatigue Major Surgical or Invasive Procedure: [**2173-11-11**] Mitral valve repair with 26 millimeter [**Doctor Last Name 405**] band History of Present Illness: This is a 49 yo African - American male with severe MR [**First Name (Titles) **] [**Last Name (Titles) **] HTN for past 10 years. This has progressed significantly and the patient has had increasing fatigue. He was referred for MVrepair vs. replacement and was admitted pre-operatively to the CSRU for Swan placement. He had dialysis this morning prior to admission. He has ESRD and is on dialysis for the past 2 years. He is also anticipating renal transplant in the near future and his wife is the planned donor. Catheterization prior to this admission showed elevated RA pressures (17) with PA 92/38, and wedge 40, CI 1.7, EF 42% with effective EF 29%. He also had global HK, mod. MR, mod. TR, mild PR. Past Medical History: severe MR [**Last Name (Titles) **]. HTN CHF HTN IDDM mild GERD ESRD ( on HD 2 years) s/p R index finger amp. ? eye surgery Social History: Mmarried. No ETOH/tobacco/drugs Family History: No premature CAD Physical Exam: General - NAD HEENT - PERRL, EOMI, sclera non-iceric Neuro - CN II-XII grossly intact, MAE [**6-10**] strengths Lungs - CTA bilaterally Heart - RRR with 2/6 diastolic murmur abd - soft, nt, nd, + BS Ext - no peripheral edema, DP 2+ nilat. with warm extrems Pertinent Results: [**2173-11-19**] 08:00AM BLOOD WBC-9.4 RBC-3.48* Hgb-11.2* Hct-33.1* MCV-95 MCH-32.2* MCHC-33.8 RDW-15.1 Plt Ct-365 [**2173-11-10**] 03:32PM BLOOD WBC-11.0 RBC-3.73* Hgb-12.9* Hct-37.3* MCV-100* MCH-34.6* MCHC-34.6 RDW-14.5 Plt Ct-177 [**2173-11-19**] 08:00AM BLOOD PT-14.3* PTT-29.9 INR(PT)-1.4 [**2173-11-19**] 08:00AM BLOOD Plt Ct-365 [**2173-11-19**] 08:00AM BLOOD Glucose-143* UreaN-51* Creat-9.3*# Na-134 K-5.2* Cl-92* HCO3-25 AnGap-22* [**2173-11-10**] 03:32PM BLOOD ALT-22 AST-26 AlkPhos-141* TotBili-0.7 [**2173-11-10**] 03:32PM BLOOD Glucose-47* UreaN-25* Creat-6.5* Na-141 K-4.5 Cl-94* HCO3-36* AnGap-16 [**2173-11-19**] 08:00AM BLOOD Calcium-9.7 Phos-7.5*# Mg-2.7* [**2173-11-10**] 06:27PM BLOOD freeCa-1.09* Brief Hospital Course: Just prior to admission, patient underwent hemodialysis. He was then directly admitted to floor, then to the CSRU for Swan placement and evaluation of pressures and volume status. He was subsequently started on a Nitro drip for pulmonary hypertension. He remained hemodynamically stable. The following day, he underwent a MV repair with Dr. [**Last Name (STitle) **], and was transferred to CSRU in stable condition on epinephrine, milrinone, insulin, and propofol drips. He awoke neurologically intact and was extubated on POD#2. He continued on his regular dialysis schedule. His inotropic support was gradually weaned over several days. An echocardiogram on POD#4 revealed only trivial MR and a LVEF of 55% - improved from prior studies. He otherwise maintained stable hemodynamics and remained in a normal sinus rhythm. Medical therapy was optimized and he was transferred to the floor on POD#7. He was followed closely by the renal and cardiology services. He worked daily with physical therapy. He continued to make clinical improvements and was cleared for discharge to home on POD#8. At time of discharge, he was tolerating room air and his chest x-ray showed improved aeration and CHF with only a small residual left pleural effusion. He had adequate pain control with Dilaudid. Medications on Admission: digoxin 0.125 mg daily glipizide 10 mg daily insulin NPH 10 units [**Hospital1 **] Avandia 4 mg daily lopressor 75 mg [**Hospital1 **] norvasc trandolapril 4 mg daily zantac 150 mg daily nephrocap one cap daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed. Disp:*40 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 8. Zestril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 9. PhosLo 667 mg Tablet Sig: Two (2) Tablet PO qac. Disp:*60 Tablet(s)* Refills:*0* 10. Glucotrol XL 10 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO once a day. 11. Avandia 4 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: s/p MV Repair End stage renal disease/ hemodialysis Insulin dependent diabetes mellitus [**Hospital **]. Hypertension Congestive heart failure Hypertension Gastro-esoph. reflux disease Right upper extrem AV fistula Discharge Condition: good Discharge Instructions: no lotions, powders or creams on incision may shower, and pat wound dry no lifting greater than 10 pounds for 10 weeks no driving for one month Followup Instructions: see Dr. [**Last Name (STitle) 5456**] in [**2-7**] weeks see Dr. [**Last Name (STitle) **] in office at 4 weeks [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) **] 2 weeks Completed by:[**2173-12-13**]

[ "397.0", "403.91", "424.0", "530.81", "585.6", "250.01", "428.0" ]

icd9cm

[ [ [] ] ]

[ "00.13", "35.33", "39.95", "99.04", "39.61" ]

icd9pcs

[ [ [] ] ]

5206, 5264

2401, 3691

308, 398

5523, 5530

1656, 2378

5722, 5932

1346, 1364

3952, 5183

5285, 5502

3717, 3929

5554, 5699

1379, 1637

249, 270

426, 1134

1156, 1281

1297, 1330

112

173,177

54003

Discharge summary

report

Admission Date: [**2196-9-27**] Discharge Date: [**2196-9-29**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7934**] Chief Complaint: Altered MS [**First Name (Titles) **] [**Last Name (Titles) **] Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo M w/ PMH multiple mylemoa, with Plasmacytoma of left clavicle dx in [**6-18**] s/p xrt (last ~[**8-26**]) with recent admission ([**Date range (3) 110715**]) for dehydration and PNA presents with one day of altered MS [**First Name (Titles) **] [**Last Name (Titles) **]. Pt recently returned home from rehab 5 days ago after completing treatment for PNA with Vanc/Zosyn. . In ED, found to be hypotensive to 90's systolic which was responsive to fluids. Also febrile, w/ T 101. Labs notable for Hct down to 25 (from baseline 28-30), Cr elevated to 2.4 (from baseline 1.1-1.3), elevated trop/CKs. Pt was trace Guiac + on exam. CXR showed improved left upper lobe opacity. In [**Name (NI) **], pt received 2.5 L NS and one unit PRBC. Pt received one dose of Vanc and 1 dose zosyn. His ECG showed inferolateral ST depressions. Cardiology was called and felt that his troponin leak was due to septic shock and not an acute MI - they recommended treatment for [**Name (NI) **]. He was then transferred to the floor. Shortly after arriving on the floor, his BP dropped into the 70's systolic and MICU eval was requested. On arrival he was found to have SBP in the 70's and to be minimally responsive. His sats were in the low eighties. An ECG was repeated and he again had inferolateral ST depressions. He had one piv. NS was agressively started and a second PIV was placed and fluids given. He was put on a NRB and Sats were in the mid nineties, and a gas showed adequate oxygenation and ventilation. His blood pressure did not respond to IVF so he was started on Levophed through his lt. piv awaiting MICU transfer. Past Medical History: Past Onc Hx The patient was referred to Dr. [**Last Name (STitle) 410**] for a left clavicular mass in [**6-18**]. The patient had a history of fx in the left humerous. In early [**2196**], he developed a mass in his left shoulder. At first this was thought to be a deformity post-fracture but it continued to grow so it was decided to biopsy it. On needle biopsy [**2196-6-23**] the mass was found to be a plasmacytoma. An SPEP was done that showed an IgA lambda monoclonal protein and lambda light chains in the serum, a 24 hour urine and UPEP revealed that the patient excreted about 7300 mg per day of light chains per day. He was originally treated with decadron in [**6-18**]. He was being treated with XRT (last ~[**8-26**]). . PMHx Hypertension Coronary artery disease s/p MI [**2179**],[**2193**] Peptic ulcer s/p GIB Benign prostatic hypertrophy h/o temporal arteritis h/o pemphigoid h/o anemia h/o small bowel volvulus s/p appendectomy s/p status post inguinal hernia repair x2 h/o colonic polyps sigmoid diverticulosis Rheumatoid arthritis "sleepwalking" h/o neck problems (?). . PAST SURGICAL HISTORY: 1. s/p appendectomy 2. s/p status post inguinal hernia repair x2 Social History: The patient is married, lives in his own home. His son helps care for both he and his wife. [**Name (NI) **] previously worked as a psychoanalyst. He was in the army in World War II in [**Location (un) **]. He had no chemical or toxin exposure, no radiation exposure. Family History: Noncontributory Physical Exam: Vitals - T 99.1 (axillary), HR 113, BP 84/40 -> SBP 62, RR 18, O2 94% 2L NC General - pt moaning, non-responsive to verbal commands HEENT - CVS - distant heart sounds, appeared regular, tachycardic, no noted M/R/G Lungs - could not clearly ascultate [**3-17**] pt's moaning Abd - soft, + palpable aortic pulse, could not assess for tenderness, normoactive bowel sounds. G tube site with significant purulence. Ext - No LE edema b/l, bt. heel ulcerations, grade [**3-18**] neuro - awake, not alert, minimally responsive Pertinent Results: [**2196-9-27**] 02:30PM PT-13.6* PTT-33.5 INR(PT)-1.2* [**2196-9-27**] 02:30PM PLT SMR-NORMAL PLT COUNT-265 [**2196-9-27**] 02:30PM NEUTS-66 BANDS-4 LYMPHS-13* MONOS-6 EOS-8* BASOS-1 ATYPS-0 METAS-1* MYELOS-1* [**2196-9-27**] 02:30PM WBC-11.0 RBC-2.78* HGB-8.8* HCT-25.4* MCV-91 MCH-31.6 MCHC-34.5 RDW-15.5 [**2196-9-27**] 02:30PM CK-MB-10 MB INDX-2.1 cTropnT-2.67* [**2196-9-27**] 02:30PM GLUCOSE-84 UREA N-43* CREAT-2.4*# SODIUM-125* POTASSIUM-4.6 CHLORIDE-86* TOTAL CO2-30 ANION GAP-14 [**2196-9-27**] 02:45PM LACTATE-1.6 K+-4.7 [**2196-9-27**] 09:30PM CALCIUM-7.6* PHOSPHATE-4.5# MAGNESIUM-2.3 [**2196-9-27**] 09:30PM CK-MB-9 cTropnT-2.46* [**2196-9-27**] 11:25PM LACTATE-2.4* Brief Hospital Course: Pt is a [**Age over 90 **] yo man with MMP including multiple myeloma, with Plasmacytoma of left clavicle , s/p recent admission for dehydration and pna (d/ced [**2196-9-8**]) who was readmitted with [**Month/Day/Year **] and 1 day MS changes. On presentation to floor, pt hypotensive, low grade fever, unresponsive, therefore got MICU evaluation and pt was transferred to MICU. Upon transfer to the MICU, patient was intubated, started on levophed, and started on vancomycin, cefepime, and flagyl for antibiotic coverage. Approximately 24 hours after admission, patient developed tachycardia and [**Month/Day/Year **] with mottled and cool extremities. [**Name (NI) **] son (his HCP) was called with initial decline in vital signs and pt's code status was then changed from full code to do not administer CPR. Patient then received a total of 3L NS, levophed was increased, 3 amps bicarb were administered, patient was started on dopamine, and patient was administered epinephrine. Patient's BP then diminished to 0 and heart rhythm was PEA. Time of death was called at 12:15am on [**2196-9-29**]. Medications on Admission: Prednisone 5mg QD Protonix 40 QD Isosorbide mononitrate CR 30mg QD Tramadol PRN Aricept 10 QD Nameda 10 [**Name2 (NI) 244**] ASA Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: 1. Septic Shock 2. Pneumonia Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None

[ "785.52", "414.01", "276.51", "518.81", "203.00", "038.9", "995.92", "486", "410.71", "585.6", "600.00", "584.9", "403.91" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "38.91", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

6130, 6139

4820, 5922

326, 332

6211, 6220

4095, 4797

6273, 6280

3523, 3540

6101, 6107

6160, 6190

5948, 6078

6244, 6250

3151, 3218

3555, 4076

223, 288

360, 2014

2036, 3128

3234, 3507

72,357

113,280

40908

Discharge summary

report

Admission Date: [**2161-4-22**] Discharge Date: [**2161-4-23**] Date of Birth: [**2128-10-6**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: S/p arrest Major Surgical or Invasive Procedure: Arterial line placement History of Present Illness: 32 yo M with PMH of alcohol abuse who is admitted s/p asysolic arrest at home. . Per his family, around 8:45pm last night they heard a thump and found the patient face down in the bathroom. Bystander CPR was started immediately and EMS arrived 5 minutes later. He was found to be in asystole. He was collared, boarded, intubated and ACLS initiated. Per cardiology fellow note, on route to OSH, EKG showed torsades at 9:07 s/p shock into VF/VT. In total, he received 3 of Epi enroute to [**Hospital1 **] and was asystolic on arrival there at 21:21. He was intubated, not sedated and was comatose on arrival with no voluntary movements and fixed and dilated pupils. He received 3 epi, 2 atropine 1 of bicarb and was reportedly briefly in PEA, followed by VF and afib with "diffuse ischemia" by 21:24. He was started on lidocaine gtt at that time, followed for neo gtt for systolic blood pressures in the 60s. By 22:00 he was in sinus tachycardia. The multiple EKGs from [**Hospital1 **] reveal a lot of baseline artifact but 21:48 reveals sinus tach with STE in AVR, V1 with diffuse st depressions inferolaterally. Labs there signifcant for trop <0.06, WBC 12, h/H 11.6/35.6, K4.5 and Creat 0.9. AST 412ALT 160. Mg was not ordered. The arctic protocol was initiated and he was transferred to [**Hospital1 18**] for further care. . In the ED, initial vital signs were BP 169/117, HR 120, RR 22, O2 sat 100% on RA. Patient was unresponsive off sedation and hypertensive even off neo. Temperature was 34 degrees at 23:50. He received 2 grams of magnesium and 100 thiamine. Initial labs showed a hct of 35.9 with a MCV of 101, WBC of 7.3. Urine and serum tox were negative. LFTs were notable for ALT 254, AST 859, AP 248, Tbili 1.7. Lactate was 12. 5, CK was 782, troponin 0.04. ABG showed pH7.30 pCO230 pO2>600 HCO315, with repeat lactate of 8.6. CT head showed occipital sub-galeal hemorrhage and loss of the [**Doctor Last Name 352**]-white matter distinction suggestive of anoxic brain injury. CT torso showed rib fractures anteriorly but no acute intra-abdominal process. He was seen by the cardiac arrest team who recommended inducing hypothermia to 33 degrees, elevating HOB to >30 degrees to minimize ICP and keeping pCO2 around 35-45. He was then seen by cardiology who recommending d/c-ing the lidocaine drip. He was admitted to the CCU for further management. His vital signs on transfer were BP 198/134 HR84 RR23 O2 sat 100% on AC ventilation. He has 2IOs and 2PIVs for access. . In the CCU, patient was intubated and unresponsive. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: Alcohol abuse Social History: From [**Country 2045**]. Lives with parents in [**Location (un) 5110**], MA. -Tobacco history: None per family. -ETOH: Extensive. Family not certain as to how much he drinks, but endorse excessive drinking for at least the past 10 years. -Illicit drugs: None per family. Family History: No family history of early MI, arrhythmia, cardiomyopathies, syncope (except in the setting of alcohol use) or sudden cardiac death; otherwise non-contributory. Physical Exam: PHYSICAL EXAMINATION: VS: T=91 (on artic sun) BP=188/134 HR=78 RR=23 O2 sat=35% GENERAL: well developed young man, unresponsive, not following commands HEENT: NCAT. Sclera anicteric. Pupils 3 -->2 mm b/l. endotracheal and orogastric tubes in place. NECK: C-collar on; appears to be extended CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. Active BS. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Cool to touch. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Neuro: Decorticate posturing; pupils 3-->2 mm b/l; no corneal or gag reflex w/ suctioning; spontaneous movements of the eyelids; non-purposeful movement of upper extremities; no observed movement of LEs; hyporeflexive throughout Pertinent Results: ADMISSION LABS: [**2161-4-22**] 12:10AM WBC-7.3 RBC-3.57* HGB-12.3* HCT-35.9* MCV-101* MCH-34.4* MCHC-34.2 RDW-15.0 [**2161-4-22**] 12:10AM NEUTS-83* BANDS-3 LYMPHS-12* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2161-4-22**] 12:10AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2161-4-22**] 12:10AM GLUCOSE-211* UREA N-10 CREAT-0.9 SODIUM-126* POTASSIUM-4.6 CHLORIDE-91* TOTAL CO2-10* ANION GAP-30* [**2161-4-22**] 12:10AM ALT(SGPT)-254* AST(SGOT)-859* CK(CPK)-782* ALK PHOS-248* TOT BILI-1.7* [**2161-4-22**] 12:10AM LIPASE-47 [**2161-4-22**] 12:10AM ALBUMIN-3.8 CALCIUM-9.4 PHOSPHATE-6.3* MAGNESIUM-32* [**2161-4-22**] 12:10AM cTropnT-0.04* [**2161-4-22**] 12:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2161-4-22**] 12:10AM URINE HOURS-RANDOM [**2161-4-22**] 12:10AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2161-4-22**] 12:10AM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.006 [**2161-4-22**] 12:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2161-4-22**] 12:10AM URINE RBC-8* WBC-10* BACTERIA-FEW YEAST-NONE EPI-0 [**2161-4-22**] 12:11AM LACTATE-12.6* [**2161-4-22**] 01:59AM LACTATE-10.2* [**2161-4-22**] 01:59AM cTropnT-0.10* [**2161-4-22**] 02:10AM LACTATE-8.6* IMAGING: [**2161-4-22**] EKG: Sinus tachycardia. Non-specific ST-T wave changes. No previous tracing available for comparison. [**2161-4-22**] CXR: Mild pulmonary vascular engorgement. [**2161-4-22**] TTE: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate to severe global left ventricular hypokinesis (LVEF = 30-35%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size is normal. with borderline normal free wall function. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderate to severe global hypokinesis with evidence of spontaneous echo contrast in left ventricle. No significant valvular abnormality seen. [**2161-4-22**] EEG: IMPRESSION: This is an abnormal continuous EEG due to the presence of a burst suppression pattern, with runs of high amplitude fast activity, occurring at a 0.5-1 Hz periodicity, in runs up to 8 seconds, separated by extremely prolonged periods of suppression up to 2 minutes. This pattern is consistent with a severe diffuse encephalopathy, likely secondary to hypothermia. However, as the patient is being rewarmed, the bursts gradually become lower voltage and the interburst intervals shorten, indicating a worsening encephalopathy. This pattern is seen after severe diffuse hypoxic injury, and portends a poor prognosis. There are no epileptiform features seen. [**2161-4-22**] CT HEAD: 1. Poor [**Doctor Last Name 352**]-white differentiation, diffusely, which, in the setting of cardiac arrest, is very concerning for global hypoxic-ischemic injury. 2. No hemorrhage. 3. Large occipital scalp subgaleal hematoma, with diffuse edema in the extracranial soft tissues. [**2161-4-22**] CT Torso: 1. No acute findings to explain the patient's decompensation. 2. Fatty liver without focal lesions identified. 3. Pulmonary atelectasis. [**2161-4-23**] EEG: IMPRESSION: This is an abnormal continuous EEG due to the presence of a burst suppression pattern, with runs of bursts of low voltage theta activity, separated by extremely prolonged periods of suppression up to 1 minute. As the patient is being rewarmed, the bursts gradually become lower voltage, and the interburst intervals lengthen indicating a worsening encephalopathy. This pattern is consistent with severe diffuse encephalopathy, likely secondary to the patients known history of severe diffuse hypoxic injury, and portends an extremely poor prognosis. Between 1 pm and 5:30 pm, there is significant shivering artifact. There are no epileptiform features seen. The study is discontinued at 7:30 pm. Brief Hospital Course: 32 year old M with history of alcohol abuse found down s/p asystolic cardiac arrest. . # S/P Cardiac Arrest: Patient found asystolic in the field with ROSC after ACLS. Initial rhythm strips were suggestive of torsades and patient's EKG showed a long QT (between 460 and 490 depending on the rate and EKG). Cooling was started at the OSH, and transferred to [**Hospital1 18**] for further management. On arrival, was unresponsive and comatose in absence of sedating agents, with CT head suggestive of global anoxic injury. Cooling process was continued at [**Hospital1 18**], but EEG protended poor prognosis. He was seen by EP and neurology. EP deferred futher workup and evaluation pending neurologic recovery. Patient was rewarmed per protocol and repeat EEG consistent with severe diffuse encephalopathy, likely secondary to the patients known history of severe diffuse hypoxic injury, portending an extremely poor prognosis. Neurology felt that pending re-evaluation after rewarming he would be brain dead. A family meeting was held, and the patient's family decided to terminally extubate the patient. He expired shortly thereafter. Medications on Admission: None Discharge Medications: None- Expired Discharge Disposition: Expired Discharge Diagnosis: EXPIRED Discharge Condition: EXPIRED Discharge Instructions: EXPIRED Followup Instructions: EXPIRED Completed by:[**2161-4-24**]

[ "807.00", "348.5", "V49.86", "305.00", "570", "431", "427.31", "287.5", "289.89", "427.41", "348.1", "E879.8", "427.5", "518.81", "796.2" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

10442, 10451

9210, 10349

323, 348

10502, 10511

4730, 4730

10567, 10605

3481, 3644

10404, 10419

10472, 10481

10375, 10381

10535, 10544

3659, 3659

3057, 3130

3681, 4711

273, 285

376, 2927

8009, 9187

4747, 8000

3161, 3177

2971, 3037

3193, 3465

54,882

188,796

51647

Discharge summary

report

Admission Date: [**2182-8-2**] Discharge Date: [**2182-8-3**] Date of Birth: [**2126-12-27**] Sex: F Service: NEUROSURGERY Allergies: No Allergies/ADRs on File Attending:[**First Name3 (LF) 1835**] Chief Complaint: SAH Major Surgical or Invasive Procedure: Bilateral EVD Placement History of Present Illness: Mrs. [**Last Name (STitle) **] is a very unfortunate 55 yo woman with unknown past medical history who presents with a massive SAH. She was apparently in her USOH until this evening when she was at a restaurant, complained of headache and said that she wanted to go to the bathroom. When she didn't come out, she was found down in the bathroom. Past Medical History: Unknown Social History: Unknown Family History: Unknown Physical Exam: Upon arriving here, she was seemingly moving all four extremities and was oriented to name. She then vomited, prompting her to be intubated. Head CT showed thick SAH with possible left Acomm aneurysm, with significant IVH and hydro, casting of the 4th ventricle and obscuration of the basal cisterns. When I saw her, 5 minutes off of propofol, she was extensor posturing. Pertinent Results: CT Head: IMPRESSION: Hemorrhage distending entire ventricular system and also subarachnoid hemorrhage in the cisterns, along bifrontoparietal sulci and interhemispheric fissures, with cerebral edema and evolving hydrocephalus. 13-mm left frontal relatively focal hematoma suggestive of aneurysm rupture, as confirmed on subsequent CTA, with a source aneurysm arising from the left supraclinoid ICA. CTA Head: IMPRESSION: 1. 10 x 8 mm aneurysm, arising dorsally from the left supraclinoid carotid artery surrounding by hematoma, likely indicating recent rupture. 2. The major vessels in the circle of [**Location (un) 431**] are patent, including the basilar artery. The patient is status post interval placement of bilateral frontal approach intraventricular shunt catheters, with tips terminating in the lateral ventricles, intraventricular and diffuse subarachnoid hemorrhage, not significantly changed since the preceding head CT. Brief Hospital Course: Mrs. [**Last Name (STitle) **] is a very unfortunate 55 yo woman with unknown past medical history who presents with a massive SAH. She was apparently in her USOH until this evening when she was at a restaurant, complained of headache and said that she wanted to go to the bathroom. When she didn't come out, she was found down in the bathroom. Upon arriving here, she was seemingly moving all four extremities and was oriented to name. She then vomited, prompting her to be intubated. Head CT showed thick SAH with possible left Acomm aneurysm, with significant IVH and hydro, casting of the 4th ventricle and obscuration of the basal cisterns. When I saw her, 5 minutes off of propofol, she was extensor posturing. Dr. [**Last Name (STitle) **] immediately came to patient's bedside and placed 2 EVDs (one on each side), one of which is at 10 and the other of which is currently open. With placement of the EVD, it was noted that 200cc of fresh blood came out. A CTA was performed right after this and showed a clear left Acomm vs. A2 aneurysm. Subsequent to the CTA Dr. [**Last Name (STitle) **] [**Name (STitle) 107004**] the patient and found her to have fixed and dilated pupils. Dr. [**Last Name (STitle) **] then felt that angiography would be too risky given her active herniation. At this time, the patient has a dismal prognosis. As a result, we will pursue end-of-life discussions with the family and elicit their wishes. Patient pronounced at 4:19 a.m. Proximate cause of death was cardiopulmonary arrest. Main cause of death was transtentorial cerebral herniation secondary to subarrachnoid hemorrhage. Examination shows fixed and dilated pupils. No corneals, no gag, no Doll's. No pulse, no breath sounds, no heart sounds. Medications on Admission: Unknown Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: SAH Hydrocephalus Aneurysm Cerebral edema Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2182-9-3**]

[ "V49.86", "430", "070.70", "348.4" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "02.21" ]

icd9pcs

[ [ [] ] ]

3981, 3990

2145, 3891

293, 318

4075, 4084

1181, 1181

4140, 4177

764, 773

3949, 3958

4011, 4054

3917, 3926

4108, 4117

788, 1162

250, 255

346, 692

1190, 2122

714, 723

739, 748

47,790

127,428

53658

Discharge summary

report

Admission Date: [**2121-5-5**] Discharge Date: [**2121-5-8**] Date of Birth: [**2048-5-29**] Sex: F Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 11344**] Chief Complaint: seizure Major Surgical or Invasive Procedure: intubation and extubation History of Present Illness: Ms. [**Known lastname **] is intubated and unable to provide any history; history obtained from speaking with ED staff and review of medical record. Ms. [**Known lastname **] is a 72 year-old woman with PMH significant for seizure disorder, metastatic [**Known lastname 499**] cancer to the liver s/p colostomy and urostomy (~6 years ago, no longer on chemo), and recent discharge from [**Hospital1 18**] for sepsis (due to polymicrobial bacteremia- VRE, strep viridans and due to cholangitis/biliary obstruction; discharged [**5-2**] with plans to complete course of Cipro- 4 more days, Flagyl- 4 more days, and [**Month/Year (2) **]- 11 more days) who presents with activity concerning for seizure. She was found in her facility to be unresponsive with food in her mouth; she was reportedly presumed to be post-ictal after a seizure, though there is no report of witnessed seizure activity. Upon arrival to the ED, she was initially noted by ED staff to be unresponsive with eyes deviated left and extensor posturing in the upper extremities. She was given Ativan 2 mg for presumed ongoing seizure activity; after this, her eyes were noted to become roving and were no longer deviated, though she remained unresponsive. She was given another dose of Ativan, this time 1 mg but remained unresponsive, she she was intubated for airway protection given her persistent unresponsive state. Regarding her prior seizure history, according to her daughter, she does not see a Neurologist; etiology of seizures unknown to daughter, previously on Dilantin, but was told not working so switched to Keppra. Her last seizure, per her daughter, was a few months ago and semiology includes eye deviation to the left, unresponsiveness and generalized convulsive activity. Past Medical History: -Sepsis-due to polymicrobial bacteremia (VRE, strep viridans) and due to cholangitis/biliary obstruction [admitted [**Date range (1) 110193**]] -s/p [**Date range (1) **] on [**4-27**]- finding biliary pus and a large obstructing stone that could not be removed. A plastic stent was placed. -metastatic [**Month/Day (4) 499**] cancer with metastatis to the liver, off chemo for at least 6 months. S/p surgery resection colostomy and urostomy -recurrent choledocholithiasis -seizure disorder -depression/anxiety -recurrent UTI Social History: Currently resides at [**Hospital 169**] Center- [**First Name4 (NamePattern1) 6107**] [**Last Name (NamePattern1) **]. No history smoking, ETOH or illicit drug use. Family History: Mother with [**Name2 (NI) 499**] and breast cancer. Daughter with breast cancer. Physical Exam: At admission: Vitals: T: 96 P: 22 R: 22 BP: 139/81 SaO2: 98% (prior to intubation) General: laying in bed, intubated, sedated HEENT: no scleral icterus, ET tube in palce Neck: supple Pulmonary: lcta anteriorly b/l Cardiac: RRR, S1S2, no murmurs appreciated Abdomen: soft Extremities: warm, well perfused Neurologic: no eye opening. no commands. PERRL 5-->3 mm, but also with hippus. Roving eye movments; eye movements full with no gaze deviation. + corneals. +cough/gag. Normal tone. Moving lower extremities spontaneously. Purposefully withdraws RUE to noxious stimulus. No withdrawal of LUE to noxious. Withdraws LE b/l to noxious stimuli. Grimmaces to noxious stimulation throughout. Reflexes 2+ and symmetric at biceps, brachioradialis and patellar. Unable to elicit ankle jerks. Extensor plantar response b/l. ******************* At discharge: Neuro: intact. no deficits Pertinent Results: [**2121-5-5**] 02:20PM BLOOD WBC-16.5*# RBC-3.27* Hgb-8.7* Hct-31.2*# MCV-95 MCH-26.5* MCHC-27.8* RDW-14.3 Plt Ct-586*# [**2121-5-5**] 02:20PM BLOOD Neuts-83.5* Lymphs-13.5* Monos-2.2 Eos-0.4 Baso-0.4 [**2121-5-8**] 05:30AM BLOOD WBC-6.5 RBC-2.99* Hgb-8.3* Hct-28.2* MCV-94 MCH-27.8 MCHC-29.5* RDW-16.1* Plt Ct-314 [**2121-5-5**] 02:20PM BLOOD Glucose-209* UreaN-15 Creat-0.9 Na-135 K-4.5 Cl-104 HCO3-13* AnGap-23* [**2121-5-8**] 05:30AM BLOOD Glucose-126* UreaN-11 Creat-0.8 Na-138 K-4.2 Cl-110* HCO3-20* AnGap-12 [**2121-5-6**] 02:56AM BLOOD ALT-18 AST-32 AlkPhos-551* TotBili-1.3 [**2121-5-5**] 02:20PM BLOOD Calcium-8.5 Phos-4.0 Mg-2.2 [**2121-5-6**] 02:56AM BLOOD Albumin-3.7 Calcium-8.1* Phos-3.0 Mg-1.9 [**2121-5-5**] 03:43PM BLOOD Type-ART Rates-22/0 Tidal V-400 PEEP-5 FiO2-100 pO2-395* pCO2-33* pH-7.33* calTCO2-18* Base XS--7 AADO2-292 REQ O2-54 -ASSIST/CON Intubat-INTUBATED [**2121-5-5**] 03:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008 [**2121-5-5**] 03:00PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM [**2121-5-5**] 03:005/14/12 3:00 pm URINE SOURCE: CVS. **FINAL REPORT [**2121-5-6**]** URINE CULTURE (Final [**2121-5-6**]): YEAST. 10,000-100,000 ORGANISMS/ML.. 0PM URINE RBC-0 WBC-13* Bacteri-FEW Yeast-MANY Epi-0 [**2121-5-6**] 2:56 am MRSA SCREEN Source: Line-Porta cath. **FINAL REPORT [**2121-5-8**]** MRSA SCREEN (Final [**2121-5-8**]): No MRSA isolated. Blood cultures x 2 - no growth to date EEG: [**5-5**]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of a mild to moderate diffuse encephalopathy with extremely frequent paroxysmal bilaterally synchronous polyspike and high voltage sharp slow discharges. This activity was central and frontal in location. No sustained seizures, however, were recorded. [**5-6**]: IMPRESSION: This is an abnormal continuous EEG monitoring study because of frequent generalized bilaterally synchronus polyspike and wave epileptic discharges which are replaced by multifocal epileptiform discharges in the second half of the recording. These findings are indicative of diffuse cortical irritability, which gradually subsided through the course of the recording. In addition, background is diffusely slow and disorganized in the first half of the recording, which gradually improves to a mildly disorganized impersistent posterior dominant alpha rhythm toward the end of the recording. These findings are suggestive of a gradullay resolving mild encephalopathy with potential infectious, metabolic or toxic etiologies. No electrographic seizures are present in the recording. [**5-7**]: IMPRESSION: This is an abnormal continuous EEG monitoring study because of a few generalized bilaterally synchronus polyspike-and-wave epileptic discharges in the first few hours of the recording. However, later in the recording only multifocal epileptiform discharges are present. These findings are indicative of diffuse cortical irritability, which gradually subsided through the course of the recording. In addition, background is mildly slow and disorganized in the first half of the recording, which gradually improved to an organized posterior dominant alpha rhythm towards the end of the recording. These findings are suggestive of a mild encephalopathy with potential infectious, metabolic or toxic etiologies, which gradually resolved through the course of this recording. No electrographic seizures are present in this study. ECG: Sinus rhythm. Normal tracing. Compared to the previous tracing of [**2121-4-26**] the rate has slowed. Otherwise, no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 85 114 88 [**Telephone/Fax (2) 110194**] 66 CXR: FINDINGS: A frontal view of the chest was performed. An ET tube is seen with its tip 4.6 cm above the carina. An OG tube is seen with its distal port in the stomach. A biliary stent is seen. A left subclavian line terminates in the mid SVC. The cardiomediastinal, pleural and pulmonary structures are unremarkable. There is no consolidation to suggest pneumonia. There is no pleural effusion or pneumothorax seen. IMPRESSION: Appropriate position of the endotracheal tube. NCHCT: FINDINGS: There is no evidence of intra-axial or extra-axial hemorrhage, edema, mass effect or shift of normally midline structures. The [**Doctor Last Name 352**]-white matter interface is preserved without evidence of acute major vascular territorial infarct. The ventricles and sulci are slightly prominent but proportional consistent with age-related involutional changes. Atherosclerotic calcification of the bilateral carotid siphons and left vertebral arteries are noted. The orbits and globes are intact. A large right [**Doctor Last Name 13856**] bullosa is noted and appears clear. The remainder of the visualized paranasal sinuses, middle ear cavities and mastoid air cells are clear bilaterally. The bony calvaria appear intact. IMPRESSION: 1. No acute intracranial process, specifically no acute intracranial hemorrhage. 2. Mild global atrophy. MRI brain with and without contrast: *** UNAPPROVED (PRELIMINARY) REPORT *** Preliminary ReportINDICATION: 72-year-old woman with seizures. Evaluate for underlying Preliminary Reportdisorder. Preliminary ReportCOMPARISON: CT from [**2121-5-5**]. Preliminary ReportTECHNIQUE: Multiplanar, multisequence images of the head were performed with Preliminary Reportand without contrast. Preliminary ReportFINDINGS: Preliminary ReportThere is no evidence of infarct or hemorrhage. There is no abnormal Preliminary Reportenhancement. There are few bilateral subcortical and periventricular T2 FLAIR Preliminary Reporthyperintensities likely representing microangiopathic chronic ischemic Preliminary Reportchanges. There is a focus of subcortical T2 FLAIR hyperintensity in the right Preliminary Reportprecentral subcortical white matter on image 14, series 10, without evidence Preliminary Reportof abnormal enhancement which might represent an area of microangiopathic Preliminary Reportischemic changes and/or gliosis. There is no mass effect or midline shift. Preliminary ReportThere is diffuse volume loss, more evident in the frontal lobes. The major Preliminary Reportintracranial flow voids are preserved. The orbits are unremarkable. The Preliminary Reportparanasal sinuses are clear. There is a left cerebellar DVA. Preliminary ReportNote is made that images are degraded by motion. Preliminary ReportIMPRESSION: Preliminary Report1. No evidence of acute infarct or hemorrhage. Preliminary Report2. Bilateral subcortical and periventricular T2 FLAIR hyperintensities likely Preliminary Reportrepresenting microangiopathic chronic ischemic changes. There is a focus of Preliminary Reportincreased T2 FLAIR signal in the right precentral subcortical white matter Preliminary Reportwithout evidence of abnormal enhancement. Interval follow up is suggested if Preliminary Reportclinically warranted. Brief Hospital Course: Ms. [**Known lastname **] is a 72 year-old woman with PMH significant for seizure disorder (unknown type, no records available and patient and PCP unable to report any additional information), metastatic [**Known lastname 499**] cancer to the liver s/p colostomy and urostomy (~6 years ago, no longer on chemo), and recent discharge from [**Hospital1 18**] for sepsis ([**1-23**] polymicrobial bacteremia- VRE, strep viridans likely due to recurrent cholangitis/biliary obstruction; discharged [**5-2**] with plans to complete course of Cipro/Flagyl (for empiric coverage of GNR/Anerobes) and [**Month/Year (2) **] (for VRE/Strep) who presents with activity concerning for seizure. . On arrival to the ED she was given ativan 2mg and then 1 mg but remained unresponsive and was intubated in the ED for airway protection. She was then admitted to the NICU and quickly extubated. . # Neuro: . Continuous EEG monitoring was initiated and has revealed ongoing generalized epileptiform discharges despite her home dose of Keppra 500mg [**Hospital1 **]. Keppra was increased and good control was achieved with Keppra 1g po bid and she was continued on this dose without adverse effects. They patient had no further events during this admission. . The most likely cause of her seizure at rehab was thought to be the seizure threshold lowering potential of her Abx regimen "Cipro/Flagyl". Given that she had completed a 9 of 10 day course for empiric treatment, these were not continued on admission (ID consulted and agreed). A brain MRI was done to ensure no new mass lesions as a cause for seizure. Her PCP was [**Name (NI) 653**] who reported brain imaging within the past year showed no cause for seizures and that she had been on the Keppra for an unclear amount of time. . # ID: continued [**Name (NI) **] for VRE/Strep viridans. Will continue treating until 5/22 per last discharge summary. . # Heme: chronic anemia with high MCV, anemia chronic disease + iron deficiency? continued iron supplementation. There was no signs or blood loss. . # GI: Given her increased arousal, she passed a bedside swallow eval. She was maintained on Famotidine as GI prophylaxis. LFTs were checked given recent transaminitis and these were in the normal range. . # DVT proph: Maintained on Hep SQ # Code: remained Full Code . Medications on Admission: -B12 1000 mcg daily -Ferrous Sulfate 325 mg daily -Prochlorperazine 10 mg daily -Venlafaxine 75 mg daily -Clonazepam 0.5 mg [**Hospital1 **] -Colace 100 mg [**Hospital1 **] -Keppra 500 mg [**Hospital1 **] -Zofran 4 mg q8h prn nausea -[**Hospital1 **] 600 mg [**Hospital1 **] x 11 days (starting [**5-2**]) -Cipro 500 mg q12h x 4 days (starting [**5-2**]) -Metronidazole 500 mg q8h x 4 days (starting [**5-2**]) Discharge Medications: 1. [**Month/Year (2) 11958**] 600 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days: please continue treatment until [**2121-5-13**]. monitor for serotonin syndrome. 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 3. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. venlafaxine 75 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 10. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 11. Outpatient Lab Work please check a CBC weekly while on [**Month/Day/Year **]. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - [**First Name4 (NamePattern1) 6107**] [**Last Name (NamePattern1) **] - [**Location (un) 3786**] Discharge Diagnosis: seizure cholangitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro: No deficits Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to the hospital after having a seizure. Due to concern for your respiratory status, you were briefly intubated. Since extubation you have done well. It is likely that your seizure was related to the antiobiotics you were on, lowering your seizure threshold. We increased your antiseizure medicine, Keppra, to 1gram by mouth twice daily. Those antibiotics were stopped and considered completed since you only had 1 more day left. Please continue [**Known lastname 11958**] 600mg po twice daily until [**5-13**], as previously instructed. During your stay we did a MRI of your brain to look for any other cause of seizures but this did not show any cause. Followup Instructions: Please follow up in the [**Hospital 18**] [**Hospital 875**] clinic with Dr. [**Last Name (STitle) 851**] on [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 860**] Bldg, [**Location (un) **]. [**6-17**] at 8am. Please call [**Telephone/Fax (1) 110195**] if you need to reschedule. Please follow up at your previously scheduled appointment: Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2121-5-15**] 3:45

[ "V10.05", "280.9", "V16.3", "576.1", "995.91", "311", "V16.0", "V09.80", "V44.3", "V13.02", "574.50", "300.00", "285.29", "V87.41", "288.60", "197.7", "V44.6", "038.0", "345.3" ]

icd9cm

[ [ [] ] ]

[ "96.71", "00.14", "96.04" ]

icd9pcs

[ [ [] ] ]

14786, 14940

10963, 13276

280, 308

15004, 15004

3849, 10940

15902, 16422

2851, 2934

13738, 14763

14961, 14983

13302, 13715

15174, 15879

2949, 3788

3802, 3830

233, 242

336, 2101

15019, 15150

2123, 2652

2668, 2835

29,921

143,151

43463

Discharge summary

report

Admission Date: [**2185-3-1**] Discharge Date: [**2185-3-6**] Date of Birth: [**2128-7-4**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: [**3-22**] week history of progressive exertional dyspnea. He was also experiencing PND and intermittent night sweats. Major Surgical or Invasive Procedure: s/p AVR(St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **].)/CABGx1(LIMA->LAD) [**3-2**] History of Present Illness: This 56 year old gentleman has a history significant for HIV infection and strep aortic valve endocarditis in [**2184-7-18**]. He completed a 4 week course of ceftriaxone. He was seen in follow up in [**Month (only) 404**] and at that time reported a [**3-22**] week history of progressive exertional dyspnea. He was also experiencing PND and intermittent night sweats. He was referred for an echo (as noted below) that demonstrated progressive dilation of his left ventricular cavity, an eccentric jet of moderate to severe, 3+AR and a preserved EF. He was referred for cardiology consultation with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] who recommended evaluation by Dr. [**Last Name (STitle) 93530**] [**Name (STitle) **] for surgical valve replacement Past Medical History: HIV ( diagnosed [**2174**], last CD4 count 723 on [**6-25**], no opportunistic infections) Depression Social History: Mr. [**Known lastname 93531**] lives a friend [**Name (NI) **] approximately 1 alcoholic beverage daily No history of tobacco History of inhaled cocaine Denies recent sexual activity. Works in managerial position at Bayside Expo Center Family History: Non-contributory Physical Exam: a/o grossly intact supple farom cta rrr pos bs sternal inc c/d/i palp pulses Pertinent Results: [**2185-3-6**] 07:30AM BLOOD WBC-4.6 RBC-3.37* Hgb-9.4* Hct-28.3* MCV-84 MCH-28.0 MCHC-33.3 RDW-14.1 Plt Ct-230 [**2185-3-6**] 07:30AM BLOOD PT-21.6* PTT-45.7* INR(PT)-2.1* [**2185-3-6**] 07:30AM BLOOD Glucose-101 UreaN-27* Creat-0.9 Na-131* K-4.0 Cl-98 HCO3-28 AnGap-9 [**2185-3-6**] 07:30AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.4 URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-<1.005 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2185-3-2**] 11:31 am TISSUE AORTIC VALVE LEAFLET. GRAM STAIN (Final [**2185-3-2**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [**2185-3-5**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Coronary Angiography COMMENTS: 1. Coronary angiography of this right dominant system revealed single vessel coronary artery disease. The LMCA had mild plaquing. The LAD had a 50% distal stenosis. The LCx and RCA had mild luminal irregularities without angiographically evident flow limiting stenosis. 2. Resting hemodynamics revealed elevated right and left sided filling pressures, with RVEDP of 12 mm Hg and LVEDP of 32 mm Hg. The mean PCWP was elevated at 24 mm Hg. Pulmonary arterial systolic pressure was elevated at 43 mm Hg. Systemic arterial pressures were normal with aortic systolic pressure of 128 mm Hg. Pulse pressure was widened at 73 mm Hg. Cardiac index was depressed at 1.9 l/min/m2. 3. Left ventriculography revealed no mitral regurgitation. The LVEF was 40% with global hypokinesis. 4. Supravalvular aortography revealed 4+ aortic regurgitation. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Severe aortic regurgitation. 3. Moderate left ventricular systolic dysfunction. 4. Biventricular diastolic dysfunction. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.3 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 35% to 40% >= 55% Aorta - Ascending: *3.7 cm <= 3.4 cm Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm Aortic Valve - Peak Gradient: 18 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 12 mm Hg Aortic Valve - LVOT diam: 2.2 cm Aortic Valve - Valve Area: *1.8 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Dilated LA. Mild spontaneous echo contrast in the LAA. Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mild spontaneous echo contrast in the body of the RA. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. Prominent Eustachian valve (normal variant). LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Moderately dilated LV cavity. Moderate global LV hypokinesis. Moderately depressed LVEF. RIGHT VENTRICLE: Moderate global RV free wall hypokinesis. AORTA: Focal calcifications in aortic root. Mildly dilated ascending aorta. Focal calcifications in ascending aorta. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve leaflets. Systolic doming of aortic valve leaflets. Aortic leaflet prolapse. No AS. Severe (4+) AR. Eccentric AR jet directed toward the anterior mitral leaflet. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Torn mitral chordae. No MS. Mild to moderate ([**1-19**]+) MR. TRICUSPID VALVE: Tricuspid valve not well visualized. Mild to moderate [[**1-19**]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions PRE CPB The left atrium is dilated. Mild spontaneous echo contrast is present in the left atrial appendage. No thrombus is seen in the left atrial appendage. Mild spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate global left ventricular hypokinesis (LVEF = 35-40 %). The right ventricle displays moderate global free wall hypokinesis. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The number of aortic valve leaflets cannot be determined - suspect 3 but can not rule out commissural fusion. The aortic valve leaflets are moderately thickened. There is systolic doming of the aortic valve leaflets. The right coronary leaflet displays mild prolapse. There is no aortic valve stenosis. Severe (4+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. A likely torn mitral chordae is seen in the left ventricular cavity. Mild to moderate ([**1-19**]+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST CPB The patient is receiving epinephrine by infusion. Biventricular systolic function is improved. Right ventricular free wall motion is normal and left ventricular systolic function is about 55%. There is septal dysynchrony most likely secondary to ventricular pacing. There is a bileaflet prosthesis in the aortic position. It appears well seated. The leaflets are very poorly seen and not much comment can be made on their function. The maximum gradient across the valve is 33 mm Hg with a mean gradient of 28 mm Hg. There is at least trace valvular aortic regurgitation. A small perivalvular jet can not be ruled out. The mitral regurgitation is improved, now mild. No other significant changes from pre bypass study. [**2185-3-4**] 5:38 PM CHEST (PA & LAT) The patient was extubated in the meantime interval with removal of the Swan-Ganz catheter, NG tube and mediastinal drains. The lung volumes are low on the current exam and this may contribute to a larger contour of the heart although close follow up is recommended to exclude the true cardiac enlargement which may be consistent with pericardial effusion. The post-sternotomy wires are intact. The replaced aortic valve is in expected location. The bibasal atelectases are mild to moderate most likely related to recent discontinuation of mechanical ventilation. No appreciable pneumothorax or sizable pleural effusion is seen. Brief Hospital Course: pt admitted underwent replacement of valve / no complications transfered to the cvicu. weaned off pressure support and extubated ct / foley / pw dc'd - no sequele heparin drip / coumadin started for valve. ptt and inr followed. hep dc when therapuetic pt had afib. amio bolus he converted. to nsr. pt to be on a amio taper pt cleared for home Medications on Admission: [**Last Name (un) 1724**]: ASA 81', Lasix 20' Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 10 days. Disp:*40 Tablet(s)* Refills:*0* 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): please taper as follows. Take 400 [**Hospital1 **] x 1 week. Then 200 [**Hospital1 **] x 1 week. then 200 qd thereafter. Disp:*120 Tablet(s)* Refills:*2* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 12. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO at bedtime: INR goal is 2.5 - 30. Your PCP will [**Name9 (PRE) **] your INR. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Endocarditis Aortic regurgitation HTN AFIB Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instrctions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, pat dry with a towel. Call our office for temp>101.5, sternal drainage. Do not use creams, lotions, or powders on wounds. Followup Instructions: Dr [**First Name (STitle) 807**] has agreed to follow your INR. You have to go to his office on [**3-8**] Tues to have a blood draw to check your INR. He will adjust it accordingly Make an appointment with Dr. [**First Name (STitle) 807**] for 2 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2185-3-6**]

[ "E878.1", "414.01", "V08", "997.1", "427.31", "311", "458.29", "424.1" ]

icd9cm

[ [ [] ] ]

[ "88.42", "37.22", "36.15", "88.72", "88.53", "88.56", "39.61", "35.22" ]

icd9pcs

[ [ [] ] ]

10929, 10987

8950, 9300

437, 550

11074, 11082

1895, 2604

11409, 11762

1765, 1783

9396, 10906

11008, 11053

9326, 9373

3548, 8927

11106, 11386

1798, 1876

279, 399

578, 1369

2640, 3531

1391, 1495

1511, 1749

10,417

127,455

24635

Discharge summary

report

Admission Date: [**2145-9-15**] Discharge Date: [**2145-9-17**] Date of Birth: [**2077-5-8**] Sex: M Service: MEDICINE Allergies: Vancomycin / Cefepime Attending:[**First Name3 (LF) 14385**] Chief Complaint: transferred from rehab for fever, hypotension, and recurrent pneumonias x 1 month Major Surgical or Invasive Procedure: intubation History of Present Illness: Pt is a 68 yo male with angioimmunoblastic T cell Lymphoma diagnosed [**9-26**] s/p 6 cycles of CHOP chemotherapy, Atrial fibrillation, COPD, CAD s/p MI, DM who presented to the ED from rehab with fever and hypotension. Pt had been discharged from [**Hospital1 **] to rehab on [**2145-7-29**] after presenting from OSH in [**Month (only) 116**] with increasing hypoxia, orthopnea, weakness, and increasing abdominal girth necessitating [**Hospital Unit Name 153**] admission; he remained in the ICU for 6 weeks with complicated hospital course. He was thought to be in decompensated CHF but did not improve with adequate diuresis. He was covered broadly for pneumonia with ceftriaxone, azithromycin, bactrim, vancomycin, and voriconazole. Was on Vanco/CTX/Azithro/Vori x 14 days([**Date range (1) 62192**]), on Zosyn for increased fever and secretions, 7 day course ([**7-1**]- [**7-8**]). Bronchoscopy/BAL was performed and was negative for AFB, PCP or bacterial microorganisms. Pt was trached and was able to be weaned off of the ventilator after many weeks intubated, but complicated by MRSA tracheobronchitis treated with Vanc and acute renal failure with peak Cr 4.6. Additionally, paracentesis at OSH prior to transfer was consistent with both malignancy and SBP and pt was treated with ceftriaxone. Pt was discharged to rehab on [**2145-7-29**] . Pt presented to the [**Hospital1 18**] ED today with reported BP in the 60s, temperature to 104 at rehab. VS in ED were: T: 96.8; HR: 115; BP: 99/60; RR: 18; O2: 96 4L. Per ED resident, pt was placed horizontally for central line and pressure fell to 65 systolic. He was unable to maintain secretion . In ED given, levaquin 500 IV x 1, flagyl 500 mg x 1, Decadron 10 IV x 1, Linezolid 600 mg IV x 1. Past month with recurrent febrile PNAs (MRSA [**8-22**], Chlamydia [**8-27**]) s/p numerous Abx treatments including doxycycline and linezolid (last dose 8/15), and treatment for C. diff on [**8-16**] treated with Flagyl. Past Medical History: 1. Angioimmunoblastic T cell lymphoma s/p 6 cycles of chop diagnosed in late [**2144-9-23**] due to symptoms of night sweats, weight loss and bulky adenopathy in the neck. 2 COPD with FEV1/FVC 124% predicted, FEV1 42%, FVC 34%, TLC 76 % predicted 3 atrial fibrillation 4. coronary artery disease 5. diabetes mellitus 6. CRI 7. Nephrolithiasis 8. CHF (EF variable reported 35-60%) Social History: retired and lives with his wife. previously smoked 1 ppd, no etoh or ivda. Originally from [**Country 6257**] Family History: mother died of trauma, father died of old age Physical Exam: VS: BP 107/76; HR 128; T ; 100% sat on GEN: Portuguese speaking male, sedated, intubated, responsive to verbal stimuli HEENT: Left subclavian line in place C/D/I. No appreciable JVD CV: distant HS, muffled by ventilator, S1 S2, irregularly irregular LUNGS: Coarse rhonchi B/L anterior fields ABD: soft, Nt. mild distension. BS normoactive. No appreciable organomegaly. EXT: Cold extremities. No C/C/E. Symmetric 1+ pulses Pertinent Results: [**2145-9-16**] 04:55PM BLOOD WBC-31.0* RBC-2.88* Hgb-8.6* Hct-27.5* MCV-95 MCH-29.7 MCHC-31.2 RDW-18.1* Plt Ct-428 [**2145-9-16**] 01:15PM BLOOD Neuts-61 Bands-22* Lymphs-6* Monos-0 Eos-7* Baso-0 Atyps-1* Metas-3* Myelos-0 [**2145-9-16**] 04:55PM BLOOD Plt Ct-428 [**2145-9-16**] 04:55PM BLOOD FDP-10-40 [**2145-9-16**] 04:55PM BLOOD Glucose-219* UreaN-26* Creat-1.4* Na-139 K-4.1 Cl-107 HCO3-11* AnGap-25* [**2145-9-16**] 01:15PM BLOOD ALT-5 AST-14 CK(CPK)-17* AlkPhos-195* TotBili-0.3 [**2145-9-16**] 04:55PM BLOOD Albumin-2.1* Calcium-6.6* Phos-4.5 Mg-1.7 [**2145-9-16**] 05:24PM BLOOD Type-ART Temp-38.3 Tidal V-600 PEEP-5 FiO2-100 pO2-78* pCO2-40 pH-7.12* calHCO3-14* Base XS--16 AADO2-601 REQ O2-97 [**2145-9-16**] 02:46PM BLOOD Type-ART Temp-39.9 Tidal V-600 pO2-95* pCO2-38* pH-7.18* calHCO3-15* Base XS--13 Intubat-INTUBATED Vent-CONTROLLED [**2145-9-16**] 01:02PM BLOOD Type-ART Temp-40.0 Rates-20/11 Tidal V-600 PEEP-5 FiO2-50 pO2-78* pCO2-42 pH-7.15* calHCO3-15* Base XS--13 -ASSIST/CON Intubat-INTUBATED Brief Hospital Course: Patient was admitted to the [**Hospital Unit Name 153**] intubated, on levophed for pressor support, with diagnosis of sepsis. CXR showed bilateral infiltrates and overall respiratory demise with WBC of 23.5. Given complicated medical history, recent [**Hospital Unit Name 153**] hopsitalization (> 2 months), and several respiratory infections (MRSA tracheobronchitis, chlamydia pneumonia), patient was started on Linezolid, Meropenem, and Ciprofloxacin for broad-spectrum antibiotics coverage. Voriconazole was added to regimen later in the morning. Given severity of condition, activated protein C was considered; however, patient had INR of 3.7, and given risks of bleeding, APC was not administered. Patient remained stable on pressor overnight. Diltiazem drip was started for control of Atrial fibrillation as patient was tachcardic to 140s. HR was [**Last Name (un) 4662**] under control, and patient remained stable on Diltiazem drip and Levophed drip that was weaned off by the morning. Insulin drip was started for tight glucose control. In the morning, patient went into rapid Atrial fibrilation that did not respond to Lopressor IV 5mg x 2. Esmolol drip was started. Patient became hypotensive to 80s requiring aggressive fluid resuscitation. Esmolol and Diltiazem drips were discontinued. Patient underwent electrical cardioversion. Phenylephrine drip was started for hypotension. Patient continued to be in pressure demise, and vasopressin was added. Patient also became hypoxic requiring increase in ventilator settings. ABG showed pH of 7.12. Patient's condition continued to deteriorate and required continued use of dual pressors and high ventilator settings, and patient expired later the next morning due to overwhelming sepsis and multi-organ failure. Medications on Admission: KCl 30mEq [**Hospital1 **] Ibuprofen PRN RISS Procrit [**Numeric Identifier **] U SC qweekly Warfarin 3mg PO qd Cardizem 240mg PO BID ASA EC 81mg PO qd Lopressor 75 PO TID Lasix 60mg PO BID Flagyl 500 TID 2nd course started [**2145-9-13**] Protonix 40mg PO qd Colace 100mg PO qd Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: Sepsis, Respiratory Failure, Pneumonia, Atrial Fibrillation, Hypotension Discharge Condition: deceased Completed by:[**2145-9-18**]

[ "486", "995.92", "202.11", "250.00", "414.01", "458.9", "584.9", "038.9", "593.9", "518.81", "427.31", "412", "428.0", "496" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "54.91", "00.14", "96.04", "99.62" ]

icd9pcs

[ [ [] ] ]

6629, 6638

4483, 6258

364, 376

6754, 6793

3441, 4460

2936, 2983

6588, 6606

6659, 6733

6284, 6565

2998, 3422

243, 326

404, 2385

2407, 2790

2806, 2920

9,576

103,193

8128

Discharge summary

report

Admission Date: [**2115-7-30**] Discharge Date: [**2115-8-2**] Date of Birth: [**2043-3-12**] Sex: F Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This is a 72-year-old woman with a history of malignant pericardial effusion who presents with a one month history of shortness of breath, orthopnea and cough. The patient presented in 12/99 to [**Hospital3 27946**] complaining of 6 week history of progressive shortness of breath, dyspnea on exertion and cough. Chest x-ray at that time showed a right lower lobe nodule and increased cardiac shadow. Chest CT, several lung nodules, carinal lymphadenopathy and a mass in her left neck with tracheal deviation. Echocardiogram demonstrated large pericardial effusion and mild tamponade for which she underwent pericardiocentesis. FNA and core needle biopsies of the left neck mass were positive for malignant cells consistent with poorly differentiated carcinoma suggestive of neuro endocrine origin, subsequently shown to be a small cell carcinoma. She has since undergone both chemotherapy and XRT. She had been relatively well since that time until about one month ago with the onset of shortness of breath gradually with development of a productive cough. Sputum was [**Known lastname **] and bloody. Over past week she notes increased shortness of breath, bilateral lower extremity edema and orthopnea/PND. She reports no fever, chills, night sweats, chest pain or palpitations. PAST MEDICAL HISTORY: Hyperthyroidism status post total thyroidectomy, cervical cancer status post conization and XRT in [**2106**], tuberculoma resection in [**2071**], status post Cesarean delivery, left neck mass with metastatic cancer of unknown primary. MEDICATIONS: On admission, Synthroid 0.125 mg q d, Multivitamins. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: She is afebrile, vital signs were stable. She was in no acute distress. Her neck was supple. She had no cervical lymphadenopathy. She had faint bibasilar crackles with decreased breath sounds on the right side greater than on the left. Her heart was regular. She had distant S1 and S2, no murmurs, rubs or gallops. Abdomen was soft, nontender, non distended. She had a well healed midline umbilical scar. There were no masses. Her extremities were warm and well perfused. She had 1+ pitting edema to the mid left calf. LABORATORY DATA: Unremarkable. EKG at the outside hospital showed sinus tachycardia at a heart rate of 103. There were no ischemic changes. Echocardiogram at the outside hospital demonstrated ejection fraction of approximately 60% and a large pericardial effusion with tamponade physiology. HOSPITAL COURSE: The patient was admitted and underwent an uncomplicated subxiphoid pericardiotomy with pericardial biopsy. The patient tolerated the procedure well. There were no complications and she was recovered in the CSRU. She had an uneventful stay in the ICU, was weaned to nasal prongs maintaining an SPO2 greater than 92%. Pericardial drain only had a scant amount of thin serosanguineous fluid. Her pain was well controlled with Percocet. She was ambulating out of bed to chair well with minimal assistance. Her arterial line was removed and her central venous line was capped and she was transferred to the floor on postoperative day #1. The remainder of her hospital course was uneventful. Her chest tube was discontinued on postoperative day #3 without complications. She was tolerating po well, making good urine, afebrile and was adequately maintaining her oxygen saturation. The results of the pathology specimen revealed a fragment of focally cauterized fibrous tissue with reactive mesothelial lining; no malignancy identified. The patient is instructed to follow-up with Dr. [**First Name (STitle) 10102**] in one week. She states that she does not currently have a primary care physician nor does she have an oncologist. The patient is encouraged to follow-up with her former oncologist, Dr. [**Last Name (STitle) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 13625**] Dictated By:[**Last Name (NamePattern1) 3801**] MEDQUIST36 D: [**2115-8-2**] 18:49 T: [**2115-8-5**] 21:11 JOB#: [**Job Number 28514**]

[ "162.8", "423.9", "198.89", "199.1", "V10.41" ]

icd9cm

[ [ [] ] ]

[ "34.09", "37.24", "37.12" ]

icd9pcs

[ [ [] ] ]

2705, 4314

1861, 2687

179, 1471

1494, 1838

7,049

177,238

27376

Discharge summary

report

Admission Date: [**2183-7-28**] Discharge Date: [**2183-8-2**] Date of Birth: [**2121-4-10**] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1232**] Chief Complaint: Hematuria. Major Surgical or Invasive Procedure: Left nephroureterectomy. History of Present Illness: Mr [**Known lastname **] is a 64 year old gentleman with a remote tobacco history who presented with hematuria. Initially, there were episodes of gross hematuria, left flank pain and left lower quadrant pain. Workup revealed suspicious urine cytology, positive NMP22 test. Cystoscopy and retrograde studies performed at an outside hospital were normal. Ureteroscopy was performed which showed a left renal pelvis tumor. MRI scan confirmed these findings and did not show significant metastatic disease. After appropriate consent, the patient decided that surgical therapy would be the most appropriate route. All questions were answered prior to proceeding. Past Medical History: 1. Ischemic heart disease 2. MI history, in [**2163**], [**2171**] with a CABG and 2 stents in [**2177**] 3. 2 shoulder surgeries 4. lumbar lamis [**2157**] 5. stomach surgery for ulcers Social History: Previous smoking history of 10 pack years (recently quit). He is married and occasionally takes alcohol. He denies any recreational drug usage. Family History: Noncontributory. Physical Exam: General: well nourished, well appearing, resting comfortably, without any apparent distress. He is orientated to time, person and place. CVS: regular rate and rhythm, audible prosthetic valve sounds. Chest: clear to auscultation bilaterally. GIT: soft, nontender and nondistended. Extremities: no abnormalities detected. Pertinent Results: [**2183-8-2**] 08:15AM BLOOD WBC-7.4 RBC-2.89* Hgb-9.2* Hct-27.4* MCV-95 MCH-32.0 MCHC-33.8 RDW-14.3 Plt Ct-144* [**2183-8-1**] 06:16AM BLOOD WBC-7.3 RBC-3.01* Hgb-9.3* Hct-27.6* MCV-92 MCH-30.9 MCHC-33.6 RDW-14.0 Plt Ct-128*# [**2183-7-31**] 03:03AM BLOOD WBC-9.1 RBC-2.86* Hgb-9.2* Hct-26.2* MCV-92 MCH-32.2* MCHC-35.1* RDW-13.9 Plt Ct-85* [**2183-8-2**] 08:15AM BLOOD Glucose-95 UreaN-26* Creat-1.5* Na-141 K-4.0 Cl-106 HCO3-26 AnGap-13 [**2183-8-1**] 06:16AM BLOOD Glucose-85 UreaN-31* Creat-1.5* Na-141 K-4.3 Cl-106 HCO3-24 AnGap-15 [**2183-7-31**] 03:03AM BLOOD Glucose-93 UreaN-24* Creat-1.8* Na-140 K-4.4 Cl-107 HCO3-26 AnGap-11 [**2183-7-30**] 02:56AM BLOOD Glucose-95 UreaN-22* Creat-1.8* Na-139 K-4.7 Cl-108 HCO3-25 AnGap-11 Brief Hospital Course: Mr [**Known lastname **] was admitted on [**2183-7-28**] for his surgical procedure. His procedure was scheduled for the same day. Preoperatively, consent was obtained, and he was prepared for surgery. In the operating room, the patient was prepped and draped in the usual sterile fashion after induction of general anesthetic and placement of a Foley catheter. Throughout the surgery, there were no complications.After completion of the procedure, The patient was transferred stable to the intensive care unit. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was the attending surgeon of record and was present and scrubbed throughout the entire procedure. In the ICU, Mr [**Known lastname **] was in a considerable amount of pain, and was heavily sedated and confused. He was given intravenous pain medication, and later became more calm and awake. He had no new issues or complaints. On occassion, he would have no recall of his surgery, but had no other symptoms including chest pain, nausea or vomiting. Over the course of the next two days, he began to become more aware of his surroundings. His nasogastric tube and chest tubes were removed, and his pain medications kept at an optimal level. He was transfered to the floor on the [**Hospital Ward Name 516**] of [**Hospital1 18**] where he was started on a regular diabetic diet after he passed flatus, and changed to oral pain medications. He continued to progress very well, although it was noted that he became confused when given doses of morphine (and hence, the dosages of morphine was kept at a minimal level). Medications on Admission: 1. aspirin 2. avapro 3. isosorbide 4. lipitor 5. toprol 6. zetia 7. nisapan 8. cholestryamine Discharge Medications: 1. Ciprofloxacin 500 mg 2. Colace 100 mg 3. Hydromorphone 4 mg 4. Acetaminophen 325 mg Discharge Disposition: Home With Service Facility: [**Location (un) 5450**] VNA Discharge Diagnosis: Left transitional cell carcinoma of the renal pelvis. Discharge Condition: Stable. Discharge Instructions: The pain medicine you are given can make you drowsy. Do not drive or operate heavy machinery while on medication. If you have medical symptoms including a high fever, chest pain, shortness of breath, please see your physician or return to the Emergency Department as soon as possible. You may continue your home medications, and those prescribed by your surgeon while in hospital. You are also being prescribed an antibiotic, for which you are meant to start the day BEFORE your follow-up appointment and continue for 3 days. Followup Instructions: Please arrange a follow-up appointment with Dr. [**First Name (STitle) **] [**Name Initial (MD) **] [**Name8 (MD) **], M.D. by calling ([**Telephone/Fax (1) 4276**]. Completed by:[**2183-8-2**]

[ "189.1", "412", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "55.51", "38.93" ]

icd9pcs

[ [ [] ] ]

4415, 4474

2560, 4160

324, 351

4572, 4582

1800, 2537

5159, 5355

1426, 1444

4304, 4392

4495, 4551

4186, 4281

4606, 5136

1459, 1781

274, 286

379, 1039

1061, 1249

1265, 1410

10,568

189,174

9186

Discharge summary

report

Admission Date: [**2119-4-12**] Discharge Date: [**2119-4-13**] Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Hypoxia / Hypotension / Fever Major Surgical or Invasive Procedure: none History of Present Illness: 84 y.o male transferred from [**Location (un) 620**] with hypoxia and hypotension and fever. Patient was found to have right pleural effusion which was tapped yielding approx 400cc of transudative fluid. Since d/c patient has been doing fairly well, but has been eating poorly. Wife saw him last night and state that he was doing well. She reports that he had stated that he was "cold" over the last few days w/a mild cough. This morning the patient was found to be hypoxic to 70's, in respiratory distress. He was brought initially to [**Hospital1 **] [**Location (un) 620**] where he was initially thought to be in CHF. He was given lasix w/minimal urine output. He was then intubated for continued hypoxia and a femoral central line was placed. He was noted to be hypotensive so dopamine was initiated. Upon arrival to [**Hospital1 18**] ED he was on levophed for his BP. Additionally, he was started empirically on a heparin gtt for a possible PE as the source of his hypoxia and hypotension. In the [**Hospital1 18**] ED he was given levo/flagyl/vanco and 2Liters of NS boluses for ? sepsis as the source for his hypotension. Past Medical History: 1. Coronary artery disease, status post non-ST-elevation myocardial infarction in [**2118-11-30**]. 2. Congestive heart failure with an ejection fraction of twenty percent and anterior septal and inferior akinesis and left ventricular apical aneurysm. 3. End-stage renal disease on hemodialysis Tuesday, Thursday, and Saturday. This was started in approximately [**12-3**]. Diabetes, type 2. 5. Recent right lower lobe pneumonia. 6. History of cerebrovascular accident. 7. Hypothyroidism. 8. Status post right total hip replacement. 9. History of low blood pressures and bradycardia Social History: Resident of [**Location 582**] NH, married. Former smoker/quit x30yrs prior. Denies ETOH hx. Family History: Noncontributory Physical Exam: T 103.3F, P 104, BP 84/59, RR 16, Sat 100%on vent, CVP 20-25 GEN: Intubated, responsive to touch HEENT: PERRLA, NCAT, ETT/OGT in place NECK: no jvd LUNGS: CTA CV: Tachy w/distant heart sounds ABD: Mild distention, soft, NT/ND, No HSM EXT: No edema, warm/dry, right fem line c/d/i, right heel ulcer w/purulent d/c. Neuro: moves x4 ext Pertinent Results: [**2119-4-12**] 07:48AM TYPE-ART RATES-/12 TIDAL VOL-600 PEEP-5 O2-100 PO2-80* PCO2-33* PH-7.46* TOTAL CO2-24 BASE XS-0 AADO2-602 REQ O2-98 INTUBATED-INTUBATED VENT-CONTROLLED [**2119-4-12**] 08:13AM LACTATE-7.4* [**2119-4-12**] 09:00AM PT-17.7* PTT-127.9* INR(PT)-2.0 [**2119-4-12**] 09:00AM PLT SMR-VERY LOW PLT COUNT-77*# [**2119-4-12**] 09:00AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [**2119-4-12**] 09:00AM NEUTS-67 BANDS-25* LYMPHS-5* MONOS-1* EOS-0 BASOS-0 ATYPS-1* METAS-1* MYELOS-0 NUC RBCS-2* [**2119-4-12**] 09:00AM WBC-7.5 RBC-3.52* HGB-11.3* HCT-35.8* MCV-102*# MCH-32.0# MCHC-31.4# RDW-17.9* [**2119-4-12**] 09:00AM CALCIUM-6.6* PHOSPHATE-1.8* MAGNESIUM-1.2* [**2119-4-12**] 09:00AM CK-MB-6 [**2119-4-12**] 09:00AM cTropnT-0.48* [**2119-4-12**] 09:00AM CK(CPK)-113 [**2119-4-12**] 09:00AM GLUCOSE-157* UREA N-18 CREAT-2.3* SODIUM-141 POTASSIUM-3.4 CHLORIDE-108 TOTAL CO2-19* ANION GAP-17 [**2119-4-12**] 10:31AM O2 SAT-98.6 [**2119-4-12**] 10:31AM TYPE-ART TEMP-39.4 PEEP-10 O2-100 PO2-282* PCO2-39 PH-7.35 TOTAL CO2-22 BASE XS--3 AADO2-394 REQ O2-69 INTUBATED-INTUBATED [**2119-4-12**] 12:00PM FIBRINOGE-199# D-DIMER-3827* [**2119-4-12**] 12:00PM PT-18.9* PTT-150* INR(PT)-2.2 [**2119-4-12**] 12:00PM PLT COUNT-95* [**2119-4-12**] 12:00PM WBC-7.5 RBC-3.81* HGB-12.3* HCT-38.6* MCV-101* MCH-32.3* MCHC-31.9 RDW-17.8* [**2119-4-12**] 12:00PM CORTISOL-23.4* [**2119-4-12**] 12:00PM CALCIUM-7.0* PHOSPHATE-2.0* MAGNESIUM-1.5* [**2119-4-12**] 12:00PM CK-MB-12* MB INDX-4.6 cTropnT-0.78* [**2119-4-12**] 12:00PM CK(CPK)-260* [**2119-4-12**] 12:00PM GLUCOSE-150* UREA N-19 CREAT-2.9* SODIUM-139 POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12 [**2119-4-12**] 12:42PM freeCa-1.03* [**2119-4-12**] 12:42PM O2 SAT-97 [**2119-4-12**] 12:42PM LACTATE-5.0* [**2119-4-12**] 12:42PM TYPE-ART PO2-99 PCO2-35 PH-7.37 TOTAL CO2-21 BASE XS--3 [**2119-4-12**] 01:05PM URINE RBC-[**3-4**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 [**2119-4-12**] 01:05PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-MOD [**2119-4-12**] 01:05PM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.018 [**2119-4-12**] 01:15PM CORTISOL-22.5* [**2119-4-12**] 01:45PM FIBRINOGE-204 D-DIMER-3449* [**2119-4-12**] 01:45PM FDP-10-40 [**2119-4-12**] 01:45PM CORTISOL-22.9* [**2119-4-12**] 02:30PM PT-18.3* PTT-130.5* INR(PT)-2.1 [**2119-4-12**] 05:30PM PT-17.3* PTT-79.5* INR(PT)-1.9 [**2119-4-12**] 05:30PM CK-MB-20* MB INDX-6.0 [**2119-4-12**] 05:30PM CK(CPK)-332* [**2119-4-12**] 05:52PM freeCa-1.08* [**2119-4-12**] 05:52PM O2 SAT-98 [**2119-4-12**] 05:52PM LACTATE-3.6* K+-4.2 [**2119-4-12**] 05:52PM TYPE-ART TEMP-38.0 TIDAL VOL-600 PEEP-10 O2-60 PO2-116* PCO2-35 PH-7.39 TOTAL CO2-22 BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED [**2119-4-12**] 09:47PM O2 SAT-98 [**2119-4-12**] 09:47PM GLUCOSE-364* [**2119-4-12**] 09:47PM TYPE-ART TEMP-36.4 PEEP-5 O2-60 PO2-119* PCO2-32* PH-7.37 TOTAL CO2-19* BASE XS--5 -ASSIST/CON INTUBATED-INTUBATED [**2119-4-12**] 11:45PM PT-16.9* PTT-55.6* INR(PT)-1.8 [**2119-4-12**] 11:45PM WBC-13.7*# RBC-4.07* HGB-12.9* HCT-40.0 MCV-98 MCH-31.7 MCHC-32.2 RDW-18.0* CT scan on [**2119-4-12**]: IMPRESSION: 1) Bilateral pleural effusions, right greater than left. Right lower lobe collapse and partial collapse of the right middle lobe. Anasarca and small pericardial effusion. These findings may relate to volume overload, but superimposed infection is not excluded. Repeat CT scan with contrast is recommended after treatment to ensure that these findings resolve and to exclude an underlying obstructive process. 2) No evidence of pulmonary embolism. 3) Nodular density in the left upper lobe measuring 1.1 cm in greatest dimension. Attention to this area on the followup examination is recommended to exclude malignancy. [**2119-4-12**] CTA: IMPRESSION: 1) Bilateral pleural effusions, right greater than left. Right lower lobe collapse and partial collapse of the right middle lobe. Anasarca and small pericardial effusion. These findings may relate to volume overload, but superimposed infection is not excluded. Repeat CT scan with contrast is recommended after treatment to ensure that these findings resolve and to exclude an underlying obstructive process. 2) No evidence of pulmonary embolism. 3) Nodular density in the left upper lobe measuring 1.1 cm in greatest dimension. Attention to this area on the followup examination is recommended to exclude malignancy. [**2119-4-12**] Cardiology Report ECG Sinus rhythm. A-V conduction delay. Left atrial abnormality. Occasional ventricular ectopy. Low limb lead voltage. Prior anterior myocardial infarction. Compared to the previous tracing of [**2114-5-7**] the limb lead voltage has diminished markedly. Evidence for prior inferior myocardial infarction or ongoing inferior ischemia is no longer recorded. There are now ST segment depressions in leads V4-V6 consistent with active lateral ischemic process, increase in rate and appearance of ventricular ectopy. Clinical correlation is suggested. Brief Hospital Course: [**2119-4-12**]: Admited to MICU. +UTI/likely urosepsis. ? consolidation on CXR/CT. Cont vanco/levo/flagyl. Decreased platelets concerning for DIC. Tube feeds started. A-line placed. Renal consulted, no evid of need for emergent HD currently. [**2119-4-13**]: CXR w/evid of CHF w/trops trending upward. ESRD w/creatinine trending upward. Continued respiratory failure requiring ventilation. Extremities w/cyanosis secondary to need for increasing levels of pressors. Family meeting w/decision to make patient CMO given extremly poor prognosis w/comorbid conditions in relation to overwhelming sepsis. Morphine/fentanyl gtt started. Patient pronounced at 2:20pm by Dr. [**Last Name (STitle) 31573**]. Medications on Admission: ASA 325 qd Synthroid 75 qd Prilosec 20 qd Captopril 6.25 tid Procrit w/dialysis Ritalin 5 qhs Colace / Senna RISS Nephrocaps Discharge Medications: NONE Discharge Disposition: Expired Facility: MICU at [**Hospital1 18**] Discharge Diagnosis: NONE Discharge Condition: Patient died on [**2119-4-13**] while in MICU Discharge Instructions: NONE Followup Instructions: NONE [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "412", "599.0", "995.92", "428.0", "250.00", "707.14", "518.81", "244.9", "785.52", "585", "038.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8690, 8737

7785, 8486

280, 286

8785, 8832

2577, 7762

8885, 9028

2191, 2208

8661, 8667

8758, 8764

8512, 8638

8856, 8862

2223, 2558

211, 242

314, 1448

1470, 2065

2081, 2175

30,220

178,149

33501

Discharge summary

report

Admission Date: [**2182-3-12**] Discharge Date: [**2182-3-20**] Date of Birth: [**2154-12-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: SSCP Major Surgical or Invasive Procedure: Bentall(#25 [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **]) [**3-14**] History of Present Illness: 27 yo M who developed substernal chest pain about 2 weeks ago. It improved with Motrin however he was noted to have enlarged cardiac silhouette on CXR. Subsequent echo showed bicuspid AV and ascending aortic aneurysm. Past Medical History: restless leg Social History: assistant to [**Male First Name (un) **] at [**Hospital1 **] [**University/College **] denies tobacco occasional etoh Family History: NC Physical Exam: HR 99 RR 16 BP 166/78 NAD Lungs CTAB Heart RRR 2/6 diastolic murmur Abdomen soft, NT/ND Extrem warm, no edema No varicose veins No carotid bruits Pertinent Results: [**2182-3-20**] 06:00AM BLOOD WBC-5.7 RBC-3.39* Hgb-10.2* Hct-30.3* MCV-89 MCH-30.2 MCHC-33.8 RDW-12.6 Plt Ct-452* [**2182-3-12**] 08:00PM BLOOD Neuts-79.7* Lymphs-15.8* Monos-3.5 Eos-0.5 Baso-0.5 [**2182-3-20**] 06:00AM BLOOD PT-25.3* PTT-74.1* INR(PT)-2.5* [**2182-3-18**] 08:20AM BLOOD Glucose-94 UreaN-20 Creat-0.8 Na-139 K-4.0 Cl-101 HCO3-29 AnGap-13 Brief Hospital Course: He was admitted to the cardiac surgery ICU for blood pressure control. Outside hospital CTA reveiwed with radiology showed no dissection, but large ascending aortic aneurysm measuring 8.5x7.6 with ? of valve involvement.He was started on IV labetalol, and then transitioned to PO labetatlol and hydrochlorothiazide. He was cleared for surgery by dental. He was taken to the operating room on [**3-14**] where he underwent a bentall with a mechanical valve. He was transferred to the ICU in stable condition. He was extubated later that same day. He received 48 hours of vancomycin as he was in the hospital preoperatively. He remained in the ICU while his IV nicardipine was weaned, and was transferred to the floor on POD #2. He was started on heparin and coumadin for his mechanical valve. He did well postoperatively and awaited therapeutic INR prior to discharge. he was ready for discharge home on POD # six. Medications on Admission: Motrin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. 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* 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 7. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 8. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*0* 9. Coumadin 5 mg Tablet Sig: 1.5 Tablets PO once a day: take 1.5 tablets (7.5 mg) daily until directed otherwise by the office of Dr. [**Last Name (STitle) 410**]. Disp:*45 Tablet(s)* Refills:*0* 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 11. Outpatient Lab Work INR draw on Friday [**3-22**] with results faxed to the coumadin clinic at [**Hospital 42317**] Medical office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] ([**Telephone/Fax (1) 77676**]. Discharge Disposition: Home With Service Facility: [**Hospital1 **] home care services Discharge Diagnosis: bicuspid aortic valve, AI, asc ao aneurysm now s/p bentall restless leg Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) 914**] 4 weeks ([**Telephone/Fax (1) 11763**]. See your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 77677**] in 2 weeks See your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] 2 weeks ([**Telephone/Fax (1) 77618**] at [**Hospital 42317**] Medical [**Street Address(2) 77678**]. Plan confirmed with [**Location (un) 1439**] [**3-20**] 2:49. Completed by:[**2182-3-20**]

[ "423.0", "333.94", "441.01", "746.4" ]

icd9cm

[ [ [] ] ]

[ "36.99", "38.45", "89.60", "35.22", "39.61" ]

icd9pcs

[ [ [] ] ]

4032, 4098

1455, 2370

325, 454

4214, 4222

1075, 1432

4535, 4987

889, 893

2427, 4009

4119, 4193

2396, 2404

4246, 4512

908, 1056

281, 287

482, 701

723, 737

753, 873

8,668

108,046

4173

Discharge summary

report

Admission Date: [**2140-6-9**] Discharge Date: [**2140-6-9**] Date of Birth: [**2067-7-11**] Sex: F Service: [**Last Name (un) 18171**] ICU HISTORY OF PRESENT ILLNESS: This is a 73 year-old female with a history of systemic lupus erythematosus and atrial fibrillation who complains of a five day history of a cough productive of white sputum. She reports that yesterday she developed increasing shortness of breath (gradual) along with subjective fevers with chills and sweats. The patient therefore called EMS. She states that she returned from a vacation in the Catskills approximately one week prior to admission and had a sore throat that subsequently resolved. REVIEW OF SYSTEMS: Negative for chest pain, shortness of breath, emesis, diarrhea, bright red blood per rectum or melena. She reports recent nausea with dry heaves. She has had chronic leg pain and edema (secondary to venostasis and peripheral neuropathy), but denies increase above baseline. The patient denies orthopnea or paroxysmal nocturnal dyspnea. She does report some palpitations and racing heart. EMS gave the patient a Lasix dose times one and sublingual nitroglycerin times three and brought the patient to the [**Hospital1 1444**] Emergency Department. In the Emergency Department her temperature was 100.0. Heart rate 100 to 117. Blood pressure 160/110. Her oxygen saturation was 85% on room air, which increased to 95% on a 100% nonrebreather. The patient's electrocardiogram showed minimal lateral nonspecific ST changes. Her chest x-ray (after the Lasix dose) showed no congestive heart failure, pneumothorax or pneumonia. An arterial blood gas done on 100% nonrebreather was 7.49, PCO2 of 37, and PO2 of 75. Significant examination findings in the Emergency Department included bibasilar crackles, jugulovenous distention and peripheral edema. With the patient's history of deep venous thrombosis and PE there was a concern for pulmonary embolus. The CT angiogram was performed, which was negative for pulmonary emboli or for any pulmonary parenchymal process. The patient was then transferred to the MICU due to her elevated oxygen requirement. On arrival to the MICU the patient reported feeling much better. Her oxygen saturations were in the mid 90s on 6 liters nasal cannula. PAST MEDICAL HISTORY: Systemic lupus erythematosus, atrial fibrillation, osteoarthritis, status post bilateral total knee replacements, peripheral neuropathy, status post venous stripping, status post hiatal hernia repair, status post cataract surgery, question of coronary artery disease (this is according to a discharge summary, the patient denies history of heart disease). History of deep venous thrombosis (occurred postop from the total knee replacement). Osteoporosis. HOME MEDICATIONS: Lasix 40 mg po every other day, Digoxin 0.125 mg p q day, Protonix, Coumadin 7.5 mg q Monday through Saturday and 10 mg q Sunday, Prednisone 10 mg po q day, Neurontin 600 mg q.i.d., Fosamax 70 mg q week, Duragesic patch 75 micrograms q 72 hours, Miacalcin nasal spray one spray q.d., Cardizem 80 mg q day. ALLERGIES: The patient has allergies recorded to aspirin, sulfa, Penicillin, percocet and Codeine. LABORATORIES ON ADMISSION: White blood cell count of 11.2 with 73% neutrophils and 15% lymphocytes, hematocrit 43.9 and platelets of 273, PT 17.0, PTT 41.1, INR 2.0. chem 7 sodium 1356, potassium 3.7, chloride 95, bicarb 29, BUN 12, creatinine 0.9, glucose 101, calcium 9.2, magnesium 1.7, phos 3.3. Urinalysis showed small blood, negative nitrite or leukocyte, 0 to 2 red blood cell and 0 to 2 white blood cell, occasional bacteria and no epithelial cells. A Digoxin level was subtherapeutic at 0.3. Electrocardiogram showed atrial fibrillation at a rate of 100 with normal axis, normal intervals, 1.[**Street Address(2) 1755**] depression in V4 through V5 compared with prior in 5 of [**2135**] (the prior also showed normal sinus rhythm). CT angiogram was negative for pulmonary embolus. It showed no consolidation and only minimal bibasilar atelectasis. HOSPITAL COURSE: The patient was admitted to the MICU at 3:00 a.m. on [**2140-6-9**]. This patient usually receives her care at [**Hospital6 2910**]. Later that morning contact was made with her primary physicians and the arrangements were made for transfer to that institution. Pulmonary: The patient reported subjective improvement in her shortness of breath after her diuresis. The patient's oxygen requirement at the time of this dictation is 5 liters nasal cannula to maintain oxygen saturations in the mid 90s. Cardiovascular: 1. Ischemia, the patient's records record a history of coronary artery disease, which is not further documented. The patient's electrocardiogram on admission showed nonspecific ST changes, which were resolved by repeat electrocardiogram this morning. The patient denies any history of chest pain associated with this shortness of breath. Serial enzymes are being obtained to rule out myocardial infarction. At the time of this dictation the first two sets are negative and the patient was maintained on telemetry and a low dose beta blocker was started during the rule out protocol. No aspirin was started as the patient reports an aspirin allergy. 2. Pump, the patient has no history of congestive heart failure and her ejection fraction is unknown. Her presentation examination was consistent with congestive heart failure and she did have subjective improvement with diuresis. 3. Rate/rhythm, the patient has chronic atrial fibrillation and is currently reasonably rate controlled on her home dose of Cardizem (heart rates have been in the 90s). The patient is on anticoagulation with Coumadin. Infectious disease: The patient presented with a low grade temperature. She had a mildly increased white blood cell count with a left shift. It was felt that this patient likely has tracheobronchitis. She did receive one dose of Levofloxacin in the Emergency Department. Sputum cultures were obtained. Endocrine: 1. The patient has a history of chronic Prednisone use. The patient received one dose of Hydrocortisone as stress dosed steroids in the Emergency Department. In the Intensive Care Unit the patient was mildly hypertensive. It was therefore felt the stress dose steroids were not necessary. She was continued on her home dose of Prednisone. 2. Osteoporosis the patient is treated with Miacalcin spray and Fosamax. Rheumatology: History of systemic lupus erythematosus. The patient will be continued on her usual Prednisone dose. Neurology: The patient has a history of peripheral neuropathy and is treated with Neurontin. The patient has a history of chronic pain and is treated with a Fentanyl patch. DISCHARGE STATUS: The patient is medically stable for [**Hospital 18172**] transfer to the [**Hospital6 2910**]. DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Tracheobronchitis. DISCHARGE MEDICATIONS: Protonix 40 mg po q day, Coumadin 7.5 mg po q day on Monday through Saturday and 10 mg on Sunday. Neurontin 600 mg po q.i.d., Prednisone 10 mg po q day, Fosamax 70 mg po q week, Duragesic patch 75 micrograms q 72 hours, Miacalcin one spray q.d., Cardizem 180 mg po q day, Lopressor 12.5 mg po b.i.d., Lasix 40 mg intravenous q.d. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**] Dictated By:[**Last Name (NamePattern1) 15468**] MEDQUIST36 D: [**2140-6-9**] 12:44 T: [**2140-6-9**] 12:54 JOB#: [**Job Number 18173**]

[ "466.0", "710.0", "356.9", "428.0", "427.31", "733.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6902, 6956

6980, 7618

4097, 6881

2805, 3226

712, 2306

190, 692

3241, 4079

2329, 2786

40,787

151,958

38560

Discharge summary

report

Admission Date: [**2131-2-12**] Discharge Date: [**2131-2-19**] Date of Birth: [**2058-11-1**] Sex: M Service: CARDIOTHORACIC Allergies: Shellfish Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2130-2-13**] Coronary Artery Bypass Graft x 4 (left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending artery to posterolateral branch) [**2130-2-12**] Cardiac cath History of Present Illness: 72 year old male presented to the OSH ED with palpitations after he had gone to the oncologist's office and found to be tachycardic with heart rate in the 160's. In the ED he was intially found to be in atrial flutter with tachycardia with heart rate in 180's and received adenosine followed by cardizem drip and intitally converted to normal sinus rhythm. His troponin was elevated at 0.77. He was transferred to [**Hospital1 18**] for further elvaluation. Past Medical History: Peripheral Vascular Disease TIA ([**2123**]/[**2124**]) Left internal carotid artery occlusion ?Right carotid stenosis Abd Aortic Aneurysm - being followed (unknown size) h/o Non Hodgkins Lymphoma h/o Tyhroid CA h/o Prostate CA Past Surgical History: s/p Achilles tendon repair s/p Thyroidectomy s/p Herniorrhaphy s/p Left SFA stenting Social History: Race:Caucasian Last Dental Exam:edentulous Lives with:wife Occupation:retired Tobacco:quit 2.5 months ago, history of smoking [**2-11**] ppdx2 years and 1-1.5 ppdx 55 years ETOH: three to four beers a week Family History: Strong family history of heart disease and atherosclerosis Physical Exam: Pulse:67 Resp:13 O2 sat:95/Ra B/P Right:140/58 Left:133/56 Height:5'8" Weight:160 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] R subclavian portacath, L infraclavicular incision (portacath site) Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: 0 Left: 0 Pertinent Results: [**2130-2-12**] Cath: 1. Coronary angiography in this right dominant system revealed severe two-vessel disease. The LMCA had a 90% proximal stenosis. The LAD had mild, diffuse disease throughout. The LCx had mild, diffuse disease throughout. The RCA had an ulcerated 70% mid-stenosis and an 85% stenosis in the PL Branch. 2. Resting hemodynamics revealed [**Month/Day/Year 1192**] systemic arterial systolic hypertension with an aortic pressure of 166/75 mmHg. [**2130-2-13**] Carotid U/S: Chronic-appearing left carotid occlusion, including the common carotid artery. Clinical correlation is warranted to ensure that this is not just a very high-grade stenosis, although this is likely. On the right, there is less than 40% carotid stenosis [**2130-2-13**] Echo: PRE-CPB: The left atrium is moderately dilated. Mild spontaneous echo contrast is present in the left atrial appendage. LAA flow velocity is low, just over .2m/s. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is low normal (LVEF 50-55%). No regional wall motion abnormalities observed. There are grade 3 atheroma in the descending thoracic aorta and distal arch. No thoracic aortic dissection is seen. The aortic valve leaflets (3) are mildly thickened calcified. Trivial aortic regurgitation is seen. The mitral valve leaflets are structurally normal. [**Month/Day/Year **] (2+) mitral regurgitation is seen. There is a small pericardial effusion. POST-CPB: The LV systolic function remains low normal, estimated EF 50%. The MR [**First Name (Titles) 17222**] [**Last Name (Titles) 1192**], the TR improved to mild. There is no evidence of dissection. Dr. [**Last Name (STitle) **] was notified in person of the results at the time the study was performed. [**2131-2-19**] 06:10AM BLOOD WBC-7.2 RBC-3.50* Hgb-10.5* Hct-31.8* MCV-91 MCH-30.0 MCHC-33.0 RDW-17.0* Plt Ct-420 [**2131-2-19**] 06:10AM BLOOD PT-18.1* PTT-27.9 INR(PT)-1.6* [**2131-2-19**] 06:10AM BLOOD Glucose-104* UreaN-17 Creat-1.1 Na-140 K-3.8 Cl-102 HCO3-31 AnGap-11 Brief Hospital Course: Mr. [**Known lastname 85751**] presented to the ED on [**2130-2-12**] after being transferred to [**Hospital1 18**] from his oncologist office because of palpitations and tachycardia. His rhythm was atrial flutter and his troponin were found to be elevated. He underwent cardiac cath which showed severe left main and right-sided disease. After cath he was admitted for surgical work-up and planned surgery the following day. On [**2-13**] he was brought to the operating room where he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Beta blockers and diuretics were started and he was gently diuresed towards his pre-op weight. He was transferred to the surgical step down floor. Chest tubes and epicardial pacing wires were removed per protocol. He experienced atrial fibrillation so he was placed on amiodarone and Coumadin. By POD # 6 he was ready for discharge to home with VNA services and the appropriate medications and follow-up appointments. His PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 25693**], [**First Name3 (LF) **] follow his INR and adjust Coumadin accordingly.First INR check tomorrow with target INR 2.0-2.5. He will see Dr. [**Last Name (STitle) **] in 2 weeks prior to resuming chemotherapy. Medications on Admission: CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg Tablet - 1 Tablet(s) by mouth once a day LEVOTHYROXINE - (Prescribed by Other Provider) - 150 mcg Tablet - 1 Tablet(s) by mouth every morning ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1 Tablet(s) by mouth every morning Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take 400mg (2 tabs) daily for 7 days, then decrease to 200mg (1 tab) daily ongoing. Disp:*60 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. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1 doses: take 4mg once today [**2-19**], then as directed by the office of Dr. [**Last Name (STitle) 85752**]. Disp:*60 Tablet(s)* Refills:*0* 8. Outpatient Lab Work postoperative Atrial Fibrillation Goal INR:2-2.5 First draw: [**2131-2-20**] tomorrow Results to phone# [**Telephone/Fax (1) 25694**], PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 10. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 11. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* 12. potassium chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary artery bypass graft x 4 Postoperative Atrial Fibrillation-placed on Coumadin [**2131-2-15**] Peripheral Vascular Disease TIA ([**2123**]/[**2124**]) Left internal carotid artery occlusion ?Right carotid stenosis Abd Aortic Aneurysm - being followed (unknown size) h/o Non Hodgkins Lymphoma h/o Tyhroid CA h/o Prostate CA Past Surgical History: s/p Achilles tendon repair s/p Thyroidectomy s/p Herniorrhaphy s/p Left SFA stenting Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema-minimal Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] on [**2131-2-28**] 1:45 [**Telephone/Fax (1) 170**] - to be seen prior to resuming chemotherapy in 3 weeks from surgery Cardiologist: Obtain referral to cardiologist from PCP [**Name Initial (PRE) 3390**]: [**Name10 (NameIs) **],[**Name11 (NameIs) **] to follow INR/Coumadin dosing as arranged with RN:[**Month (only) **] on [**2131-2-16**]-Ist VNA draw to be done [**2131-2-20**] and called in to #[**Telephone/Fax (1) 25694**] Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 25693**] in [**5-15**] weeks for follow up **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: Daily PT/INR for Coumadin drawn by VNA?????? indication: postoperative Atrial Fibrillation Goal INR:2-2.5 First draw: [**2131-2-20**] Results to phone# [**Telephone/Fax (1) 25694**], PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] to follow as arranged with RN:[**Month (only) **] on [**2131-2-16**] Completed by:[**2131-2-19**]

[ "V10.87", "441.4", "V15.82", "286.7", "424.0", "427.31", "410.71", "433.30", "285.9", "202.80", "V12.54", "414.01", "443.9", "433.10", "V10.46" ]

icd9cm

[ [ [] ] ]

[ "36.15", "88.56", "88.72", "39.61", "36.13" ]

icd9pcs

[ [ [] ] ]

8344, 8403

4547, 6011

287, 544

8913, 9148

2411, 4524

10071, 11221

1629, 1689

6487, 8321

8424, 8782

6037, 6464

9172, 10048

8805, 8892

1704, 2392

237, 249

572, 1031

1053, 1281

1406, 1613

9,234

177,488

25998

Discharge summary

report

Admission Date: [**2103-12-6**] Discharge Date: [**2104-2-18**] Service: SURGERY Allergies: Heparin Agents Attending:[**First Name3 (LF) 4111**] Chief Complaint: enterocutaneous fistula Major Surgical or Invasive Procedure: On [**2104-1-3**] he was taken to the operating room for (1) Exploratory laparotomy, (2)lysis of adhesions (3.5 hours), (3) Enterectomy, (4) enteroenterostomy, (5)colostomy, (6) closure of 2 enterotomies, (7) feeding jejunostomy, (8) component separation and (9) placement of Vicryl mesh to reinforce the closure. History of Present Illness: Patient is an 82 male who underwent a large bowel resection [**4-25**] for a sigmoid vulvulous at the [**Hospital6 6689**]. His course was complciated by an enterocutaneous fistula and MRSA wound infection. On [**2103-8-16**] he was taken back to the operating room for lysis of adhesions, takedown of the enterocutaneous fistula, and a small bowel resction. Post-operatively he had a wound dehisence. On [**2103-8-21**] the patient returned to the OR for an abdominal exploration with debridement of abdominal wound and fascia and wound closure with insertion of Sergisis. The exterocutaneous fistula evidentally recurred. On [**2103-11-27**] he was taken to the OR for STSG of the abdominal wound. The fistula was closed with a chromic stitch with fibrin glue. A full thickness skin graft was laid over this. Postoperatively the patient continued to have problems with drainage of the inferior protion of the wound in the location of the fistula. A fistula again developed. He was transfered to the care of Dr. [**Last Name (STitle) 957**] at [**Hospital1 18**] on [**2103-12-6**] for definitive care of this fistula. Past Medical History: Pacemaker Loop colostomy Small bowel resection Take down of fisutla Prior J-tube placeement fx Ri shoulder Appendectomy Brief Hospital Course: Mr. [**Known lastname 25699**] was admited to the general surgery service under Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 957**]. He was made NPO and TPN was started. His wound was dressed by the surgical team with the ostomy nurse. [**First Name (Titles) **] [**Last Name (Titles) **] was used to keep the fistula contents away from the skin. From [**12-5**] through [**1-2**] this same routine was continued. His nutritional status was improved, and PT worked with him to improve his strength. However, given his deconditioning, he was not able to ambulate prior to surgery. On [**2104-1-3**] he was taken to the operating room for (1) Exploratory laparotomy, (2)lysis of adhesions (3.5 hours), (3) Enterectomy, (4) enteroenterostomy, (5)colostomy, (6) closure of 2 enterotomies, (7) feeding jejunostomy, (8) component separation and (9) placement of Vicryl mesh to reinforce the closure. There were no complications but he was transfered to the SICU from the OR for close monitoring. He was extubated prior to transfer. On POD 1 his respiratory status declined likely secondary to fluid shifts; he was re-intubated. He was able to be weaned from the vent the following day and was extubated [**1-7**] with success. TF were started at 10cc on POD 1. Over the next week his tube feeds were advanced daily, he was diuresed as needed, and he was placed on agressive pulmonary toliet. His TPN was decreased as TF were slowly advanced. On [**2104-1-6**] he proved to be positive for heparin-dependent antiboties; he was diagnosed with heparin induced throbocytopenia thus all heparin products were discontinued and prophylaxis was continued with venodynes on at all times. On [**2104-1-6**] he also spiked a temperature. Blood cx later showed Vancomycin resistant enterococcus. Bronchoalveolar lavage showed MRSA. On [**2107-1-10**] he tested positive for Cdiff and he was given appropriate antibiotics to treat all of these infections. Gastrograffin study on [**1-13**] demonstrated passage through small intestine and into colon easily, and the patient was begun on soft mechanical diet. He demonstrated questionable ability to eat without coughing and a swallow study was obtained that demonstrated overt aspiration signs with all consistencies. Nutrition was therefore continued with TPN and tube feeds alone. [**1-18**] the patient suddenly became confused with slurred speech while resting comfortably in bed moments before. While examining the patient he spiked temperature to 102, became tachycardic to 120s and was not able to follow commands. EKG showed no acute changes, stat head CT was normal and he proved to have blood cultures positive for pan-sensitive enterococcus for which he was appropriately treated and his clinical picture quickly improved. He remained stable for the next week before he developed some mild abdominal distension and serial abdominal plain films showed a persistent dilated loop of bowel in the LUQ. Tube feeds were held and on [**1-28**] a gatrograffin enema was obtained that showed no colonic stricture/obstruction however was not quite normal due to apparent mucosal and anastamotic abnormalities. Tube feeds were re-initiated and a video swallow showed evidence that patient could tolerate thin liquids and pureed diet without significant aspiration risk. He tolerated this diet for several days with 1:1 feedings, however on [**2-3**] he had an aspiration event and was transferred back to the intensive care unit after emergent intubation for respiratory distress. On [**2-6**] his sputum grew ACINETOBACTER BAUMANNII sensitive to gent, imipenem and tobramycin and he was started on imipenem. He was weaned from the ventilator over several days and extubated on [**2-7**]. However he was electively re-intubated later the same day for hypercarbia. Antibiotics, TPN and tube feeds were continued and the patient was very gently diuresed over the next week. By [**2-12**] he was felt to be euvolemic and he successfully extubated on [**2-13**]. His family requested his transfer to a facility closer to home, and now that he is stable post-extubation this request can be more safely honored. He is being transferred afebrile, tolerating tube feeds (half strength impact with fiber at 40cc/hour) and has completed a 14 day course of imipenem for an acinetobacter pneumonia. He has a small open part of his abdominal incision that is nearly completely granulated but will continue to need wet to dry dressings until completely healed. He was transferred to [**Hospital **] Hospital in stable condition and with instructions to remain NPO with TF for nutrition. Instructions were given to continue pulmonary toilet with nebulizer treatments. Medications on Admission: ASA 81mg po daily Protonix 40mg po daily Reglan Maalox Tylenol Albuterol Ultram Benadryl Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) as direc Injection ASDIR (AS DIRECTED). 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): pls give via J-tube. 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhal Inhalation Q2H (every 2 hours) as needed. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhal Inhalation Q6H (every 6 hours). 8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) dose PO DAILY (Daily). 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q2H (every 2 hours) as needed. 10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily). Disp:*100 ML(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 6689**] - [**Location (un) 6691**] Discharge Diagnosis: Primary: admitted for care of enterocutaneous fistula, now repaired. Secondary: Emphysema/COPD, CAD/ANGINA/MI, Pacemaker, CHF, paroxysmal a flutter, HTN, anemia, h/o MRSA/VRE, osteoporosis Discharge Condition: Good Discharge Instructions: Cont TF at 80cc/hr at 1/2 strength, then advance to 3/4 strength as tolerated. Please use a wet to dry dressing on abdominal wound twice daily. Absolutely nothing by mouth. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 957**]. Call [**Telephone/Fax (1) 17478**] for an appointment. any questions or concerns.

[ "482.83", "V45.01", "482.41", "287.4", "518.5", "276.52", "569.81", "E934.2", "790.7", "998.32", "998.2", "568.0", "496", "428.0", "997.4", "507.0", "560.89", "008.45", "V09.0", "273.8", "996.62" ]

icd9cm

[ [ [] ] ]

[ "45.62", "46.79", "46.74", "99.04", "96.6", "99.15", "46.39", "96.72", "54.59", "33.24", "54.72", "38.93", "96.04", "33.22" ]

icd9pcs

[ [ [] ] ]

7729, 7803

1884, 6606

245, 560

8035, 8041

8262, 8404

6745, 7706

7824, 8014

6632, 6722

8065, 8239

182, 207

588, 1717

1739, 1861

30,322

165,207

23075

Discharge summary

report

Admission Date: [**2148-2-8**] Discharge Date: [**2148-2-20**] Date of Birth: [**2082-4-25**] Sex: M Service: SURGERY Allergies: Zosyn / Morphine / Penicillins Attending:[**First Name3 (LF) 148**] Chief Complaint: Recurrent cholangitis Major Surgical or Invasive Procedure: 1. Biliary bypass (Roux-en-Y hepaticojejunostomy). 2. Partial appendectomy. 3. Liver biopsy. 4. Extended adhesiolysis History of Present Illness: This 65-year-old gentleman who has a history of a presumed unresectable pancreatic malignancy over 4 years ago. This was never biopsy proven. He ultimately received an indwelling metallic stent for this for an anticipated short term survival. As it turns out, he has survived over 4 years. There appears to be no evidence of tumor at this point in time. He never received adjuvant therapies. In the interim, he has had obstruction of the metal stent and on multiple occasions, has had cholangitis. Most recently, he had a significant cholangitis and pneumonia and during that period of time, he was found to have biliary obstruction above the stent in the liver. A plastic stent was placed through the metal stent in order to obtain drainage of the biliary tract. He settled out from this and went to rehabilitation for a week and now comes back for definitive operative approach to his long-term festering bile duct infection. Past Medical History: s/p metal stent placement [**2145**] recurrent cholangitis HTN Asthma Diabetes Cholecystectomy Esophageal stricture Social History: Retired maintenance technician for the [**Company 2318**]. smoker, alcohol, last drink new year's eve. Family History: NC Physical Exam: Discharge Exam: VS: 97.8 PO, 96/60, 56, 16, 97% RA GEN: WEll in NAD HEENT: NCAT. PERRLA. Sclerae anicteric. O-P intact, no exudate. NECK: Supple. No [**Doctor First Name **]. CV: RRR LUNGS: CTA(B) ABD: SOFT, NT, ND. Midline incision well approximated with small area erythema and scant serosang drainage. NT, ND. EXT: No edema. SKIN: Intact. Pertinent Results: [**2148-2-8**] 02:33PM GLUCOSE-169* UREA N-6 CREAT-0.8 SODIUM-136 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-11 [**2148-2-8**] 02:33PM ALT(SGPT)-60* AST(SGOT)-75* ALK PHOS-175* TOT BILI-2.0* [**2148-2-8**] 02:33PM ALBUMIN-3.2* CALCIUM-8.7 PHOSPHATE-4.3 MAGNESIUM-1.5* [**2148-2-8**] 02:33PM WBC-8.8 RBC-2.93* HGB-10.3* HCT-28.7* MCV-98 MCH-35.0* MCHC-35.7* RDW-14.8 [**2148-2-8**] 02:33PM PLT COUNT-224 . [**2-20**] PT 35.4/INR 3.7 (Coumadin on hold) . STUDIES: [**2-8**] Liver Bx: chronic inflammation, no malignancy [**2-10**] CXR: Low volumes/atelectasis. R retrocardiac opacity c/w RLL PNA [**2-13**] EKG: Sinus rhythm and frequent atrial ectopy. Diffuse low voltage. Left atrial abnormality. Right bundle-branch block. Q-T interval prolongation. Compared to the previous tracing of [**2148-1-13**] the rate has slowed. The Q-T interval is prolonged and sinus rhythm has appeared. . MICRO: [**2-8**] Biliary Stent Cx: mixed bacterial x2, not speciated. [**2-13**] Cath-tip Cx Staph aureus coag (+)/MRSA ([**Last Name (un) 36**] to Vanc) [**2-14**] BCx2: Staph aureus coag (+)/MRSA ([**Last Name (un) 36**] to Vanc), Sputum Cx: neg, UCx: neg [**2-15**] CDiff: neg, Cath-tip Cx: no sig growth Brief Hospital Course: The patient was admitted following the above procedure. He had an NGT placed intraoperatively, foley to gravity, JP drain in the abdomen, diet NPO, IVF for hydration, epidural for pain control. [**2-9**] epidural removed, continued on PCA for pain control, continued NPO, IVF [**2-10**] continued NPO, IVF, PCA for pain, mild confusion noted and patient placed intermittently in restraints [**2-11**] transferred to the unit for significant bradycardia followed by tachycardia, continued NPO, IVF, cardiac enzymes negative [**2-12**] diet advanced to clears, started on amiodarone [**2-13**] changed to oral metoprolol for rate control, d/c PCA, started on PO pain medication, central line removed, PICC line placed [**2-14**] vancomycin started for central line infection (MRSA), diet advanced to regular, started on heparin drip [**2-15**] continued heparin drip, coumadin started, continued PO lopressor, regular diet, transfused one unit RBC, central line placed for hypotension [**2-16**] - heparin drip stopped, lovenox started, continued coumadin, transferred to the floor for continued monitoring, PO pain medication [**2-17**] - continued coumadin, lovenox, diet advanced from clears to regular [**2-18**] - held coumadin and discontinued lovenox due to supratherapeutic INR [**2-19**] - continued to hold coumadin for supratherapeutic INR [**2-20**] - Vanco d/c'd as IV RN unable to place PICC due to INR this am of 3.7. ABX changed to PO Linezolid for discharge to rehab. Plan to restart Coumadin tonite at 2.5mg, and repeat INR daily at rehab until reaches therapeutic goal of 2.5-3.5. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, voiding without assistance, and pain was well controlled. He ambulatated with assistance, and will require conditioning at rehab by Physical Therapy. Medications on Admission: accupril 20', advair 250/50", combiven INH d, fentanyl patch, flonase NS qd, glucatrol 5 [**Hospital1 **], singulair 10', zyrtec 10 Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 5. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 6. Combivent 18-103 mcg/Actuation Aerosol Sig: [**1-12**] Inhalation four times a day. 7. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms. 9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 10. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-15**] hours as needed for pain. Discharge Disposition: Extended Care Facility: Bostonian - [**Location (un) 86**] Discharge Diagnosis: Primary: 1. Biliary stricture and obstruction. 2. Extensive adhesions of the peritoneum and upper abdomen. 3. Liver mass. 4. New onset atrial fibrillation Secondary: 1. Hypertension 2. Asthma 3. Diabetes Type 2 4. Esophageal stricture Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Any bleeding, significant bruising, coffee-ground vomit, dark colored stool, blood in urine or stools. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please call the office of Dr. [**Last Name (STitle) **] to arrange a follow up appointment in [**2-13**] weeks at [**Telephone/Fax (1) 1231**] Completed by:[**2148-2-20**]

[ "E878.1", "572.3", "530.3", "576.1", "543.9", "493.90", "996.79", "458.29", "427.31", "401.9", "250.00", "V45.89", "427.89", "574.51", "572.0", "568.0" ]

icd9cm

[ [ [] ] ]

[ "54.59", "51.49", "50.12", "47.09", "03.90", "51.37", "38.93", "99.04", "96.07", "97.55" ]

icd9pcs

[ [ [] ] ]

6337, 6398

3284, 5180

310, 430

6678, 6685

2047, 3261

8319, 8493

1664, 1668

5362, 6314

6419, 6657

5206, 5339

6709, 7959

7974, 8296

1683, 1683

1700, 2028

249, 272

458, 1389

1411, 1528

1544, 1648

62,316

181,287

34388

Discharge summary

report

Admission Date: [**2166-5-8**] Discharge Date: [**2166-5-15**] Date of Birth: [**2093-6-1**] Sex: F Service: SURGERY Allergies: Prochlorperazine Attending:[**First Name3 (LF) 695**] Chief Complaint: Intrahepatic cholangio carcinoma Major Surgical or Invasive Procedure: [**2166-5-8**]: Right hepatic trisegmentectomy, cholecystectomy, intraoperative ultrasound, caudate lobe resection. History of Present Illness: 72 y/o femaile who was found to have a right lobe liver mass on Abdominal CT. MRI was done showing in [**Month (only) 404**] a 7.1 x 6.4 x 7.2-cm mass in the right lobe of the liver suggestive of malignancy. The main portal vein was patent. The left hepatic vein was normal. The middle hepatic vein was displaced by the mass and the right hepatic vein was encased but did enhance near the IVC. CT guided biopsy in [**Month (only) 956**] demonstrated poorly- differentiated adenocarcinoma. Morphology and immunohistochemical staining pattern did not support a primary site. A negative stain for HepR1, AFP and polyclonal CEA mitigated against a primary hepatocellular carcinoma. A PET CT scan on [**2-20**] demonstrated intense activity in the lesion of the liver with an SUV of 10 but no other areas of FDG avidity were noted. Tumor markers included a normal CA- 125 at 6.3, a CA19-9 elevated mildly at 79, a CA27.29 mildly elevated at 50.3 and a CEA to 0.6. No pulmonary metastases were demonstrated on chest CT. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: 2 Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] here [**2164**] -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: Hypertension Hyperlipidemia L ankle repair [**2149**] Osteoarthritis Social History: Retired, lives alone -Tobacco history: None -ETOH: 0 weekly -Illicit drugs: Denies Family History: Mother died when young, cause unknown. Father passed away after suicide. Physical Exam: VS: 98.7, 70, 160/74, 12, 100% General: Pain initially not well controlled, but improved with adjustments Card: RRR, no M/R/G Lungs: CTA bilaterally Abd: JP in place, initially bilious in appearance, improved over time to serous, incision C/D/I, non-tender, non-distended Extr: warm, no edema, R shoulder has lipoma Skin warm and dry Neuro: Oriented but forgetful Pertinent Results: On Admission: [**2166-5-8**] WBC-8.5 RBC-2.80*# Hgb-8.2*# Hct-24.4*# MCV-87 MCH-29.2 MCHC-33.5 RDW-14.1 Plt Ct-98* PT-21.1* PTT-62.6* INR(PT)-1.9* Glucose-122* UreaN-12 Creat-0.7 Na-142 K-4.4 Cl-110* HCO3-20* AnGap-16 ALT-1083* AST-1039* CK(CPK)-357* AlkPhos-73 TotBili-1.9* Albumin-2.7* Calcium-10.7* Phos-3.7 Mg-2.0 At Discharge: [**2166-5-15**] WBC-12.4* RBC-4.56 Hgb-13.1 Hct-39.1 MCV-86 MCH-28.8 MCHC-33.6 RDW-16.5* Plt Ct-119* Glucose-110* UreaN-25* Creat-0.9 Na-139 K-3.8 Cl-107 HCO3-28 AnGap-8 ALT-169* AST-89* AlkPhos-303* TotBili-5.3* Albumin-2.7* Calcium-8.6 Phos-2.4* Mg-2.2 Brief Hospital Course: 72 y/o female who underwent Right hepatic trisegmentectomy, cholecystectomy, intraoperative ultrasound, caudate lobe resection with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. She received At the time of surgery, the patient had a large mass in the right lobe of the liver extending into segment [**Doctor First Name **]. By intraoperative ultrasound, it extended down to approximately the confluence of the right and left portal vein. It did not appear that there would be great deal of segment IVB left and its blood supply might be tenuous. It was then determined based on that information to proceed with a trisegmentectomy. The left lateral segment was free of disease. She had normal anatomy. Final pathology showed invasive adenocarcinoma (cholangiocarcinoma) Post operatively she was initially transferred to the SICU with a very labile BP ranging from 70 systolic to 160's. She had a hct drop to 24% and received RBC and cryo in the unit after receiving 5 units pRBCs, 2 u PLts and 2 U FFP while in surgery. She was extubated on [**5-10**]. A PICC was placed which was removed the day of discharge. She was transferred to [**Hospital Ward Name 121**] 10 on POD 3. She received 2 more units of pRBCs for a Hct of 26% after which time she remained completely stable. Aspirin was restarted on POD 3 and PLavix restarted on POD 7. Through the rest of the hospitalization she remained afebrile, diet was advanced with good tolerance but only fair appetite, regained bowel function and was working with physical therapy. The patient wsa screened for skilled nursing facility as she lives alone and family support was not assured. She received lasix while in house for lower extremity edema and hand puffiness. She was not discharged on lasix but should wear TEDS hose. Medications on Admission: ASA 325' (held), plavix 75' (held), lisinopril 20', nitro prn, crestor 40', trazodone 25 hs prn, vitC, glucosamine, MVI Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day: old for SBP < 110. 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual x1 may repeat x 2 in 15 mins as needed for chest pain: may repeat x 2. 7. Crestor 40 mg Tablet Sig: HOLD Tablet PO once a day: Crestor on hold until liver heals, at least one month. 8. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day. 9. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet PO once a day. 10. Glucosamine-Chondroitin 500-250 mg Capsule Sig: One (1) Capsule PO once a day. 11. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for pain: As needed for constipation, especially while taking narcotics. 13: TEDS hose to lower extremities Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 5165**] Discharge Diagnosis: Intrahepatic cholangiocarcinoma. Discharge Condition: Stable A+Ox3, can be a little forgetful Ambulatory with assist, see PT recs Discharge Instructions: Please call Dr [**Last Name (STitle) 4727**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea, voiting, diarrhea, inability to take or keep down food, fluids or medications, increased abdominal pain, yellowing of skin or eyes or any other concerning symptoms. Monitor the incision for redness, drainage or bleeding Drain and record the JP drain output twice daily and more often as needed. Send copy of drain output record to clinic visit with Dr [**Last Name (STitle) **]. Please call if the drain output changes in color, becomes bloody or develops a foul odor. Patient may shower, do not allow drain to hang freely and allow water to run over incision and then pat dry. The incision may be left open to air, the drain sponge around the drain site should be changed daily and area inspected for leakage. No heavy lifting TEDS hose to lower extremities Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2166-5-21**] 1:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2166-5-15**]

[ "790.01", "564.1", "401.9", "155.1", "414.01", "413.9", "458.29", "575.11", "V45.82", "327.23", "573.8" ]

icd9cm

[ [ [] ] ]

[ "38.93", "50.22", "51.22", "97.49" ]

icd9pcs

[ [ [] ] ]

6161, 6232

3022, 4825

306, 424

6309, 6387

2411, 2411

7304, 7623

1937, 2011

4996, 6138

6253, 6288

4851, 4973

6411, 7281

2026, 2392

1562, 1718

2743, 2999

234, 268

452, 1468

2425, 2729

1749, 1820

1490, 1542

1836, 1921

7,151

147,626

9987

Discharge summary

report

Admission Date: [**2130-1-2**] Discharge Date: [**2130-1-4**] Date of Birth: [**2070-3-9**] Sex: M Service: MEDICINE Allergies: Percocet / Vicodin / Zocor / Protonix Attending:[**Last Name (NamePattern1) 7539**] Chief Complaint: pericardial effusion Major Surgical or Invasive Procedure: pericardiocentesis with pericardial drain History of Present Illness: 59 year old male with history of prostate adenoca s/p radical prostatectomy, CAD s/p angioplasty '[**19**] presents with large pericardial effusion for drainage. The effusion was identified incidentally on Abdominal CT during workup for persistent belching. Small bilateral pleural effusions also noted on Ab CT, but no GI abnormalities. Patient does not note exertional dyspnea in recent past; he routinely exercises (walking, gym) with no recent change in exercise tolerance. Pt also denies syncope, dyspnea, cough, fever, recent URIs or other infections, chills, night sweats. Also denies swollen or sore joints, dry mouth or eyes, hx of lupus, hx of rheumatoid arthritis; he does describe some pain in his lower back over the past 5 yrs, attributed to arthritis. Patient describes some difficulty with swallowing both solids and liquids over past year, and had a barium swallow at NEBH on [**2129-12-29**] which was grossly normal, but with some ineffectiveness in primary peristalsis. Pt has not had a PPD that he can remember. His prostate cancer has been in remission; last PSA was undetectable on [**2129-2-10**]. Past Medical History: Hyperlipidemia CAD (s/p LAD angioplasty in [**2119**]) Prostate CA s/p radiacal prostatectomy ([**2124**]), PSA undetectable Penile prosthesis Social History: Patient was born in [**Country 1684**] and his wife is from [**Country 5881**]; they have lived in the US for many years. He works as a structural engineer and has had work exposure to numberous airborne particles, including asbestos. He has a 30 pack-year smoking history. He does not abuse alcohol and has never used illict drugs. Family History: No family history of cancer. Physical Exam: Vitals: Gen: well-appearing, NAD. HEENT: NC/AT, PERRL, no erythema or exudates in oropharynx. No cervical LAD. CV: regular rate rhythm, +S1, +S2, no murmurs rubs or gallops. Heart sounds not distant. No JVD. No hepatojugular reflex. No pericardial rub auscultated directly after procedure (but observed HD#1). No right ventricular heave. Pulm: CTA anteriorly. No pleural rub noted. Abd: soft, nontender, nondistended. +BS, normal. liver width normal, spleen not palpable. Ext: WWP Bil. 1+ DP/DT bil. No edema bilaterally. Pertinent Results: [**2130-1-2**] 11:57PM POTASSIUM-3.1* [**2130-1-2**] 11:57PM MAGNESIUM-3.1* [**2130-1-2**] 05:16PM GLUCOSE-78 UREA N-17 CREAT-0.8 SODIUM-145 POTASSIUM-2.6* CHLORIDE-111* TOTAL CO2-25 ANION GAP-12 [**2130-1-2**] 05:16PM LD(LDH)-137 [**2130-1-2**] 05:16PM TOT PROT-5.6* MAGNESIUM-1.7 [**2130-1-2**] 05:16PM WBC-6.1 RBC-5.27# HGB-15.4# HCT-41.4# MCV-78* MCH-29.1 MCHC-37.1* RDW-14.6 [**2130-1-2**] 05:16PM PLT COUNT-165 [**2130-1-2**] 05:16PM PT-11.6 PTT-25.3 INR(PT)-1.0 [**2130-1-2**] 02:00PM OTHER BODY FLUID TOT PROT-2.2 GLUCOSE-100 LD(LDH)-78 AMYLASE-12 ALBUMIN-1.7 [**2130-1-2**] 02:00PM OTHER BODY FLUID WBC-350* RBC-1225* POLYS-1* LYMPHS-39* MONOS-2* MACROPHAG-58* Brief Hospital Course: Hospital course by problem: Pericardial Effusion: 410 cc of pericardial fluid was drained in the cath lab on [**2130-1-2**] and after drainiage of the fluid, pericardial pressure reduced to zero. Pericardial fluid was sent for cytology, fluid culture, (including fungal, anaerobic, and acid fast cx) and microscopic analysis (gram stain and acid fast stain). A pericardial drain was left in place. There was no tamponade physiology demonstrated before or during the procedure. The patient was transferred to the CCU. In the immediate post-procedure period, the patient complained of mild, nonradiating chest pain localized over his sternum, but EKG showed no ischemic changes and the pain responded to low dose morphine. This mild chest pain decreased over the period of the [**Hospital 228**] hospital course and was considered to be pericarditic in origin. A pericardial rub was heard directly after the procedure. The pericardial drain had decreasing output after the procedure; 12 hour post-procedure drain output totaled 103cc and the following 12 hours totaled 15cc. On [**2130-1-3**], tranthoracic echocardiogram revealed no residual effusion and normal RV size. The pericardial drain was therefore removed after instilling 5cc of 1% lidocaine into the drain for local pain relief. A wound dressing was placed over the previous site of the drain. On [**2130-1-4**], the patient continued his recovery, with no SOB or oter cardiac symptoms. The wound dressing was changed after the first had sersanginous drainage; the second dressing showed minimal drainage. THe pericardial rub was not present on physical examination on [**2130-1-4**]. Repeat echcardiogram on [**2130-1-4**] again revealed no pericardial effusion. Results of pericardial fluid analysis available during the hospital course suggested a viral vs. idiopathic etiology for the pericardial effusion. Pericardial fluid chemistries showed the pericardial fluid to be transudative (LDH, Tot Pro low). Cytology was negative for malignant cells. Micro analysis revealed no growth in fluid cx and a negative AFB smear. The patient's PCP was advised to follow up AF cx, fungal cx, anaerobic cx, which were not available by the time of discharge. A PPD was placed on the patient's L ant forearm [**2130-1-3**] at 2pm. The patient was advised to follow up with his PCP to have the PPD read on [**2130-1-5**]; the PCP was also informed of this. Ischemia: The patient had angioplasty of LAD in '[**19**]. Mild chest pain felt during the hospital course was thought to be pericarditic in origin, given no ischemic EKG changes and prompt response to pain meds. The patient was discharged on ASA, CCB, and a BB for management of his chronic HTN and CAD. Prostate Ca: The patient's Prostate CA has been in remission as of [**2129-2-10**]. He is followed at [**Hospital1 18**] by Dr. [**Last Name (STitle) 33427**] of Urology. FEN: The patient was maintained on a regular diet throughout his hsopital course. He had a persistently low potassium level (2.6 on [**1-3**]), which was repleted with KCl tablets QD. He was discharged with his home dosage of KCl tablets--20meq--and a normal potssium level of 3.4. Medications on Admission: Pravachol 40 mg QD Toprol XL 25 mg QD Norvasc 10 mg QD ASA 325 mg QD Discharge Medications: Pravachol 40 mg QD Toprol XL 25 mg QD Norvasc 10 mg QD ASA 325 mg QD Potassium Chloride 20meq QD Discharge Disposition: Home Discharge Diagnosis: Pericardial Effusion Discharge Condition: Good Discharge Instructions: Return to the hospital if you have fever (>101.5 F), acute shortness of breath, persistent chest pain, swelling of legs, trouble breathing with exertion, or redness and sweling at your wound site in the week following your procedure. Keep the wound site clean with a sterile gauze dressing or band aid applied for the two weeks following the procedure. Followup Instructions: Please follow up with your cardiologist, Dr. [**First Name (STitle) 33428**] [**Name (STitle) **] within 2 weeks, phone [**Telephone/Fax (1) 33429**] Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 33430**] [**Name (STitle) 29994**] TOMORROW ([**2130-1-5**]) to have your PPD read. (phone [**Telephone/Fax (1) 33431**]) Completed by:[**2130-1-4**]

[ "414.01", "276.8", "511.9", "V45.82", "V10.46", "423.9" ]

icd9cm

[ [ [] ] ]

[ "37.21", "88.55", "37.0" ]

icd9pcs

[ [ [] ] ]

6800, 6806

3369, 3369

324, 367

6870, 6876

2657, 3346

7278, 7686

2059, 2089

6679, 6777

6827, 6849

6586, 6656

6900, 7255

2104, 2638

264, 286

3398, 6560

395, 1524

1546, 1690

1706, 2043

4,538

109,082

19204

Discharge summary

report

Admission Date: [**2124-3-28**] Discharge Date: [**2124-4-14**] Date of Birth: [**2047-6-24**] Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: This patient is a 76 year old male with known left bundle branch block who was admitted to the Medical Service for increasing exertional arm and back pain. Associated symptoms were dyspnea on exertion. PAST MEDICAL HISTORY: 1. Hypertension. 2. History of malaria. 3. Gastroesophageal reflux disease. 4. Barrett's esophagus. 5. Colonic polyps. 6. Iron deficiency anemia. 7. History of proteinuria. 8. History of asbestos exposure. PAST SURGICAL HISTORY: Unremarkable. MEDICATIONS ON ADMISSION: 1. Protonix 20 mg p.o. q. day 2. Iron Sulfate 3. Lisinopril ALLERGIES: Lobster. SOCIAL HISTORY: Unremarkable. PHYSICAL EXAMINATION: The patient, on physical examination, was afebrile with vital signs stable. Head was atraumatic, normocephalic. No scleral icterus noted. Neck was soft, supple, no carotid bruits noted. Heart was regular rate and rhythm with a II/VI systolic ejection murmur noted. Chest was clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended, positive bowel sounds. Extremities with no edema. Pulse examinations were palpable throughout bilaterally. HOSPITAL COURSE: The patient was admitted on [**2124-3-28**] to the Medical Service and taken for cardiac catheterization which revealed a 50% occlusion of the left main, 80% occlusion of the ostial left anterior descending, 95% occlusion of the left circumflex and 100% occlusion of the mid right coronary artery. In addition, echocardiogram in [**2124-2-10**] revealed an ejection fraction of 25%, global left ventricular hypokinesis and mild diastolic aortic root, trace aortic regurgitation, 2+ mitral regurgitation and 2+ tricuspid regurgitation. Cardiac Surgery was consulted on the date of admission for evaluation and treatment via possible coronary artery bypass graft. At this time, the patient also had ongoing medical problems including renal insufficiency with a creatinine up to 2.0 and iron deficiency anemia. At this time ACE inhibitor was held and the patient was gently hydrated with 1/2 normal saline. Between the date of admission and [**2124-4-2**], the patient's chronic renal insufficiency appeared to stabilize with a creatinine approximately between 1.8 and 2.0. During this interval time, the patient was approached and options for surgery were discussed. The patient agreed to surgery on [**2124-4-3**] and went to the Operating Room for coronary artery bypass graft times four, left internal mammary artery to left anterior descending, saphenous vein graft to ramus, saphenous vein graft to obtuse marginal and saphenous vein graft to right coronary artery. For more details, please see operative report. Postoperatively, the patient went to the Cardiac Surgery Recovery Unit. On postoperative day #0 the patient was noted to be in accelerated junctional rhythm, however, when his rate slowed down the patient would commence to enter complete heartblock. The patient lost his atrial fibrillation with P pacing and was unable to A pace when in complete heartblock. His blood pressure remained labile, sensitive to rate and rhythm changes and was being managed with Levophed GTT. On postoperative day #1, the patient was on Levophed and Milrinone drips with a pressure in the 1-teens. The patient was extubated on postoperative day #1 and pressors were continuously weaned over the day which the patient tolerated well. On postoperative day #2, the patient went into atrial fibrillation with the rates in the 130s to 140s, otherwise hemodynamically stable. The patient was treated with Lopressor 2.5 mg intravenously times two with good effect, heart rate decreasing to the 1-tens. The pacer settings were changed appropriately and Amiodarone bolus 150 mg was given. The patient converted to a rate of 40s to 50s with Amiodarone bolus and required A pacing to maintain blood pressure and indices. Amiodarone drip was started shortly thereafter. The patient was diuresed over the next several days with good effect. Creatinine was stable at 1.9 to 2.0. On postoperative day #4, the patient again went into atrial fibrillation and Amiodarone bolus was once again given. The patient went back into normal sinus rhythm and the patient was on p.o. Amiodarone. On postoperative day #5, later in the day the patient was put on a heparin drip. On postoperative day #6, the patient was transferred to the floor, and on postoperative day #7 the patient was started on Coumadin with a therapeutic range of 2.0. Of note, as well is that postoperative echocardiogram revealed an ejection fraction of 15 to 20%. The remainder of the [**Hospital 228**] hospital course was unremarkable. The patient remained in sinus rhythm with being loaded for Coumadin with INRs being checked daily and in the meantime being on a heparin drip. On postoperative day #11, the patient's INR was reacting appropriately to Coumadin dosing at 1.6. The patient was still on a heparin drip. The patient was deemed well enough to go home with services with Lovenox to bridge the patient until he was therapeutic. DISCHARGE STATUS: Home. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Chronic renal insufficiency. 3. Hypertension. 4. Gastroesophageal reflux disease. DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. b.i.d. 2. Aspirin 325 mg p.o. q. day 3. Percocet 1 to 2 tablets p.o. 4-6 hours prn for pain 4. Metoprolol 12.5 mg p.o. q. day, extended release. 5. Amiodarone 400 mg p.o. b.i.d. times one week, then 400 mg p.o. q. day times one week and then 200 mg p.o. q. day. 6. Nexium 40 mg p.o. q. day. 7. Coumadin 5 mg p.o. q.h.s. with therapeutic INR of 2.0. 8. Iron sulfate 325 mg p.o. b.i.d. 9. Lovenox dosed for b.i.d. dosing times three days. FOLLOW UP: The patient is to follow up in [**Hospital 409**] Clinic in two weeks, Dr. [**Last Name (STitle) 5717**] in three to four weeks and also for INR checks, Dr. [**Last Name (STitle) **] on [**5-1**], Dr. [**Last Name (STitle) **] in the Electrophysiology Clinic in one month and Dr. [**Last Name (STitle) 70**] in six weeks. [**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 7190**] MEDQUIST36 D: [**2124-4-14**] 10:16 T: [**2124-4-14**] 10:40 JOB#: [**Job Number 52346**]

[ "427.31", "280.9", "593.9", "530.81", "414.01", "428.0", "401.9", "997.1", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.13", "37.23", "36.15", "88.56" ]

icd9pcs

[ [ [] ] ]

5271, 5278

5440, 5909

5299, 5417

683, 769

1311, 5249

642, 657

5921, 6520

824, 1293

177, 381

403, 618

786, 801

9,402

138,054

2634

Discharge summary

report

Admission Date: [**2154-2-17**] Discharge Date: [**2154-2-22**] Date of Birth: [**2084-3-11**] Sex: F Service: MEDICINE Allergies: Aspirin / Aleve Attending:[**First Name3 (LF) 4219**] Chief Complaint: - GIB - Anemia Major Surgical or Invasive Procedure: - Emergent intubation for pulmonary edema History of Present Illness: 69yo F with ESRD on HD, CAD, DM, HTN, CHF (EF 60-70%, 3+ MR), who had HD on Friday and then came to ED today with c/o darker stools. She went to HD on Friday and was told that her hct was lower but did not recieve a tranfusion. This mornign she awoke and had a BM which was dark and states there was blood in his stool but could not provide mroe informaiton than that. +LH/dizziness at all times. She said that there were multiple dark sotols over the last several weeks. She deneis any chest pain but did admit to chest pressure on the left side without radiation which was reilieved with one ntg in the ED. No abd pain. good appetite yesterday but none today; some nausea. . During her admission [**2153-12-26**], the pt received an EGD which demonstrated GAVE (watermelon stomach) s/p APC (Argon Laser). She received 2units of PRBCs during the previous admission. The pt also has a history of colonic polyps from c-scope in [**2152**] s/p polypectomy. . In the ED, 98.3, 112, 119/55, 16, 100% RA. Received 2 u PRBCS for Hct drop to 22. Rectal dark brown/black stool G+, NG lavage blood tinged, mild [**Year (4 digits) 13223**] and hypotension, also transient EKG change w/ ST depression, given 1L IVF, txn'ed 2u RBC (1st unit [**Unit Number **] mins, second unit over 2 hrs). First set of CE's negative. . Admitted to MICU for further monitoring of hct in setting of likely GIB. Pt was assessed in the MICU at 5 15. Pt extremly conversant and wihtout any complaints Past Medical History: 1. Type 2 diabetes mellitus complicated by nephropathy and neuropathy. 2. ESRD on HD since [**November 2153**] 3. CAD: suspected by stress test in [**2153-5-22**], not reperfused. 4. CHF: TTE on [**2153-11-1**]. It showed a LVEF of 60 to 70% with 3+ MR and 2+ TR. 5. Anemia: Felt to be multifactorial from ESRD and also guiac positive. Pt had a colonoscopy on [**2153-8-7**] significant for two nonbleeding polyps in the sigmoid colon. She also had an EGD on the same date which was significant for erythema, edema, and erosion in the antrum compatible with gastritis in addition to erythema in the proximal bulb compatible with duodenitis. No bleeding was noted. EGD has since demonstated GAVE on 2'[**53**]. 6. Occult GI bleed [**7-/2153**] with studies as above 7. Gout Social History: Pt lives alone in an [**Hospital3 **] community. She has a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 13222**]. Son lives close by and helps mother. [**Name (NI) **] ETOH, tobacco, or drugs. Family History: [**Name (NI) 1094**] son and daughter have DM. Her son also has HTN. She has no family history of CAD. Physical Exam: VS: 98.3, 120/55, HR 113-118, 97% 4L NC--->intubated GEN: well nourished elderly AA female in NAD, comfortable, intubated with pink material from ETT HEENT: EOMI, anicteric, [**Last Name (un) **] mm, op clear NECK: no appreciable JVD CV: [**Last Name (un) 13223**], s1, s2, ?1/6 SEM CHEST: crackles in lungs ABD: obese, soft, NT, ND, BS+, ventral hernia RECTAL: guiac + per ED EXT: L UE fistula with thrill. NEURO: A+O x3, strength 5/5 bilaterally in UE, LE not tested. Gait not assessed. . Pertinent Results: Labs on admission: WBC 9.8, HCT 21.7, MCV 107, Plt 291 (DIFF: NEUTS-78.6* BANDS-0 LYMPHS-15.8* MONOS-3.2 EOS-2.2 BASOS-0.2) PT 12.4, PTT 27.3, INR(PT) 1.1 Na 143, K 4.7, Cl 99, HCO3 30, BUN 47, Cr 5.4, Glu 188 Lactate 1.9, free Ca 1.06 Hct 29.8 . Blood gases: [**2154-2-17**] 7:47PM ABG PO2-240* PCO2-46* PH-7.37 TOTAL CO2-28 BASE XS-1 [**2154-2-18**] 12:00AM ABG PO2-118* PCO2-41 PH-7.40 TOTAL CO2-26 BASE XS-0 . Urinalysis: [**2154-2-17**] 02:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015 BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE EPI-0-2 . Cardiac enzymes: [**2154-2-17**] 10:20AM CK(CPK)-94 CK-MB-NotDone cTropnT-0.08* [**2154-2-17**] 07:34PM CK(CPK)-66 CK-MB-NotDone . Labs on discharge: WBC 10.0, Hct 37.7, MCV 93, Plt 286 INR 1.1 Na 136, K 4.9, Cl 92, HCO3 26, BUN 75, Cr 6.7, Glu 78, Ca 8.7, Ph 10.0, Mg 2.3 . Micro: [**2154-2-18**] - MRSA, VRE neg [**2154-2-18**] - blood cx neg x4 [**2154-2-18**] - urine cx URINE CULTURE (Final [**2154-2-22**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | ENTEROCOCCUS SP. | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S 1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2154-2-18**]): SPECIMEN UNACCEPTABLE FOR ANAEROBES. TEST CANCELLED, PATIENT CREDITED. [**2154-2-21**] - urine cx URINE CULTURE (Final [**2154-2-23**]): Culture workup discontinued. Further incubation showed contamination with mixed fecal flora. Clinical significance of isolate(s) uncertain. Interpret with caution. GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. . Imaging: EGD [**2154-1-10**]: Esophagus: Normal mucosa. Stomach: Linear streaks of erythema of the mucosa with contact bleeding and in a watermelon distribution was noted in the antrum. These findings are compatible with GAVE. An Argon-Plasma Coagulator was applied for hemostasis successfully. Duodenum: Normal mucosa was noted from the duodenum to the proximal jejunum. There were no blood or any bleeding lesions. Impression: Erythema in the antrum compatible with GAVE s/p APC . EGD [**2154-1-22**]: Impression: Erythema and congestion in the duodenal bulb consistent with duodenitis. Erythema and congestion in the antrum compatible with GAVE Small angioectasias in the jejunum without evidence of bleeding Recommendations: Protonix 40 mg Twice daily Capsule endoscopy . Colonoscopy [**2154-1-22**]: Impression: Scant stool mixed in with prep liquid in the colon Findings do not explain bleeding. Recommendations: Source of bleeding not identified, recommend capsule endoscopy . ECG: Poor baseline. NSR @89 w/borderline QTC, nl axis. Compared w/priors, ST depression in inferolateral distribution has changed to .5mm ST elevation in aVL, 1mm ST elevation in V2-V6, concering for anterolateral ischemia. . CXR [**2154-2-17**]: An endotracheal tube is present, with the tip in the proximal right main stem bronchus. Right internal jugular dialysis catheter is unchanged in position. The heart is normal in size. There are new bilateral central alveolar opacities as well as peripheral septal lines, consistent with pulmonary edema. Findings communicated by telephone to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2154-2-17**]. . CXR [**2154-2-18**]: Moderately severe pulmonary edema has improved since 6:30 p.m. on [**1-28**]. Heart size is normal and mediastinal vasculature is no longer distended. Little if any pleural effusion is present. ET tube is in standard placement. Tip of a right supraclavicular dual channel central venous line project over the SVC. No pneumothorax. . CXR [**2154-2-20**]: There is interval resolution of the pulmonary edema. A right-sided central venous catheter is seen with its tip in the right atrium. The heart size, mediastinal and hilar contours are unremarkable. . EGD [**2154-2-21**]: - Normal esophagus. - Stomach: Flat Lesions Multiple angiodysplasias/watermelon stomach was seen in the antrum compatible with GAVE. An Argon-Plasma Coagulator was applied for hemostasis successfully. - Duodenum: Angiodysplasias distributed in a linear pattern was noted in the first part of the duodenum. - Impression: Watermelon stomach in the antrum, Angiodysplasias in the first part of the duodenum, Otherwise normal egd to second part of the duodenum . Brief Hospital Course: # RESPIRATORY FAILURE: The patient was admitted to the MICU and initially was HD stable. Mrs. [**Known lastname 13224**] had received 1 L NS in the ED, as well as 2u pRBCs (Hct 21.7 -> 29.8). However, she then became acutely dyspneic, with pink frothy sputum production. She was quickly intubated for airway protection for flash pulmonary edema [**12-27**] volume overload. Differential diagnosis at that time included diffuse alveolar hemorrhage, PNA (though she was afebrile, with no WBC), PE, or cardiogenic shock (though her troponins were not above her baseline, but still possible with 3+ MR [**First Name (Titles) **] [**Last Name (Titles) 13223**]). An A-line was placed. Lasix was given with minimal effect as Mrs. [**Known lastname 13224**] is oliguric. HD was initiated, with simultaneous transfusion of 2u pRBCs, but the session was aborted after 1 kg of fluid was removed due to hypotension requiring the use of neosynephrine. Mrs. [**Known lastname 13224**] was comfortable on the ventilator with AC settings, so sedation was not necessary. Her CXR confirmed pulmonary edema. Her enzymes were trended and remained flat. She subsequently underwent another HD session on [**2-18**] and was extubated on [**2-19**] as her O2 requirement was markedly decreased and her CXR showed improvement in her edema. Mrs. [**Known lastname 13224**] was then transfered to the floor with stable RA sats. . # UGIB: Mrs. [**Known lastname 13224**] has a h/o GAVE. After being stabilized in the MICU, she was transferred to the floor. She underwent an EGD which again showed GAVE and argon cauterization was performed. She continued to have some blood in her stool, but her Hct remained stable. She was discharged with a Hct of 37.7. . # ANEMIA: Mrs. [**Known lastname 13224**] is anemic, likely of a multifactorial etiology including ESRD and iron deficiency from GIB. She required 4 units of pRBCs on [**2-17**] to keep her Hct >28 with a concern for demand ischemia given her h/o CAD. Her Hct subsequently remained stable. She was continued on epo with HD and daily iron supplements. . # CAD: In the ER, her EKG showed the acute onset of lateral ST depressions and dynamic which were concerning for demand ischemia. Cardiology was consulted and felt that she may require a repeat stress test and possibly a cath in the future once her GIB issue has been resolved. However, it was felt that she was stable and not having an ACS. Her EKG changes resolved with correction of her Hct and her enzymes remained unchanged. She was monitored on telemetry and remained in NSR. She was continued on lipitor and metoprolol. She was not given an aspirin given her GIB. . # CHF: Mrs. [**Known lastname 13224**] has a h/o CHF with preserved EF of 60-70% per ECHO on [**2154-2-18**] with 3+ MR [**First Name (Titles) 13225**] [**Last Name (Titles) 7216**] dysfunction. Her flash pulmonary edema was likely due to volume overload from rapid infusion of pRBCs. Her weight and her I/O were closely monitored with a goal of I/O even. Her volume status was managed by HD and a low sodium diet. Her beta blocker was continued. . # DM TYPE II: While hospitalized, Mrs.[**Known lastname 13226**] oral antihyperglycemic was held and she was covered with a RISS as she was not eating regularly. Once her diet was restarted, glipizide was restarted. She was somewhat hypoglycemic with her glipizide, so it was advised that she hold off on glipizide until she resumes a normal diet at home. . # ESRD: Mrs. [**Known lastname 13224**] has been on HD since [**2153-11-25**]. She was continued on her regular HD schedule while hospitalized and was followed by the renal service. She was continued on nephrocaps and calcium acetate. . # GOUT: She was continued on her outpatient dose of allopurinol. . # THRUSH: She was continued on nystatin. . # FEN: She was kept NPO until her EGD, then she was advanced to a regular [**Doctor First Name **] diet. She was given no other IVF due to her tenous volume status. Her electrolytes were checked daily and were repleted prn to keep K>4 and Mg>2. . # PPX: PPI, pneumoboots for DVT ppx. No bowel regimen indicated. . # ACCESS: Peripheral IVs. . # DISPO: To home, with services. . # CODE: FULL . # COMM: [**Name (NI) **] [**Name (NI) **], at [**Telephone/Fax (1) 13227**] Medications on Admission: phoslo folic acid MVI toprol xl glucophage vit B lipitor allopurinol protonix glipizide Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. 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* 4. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day) for 2 weeks. Disp:*1200 ML(s)* Refills:*2* 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Glipizide 2.5 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO once a day. 7. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a day: Please take w/ meals. 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 9. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 10. Vitamin B Complex Tablet Sig: One (1) Tablet PO once a day. 11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 12. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 13. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. 14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: GAVE Pulmonary edema . Secondary diagnosis: Diabetes mellitus type II Diabetic neuropathy/nephropathy ESRD on HD since [**11-30**] CAD Anemia CHF with EF 60-70%, 3+ MR, 2+ TR Gout Discharge Condition: Good, BP 110/60, HR 86, RR 18, sats 99% on 2L Discharge Instructions: 1. Please call your PCP or go to the nearest ER if you develop any of the following symptoms: fever, chills, chest pain, dizziness, lightheadhedness, dark, tarry or bloody stools, burning on urination, abdominal pain or tenderness, or any other worrisome symptoms. . 2. You should weigh yourself every morning and call your PCP if weight > 3 lbs. . 3. You should take all your medications as prescribed. The only change in your medications is to take Toprol XL 50mg daily. . 4. You should follow-up with the GI department as previously scheduled for a repeat EGD on [**2154-3-7**]. . 5. Please have a hematocrit (a measure of your red blood cells) checked at each hemodialysis session. Per your GI doctors, you should be transfused for any hematocrit less than 25. Followup Instructions: 1. Provider [**Name9 (PRE) 13228**] [**Name9 (PRE) 13229**], [**First Name3 (LF) **] on [**2154-3-5**] at 12:00 #[**Telephone/Fax (1) 2226**] . 2. Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD on [**2154-3-7**] at 8:00 #[**Telephone/Fax (1) 1983**] Provider GI WEST,ROOM ONE GI ROOMS on [**2154-3-7**] at 8:00 . 3. Please call your PCP: [**Name10 (NameIs) **],[**Known firstname **] [**Name Initial (NameIs) **]. at [**Telephone/Fax (1) 7976**] for a follow-up within 1-2 weeks. You should have a urinalysis checked within a week to make sure that you have cleared your urinary tract infection. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]

[ "112.0", "537.83", "403.91", "518.81", "250.40", "424.0", "585.6", "285.21", "428.0", "250.60", "428.33", "285.1", "357.2", "397.0", "599.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "39.95", "96.71", "99.04", "44.43", "38.91" ]

icd9pcs

[ [ [] ] ]

14541, 14598

8776, 13060

291, 334

14841, 14889

3508, 3513

15702, 16430

2876, 2981

13199, 14518

14619, 14619

13086, 13176

14913, 15679

2996, 3489

4190, 4308

237, 253

4327, 8753

362, 1833

14682, 14820

14638, 14661

3527, 4173

1855, 2630

2646, 2860

16,698

161,491

51639

Discharge summary

report

Admission Date: [**2126-1-8**] Discharge Date: [**2126-1-15**] Date of Birth: [**2045-6-8**] Sex: M Service: CARDIOTHORACIC Allergies: A.C.E Inhibitors / Beta-Adrenergic Blocking Agents Attending:[**First Name3 (LF) 2969**] Chief Complaint: Right pleural mesothelioma with symptomatic recurrent right pleural effusion. Major Surgical or Invasive Procedure: cardiac catheterization with right coronary artery embolectomy and stent right chest tube and talc pleuradesis. History of Present Illness: Mr. [**Known lastname 105691**] is an 80-year-old gentleman with biopsy-proven right pleural mesothelioma which was a delayed diagnosis at the time of original pleural biopsy which was interpreted as reactive initially and subsequently malignant. He has accumulated pleural fluid which is symptomatic and lifestyle-limiting. he is admitted for drainage and talc poudrage. Past Medical History: PMHx: 1. Hypertension 2. Hypercholesterolemia 3. Cataract, left eye. 4. Macular hole, left eye. PSHx: 1. Total knee replacement. 2. Prostatectomy 3. Cataract extraction Stent to RCA after circulatory collapse Social History: He currently lives with his girlfriend. [**Name (NI) **] is a retired laboratory technician and was exposed to significant amounts of beryllium over his professional career. He denies any exposure to asbestos. He currently smokes about two packs a week and has a 30 pack-year smoking history. Family History: He denies any family history of lung disease. Physical Exam: general; well appearing, young 80 yr old male in NAD at rest w/SOB w/ activity. HEENT: unremarkable chest: breath sounds clear on left/decreased on right. COR: RRR S1, S2 Abd: soft, NT, ND, +BS Extrem: no C/C/E neuro: intact Pertinent Results: Emergent ECHO in OR for cirulatory collapse: initial EF w/ CPR 5-10%. On inotropic support (epinephrine): Improved biventricular systolic function. LVEF now 60%. No wall motion abnormalities seen. 1+ MR. [**Name13 (STitle) **] Tamponase Emergent cardiac cath [**2126-1-8**] RIGHT CORONARY 1) PROXIMAL RCA DISCRETE 70 2) MID RCA DIFFUSELY DISEASED 2A) ACUTE MARGINAL DIFFUSELY DISEASED 3) DISTAL RCA DIFFUSELY DISEASED COMMENTS: Successful PCI of the proximal and mid RCA using bare metal stents as described in the PTCA portion of this report. FINAL DIAGNOSIS: 1. Single vessel coronary artery disease. 2. Successful PCI of the proximal and mid RCA using bare metal stents. cxr [**2126-1-15**]: Unchanged right-sided loculated hydropneumothorax Brief Hospital Course: Pt taken to the OR for right VATS for drainage of effusion and poudrage. After induction and intubation pt developed progressive hypotension, bradycardia and eventually asystole. This was during prepping and draping. He was returned to the supine position urgently and CPR was initiated. ACLS protocol was followed. Echo wa done w/ depressed LV function. Inotrope support w/ epi was initiated. This resulted in restoration of rhythm and subsequently blood pressure. A right 28-French angled chest tube was placed in approximately the 6th to 7th interspace in the mid- clavicular line. Approximately 2 liters of pleural fluid were drained. Throughout the rest, the patient had adequate blood gases with a pO2 over 200 and a normal pCO2.After obtaining hemodynamic stability, the patient was transferred immediately from the operating room to the cardiac cath lab for diagnostic coronary evaluation and possible percutaneous intervention. The Cath revealed thrombus and stenosis in the proximal RCA with TIMI 2 flow. Integrilin and heparin were administered with therapeutic ACT monitoring. Successful PCI of the proximal and mid RCA using bare metal stents. Upon completion of the procedure pt was transferred to the CRSU for ongoing invasive monitoring and ventilatory support. Initially on neo for BP support-weaned off quickly. POD#1 Extubated. Integrilin then on asa and plavix per protocol. [**Last Name (un) **] beta blockade. BUN and creat elevated likely d/t ATN/dye load. Chest tube to sxn with moderate drainage. POD#2 Decreasing chest tube output. Talc pleuradesis at bedisde. liver ultrasound done to eval access of liver lesions for future biopsy. POD#3 chest tube maintained on sxn. Progressing w/ post op care. [**Last Name (un) **] diet, ambulating, pain controlled w/ PCA. POD#4 chest tube placed to water seal. Creat improving. Rec'd unit PRBC for post op anemia. POD#5 chest tube d/c'd. CXR Status post right chest tube removal, with largely unchanged effusion/loculated hydropneumothoraces except for a new small loculated hydropneumothorax near the prior tube site posteriorly. POD#6 -7 Cardiac meds adjusted to better control HR and blood pressure and pt d/c'd to home w/ VNA services for ongoing cardiopulmonary assessment. Medications on Admission: Losartan 50', Atorvastatin 40', Amlodipine 5', ASA, Percs Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*90 Tablet(s)* Refills:*0* 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 9. oxygen oxygen 2liters continuous for portability pulse dose system Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. Right pleural mesothelioma with symptomatic recurrent right pleural effusion. 2. Cardiovascular collapse. 3. HTN Discharge Condition: Good/oxygen dependent at present- oxygen saturation 87% on 1 liter nasal cannula with ambulation Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you have fever, chills, cough, chest pain or redness or drainage from your chest incision or any questions regarding your future surgery. Please resume your home medications. Take all new medications as prescribed. Do not drive while taking narcotic pain medications. You may shower. after showering, remove your chest tube site dressing and cover the area with a clean gauze daily until healed. Resume your regular diet. No heavy lifting (>10 lbs) until after your follow up visit. Wear oxygen 2Liters during sleep and with ambulation Followup Instructions: Please call Dr.[**Doctor Last Name 4738**] office ([**Telephone/Fax (1) 1504**], to arrange a follow up appointment. Call Dr.[**Name (NI) 26896**] office [**Telephone/Fax (1) 4022**] to arrange a follow up appointment to be seen in [**3-17**] weeks. Completed by:[**2126-1-28**]

[ "401.9", "511.9", "V43.65", "414.01", "410.71", "573.9", "162.4", "997.1", "585.9", "584.5", "512.1" ]

icd9cm

[ [ [] ] ]

[ "36.06", "88.72", "34.04", "00.40", "38.93", "99.60", "00.17", "00.66", "37.23", "88.56", "00.46", "99.04", "99.20", "34.92" ]

icd9pcs

[ [ [] ] ]

5789, 5847

2564, 4822

394, 508

6007, 6106

1778, 2337

6769, 7050

1471, 1518

4930, 5766

5868, 5986

4848, 4907

2354, 2541

6130, 6746

1533, 1759

276, 356

536, 909

931, 1144

1160, 1455

19,812

109,621

7418

Discharge summary

report

Admission Date: [**2155-4-14**] Discharge Date: [**2155-4-17**] Date of Birth: [**2118-3-19**] Sex: F Service: CHIEF COMPLAINT: Right swollen arm times two days. HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old female with only significant past medical history for insulin-dependent diabetes mellitus since the age of 21, status post total thyroidectomy for hurtle cell multinodular goiter in [**Month (only) **] of [**2152**]. Also on oral contraceptive pills. The patient presented to her primary care physician's office on [**4-14**] with a complaint of swollen and painful right arm for the last two days. The patient stated that her arm felt warmer, and the pain was radiating from the lower aspect of the upper arm to the right shoulder and upper back. The patient also felt mild paresthesias in her right fingers. The patient was seen her primary care physician's office and was sent to the Emergency Department for further evaluation for her swollen right arm to rule out deep venous thrombosis. REVIEW OF SYSTEMS: The patient stated that the pain is worsened with exertion of the right upper extremity. She denied any shortness of breath, chest pain, or palpitations. She has no history of recent trauma; although, she did apparently give a toddler a piggyback ride prior to the onset of her symptoms. She has no prior history of blood clots and is a nonsmoker, but she has been taking oral contraceptive pills for the last five to six years. She works her upper extremities with weights of 10 to 15 pounds. Her mother had a lower extremity deep venous thrombosis after giving birth, but she has no other family history of deep venous thrombi or pulmonary emboli. Also, on review of systems, the patient had mild lower extremity pain behind the left popliteal fossa for the last two to three weeks with some mild left ankle swelling as well. She denied any recent periods of immunization. PAST MEDICAL HISTORY: 1. Insulin-dependent diabetes mellitus diagnosed at the age of 21 when the patient had experienced an episode of diabetic ketoacidosis. She is on an insulin pump that she has managed for the last eight years. 2. History of multinodular goiter; status post thyroidectomy. Pathology revealed hurtle cell. FAMILY HISTORY: Mother with a history of postpartum deep venous thrombosis after giving birth to the patient. The deep venous thrombosis was apparently in the lower extremities. Father with coronary artery disease and 3-vessel coronary artery bypass graft at the age of 57. SOCIAL HISTORY: The patient lives with her boyfriend. She denied any tobacco or significant alcohol use. She regularly exercises and is very active, working out five days a week and lifts weights on [**Month (only) 766**] and Friday. ALLERGIES: PENICILLIN (which causes a rash). MEDICATIONS ON ADMISSION: 1. Levoxyl 112 mcg by mouth once per day. 2. Humalog insulin pump; managed by the patient for the last eight years. 3. Trivora oral contraceptive pill; the patient most recently completed her recent pack two days ago. PHYSICAL EXAMINATION ON PRESENTATION: On admission to the Medical Intensive Care Unit the patient's temperature was 98.9 degrees Fahrenheit, her blood pressure was 130/80, her pulse was 60 to 70, her respiratory rate was 14, and she was saturating 100% on room air. In general, the patient was alert and oriented times three. She was appropriate and in no apparent distress. Head, eyes, ears, nose, and throat examination revealed the oropharynx was clear. The pupils were equal, round, and reactive to light. The extraocular movements were intact. The mucous membranes were moist. The neck was supple and nontender. There was no jugular venous distention. Cardiovascular examination revealed a regular rate and rhythm. No murmurs. The lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended. There were good bowel sounds. Extremities were warm and well perfused. There was no lower extremity edema. Right upper extremity with increased warmth and mild edema. The patient had a TPA catheter in place with no ecchymoses or signs of bleeding. No lower extremity edema, but there was mild tenderness to palpation of the left popliteal fossa. Neurologically, cranial nerves II through XII were intact with no focal deficits. PERTINENT LABORATORY VALUES ON PRESENTATION: On admission to the Medical Intensive Care Unit the patient had a white blood cell count of 7.9, her hematocrit was 38.6, and her platelets were 192. Prothrombin time was 13.3. Her INR was 1.5. Chemistry-7 revealed sodium was 138, potassium was 3.8, chloride was 104, bicarbonate was 25, blood urea nitrogen was 12, creatinine was 0.8, and her blood glucose was 61. Alanine-aminotransferase was 16, her aspartate aminotransferase was 17, her alkaline phosphatase was 35, and her total bilirubin was 0.6. PERTINENT RADIOLOGY/IMAGING: A lower extremity ultrasound of the left leg was negative. A right upper extremity ultrasound revealed complete thrombosis of the right subclavian, right axillary, and right brachial veins with intraluminal thrombus and thrombosis of the right basilic vein. The patient had a patent right internal jugular. An electrocardiogram showed a normal sinus rhythm at 70 beats per minute with normal axis and normal intervals. There were biphasic T waves in leads III. No old electrocardiogram for comparison. A chest x-ray was clear with no cardiopulmonary process. ASSESSMENT: The patient is a 37-year-old female with spontaneous right upper extremity venous thrombosis, status post Interventional Radiology guided direct catheter placement for thrombolysis. SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient had an ultrasound of the right upper extremity which revealed a right subclavian, axillary, brachial, and basilic vein thrombosis. She was started on a heparin drip. She was also taken to Interventional Radiology for a catheter-directed percutaneous transluminal angioplasty therapy given that she has a spontaneous right upper extremity deep venous thrombosis (Paget-Schr??????tter) syndrome. The patient was then transferred to the Medical Intensive Care Unit status post catheter-directed thrombolysis of her spontaneous right upper extremity venous thrombosis. 1. RIGHT UPPER EXTREMITY VENOUS THROMBOSIS ISSUES: On admission to the medicine floor, the patient was initially placed on a heparin drip per weight based guidelines. Her lower extremity ultrasound of the left leg was negative for deep venous thrombosis. The patient was taken to Interventional Radiology for catheter-directed thrombolysis. After her Interventional Radiology procedure, she remained supine with the head of the bed less than 20 degrees, and she had frequent monitoring of her prothrombin time, INR, fibrinogen, and hematocrit. The patient was taken to Interventional Radiology three times after her initial catheter-directed TPA was placed for re-visualization. After her initial placement of the TPA catheter and overnight infusion of the t-PA as well as heparin directly at the sight of thrombosis, the patient returned to Interventional Radiology for re-visualization and was still found to have residual clot; although, 90% of the clot had resorbed. The patient also had a balloon angioplasty of the stenosed area of the subclavian vein performed at that time. She remained in the Medical Intensive Care Unit overnight for further monitoring since t-PA infusion continued at a rate of 1 mg per hour in her right arm. The next morning, [**4-17**], the patient was again seen by Interventional Radiology and was found to have no evidence of residual intraluminal thrombus. The patient continued to have high-grade stenosis of the subclavian vein with a jet flow through it, and no evidence of thrombus. However, since she continued to have stenosis of the vein, it was likely the patient may have an anatomic abnormality such as clavicle/rib compression causing a thoracic outlet syndrome which may have caused the initial clot. The patient was encouraged to discontinue use of her oral contraceptive pills. She was also instructed by the nurse how to give Lovenox injections prior to discharge. 2. ANTICOAGULATION ISSUES: Her t-PA was discontinued in the Interventional Radiology suite. The patient returned to the Unit for monitoring during the day and was found to be stable. The patient will be discharged on Lovenox and Coumadin and was to follow up at the [**Hospital6 733**] Clinic for an INR check on [**Hospital6 766**], [**3-24**]. The patient's primary care physician (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) will follow up on this INR level and call the patient for an appropriate adjustment of her Coumadin dosage. The patient will need to have frequent monitoring of her INR while she is on Coumadin. The patient will likely continue Lovenox for five to six days while she becomes therapeutic on her Coumadin. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**] was consulted as an inpatient regarding the question of need for a hypercoagulable workup and the length of treatment. The patient will have a follow-up appointment scheduled with Dr. [**Last Name (STitle) 3060**] as an outpatient regarding the need for further hypercoagulable workup followup, and this will be arranged by the patient's primary care physician. Regarding anatomic abnormality causing a thoracic outlet syndrome, the patient may need surgical followup as an outpatient as well to prevent further thrombosis. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**] will also follow up with the patient regarding expected duration of treatment. With the patient's particular syndrome, a spontaneous right upper extremity deep venous thrombosis status post t-PA thrombolysis, it is common the patient will most likely only need anticoagulation for six to eight weeks, but this should be followed up as an outpatient. 3. HYPOTHYROIDISM ISSUES: The patient is status post total thyroidectomy. She was continued on her Synthroid. 4. DIABETES MELLITUS ISSUES: The patient initially had elevated blood sugars secondary to being on D-5 half normal saline while she was nothing by mouth. She managed her own insulin through her insulin pump. Her blood sugars remained under adequate control during the rest of her hospitalization. 5. PAIN CONTROL ISSUES: The patient's right upper extremity pain related to the catheter was adequately controlled with Percocet as needed. 6. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was restarted on her diabetic diet prior to discharge. Her electrolytes remained normal. 7. PROPHYLAXIS ISSUES: The patient was to be on Lovenox and Coumadin. DISCHARGE DIAGNOSES: 1. Right upper extremity deep venous thrombosis. 2. Type 1 diabetes mellitus (on an insulin pump). 3. History of hurtle cell goiter; status post total thyroidectomy. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: To home. MEDICATIONS ON DISCHARGE: 1. Levothyroxine 112 mcg by mouth once per day. 2. Coumadin 5 mg by mouth at hour of sleep. 3. Lovenox 60 mg subcutaneously twice per day (times seven doses). 4. Insulin pump (per patient management). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or her nurse practitioner within the next two weeks. 2. The patient was instructed to have a follow-up INR check on [**Last Name (LF) 766**], [**4-23**], at the [**Hospital 27232**] Clinic; and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] will follow up her INR and call the patient to adjust her Coumadin dosage. 3. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**] of Hematology; and this will be arranged by her primary care physician. [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3060**] will address the need for hypercoagulable workup as well as the duration of anticoagulation therapy. 4. The patient was instructed to follow up with the [**Hospital **] Clinic (Dr. [**Last Name (STitle) **] for her diabetes management as needed. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Name8 (MD) 10397**] MEDQUIST36 D: [**2155-4-17**] 15:21 T: [**2155-4-17**] 19:40 JOB#: [**Job Number 27233**]

[ "244.0", "250.01", "453.8", "731.0" ]

icd9cm

[ [ [] ] ]

[ "99.10", "88.51", "39.50" ]

icd9pcs

[ [ [] ] ]

11272, 11452

11531, 11737

2951, 5911

11770, 13025

5946, 11251

11467, 11505

145, 1999

2021, 2925

20,225

113,524

26299

Discharge summary

report

Admission Date: [**2124-1-14**] Discharge Date: [**2124-1-19**] Date of Birth: [**2059-7-17**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: emergency cabg x4 on [**2124-1-14**] (LIMA to LAD, SVG to ramus, SVG to OM, SVG to PDA History of Present Illness: 64 year old male with history of chest pain intermittently since last summer. It increases with exertion and is resolved with rest. Had a + ETT on [**1-5**] and referred for cath today. He had a dye reaction? in the cath lab and received solumedrol at that time. He continued to have some chest pain in the cath lab and was referred emergently to Dr. [**Last Name (STitle) **] for CABG. Cath showed LM 30%, LAD 80%, Ramus 90%, CX 70%, RCA 50%, EF 60%. Patient admits to having taken 40 mg oral prednisone the evening prior to cath for asthma flare. Past Medical History: asthma GERD hepatitis C at age 18 HTN elev. chol Social History: married and lives with wife businessman one drink per day quit smoking 15 years ago, 35 pk/yr history Family History: father died of MI at 52, mother with CABG Physical Exam: HR 94 165/77 RR 17 5'7" 179# RRR S1 S2 no murmur CTAB soft, NT, ND grossly nonfocal neuro exam right fem art. line in place with 2+ bilat. fem pulses + DP/PT pulses Pertinent Results: [**2124-1-17**] 06:00AM BLOOD WBC-6.8 RBC-3.51* Hgb-10.5* Hct-27.9* MCV-80* MCH-29.9 MCHC-37.5* RDW-14.6 Plt Ct-103* [**2124-1-17**] 06:00AM BLOOD Plt Ct-103* [**2124-1-17**] 06:00AM BLOOD Fibrino-638*# [**2124-1-17**] 06:00AM BLOOD Glucose-111* UreaN-18 Creat-0.8 Na-133 K-4.0 Cl-98 HCO3-26 AnGap-13 [**2124-1-14**] 09:10AM BLOOD ALT-16 AST-15 AlkPhos-74 Amylase-76 TotBili-0.3 [**2124-1-14**] 09:10AM BLOOD WBC-10.6 RBC-3.31* Hgb-10.3* Hct-28.0* MCV-85 MCH-31.2 MCHC-36.8* RDW-12.8 Plt Ct-233 [**2124-1-17**] 06:00AM BLOOD Calcium-8.2* Phos-2.1* [**2124-1-14**] 09:10AM BLOOD VitB12-417 [**2124-1-14**] 09:10AM BLOOD Triglyc-27 HDL-46 CHOL/HD-2.7 LDLcalc-73 Brief Hospital Course: Admitted for cath as above on [**1-14**] and taken to OR urgently for CABG by Dr. [**Last Name (STitle) **]. Transferred to CSRU in stable condition on titrated neo and propofol drips. Extubated in the early AM POD #1. Chest tubes were removed and lasix diuresis started along with beta blockade. Swan removed and transferred out to the floor on POD #2. Began to ambulate on the floor and made rapid progress. He went into afib briefly on [**1-17**], but converted to SR on lopressor and amiodarone. Pacing wires were removed on POD #4. Prelim. CXR on [**1-19**] shows left pleural effusion. Patient is asymptomatic , no rales or wheezing, but has decreased BS at left lung base. He remained in SR and was discharged to home with VNA services on POD #5. Medications on Admission: adviar discus 500 mg/50 mg one puff [**Hospital1 **] lisinopril 20 mg daily [**Doctor First Name 130**] 180 mg daily ASA 325 mg daily plavix 75 mg daily ( had dose AM of admission) lovastatin 20 mg daily singulair 10 mg daily toprol XL 25 mg daily prevacid 30 mg daily prednisone 20 mg po prn asthma flare ( had 40 mg last PM) Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*1 Disk with Device(s)* Refills:*2* 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. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 5 days. Disp:*10 Capsule, Sustained Release(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days; then 400 mg daily for one week, then 200 mg daily ongoing. Disp:*80 Tablet(s)* Refills:*1* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] HOME CARE Discharge Diagnosis: CAD s/p cabg x4 asthma HTN GERD Hepatitis C a fib elev. chol. Discharge Condition: stable Discharge Instructions: may shower over wounds and pat dry no lotions, creams or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100, or wound drainage Followup Instructions: follow up with Dr. [**Last Name (STitle) 2912**] in [**1-21**] weeks follow up with Dr. [**Last Name (STitle) **] in 4 weeks follow up with Dr. [**Last Name (STitle) **] in [**12-20**] weeks Completed by:[**2124-1-19**]

[ "V17.3", "V15.08", "794.31", "V15.82", "070.70", "997.1", "272.0", "530.81", "493.90", "401.9", "E879.0", "E947.8", "411.1", "285.9", "414.01", "693.0", "427.31" ]

icd9cm

[ [ [] ] ]

[ "99.05", "34.04", "99.04", "88.56", "39.61", "38.91", "37.22", "89.64", "88.72", "99.07", "36.13", "36.15", "88.53", "39.64" ]

icd9pcs

[ [ [] ] ]

4786, 4843

2095, 2851

289, 378

4949, 4958

1411, 2072

5210, 5432

1163, 1206

3230, 4763

4864, 4928

2877, 3207

4982, 5187

1221, 1392

239, 251

406, 956

978, 1028

1044, 1147

18,239

199,907

17158+17159

Discharge summary

report+report

Admission Date: [**2176-12-30**] Discharge Date: [**2177-1-8**] Date of Birth: [**2119-8-23**] Sex: F Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old female, who had been experiencing increasing chest tightness over the few months prior to admission. She was born with a heart murmur and was followed by serial echocardiograms. She did have a presyncopal episode and recently prior to her increasing dyspnea on exertion. Her cardiac catheterization done in [**2176-5-30**] showed an EF of 64% with mild MR and normal coronaries with an aortic valve area of 0.8 cm squared. [**Last Name (STitle) 48142**]ardiogram done more recently showed an aortic valve area of 0.5 cm squared. She was then referred to Dr. [**Last Name (Prefixes) 411**] for aortic valve replacement. PAST MEDICAL HISTORY: 1. Aortic stenosis. 2. Asthmatic bronchitis for which she takes rare antibiotics. 3. Anxiety attacks. 4. Migraines. 5. Hypertension. 6. Obesity. 7. She has an old fourth finger fracture on her left hand. PAST SURGICAL HISTORY: Total abdominal hysterectomy in [**2166**]. MEDICATIONS ON ADMISSION: 1. Vasotec 10 mg p.o. q.d. 2. Lasix 20 mg p.o. q.d. 3. Estrace 5 or 10 mg p.o. q.d. ALLERGIES: Prempro which gives her a rash. SOCIAL HISTORY: She is an office worker, who lives with her boyfriend and her son. She never smoked. She rarely drinks alcohol. REVIEW OF SYSTEMS: Significant for the fact that she wears [**Location (un) 1131**] glasses. She has asthmatic bronchitis. She does experience palpitations and did have presyncopal episode. She has constipation and hemorrhoids with a negative colonoscopy three years ago. She has no history of CVA or TIA, and remaining review of systems is noncontributory. PHYSICAL EXAMINATION: She is a pleasant female in no apparent distress. Her vital signs include a heart rate of 72, blood pressure of 152/90 in the right and 148/98 on the left. Her skin has no obvious disease. Her HEENT was PERRL. EOMI. She is nonicteric. Her neck is supple with no JVD. Cardiac: Aortic stenosis, murmur radiates to her neck bilaterally. Chest was clear to auscultation bilaterally. Heart is regular, rate, and rhythm with a 4/6 systolic ejection murmur that radiates throughout the precordium. Her abdomen is obese, it is soft, it is nontender and nondistended with positive bowel sounds. She has no hepatosplenomegaly, no CVA tenderness. Her extremities are warm and well perfused. She has no clubbing, cyanosis, or edema. She has no noted varicosities. Her neurological examination shows her to be grossly intact with no focal abnormalities and her cranial nerves are intact. Her pulses show 1+ bilaterally in femoral artery. Her dorsalis pedis and posterior tibialis pulses are 2+ bilaterally and renal arteries are 2+ bilaterally. HOSPITAL COURSE: Patient underwent aortic valve replacement by minimally invasive incision with a #[**Street Address(2) 6158**]. [**Male First Name (un) 923**] mechanical valve. The surgery is performed by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) 2545**] with Dr. [**First Name (STitle) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PA-C as assistants. The surgery was performed under general endotracheal anesthesia with a cardiopulmonary bypass time of 120 minutes with a cross-clamp time of 88 minutes. The patient tolerated the procedure well, and was transferred to the Intensive Care Unit normal sinus rhythm and on Neo-Synephrine and propofol drips. In the Intensive Care Unit, she was weaned off propofol, and was noted to be very acidotic. She was put back on the propofol while respiratory acidosis was fixed. She had her acidosis corrected, and was eventually weaned to CPAP and extubated on the evening of the operative night without incident. On the morning of postoperative day #1, she was doing well until she was noted to have right sided weakness, which was transient in nature. She did have a head CT which showed no evidence of hemorrhage and went for cerebral angiogram to assess her carotids and intracranial vessels. This was done and showed no evidence of carotid dissection or branch occlusion. Over the day, her symptoms resolved and she was eventually able to move all extremities and have good strength on her right side. Over the next couple of days, she was kept on a Neo-Synephrine drip to keep her blood pressure in the 140s-160s. During this time, she continued to have improvement of her right sided weakness. She was started on Coumadin for her mechanical valve. By postoperative day #3, was off of her Neo-Synephrine drip and able to be transferred to the surgical floor. She continued to do well and worked with Physical Therapy and Cardiac Rehab. Her wires were discontinued on postoperative day #3 without incident and she was continued on her Heparin and Coumadin for anticoagulation. She continued to do well until postoperative day #8 when it was noted that she had positive E. coli UTI by culture. She was started on Levaquin to which the E. coli was sensitive. By postoperative day #9, she was noted to have therapeutic INR of 2.4 which will allow her to be discharged to home. She will have visiting nurse services to help assess her wound healing and also to cover her coags. Her coags will be followed by Dr. ............'s office. Her discharge exam shows her to be alert and oriented times three, moving all extremities with good grip strength. Her vital signs are stable, and her lungs are clear to auscultation bilaterally. Heart regular, rate, and rhythm. Abdomen has positive bowel sounds, soft, nontender, nondistended. Her extremities without clubbing, cyanosis, or edema. Her sternal wound is stable and clean, dry, and intact. Her laboratories on discharge include a white count of 11.2, hematocrit of 26.1%, platelet count of 566,000. Sodium 138, potassium 5.0, chloride 103, CO2 26, BUN 12, creatinine 0.6, and glucose of 92. Her PT was 19.1, INR 2.4, and PTT of 44. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. b.i.d. for seven days. 2. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d. for seven days. 3. Lopressor 50 mg p.o. b.i.d. 4. Estradiol 1 mg p.o. q.d. 5. Levofloxacin 500 mg p.o. q.d. x10 days. 6. Coumadin: She should take 5 mg on the day of discharge, and her dosage thereafter will be directed as per Dr. ............'s office. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSES: 1. Status post aortic valve replacement with a #21 mm St. Jude valve on [**12-30**]. 2. Status post transient ischemic attack on [**12-31**] with no residual. 3. Hypertension. 4. Asthmatic bronchitis. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 31272**] MEDQUIST36 D: [**2177-1-8**] 11:32 T: [**2177-1-8**] 11:52 JOB#: [**Job Number 48143**] Admission Date: [**2176-12-30**] Discharge Date: [**2177-1-9**] Date of Birth: [**2119-8-23**] Sex: F Service: ADDENDUM - HOSPITAL COURSE: The patient remained in the hospital for an additional day. After working with physical therapy and attempting to climb a set of stairs, her vital signs were taken. She was noted to have a systolic blood pressure in the high-70s. An adjustment was made to her Lopressor dose by decreasing it to 25 mg po bid. On postoperative day #10, she again ambulated and attempted climbing stairs with physical therapy, and her blood pressure remained stable with a systolic pressure of around 100-105. It is felt now that she is stable and ready for discharge home with visiting nurse services. She will again receive 5 mg of Coumadin on the night of discharge, with her labs to be drawn the following day by visiting nurse services, and results to be called to Dr.[**Name (NI) 48144**] office. DISCHARGE MEDICATIONS: Lopressor from 50 mg po bid to 25 mg po bid. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 31272**] MEDQUIST36 D: [**2177-1-9**] 10:04 T: [**2177-1-9**] 10:29 JOB#: [**Job Number 48145**]

[ "278.00", "424.1", "276.2", "435.9", "V58.61", "599.0", "493.90", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.22" ]

icd9pcs

[ [ [] ] ]

6492, 6499

6520, 7125

7958, 8267

1160, 1290

7143, 7934

1089, 1134

1808, 2856

1442, 1785

184, 838

860, 1065

1307, 1422

22,754

171,894

3261

Discharge summary

report

Admission Date: [**2119-5-12**] Discharge Date: [**2119-5-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: altered MS, hypoxia Major Surgical or Invasive Procedure: intubation arterial line placement lumbar puncture History of Present Illness: 81M w/ history of recent subdural hematoma s/p right sided craniotomy/evacuation [**3-30**], chf thought secondary to MR/AR, afib, aortic aneurysm, now being admitted to [**Hospital Unit Name **] for altered mental status and hypoxia. . Recently discharged from [**Hospital1 18**] in late [**3-30**] after evaluation for altered mental status and ultimate discovery of subdural hematoma w/ subsequent evacuation of hematoma. Per OMR notes, his mental status was back to baseline at time of discharge. Also, he was found to have a UTI growing enterobacter and a possible LLL pneumonia. He was treated with levofloxacin for a short course. . At [**Hospital 100**] Rehab, he was in his USOH until late this morning when he was noted to be delirious and had O2 sat of 88% on RA. He did not appear to be in any respiratory distress, and the remainder of his vitals were stable. He was then referred to the ED for further evaluation. . In the ED, his initial vitals were T 101.2 BP 142/48 HR 85 RR 38 O2 sat 88%RA. He was oriented to self, pupils reactive, but he was agitated, per ED notes. As pt became more agitated and less responsive, he was given ativan 2mg iv and vecuronium 10mg iv x1 and intubated for airway protection. CXR taken to verify position of ED tube revealed possible RML pna, and he was treated empirically with levo/flagyl and vancomycin. However, although this AP film was rotated, there was some concern regarding possible aortic dissection - - he remained hemodynamically stable, and his CXR was difficult to evaluate. He also had a head CT w/o contrast to r/o ICH, edema, mass - this showed residual hypodensity on the R subdural region. U/A negative, EKG normal. He was then transferred to the [**Hospital Unit Name 153**] for further management. Past Medical History: 1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely overestimation with degree of MR 2. 3+ mitral regurgitation 3. Atrial fibrillation 4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable (pt. currently not interested in surgery) 5. DM2 6. Gout 7. Inflammatory Colitis (?)on chronic sulfasalazine. No prior surgeries or recent flares. 8. Hypertension 9. GERD 10. h/o Asbestosis 11. Recent B12 and Fe def. anemia Social History: Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a salesman. h/o asbestosis exposure when in the service (?shipyards). Family History: no Alzhemer's or Parkinson's Physical Exam: VS: T 98.7 HR 85 BP 118/53 RR 14 O2 sat 100% on AC 450x14, FiO2 50% PEEP 5 Gen: sedated, intubated, NAD Skin: warm, dry HEENT: pupils reactive bilaterally, mucosa moist Neck: elevated JVD CV: RRR, no M/R/G Pulm: CTA by anterior exam Abd: soft, NT/ND, +BS Ext: no pitting edema, 2+ DP pulses Neuro: moving all extremities spontaneously Physical Exam Upon transfer to floor: -VS: Tmax 98.2 HR 86-105 irreg irreg, BP 101/52 (SBP range 101-153), RR 15-22, O2 sat 100% on RA -Gen: elderly M in NAD -Skin: old surgical scars on head; o/w C/D/I; no rashes appreciated -HEENT: OP clear, MMM, EOMI, PERRLA -Neck: JVD to mid-neck at 45 degrees -CV: S1S2, RRR, no M/R/G -Pulm: CTA anteriorly -Abd: soft, NT, ND, NABS -Ext: thin, no edema, 2+ DP pulses -Neuro: A&Ox2 (person & "[**Hospital1 **]"), fluent speech, follows commands Pertinent Results: CT chest w/o contrast [**5-12**]: 1. CHF with large bilateral pleural effusions. 2. Noncalcified bilateral pulmonary nodules. 3. Right middle lobe consolidation, worrisome for pneumonia. 4. Ascending aorta measures 4.9 x 4.9 cm. 5. Calcified pleural plaques indicative of asbestosis exposure. CXR AP [**5-12**] (#1): Endotracheal tube in a standard position. Moderate congestive heart failure with bilateral pleural effusions. CT head w/o contrast [**5-12**]: Persistent small hypodense subdural collection over the right cerebral hemisphere. No evidence of mass effect, shift of normally midline structures, or acute hemorrhage. CXR AP [**5-12**] (#2): 1. ETT at top level of clavicles with room for advancement. 2. Possible right mid lung opacity for which a nonrotated radiograph would provide further evaluation. Sputum culture with MRSA sensitive to vancomycin Brief Hospital Course: 81M w/recent subdural hematoma s/p evacuation in [**3-30**], CHF, Afib, aortic aneurysm, initially admitted to [**Hospital Unit Name 153**] for altered mental status and hypoxia. Found to be fluid overloaded & have MRSA in sputum. Was intubated in ED, now stable on RA. # Previous hypoxia: most likely combination of PNA & fluid overload. BNP >30,000 in ED. Was intubated for tachypnea & airway protection during agitated state. Diuresed with lasix and pt was extubated successfully on [**5-16**]. Pt was weaned to room air with further gentle diuresis. # CHF: last echo ([**2119-4-3**]) w/EF >55%, 2+ MR, mod AR. Fluid overloaded at admission as above. No EKG changes, CK-MB flat @ admission w/TropT slightly elevated but stable (likely related to infection and increase HR). Remained stable on ACE-I, Bblocker, and PO lasix 40 daily. # PNA: seen on CT in right middle lobe. No leukocytosis or high fevers. Sputum grew MRSA ([**5-12**] & [**5-14**]), sensitive to vanco. Respir status stable on RA within 24 hours of extubation. Plan 10 day course of vancomycin (started [**2119-5-16**]). # Pleural effusions: thoracentesis done on [**5-13**] for evaluation for infectious source revealed transudative fluid (pH 7.4, LDH 100, total protein 1.9), likely from congestive heart failure. # Mental Status: agitated at admission, most likely related to infection and acute illness. Also likely continued worsening baseline dementia. Repeat CT showed small amount of residual hypodensity over the R hemisphere, but no evidence of acute hemorrhage. LP on [**2119-5-13**] showed 3 WBC. Apparently also had recent changes in meds, including higher ritalin dose & starting xanax. After extubation, pt's mental status remained stable. Neuro consult followed patient & thought his mental status was at recent baseline. Did not restart ritalin or Xanax. # Subdural hematoma: no signif recurrance on head CT. Pt was continued on Keppra for seizure prophylaxis post-craniotomy but this was weaned slightly as it can cause agitation. Could continue to wean by 250 mg q3days if pt becomes agitated. Plan to continue this medication until neurology or neurosurgical follow-up. # AAA: ascending; measured >5cm in [**11-27**] & pt refused surgical intervention at that time. There was question of widened mediastinum on CXR in [**Hospital Unit Name 153**] but CT chest showed stable size. # CRI: stable at baseline (creatinine 1.2-1.6) # Paroxysmal Afib: remained rate-controlled on metoprolol. Anticoagulation with warfarin was not used given recent subdural hematoma and h/o frequent falls. # DM2: remained stable. Pt was covered with RISS. Diabetic diet. # Elevated LFTs @ admission: resolved. Pt dose have history of hepatotoxicity due to dilantin. AST elevated at admission, but remainder of liver enzymes normal. AST normalized within 1 day of admission. No further S/Sx of liver dz during this hospitalization. # Anemia: iron studies most c/w chronic dz (ferritin 86). Hct stable. Cont ferrous sulfate. # Hypothyroidism: clinically euthyroid. Synthroid was continued at home dose. # Depression: remained stable. Celexa was continued @ home dose. # FEN: tolerated POs well # Prophylaxis: maintained on Protonix & pneumoboots # Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (daughter) [**Telephone/Fax (1) 15217**] # Code: DNR/I, confirmed with family & ICU team Medications on Admission: Celexa 10 qd Colace 100 [**Hospital1 **] Combivent q6 Levoxyl 25mcg qd Furosemide 40 qd Senna Colace Protonix 40mg qd Ferrous Sulfate 325 qd metoprolol 50mg [**Hospital1 **] seroquel 12.5mg qhs ritalin 10mg qd xanax Discharge Medications: 1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 7 days. 9. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: congestive heart failure pneumonia dementia stable subdural hematoma Discharge Condition: medically stable; mental status stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 liters per day Take all medications as directed Followup Instructions: --follow-up with your primary care physician (Dr. [**Last Name (STitle) 3649**] within 1 month --follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6817**] of behavioral neurology ([**Telephone/Fax (1) 1690**]) within 1 month [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2119-5-19**]

[ "424.0", "518.81", "428.0", "427.31", "V09.0", "311", "482.41", "285.9", "244.9", "511.9", "441.4", "401.9", "250.00", "274.9", "294.8", "530.81" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "03.31", "96.72", "34.91" ]

icd9pcs

[ [ [] ] ]

9083, 9153

4538, 5831

281, 333

9266, 9307

3644, 4515

9524, 9906

2760, 2790

8202, 9060

9174, 9245

7961, 8179

9331, 9501

2805, 3625

222, 243

361, 2131

5846, 7935

2153, 2588

2604, 2744

28,036

100,847

6502

Discharge summary

report

Admission Date: [**2149-2-21**] Discharge Date: [**2149-3-3**] Date of Birth: [**2099-7-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2745**] Chief Complaint: Left Foot Infection, DKA Major Surgical or Invasive Procedure: Mr. [**Known lastname 24962**] underwent podiatric surgery on [**2149-2-24**] to for left wound debriment and underwent wound closure on [**2149-3-3**]. History of Present Illness: Mr. [**Known lastname 14611**] is a 49 year old male with a history of type II diabetes, charcot's foot s/p multiple surgeries, and previous MRSA infection who presented to his podiatrist on [**2149-2-21**] with two days of nausea, vomiting (clear, non-bilious, non bloody) , productive cough (sputum color not noted), fatigue, and pain and redness of his left foot. He was found to have a draining wound (approximately 1 cm in width x 1 cm in depth) on his left lower leg, just superior to the lateral malleolus with an area of surrounding cellulitis. He was transferred to the Emergency Department for treatment with IV antibiotics, and observation. Of note is that the patient missed his last four doses of lantus insulin, due to running out of medication. . In the ED his vitals were: T 99.3, HR 102, BP 134/74, R 18, and O2 sat 100% on room air. Labs were drawn and significant for a glucose of 377, Anion Gap of 24, lactate of 1.2 and ketones in this urine, consistent with Diabetic Ketoacidosis. He was given 6 units of insulin, 2 liters of IV fluid, a dose of Vancomycin x1 (for cellulitis), and a percocet in the ED and transferred to the MICU for further management of his DKA and infection. . In the MICU he was treated with his 5th liter of normal saline and started on an insulin drip. He was continued on Vancomycin and started on Zosyn. He was stable with a heart rate of 77 and a blood pressure of 140/66. Podiatry reported that plain film imaging showed "interval osteolysis adjacent to the fixation screws that is suggestive of infection or interval losening". Blood and swab cultures were obtained, and a urine culture was negative for growth. Mr. [**Known lastname 14611**] developed skin reactions in the MICU on his back and neck, consistent with a similar exanthem his developed in [**2148-10-12**] during his previous admission and was seen by dermatology. He was subsequently admitted to the [**Doctor Last Name **] B service of CC7. Past Medical History: PMH: -Diabetes Mellitus Type 2 -Bilateral Charcot Foot with multiple surgeries -History of MRSA -Left Lower Extremity DVT ([**2145-7-13**]) . PSH -Left Charcot foot reconstruction ([**2148-10-12**]) -Right pan-metatarsal resection and [**Doctor First Name **] ([**2148-10-12**]) -Right foot I& drainage with 2nd Metatarsal head resection packed open ([**2147-10-13**]) -Left and right foot debridment ([**2147-12-13**]) -Cataract extraction of right eye ([**2147-4-12**]) -Excision of right foot ulcer ([**2145-11-12**]) -Skin lesion biopsy from sensitivity reaction done by dermatology during MICU stay. Social History: Mr. [**Known lastname 14611**] lives in [**Location 24963**], MA in an apartment unit alone, however his mother and aunt live in the unit downstairs. He is not married, nor in a relationship and does not have children. He has a brother whom he considers his closest contact and person who would make medical decisions for him. Mr. [**Known lastname 14611**] is of Irish descent and has a high school education. He worked at an auto dealership until he was fired in [**Month (only) **]. He has not been able to look for a job because of his recent hospitalizations and he states that he may not have medical insurance, but he is not too concerned about it. He smoked 2-3 packs per day but quit over two years ago. He drinks 3-5 beers per day, sometimes more. Patient denies illicit drug use. Family History: Mother has a history of type II Diabetes Mellitus. Physical Exam: Exam: Vital Signs during exam on [**2149-2-23**]: T=97.5 HR=18 BP=152/90 RR=18 SaO2=97% on room air FINGERSTICKS 24h: [**Telephone/Fax (3) 24964**] - [**Telephone/Fax (3) 24965**] . General:No apparent distress Skin:Raised and erythematous, non-pruritic lesions visible across back and neck. Lymph:No occipital, submandibular, cervical, supraclavicular, axillary, epitrochlear, or inguinal LAD. HEENT:Normocephalic; no proptosis; anicteric sclera; conjunctiva clear and nonerythematous; moist mucous membranes Neck:Supple; full ROM; no c-spine tenderness to palpation; JVP +1; carotids 2+ w/o bruits; no thyromegaly or nodules; trachea midline Back: no t-spine or l-spine tenderness to palpation; no CVAT Core:CTAB; symmetrical air movement bilaterally, no wheezes, rales, or rhonchi; resonant to percussion bilaterally; PMI non-displaced; S1, S2; no murmurs, gallops, or rubs Abd:obese; +BS; nondistended; resonant to percussion; soft; nontender; no rebound; no HSM; no ventral hernias GU:Deferred (no inguinal hernias) Rectal:Deferred Extr:Lateral, lower left foot noted to have erythema, increased warmth, consistent with cellulitis. A small ulceration superior to lateral malleolus that was 1cm in length by 1cm in depth, with slight pus and without odor. 2+ edema of lower extremities bilaterally without cyanosis. Femoral, and radial pulses 2+ bilaterally. Pedal pulses could not be palpated bilaterally. Neuro: MS: Orientation: to person, place, date, and purpose for visit Attention: repeats 10 digits forwards Frontal:follows and repeats 3-step motor pattern with both hands Speech:spontaneous; fluent Memory:knows current events. patient refused more extensive memory testing. Parietal:correctly performs crossed-body, 2-step command Cognition:explains proverbs "an apple doesn't fall far from the tree"; good insight; appropriate judgment Thought Content:no hallucinations; no delusions Mood:upset and agitated at the moment. CN: I:not tested II,III:PERRL, blinks to threat III,IV,VI:gaze full in all directions; no ptosis. V:sensation symmetric to LT V1-V3 VII:face symmetric w/o weakness VIII:hearing symmetric to finger rub IX,X:palate rises symmetrically; no dysarthria or dysphagia; gag reflex intact [**Doctor First Name 81**]:SCM??????s and trapeziums [**6-16**] XII:tongue midline; no gross atrophy or fasciculation Motor:Normal bulk in upper extremities. Lower bulk in lower extremities. Normal tone; no spasticity or rigidity. No tremor, chorea, athetosis, hemiballismus, or bradykinesia. No pronator drift. Could not stand without assistance or support. EXT: 2+ radial pulses bilat, unable to palpate DP, slightly cool LE, paler L than right foot, charcot feet, onychomycosis Sensory: Patient has decreased light touch, vibration, pain and temperature in both feet. Patient did not allow for examination of proprioception nor upper extremities. Reflexes No clonus or asterixis. Coordination / Gait: Patient would not cooperate with testing. Pertinent Results: ADMISSION LABS: 130 93 18 ============< 377 4.8 18 1.0 . CK: 150 MB: 5 Trop-T: <0.01 . 12.1 D > 34.1 < 336 N:87.7 L:7.6 M:4.2 E:0.3 Bas:0.2 . U/A: trace protein, 1000glucose, 150ketones, neg for infxn . TRANSFER LABS: 138 106 5 ============< 196 3.5 23 0.7 Ca: 8.4 Mg: 1.7 P: 3.2 Vanco: 9.5 . 4.7 > 27.3 < 319 . SED-Rate: 58 Discharge Labs: [**2149-3-3**] 06:55AM BLOOD WBC-4.9 RBC-3.02* Hgb-9.2* Hct-26.7* MCV-88 MCH-30.4 MCHC-34.5 RDW-14.5 Plt Ct-353 [**2149-3-3**] 06:55AM BLOOD Glucose-163* UreaN-8 Creat-0.8 Na-138 K-4.1 Cl-103 HCO3-27 AnGap-12 MICRO: GRAM STAIN (Final [**2149-2-22**]): 2+(1-5 per 1000X FIELD):POLYMORPHONUCLEAR LEUKOCYTES. No MICROORGANISMS SEEN. . WOUND CULTURE (Final [**2149-2-24**]): KLEBSIELLA PNEUMONIAE.SPARSE GROWTH. . GRAM STAIN (Final [**2149-2-28**]):1+(<1 per 1000X FIELD):POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. . WOUND CULTURE (Final [**2149-3-3**]):STAPHYLOCOCCUS, COAGULASE NEGATIVE.RARE GROWTH. . WOUND CULTURE (Final [**2149-2-26**]): CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH. . WOUND CULTURE (Final [**2149-2-28**]): BETA STREPTOCOCCUS GROUP B. RARE GROWTH. ANAEROBIC CULTURE (Final [**2149-3-6**]):NO ANAEROBES ISOLATED. . Blood Culture, Routine (Final [**2149-2-27**]):NO GROWTH. . URINE CULTURE (Final [**2149-2-23**]): <10,000 organisms/ml. . FOOT XR [**2149-2-21**]: IMPRESSION: 1. No skin ulcer or focal osteolysis is noted to suggest osteomyelitis. 2. Interval osteolysis adjacent to the fixation screws is suggestive of infection or interval loosening. 3. Relatively stable neuropathic changes of the foot. . CXR [**2149-2-22**]: There are low lung volumes in the semi-upright position. The lung fields appear clear. No failure or pneumonia is identified. IMPRESSION: No pneumonia. Brief Hospital Course: Mr. [**Known lastname 14611**] is a 49 year old male with a history of type II diabetes, charcot's foot s/p multiple surgeries, and previous MRSA infections who presents with left foot cellulitis, ulceration, and a resolving DKA. He developed drug rash allergy on his neck and back while in the ED. . 1. Left foot abscess/cellulitis/drug reaction: Mr. [**Known lastname 14611**] presented to his podiatrist on [**2149-2-21**] with two days of nausea, vomiting(clear, non-bilious, non bloody) , productive cough (sputum color not noted), fatigue, and pain and redness of his left foot. He was found to have a draining wound (approximately 1 cm in width x 1 cm in depth) on his left lower leg, just superior to the lateral malleolus with an area of surrounding cellulitis. He as admitted to the ED for IV antibiotics and observation. In the ED 2 liters of IV fluid, a dose of Vancomycin x1 (for cellulitis, first dose [**2149-2-22**]), and a percocet and transferred to the MICU for further management. In the MICU he was treated with his 5th liter of normal saline. He was stable with a heart rate of 77 and a blood pressure of 140/66. Podiatry reported that plain film imaging showed "interval osteolysis adjacent to the fixation screws that is suggestive of infection or interval loosening". Blood and swab cultures were obtained, and a urine culture was negative for growth. He was then admitted to the medicine floor for further management. On the floor He was continued on Vancomycin 1g [**Hospital1 **] and started on Zosyn (Pip-tazo) 4.5g Q8H on [**2149-2-22**]. He also developed a allergic reaction on his back, which appeared as erythematous, non-raised target lesions. He was taken by podiatry to the operating room on [**2149-2-24**] for surgical debridement of his foot ulcer, and found to have an abscess that was drained. Wound cultures grew Klebissela pneuomiae with sensitivites to Cipro, Meropenum, Gent, ceftriaxone and less sensitivities to Zosyn, amp/sublactam. He was continued on Vanc, but the Zosyn was stopped and he was started on Cipro (500mg PO bid) on [**2149-2-25**]. Wound cultures came back with gram positive cocci, so he was started on Keflex PO 500mg qid (first dose [**2149-2-26**].)Mr. [**Known lastname 24962**] improved with pain management after the debridement, and underwent surgical closure on [**2149-3-3**] and was discharged in good condition. . 2. Diabetic Ketoacidosis: The patient presented to the emergency department with a glucose of 377, Anion Gap of 24, lactate of 1.2 and ketones in this urine, consistent with Diabetic Ketoacidosis. Of note he also had missed his previous 4 doses of lantus insulin. He was given 6 units of insulin, 2 liters of IV fluid and transferred to the MICU where he was started on an inslin drip. His anion gap eventually close, he glucose was controlled in the 150-240's range, and his anion gap closed before he was admitted to the medicine floor. On the medicine floor the patient was followed by the [**Hospital **] clinic. His lantus dose was reduced to half while he was NPO before procedures, and kept at 20mg [**Hospital1 **] when eating regularly. His humalog scale was increased 2 units during his stay because of increasing glucose levels. Upon discharge his glucose was stable at 163 and his anion gap was 12. . 3. Anemia: [**Known lastname 14611**] had a hematocrit of 27.3 on admission, with a range of 24.4 to 28.3, with a discharge hematocrit of 26.7. Of note, he loss 300cc of blood during the surgical debridement of his foot ulcer on [**2149-2-24**]. Two units of blood were cross and matched, but a transfusion was not needed. He was mainted on Iron supplementation with ferrous sulfate, 325mg PO. His anemia was stable at discharge. . 4. Skin lesions: The patient has developed blanching, raised, erythematous lesions with a target like appearance on his back and neck in a similar distribution to a previous admission in [**2148-10-12**]. Dermatology consulted on the patient, and a biopsy was performed and found to be consistent with a drug reaction, although erythema multiforme could not be excluded. The patient was treated with HydrOXYzine 25 mg PO PRN/Q6H, and Sarna lotion application PRN. The drug allergy improved over the course of the admission and was stable at discharge. A follow up appointment was made with the allergy clinic for the patient. Medications on Admission: Lisinopril 20mg qd Lantus 20U (AM&PM) Humalog SS Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for 20 doses: do not exceed 8 tablets in 24 hours. Disp:*20 Tablet(s)* Refills:*0* 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for Rash. Disp:*QS QS* Refills:*0* 7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for pruritis. 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days: FINISH ALL OF YOUR ANTIBIOTICS. Disp:*40 Capsule(s)* Refills:*0* 10. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous four times a day: please follow new sliding scale and adjust [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. Disp:*QS QS* Refills:*2* 11. SYRINGE BD ultra-fine Ii short - syringes 31g 1/2cc as directed use 5x/day. Dispense: QS x 1 month, Refill 6 12. glucose strips one touch ultra fine strips. QS for one month, 6 refills 13. lancets one-touch lancets for glucose meter. QS one month, 6 refills 14. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous at bedtime. 15. Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous qAM. Disp:*QS QS* Refills:*6* Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Diabetic Ketoacidosis Diabetic foot ulcer infection . SECONDARY: Bilateral Charcot Foot with multiple surgeries Drug sensitivy skin rash Discharge Condition: Good . FSBG 85-277 . Afebrile, comfortable Discharge Instructions: You were admitted with Diabetic Ketoacidosis and a left foot infection. Your glucose was at 377 and you were dehydrated, thus you were treated with an insulin drip and IV fluids. You were started on the IV antibiotics piperacillin and tazobactam and vancomycin for your foot infection. Your wound culture grew the bacteria klebisella pneumonia and group [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 24966**], [**First Name3 (LF) **] you were switched to a 14 day course of the oral antibiotics ciprofloxacin and cephalexin. You were taken to surgery by the podiatry service for debridement of the wound on [**2149-2-24**]. Your incision was left open for 4 days to heal, and was then reclosed in the operating room on [**2149-2-28**] and a wound vaccum was placed as they were not able to close the entire wound. . Wound vac will be removed and you will need to perform wet to dry dressings 2 times per day. You will f/u with podiatry next week. . You were also noted to have a rash on your back. You were seen by dermatology who thought that you had a drug sensitivity reaction. Your rash appeared to improve after discontinuation of the antibiotics piperacillin and tazobactam, but the exact cause was unknown. You will need to see allergy specialist at [**Hospital1 18**]. Please call the allergy clinic at [**Telephone/Fax (1) 8645**]. . CHANGES IN MEDICATIONS: Humalog scale adjusted according to print-out Ciprofloxacin finish additional 10 day course Cephalexin four times a day finish additional 10 day course Glargine (lantus) insulin remains 20units in AM but now PM dose increased to 25units. . No other changes to your medications were made . Please adhere to all of your appointments adn call to reschedule if needed. . If you develop any concerning symtoms such as increased urinary frequency, dizzyness, chills, fever above 101 degrees, light headedness or any other major concerns, please see your doctor immediately. Followup Instructions: 1)Please contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for a PCP follow up within the next week. Call ([**Telephone/Fax (1) 24967**]. . 2) [**Hospital **] Clinic with Dr. [**First Name8 (NamePattern2) 7208**] [**Last Name (NamePattern1) 978**] on Thursday, [**2149-3-6**] at 9:30 am. Phone number ([**Telephone/Fax (1) 17484**]. Please bring referral from PCP. . 3)Podiatry- with Dr. [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], on [**Last Name (LF) 766**], [**2149-3-10**] at 2:30 pm. Phone:[**Telephone/Fax (1) 543**]. . 4) [**Hospital 9039**] clinic: Please call [**Telephone/Fax (1) 8645**] to schedule an appointment next week.

[ "357.2", "250.12", "V58.67", "713.5", "280.9", "682.7", "707.14", "693.0", "250.62", "E930.9" ]

icd9cm

[ [ [] ] ]

[ "78.68", "86.04", "86.22", "86.11", "93.59" ]

icd9pcs

[ [ [] ] ]

14969, 14975

8819, 13190

339, 493

15165, 15210

7008, 7008

17207, 17937

3940, 3992

13289, 14946

14996, 15144

13216, 13266

15234, 17184

7364, 8796

4007, 6989

275, 301

521, 2487

7024, 7348

2509, 3116

3132, 3924

28,914

117,362

25437

Discharge summary

report

Admission Date: [**2172-4-2**] Discharge Date: [**2172-4-10**] Date of Birth: [**2109-10-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: Incarcerated ventral hernia, fever Major Surgical or Invasive Procedure: [**2172-4-2**]: -Exploratory laparotomy, resection of torsed and necrotic omentum, primary repair of ventral hernia, mesh onlay repair of ventral hernia and repair of umbilical hernia. History of Present Illness: 62 y/o with known umbilical hernia. He has noticed increased pain and erythema. He initially presented to an outside hospital and was subsequently transferred to [**Hospital1 18**] by [**Location (un) **] for surgery. Past Medical History: Hepatitis C, Cirrhosis CAD (s/p cath with stenting circumflex and RCA) Social History: Rare alcohol, no IVDU, Tattoos Family History: Siblings with diabetes, CAD Physical Exam: VS: Gen: A+Ox3 CArd: RRR Lungs: CTA bilaterally Abd: soft, mildly distended, incision and staples C/d/i extr: 2+ pitting edema b/l lower extremity Pertinent Results: On Admission: [**2172-4-2**] WBC-14.9*# RBC-2.96* Hgb-10.4* Hct-32.7* MCV-110* MCH-35.0* MCHC-31.8 RDW-18.7* Plt Ct-80* PT-15.7* PTT-36.0* INR(PT)-1.4* Glucose-62* UreaN-14 Creat-0.9 Na-131* K-4.3 Cl-103 HCO3-20* AnGap-12 ALT-34 AST-93* AlkPhos-145* TotBili-4.1* Albumin-1.7* Calcium-7.3* Phos-2.1* Mg-1.9 calTIBC-130* Ferritn-747* TRF-100* Ammonia-51* TSH-2.7 On Discharge: [**2172-4-9**] WBC-6.1 RBC-2.83* Hgb-9.4* Hct-29.0* MCV-102* MCH-33.1* MCHC-32.4 RDW-18.4* Plt Ct-76* PT-16.3* PTT-39.6* INR(PT)-1.5* Glucose-81 UreaN-17 Creat-0.7 Na-134 K-3.6 Cl-105 HCO3-24 AnGap-9 ALT-12 AST-43* AlkPhos-87 TotBili-3.6* Albumin-2.4* Brief Hospital Course: 62 y/o male received from OSH via [**Location (un) 7622**] with an incarcerated hernia in need of urgent surgical repair. Patient was initially stablized with aggressive fluid resuscitation. The patient was taken to the OR on [**2172-4-2**] by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Initially a large hernia sac was found and it was discerned that he had 2 hernias. A fluid filled umbilical hernia and a ventral hernia which was quite large and had torsed, was necrotic and stuck omentum. The sac of the hernia was very thick and the area looked grossly infected. Resection of the omentum reported as difficult due to the varices from portal hypertension. The sac was completely excised, and then primary repair with Vicryl mesh onlay was done. The umbilical hernia was able to be repaired primarily. Please see the operative note for further detail. The pathology was returned on both hernia scs and omentum as "Fibrofatty tissue and mesothelium with acute and chronic inflammation and reactive changes" Following surgery he remained intubated and was transferred to the SICU for further care. He did initially require pressor support. He was extubated on POD 1. He was initially started on Cipro and Cefazolin and received these for 2 days. He was then switched to Ceftriaxone in the setting of continued fever. He grew E coli from the peritoneal fluid culture. On POD 2 he underwent liver ultrasound, findings as follows: - Cirrhosis and a large amount of ascites. The main portal vein is patent. - Sludge and stones within the gallbladder. He was transferred to the regular surgical floor on POD 5. He was tolerating a regular diet and ambulating well. Cleared by PT for home. He was placed on aldactone and lasix for diuresis. Additionally he received multiple doses albumin with lasix IV. He was determined to be stable for discharge on [**2172-4-10**]. He will be staying with his sister for several days prior to heading back home on [**Hospital1 6687**], where he will follow up care with his PCP and Dr [**First Name (STitle) 572**]. Medications on Admission: ASA 81', prilosec 20', ribavirin 600am/400pm, nadolol 20', simvastatin 20', aldactone 75', MVI', Fe 325' Discharge Medications: 1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*10 Tablet(s)* Refills:*0* 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks: continue until follow up appointment. Disp:*20 Tablet(s)* Refills:*0* 3. Ribavirin 200 mg Capsule Sig: Two (2) Capsule PO Q PM (). Disp:*30 Capsule(s)* Refills:*0* 4. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Ribavirin 200 mg Capsule Sig: Three (3) Capsule PO Q AM (). Capsule(s) 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*10 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 8. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*10 Tablet(s)* Refills:*0* 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: incarcerated ventral hernia, Discharge Condition: Stable Discharge Instructions: Please call Dr [**Last Name (STitle) 15283**] office at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, diarrhea, inability to take or keep down food or medications, monitor skin and eyes for yellowing (jaundice) No heavy lifting Do not drive if taking narcotic pain medication You may shower, pat incision dry Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Phone:[**Telephone/Fax (1) 63560**] Date/Time:[**2172-4-30**] 5:15 Follow up with Dr. [**Last Name (STitle) 816**] in [**6-25**] days, call [**Telephone/Fax (1) 673**] to schedule an appointment. Completed by:[**2172-4-10**]

[ "414.01", "567.29", "552.20", "571.5", "070.54", "553.1", "V45.82", "287.5" ]

icd9cm

[ [ [] ] ]

[ "54.4", "53.49", "53.69" ]

icd9pcs

[ [ [] ] ]

5156, 5162

1804, 3886

349, 536

5235, 5244

1152, 1152

5626, 5930

941, 970

4042, 5133

5183, 5214

3912, 4019

5268, 5603

985, 1133

1528, 1781

275, 311

564, 783

1166, 1513

805, 877

893, 925

72,670

189,049

36163

Discharge summary

report

Admission Date: [**2116-6-8**] Discharge Date: [**2116-9-11**] Date of Birth: [**2052-6-13**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 2297**] Chief Complaint: elective admission for stem cell transplant Major Surgical or Invasive Procedure: Stem Cell Transplant History of Present Illness: Mr. [**Known lastname 82035**] is a 63 year old gentleman with relapsed Non-Hodgkins lymphoma s/p auto-HSCT D+433 who presented from clinic for reduced-intensity conditioning sibling-donor allo-HSCT with ATG/TLI/clofarabine. Patient had finished 4 cycles of gemcitabine/pralatrexate with partial response [**Date range (3) 82036**]. In his 2[**Hospital **] clinic follow up, he felt well overall. On presentation, patient had no complaints except bilateral shoulder pain from having his arms raised for a couple of hours for central line placement by Interventional Radiology. He had some soreness at site of insertion as well. On review of systems, patient denied fevers, chills, vision changes, congestion, sore throat, cough, shortness of breath, nausea, vomiting, chest pain, abdominal pain, hematochezia, diarrhea, urinary difficulties, leg swelling, rash. Past Medical History: Follicular Cell Lymphoma Hx Kidney Stones BPH s/p L hip replacement ~[**2111**] No history of cardiac disease. No history of pulmonary disease No hx of hemorrhagic cystitis s/p Cytoxan Past Oncologic History: 1. Excisional biopsy of an enlarged submandibular lymph node on [**2106-11-3**] showing follicular lymphoma, histological grade 2 with positive BCL2 staining, bone marrow not involved. 2. Clinical followup between [**2107**] and [**2113**]. 3. Parotid mass noticed in [**2113**], which was biopsied on [**2113-6-21**] showed involvement with mixed small and large cell follicular lymphoma. There was positive staining for BCL6 and BCL2 with BCL2 chain rearrangement by PCR. No rearrangements of immunoglobulin heavy chain or BCL1 was demonstrated. This was consistent with non-Hodgkin's lymphoma, B-cell with mixed small and large cell type of follicular center cell origin. 4. Six cycles of R-CHOP between [**Month (only) **] and [**2113-11-23**]. 5. Clinical followup with serial CT scans showing enlarging lymph nodes over time in the chest, abdomen, and pelvis suggestive of recurrence. 6. Two cycles of RICE by Dr. [**Last Name (STitle) 41471**] in 1/[**2115**]. 7. High-dose Cytoxan given on [**2115-2-28**]. 11. Peripheral stem cell collection [**Date range (1) 82037**]. 12. BEAM preparative regimen followed by auto-HSCT on [**2115-4-2**]. 13. 3 doses of CT-011 on [**2115-6-26**], [**2115-8-7**] and [**2115-9-18**] on the clinical trial 07-360 (evaluating the role of PD-1 blockade in the post-transplant setting in patients with non-Hodgkin lymphoma). 14. Disease progression diagnosed in [**2115-11-24**] by a fine-needle aspiration of right preauricular mass. This showed cells suspicious for lymphoma, flow cytometry showed a kappa restricted CD10 positive B-cell lymphoproliferative disorder. 15. 4 cycles of gemcitabine and pralatrexate ([**Date range (3) 82036**]) on the clinical study 08-164. 16. PET-CT on [**2116-5-13**] showed mixed response. Social History: Mr. [**Known lastname 82035**] lives with his wife in [**Name (NI) 3844**]. He quit smoking in [**2113**]. He used to smoke two packs per day for 25 years. He occasionally drinks alcohol but has not had a drink recently. Has a daughter also in [**Name (NI) **]. Family History: He has two brothers and one sister without any significant medical problems. Physical Exam: On presentation: GEN: alert, well-appearing, lying in bed supine with eyes closed most of the time when talking, no acute distress HEENT: extraoccular muscles intact, sclerae anicteric, conjunctiva pink, oropharynx clear, moist mucus membranes Chest: clear to auscultation bilaterally Heart: regular rhythm, normal rate, S1/S2, no murmurs appreciated Abdomen: soft, non-tender, mildly distended, bowel sounds present Extremities: no clubbing, no edema, 2+ dorsalis pedis pulses Neuro: oriented x 3 Skin: face erythematous, flushed-appearing similar to rosacea; back with chronic folliculitis Pertinent Results: Radiology Report [**Numeric Identifier 12139**] TUNNELED W/O PORT Study Date of [**2116-6-8**] 10:05 AM IMPRESSION: Successful ultrasound and fluoroscopically-guided placement of a tunneled triple-lumen central venous catheter via right IJ accss with the tip terminating in the distal SVC. The line is ready for use. Radiology Report RENAL U.S. PORT Study Date of [**2116-6-10**] 9:45 AM FINDINGS: The left kidney measures 11 cm. The right kidney measures 12 cm. There is a 1-cm simple-appearing cyst in the upper pole of right kidney. A 5-mm non-obstructive stone is present within the interpolar region of left kidney. There is no hydronephrosis or mass. The prostate is enlarged. Partially distended bladder appears within normal limits. IMPRESSION: 1. No evidence of hydronephrosis. 2. 1-cm simple right upper pole renal cyst. 3. 5-mm non-obstructive left renal stone in the interpolar region. Cardiology Report ECG Study Date of [**2116-6-14**] 4:45:24 PM Normal sinus rhythm, rate 76. Borderline low voltage. Compared to the previous tracing of [**2116-5-27**] the sinus rate is marginally slower and borderline low voltage is new, possibly a precordial electrode lead placement effect. Intervals Axes Rate PR QRS QT/QTc P QRS T 76 136 84 [**Telephone/Fax (2) 82038**]4 Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT Study Date of [**2116-6-19**] 1:28 PM 1. echogenic liver, compatible with fatty infiltration, although more advanced disease such as fibrosis cannot be excluded. 2. non-dilated gallbladder full of sludge. 3. CBD not dilated. No intrahepatic biliary ductal dilatation. 4. main portal vein patent, with normal hepatopedal flow. 5. Small bilateral pleural effusions. . [**2116-6-27**] Liver u/s IMPRESSION: No evidence of portal vein or large vessel venous thrombosis. . [**2116-6-30**] ECHO The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis (LVEF = 45%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Moderate to severe (3+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: At least mild global left ventricular systolic dysfunction. Moderate to severe mitral regurgitation. Moderate pulmonary hypertension. Pleural effusions. Compared with the prior study (images reviewed) of [**2116-5-26**], LV systolic dysfunction, mitral regurgitation, pulmonary hypertension and substantial pleural effusions are all new. Findings discussed with Dr. [**Last Name (STitle) **] at 1425 hours on the day of the study. . [**2116-6-30**] CT Head IMPRESSION: 1. No acute intracranial hemorrhage or mass effect. 2. Mild sinus mucosal disease. . [**2116-7-6**] ECHO The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. 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 borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 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 [**2116-6-30**], LVEF has improved and trivial MR is now seen. . Microbiology Data [**2116-7-10**] 04:02AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND [**2116-7-10**] 04:02AM BLOOD B-GLUCAN 183 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL [**2116-7-7**] 06:08AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD- none detected [**2116-7-6**] 12:00PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN Test Result Reference Range/Units ASPERGILLUS ANTIGEN 0.2 <0.5 [**2116-7-6**] 12:00PM BLOOD B-GLUCAN Results Reference Ranges ------- ---------------- 75 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL [**2116-7-6**] 02:39AM BLOOD HERPES 6 DNA PCR, QUANTITATIVE Test Name In Range Out of Range Reference Range --------- -------- ------------ --------------- Herpes Virus 6 DNA, Quantitative Real-Time PCR Herpes Virus 6 DNA, QN PCR <500 <500 copies/mL [**2116-7-6**] 02:39AM BLOOD ADENOVIRUS PCR-Test Name [**2116-6-30**] 03:47AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test [**2116-6-30**] 03:47AM BLOOD B-GLUCAN Results Reference Ranges ------- ---------------- <31 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL . [**2116-7-14**] Immunology (CMV) CMV Viral Load-PENDING INPATIENT [**2116-7-10**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY INPATIENT [**2116-7-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2116-7-7**] URINE VIRAL CULTURE-PRELIMINARY INPATIENT [**2116-7-7**] Immunology (CMV) CMV Viral Load-FINAL INPATIENT [**2116-7-6**] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL INPATIENT [**2116-7-6**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; LEGIONELLA CULTURE-FINAL; POTASSIUM HYDROXIDE PREPARATION-FINAL; Immunoflourescent test for Pneumocystis jirovecii (carinii)-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY; VIRAL CULTURE: R/O CYTOMEGALOVIRUS-PRELIMINARY INPATIENT [**2116-7-5**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2116-7-5**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2116-7-5**] URINE ANAEROBIC CULTURE-FINAL INPATIENT [**2116-7-4**] URINE URINE CULTURE-FINAL INPATIENT [**2116-7-2**] URINE URINE CULTURE-FINAL INPATIENT [**2116-6-30**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2116-6-30**] Immunology (CMV) CMV Viral Load-FINAL INPATIENT [**2116-6-29**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2116-6-29**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2116-6-27**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2116-6-27**] URINE URINE CULTURE-FINAL INPATIENT [**2116-6-27**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2116-6-22**] Immunology (CMV) CMV Viral Load-FINAL INPATIENT [**2116-6-21**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2116-6-20**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2116-6-19**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2116-6-19**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2116-6-19**] Stem Cell - Blood Culture Stem Cell Aer/[**Doctor First Name **] Culture-FINAL [**2116-6-17**] Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV IgM ANTIBODY-FINAL [**2116-6-9**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2116-6-9**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2116-6-8**] Blood (CMV AB) CMV IgG ANTIBODY-FINAL Brief Hospital Course: Mr. [**Known lastname 82035**] is a 63 year old gentleman with relapsed NHL D+ 433 s/p auto-HSCT, recently s/p 4 cycles of gemcitabine/ pralatrexate with partial response, now admitted for reduced-intensity conditioning sibling-donor allo-HSCT on [**2116-6-8**] with ATG/TLI/clofarabine. # Follicular Lymphoma: Patient was admitted for allo stem cell transplant with ATG/TLI/clofarabine preconditioning on a study protocol. He tolerated the initial preconditioning well with ATG, reacting with rigors/chills/fevers only on the first night. He did have asymptomatic fevers on the second night of ATG, and blood pressures were noted to be lower than baseline in the 90s systolic, but the last three doses of ATG were tolerated well with no complaints. Patient was, however, noted to be retaining significant amount of fluid and had gained over 40 lbs in fluid weight in the first two weeks. In setting of fluid overload, diffusely erythematous skin, and renal failure, patient may have been experiencing a type of serum sickness secondary to the ATG remaining in his circulation. The total lymphocyte irradiation (TLI) directed at his lymph nodes also led to increased erythema of his face, neck and back; because it was directed particularly at a large lymph node in right sided cervical chain, patient secondarily experienced increased pain in right cheek from radiation-induced mucositis. Partial matched sibling donor stem cells were transfused on [**6-19**], after which he appeared to have mild hemolysis and had his first neutropenic fever. # Neutropenic Fevers: Patient began having neutropenic fevers on [**6-19**] and was started on cefepime that evening. He was started on Vancomycin the following day, which was discontinued on [**6-22**] after 48 hours of being afebrile. # Acute Renal Failure: On presentation, patient's creatinine was 1.3, above his baseline of 1.0. Creatinine improved briefly to 1.2 with fluids but was noted to increase acutely in next couple of days up to 1.7 in setting of ATG treatment. With blood transfusion and normal saline boluses, patient's creatinine trended back down to 1.0 and was stable for nearly one week. Once fluids were stopped after clofarabine treatment and stem cell infusion, patient's creatinine was again noted to increase to 1.5. He may have been experiencing a serum sickness type of reaction secondary to the ATG still in his system, causing inflammatory changes and extravasation of fluids resulting in intravascular volume depletion. On [**6-20**], he was started on [**Hospital1 **] dosing of IV solumedrol to attempt to decrease the effects of any ATG remaining in his system. # Elevated LFTs: Prior to stem cell infusion, patient's LFTs were noted to be rising slowly. On Day 1 s/p stem cell transplant, a RUQ ultrasound without doppler was done to rule out obstruction, showing only gall bladder sludge and fatty infiltration of the liver. Mild rise in T Bili after stem cell infusion was likely in setting of mild hemolysis. Patient had been started on ursodiol on Day -2 for VOD prophylaxis. = = = = = = = ================================================================ On the evening of [**5-14**] Mr. [**Known lastname 82035**] developed hypoxia. His sats decreased to 88%. He was transferred to the [**Hospital Unit Name 153**] for closer monitoring. Below is a description of his ICU events. . # Hypoxia: Thought to be multifactorial initially- edema, engraftment, and infection. He was grossly volume overloaded in setting of pre chemo hydration. A chest x ray obtained showed increased nodular/fluffy opacities. He was started on vancomycin in addition to the cefipime he had been on for several days due to neutropenic fever. He was aggressively diuresed. He was also on steroids for possible engraftment syndrome and being treated for laryngeal edema. He initially improved with treatment of all these etiologies. He began to clinically worsen and needed to be intubated. While intubated, he was continued on a broad spectrum of antibiotics. He was also aggressively diuresed with a lasix gtt. He was ultimately found to have invasive aspergillis of the lungs, likely explaining his respiratory symptoms. His blood and sputum tested positive for galactomannon. He overall improved from a respiratory standpoint. However, his mental status prevented extubation. He was on [**5-27**] for several days, but was unable to be weaned because he had no gag and was not following commands. His sedation was decreased and precedex was given to help improve mental status. He was eventually extubated and satting well on face mask. His respiratory status was stable for a few days but then acutely deteriorated on [**2116-7-21**] with worsening opacities on CXR. He was re-intubated, complicated with spontaneous pneumothorax on left side. Chest tube was placed. Patient continued to get aggressive anti-fungal treatment for a worsening aspergillis pneumonia which eventually cleared; per BMT, will continue micafungin. Patient is s/p 2 intubations x 10 and 8 days, is now Day 3 post extubation and doing well. # Pneumonia: The ID team was following. He was continued on vancomycin and switched to meropenem from cefepime. His antifungal coverage was initially micafungin which switched to andilufungin. This was then switched back to micafungin. He was started on voriconazole when his beta glucan increased. Aspergillis was thought to be source of pulmonary infection given the positive sputum and blood galactomannon. Voriconazole was then switched to micofungin since his LFTs increased thought to be possible due to voriconazole hepato-toxicity. # Laryngeal Edema/Airway Protection: Patient had total lymph node radiation pre-transplant with resultant mucositis, causing edema and potential airway compromise. Fibroscopic exam by ENT showed improved pharyngeal edema. He was initially placed on steroids for this issue, and is now continued on IV solumedrol. . # Hemoptysis: Superficial erosions seen on fiberoptic exam by ENT. Likely hemoptysis from coughing/trauma in setting of low platelets. No further episodes. . # Delirium: Patient developed altered mental status during ICU course and found to have parieto-occipital white matter changes suggestive of PRES syndrome possibly from cyclosporine. Neuro was consulted and confirmed that PRES was the likely underlying condition since Video EEG and LP all returned negative. Over time, he became more lucid and MRI showed resolution of PRES. His mental status is more lucid now, although he still waxes and with respect to attention. He sporadically recieved Haldol PRN for agitation and delerium; however, has not needed it in a week. # Follicular lymphoma: s/p ATG, TLI and allotransplant [**6-19**]. He was continued on antifungal coverage, Acyclovir, Cyclosporine 110 MG IV q12 hours, and Mycophenolate Mofetil 1250 mg IV BID. The cyclosporine was monitored with daily levels. It was eventually stopped because of sinificant elevation of LFT's. LFTs have now returned to [**Location 213**]. Pt received one dose of inhaled pentamidine on [**8-16**] (a q4week medication) for PCP [**Name Initial (PRE) 1102**]. He was not able to take PO/NG meds due to ileus and Bactrim was not given due to renal failure. . #Abrnormal LFTs: Several weeks into hospital course, Mr. [**Known lastname 82035**] developed rising LFTs (in the 100s), rising amylase and lipase (in the 500s) and rising [**Female First Name (un) **]- total (peaked at 8.0). Voriconazole was switched to Micogunfin to limit liver toxicity and we stopped TPN which is associated with liver failure. GI was consulted who reccomended MRCP when pt is more stable. LFTs have now returned to [**Location 213**]. . # Trombocytopenia: Secondary to chemotherapy. Required multiple platelet transfusions (every other day) for goal ? 35. # HYpertension: He had significant hypertension while being mechanically ventilated. He was placed on labetalol 200 TID and Hydral 10 PRN. Pressures now better controlled, these 2 meds have been dc'ed. He is on amlodipine 5 at home. . # Nutrition: He received tube feeds; NGT dc'ed 2 days ago. Now on PO clears, diet to be advanced. # Hemolysis: Likely secondary to A/B mismatch of patient and donor. He required several units of blood. He was monitored with hemolysis labs. He was placed on steroids. Patient transfused several times per week, # Hypernatremia: Mr. [**Known lastname 82035**] had significant hypernatremia. This was corrected by replacing a free water deficit. Has been normal for 5 days. . # Acute Renal Failure: Creatinine steadily increased during admission. It worsened while in the ICU. A renal ultrasound showed no evidence of obstuction. The renal team was consulted and felt the scenario was consistent with ATN. He was started on a furosemide gtt and showed a steady improvement in this creatinine. Cr has returned to baseline. . Mr. [**Known lastname 82035**] was a full code. = = = = = = = = = = = = = = = = = = = = = ================================================================ ICU Course from [**8-9**] - [**9-11**]: Respiratory Failure: Patient was transferred from BMT for increasing respiratory distress. On [**8-9**], he was intubated for hypoxemic respiratory failure. Bronchoscopy was completed to rule out PCJ pneumonia and was negative. Patient remained intubated throughout majority of the ICU course as his mental status (likely [**2-25**] prolonged sedation and uremia) posed a barrier to extubation. Because of prolonged intubation, patient had tracheostomy placed. Required increasing ventilator support. Was ultimately withdrawn from the ventilator at the request of family, at which point the patient died. Cardiac: Initially on admission, patient was in sinus rhythm however during the ICU stay, patient converted in Afib/Aflutter. Patient had history of this in past and was placed on metoprolol for rate control. The patient initially required pressors, was able to wean from pressors, but on [**9-11**] began to require maximal doses of three pressors. Cholecystitis/Hyperbilirubinemia: The patient had cholecystitis (diagnosied by RUQ u/s and elevated LFTs). Surgery was consulted and recommended PTC. Patient was started empirically on antibiotics for possible cholangitis, and a PTC was placed. Later in the course of his stay, the patient began to have a rising bilirubin which was shown to be a direct hyperbilirubinemia. Numerous RUQ ultrasounds indicated that the patient's biliary drain was in place, without any evidence of blockage or obstruction. A transjugular hepatic biopsy showed pathology consistent with sepsis versus drug reaction, at which point the patient was DC'ed from several hepatotoxic drugs, without resolution of hyperbilirubinemia. Kidney fucntion: Course was complicated by acute renal failure which was thought to be [**2-25**] ATN from either hypotension or from acyclovir. Additionally, the patient had profound uremia and hyponatremia. In the setting of uremia, CVVH was started. Hyponatremia was thought to be [**2-25**] hypervolemia and resolved with volume restriction. Patient's renal function remained stable on CVVH and dialysis, which he required daily. Anemia/Thrombocytopenia: Patient also remained thrombocytopenic and anemia and in the setting of acute renal failure, there was concern for a transplant associated thrombotic [**Doctor First Name **]. Pheresis medicine was consulted however the patient was deemed not a candidate for pheresis. Throughout the ICU course patient required several platelet and blood transfusion. On [**8-11**] at 544 AM the patient passed away from hypoxic respiratory failure after being removed from the ventilator at the wishes of his family. Medications on Admission: none Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: Follicular Lymphoma Secondary Diagnoses: Acute Renal Failure Transaminitis Mucositis Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "484.6", "585.6", "202.00", "518.81", "V43.64", "E932.0", "584.5", "286.6", "E933.1", "786.3", "577.0", "995.92", "528.01", "998.11", "249.00", "038.9", "348.39", "570", "403.91", "427.32", "117.3", "518.4" ]

icd9cm

[ [ [] ] ]

[ "50.13", "38.93", "45.25", "00.91", "31.1", "41.03", "33.24", "29.11", "51.01", "03.31", "96.72", "39.95", "31.42", "99.15" ]

icd9pcs

[ [ [] ] ]

24470, 24479

12680, 24415

317, 340

24628, 24637

4263, 12657

24693, 24703

3556, 3635

24500, 24500

24441, 24447

24661, 24670

3650, 4244

24561, 24607

234, 279

368, 1236

24519, 24540

1258, 3260

3276, 3540

25,538

175,395

46854

Discharge summary

report

Admission Date: [**2199-12-9**] Discharge Date: [**2199-12-22**] Date of Birth: [**2130-4-10**] Sex: F Service: MEDICINE Allergies: E-Mycin / Ceftazidime / Fosamax Attending:[**First Name3 (LF) 905**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Blood transfusions Electrophysiology ablation History of Present Illness: Pt is a 69 yo female with a history of 3VD CAD, s/p CABG in [**2169**] and awaiting repeat, mixed systolic/diastolic CHF with EF 40-45%, who presented with 10 days of progressive dyspnea. 10 days prior to admission, pt felt dyspneic and a decrease in how far she could walk. + new 2 pillow orthopnea. + subjective "low grade fever," though did not measure it at home. + cough productive of white frothy sputum. +2 pillow orthopnea, whereas normally can lay flat. No PND. No LE edema. Recent Cardiac cath [**2199-9-10**] showed diffuse 3 vessel disease, severe mitral regurgitation, and mild systolic and diastolic ventricular dysfunction. ECHO [**2199-8-27**] also showed severe MR [**First Name (Titles) **] [**Last Name (Titles) 75827**]y reduced LV and RV systolic function. Pt is followed by Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] of CT [**Doctor First Name **] at [**Hospital1 112**], and is to get repeat CABG/MVR in near future once cleared by Dr. [**Last Name (STitle) 497**] for her esoph varices (to have repeat EGD [**2198-12-17**] after recent banding), and once her R axillary LAD etiology is determined (had negative dissection with bx 1y PTA, was to have another recently but did not make the appt because of her current illness. Pt was admitted to the MICU as she was found to be in atrial fibrillation with RVR, tachypnic, confused, and with a new renal failure. She was initially on a diltiazem gtt for her atrial fibrillation. She was seen by cardiology, and despite increasing beta blocker and diltiazem, was persistently in afib with RVR. Pt underwent ibutilide cardioversion with success on [**2199-12-11**]. On transfer to the regular medicine service, pt feels well. No CP/SOB. No F/C/N/V. Past Medical History: 1. CAD, CABG x3 at age 39 at [**Hospital1 112**] 2. Congestive heart failure, EF 40-50% ([**8-19**]), moderate-severe MR. 3. Paroxysmal atrial fibrillation 4. Upper GI bleed with esophageal varicies diagnosed in [**Month (only) 216**] [**2192**], most recent EGD showing grade III esophageal varices, status post banding [**11-18**] 5. Ascites secondary to [**Month/Year (2) 32004**] vein thrombosis, [**2188**]. 6. Idiopathic thrombocytopenic purpura s/p splenectomy in [**2188**] (in the setting of chemotherapy treatment for breast cancer). 7. Sarcoidosis - diagnosed in [**2164**] 8. Left breast cancer diagnosed in [**2188**], status post lumpectomy, chemotherapy and radiation treatment. Was on tamoxifen until [**2194-3-15**]. 8. Hypercholesterolemia 9. Osteoporosis 10. IBS 11. Hyperparathyroidism 12. Depression 13. Lactose intolerance 14. Status post cholecystectomy in [**2190**] 15. Stable AAA - 4.2 x 3.9 cm 16. Right axillary dissection and neck exploration for enlarged right adenopathy Social History: Married, formerly worked at a department store. H/o tobacco use (1 ppd quit 14 years ago) Denies EtOH, IVDA Family History: F: died of CHF M: CAD S: DM2 Physical Exam: VS: T: 97.4 (98.0); BP: 122/85 (117-134/54-85); P: 60s-70s; RR: 22; O2: 96 ; I/O 350/475; 14 hr: 620/350 General: Older female speaking in full sentences, though has to take a breath mid-sentence. Mildly tachypnic HEENT: Sclera anicteric; EOMI; OP clear Neck: Right EJ in place. JVD to angle of jaw? CV: RRR S1S2. II/VI systolic murmur at apex Chest: Rales at left base. Otherwise clear Abd: +BS. +fluid wave. Soft, nt, ND Ext: No edema Neuro: A&O x 3. Reflexes: biceps, bracio, patellar all [**1-16**]. MS [**4-18**] throughout. CN II-XII tested and intact. Pertinent Results: Labs on admission: [**2199-12-9**] 11:50AM BLOOD WBC-13.1* RBC-4.04* Hgb-11.7* Hct-35.3* MCV-87 MCH-28.9 MCHC-33.1 RDW-17.2* Plt Ct-124* [**2199-12-9**] 11:50AM BLOOD Neuts-59.0 Lymphs-32.0 Monos-6.2 Eos-1.1 Baso-1.7 [**2199-12-9**] 12:53PM BLOOD PT-15.0* PTT-28.2 INR(PT)-1.5 [**2199-12-9**] 11:50AM BLOOD Glucose-147* UreaN-46* Creat-2.9*# Na-140 K-7.9* Cl-108 HCO3-13* AnGap-27* [**2199-12-9**] 11:59AM BLOOD ALT-33 AST-105* CK(CPK)-137 AlkPhos-128* Amylase-57 TotBili-1.0 [**2199-12-9**] 11:59AM BLOOD CK-MB-3 cTropnT-0.17* [**2199-12-9**] 08:52PM BLOOD Ammonia-<6 [**2199-12-9**] 09:26PM BLOOD Lactate-2.2* _______________________ Cardiac Labs: [**2199-12-9**] 11:59AM BLOOD CK-MB-3 cTropnT-0.17* [**2199-12-9**] 03:00PM BLOOD CK-MB-3 cTropnT-0.23* [**2199-12-9**] 08:52PM BLOOD CK-MB-3 [**2199-12-10**] 05:02AM BLOOD CK-MB-NotDone cTropnT-0.23* [**2199-12-11**] 05:47AM BLOOD proBNP-4003* [**2199-12-14**] 01:15PM BLOOD CK-MB-NotDone cTropnT-0.31* [**2199-12-14**] 07:25PM BLOOD CK-MB-NotDone cTropnT-0.32* [**2199-12-15**] 06:45AM BLOOD CK-MB-1 cTropnT-0.22* _______________________ Other Labs: [**2199-12-15**] 06:45AM BLOOD calTIBC-311 Ferritn-68 TRF-239 [**2199-12-12**] 06:33AM BLOOD C3-98 _______________________ Labs on discharge: [**2199-12-22**] 05:41AM BLOOD WBC-12.5* RBC-3.54* Hgb-9.7* Hct-29.5* MCV-83 MCH-27.4 MCHC-32.9 RDW-16.1* Plt Ct-223 [**2199-12-22**] 05:41AM BLOOD Glucose-112* UreaN-36* Creat-1.5* Na-138 K-4.0 Cl-103 HCO3-23 AnGap-16 [**2199-12-22**] 05:41AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8 _______________________ Radiology: Chest AP 12/26/06-1. Cardiomegaly with mild CHF. 2. Biapical scarring unchanged. By report, the patient has a history of sarcoid. 3. No focal infiltrate identified. 4. Small nodular density left mid zone. See comment above. - - - - - - - - - - - - Abdominal ultrasound with dopplers [**2200-12-9**] 1. Redemonstration of [**Month/Day/Year 32004**] vein thrombosis. 2. No evidence of liver mass or ascites. 3. IVC enlargement and increased dynamic flow in the hepatic veins consistent with patient's history of known CHF. - - - - - - - - - - -- Echo [**2200-12-10**]-There is mild regional left ventricular systolic dysfunction. Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). Resting regional wall motion abnormalities include basal to mid inferior and distal septal hypokinesis. Right ventricular chamber size is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. Compared with the prior study (tape not available) of [**2199-8-27**], overall left ventricular systolic function is probably similar (however distal septal hypokinesis noted in the current study but not in the prior report). Mitral regurgitation is now less prominent. There is now a restrictive left ventricular filling pattern. - - - - - - - - - - - - - Chest PA/LAT [**2199-12-17**]-IMPRESSION: Cardiomegaly, interstitial edema, and small left pleural effusion unchanged. EKG on admission: Atrial fibrillation, rate ~140s. Left axis. New STD II,III, AvF, V4-V6. Brief Hospital Course: Pt is a 69 yo female with h/o 3VD CAD, s/p CABG in [**2169**] and awaiting repeat, mixed systolic/diastolic CHF with EF 40-45%, who presents with 10 days of progressive dyspnea, found to have a fib with RVR, ARF, and increased ascites. She is s/p cardioversion with ibutilide and had an EP ablation. 1. Cardiovascular: a. [**Name (NI) 9520**] Pt was in Afib/Aflut and is s/p ibutilide conversion to sinus rhythm when she was in the ICU. She was being rate controlled with PO metoprolol which was being uptitrated but she went back in to aflutter with RVR on HD 10. She maintained her pressure and was put on a diltiazem drip, uptitrated to 15 units/hour. She spontaneously converted to normal sinus on HD 12 and had an EP study with ablation that day. Metoprolol was continued and she was discharged on 50 mg tid. It was decided not to anticoagulate this patient with varices after speaking with liver as she is an extreme risk of bleeding. b. CAD- known 3VD. Pt had new inferolateral ST depressions which got better on subsequent EKGs. We continued ASA and beta blocker. c. Pump/BP- Known mixed systolic, diastolic heart failure. Repeat echo here showed EF 40-45%. Additionally, it appeared on physical exam and based on chest xray with b/l pleural effusions that pt was in CHF exacerbation likely secondary to the RVR. She was diuresed 1-2 L/day with lasix and her spironolactone was initially held but slowly uptitrated. While she was in rapid afib, diuresis was held as we wanted to maintain her pressures. Hydralazine and isosorbide were held as pressures were borderline and we wanted to diurese her. Isosorbide was able to be restarted post-ablation. Strict I/Os were kept, pt was on a fluid restriction, and a low sodium diet. Wt on discharge was 61.5 kg and likely represents her dry weight. 2. ARF-baseline cr 0.9-1.0, was 3.0 at peak and slowly came down. It was thought to be a prerenal state from CHF, less likely afib with RVR as time correlation between the two was a few days to resolve. Urine Eos were negative, and C3 was normal therefore it unlikely artheroembolic. Renal u/s showed no evidence of obstruction or hydronephrosis. As pt was diuresed, her creatinine came down. On discharge her creatinine was 1.5-1.7 and this likely represents a new baseline for her. 3. [**Name (NI) 1621**] Pt was dyspneic in the first half of her hospitalization. It was likely [**1-16**] CHF, anxiety, worsening ascites. As she was diuresed, and with ativan, pt became less dyspneic. Also, at the end of hospitalization, pt was ambulation and satting in the mid-upper 90s. 4. Leukocytosis- Peak WBC of 18.8 and Low grade temperatures in upper 99s. There were no signs of infection and pt was pancultured multiple times. U/As were negative. BCx x 2 were negative, UCx were negative. 5. Hepatology/[**Name (NI) **] Pt with [**Name (NI) 32004**] vein thrombosis that is chronic. We did not anticoagulate her afib/flutte [**1-16**] varices, and an extremely high risk of bleeding. Aldactone was initially held when pt went back in to afib/flutter which was restarted and uptitrated after the EP ablation. In terms of varices, stools were gauaiced and negative. An active T&S was kept at all times. Sucralfate and PPI were continued. She will need repeat banding as an outpt. 6. Anemia- As above. Iron studies were consistent with anemia of chronic disease (Iron 12, TIBC, ferritin nl). Pt was given 2 units of pRBC, one each on HD6 and HD 7. 7. F/E/N-renal, cardiac, low salt diet. Electrolytes were checked and repleted prn. 8. Prophylaxis-Pt was on pneumoboots (given risk of bleeding), PPI, sucralfate 9. Access- 2 PIVs. 10. [**Name (NI) 8410**] Pt was Full Code. Medications on Admission: Propranolol 80 mg daily Aldactone 100 mg daily Protonix 40 mg daily Lovastatin 40 mg daily Centrum Silver one tablet daily Medications on transfer: ASA 325 mg po qday Atorvastatin 40 mg qday Benzonatate 100 mg tid MVI Colace 100 mg [**Hospital1 **] Anzemet 12.5 mg prn nausea Guafenesin with codeine q 6 prn Hydralazine 10 mg po q6 hours Isosorbide dinitrate 10 mg [**Hospital1 **] Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 4. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 9. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Primary diagnosis: Atrial flutter with rapid ventricular rate S/P ablation Congestive heart failure Acute renal failure Anemia Secondary Diagnosis: Coronary artery disease Esophageal Varices Discharge Condition: Better. Pt is in sinus rhythm at a normal rate. She is ambulating and her oxygen saturation is good. Discharge Instructions: Low sodium diet (2 grams) Fluid restriction [**2193**] ml Please call your doctor or go to the emergency room if you have chest pain, shortness of breath, worsening breathing, weakness, lightheadedness, or any other health concern. Please make note that you have many medication changes. Followup Instructions: -Please call Dr.[**Name (NI) 60978**] Office for followup in the next few weeks. You will need repeat banding of your varices. The number is [**Telephone/Fax (1) 7091**]. -You will need follow up with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] at [**Hospital1 3372**]. YOu should call him this week. Additionally, you can get a copy of your discharge summary by calling medical records at [**Telephone/Fax (1) 2806**]. It should be ready in ~1 week. -You will need to follow up with electrophysiology per their recommendations. Their number is [**Telephone/Fax (1) 99417**]. -You will need to call Dr.[**Name (NI) 2935**] office at [**Telephone/Fax (1) 2936**]. You should have follow up in the next 7-10 days. -You will need to get your right axiallary lymph nodes followed up as you know about. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "V10.3", "733.00", "428.0", "285.29", "789.5", "428.43", "452", "V45.81", "571.5", "441.4", "456.21", "276.7", "135", "276.2", "496", "584.9", "424.0", "427.32", "401.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "37.34", "99.62", "99.04", "37.26" ]

icd9pcs

[ [ [] ] ]

12642, 12697

7394, 11075

300, 348

12932, 13035

3920, 3925

13373, 14301

3296, 3326

11508, 12619

12718, 12718

11101, 11225

13059, 13350

3341, 3901

253, 262

5164, 7283

376, 2129

12867, 12911

12737, 12846

7297, 7371

11250, 11485

2151, 3155

3171, 3280

5022, 5145

9,620

143,937

45389

Discharge summary

report

Admission Date: [**2188-5-15**] Discharge Date: [**2188-5-21**] Date of Birth: [**2110-1-16**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: angina Major Surgical or Invasive Procedure: [**2188-5-15**] - CABG x5 (LIMA to LAD, SVG to OM2 with Y graft to Diag 1, SVG to OM 1, SVG to RCA; OM 2 endarterectomy) [**2188-5-15**] - Cardiac Catheterization History of Present Illness: 78 yo female with breast biopsy on [**4-30**], presented to ED with angina radiating to her left arm and nausea with SOB. Angina not relieved in ER on a nitro drip. EKG showed ST depressions. CTA ruled out a PE but showed coronary calcifications. Heparin and integrilin drips started and plavix load done. St depressions continued, so referred for emergent cath.Ruled in for NSTEMI. Past Medical History: HTN elev. lipids elevated glucose with normal HbA1Cs right breast Ca with biopsy hypothyroidism Social History: no smoking in past 20 years no ETOH Family History: father deceased with 3 MIs 2 brothers with CABG Physical Exam: 63" 81 kg 98% O2 sat 4L NC 128/57 HR 82 RR 16 A X O x3, NAD EOMI, dry MM [**1-29**] SEM , RRR bibasilar rales soft, NT, ND, no HSM or tenderness abd. aorta not enlarged by palpation, no abdominal bruits no c/c/e; IABP in place 2+ bil. carotids/DP/PTs Pertinent Results: [**2188-5-20**] 05:29AM BLOOD WBC-17.4* RBC-2.89* Hgb-8.9* Hct-26.0* MCV-90 MCH-30.6 MCHC-34.1 RDW-16.2* Plt Ct-259 [**2188-5-20**] 05:29AM BLOOD Plt Ct-259 [**2188-5-20**] 05:29AM BLOOD Glucose-112* UreaN-28* Creat-0.6 Na-142 K-4.6 Cl-102 HCO3-35* AnGap-10 [**2188-5-20**] 05:29AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.5 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2188-5-18**] 12:14 PM CHEST (PORTABLE AP) Reason: eval ptx/infiltrate [**Hospital 93**] MEDICAL CONDITION: 78 year old woman with chest pain, ekg changes, s/p cath with IABP placement. s/p chest tube removal REASON FOR THIS EXAMINATION: eval ptx/infiltrate EXAMINATION: AP chest. INDICATION: Chest pain. Status post chest tube removal. A single AP view of the chest is obtained [**2188-5-18**] at 12:26 and is compared with the prior evening's radiograph. Bilateral pleural tubes have been removed. There is no evidence of pneumothorax. Dense retrocardiac opacity persists on the left side consistent with airspace disease/atelectasis in the left lower lobe with possible left pleural effusion in addition. Right-sided IJ line is again seen with its tip positioned near the junction of the IVC and right atrium. [**2188-5-15**] - ECHO PRE-BYPASS: 1. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are three aortic valve leaflets. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. 5. Physiologic mitral regurgitation is seen (within normal limits). 6. There is no pericardial effusion. 7. IABP is seen well positioned in the descening aorta, inferior to the take off of the left subclavian artery POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. 1. Biventricular function is preserved. 2. IABP still in good position, aorta is intact post decannulation 3. Other findings are unchanged [**2188-5-20**] CXR Compared with [**2188-5-18**], the left pleural effusion may be smaller in size, although some of the clearing at the left lung base can be attributed to reexpansion of retrocardiac atelectasis. The left upper lobe and the right lung are grossly clear. [**2188-5-15**] Cardiac Catheterization COMMENTS: 1. Coronary angiography in this right dominant system demonstrated an LMCA free of angiographically significant disease. The LAD had diffuse proximal calcific disease with serial 60-80% stenoses. The LCX system was notable for slow flow in a subtotally occluded bifurcating OM2; the AV-groove LCX was a small vessel without significant stenoses. 2. Limited resting hemodynamics revealed systemic pressures of 140/65 mmHg. 3. An IABP was placed via right femoral access and the patient was transferred to the CCU in stable condition in anticipation of CABG. Brief Hospital Course: Admitted [**5-15**] and IABP placed during her cardiac catheterization as it showed severe three vessel disease. The cardiac surgical service was consulted and she was worked-up in the usual preoperative manner. Later on [**2188-5-15**], Ms. [**Known lastname **] was taken to the operating room where she underwent coronary artery bypass grafting to five vessels. Postoperatively she was taken to the intensive care unit for monitoring. On postoperative day one, her intra-aortic balloon pump was weaned off and removed without complication. She was slowly weaned from her inotropes and pressors. On postoperative day two, she awoke neurologically intact and was extubated. Gentle diuresis was initiated. On postoperative day three, she was transferred to the step down unit for further recovery. The physical therapy service worked with her daily. She developed atrial fibrillation which converted to normal sinus rhythm with treatment with amiodarone. A breast biopsy was obtained given her recurrence of breast cancer however the results were not available at the time of discharge. Her white cell count was noted to be elevated however all culture data was negative. There were no clinical signs of infection and her white cell count began to trend down. Ms. [**Known lastname **] continued to make steady progress and was discharged to rehabilitation on [**2188-5-21**]. She will follow-up with Dr. [**First Name (STitle) **], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Levoxyl 137mcg, Quinapril 10mg qd, atenolol 50qd Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): While taking narcotic pain medications. . 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 12 months: For coronary endarterectomy. To be taken for 12 months or per cardiologist. . 5. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO Take 400mg twice daily until [**5-25**], then take 400mg once daily until [**6-1**]. Starting [**6-2**], take 200mg once daily until instructed by cardiologist. Monitor heart rate and QT interval.: Take 400mg twice daily until [**5-25**], then take 400mg once daily until [**6-1**]. Starting [**6-2**], take 200mg once daily until instructed by cardiologist. Monitor heart rate and QT interval. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: Take for 7 days then stop. Monitor electrolyetes and replete as needed. . 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days: Take with lasix and stop when lasix stopped. 10. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Armenian Nursing & Rehabilitation Center - [**Location (un) 538**] Discharge Diagnosis: CAD now s/p CABG AF HTN elev. glucose with normal HbA1Cs breast CA with right biopsy hypothyroidism elev. lipids PSH: TAH/BSO, bladder suspension with bowel repair, shoulder and finger surgeries Discharge Condition: stable 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. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Amiodarone: Take 400mg twice daily until [**5-25**], then take 400mg once daily until [**6-1**]. Starting [**6-2**], take 200mg once daily until instructed by cardiologist. Monitor heart rate and QT interval. 8) Take lasix 40mg and potassium 20mEq once daily for 7 days then stop. Monitor electrolytes and replete as needed. Preop weight is 180 pounds. 9) Please wear surgical bra at all times for 5 weeks. 10) Please check white blood cell count once at rehab. 11) Call with any questions or concerns. Followup Instructions: see Dr. [**Last Name (STitle) 2204**] (PCP) in [**1-26**] weeks [**Telephone/Fax (1) 2936**] see Dr. [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) 17976**] (Cardiologist) in 2 weeks. ([**Telephone/Fax (1) 72390**] Your [**Hospital1 18**] cardiologist is Dr. [**Last Name (STitle) 171**] if you wish to see him. [**Telephone/Fax (1) 1989**] see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Call all providers for appointments. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2188-5-21**]

[ "414.01", "401.9", "458.29", "997.1", "V17.3", "244.9", "272.4", "427.31", "174.8", "790.29" ]

icd9cm

[ [ [] ] ]

[ "88.56", "89.60", "99.04", "37.22", "37.61", "36.15", "99.05", "38.93", "39.61", "97.44", "36.14" ]

icd9pcs

[ [ [] ] ]

7718, 7811

4502, 6002

327, 492

8050, 8059

1435, 1875

9240, 9834

1093, 1142

6102, 7695

1912, 2013

7832, 8029

6028, 6079

8083, 9217

1157, 1416

281, 289

2042, 4479

520, 904

926, 1023

1039, 1077

73,265

168,973

42630

Discharge summary

report

Admission Date: [**2180-3-13**] Discharge Date: [**2180-3-21**] Date of Birth: [**2124-3-31**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 668**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2180-3-13**] Exploratory laparotomy, lysis of adhesions History of Present Illness: Ms. [**Known lastname 92189**] is a 55F with history of chronic low back pain s/p biopsy of periaortic mass on [**2180-9-24**] consistent with retroperitoneal fibrosis, on prednisone therapy, who presents with one day of abdominal pain. Patient reports gradual onset of epigastric and periumbilical pain yesterday afternoon with associated nausea. She had 3 episodes of emesis today. Her last BM was yesterday and she has not passed flatus since onset of pain. On arrival to ED, patient was vomiting and NGT was placed with 200 cc of thin nonbilious output. Patient reports improvement in her abdominal pain since NGT placement. CT scan findings consisent with high grade small bowel obstruction with mesenteric fluid and possible closed loop. The patient was taken to the OR for operative exploration. Past Medical History: PM: chronic low back pain, borderline HTN, retroperitoneal fibrosis, aspergillus in R ear cholesteatoma PS: R ear mass resection, L wrist ORIF, open retroperitoneal biopsy of periaortic mass Social History: former tobacco use (20 pack years), denies alcohol and illict drug use, owns convenience store, lives with husband, has two children Family History: mother - died cirrhosis, thought d/t infection from blood transfusion father - died throat cancer. Smoker, asbestos exposure. sister - died MI, IVDU heroin addiction Physical Exam: 98.8, 72, 110/62, 14, 93% on room air no acute distress regular rate and rhythm clear to auscultation bilaterally, bibasilar crackles that clear w/cough abdomen soft, nontender, mildly distended, incision with staples is clean and dry without surrounding erythema or abnormal drainage minimal peripheral edema Pertinent Results: [**2180-3-13**] 12:30AM BLOOD WBC-13.7* RBC-4.92 Hgb-13.6 Hct-43.3 MCV-88 MCH-27.6 MCHC-31.4 RDW-14.1 Plt Ct-359 [**2180-3-13**] 12:12PM BLOOD WBC-15.6* RBC-4.27 Hgb-12.0 Hct-38.6 MCV-91 MCH-28.0 MCHC-31.0 RDW-14.3 Plt Ct-299 [**2180-3-14**] 05:45AM BLOOD WBC-9.8 RBC-3.88* Hgb-11.1* Hct-34.6* MCV-89 MCH-28.7 MCHC-32.1 RDW-13.8 Plt Ct-320 [**2180-3-16**] 09:10AM BLOOD WBC-16.6*# RBC-4.18* Hgb-11.7* Hct-37.1 MCV-89 MCH-28.0 MCHC-31.5 RDW-13.8 Plt Ct-315 [**2180-3-16**] 08:10PM BLOOD WBC-10.9 RBC-3.62* Hgb-10.2* Hct-32.6* MCV-90 MCH-28.1 MCHC-31.3 RDW-13.7 Plt Ct-366 [**2180-3-17**] 03:53AM BLOOD WBC-11.1* RBC-3.66* Hgb-10.3* Hct-32.6* MCV-89 MCH-28.1 MCHC-31.5 RDW-14.1 Plt Ct-317 [**2180-3-18**] 01:59AM BLOOD WBC-8.9 RBC-3.27* Hgb-9.0* Hct-30.0* MCV-92 MCH-27.7 MCHC-30.1* RDW-14.0 Plt Ct-316 [**2180-3-19**] 05:38AM BLOOD WBC-9.7 RBC-3.21* Hgb-9.0* Hct-28.6* MCV-89 MCH-28.0 MCHC-31.4 RDW-14.6 Plt Ct-292 [**2180-3-20**] 05:29AM BLOOD WBC-10.7 RBC-3.61* Hgb-10.0* Hct-32.8* MCV-91 MCH-27.6 MCHC-30.4* RDW-14.1 Plt Ct-405 [**2180-3-21**] 06:05AM BLOOD WBC-8.9 RBC-3.41* Hgb-9.5* Hct-31.5* MCV-92 MCH-27.9 MCHC-30.2* RDW-14.3 Plt Ct-440 [**2180-3-13**] 07:53AM BLOOD PT-9.1* INR(PT)-0.8* [**2180-3-17**] 03:53AM BLOOD PT-11.6 PTT-38.7* INR(PT)-1.1 [**2180-3-19**] 05:38AM BLOOD PT-13.2* PTT-65.5* INR(PT)-1.2* [**2180-3-19**] 11:33AM BLOOD PT-14.9* PTT-64.1* INR(PT)-1.4* [**2180-3-20**] 05:29AM BLOOD PT-22.2* PTT-76.2* INR(PT)-2.1* [**2180-3-21**] 06:05AM BLOOD PT-32.1* INR(PT)-3.1* [**2180-3-13**] 12:30AM BLOOD Glucose-157* UreaN-13 Creat-0.5 Na-140 K-4.0 Cl-98 HCO3-32 AnGap-14 [**2180-3-13**] 12:12PM BLOOD Glucose-221* UreaN-11 Creat-0.7 Na-136 K-4.7 Cl-99 HCO3-27 AnGap-15 [**2180-3-14**] 05:45AM BLOOD Glucose-168* UreaN-8 Creat-0.5 Na-138 K-3.9 Cl-100 HCO3-28 AnGap-14 [**2180-3-15**] 05:35AM BLOOD Glucose-133* UreaN-10 Creat-0.4 Na-137 K-3.4 Cl-100 HCO3-31 AnGap-9 [**2180-3-16**] 05:30AM BLOOD Glucose-169* UreaN-10 Creat-0.4 Na-141 K-3.3 Cl-102 HCO3-30 AnGap-12 [**2180-3-16**] 09:10AM BLOOD Glucose-244* UreaN-9 Creat-0.5 Na-142 K-2.8* Cl-96 HCO3-32 AnGap-17 [**2180-3-16**] 08:10PM BLOOD Glucose-144* UreaN-12 Creat-0.4 Na-146* K-3.7 Cl-105 HCO3-31 AnGap-14 [**2180-3-17**] 03:53AM BLOOD Glucose-206* UreaN-16 Creat-0.5 Na-147* K-3.4 Cl-106 HCO3-31 AnGap-13 [**2180-3-17**] 08:09PM BLOOD Glucose-151* UreaN-16 Creat-0.6 Na-145 K-3.3 Cl-106 HCO3-29 AnGap-13 [**2180-3-18**] 01:59AM BLOOD Glucose-228* UreaN-18 Creat-0.6 Na-143 K-3.7 Cl-105 HCO3-26 AnGap-16 [**2180-3-19**] 05:38AM BLOOD Glucose-156* UreaN-14 Creat-0.4 Na-142 K-3.1* Cl-105 HCO3-28 AnGap-12 [**2180-3-20**] 05:29AM BLOOD Glucose-141* UreaN-16 Creat-0.6 Na-139 K-3.7 Cl-104 HCO3-27 AnGap-12 [**2180-3-21**] 06:05AM BLOOD Glucose-107* UreaN-15 Creat-0.7 Na-142 K-3.8 Cl-104 HCO3-28 AnGap-14 [**2180-3-13**] 12:30AM BLOOD ALT-30 AST-16 AlkPhos-128* TotBili-0.2 [**2180-3-16**] 09:10AM BLOOD CK(CPK)-147 [**2180-3-16**] 02:17PM BLOOD CK(CPK)-360* [**2180-3-16**] 08:10PM BLOOD CK(CPK)-303* [**2180-3-17**] 03:53AM BLOOD CK(CPK)-222* [**2180-3-18**] 01:59AM BLOOD CK(CPK)-73 [**2180-3-16**] 09:10AM BLOOD CK-MB-10 MB Indx-6.8* cTropnT-0.45* [**2180-3-16**] 02:17PM BLOOD CK-MB-32* MB Indx-8.9* cTropnT-1.05* [**2180-3-16**] 08:10PM BLOOD CK-MB-28* MB Indx-9.2* cTropnT-1.09* [**2180-3-17**] 03:53AM BLOOD CK-MB-21* MB Indx-9.5* cTropnT-0.63* [**2180-3-18**] 01:59AM BLOOD CK-MB-6 cTropnT-0.37* [**2180-3-17**] 03:53AM BLOOD Triglyc-220* HDL-47 CHOL/HD-5.1 LDLcalc-150* [**2180-3-17**] 03:53AM BLOOD %HbA1c-7.6* eAG-171* [**2180-3-16**] echocardiogram The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses are normal. There is severe regional left ventricular systolic dysfunction with akinesis of the middle third of the left ventricle. There is no ventricular septal defect. The right ventricular cavity is unusually small. with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: there is akinesis of the middle third of the left ventricle. This pattern is not consistent with coronary artery disease and suggests regional cardiomyopathy/myocarditis or atypical stress cardiomyopathy. Mild mitral regurgitation. Mild to moderate pulmonary artery systolic hypertension. [**2180-3-16**] CTA chest 1. Bilateral consolidation, with some volume loss in the right middle lobe and lowers lobe is more likely atelectasis than pneumonia. 2. Three left lower lobe subsegmental pulmonary emboli of questionable clinical significance. 3. A 7-mm right lower lobe nodule seen on PET CT [**2179-8-2**] is not visualized on this study due to the right lower lobe atelectasis. [**2180-3-16**] LE U/S Duplex and color Doppler demonstrate no DVT either acute or chronic, involving both lower extremities from the common femoral through to the proximal tibial veins. [**2180-3-17**] cardiac catheterization 1) Selective angiography of this right-dominant system demonstrated no significant coronary artery disease. The LMCA had no angiographically-apparent flow-limiting stenoses. The LAD had mild luminal irregularities with a 20-30% mid-vessel stenosis. The LCx and RCA had mild luminal irregularities. 2) Limited resting hemodynamics revealed markedly-elevated left-sided filling pressures, with an LVEDP of 22 mmHg. There was moderate pulmonary arterial hypertension, with a PA pressure of 40/23 mmHg, likely due to elevated left-sided filling pressures (low transpulmonary pressure gradient). The cardiac output and cardiac index were preserved. 3) The right CFA was closed with an AngioSeal device. FINAL DIAGNOSIS: 1. No significant angiographically-apparent coronary artery disease. 2. Markedly-elevated left-sided filling pressures and moderate pulmonary arterial hypertension. Brief Hospital Course: Ms. [**Known lastname 92189**] presented to the ED as per HPI and was taken to the operating room with concern for a closed loop obstruction. Given her chronic steroid use, she was given stress dose steroids intraoperatively. In the OR, a large amount of dilated proximal small bowel and collapsed distal small bowel was seen and the dilated bowel was followed to a large kind of tangled mass of small bowel. Adhesiolysis was completed until the small bowel was able to be run from the ligament of Treitz to the terminal ileum. The transition zone was identified and the causal adhesion was lysed. There did not appear to be any internal herniation. POD1 - The patient had good urine output, minimal NGT output, and was out of bed and ambulating. She was kept NPO with IVF awaiting return of bowel function. Dilaudid PCA and standing IV tylenol for pain control. POD2 - Abdomen distended. NGT output increased and was 600cc in 8 hours so it was left in place and the patient was changed to maintenance IVF. Foley was removed at midnight into POD3. Patient lost IV access and had significant anxiety associated with this event and the placement of a new IV. POD3 - Shortly after midnight, the patient had an episode of shortness of breath. She was encouraged to use incentive spirometry and produce a deep cough. She worked with her nurse on this and was out of bed ambulating the halls before going back to bed. When seen on morning rounds around 6am, the patient appeared anxious and sweaty, stating that she was having trouble with her breathing. Her vitals were stable and she was breathing comfortably. Her lungs sounded congested so a stat portable CXR was ordered. The patient had not been clearing her secretions well since the OR. The CXR was significant for right greater than left lower lobe atelectasis with low lung volumes. At around 7am, the team was called to see the patient who was having acute respiratory distress and anxiety. She was agitated, tachypneic at 30-40 breaths per minute, tachycardic to the 120's and hypertensive to 170's-180's. Her oxygen saturations were essentially mid to high 90's throughout but the patient was on and off face mask and nonrebreather, grunting, and audibly wheezing. She was given ativan .5 mg IV x 1 which resulted in a mild improvement in symptoms. She was also given lasix 20 IV x 1, her NGT was d/c'ed, her foley was replaced, and she was given multiple rounds of nebulizers also with moderate improvement. Throughout this period, her sats were in the 90's with oxygen supplementation and a room air sat of 89% was recorded. Her EKG was significant for mild ST elevations in the lateral leads and some ST depression across the precordial leads which were new compared to her ED EKG. Once the patient settled down, her HR was in the low 100's, BPs within normal limits, put out 400 cc of urine the hour following the dose of lasix. Her RR was 20-30, with audible grunting, and her sats were in the 90's on face mask. CT chest PE protocol was ordered and an ICU transfer was arranged in order to better monitor the patient and her respiratory status. Three subsegmental left lower lobe pulmonary emboli were seen on the CT, as well as significant atelectasis in the right middle and lower lobes that was described as near collapse. A heparin gtt was started and titrated with goal PTT 50-70. Cardiology was consulted to evaluate her EKG changes and an echocardiogram was performed which was signficant for akinesis of the middle third of the left ventricle which is not consistent with coronary artery disease and suggests regional cardiomyopathy/myocarditis or atypical stress cardiomyopathy. Mild mitral regurgitation and mild to moderate pulmonary artery systolic hypertension was noted. Troponins were checked which were elevated and peaked at 1.09 before trending down. The patient was plavix loaded and aspirin was started with plans for cardiac catheterization for the following day to evaluate the coronaries. A left IJ was placed for better access. Her respiratory status improved with standing nebs and aggressive pulmonary toilet. POD4 - Cardiac cath was negative for coronary artery disease but notable for markedly-elevated left-sided filling pressures and moderate pulmonary arterial hypertension. Plavix was stopped, aspirin was changed to 81mg, lisinopril 2.5 mg and lipitor 40 mg were started. Metoprolol 5mg IV q4 was also continued which had been started the day prior. Lasix 10mg IV x 1 was given post-cath which the patient responded well to. Overall, the patient is thought to have had demand ischemia secondary to the acute stress of her episode of respiratory distress and her decreased EF is thought to be secondary to stress induced cardiomyopathy. The patient will be continuing these new cardiac medications at home and will follow up with cardiology for repeat TTE with hope that the akinesis will reverse. POD5 - The patient began passing flatus, was advanced to clears, steroids transitioned to PO, cardiac meds continued, and PO pain meds started. She was given 3mg of warfarin and the hep gtt was continued. Her foley was removed and she voided. She was transferred to the floor and continued on standing nebulizers and encouraged to do regular incentive spirometry and walk frequently. POD6 - The patient became therapeutic on her heparin gtt, was advanced to a regular diet, and again given 3mg of coumadin. The patient refused PO pain medications and continued to use only dilaudid IV for pain control. POD7 - The patient felt nauseous overnight and had a small episode of emesis. Her abdomen was softly distended. She had two formed bowel movements and a couple of episodes of diarrhea. She was moved back to sips of clears. Her INR was 2.1, the heparin gtt was stopped, and 2.5 mg of coumadin was given. KUB was taken which did not show gastric distension and did show air in the rectum with some mildly dilated small bowel in the midabdomen. Her nausea resolved as the day progressed and she tolerated clears and crackers that evening. Her CVL was removed without incident. POD8 - The patient was advanced to a regular diet and encouraged to take PO pain meds. The patient was quite resistant to PO pain medication believing that it makes her pain worse. She was eventually willing to take PO dilaudid and PO tylenol as needed. She was out of bed ambulating, satting fine on room air, and provided with coumadin teaching. She was set up with VNA to assist in transitioning her to home with her new medications and facilitating INR checks and coumadin dosing. She was discharged with her staples in place, to be removed at her follow up visit. She will follow up with her PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], and cardiology, as well as her rheumatologist and other physicians as previously scheduled. Medications on Admission: senna 8.6 mg Cap [**Hospital1 **], Vitamin D 1,000 unit daily, calcium carbonate 1,500 mg [**Hospital1 **], acetaminophen 325 mg prn, alendronate 70 mg weekly, OxyContin 40 mg q12h (recently stopped), oxycodone 5 mg q6h prn pain (recently stopped), bisacodyl 5 mg [**Hospital1 **], bisacodyl 10 mg Rectal prn, prednisone 25 mg Tab daily Discharge Medications: 1. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*3* 2. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 5. prednisone 10 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours as needed for pain: no more than 3000mg per day. 10. Outpatient [**Name (NI) **] Work PT/INR as needed Diagnosis: pulmonary embolism, goal INR [**1-28**] 11. Vitamin D3 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 12. calcium carbonate 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 13. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 14. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: small bowel obstruction hyperglycemia pulmonary embolism stress cardiomyopathy Discharge Condition: activity as tolerated no heavy lifting/do not lift anything greater than 10 pounds no driving while taking pain medication Discharge Instructions: Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if you have any of the following: shortness of breath, chest pain, temperature of 101, shaking chills, nausea, vomiting, increased abdominal pain, abdominal distension, constipation or diarrhea, incision redness/bleeding/drainage, prolonged bleeding You are going to be taking an important medication called coumadin to treat the small blood clots in your lungs. [**Hospital1 18**] Anticoagulation Management Service will manage your coumadin dosing under the supervision of your primary care provider. [**Name10 (NameIs) **] visiting nurses will check your INR level which tells us how thin or thick your blood is. They will then discuss the number with the [**Hospital1 18**] Anticoagulation Management Service and call you to let you know what dose of coumadin to take and when to get your levels checked. Call them with any questions or concerns at [**Telephone/Fax (1) 2173**]. In addition to the coumadin, you will also be continuing some of the other new medications for your blood pressure, cholesterol, and heart health that the cardiologist started for you during your stay. You will follow up with your cardiologist in 4 weeks and they will help you arrange for a repeat echocardiogram of your heart to compare it to the one that you had in the hospital and determine if they want to change any of your medications. It is very important that you take these medications everyday and that if you have any questions about them that you call the [**Hospital6 **] or your primary care provider. Your sugars have been high in the hospital. The visiting nurses will be checking your sugars and talking to your primary doctor about your levels. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. You have an incision with staples. The staples will be removed at your follow up visit with Dr. [**First Name (STitle) **] on [**2180-3-30**]. You may shower daily and pat your incision dry. Do not bathe or swim. No heavy lifting greater than [**5-4**] pounds. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2180-3-30**] 2:45 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16202**], MD Phone:[**Telephone/Fax (1) 2010**] Date/Time:[**2180-4-7**] 2:35 Follow up with Cardiology - Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2180-4-20**] 1:00 Follow up with your Rheumatologist and other physicians as previously scheduled. Completed by:[**2180-3-22**]

[ "V58.65", "415.11", "518.0", "E878.8", "997.39", "790.29", "560.81", "300.00", "518.52", "429.83", "593.4", "724.2" ]

icd9cm

[ [ [] ] ]

[ "38.91", "54.11", "54.59", "37.23", "38.93", "88.56" ]

icd9pcs

[ [ [] ] ]

16869, 16926

8262, 15099

317, 378

17049, 17174

2107, 8055

19296, 19918

1592, 1762

15486, 16846

16947, 17028

15125, 15463

8072, 8239

17198, 19273

1777, 2088

263, 279

406, 1211

1233, 1426

1442, 1576

18,072

186,274

19456

Discharge summary

report

Admission Date: [**2185-1-20**] Discharge Date: [**2185-1-27**] Date of Birth: [**2123-2-22**] Sex: M Service: VASCULAR CHIEF COMPLAINT: Enlarged abdominal aortic aneurysm with questionable leak. HISTORY OF PRESENT ILLNESS: This is a 61-year-old male with a history of coronary artery disease, status post coronary artery bypass grafting, who presented to our institution from an outside hospital with increasing abdominal aortic aneurysm by CAT scan. The patient was initially evaluated at an outside hospital Emergency Room with the complaint of sudden onset of right groin and right lower flank pain. The patient underwent a CT scan which demonstrated a 9 cm abdominal aortic infrarenal aneurysm. The patient was transferred here for evaluation. The patient denied back pain, dizziness, nausea, vomiting, diarrhea, chest pain, and shortness of breath. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS ON ADMISSION: Zantac 150 mg q.d., Lipitor 10 mg q.d., Atenolol 25 mg q.d., Aspirin 325 mg q.d. PAST MEDICAL HISTORY: Coronary artery disease. Dyslipidemia. Gastroesophageal reflux disease. Hypertension. PAST SURGICAL HISTORY: Coronary artery bypass grafting. Ophthalmic surgery. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient has two drinks per day. Tobacco use is positive. PHYSICAL EXAMINATION: Vital signs: 97.6??????, 67, 157/96, 22, 100% oxygen saturation on 2 L. General: The patient was a white male in no acute distress. No mental status changes. He was oriented times three. Chest: Lungs clear to auscultation bilaterally. Heart: Regular, rate and rhythm. Abdomen: Protuberant and soft. There was no rebound. Diminished breath sounds. No hernia. Extremities: Without deformity. Femoral pulses were 3+ bilaterally, popliteals 3+ bilaterally. Dorsalis pedis and posterior tibial 3+ bilaterally. LABORATORY DATA: CBC with a white count of 6.2, hematocrit 43.7; BUN 15, creatinine 0.1. Abdominal CT with contrast showed an 8.6 cm infrarenal aortic aneurysm. HOSPITAL COURSE: The patient was made NPO. On hospital day #2, he underwent abdominal aortic repair with a tube graft, 18 x 40 cm. He tolerated the procedure well and was transferred to the PACU in stable condition. He did require Nitroglycerin for systolic hypertension. History postoperative hematocrit was stable. BUN and creatinine was stable. Troponin was less than 0.01. The patient was extubated and then transferred to the VICU for continued monitoring and care. The patient was followed by the Pain Service. An epidural was placed in the Recovery Room for analgesic control. On postoperative day #1, the epidural placed was converted to a PCA for improved analgesic control. Hematocrit remained stable at 33.3. BUN and creatinine were 16 and 0.8. Physical exam was unremarkable. Incisions were clean, dry, and intact. He had intact pulses. The patient remained NPO. The NGT was removed. He was continued on perioperative Kefzol. On postoperative day #2, T-max was 38.0-37.9??????C. He required diuresis with Lasix, total of 30. His intravenous fluids were Hep-Locked. He remained in the VICU. On postoperative day #3, exam was unchanged. The patient was without flatus or bowel movement. He was afebrile. His hematocrit drifted to 29.5. Abdomen was distended and tympanic. There were no bowel sounds. Incisions were clean, dry, and intact. The patient was continued on Dilaudid p.r.n. for pain. His Hydralazine and Lopressor were continued with improvement in his systolic blood pressure control. His Swan-Ganz was converted to a triple-lumen catheter. He remained in the VICU. On postoperative day #4, there were no overnight events. The patient was begun on clear liquids. Ambulation was begun. Physical Therapy was requested to see the patient. Discharge planning was begun. The epidural was discontinued, and the Foley was removed. The patient was transferred to the regular nursing floor on postoperative day #4. The remaining hospital course was unremarkable. The patient was discharged in stable condition. Wounds were clean, dry, and intact. The patient should follow-up with Dr. [**Last Name (STitle) 1391**] in [**6-25**] days for skin clip removal. The patient may take showers, but he is not to drive until seen in follow-up. DISCHARGE MEDICATIONS: Metoprolol 50 mg b.i.d., hold for systolic blood pressure less than 100, heart rate less than 60, Oxycodone/Acetaminophen [**12-17**] q.4-6 hours p.r.n. pain, Hydromorphone 2-4 mg p.o. q.4 hours p.r.n. pain, ..................20 mg b.i.d., Atorvastatin 10 mg q.d., Aspirin 325 mg q.d. DISCHARGE DIAGNOSIS: 1. Enlarging abdominal aortic aneurysm status post aneurysm repair with tube graft. 2. Hypertension, controlled. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2185-1-25**] 10:43 T: [**2185-1-25**] 10:47 JOB#: [**Job Number 52857**]

[ "530.81", "414.00", "401.9", "272.0", "560.1", "441.4", "V45.81", "997.4" ]

icd9cm

[ [ [] ] ]

[ "38.44" ]

icd9pcs

[ [ [] ] ]

1237, 1255

4360, 4646

4667, 5058

949, 1031

2061, 4336

1166, 1220

1358, 2043

159, 219

248, 922

1054, 1142

1272, 1335

65,535

178,280

1380

Discharge summary

report

Admission Date: [**2193-5-22**] Discharge Date: [**2193-6-1**] Date of Birth: [**2126-7-31**] Sex: F Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old female who presents with a history of angina and hypertension. She underwent an angioplasty in the past and stent placed recently. An angiogram after the stent showed an aortic valve disease. Six months ago she was hospitalized with congestive heart failure and treated with Lasix. Currently she is unable to lie flat in bed or at least since that episode. PAST MEDICAL HISTORY: Type 2 diabetes time five years treated with oral medicines, hypertension, high cholesterol, coronary artery disease. In [**2162**]'s she had empyema, in [**2164**] she had a Cesarean section. Cardiac catheterization showed severe aortic disease with less than .57 cm sq valve area and coronary arteries without significant lesions and severe diastolic ventricular dysfunction. Her echo showed an EF of 25%, mild LVH, moderate LVH, aortic valve leaflets thickened with stenosis, no regurg, 3+ mitral regurgitation with a thickened valve. MEDICATIONS: Preoperative meds are Aspirin, Atenolol, Lasix, Zestril, Premarin and Provera, Glyburide, Glucophage, Lipitor, Paxil, Multivitamin and Motrin. She has a rash allergy to Sulfa drugs. HOSPITAL COURSE: So on [**2193-5-22**] the patient was taken to the operating room where she had an aortic valve replacement surgery with Porcine valve. The indications for surgery were an aortic stenosis with valve area less than .5 and CHF and symptomatic severe aortic stenosis with shortness of breath at rest, edema and occasionally cough. She tolerated the procedure well. The day after surgery, when she awoke, she was initially alert and oriented times three. However, by mid morning she was confused and agitated with some paranoid features. Her vital signs were stable with a heart rate of between 80's and 90's and sinus rhythm with occasional APC's and she had an episode of supraventricular tachycardia to the 130's which resolved. She also had a thick yellow sputum cough and she was started on Captopril on postoperative day #1, 25 mg [**Hospital1 **] for her ejection fraction. Her postoperative cardiac index was around 2.5, hematocrit 29 and she was alert with some confusion but hemodynamically she was stable and she was transferred to the floor. On the floor she had an episode of being found with sudden onset of unresponsiveness with eyes deviated to the left side. She had no verbal output and was not moving her right arm and leg. She was transferred to the CTIC and was intubated. She then underwent a stat head CT which was negative for an acute bleed. She was awakened the next morning and she had gradual resolution of the symptoms on the right side of her body. Aspirin was given to her as well and she was kept with systolic blood pressure around 140/80. Anesthesia was called for the emergent intubation. Dr. [**Last Name (STitle) **] was made aware of this event. The following day she was extubated and continued to have improvement in her exam. She was not aware what had happened to her the day prior. She was found to have a right pleural effusion and she had a chest tube placed which drained about 400 cc of serosanguineous fluid. She had gradual increase in her WBC count from 13 to 24 and she was started on Ciprofloxacin. She was being treated for E. coli in her UTI and sputum H flu and found to have enterococcus and we added Ampicillin to her antibiotic regimen. The patient on the floor was kept on Ampicillin and Ciprofloxacin and she had slow progression. She was seen by physical therapy. Her mental status changes gradually improved and on postoperative day #9 she was thought to be pretty much back to her baseline. She was afebrile. Her WBC count was coming down and she will be followed up at the skilled nursing facility, similar to where she came from. DISCHARGE MEDICATIONS: Lopressor 50 mg [**Hospital1 **], Multivitamin, Darvocet N 100 mg prn, prn Albuterol nebs, Premarin, Glucophage, Glyburide, Provera, Paxil, Captopril 25 mg [**Hospital1 **], Lipitor 20 mg q d, Triamcinolone cream, Tylenol prn, Motrin prn and Aspirin 81 mg po q d. DISCHARGE INSTRUCTIONS: Include following up with neuro clinic [**Telephone/Fax (1) **] in approximately two weeks, to continue to check her WBC count. She should get a repeat urinalysis and she should continue Cipro for 9 additional days. She should continue Ampicillin for 6 more days for a total course of 10. DISCHARGE DIAGNOSIS: 1. Status post AVR with hancok porcine valve. 2. Urinary tract infection. 3. Congestive heart failure. DISCHARGE CONDITION: Stable. She will be followed up by Dr. [**Last Name (STitle) **] in his office three weeks from date of surgery, approximately 10 days from her discharge date and she should get her staples removed in approximately 5 days from discharge, postoperative day #14. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 8344**] MEDQUIST36 D: [**2193-6-1**] 06:20 T: [**2193-6-1**] 07:28 JOB#: [**Job Number 8345**]

[ "401.9", "414.01", "511.9", "428.0", "250.00", "396.2", "293.9", "041.4", "599.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "35.21", "39.61", "34.04" ]

icd9pcs

[ [ [] ] ]

4714, 5253

3983, 4248

4586, 4692

1347, 3959

4273, 4565

176, 566

589, 1329

27,210

157,329

27984

Discharge summary

report

Admission Date: [**2168-5-27**] Discharge Date: [**2168-5-31**] Date of Birth: [**2142-10-11**] Sex: F Service: MEDICINE Allergies: Haldol / Oxycodone / Demerol / MS Contin / Penicillins / Fentanyl / Bactrim / Tamiflu / Keflex Attending:[**First Name3 (LF) 2782**] Chief Complaint: Malaise/DKA Major Surgical or Invasive Procedure: IR guided G tube placement [**5-31**] History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE Date: [**2168-5-28**] Time: 20:40 The patient is a 25F hx poorly controlled IDDM, gastroparesis (last gastric emptying study normal on [**2-17**]; J-G tube and power port in place for occasional TPN in the past), with frequent rehospitalizations for abdominal pain and nausea, who presents with malaise, hyperglycemia despite taking insulin, also purulent drainage from tube site over past several days, transferred to [**Hospital Unit Name 153**] for insulin gtt. Pt states that over the last week she initially had several episodes of vomiting and then several days of frequent watery diarrhea. Abdominal pain has limited her po or Gtube intake over the last week. She noted that her blood sugars this week were in the 500-600 range despite compliance with her regular insulin regimen. The week prior to that her fsg were between 100 and 200. She endorses 1 week of thirst and frequent urination without dysuria. States she also had fevers up to 100.6 at home. Has some mild cough which is chronic; is also a long time smoker although she has stopped smoking over the last week [**3-10**] illness. She noted foul smelling drainage at the site of the Gtube and now tender around the Gtube site as well. Of note, the patient has a Gtube and power port as she has gastroparesis which requires tube feeds and during frequent hospitalizations requiring TPN occasionally. ED course: initial vitals: 96.8 116 129/72 20 100% exam: abdominal exam reported to be benign but noted that tube was not secured (unclear when stictch came out) small amt of pus noted, no erythema. labs showed: LFTs wnl but alk phos 160 (has been in 160s b/l). lip 15. tri 197. serum osm 289 CBC 8.2>42<255 PMNs 65% ca 9.0 ph 3.7 mg 1.6 chem: 139/3.5; 89/21; 11/0.9<697 AG 19 UA: glucose 1000 but neg ketones imaging: u/s of Gtube insertion site revealed no abscess. intervention: pt received 2L IVF. got 9u of IV insulin and started on insulin gtt. was given flagyl with plan for vanc/cipro but did not receive these. received dilaudid IV. Started on D5 1/2NS with K and transferred to [**Hospital Unit Name 153**]. In the ICU, pt c/o abd pain, requesting dilaudid, benadryl, and valium be given IV. She stated that eating is too hard on her stomach and she can not swallow pills. Her anion gap was closed with IVFs and insulin drip. She had no fever or leukocytosis in the ICU. On the medicine floor, she was noted to no longer have the G-J external tube attached. The [**Hospital Unit Name 153**] staff was not aware of when it was removed or dislonged. Yesterday she was receiving medications down the G-J tube. The patient reports being unaware of when it came out. She continues to report abdominal pain, nausea and anxiety. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. Denies chest pain, palpitations, orthopnea, dyspnea on exertion. Denies shortness of breath, cough or wheezes. Denies nausea, vomiting, heartburn, diarrhea, constipation, BRBPR, melena, or abdominal pain. No dysuria, urinary frequency. Denies arthralgias or myalgias. Denies rashes. No increasing lower extremity swelling. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: 1. Diabetes, type I 2. Gastroparesis with h/o chronic g-j tube, though most recent gastric emptying study in [**4-17**] was normal 3. Chronic abdominal pain presumed to be chronic pancreatitis - narcotics contract with PCP (recieves weekly prescription on Tuesdays) - pancreatic divisim (fibrosis and calcification in the pancreas as well as 2 completely separate pancreatic ducts on ERCP) - ampullary stenosis s/p stenting 4. Depression & Borderline personality disorder - history of cutting behavior and suicide attempts 5. Asthma 6. History of urinary retention, chronic with episodes of worsening. Has seen by Dr. [**Last Name (STitle) 770**] in urology in past, not within past year. 7. PUD secondary to H. pylori 8. gastritis 9. iron deficiency anemia 10. right adnexal cyst 11. S/p Cholecystectomy Social History: Born in the [**Country 13622**] Republic. She was sent to the US at age 11-12 years due to onset of medical problems (i.e. diabetes). She has a twin sister [**Name (NI) 68143**] who is married with a baby. [**Name (NI) **] smokes cigarettes intermittently. She denies ETOH, recreational drug use. She works at an electronics store in [**Location (un) 538**] as a technician. She has a very complicated psychosocial history including tense relationships w/current roommates in 4-bedroom apartment in [**Location (un) 686**]. Currently applying for [**Location (un) 86**] public housing, awaits a 1-bedroom apartment. Family History: Grandmother, uncle and mother with DM. Uncles with chronic pancreatitis. No family history of diabetic gastroparesis. Physical Exam: VS: 97.1 143/94 95 18 100% RA; [**11-16**] abdominal pain GEN: Tearful and anxious HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: Clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, tender to palpation difusely, non-distended; no guarding/rebound; no J-G tube in place EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present NEURO: Alert and oriented to person, place and situation; CN II-XII intact, [**6-11**] motor function globally DERM: no erythema or pus at ostomy site Pertinent Results: [**2168-5-27**] 05:11PM LACTATE-1.3 [**2168-5-27**] 05:03PM GLUCOSE-222* UREA N-8 CREAT-0.5 SODIUM-137 POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-24 ANION GAP-10 [**2168-5-27**] 05:03PM ALBUMIN-3.3* CALCIUM-8.0* PHOSPHATE-2.6* MAGNESIUM-1.7 [**2168-5-27**] 05:03PM WBC-5.8 RBC-4.02* HGB-13.0 HCT-37.1 MCV-93 MCH-32.4* MCHC-35.1* RDW-13.6 [**2168-5-27**] 05:03PM PLT COUNT-219 [**2168-5-27**] 05:03PM PT-10.9 PTT-32.5 INR(PT)-1.0 [**2168-5-27**] 05:09AM GLUCOSE-106* UREA N-10 CREAT-0.6 SODIUM-139 POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-27 ANION GAP-11 [**2168-5-27**] 05:09AM ALT(SGPT)-24 AST(SGOT)-21 LD(LDH)-104 ALK PHOS-160* TOT BILI-0.3 [**2168-5-27**] 05:09AM LIPASE-15 [**2168-5-27**] 05:09AM CALCIUM-9.0 PHOSPHATE-3.7 MAGNESIUM-1.6 [**2168-5-27**] 05:09AM TRIGLYCER-197* [**2168-5-27**] 04:51AM LACTATE-3.5* [**2168-5-27**] 03:00AM GLUCOSE-206* UREA N-9 CREAT-0.6 SODIUM-137 POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-22 ANION GAP-17 [**2168-5-27**] 03:00AM OSMOLAL-289 [**2168-5-27**] 12:56AM LACTATE-4.8* [**2168-5-27**] 12:45AM GLUCOSE-697* UREA N-11 CREAT-0.9 SODIUM-128* POTASSIUM-3.5 CHLORIDE-89* TOTAL CO2-21* ANION GAP-22* [**2168-5-27**] 12:45AM estGFR-Using this [**2168-5-27**] 12:45AM CALCIUM-10.1 PHOSPHATE-3.8# MAGNESIUM-1.8 [**2168-5-27**] 12:45AM WBC-8.2 RBC-4.54 HGB-14.5 HCT-42.0 MCV-93 MCH-31.9 MCHC-34.5 RDW-12.9 [**2168-5-27**] 12:45AM NEUTS-65.7 LYMPHS-28.4 MONOS-3.6 EOS-1.6 BASOS-0.7 [**2168-5-27**] 12:45AM PLT COUNT-255 [**2168-5-27**] 12:45AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.024 [**2168-5-27**] 12:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2168-5-27**] Radiology US ABD LIMIT, SINGLE OR: LIMTED ABDOMINAL US: Limited ultrasound around the J-tube site demonstrated no focal fluid collections in the subcutaneous soft tissues. Should evaluation of the abdomen be required, a CT should be performed. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: #. GJ tube displacement: The external portion of the GJ tube was not present on transfer from the ICU to the medical floor. Patient and nursing from ICU were unable to relate what happened to the GJ tube. No evidence of infection on u/s or on exam. The ICU resident reported that the patient's initial report of pus changed to no pus after the patient found out she would not receive IV benadryl or IV opiates. On exam of the patient the GJ tube was present at the insertion site in the ICU and on arrival to the medical floor the tube was no longer present. The G tube was replaced by IR on [**5-31**]. She was tolerating meals so no tube feeds were started prior to discharge. #. Diabetes Mellitus, type 1: Improved glycemic control from insulin drip and IVFs in ICU. Patient received [**Month/Year (2) **] 40u @ 20:30 4/21 [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations of 44 [**Last Name (un) 8472**] QHS. She is advised to call to schedule appt with [**Last Name (un) 387**] #. Borderline personality disorder: She has medical [**Last Name (un) 18297**] and cannot refuse fingersticks, insulin, etc. Security was called [**5-28**] when she refused tube feeds, and she finally acquiesed. Security was also called on [**5-30**] when she threatened to leave AMA on [**5-30**]. Chronic pain. She missed appointment with staff at her pain clinic in [**Location (un) **]. I spoke to them and they said she received 432 tabs of dilaudid on [**5-12**]. I gave her Rx for 12 tab of dilaudid to take so she can make appt with pain clinic on [**6-1**] at 1145. #. DKA: Resolved. Hyperglycemia with anion gap of 18 and lactate 4.8 on presentation. I was in touch with her PCP throughout the hospitalization as well as as regularly updating her [**Month/Year (2) 18297**] including telling him about the discharge plans on [**5-31**]. Medications on Admission: Home Medications (verified with patient on this admission) 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for wheezing. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 3. Boost Liquid Sig: One (1) can PO three times a day. 4. diazepam 5 mg Tablet Sig: Two (2) Tablet PO three times a day as needed for anxiety. 5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 6. gabapentin 250 mg/5 mL Solution Sig: Ten (10) ML PO QHS (once a day (at bedtime)). 7. hydromorphone 2 mg Tablet Sig: Three (3) Tablet PO Q3H (every 3 hours) as needed for pain. 8. ibuprofen 100 mg/5 mL Suspension Sig: Thirty (30) ml PO every six (6) hours as needed for pain. 9. insulin glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous at bedtime. 10. insulin lispro 100 unit/mL Solution Sig: AS DIRECTED Subcutaneous three times a day: as directed by [**Last Name (un) **] (see attached insulin sliding scale). 11. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 12. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: One (1) inh Inhalation every six (6) hours as needed for shortness of breath or wheezing. 13. lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO Q8H (every 8 hours) as needed for constipation. 14. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 17. pioglitazone 15 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 18. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day as needed for constipation. 19. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 20. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 21. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 22. acetaminophen 160 mg/5 mL Elixir Sig: Two (2) tsp PO every six (6) hours as needed for fever or pain. 23. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 24. diphenhydramine HCl 12.5 mg/5 mL Liquid Sig: Forty (40) ml PO at bedtime as needed for insomnia. 25. docusate sodium 50 mg/5 mL Liquid Sig: Five (5) ml PO BID (2 times a day). 26. Maalox Advanced 1,000-60 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO every 4-6 hours as needed for indigestion. Disp:*120 Tablet, Chewable(s)* Refills:*0* Discharge Medications: 1. diazepam 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 2. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for fever/pain. 3. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inh Inhalation Q4H (every 4 hours) as needed for wheezing/sob. 10. gabapentin 100 mg Capsule Sig: Five (5) Capsule PO qhs (). 11. hydromorphone 2 mg Tablet Sig: Three (3) Tablet PO Q3H (every 3 hours) as needed for pain. Disp:*12 Tablet(s)* Refills:*0* 12. ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 13. [**Hospital1 8472**] Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Seventy (70) units Subcutaneous at bedtime. Disp:*1 pen* Refills:*0* 14. Humalog 100 unit/mL Solution Sig: sliding scale units Subcutaneous with meals and at bed time: as directed by [**Last Name (un) **], see sliding scale below. 15. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 16. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day. 17. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day. 18. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Discharge Disposition: Home Discharge Diagnosis: Diabetic ketoacidosis Hyperglycemia Abdominal pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with high blood sugars and abdominal pain. You were initially in the ICU, then you were transferred to the floor. At some point in the hospitalization your GJ tube external tubing was cut off, and you had to have the GJ tube replaced by radiology. Please take your insulin as instructed. It is important that you eat a stable diet every diet and take your insulin with meals. Please do not miss [**First Name (Titles) **] [**Last Name (Titles) **] in the evenings. Take note of the dosage changes. Followup Instructions: pain clinic tomorrow at 1145 Department: [**Hospital1 7975**] INTERNAL MEDICINE When: THURSDAY [**2168-6-2**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 63642**], MD [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site You are also recommended to call [**Telephone/Fax (1) 68145**] to schedule an appointment with your endocrine providers at [**Last Name (un) **].

[ "276.8", "305.1", "401.9", "V58.67", "276.1", "250.13", "280.9", "275.2", "301.83", "493.90", "536.3", "569.62", "338.29", "V55.4", "577.1" ]

icd9cm

[ [ [] ] ]

[ "97.03" ]

icd9pcs

[ [ [] ] ]

14707, 14713

8203, 10068

368, 407

14807, 14807

6145, 8179

15502, 16025

5353, 5473

12912, 14684

14734, 14786

10094, 12889

14957, 15479

5488, 6126

3211, 3875

317, 330

435, 3192

14822, 14933

3897, 4703

4719, 5337

18,928

179,331

50872

Discharge summary

report

Admission Date: [**2160-6-19**] Discharge Date: [**2160-6-26**] Date of Birth: [**2086-6-5**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 74 year old male with a history of coronary artery bypass graft times three, most recently [**7-16**], and coronary stents, who complains of shortness of breath with chest pain times one day. He described a nonproductive cough for the past two months, but has had worsened cough overnight. He also complains of fevers and chills on the day of admission. The patient presented to his primary care physician's office on the morning of admission and was noted to be tachycardic to 120s and shaky. He also vomited times one. On evaluation in the Emergency Department, the patient's vital signs were temperature of 103.8, heart rate 120, blood pressure 90/50, respiratory rate 16, oxygen saturation 94% in room air. He received Aspirin, Tylenol, had two sets of blood cultures drawn and received 1.5 liters of normal saline in addition to Levofloxacin and Ceftriaxone. While in the Emergency Department, the patient had episodes of hypotension with systolic pressure in the 60s, though he mentated and did not feel lightheaded at any time. He was admitted to the CCU for further management. Significant cardiac history includes a transthoracic echocardiogram in [**8-16**], which demonstrated moderately dilated left ventricle with ejection fraction of 50%, anterior, anteroseptal, and inferior akinesis and hypokinesis, and depressed right ventricular function with 2+ mitral regurgitation. Cardiac catheterization [**2159-9-16**], resulted in stenting of the saphenous vein graft to OM1 and OM2. Prior coronary artery bypass graft redo in [**2159-7-16**], included left internal mammary artery to left anterior descending, radial artery to posterior descending artery, saphenous vein graft to D1, saphenous vein graft to D2, saphenous vein graft to OM1 and saphenous vein graft to OM2. Exercise stress test on [**2160-4-28**], resulted in a rate pressure product of 11,900, modified [**Doctor First Name **] protocol. The patient exercised for nine minutes and stopped due to fatigue with no anginal equivalents and an uninterpretable electrocardiogram. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction. 2. Coronary artery bypass graft times three. 3. Congestive heart failure with ejection fraction 50%. 4. History of ventricular fibrillation arrest. 5. Hypertension. 6. Elevated cholesterol. 7. Hepatitis B positive. 8. Back pain. ALLERGIES: 1. Penicillin causes a rash. 2. Morphine causes hypotension. 3. Sulfa. 4. Iodine. 5. Codeine. 6. Benadryl. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. once daily. 2. Carvedilol 3.125 mg p.o. twice a day. 3. Lisinopril 5 mg p.o. once daily. 4. Digoxin 0.125 mg p.o. once daily. 5. Lasix 40 mg p.o. twice a day. 6. Aldactone 25 mg p.o. once daily. 7. Protonix 40 mg p.o. once daily. 8. Remeron p.r.n. SOCIAL HISTORY: The patient has a distant tobacco history, discontinued almost forty years ago. He lives at home by himself. PHYSICAL EXAMINATION: On physical examination, the patient has a temperature of 100.9, heart rate 100, blood pressure 67/40, respiratory rate 22, oxygen saturation 95% on two liters by nasal cannula. In general, the patient was a pleasant elderly male in no apparent distress. Head and neck examination revealed moist mucous membranes, anicteric sclera, normal jugular venous distention. Lungs had crackles at the bases bilaterally with decreased breath sounds at the right lower lobe. Cardiovascular examination revealed tachycardia with normal S1 and S2 and a II/VI systolic murmur best heard at the apex. Abdomen was benign with no tenderness. Extremities had no edema. LABORATORY DATA: White blood cell count was 8.6, hematocrit 30.4, and platelet count 195,000. There was a left shift with 86% neutrophils and 9% lymphocytes. Coagulation studies demonstrated a prothrombin time of 14.5, INR 1.4. Panel seven was significant for a blood urea nitrogen of 32 and creatinine of 1.0. Two sets of cardiac enzymes revealed sequential CKs of 54 and 62 with MB of 1.0 and 0.9, respectively. Urinalysis showed no nitrites and no leukocyte esterase. Chest x-ray demonstrated prominent pulmonary vasculature with small left pleural effusion and retrocardiac haziness read as atelectasis versus consolidation. Electrocardiogram demonstrated sinus tachycardia of 120 beats per minute, with normal axis, left bundle branch block, unchanged from prior electrocardiogram in [**2159-11-16**]. HOSPITAL COURSE: 1. Hypotension - The patient was thought to be septic and thus received fluid resuscitation in the Emergency Department. A right internal jugular central venous catheter was placed and initial CVPs were measured at 3.0 to 4.0 of water. The patient's diuretics and antihypertensive medications were held, and he was started on Neo-Synephrine to maintain his blood pressure. The suspected source of infection was a pneumonia, although an abdominal process could not be ruled out given recent hospitalization at the [**Hospital3 2358**] six months prior with abdominal pain. Therefore, the patient was started on Levofloxacin and Flagyl. On the second day of hospitalization, the patient's white blood cell count peaked at 20.2 with a continued left shift. he had a temperature spike of 101.6, and subsequent blood cultures, urine cultures, and sputum cultures were all negative. His white blood cell count subsequently normalized within two days and he remained afebrile thereafter through the rest of his hospitalization. In addition, the Neo-Synephrine was quickly weaned off within 48 hours of admission and he required no further pressor support. The patient will complete a ten day course of Levofloxacin and Flagyl for sepsis with suspected pneumonia as the source. 2. Congestive heart failure - Following his fluid resuscitation, the patient appeared to be in mild congestive failure with tachypnea and hypoxia. He was diuresed with Lasix and then switched over to his outpatient regimen. He continued to diurese for several days, after which he felt at his baseline respiratory status. Electrophysiology was consulted, and they recommend biventricular pacing as possible aid to his congestive heart failure. This will be addressed on a return visit as an outpatient. 3. Coronary artery disease - The patient ruled out for myocardial infarction, and had no further episodes of chest pain. He was continued on his Aspirin and had no evidence of ischemia during his hospitalization. 4. Arrhythmias - During his first night of hospitalization, the patient had a twenty beat run of nonsustained ventricular tachycardia. He had additional episodes of nonsustained ventricular tachycardia on ablators and should thus have an AICD placed. Due to his recent sepsis, the patient should complete his antibiotic course and return as an outpatient for placement of his AICD as well as biventricular pacer. He was started on Amiodarone for his arrhythmias, and should continue this until follow-up with Electrophysiology. CONDITION ON DISCHARGE: The patient was discharged in stable condition to home. DISCHARGE DIAGNOSES: 1. Pneumonia. 2. Sepsis. 3. Congestive heart failure. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg p.o. once daily. 2. Levofloxacin 500 mg p.o. once daily times three days. 3. Metronidazole 500 mg p.o. three times a day times three days. 4. Digoxin 125 mcg p.o. once daily. 5. Furosemide 40 mg p.o. twice a day. 6. Spironolactone 25 mg p.o. once daily. 7. Klonopin 0.5 mg p.o. q.h.s. and 0.25 mg p.o. twice a day. 8. Amiodarone 200 mg p.o. three times a day times three weeks. 9. Carvedilol 3.125 mg p.o. twice a day. DISCHARGE PLAN: 1. The patient should follow-up with his primary care physician within two weeks. 2. At this time, the patient's ace inhibitor may be restarted. 3. The patient will follow-up with Electrophysiology in two weeks for placement of AICD as well as biventricular pacer. 4. The patient should continue taking Klonopin which was prescribed by his outpatient psychiatrist for anxiety and depression symptoms. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1544**], M.D. [**MD Number(1) 1545**] Dictated By:[**Last Name (NamePattern1) 6916**] MEDQUIST36 D: [**2160-6-26**] 12:13 T: [**2160-6-30**] 20:10 JOB#: [**Job Number 105769**]

[ "427.1", "038.9", "428.0", "486", "272.0", "070.32", "V45.81", "401.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

7279, 7337

7363, 7810

2716, 2996

4638, 7176

3147, 4621

160, 2242

7826, 8511

2264, 2690

3013, 3124

7201, 7258

56,798

110,636

49687

Discharge summary

report

Admission Date: [**2105-1-11**] Discharge Date: [**2105-1-17**] Date of Birth: [**2021-12-18**] Sex: M Service: MEDICINE Allergies: Blue Dye / Aspirin / Dyazide / Lisinopril / Ace Inhibitors Attending:[**First Name3 (LF) 509**] Chief Complaint: bloody stool Major Surgical or Invasive Procedure: EGD polypectomy History of Present Illness: 83yoM w/ PMH cerebral palsy, afib/recent DVT on coumadin+lovenox with h/o bleeding gastric polyp s/p polypectomy [**9-22**] (this same polyp was partial removed 5 years prior) and also w/ hospitalization [**Date range (1) 12661**] with UGIB p/w severe anemia and melena. Patient states he has been having dark stools over the past 3 days, but this morning while on the commode felt very lightheaded after passing a very large amount of dark tarry stool. He states that after this he was sufficiently concerned enough to call EMS. . On most recent hospitalization earlier this month, patient transfused 2 units. Upper endoscopy again revealed numerous gastric polyps, the likely source of slow GI bleeding. His warfarin was temporarily reversed and then restarted with Lovenox in light of recent DVT. He is currently on a coumadin/lovenox bridge. . In the ED, initial vs were: T 97 P 105 BP 110/52 R 24 O2 sat 100% 4LNC. Initial Hct was 16, INR 3.4. Patient was given 2 units PRBC's and 2 units FFP, as well as 1 liter NS in the ED. Protonix drip was started, NGT/lavage was attempted x 2 (by ED and surgery) but patient unable to tolerate. Femoral cordis placed in ED, also w/ 3 PIV's. . On the floor, patient stated he felt lightheaded. Denied CP, SOB, dyspnea, abdominal pain, dysuria, fevers, chills, BRBPR. . Past Medical History: -h/o bleeding gastric polyp s/p polypectomy [**9-22**] (this same polyp was partial removed 5 years prior) -cerebral palsy (left HP) -GERD -DM2 -left ankle fracture s/p ORIF complicated by LLE DVT in [**11-23**] (on coumadin) -Bladder Ca -HTN -Hypercholesterolemia -BPH -pancreatic tail lesion (MRI sched as outpt) -CRI - baseline Cr 1.7 PSH: -ORIF - ankle fx -appy -heria repair -AVR - '[**85**] - tissue valve -TURBT s/p ORIF DM Social History: Lives alone, has multiple friends come by the house to help w/ dog. Has a sister and [**Name2 (NI) 802**] on the West [**Name (NI) **], has a cousin who lives nearby. No smoking, EtOH. Family History: Mother with melanoma. Physical Exam: Vitals: T: 97.1 BP: 138/60 P: 82 R: 16 O2: 95% on 2L NC General: Alert, oriented, no acute distress, mildly dyspneic with talking. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD Lungs: Ronchorus bronchial sounds. Basilar crackles bilaterally, improved per MICU nurse. Lipoma on right chest and back. CV: Irregularly irregular, no murmurs, rubs, gallops Abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly [**Name (NI) **]: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2105-1-11**] 01:30PM BLOOD WBC-9.5 RBC-2.01*# Hgb-4.9*# Hct-16.1*# MCV-80* MCH-24.5* MCHC-30.7* RDW-16.4* Plt Ct-370 [**2105-1-11**] 06:08PM BLOOD WBC-9.7 RBC-2.32* Hgb-6.3*# Hct-19.2* MCV-83 MCH-27.3# MCHC-33.0 RDW-16.1* Plt Ct-231 [**2105-1-11**] 09:36PM BLOOD WBC-9.3 RBC-2.83* Hgb-7.9*# Hct-23.4* MCV-83 MCH-27.9 MCHC-33.7 RDW-15.5 Plt Ct-199 [**2105-1-14**] 06:20AM BLOOD WBC-6.4 RBC-3.45* Hgb-10.1* Hct-30.1* MCV-87 MCH-29.3 MCHC-33.5 RDW-17.1* Plt Ct-173 [**2105-1-16**] 04:55PM BLOOD WBC-6.9 RBC-3.93* Hgb-11.5* Hct-34.0* MCV-87 MCH-29.4 MCHC-33.9 RDW-16.4* Plt Ct-179 [**2105-1-11**] 01:30PM BLOOD Neuts-82.4* Lymphs-14.2* Monos-2.4 Eos-0.6 Baso-0.5 [**2105-1-11**] 01:30PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-2+ Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Schisto-1+ Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 15924**] [**2105-1-11**] 01:30PM BLOOD PT-33.8* PTT-29.1 INR(PT)-3.4* [**2105-1-11**] 06:08PM BLOOD PT-24.1* PTT-28.2 INR(PT)-2.3* [**2105-1-16**] 06:45AM BLOOD PT-15.6* INR(PT)-1.4* [**2105-1-17**] 07:00AM BLOOD PT-16.5* INR(PT)-1.5* [**2105-1-11**] 01:30PM BLOOD Glucose-163* UreaN-63* Creat-1.9* Na-140 K-5.6* Cl-110* HCO3-23 AnGap-13 [**2105-1-11**] 06:08PM BLOOD Glucose-146* UreaN-61* Creat-1.7* Na-147* K-5.3* Cl-115* HCO3-22 AnGap-15 [**2105-1-13**] 04:37AM BLOOD Glucose-133* UreaN-44* Creat-1.6* Na-149* K-4.4 Cl-118* HCO3-24 AnGap-11 [**2105-1-16**] 06:45AM BLOOD Glucose-71 UreaN-25* Creat-1.2 Na-142 K-3.8 Cl-108 HCO3-26 AnGap-12 [**2105-1-11**] 06:08PM BLOOD CK(CPK)-57 [**2105-1-13**] 04:37AM BLOOD ALT-15 AST-18 AlkPhos-93 TotBili-0.4 [**2105-1-11**] 01:30PM BLOOD cTropnT-0.03* [**2105-1-11**] 06:08PM BLOOD CK-MB-4 cTropnT-0.02* [**2105-1-11**] 01:30PM BLOOD Calcium-8.8 Phos-3.9 Mg-2.1 [**2105-1-13**] 03:00PM BLOOD Calcium-8.1* Phos-2.8 Mg-2.1 [**2105-1-16**] 06:45AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.0 [**2105-1-12**] 02:23AM BLOOD Lactate-1.3 [**2105-1-11**] 01:36PM BLOOD Hgb-5.1* calcHCT-15 [**2105-1-12**] 02:23AM BLOOD freeCa-1.01* [**2105-1-12**] 05:44AM BLOOD freeCa-1.09* [**2105-1-11**] 03:05PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012 [**2105-1-11**] 03:05PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . [**2105-1-11**] 3:05 pm URINE Site: CATHETER **FINAL REPORT [**2105-1-12**]** URINE CULTURE (Final [**2105-1-12**]): NO GROWTH. [**2105-1-11**] CT abd/pelvis IMPRESSION: 1. No evidence of retroperitoneal hematoma. 2. Small bilateral pleural effusions. 3. Stable pancreatic tail cystic lesion since [**2104-12-22**], though lesion has increased in size since [**2095**]. Please note, this lesion has been characterized on prior MRI Abdomen. 4. Large hiatal hernia. [**2105-1-11**] Chest xray IMPRESSION: AP chest compared to [**8-2**] and [**2104-11-25**]: Large hiatus hernia, filled with air and fluid occupies the midline. Heart size is top normal, but there is greater mediastinal vascular engorgement reflecting mild volume overload. Lung volumes are lower and making it difficult to distinguish between mild dependent edema and atelectasis, particularly on the left. Small right pleural effusion is new. No pneumothorax. [**2105-1-12**] LENI FINDINGS: Grayscale, color and Doppler images were obtained of bilateral common femoral, superficial femoral, popliteal and tibial veins. There is normal flow, compression and augmentation seen in all the vessels. IMPRESSION: No evidence of deep vein thrombosis in either leg. [**2105-1-15**] Pathology Report Tissue: GI BX (1 JAR) Study Date of [**2105-1-15**] Report not finalized. Assigned Pathologist BROWN,[**Hospital1 **] F. Please contact the pathology department, [**Name (NI) **] [**Numeric Identifier 1434**] PATHOLOGY # [**-1/4919**] EGD [**2105-1-12**] Impression: Hiatal hernia noted. Erythema and friability in the whole stomach compatible with gastritis Polyps in the stomach body Bile noted in duodenum. Small lipoma visualized in 2nd portion of the duodenum. Otherwise normal EGD to second part of the duodenum Recommendations: Hemorrhagic appearing gastric body polyps likely source of melena. No other ulcer or source of bleeding identified. Recommend continued PPI gtt, will discuss carafate at a later date to aid. Do not initiate currently in the event of recurrent bleed and need for endoscopic intervention. Will discuss need for endoscopic resection given recurrent bleeding. Please remain in ICU. EGD [**2105-1-15**] Findings: Esophagus: Normal esophagus. Stomach: Protruding Lesions Four mixed polyps of benign appearance with stigmata of recent bleeding and ranging in size from 10 mm to 20 mm were found in the stomach body. Small ulcerations were seen on the surface of 2 of the larger polyps. Single-piece polypectomies were performed using a hot snare in the stomach body. The polyps were completely removed. Two polyps were retrieved for path. Duodenum: Normal duodenum. Impression: Polyps in the stomach body (polypectomy) Recommendations: In patient care. NPO for 24 hours, then clear liquids for another day. FFP as planned, serial hematocrits, PPI Rx and carafate slurry for 72 hours. Additional notes: The attending was present for the entire procedure. FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss=zero. Specimens were taken for pathology as listed. Brief Hospital Course: MICU Course [**Date range (1) 14898**] . #. GI Bleed: Patient presented with UGIB in setting of supratherapeutic INR (3.4). He remained hemodynamically stable during course. He was transfused a total of 7 U PRBCs, 3 [**Location 61464**], and received Vitamin K IV and PO. General surgery and GI teams were consulted for further management. GI performed EGD which demonstrated no active bleeding, but did identify polyps as the likely source of his HCT drop. His HCT stabilized by the time of transfer. . #. History of DVT: Supratherapeutic INR on admission; lovenox/coumadin held in the setting of GI bleed. Duplex scan demonstrated no residual clot in either leg. . #. Hypernatremia: The patient's sodium trended from 140 to 150 in setting of GI bleed. Derangement was believed to be hypovolemic hypernatremia, as he was made NPO and lacked access to free water. The patient was started on a slow infusion of D5W to correct the metabolic abnormlity. This was corrected at time of transfer to general wards. . *General Wards Course [**Date range (1) 103906**]* # GI bleed: Pt was transferred form the MICU with plans to undergo polypectomy w INR reversal to <1.4. His coumadin was held on admission and he was given vit K x2 prior to transfer. On [**1-15**] prior to EGD INR was 1.4 and he was transfused 1u FFP pre-procedure and 2u FFP post-procedurally to encourage hemostasis of polypectomy sites. EGD showed 4 polyps requiring resection (+ulceration noted). He was started on carafate slurry x 72 hours post procedure (stopped Sat evening), continued on [**Hospital1 **] pantoprazole 40mg IV, and monitored w Q8 hct levels. His hct was noted to be stable in his postprocedural course. He did not require tranfusion of pRBCs on the general wards. Anticoagulation was witheld for concern for rebleeding and multiple episodes of GIB on coumadin in recent months. He was discharged on PO omeprazole 40mg [**Hospital1 **] per GI recs. Tolerating regular foods (passed speech/swallow evaluation). Since pt is independent and lives alone, it was decided to send pt for close monitoring for 3-4 days at rehab center and physical therapy services. Pt was made aware that he may continue to experience melenic stools for additional 5-7 days given his current constipation. This does not necessarily indicate re-bleed. Plan to monitor clinically (BP, HR) and check Hct Sunday AM, Monday AM, Wednesday AM, and Friday AM. If Hct stable, then assume GI hemostasis. Hct level may fluctuate between 28 - 34 depending on lab variability and volume status/po intake. Pt will follow up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 131**] on [**2105-1-22**]. #. History of DVT: DVT diagnosed [**2104-11-25**], on coumadin prior to admission for DVT treatment and afib w high CHADS score. DVT was in setting of recent immobilization after ankle fracture, and patient received approx 7 weeks of anticoagulation. Recent LENI was negative for DVT obtained in MICU. Discussion was held between PCP and inpatient team and given his recurrent GIB and gastric polyps decision was made to avoid anticoagulation for now. Decision for aspirin therapy deferred to outpt pending full stability from GIB standpoint in [**3-19**] weeks. Dr. [**Last Name (STitle) 131**] aware of plan. . #. Afib: Currently in paroxysmal afib with long PR, holding anticoagulation as above. Repeat EKG showed NSR. He was monitored and did not require any rate controlling meds. . # HTN: Restarted home dose of antihypertensives. . # HL: continued on home statin . # Pancreatic tail lesion: Unclear significance. MRCP ordered as outpt. PCP aware, plan to follow as outpt. . # Urethral irritation: Foley cath was discontinued on [**1-16**] and pt reports some urethral discomfort since it was removed. No polyuria, WBC or fever to suggest UTI. Would expect some mild discomfort for couple days but if symptoms persist would obtain a UA to check for possible UTI. UA checked prior to discharge on [**1-17**] was negative for WBC and suggested contamination rather than infection. Pt is noted to be incontinent of urine at baseline. Medications on Admission: ATORVASTATIN [LIPITOR] 10mg daily ENOXAPARIN [LOVENOX] - 80 mg/0.8 mL Syringe SQ daily GLIPIZIDE - 5 mg daily LISINOPRIL - 10mg daily OMEPRAZOLE - 20 mg daily OXYBUTYNIN CHLORIDE [DITROPAN XL] - 5 mg daily TAMSULOSIN [FLOMAX] - 0.4 mg daily WARFARIN - 1 mg Tablet - 1.5-3 Tablet(s) by mouth as directed AMLODIPINE [NORVASC] 10 mg daily FERROUS SULFATE [SLOW RELEASE IRON] - (OTC) - Dosage uncertain Discharge Medications: 1. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 3. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day for 14 days. Disp:*28 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 11. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 3 days: mix tab w/ hot water to make a slurry and drink 4 times daily. This medicine protects your stomach after your procedure. Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Upper GI bleed - ulcerated polyps Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital for bleeding in your stomach from polyps. These were removed by endoscopy (swallowed camera test) and we consider them the likely source of your bleeding. You were treated with IV anti-acid medication, carafate (protect the stomach), and blood products to boost blood clotting ability. We stopped your coumadin since the blood thinning function was causing you to bleed. It was decided to hold any anticoagulation at this time given your multiple recent bleeding episodes. A leg ultrasound showed resolution of the blood clot in your leg. . It is important to note that some bleeding is still expected from your recent procedure. We recommend hematocrit checks on Sunday and Monday, and this can be done 2x/week (Wed/Fri) next week. Subsequently, hematocrit labs can be stopped and you can be followed clinically for any concern for bright red bleeding. . You missed your MRCP as scheduled by your primary care doctor due to your admission for your bleeding. Please discuss setting this up as an outpatient if your primary care doctor would like this completed. . The following changes were made to your medications: - STARTED Carafate, mix tab w/ hot water to make a slurry and drink 4 times daily. This medicine protects your stomach after your procedure. - STARTED Omeprazole 40 mg twice a day for acid control and to prevent ulcers from forming - STOPPED Coumadin - STOPPED Enoxaparin . Please follow up with your doctors as stated below. Your primary care doctor may decide to place you on an aspirin in the future, once your bleeding has completely resolved. Followup Instructions: Department: SURGICAL SPECIALTIES When: WEDNESDAY [**2105-2-18**] at 1 PM With: [**Name6 (MD) 161**] [**Name8 (MD) 6476**], MD [**Telephone/Fax (1) 921**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: Primary Care Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**] When: Thursday [**2105-1-22**] at 10 AM Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL GROUP Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 133**]

[ "518.81", "276.0", "585.9", "272.0", "V10.51", "790.01", "V58.61", "427.31", "799.02", "578.1", "584.9", "530.81", "553.3", "286.9", "403.90", "V12.51", "211.1", "600.00", "535.50", "250.00", "214.3", "343.9", "V42.2" ]

icd9cm

[ [ [] ] ]

[ "38.93", "45.13", "43.41" ]

icd9pcs

[ [ [] ] ]

14105, 14175

8404, 12506

332, 350

14253, 14253

2997, 8381

16063, 16683

2366, 2389

12956, 14082

14196, 14232

12532, 12933

14438, 16040

2404, 2978

280, 294

378, 1693

14268, 14414

1715, 2147

2163, 2350

17,260

180,007

1317

Discharge summary

report

Admission Date: [**2115-12-30**] Discharge Date: [**2116-1-11**] Service: SURGERY Allergies: Penicillins / Plavix Attending:[**First Name3 (LF) 2836**] Chief Complaint: severe abdominal pain, nausea, and vomiting Major Surgical or Invasive Procedure: exploratory laparotomy, lysis of adhesions History of Present Illness: 86M who presents with a 1 day h/o severe abdominal pain, nausea and vomiting. He states that he began to experience diffuse severe sharp abdominal pain around 2am this past morning. The pain seemed to migrate over his abdomen. He reports nausea with emesis x2. He states that he has not been able to pass flatus since this morning. He reports a small hard bowel movement this morning but has not moved his bowels since then. He states that his pain is worsening and that he has ongoing nausea. He now presents for further care. Past Medical History: PMH: CAD s/p MI x2, CHF (EF 55% in [**2108**] with diastolic dysfunction), DM2, h/o internal hemorrhoids (bleeding on anoscopy in [**2109**]), colonoscopy in [**2109**] with hyperplastic polyp and diverticulosis, hyperlipidemia, hypothyroidism, history of TIAs, prostate CA s/p TURP and radiation proctitis, irritable bowel syndrome, BPH, s/p cataract surgery R eye, HTN, CKD, secondary hyperparathyroidism, h/o spinal stenosis and radiculopathy PSH: s/p AICD placement in [**10/2107**] (due to NSVT and inducible monomorphic VT), RCA stent [**2104**], TURP [**2085**]'s Social History: Lives in [**Hospital3 **] alone, wife passed away last year. He is a retired businessman, former cigar smoker > 10y ago, denies EtOH and other drugs. Family History: Father died of emphysema. Mother died of complications from hypertension. [**Name (NI) **] brother died of "heart disease". Physical Exam: Exam on discharge: VS Gen NAD, alert CV RRR Pulm Abd soft, NT, ND, incision c/d/i, staples intact, no erythema of wound Ext wwp, no edema Pertinent Results: Labs on admission: [**2115-12-30**] 03:43PM LACTATE-1.7 [**2115-12-30**] 08:21PM PT-12.5 PTT-20.9* INR(PT)-1.1 [**2115-12-30**] 03:20PM GLUCOSE-127* UREA N-32* CREAT-1.7* SODIUM-141 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13 [**2115-12-30**] 03:20PM ALT(SGPT)-15 AST(SGOT)-23 ALK PHOS-40 TOT BILI-0.5 [**2115-12-30**] 03:20PM LIPASE-34 [**2115-12-30**] 03:20PM ALBUMIN-4.2 [**2115-12-30**] 03:20PM WBC-8.0 RBC-4.62# HGB-13.7* HCT-43.9 MCV-95 MCH-29.7 MCHC-31.2 RDW-14.0 [**2115-12-30**] 03:20PM NEUTS-82.7* LYMPHS-12.9* MONOS-3.2 EOS-1.2 BASOS-0.1 [**2115-12-30**] 03:20PM PLT COUNT-217 Labs on discharge: [**2116-1-8**] 06:30AM BLOOD WBC-11.5* RBC-3.78* Hgb-11.6* Hct-35.9* MCV-95 MCH-30.5 MCHC-32.2 RDW-14.3 Plt Ct-282 [**2116-1-8**] 06:30AM BLOOD Glucose-81 UreaN-22* Creat-1.4* Na-138 K-4.4 Cl-98 HCO3-31 AnGap-13 [**2116-1-8**] 06:30AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1 Cardiac labs: [**2115-12-31**] 05:30PM BLOOD CK(CPK)-87 [**2116-1-1**] 02:15AM BLOOD CK(CPK)-130 [**2116-1-1**] 08:45AM BLOOD CK(CPK)-132 [**2116-1-3**] 07:59AM BLOOD CK(CPK)-288 [**2116-1-3**] 05:25PM BLOOD CK-MB-6 cTropnT-0.06* [**2116-1-3**] 07:59AM BLOOD CK-MB-6 cTropnT-0.05* [**2116-1-2**] 08:50PM BLOOD CK-MB-8 cTropnT-0.07* [**2116-1-1**] 08:45AM BLOOD CK-MB-4 cTropnT-0.03* [**2116-1-1**] 02:15AM BLOOD CK-MB-4 cTropnT-0.03* [**2115-12-31**] 05:30PM BLOOD CK-MB-NotDone cTropnT-0.02* Imaging: CT abd/pelvis [**2115-12-30**]: 1. Dilated fluid-filled loops of small bowel measuring up to 3.4 cm with decompressed colon and terminal ileum consistent with high- grade small-bowel obstruction. One definite transition point seen within the right lower quadrant (301b:26); however, a second transition point may also be prsent within RLQ. Suggestion of swirling of the mesentery and abnormal configuration of small bowel loops raises the possibility of internal hernia. Associated small amount of right lower quadrant and pelvic free fluid along with mesenteric stranding specifically in the right lower quadrant could be related to congestive change, although early ischemia is not excluded. 2. Interval increase in size of infrarenal abdominal aortic aneurysm, now measuring 3.4 cm where on [**2-24**] it measured up to 2.8 cm. Increased right internal iliac aneurysm measuring 3.3 cm (measured 2.5cm in [**2-24**]). Ectasia of the right common iliac artery measuring up to 1.5 cm. 3. Diverticulosis without secondary signs of diverticulitis. 4. Bronchiectasis and reticulation could relate to chronic inflammatory/infectious changes within the bilateral lung bases. CXR [**2115-12-30**]: 1. Bibasilar right greater than left atelectasis without definite superimposed pneumonia. 2. Nasogastric tube seen coursing below the diaphragm. CXR [**2116-1-2**]: 1. Mild pulmonary edema is worsening since [**2115-12-31**]. 2. Moderate bibasilar atelectasis is improved in the right and stable on the left. 3. Left-sided pleural effusion is unchanged since [**2115-12-31**]. KUB [**2116-1-3**]: 1. Diffuse small bowel distention with gas seen within the colon and rectum. This is a nonspecific pattern. Recommend follow-up. CXR [**2116-1-6**]: In comparison with study of [**1-2**], there is decrease in the pulmonary vascular congestion with persistent bibasilar atelectasis. Increasing opacification at the left base could reflect worsening atelectasis or increasing pleural effusion. Persistent low lung volumes. Nasogastric tube has been inserted with its tip in the body of the stomach. CXR [**2116-1-7**]: In comparison with the study of [**1-6**], the patient has taken a somewhat better inspiration. Enlargement of the cardiac silhouette persists in a patient with a dual-channel pacemaker device in place. Bibasilar atelectasis is again seen without definite effusion. The nasogastric tube has been removed. Brief Hospital Course: The patient presented to the [**Hospital1 18**] emergency department on [**2115-12-30**] for evaluation and treatment of abdominal pain, nausea, and vomiting. In the emergency department, the patient was resuscitated, and a foley/NGT were placed with moderate relief of abdominal pain. He was then admitted to the general surgery service, NPO, IVF. On the morning following admission, the patient was complaining of increased abdominal pain and was focally and markedly tender with guarding in the RLQ. Given his worsening exam and CT findings of high-grade SBO with potential internal hernia, the patient was taken to the operating room. Thus, on [**2115-12-31**], the patient underwent an exploratory laparotomy with lysis of adhesions. He was found to have one adhesion causing the obstruction. This was taken down. No bowel was resected. The operation went well without complications (reader referred to the Operative Note for details). While in the PACU, the patient experienced a 30 second run of ventricular tachycardia with a fall in SBP to the 60s. The patient spontaneously converted (back to NSR) and did not receive a shock. He regained an SBP within normal limits. EKG at that time showed sinus rhythm with frequent ventricular premature beats. Compared to the previous tracing of [**2115-12-30**] there was no significant diagnostic change. Cardiac enzymes were negative x 3. EP was called to evaluate his ICD, which had been placed in [**2106**] for intermittent Vtach. The ICD was functioning properly, and EP did not recommend changing the settings. Cardiology also saw the patient and recommended restarting his home aggrenox and carvedilol when possible. (The patient had been placed on IV lopressor while NPO). [**2116-1-1**] The rest of his PACU stay was uneventful, and the patient arrived on the floor NPO, on IV fluids, with a foley catheter, NGT, and on tele. He was receiving IV dilaudid for pain control, which was switched to IV morphine and toradol. The patient was hemodynamically stable. However, his mental status had changed from AAOx3 to AAOx2. His narcotics were stopped and replaced with tylenol. Electrolytes were checked and repleted, and he was reoriented frequently. He self-d/c'd his NGT, and it was decided not to replace it. Patient was kept NPO. [**2116-1-2**] Mental status did not improve, and the patient became combative. He was placed in soft restraints, and he was given haldol with minimal effect. His urine output was borderline, and he was bolused with moderate response. His UOP decreased again, and his O2 sats decreased. He sounded wet on exam. CXR showed mild pulm edema, bibasilar atelectasis, and left pleural effusion. He was given lasix with good result. [**2116-1-3**]: Mental status improved, but he was still confused at times. He had a 10-beat run of Vtach, hemodynamically stable, no shock received. The patient was more distended and nauseated. An NGT was placed with immediate return of copious gastric contents. KUB showed diffuse small bowel distention with gas seen within the colon and rectum, nonspecific pattern. His foley catheter was removed and replaced with a condom catheter. Good UOP. [**2116-1-4**]: Patient was fully alert and oriented. NGT in place with good effect, still returned significant amounts of bilious gastric contents. No flatus or bowel movements. He was seen by PT, who recommended rehab. [**2116-1-5**]: Alert and oriented x 3. Runs of Vtach again, hemodynamically stable, no shock received. No other events. [**2116-1-6**]: The patient was triggered for respiratory distress and copious secretions. He could not protect his airway, especially with the NGT in place. Given the need for q1 hour suctioning, the patient was sent to the ICU. CXR showed atelectasis. He was 8kg over his starting weight, so he was given lasix with good effect. Secretions slowed and normalized. The NGT was removed since his abdomen was soft and NT, he had passed flatus, and the NGT had been minimal x 2 days. [**2116-1-7**]: Additional runs of Vtach, hemodynamically stable, no shock received. EP came again, ICD still functioning, no changes to settings needed. Clears started. Home cardiology medications restarted. Patient transferred back to the floor. Follow-up CXR showed atelectasis. [**2116-1-8**]: Patient doing well. No copious secretions, saturating 97% on room air. Advanced from clears to regular diet with supplements without issue. He was ambulating with assistance on the floor. Case management began screening him for rehab. [**2116-1-9**]: Patient continued doing well. His staples were removed and steri strips applied. The wound is clean, dry, and intact. [**2116-1-10**]: Patient continued doing well. At the time of discharge, the patient was afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Systems summary: Neuro: The patient received IV narcotics initially but was switched to tylenol only due to altered mental status. This produced adequate pain control. CV: As discussed in the hospital course; intermittent episodes of Vtach not needing intervention; vital signs were routinely monitored. Pulmonary: As discussed in the summary; intermittent doses of lasix for mild pulmonary edema; transfer to the unit for copious secretions, resolved with lasix. Subsequently stable from a pulmonary standpoint, saturating well on room air; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. NGT was self-d/c'd and then replaced after development of nausea. NGT removed and diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. The wound dressing was removed on POD2 and the wound remained c/d/i. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. Medications on Admission: Aggrenox 1 tab daily Glipizide 2.5mg daily Pioglitazone 15mg daily coreg 12.5mg [**Hospital1 **] Rosuvastatin 10mg daily Levothyroxine 112mcg PO daily Gabapentin 300mg [**Hospital1 **] Fe 325 daily Vit D [**Numeric Identifier 1871**] units twice monthly Calcitriol 0.25mg daily Vit B12 1000mcg daily Spiriva handihaler daily Flunisolide nasal spray 2 sprays per nostril daily Tiotroprium bromide 18mcg daily Atropine 0.025mg q6h prn Ciclopirox 0.077% prn Albuterol 90mcg 2 puffs q4h prn Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO DAILY (Daily). 6. Calcitriol 0.25 mcg IV 3X/WEEK (TU,TH,SA) 7. Insulin Insulin sliding scale as needed 8. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 9. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. Flunisolide 25 mcg (0.025 %) Spray, Non-Aerosol Sig: Two (2) sprays Nasal daily (): to each nostril. 14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation every four (4) hours as needed for wheeze. 15. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 16. Atropine Oral 17. Ciclopirox 0.77 % Cream Sig: One (1) application Topical once a day as needed for itching. 18. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **] Discharge Diagnosis: small bowel obstruction due to adhesions delirium, now resolved acute kidney injury responsive to hydration 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: General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**3-30**] 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 steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after placement. . If you experience any of the following, please call your doctor or come to the emergency room: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2998**]. PLEASE CALL THE OFFICE FOR YOUR FOLLOW-UP APPOINTMENT. THIS WILL BE IN [**11-23**] WEEKS. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2116-4-29**] 10:00 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2116-4-29**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2116-4-29**] 1:40

[ "E935.8", "518.0", "427.0", "V45.82", "412", "414.01", "518.82", "564.1", "428.0", "585.9", "562.10", "560.81", "V10.46", "244.9", "584.9", "428.33", "272.4", "250.00", "780.09", "600.00", "458.29", "403.90", "V12.54", "588.81", "E878.8", "V15.82", "V45.02", "997.1" ]

icd9cm

[ [ [] ] ]

[ "99.77", "54.59", "54.11" ]

icd9pcs

[ [ [] ] ]

14577, 14671

5806, 12508

272, 317

14823, 14823

1956, 1961

17069, 17676

1655, 1782

13045, 14554

14692, 14802

12534, 13022

15000, 15000

15629, 17046

1797, 1797

15033, 15613

189, 234

2591, 5783

345, 875

1816, 1937

1975, 2572

14837, 14976

897, 1471

1487, 1639

28,217

183,279

12945

Discharge summary

report

Admission Date: [**2143-6-13**] Discharge Date: [**2143-6-18**] Date of Birth: [**2065-12-15**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**6-13**] cardiac catheterization [**6-14**] CABG x 4 (LIMA to LAD, SVG to OM with proximal SVG to PDA,and additional proximal SVG to RAMUS) History of Present Illness: 77 yo M who presented to OSH with chest pain ruled in for NSTEMI. Transferred to [**Hospital1 18**] for cardiac cath. Past Medical History: CAD, s/p MI x 4 and cardiac catheterization x 2 ([**2120**], [**2126**]), Type 2 Diabetes Mellitus, Hyperlipidemia, Hypertension, History of recurrent DVTs (BLE, LUE, ?PE) on chronic Coumadin, GERD, Depression, S/P cataract surgery, Positive Hepatitic C antibody Social History: retired no tobacco no etoh lives alone Family History: mother with "heart problems" Physical Exam: HR 67 RR 16 BP 110/69 NAD Lungs CTAB Heart RRR, no Murmur Abdomen benign Extrem warm, no edema 5'6" 183# + peripheral pulses Pertinent Results: [**2143-6-17**] 03:05AM BLOOD WBC-9.9 RBC-2.88* Hgb-8.6* Hct-24.7* MCV-86 MCH-29.7 MCHC-34.6 RDW-16.0* Plt Ct-113* [**2143-6-17**] 10:39AM BLOOD K-4.6 [**2143-6-17**] 03:05AM BLOOD Glucose-77 UreaN-16 Creat-0.9 Na-139 K-3.9 Cl-105 HCO3-31 AnGap-7* CHEST (PORTABLE AP) [**2143-6-16**] 9:20 AM CHEST (PORTABLE AP) Reason: PTX [**Hospital 93**] MEDICAL CONDITION: 77 year old woman s/p chest tube removal REASON FOR THIS EXAMINATION: PTX PORTABLE CHEST ON [**2143-6-16**] AT 1009 INDICATION: Chest tube removal. COMPARISON: [**2143-6-15**]. FINDINGS: The right Swan-Ganz catheter is seen with the tip in the main pulmonary outflow tract. Other lines and tubes have been removed, and there is no PTX. Some left mid lung atelectasis is seen in a plate-like fashion overlying the cardiac silhouette. In addition, there is an area of plate-like subsegmental atelectasis in the right upper lobe. The level of inspiration is somewhat shallow though deeper than the prior study. IMPRESSION: No PTX after tube removal; subsegmental atelectatic changes as described above. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 39748**] [**Hospital1 18**] [**Numeric Identifier 39749**] (Complete) Done [**2143-6-14**] at 12:13:26 PM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2065-12-15**] Age (years): 77 F Hgt (in): 66 BP (mm Hg): 180/50 Wgt (lb): 183 HR (bpm): 60 BSA (m2): 1.93 m2 Indication: Intraoperative TEE for CABG ICD-9 Codes: 428.0, 410.91, 786.05, 786.51, 440.0 Test Information Date/Time: [**2143-6-14**] at 12:13 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW4-: Machine: [**Pager number 29377**] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 30% >= 55% Aorta - Ascending: 2.8 cm <= 3.4 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Findings LEFT ATRIUM: Dilated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. Dynamic interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Top normal/borderline dilated LV cavity size. Moderate regional LV systolic dysfunction. Moderately depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Focal calcifications in aortic root. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Focal calcifications in ascending aorta. Simple atheroma in aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Calcified tips of papillary muscles. Physiologic MR (within normal limits). TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Emergency study. Results were personally post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). An intra-aortic balloon pump was placed. The proximal balloon tip is positioned distal to the takeoff of the left subclavian. Conclusions PRE-BYPASS: 1. The left atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is moderate regional left ventricular systolic dysfunction with apical akinesis, and severe hypokinesis of mid and distal segments of septum, anterior, anterolateral, and lateral walls. Overall left ventricular systolic function is moderately to severely depressed (LVEF= 30 %). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). 7. The tricuspid valve leaflets are mildly thickened. 8. There is a trivial/physiologic pericardial effusion. 8. An intraaortic balloon is seen in the descending thoracic aorta with its tip about 2 cm below the distal aortic arch. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including epinephrine, milrinone, phenylephrine. Pt is in an intrinsic sinus rhythm. 1. There is global left ventricular systolic dysfunction with an estimated LVEF of 35 %. 2. Right ventricular systolic function is normal. 3. An intra-aortic balloon pump is in place. The proximal balloon tip is positioned 2 cm distal to the takeoff of the left subclavian. 4. Aortic contours are intact post-decannulation. Brief Hospital Course: Cardiac catheterization showed severe 3VD, IABP was placed and she was transferred to the CCU. Carotid u/s and vein mapping were done preoperatively. She was taken to the operating room on [**6-14**] where she underwent a CABG x 4. She was transferred to the ICU in critical but stable condition. IABP was dc'd and milrinone was weaned off on POD #1. She was extubated on POD #2. She was started on coumadin for history of DVT. She was transferred to the floor on POD #3. Wires and chest tubes were pulled without incident. Beta blockade titrated and gently diuresed toward preop weight. Unable to add ACE-I due to low BP. Cleared for discharge to rehab on POD #4. Target INR is 2.0-3.0 for prior DVT. Pt. is to make all followup appts.as per discharge instructions. Medications on Admission: Lipitor 80 mg daily, Lopressor 50 mg [**Hospital1 **], Coumadin 5 mg, NPH 50 Units in am and 40 Units in pm, lisinopril 20 mg 1 tab daily, Sliding scale insulin, Zetia 10 mg 1 tab daily, ASA 325 mg 1 tab daily, Colace 100 mg [**Hospital1 **], Trilafon 2 mg [**Hospital1 **], Zocor 80 mg 1 tab daiy, Plavix 75 mg 1 tab daily loaded on [**2143-6-10**], Nexium 40 mg 1 tab daily . Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily): rehab provider to dose daily coumadin-5 mg dose for [**6-18**] only. 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours): hold for K > 4.5. 10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Insulin Lispro 100 unit/mL Solution Sig: 0-8 units Subcutaneous QACHS: see printed sliding scale attached-PLEASE RESUME LANTUS WHEN EATING NORMALLY. Discharge Disposition: Extended Care Facility: Braemore Discharge Diagnosis: CAD now s/p CABG PAST MEDICAL HISTORY: CAD, s/p MI x 4 and cardiac catheterization x 2 ([**2120**], [**2126**]), Type 2 Diabetes Mellitus, Hyperlipidemia, Hypertension, History of recurrent DVTs (BLE, LUE, ?PE) on chronic Coumadin, GERD, Depression, S/P cataract surgery, Positive Hepatitic C antibody Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower daily, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon, or at least one month. Followup Instructions: Dr. [**Last Name (STitle) 24862**] 2 weeks Dr. [**Last Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) **] 4 weeks [**Telephone/Fax (1) 170**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2143-6-18**]

[ "401.9", "410.71", "414.01", "272.4", "250.00", "311", "287.5", "412", "V45.82", "V12.09", "V12.51" ]

icd9cm

[ [ [] ] ]

[ "97.44", "99.05", "99.04", "99.07", "89.60", "37.22", "37.61", "39.61", "88.56", "36.13", "36.15" ]

icd9pcs

[ [ [] ] ]

10020, 10055

7488, 8256

332, 479

10402, 10410

1177, 1506

10752, 11021

984, 1015

8685, 9997

1543, 1584

10076, 10093

8282, 8662

10434, 10729

1030, 1158

282, 294

1613, 7465

507, 626

10115, 10381

928, 968

3,591

149,445

12913

Discharge summary

report

Admission Date: [**2162-11-19**] Discharge Date: [**2162-11-30**] Date of Birth: [**2085-11-29**] Sex: M Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: This is a 76 year-old white male with a history of Parkinson's disease, idiopathic cardiomyopathy with an EF of 15%, who presented to an outside hospital on [**11-15**] with a chief complaint of shortness of breath. He was found to have mild congestive heart failure and treated with diuresis and Accupril. The patient was also found to have decrease hematocrit and guaiac in stools. He had an upper endoscopy significant for peptic ulcer disease. The patient notes subacute decline with increase dyspnea on exertion in [**2162-7-29**]. The patient was admitted in early [**Month (only) 359**] with congestive heart failure with an echocardiogram revealing an ejection fraction 50%, moderate AS and 4+ MR. The patient had an extensive workup to investigate the cause of this cardiac myopathy, which was suspected to be nonischemic. The patient was readmitted on [**11-15**] with similar symptoms, given unclear etiology of decreased cardiac function, transferred to [**Hospital1 346**] for catheterization. PHYSICAL EXAMINATION: Temperature 97.7, 118/84. Heart rate 90. Respiratory rate 20. Preop weight 75.1 kilogram. HEENT mucous membranes are moist. Heart regular rate and rhythm. S1 and S2. Positive systolic ejection murmur at right upper sternal border radiating to carotids. Lungs bibasilar crackles otherwise clear to auscultation bilaterally. Abdomen soft, nontender, nondistended. Positive bowel sounds. Extremities warm, trace edema, 2+ dorsalis pedis pulses. No femoral hematoma or bruits. Neurological cranial nerves II through XII grossly intact, 5 out of 5 upper and lower extremities bilateral strength. PERTINENT LABORATORIES: Hematocrit 32.4, white blood cell count 5.4, creatinine 0.8, AST 14, T bili 1.1, albumin 3.3. HOSPITAL COURSE: The patient was admitted on [**11-19**] to the medical service for complaints of shortness of breath. The patient had a catheterization at which time it was shown that the patient had 90% stenosis of the left anterior descending coronary artery, 80% stenosis of proximal DI, 80% of mid D3 not amenable to PCI. Ejection fraction at that time was 20%, which was attributed to both coronary artery disease and aortic stenosis. The patient's Coumadin dose was noted to be held secondary to his history of recent GI bleed. Of note, the patient was on triple therapy for H pylori prophylaxis, which included Protonix, amoxicillin and Azithromycin. On the [**8-21**] cardiac surgery was consulted at which time a plan was formulated to proceed with an aortic valve replacement with a tissue valve and coronary artery bypass graft was also planned. The possible complications were explained to the patient and clearly understood. Preoperatively there was no evidence of upper gastrointestinal bleed and the subQ heparin was discontinued. On [**2162-11-24**] the patient underwent an aortic valve replacement with a 23 mm Bovine pericardial valve, and a coronary artery bypass graft times three vessels (left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to ramus, saphenous vein graft to RPL). Postoperatively, the patient was admitted to the Intensive Care Unit. Cardiovascular wise the patient was placed on Dopamine and maintained good cardiac index and was able to be weaned off at night. A Swan-Ganz catheter was also placed intraoperatively as well as chest tubes, which were discontinued on postoperative day one. The patient was extubated without complications in the Intensive Care Unit. Of note, intraoperatively, cardiopulmonary bypass was 126 minutes and the cross clamp time was 105 minutes. On postoperative day three the patient was transferred to the floor and reverted to atrial fibrillation rhythm at which time he was started on Amiodarone 150 mg intravenous times one and 400 mg po t.i.d. The patient was maintained on telemetry on the floor. In addition, the patient was also found to have a primary AV block with a PR interval of .281. The patient did not progress in terms of the AV block and pacing was unnecessary. On postoperative day six the patient was found to be in good condition, in normal sinus rhythm and hemodynamically stable and was subsequently discharged to home with [**Hospital6 407**]. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home with [**Hospital6 407**]. PATIENT INSTRUCTIONS: After discussion with Dr. [**Last Name (STitle) 5293**] the patient was started on Amiodarone 800 mg po q day and the Coumadin was started at 2 mg po q day on the day of discharge. Dr. [**Last Name (STitle) 5293**] is to follow the INR and the patient is to follow up with Dr. [**Last Name (STitle) 5293**] on Monday [**12-6**]. The patient is also to follow up with Dr. [**Last Name (STitle) **] in two weeks. DISCHARGE DIAGNOSIS: Coronary artery disease and aortic valve stenosis. DISCHARGE MEDICATIONS: Amiodarone 800 mg po q day, Metoprolol 15 mg po b.i.d., Pantoprazole 40 mg po b.i.d., Amoxicillin 500 mg po q 8 hours times three days, Clonazepam 0.5 mg po t.i.d., Percocet one to two tabs po q 4 to 6 hours prn pain, Carbidopa-Levodopa (25/100) one tab po t.i.d., aspirin 81 mg po q day, Coumadin 2 mg po q day. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 14176**] MEDQUIST36 D: [**2162-11-30**] 13:23 T: [**2162-12-2**] 09:46 JOB#: [**Job Number 38264**]

[ "041.86", "414.01", "997.1", "398.91", "E878.8", "426.11", "396.2", "427.31", "531.40" ]

icd9cm

[ [ [] ] ]

[ "88.56", "88.72", "88.53", "36.12", "42.23", "37.23", "39.61", "35.21", "36.15" ]

icd9pcs

[ [ [] ] ]

5063, 5659

4987, 5039

1954, 4443

1213, 1936

175, 1190

4468, 4966

8,970

176,312

2568+2569

Discharge summary

report+report

Admission Date: [**2123-10-25**] Discharge Date: [**2123-11-4**] Date of Birth: [**2049-4-18**] Sex: M Service: DR.[**Last Name (STitle) **],[**First Name3 (LF) **] J. 12-749 Dictated By:[**Name8 (MD) 12984**] MEDQUIST36 D: [**2123-11-7**] 12:22 T: [**2123-11-7**] 12:29 JOB#: [**Job Number 12985**] Admission Date: [**2123-10-25**] Discharge Date: Date of Birth: [**2049-4-18**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 74 year-old male with a past medical history significant for coronary artery disease (single vessel disease of RCA, status post stent in [**Month (only) 404**] of 199), congestive heart failure class 3, chronic obstructive pulmonary disease and asthma, and prostate cancer, presenting with shortness of breath over the past few days. The patient was seen at [**Hospital 12986**] Clinic, where he was noticed to have pulmonary rales, lower extremity edema, after which patient was referred to the emergency department for evaluation of congestive heart failure. The patient stated that he had not taken his medication (the patient had been on Lasix and Digoxin among several other medications) for the past few days as he had been out of them. In the emergency department, the patient was noted to have an oxygen saturation of 82 percent on 5 liters nasal cannula oxygen. The patient was normally on 3 liters of oxygen at home. The patient's oxygen saturations had improved to 96 percent on 100 percent nonrebreather mask. In the emergency department, the patient was also noted to be in sinus tachycardia at 124 beats per minute. The patient was given 40 mg of Lasix intravenous twice in the emergency department, after which he put out 1200 cc of urine. For his rate, the patient was given 5 mg intravenous diltiazem, after which his rate decreased into the 80s. The patient had also admitted to an episode of chest pain the night prior to presentation. The patient stated that the chest pain was mild, radiating to bilateral shoulders, with relief with one sublingual nitroglycerin. The patient stated that he had always got chest pain off and on of similar nature. The patient denied diaphoresis, nausea or vomiting. The patient did admit to occasional light headedness. The patient admitted to a stable two pillow orthopnea. Patient denied paroxysmal nocturnal dyspnea. The patient admitted to increased leg swelling and shortness of breath at rest. PAST MEDICAL HISTORY: 1) Class 3 congestive heart failure. 2) Coronary artery disease. Status post stent to RCA in [**2121-1-31**]. 3) Asthma. 4) Chronic obstructive pulmonary disease. Home oxygen dependent on 3 liters nasal cannula at home. 5) Dilated cardiomyopathy with an ejection fraction of less than 20 percent. 6) Pulmonary hypertension. 7) History of prostate cancer. MEDICATIONS ON TRANSFER: Albuterol 2 puffs q.i.d., aspirin 325 mg p.o. q.d., Carvedilol 6.25 mg p.o. q.d., Cozaar 50 mg p.o. b.i.d., Digoxin .25 mg q.d. p.o. q.h.s., Lasix 20 mg p.o. q.d., ibuprofen 400 mg p.o. b.i.d., ipratropium 2 puffs p.o. q.i.d., sublingual nitroglycerin, oxygen 3 liters nasal cannula, Ultram 50 mg p.o. b.i.d. ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. The patient was not entirely cooperative during history taking. SOCIAL HISTORY: The patient lives alone. The patient state that he takes all his medications by himself. Patient admitted to an 80 pack per year history of smoking. Quit two years ago. The patient admitted to a history of alcohol abuse, but now admitted only to social drinking. PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 110/80, pulse 82, respirations 23, oxygen saturation 89% on 50 percent face mask. General: the patient is a 74 year-old male in mild respiratory distress. Head and neck examination normocephalic, atraumatic, pupils equal, round, reactive to light. Extraocular movements intact. Anicteric. Jugular venous pressure 10 cm. Cardiac examination: S1 and S2 audible, irregularly irregular, tachycardic. No murmurs, rubs or gallops. Pulmonary examination: crackles bilateral lower [**2-3**]. No wheezes or rhonchi. Abdomen soft, nontender, nondistended, good bowel sounds in all four quadrants. No masses. Questionable hepatomegaly. Extremities: 1+ ankle edema bilaterally, +2 dorsalis pedis and posterior tibial pulses bilaterally. Neurologically alert and oriented times three. Cranial nerves 2 through 12 intact. Presents 4 out of 5 bilateral upper and extremities. PERTINENT LABORATORY FINDINGS ON ADMISSION: CBC revealed WBC of 6.1, hemoglobin 17.3, hematocrit 49.8, platelets are 85. Chem-7 revealing sodium of 138, potassium of 5.7 (hemolyzed), chloride of 100, bicarbonate of 25, BUN of 11, creatinine 0.7, glucose 150. PT 16.6, PTT 33.8, INR of 1.8. Chest x-ray showing no effusions or infiltrate. There was engorgement of the pulmonary vasculature at the upper lobe. There were curly B lines especially prominent in the right lung field. Echocardiogram done in [**2121-1-31**] showed severe global left ventricular dysfunction. There was abnormal septal motion consistent with conduction delay. There was no thrombus. Right ventricular function was severely depressed. There was no aortic regurgitation with mild mitral regurgitation. The impression was severe biventricular dysfunction. Electrocardiogram showed atrial flutter at 124 beats per minute. There was left axis deviation. Poor R wave compression. The assessment at this point was that this was a 74 year-old male with a past medical history significant for coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease and asthma presenting with worsening shortness of breath, episodes of intermittent chest pain, and atrial flutter. Chest x-ray revealed acute pulmonary edema. The patient had not been taking his medication for the past three days and had been reporting increasing leg edema since. The patient was presumed to be have an episode of congestive heart failure exacerbated by lack of medication use as well as his arrhythmia. #1: Pulmonary. A) Congestive heart failure. The patient received Lasix 40 mg intravenous twice in the Emergency Room, to which he put out 1200 cc of urine. The plan was to continue to bolus the patient with Lasix with the goal of having him be 2 liters negative over each 24 our period. The patient was continued on Digoxin and his oxygen saturations were monitored. Over the 24 hour period after admission, the patient had become 4 liters negative secondary to the Lasix bolussing in the emergency department. As a result, the patient had developed a severe contraction alkalosis secondary to overaggresive diuresis with bicarbonate of 39 (bicarbonate 25 on admission). The plan was to hold off on Lasix diuresis and to continue to monitor the patient's fluid status. The patient's shortness of breath gradually improved throughout the hospital course, and he stated that his shortness of breath had markedly improved. The patient's oxygen requirement decreased to 2 liters nasal cannula from 10 liters nasal cannula on transfer to the floor. The patient was ultimately placed back on his outpatient Lasix regime of 20 mg p.o. once a day. Reassessing the patient revealed that he had decrease in his lower extremity edema and a decrease in his pulmonary rales, but a persistently elevated jugular venous pressure. The patient was rebolussed with 40 mg of intravenous Lasix, after which he once again was 4 liters negative in terms of his fluid balance. B) Chronic obstructive pulmonary disease: The patient was continued on his albuterol, Atrovent inhalers. Secondary to the patient's atrial flutter with rapid rate, the albuterol inhaler was discontinued. The patient's oxygen requirements decreased from 10 liters oxygen nasal cannula on transfer to the floor to 2 liters nasal cannula. The patient was saturating 90 to 97 percent on 2 liters nasal cannula. #2: Cardiovascular. A) Rhythm. The patient was in atrial flutter with variable conduction with heart rate in the 120s. The patient's beta blocker was initially discontinued as the patient had a history of chronic obstructive pulmonary disease. The patient was given 5 mg intravenous diltiazem for his elevated heart rate, after which his heart rate decreased into the 80s. However, the patient's heart rate then rebounded back up into the 120s and 130s. The patient was then started on Cardizem CD 120 mg p.o. q. day, after which his heart rate was better controlled (heart rate 60s to 80s). However, the patient still continued to be in atrial flutter with an occasional increase in his heart rate into the 120s. The patient was started on a heparin drip anticoagulant. Electrophysiology was consulted and arrange for a PEE cardioversion. The patient underwent successful DC cardioversion. However, after cardioversion, telemetry readings showed a four beat run of nonsustained ventricular tachycardia with paroxysmal ventricular contractions. Electrophysiology was once again consulted and the plan was that patient should go for a V stimulation test with possible photo ablation of his atrial flutter focus and AICD placement. B) Coronary artery disease. The patient had been complaining of intermittent episodes of chest pain on admission. The patient was ruled out for myocardial infarction with three sets of cardiac enzymes. The patient was continued on aspirin 325 mg one a day, Cozaar 50 mg p.o. b.i.d., and sublingual nitroglycerin p.r.n. Carvedilol was initially on hold secondary to the patient's chronic obstructive pulmonary disease. However, the patient was resumed on his Carvedilol 6.25 mg p.o. b.i.d. secondary to his elevated heart rate. The patient's antihypertensive medications were frequently put on hold secondary to continuous low blood pressures (systolics in the 80s and 90s at times). During the hospital course the patient had an episode of diaphoresis. Cardiac enzymes were cycled for two sets after this episode of diaphoresis and were negative. An electrocardiogram was taken at the time of the episode of diaphoresis and showed changes in the admission electrocardiogram. #3: Leukopenia. The patient had a low white blood cell count of 6.1 on admission which had further climbed throughout the hospital admission. The impression was that this patient's leukopenia was secondary to his polycythemia leading to MDS (myelodysplastic syndrome) or CMML. #4: Alkalosis. The patient had developed a severe contraction alkalosis presumably secondary to over-aggressive diuresis. The patient was started on Diamox 250 mg p.o. b.i.d. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**MD Number(1) 5226**] Dictated By:[**Name8 (MD) 2692**] MEDQUIST36 D: [**2123-11-7**] 13:02 T: [**2123-11-7**] 13:16 JOB#: [**Job Number 12987**]

[ "427.1", "288.0", "428.0", "276.4", "427.32", "493.20", "242.90", "458.2", "425.4" ]

icd9cm

[ [ [] ] ]

[ "37.34", "99.61" ]

icd9pcs

[ [ [] ] ]

3269, 3352

506, 2493

4615, 10986

2904, 3252

2516, 2878

3369, 3658

61,912

151,827

48707

Discharge summary

report

Admission Date: [**2124-11-1**] Discharge Date: [**2124-11-6**] Date of Birth: [**2066-6-9**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Seizures Major Surgical or Invasive Procedure: Crani for mass resection History of Present Illness: This is a 58 year old female who is known to our neurosurgery clinic. She is status post Left frontal anaplastic oligodendroglioma mass resection in [**2117**], with subsequent XRT and CTx treatments. Over the past year or so she has shown increased occurrence of her seizures despite high dose of antisiezure medications. Sequential MRI imaging have demonstrated recurrence of the tumors. She presents to clinic today to discuss the possibility of a craniotomy for mass resection. She currently complains of nausea, vomiting, dizziness. She denies headaches or unintentional weight loss. Past Medical History: Left frontal anaplastic oligodendroglioma with 1p and 19q deletions s/p nearly complete resection [**2117**], postoperative temozolomide, radiation therapy 6000cGy [**2118**] Gastric ulcer Hypothyroidism Bilateral knee osteoarthritis. History of perioral dyskinesias on Risperdal. Past Surgical History: Left frontal craniotomy. Cesarean section [**2097**]. Past Psychiatric History: Depression, OCD. Social History: Living situation: living alone, in senior center. Has dog walker 3x daily. Meals provided. Son and sister help with shopping, cleaning. Marital status: Divorced Children and ages: 26 year old son. Highest education: masters, SW Employment: occupational therapist, not working since tumor diagnosis. Disability: Yes, since tumor diagnosis Family History: (per Dr.[**Name (NI) 7029**] note of [**2124-3-30**], confirmed w/ pt) Mother: died age 78, hypercholesterolemia and HTN. Father: died 67, lung cancer Siblings: twin sister, [**Name (NI) **] [**Name2 (NI) **]. 60 year old sister, breast cancer. 50 year old sister has special needs, in a group home, but otherwise well. Three brothers, one died 1.5 years as above from seizures, one died 25 from seizure, hydrocephalus, shunt complication. Brother died 59 from sepsis. Physical Exam: PHYSICAL EXAM: on ADMISSION Gen: Well developed, well nourished, comfortable, no apparent distress. HEENT: normocephalic, atraumatic, anicteric sclerae,. Neurological Examination: Mental status: Awake and alert, cooperative with exam, slightly flatened affect, but normal interactions when prompted. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension. No dysarthria or paraphasic errors. Prosodia flat. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to 4 mm 3.5 bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Grip [**Hospital1 **] Tri Delt WE WF IP Quad Ham AT [**First Name9 (NamePattern2) 5040**] [**Last Name (un) 938**] ? R drift Sensation: Intact to light touch. denies paresthesias no extrapyramidal signs no Hoffmann's, no clonus or Babinski. stable, somewhat broad based gait. PHYSICAL EXAM UPON DISCHARGE: awake, A+Ox3 PERRL slight R NL fold slight L tongue deviation MAE's with good strengths. incision- well healing, sutures Pertinent Results: ADMISSION LABS: [**2124-11-1**] 12:50PM GLUCOSE-156* LACTATE-1.8 NA+-142 K+-3.9 CL--110 [**2124-11-1**] 05:56PM GLUCOSE-160* UREA N-10 CREAT-0.9 SODIUM-148* POTASSIUM-4.5 CHLORIDE-118* TOTAL CO2-21* ANION GAP-14 DISCHARGE LABS: IMAGING: POst op Head CT [**11-1**]: Expected postoperative changes after left frontal craniotomy and resection of left frontal lobe. No hemorrhage seen. [**11-2**] MRI: IMPRESSION: Post-surgical changes after left frontal craniotomy, resection of the left frontal lobe, with residual smaller area of encephalomalacia. No acute hemorrhage. Brief Hospital Course: The patient was taken to the operating room electively on [**11-1**] for a frontal craniotomy for resection of the right frontal lobe. She tolerated the procedure well and was transferred directly to the SICU for further care including Q1 neuro checks and strict blood pressure control. She did well overnight and had a normal post op head CT. On the morning of [**11-2**] she had mild nausea, but felt well. She was transferred to the SDU on the afternoon of [**11-2**]. Upon arrival to the SDU she was able to void on her own and she was tolerating a PO diet. She remained on her current anti-epileptic drugs with no change in regimen. On [**11-3**] pt was transfered to the floor and she was seen by PT/OT and cleared for DC to a rehab facility. Her incision remained clean and dry while in the hospital and she had no complications or complaints. She will be discharged to rehab facility on [**11-6**] in stable condition. On [**11-6**] she was neurologically stable and cleared for discharge to rehab. Medications on Admission: Keppra 1250 [**Hospital1 **] Zonisamide 500 QPM Vimpat 200 [**Hospital1 **] Diazepam 2.5 mg QID Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. lacosamide 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. diazepam 5 mg Tablet Sig: 0.5 Tablet PO QID (4 times a day). 8. levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). 9. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. zonisamide 100 mg Capsule Sig: Five (5) Capsule PO QPM (once a day (in the evening)). 12. lithium carbonate 450 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 13. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 15. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Left frontal brain mass 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: GENERAL INSTRUCTIONS WOUND CARE: ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry. ?????? You may wash your hair with a mild shampoo 24 hours after your sutures are removed. ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. DIET Usually no special diet is prescribed after a craniotomy. A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. Be sure however, to remain well hydrated, and increase your consumption of fiber, as pain medications may cause constipation. MEDICATIONS: ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: o Narcotic pain medication such as Dilaudid (hydromorphone). o An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your surgery, you may safely resume after your neurosurgeon tells you ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase your chances of bleeding. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ACTIVITY: The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour, that you are awake. Followup Instructions: FOLLOW UP APPOINTMENT INSTRUCTIONS ??????Please have the rehabilitation facility remove your staples/sutures 10days from surgery ([**11-9**]). If they have questions, please call [**Telephone/Fax (1) 2731**]. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2124-11-20**] at 9:30 am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. This is a multi-disciplinary appointment. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. Completed by:[**2124-11-6**]

[ "V58.83", "244.9", "V12.71", "V16.3", "715.96", "V58.69", "191.1", "296.20", "348.89", "V17.49", "787.01", "345.51", "784.0", "333.1" ]

icd9cm

[ [ [] ] ]

[ "89.14", "01.59" ]

icd9pcs

[ [ [] ] ]

6778, 6863

4323, 5335

327, 353

6931, 6931

3721, 3721

10795, 11492

1775, 2253

5481, 6755

6884, 6910

5361, 5458

7114, 7135

3956, 4300

1301, 1402

2283, 2450

279, 289

3580, 3702

7147, 10772

381, 973

2737, 3550

3738, 3939

6946, 7090

995, 1277

1418, 1759

16,549

159,008

28519

Discharge summary

report

Admission Date: [**2112-11-25**] Discharge Date: [**2112-12-12**] Date of Birth: [**2049-12-4**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: fever/vomiting/abdominal pain Major Surgical or Invasive Procedure: sternal debridement [**11-28**] omental/pectoral flaps [**11-30**] History of Present Illness: 62 yo female who underwent CABG on [**10-28**] developed fever, abd pain and vomiting today and was admitted to [**Hospital3 1280**]. She denied any incisional complaints or chest pain. Labs there revealed poor glucose control with BS up to 500 and fever to 103, WBC 14,000. CXR there showed some evidence of haziness but no clear consolidation. KUB showed fluid/air levels with no sign of obstruction.Transferred here for further evaluation. Past Medical History: CABG [**2112-10-28**] Asthma Hypertension Cerebral vascular accident Gastroesophageal Reflux disease Diabetes mellitus Neuropathy Renal insufficiency Social History: Primary language spanish, lives with spouse denies alcohol denies tobacco Family History: NC Physical Exam: On admission: T 101.8 126/61 HR 73 RR 20 60" 67.8 kg NAD sternal wound erythema on lower part of the incision with small amount of fluid drainage. Sternum stable . abd soft/NT/ND Pertinent Results: [**2112-12-7**] 05:13AM BLOOD WBC-21.9* RBC-3.26* Hgb-9.6* Hct-27.3* MCV-84 MCH-29.4 MCHC-35.2* RDW-14.7 Plt Ct-305 [**2112-11-28**] 06:20PM BLOOD Neuts-87.3* Bands-0 Lymphs-6.0* Monos-4.5 Eos-2.1 Baso-0.1 [**2112-11-28**] 06:20PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Stipple-OCCASIONAL [**2112-12-7**] 05:13AM BLOOD Plt Ct-305 [**2112-12-2**] 02:07AM BLOOD PT-14.3* PTT-27.7 INR(PT)-1.3* [**2112-12-7**] 05:13AM BLOOD Glucose-53* UreaN-42* Creat-1.4* Na-135 K-4.3 Cl-101 HCO3-26 AnGap-12 [**2112-11-26**] 10:40AM BLOOD Lipase-13 [**2112-12-6**] 06:10AM BLOOD Mg-2.1 [**2112-12-11**] 05:30AM BLOOD WBC-11.6* RBC-3.19* Hgb-9.4* Hct-26.7* MCV-84 MCH-29.4 MCHC-35.1* RDW-14.8 Plt Ct-314 [**2112-12-12**] 05:25AM BLOOD WBC-12.7* RBC-3.21* Hgb-9.2* Hct-27.3* MCV-85 MCH-28.7 MCHC-33.8 RDW-14.9 Plt Ct-376 [**2112-12-10**] 06:38AM BLOOD WBC-23.1* RBC-3.30* Hgb-9.9* Hct-27.7* MCV-84 MCH-30.0 MCHC-35.8* RDW-14.7 Plt Ct-326 [**2112-12-2**] 02:07AM BLOOD PT-14.3* PTT-27.7 INR(PT)-1.3* [**2112-12-11**] 05:30AM BLOOD Glucose-179* UreaN-26* Creat-1.3* Na-135 K-4.2 Cl-98 HCO3-32 AnGap-9 [**2112-12-10**] 06:38AM BLOOD Glucose-133* UreaN-25* Creat-1.2* Na-135 K-4.7 Cl-98 HCO3-27 AnGap-15 [**2112-12-9**] 05:30AM BLOOD Glucose-72 UreaN-31* Creat-1.1 Na-137 K-3.9 Cl-100 HCO3-29 AnGap-12 [**2112-12-8**] 06:39AM BLOOD Glucose-152* UreaN-40* Creat-1.3* Na-133 K-4.0 Cl-98 HCO3-27 AnGap-12 [**2112-12-7**] 05:13AM BLOOD Glucose-53* UreaN-42* Creat-1.4* Na-135 K-4.3 Cl-101 HCO3-26 AnGap-12 Brief Hospital Course: Admitted [**11-25**] and underwent CT of chest and abd, both negative.Sternal wound opened at inferior aspect with pus present. Vancomycin and levaquin started with blood, wound and urine cultures done. Blood cultures showed staph/gram + cocci. Dressing changes started and well as tight glucose management. Patient exhibits poor hygiene. Went to OR for sternal debridement and exploration with Dr. [**Last Name (STitle) **] on [**11-28**]. Chest left open for further evaluation by plastic surgery and transferred to the CSRU for monitoring. Returned to OR on [**11-30**] with Dr. [**First Name (STitle) **] for pectoral and omental flaps.Extubated on [**12-2**]. PICC line placed [**12-5**] for continued IV abx. She was seen in consultation by infectious disease for continued IV antibiotic follow up. Echocardiogram showed no evidence of endocarditis. Her JP drains were all dc'd by [**12-11**]. Repeat UA/culture showed < 10,000 yeast. She is to complete 6 weeks of IV vancomycin. She is discharged on 80 mg [**Hospital1 **] of lasix, her diuresis needs should be reassessed PRN. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for periarea. 6. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb IH Inhalation Q6H (every 6 hours) as needed. 10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Vancomycin 500 mg Recon Soln Sig: 1250 mg Recon Solns Intravenous Q 24H (Every 24 Hours) for 4 weeks: End date [**1-6**] or per ID. 12. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 14. DuoDERM Hydroactive Gel Sig: One (1) Topical every 3 days () as needed for sacral ulcer. 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day). 19. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed. 20. Hydralazine 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours). 21. Senna 8.6 mg Capsule Sig: [**1-11**] Capsules PO twice a day. 22. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 23. Lantus 100 unit/mL Cartridge Sig: Fourteen (14) units Subcutaneous at bedtime. 24. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: per printed sliding scale Subcutaneous four times a day. 25. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO DAILY (Daily). 26. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day: Reassess diusresis PRN. Discharge Disposition: Extended Care Facility: [**Hospital1 13316**]Health Center Discharge Diagnosis: sternal infection s/p cabg IDDM HTN asthma GERD s/p CVA neuropathy s/p renal insufficiency bacteremia Discharge Condition: good Discharge Instructions: no lotions, creams or powders on any incision no driving for one month shower over incision and pat dry call for fever greater than 100, redness or drainage no lifting greater than 10 pounds for 10 weeeks Followup Instructions: follow up with Dr. [**Last Name (STitle) 23070**] (PCP) in [**1-11**] weeks follow up with Dr. [**First Name (STitle) **] (Plastic Surgery) in [**1-11**] weeks follow up with Dr. [**Last Name (STitle) **] (Cardiac Surgeon) in 2 weeks [**Telephone/Fax (1) 170**] follow up with Dr. [**Last Name (STitle) 11382**] (Infectious diseases) [**Telephone/Fax (1) 457**]. Please call to make an appointment for 2 weeks. MRI Spine in the next 2 weeks Completed by:[**2112-12-12**]

[ "998.59", "356.9", "V09.0", "731.3", "V58.67", "585.9", "278.00", "110.3", "724.5", "041.11", "584.5", "682.2", "250.00", "493.90", "998.83", "V45.81", "530.81", "401.9", "790.7" ]

icd9cm

[ [ [] ] ]

[ "96.72", "34.79", "77.61", "86.74", "38.93" ]

icd9pcs

[ [ [] ] ]

6579, 6640

2960, 4046

353, 422

6786, 6793

1401, 2937

7046, 7519

1176, 1180

4069, 6556

6661, 6765

6817, 7023

1195, 1195

284, 315

450, 894

1209, 1382

916, 1068

1084, 1160

8,995

117,356

8548

Discharge summary

report

Admission Date: [**2192-5-18**] Discharge Date: [**2192-5-24**] Service: CARDIOTHORACIC Allergies: Iodine Containing Agents Classifier / Heparin Agents Attending:[**First Name3 (LF) 1283**] Chief Complaint: Patient returned from [**Hospital3 **] after UE ultrasound revealed LUE DVT involving entire subclavian. Patient is HIT+ and required tx w/Argatroban and therefore returned to [**Hospital1 18**] for tx Major Surgical or Invasive Procedure: none History of Present Illness: s/p Asc Ao replacemnt [**4-24**], after complicated postop course transferred to [**Hospital3 **] [**5-17**]. Returned to [**Hospital1 18**] [**5-18**] for tx of UE DVT with Argatroban and Coumadin Past Medical History: HTN hypercholesterolemia R fem AV fistula anxiety/depression osteoporosis varicose veins h/o R ankle fx hard-of-hearing Social History: 3 sons. non-[**Name2 (NI) 1818**] Family History: Sister with aortic aneurysm. Physical Exam: Admission Neuro: Awake and responsive Pulm: BS course w/rhonchi bilat, Trach in place CV: RRR Sternum stable Abdm: soft NT/ND NABS. PEG in place Ext: Warm no pedal edema, + left arm edema Discharge VS 98.6 81SR 142/50 18 100% on 40%TM Gen: NAD Neuro: Alert, responsive follows commands CV: RRR, sternum stable wound CDI Pulm: scattered rhonchi w/productive cough Abdm: soft +BS/PEG site CDI Ext: Warm no pedal edema, 1+ LUE edema Pertinent Results: [**2192-5-17**] 04:48AM GLUCOSE-187* UREA N-28* CREAT-0.7 SODIUM-145 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-27 ANION GAP-12 [**2192-5-17**] 04:48AM WBC-9.5 RBC-3.68* HGB-10.6* HCT-32.9* MCV-89 MCH-28.7 MCHC-32.2 RDW-15.1 [**2192-5-17**] 04:48AM PLT COUNT-291 [**2192-5-24**] 08:40AM BLOOD PT-21.1* PTT-41.1* INR(PT)-2.0* Brief Hospital Course: Admitted to [**Hospital1 18**] [**5-18**] from [**Hospital3 **] for tx of UE DVT in HIT+ patient w/Argatroban and transition to Warfarin. Pt begun on Argatroban shortly after arrival at [**Hospital1 18**]. Over the next several days her Argatroban dose was titrated up to acheive therapeudic levels. The patient was also begun on Warfarin and dose was titrated up while maintaining Argatroba infusion until [**5-24**] pt had therapeudic INR and Argatroban infusion was stopped. Her transfer medications were continued unchanged. The patient was also begun on Glipizide for persistantly elevated blood glucose levels. Her blood sugars will need to be monitored for additional dose adjustments. Medications on Admission: lorazepam 1mg QID/PRN Nystatin Susp QID Ca Acetate 667mg TID Albuterol MDI 2P Q@/PRN Metoprolol 100 [**Hospital1 **] Lisinopril 10 QD Lansoprazole 30mg QD Norvasc 10 QD Amiodarone 200 QD Dlantin 100 TID Simvastatin 80 QD ASA 325 QD tylenol 650 Q6/PRN Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Phenytoin 100 mg/4 mL Suspension Sig: Five (5) ml PO Q8H (every 8 hours): 125mg/TID. 10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 11. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Warfarin 2 mg Tablet Sig: as directed Tablet PO once a day: 5mg [**5-24**] then as directed to maintain target INR 2-2.5. 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: s/p Asc Ao Aneurysm repair CVA DVT Lft UE, Tx w/Argatroban and Coumadin HIT+ s/p retroperitoneal bleed s/p Trach/PEG PMH: HTN,^choldepression, Anxiety, Osteoporosis, Varicose veins Discharge Condition: good Discharge Instructions: keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any [**Location (un) **], redness or drainage from wounds Followup Instructions: Dr [**Last Name (STitle) 141**] upon discharge from rehab Dr [**Last Name (STitle) **] in 1 month or upon discharge from rehab Completed by:[**2192-5-24**]

[ "401.9", "V12.59", "V58.83", "V44.0", "780.39", "V44.1", "453.8", "V58.61", "V15.1", "733.00", "300.00" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.6" ]

icd9pcs

[ [ [] ] ]

3794, 3864

1763, 2458

468, 475

4089, 4096

1413, 1740

4312, 4470

913, 943

2759, 3771

3885, 4068

2484, 2736

4120, 4289

958, 1394

227, 430

503, 702

724, 845

861, 897

82,393

183,428

54339

Discharge summary

report

Admission Date: [**2190-7-4**] Discharge Date: [**2190-7-14**] Date of Birth: [**2110-9-23**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: mute and right sided weakness. Major Surgical or Invasive Procedure: IVtPA administration History of Present Illness: CC:[**CC Contact Info **] Code paged 4:54pm Patient seen 5:04pm NIHSS per ED staff 18 HPI: Patient is a 79yo RHW with complicated PMH including CAD, Afib and s/p pacemaker who was found to be mute with R sided weakness around 3pm today by her husband. [**Name (NI) **] husband, she was seen in her usual self (independently ambulatory and does all ADLs on her own) between 2:30 to 3 when he left to pick up food. When he returned around 3pm, he found her in bed not talking and unable to move her R hence 911 was called. Of note, the patient has Afib and is on Coumadin but this has been suspended for the past 8~9 days for US/endoscopy which she underwent 3 days ago. She was suppose to restart Coumadin as of tomorrow. ROS completely negative otherwise and she has no hx of prior strokes or hemorrhage including GI bleed. Given that she arrived within 3 hours of last well known time and found to be mute with R facial droop, L gaze deviation and R sided weakness, IV tPA was administered after stat imaging including CTA/P showed no bleed but likely M2 occlusion. INR was 1.2 in the ED. Past Medical History: 1. Atrial fibrillation 2. Coronary artery disease s/p stent RCA, LAD. 3. Hypertension 4. Mitral regurgitation 5. Hyperlipidemia 6. Previous smoking history 7. Gastric and Duodenal Ulcer by EGD [**2189-9-11**] 8. H.Pylori gastric biopsy, treated with Prevpac x14 days 9. CHF 10. s/p pacemaker placement in [**3-/2190**] 11. s/p cataract repair Social History: She lives in [**Location 3146**] with her husband. She ambulates independently. She denies any falls. She is independent with ADL's and takes care of her home but does not drive. She used to do secretarial work. She smoked 2 packs per day for approximately 20 years but stopped 2~5 years ago. She endorses drinking one [**Doctor Last Name 6654**] per night with dinner, occasionally two per night. Husband is HCP and full code. Family History: Non-contributory Physical Exam: Admission exam: Exam: T 98.5 BP 148/67 HR 81 RR 19 O2Sat 100% 2L NC Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa CV: Irregularly irregular, no murmurs/gallops/rubs Lung: Clear Abd: +BS, soft, nontender Ext: No edema Neurologic examination: Mental status: Awake and alert, nonverbal. Able to follow commands including sticking tongue out, showing L thumb and moving L toes. Occasionally blurts "what" or "yes" but nonverbal otherwise. Possible R side neglect. Cranial Nerves: Pupils asymmetric but s/p cataract repair - both are reactive. Blinks to visual threat on L only. Appears to cross midline with doll's eyes maneuver but L gaze deviation. R facial droop but tongue appears midline. Motor: Decreased tone on the R. Moves L side purposefully and spontaneously - anti-gravity. Withdraws R side to noxious stim but more on RLE than RUE. Sensation: Intact to nocious stim. Reflexes: 2+ for L biceps and patellar but trace for R biceps and patellar. Both toes appear upgoing. Discharge exam: Please see discharge worksheet. Pertinent Results: Labs on admission and discharge: [**2190-7-4**] 05:00PM BLOOD WBC-8.9 RBC-3.92* Hgb-8.2* Hct-28.2* MCV-72* MCH-20.9* MCHC-29.1* RDW-22.8* Plt Ct-283 [**2190-7-7**] 04:50AM BLOOD WBC-8.8 RBC-4.09* Hgb-8.3* Hct-30.1* MCV-74* MCH-20.3* MCHC-27.6* RDW-22.7* Plt Ct-340 [**2190-7-4**] 05:00PM BLOOD PT-14.2* PTT-25.6 INR(PT)-1.2* [**2190-7-8**] 05:15AM BLOOD PT-15.7* PTT-63.7* INR(PT)-1.4* [**2190-7-4**] 05:00PM BLOOD Glucose-99 UreaN-37* Creat-1.3* Na-142 K-3.8 Cl-102 HCO3-25 AnGap-19 [**2190-7-8**] 05:15AM BLOOD Glucose-142* UreaN-24* Creat-0.8 Na-142 K-3.5 Cl-104 HCO3-30 AnGap-12 [**2190-7-5**] 02:58AM BLOOD CK(CPK)-36 [**2190-7-5**] 02:58AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2190-7-5**] 02:58AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.9 Cholest-106 [**2190-7-5**] 02:58AM BLOOD %HbA1c-6.5* eAG-140* [**2190-7-5**] 02:58AM BLOOD Triglyc-85 HDL-32 CHOL/HD-3.3 LDLcalc-57 Urine: [**2190-7-4**] 05:45PM URINE RBC-[**4-16**]* WBC-0-2 Bacteri-RARE Yeast-NONE Epi-<1 [**2190-7-4**] 05:45PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2190-7-4**] 05:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 Imaging/Studies: CTA/CT/CTP [**7-4**]: CTA: There is a normal variant bovine configuration of the aortic arch with mild atherosclerosis involving the arch and origins of the great vessels. There is no high-grade stenosis. The image quality is degraded by motion artifact, the common and cervical internal carotid arteries are patent with mild atherosclerotic disease at the bifurcations. There is tortuosity of the cervical segments of the internal carotid arteries, which are medialized. ICA luminal transverse dimensions are 5 mm on the right and 4 mm on the left. There is mild atherosclerotic disease involving the cavernous segments of the internal carotid arteries bilaterally. There is abrupt cutoff of the distal M1 segment of the left middle cerebral artery with slightly diminished asymmetric enhancement of the more distal MCA branches on the left. Associated with this, there is a more evident region of hypoattenuation within the parenchyma of the left frontal lobe with abnormal low attenuation extending into the insular cortex where there is loss of differentiation. The lentiform nucleus is defined on the left side. The right middle cerebral artery is normal, as are the anterior cerebral arteries. The posterior circulation is normal. There is persistent fetal formation of the right posterior cerebral artery with a hypoplastic right P1 segment. The vertebral arteries are patent bilaterally. PERFUSION: There is diminished blood volume throughout approximately the anterior one-third of the left middle cerebral artery territory. There is a similar distribution of elevated mean transit time throughout this region, with slightly expanded region of nearing the vertex. Findings are compatible with a completed infarct involving just over one-third of the left MCA territory with a very small number superiorly. There is extensive pleural thickening and/or fluid on the right. There is normal interlobular septal thickening. There are scattered nodes throughout the neck without identifiable pathologic features. There is slight nodularity to the membranous portion of the trachea, which may represent retained secretions. There are advanced multilevel degenerative changes of the cervical spine with multilevel foraminal narrowing. IMPRESSION: 1. The findings suggest an acute embolus in the distal M1 segment of the left middle cerebral artery resulting in infarction of just over one-third of the middle cerebral artery distribution anteriorly, with minimal ischemic tissues at risk near the vertex. There is no hemorrhagic conversion. 2. Extensive pleural thickening and/or fluid on the right, which should be correlated with chest imaging. [**7-5**] CT head: IMPRESSION: 1. Left MCA stroke, status post tPA without evidence of intracranial hemorrhage. 2. Mild right sphenoid sinus mucosal disease. ECHO [**7-5**]: The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. Mild to moderate ([**2-13**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2189-11-13**], the severity of mitral regurgitation is slightly increased. The other findings are similar CXR: FINDINGS: AP single view of the chest has been obtained with patient in sitting semi-upright position. Analysis is made in direct comparison with a preceding PA and lateral chest examination of [**2190-5-18**]. Moderate cardiomegaly, including evidence of left atrial enlargement and previously described permanent pacer with dual intracavitary electrodes remain unchanged. Also the pulmonary congestive pattern with increased interstitial pattern remains. Noteworthy is persistence of the previously described bilateral pleural effusions which have further increased in comparison. It is more marked on the right side where it conceals the entire right diaphragmatic contour and the right pleural sinus and clearly accounts for the clinically described diminished lung sounds in this area. There is no evidence of new discrete pulmonary parenchymal infiltrates and no pneumothorax is present. IMPRESSION: Cardiomegaly and chronic pulmonary congestion with increasing pleural effusions. Brief Hospital Course: 79yo RHW with CAD s/p pacemaker, multiple stents, Afib on Coumadin which was held for the past 8~9 days for US/endoscopy p/w with aphasia and R sided weakness. She arrived as code stroke at 4:54pm and last well known time between 2:30 to 3pm - she was nonverbal with R facial, L gaze deviation and R sided weakness. INR was only 1.2 in the ED and given the arrival within three hours, IVtPA was administered at around 5:30pm. CTA suggested an acute embolus in the distal M1 segment of the left middle cerebral artery resulting in infarction of just over one-third of the middle cerebral artery distribution anteriorly, with minimal ischemic tissues at risk near the vertex. NEURO: Etiology was felt to be due to an embolic stroke in setting of lack of anticoagulation. Pt. was admitted to NEURO ICU for monitoring. She had mild improvement in attention and began to follow axial commands by HD1. RIGHT side remained hemiplegic. Repeat HCT showed no hemorrhagic transformation, she was started on heparin gtt and Coumadin was started on [**2190-7-6**]. ECHO did not show a large [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] thrombus. The INR was 1.7 on [**2190-7-13**]. She will be maintained on a heparin gtt until she is theraputic for a coumadin range of [**3-17**]. Her INR will need to be monitored, particularly while she is on the Cipro. She had some issues on S/S evaluation, thus dobhoff was placed and TFs started. Repeat evaluation showed improved swallowing. Calorie counts om [**7-12**] showed a 24 calorie count of 931 with 48 grams of protein. On [**7-13**] she her intake was good. She was deemed to be able to swallow by speech and swallow: She was started on a Cardiac/Heart healthy Consistency: Pureed (dysphagia); Nectar prethickened liquids 1:1 supervision/max assist with all PO to help with self feeding, maintain aspiration precautions Modifiable stroke RFs included A1C of 6.5%, ISS was used and LDL of 57, pt. was continued on home statin dose. CV/PULM. Pt. was noted to have increased WOB and 2L oxygen requirement. Her diuretics were held in immediate post stroke period for 48 hours. CXR revealed enlarged bilateral effusions. On [**7-7**] bumex was resumed and on [**7-9**] Spironoloactone was resumed. O2 requirement resolved on [**7-9**]. Nebulizer treatments were instituted for COPD. ID she was noted to have a dirty UA and was started on a 3 day course of Cipro. UCx showed e.coli but sensitivites were pending at time of discharge GU - patient was intermittently retaining urine and occasionally required straight cathing. Please monitor output and if urine output decreases bladder scan and consider straight cath if retaining. Patient was discharged to rehabilitation facility. Medications on Admission: 1. BUMETANIDE - 1 mg daily 2. DILTIAZEM HCL - 120 mg daily 3. FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg [**Hospital1 **] 4. METOPROLOL TARTRATE - 25 mg [**Hospital1 **] 5. NITROGLYCERIN [NITROSTAT] - 0.3 mg daily 6. OMEPRAZOLE - 20 mg daily 7. SERTRALINE - 25 mg daily 8. SIMVASTATIN - 80 mg daily 9. SPIRONOLACTONE - 25 mg daily 10. WARFARIN [COUMADIN] - 4 mg daily - on hold for the past 8 days as noted above. 11. ZOLPIDEM [AMBIEN CR] - 12.5 mg bedtime 12. CENTRUM SILVER daily Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for T>100.4 or pain. 2. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Simvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 7. Sertraline 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 8. Bumetanide 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 9. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 11. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 12. Spironolactone 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 13. Warfarin 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4 PM: check INR for a goal of [**3-17**] for afib. 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 15. Ciprofloxacin 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every 12 hours) for 3 days. 16. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution [**Last Name (STitle) **]: One (1) Intravenous ASDIR (AS DIRECTED): rate 625U/hr for goal rate of 50-70 please check q6-8hrs, stop when INR is between [**3-17**] on Coumadin. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: Left MCA (M2) occlusion with frontoparietal embolic stroke Secondary: atrial fibrillation, HTN, HL, CAD. Discharge Condition: Examination at time of discharge notable for: PULM: bilateral crackles and decreased sounds on Right. NEURO: MS. Awake, alert. Follows one step appendicular and axial commands (closes/opens eyes/mouth, shows thumb/fist, wiggles toes, does not point to ceiling or window). Mute in response to questions. Spontaneous groaning. Sings 'happy birthday' only, waves goodbye. Left sided preference and decreased attention on the Right. CNs: R homonymous hemianopia. LEFT gaze preference but crosses midline, EOM otherwise intact. Dense R facial droop. Motor: Flacid RUE and RLE. Noxious to RUE -> grimace and LUE flexion. Noxious to RLE -> triple flex. Full strenght in LUE and LLE. DTRs are 2+ in UEs and 1 at b/l patella and 4 w/ clonus in R foot and 2 in L foot. Plantar: extensor on RIGHT, flexor on LEFT. Discharge Instructions: You were admitted to [**Hospital1 18**] with inability to speak and right sided weakness. You were found to have a stroke on the left side of your brain. This was felt to be due to being off coumadin for several days. You were restarted on coumadin. You required a feeding tube initially but began to swallow well. The following changes were made to your medications: - Diltiazem was discontinued - Spironolactone was cut in half - Coumadin was restarted - You were stared on a short course of Cipro for a UTI. You were discharged to a rehabilitation facility Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: NEUROLOGY: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2190-8-17**] 5:00 Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2190-10-19**] 10:40 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2190-10-19**] 10:00 [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "427.31", "492.8", "342.91", "784.3", "V45.01", "428.32", "434.11", "V45.82", "428.0", "401.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "99.10", "96.6" ]

icd9pcs

[ [ [] ] ]

14407, 14477

9237, 11998

346, 369

14635, 15457

3437, 7300

16161, 16730

2334, 2352

12545, 14384

14498, 14614

12024, 12522

15481, 16138

2367, 2595

3385, 3418

276, 308

397, 1498

2858, 3368

7310, 9214

2634, 2842

2619, 2619

1520, 1865

1881, 2318

23,761

111,184

10551

Discharge summary

report

Admission Date: [**2187-9-8**] Discharge Date: Date of Birth: [**2130-3-24**] Sex: F HISTORY OF PRESENT ILLNESS: The patient is a 57 year old morbidly obese female who has been immobile at home who presents to the Emergency Department with a five day history of shortness of breath. At home she had been on 4 liters of increasing amount of oxygen secondary to shortness of breath. She denies any fevers, chills, cough or chest pain. She does admit to some diarrhea at home. In the Emergency Department she became grossly more short of breath. She was given nebulizer treatment and nasal cannula was increased to 10 liters. The arterial blood gases was 7.28, 82, and 42. Her baseline carbon dioxide from [**2187-3-15**] is 48. Because Department. PAST MEDICAL HISTORY: 1. Congestive heart failure with normal left ventricular ejection fraction. 2. Cardiomyopathy. 3. COR pulmonale. 4. Osteoarthritis. 5. Rheumatoid arthritis. 6. Hypertension. 7. Peptic ulcer disease. 8. Chronic obstructive pulmonary disease. 9. Obesity. 10. History of acute renal failure. MEDICATIONS: 1. Combivent 2 puffs four times a day 2. Lasix 100 mg q.d. 3. Vioxx 25 mg q.d. 4. Aspirin 325 mg q.d. 5. Prozac 20 mg q.d. 6. Trazodone 50 mg q.h.s. 7. Detrol 5 mg b.i.d. 8. Milk of magnesia 38 ml prn 9. Prevacid 30 mg b.i.d. 10. Iron 325 mg t.i.d. 11. Lovenox 12. 25 mg every Tuesday and Saturday 13. Plaquenil 200 mg q.d. 14. Ambien prn 15. Neurontin 30 mg q.h.s. 16. Elocon 80 mg b.i.d. 17. Glucosamine 100 mg q.d. 18. Triple antibiotic cream to buttocks ALLERGIES: Demerol and cashew nuts, to the nuts she develops an anaphylactic reaction. FAMILY HISTORY: Father died of an myocardial infarction. SOCIAL HISTORY: The patient lives with friend. She has 72 pack year history of smoking. She denies any alcohol use. PHYSICAL EXAMINATION: In the Emergency Department temperature was 96.5, heartrate 68, blood pressure 90/44, respiratory rate 18, 90% oxygen saturation. In general the patient is an obese female who was intubated. Head, eyes, ears, nose and throat: Pupils are equal, round, and reactive to light and accommodation. Neck was supple. Chest with bilateral wheezes diffusely. Cardiac: Distant heartsounds, S1 and S2 normal. Abdomen soft, nontender, nondistended with positive bowel sounds. LABORATORY DATA: On admission white count was 8.7, hematocrit 30.4, platelets 183. Neutrophils 79.9, 0 bands, PT 14.3, INR 1.3, PTT 30.6, sodium 135, potassium 5.8, chloride 93, bicarbonate 24, BUN 78, creatinine 2.1, glucose 96. Chest x-ray showed several opacities in the right lung base. Electrocardiogram showed normal sinus rhythm and old right bundle branch block. There were no ST or T wave changes. HOSPITAL COURSE: 1. Pulmonary - The patient had been intubated on initial settings of title volume 100, positive end-expiratory pressure 5, respiratory set at 14 and FIO2 of 50%. Periodic arterial blood gases were taken. The patient was started on Solu-Medrol and then converted to Prednisone, starting at 30 mg q.d. She was also given nebulizer treatment with Albuterol and Atrovent. Because of the chest x-ray she was also started on Levofloxacin 500 mg intravenously q.d. She had lower extremity ultrasound done. It was negative for deep vein thrombosis. She was started on pressor support. She had apnea, however, she was able to spontaneous about every q. 12 seconds. She gradually improved in her respirations. On [**9-21**], the patient was extubated. She was able to maintain decent oxygenation on shovel mask. She was transferred to the floor on [**9-22**], where she was placed on nasal cannula and was able to tolerate it. She was continued on her nebulizer treatments and her puffs of Serevent and Atrovent. She was also started on Flovent. Her Prednisone was started to taper from 30 to 20 mg. 2. Infectious disease - The patient was noted to have pneumonia, based on chest x-ray as a finding. Sputum for sent for culture and Gram stain and came back positive for Methicillin-resistant Staphylococcus aureus. She was started on Vancomycin along with the Levaquin. Eventually the Vancomycin was continued for a total of 14 days. Her urine was positive for Enterococcus. Because it was sensitive to Vancomycin, she was not started on any other antibiotics. She also had a rash on her gluteal region. She had initially been given triple antibiotic ointment, however, Nystatin was then added. Her lesions then became clear for vesicular eruptions. She was then started on Acyclovir 800 mg p.o. five times a day for a total of ten days planned. She has diarrhea, however, all Clostridium difficile screens were negative. 3. Renal - Her initial creatinine was elevated, however, with hydration her creatinine came down towards baseline. 4. Gastrointestinal - The patient had developed diarrhea. She also had Clostridium difficile screen sent, which all returned negative. She had been started on tube feedings when the diarrhea had developed. The diarrhea was felt secondary to these tube feedings. The tube feedings were stopped, and she had improved bowel movements. They decreased in frequency and watery quality. CONDITION ON DISCHARGE: The patient will be going to rehabilitation center to become more functional. DISCHARGE STATUS: Stable. DIAGNOSES: Chronic obstructive pulmonary disease exacerbation MRSA Pneumonia Shingles Prerenal Azotemia DISCHARGE MEDICATIONS: 1. Acyclovir 800 mg p.o. five times a day for ten days 2. Prednisone 20 mg p.o. q.d. for a total of five days and then a 10 mg p.o. q.d. for another five days 3. Flovent 6 to 8 puffs b.i.d. 4. Serevent 2 puffs b.i.d. 5. Atrovent 2 puffs q.i.d. 6. Aspirin 325 mg p.o. q.d. 7. Prozac 20 mg p.o. q.d. 8. Imipenem 300 mg p.o. q.d. 9. Plaquenil 20 mg p.o. q.d. 10. Protonix 30 mg p.o. q.d. 11. 25 mg subcutaneously two times a week 12. Furosemide 12 mg p.o. q.d. 13. Iron Sulfate 325 mg p.o. t.i.d. 14. Heparin 700 units subcutaneously b.i.d. 15. Albuterol 2 puffs every 4 hours as needed for dyspnea [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Name8 (MD) 4523**] MEDQUIST36 D: [**2187-9-25**] 16:49 T: [**2187-9-25**] 18:03 JOB#: [**Job Number 34721**] cc:[**Hospital3 34722**]

[ "787.91", "401.9", "041.04", "491.21", "425.4", "599.0", "482.41", "V09.0", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.72" ]

icd9pcs

[ [ [] ] ]

1687, 1729

5476, 6362

2774, 5216

1872, 2757

133, 774

796, 1670

1746, 1849

5241, 5453

18,673

192,967

26386

Discharge summary

report

Admission Date: [**2131-12-28**] Discharge Date: [**2132-1-2**] Date of Birth: [**2058-10-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4365**] Chief Complaint: altered mental status and dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 65259**] is a 72 yo female with HTN, DM2, COPD, CHF EF 40%, CAD s/p cabg [**19**], schizophrenia who presents with SOB, orthopnea, LE edema, headache/neck pain and some confusion. History is obtained from her daughter. [**Name (NI) **] daughter lives close by to her mother. [**Name (NI) **] usually have lifeline to call her daughter. [**Name (NI) **] has been calling her daughter more frequently in the last few days with neck/head pain and the daughter decided to stay overnight during the last three days. Patient has chronic shortness of breath but complained more frequently in the last few days. She has been trying to sleep vertically in the last three days but her daughter does not know how her mother usually sleeps prior to this episode. Patient was slightly weak. Her lasix was increased to 120 mg from 80 mg 5 days ago by her primary care doctor for increased bilatral lower extremity edema and shortness of breath. Patient has chronic neck and head pain due to cervical DJD changes. Denies any fever, chills, nightsweats, chest pain, palpiations, abdominal pain, diarrhea, constipation, dysuria, hematuria, focal numbness, weakness. . In the ED vitals were T 98.8 HR 89 BP 102/55 RR 25 86% ? RA to 99% NRB 100%. ABG showed 7.37/78/62. Patient received solumedrol 125 IV once, furosemide 60 mg IV once and lovenox 80 mg IV once. . On arrival to the MICU patient was comfortable on BiPAP with vitals of T 98.4 HR 69 BP 128/61 RR 19 91% on FiO2 35% with [**11-4**]. Patient was able to follow commands. . Past Medical History: 1. CAD: s/p 4-vessel CABG [**2119**] 2. CHF: ECHO [**1-4**] w/ 1+ MR, minimal AS, EF 40% w/ regional wall motion abnormalities 3. DM Type 2 4. HTN 5. COPD: on home O2 3.5L/m, BIPAP (settings 14/10) with multiple past admissions w/ pCO2 in the 70-80 range 6. Schizophrenia: initially symptomatic w/ paranoia and hallucinations, well controlled w/ meds 7. L3 fracture: [**2127**] 8. Symptomatic VT: s/p ICD in [**1-3**] 9. Hypothyroidism Social History: Lives alone in [**Hospital3 **] apartment; has home health aide daily; meals are prepared by the pt's daughter; walks independently but sometimes uses walker; uses home O2 and BiPAP at night; smoked 60 pack-years but quit in [**2123**]; no alcohol, IVDU, or cocaine use. Her daughter is lives near by and is involved in her care. Family History: mother died of MI at unknown age Physical Exam: Vitals: T 98.4 HR 69 BP 128/61 RR 19 91% on FiO2 35% with [**11-4**]. General: NAD, sleepy, opens eyes to verbal stimuli, Farsi-speaking only HEENT: NCAT, anicteric, chronic left sided droop per ED team who have taken care of her in the past, no injections, OP clear, MMM Neck: no LAD, supple, no jvd Heart: RRR no m/r/g Lungs: coarse diffuse inspiratory breath sounds on BiPAP, no crackles or wheezes. Abd: mildly distended, +BS, NT, soft, no mass or organomegaly. Ext: trace edema Neuro: moving all extremities spontaneously, finger grip and plantar flexion [**6-4**] bilaterally, normal muscle tone. Psych: sleepy but following commands, oriented to self and hospital, not date (baseline per daughter) Skin: no rashes Pertinent Results: [**2131-12-28**] 03:30PM BLOOD WBC-6.4 RBC-3.64* Hgb-11.1* Hct-31.8* MCV-87 MCH-30.6 MCHC-34.9 RDW-15.6* Plt Ct-209 [**2131-12-28**] 03:30PM BLOOD Neuts-77.8* Lymphs-14.5* Monos-5.4 Eos-1.8 Baso-0.4 [**2131-12-28**] 03:30PM BLOOD PT-12.5 PTT-22.9 INR(PT)-1.1 [**2131-12-28**] 03:30PM BLOOD Plt Ct-209 [**2131-12-28**] 03:30PM BLOOD Glucose-291* UreaN-30* Creat-1.2* Na-142 K-3.4 Cl-91* HCO3-43* AnGap-11 [**2131-12-28**] 03:20PM BLOOD cTropnT-<0.01 [**2131-12-28**] 03:30PM BLOOD CK-MB-NotDone proBNP-487* [**2131-12-30**] 01:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2131-12-28**] 03:30PM BLOOD Albumin-4.2 Calcium-10.1 Phos-3.7 Mg-1.6 [**2132-1-1**] 05:35AM BLOOD TSH-2.3 [**2131-12-28**] 04:16PM BLOOD Type-ART Rates-/25 pO2-62* pCO2-78* pH-7.37 calTCO2-47* Base XS-14 Intubat-NOT INTUBA Vent-SPONTANEOU EKG [**12-28**] - Rhythm is most likely sinus rhythm with frequent atrial premature beats. Diffuse ST-T wave changes which are non-specific. Compared to the previous tracing of [**2131-10-27**] there is no significant diagnostic change. Chest x-ray [**12-28**] - No significant change since the prior examination. Appearances are suggestive of mild CHF. Followup radiography is recommended post-diuresis. Chest x-ray [**12-31**] - IMPRESSION: Subsegmental atelectasis Brief Hospital Course: # Dyspnea: Complicated picture likely multifactorial. Patient not taking BiPAP at home, also patient with upper respiratory symptoms and sounds congested on exam. Initially concern for COPD exacerbation in the MICU and recieved 1 dose of prednisone but this was stopped. Also with chest x-ray there is some suggestion of mild CHF and patient has gotten one time doses of diuresis. Of note, patient also requires home oxygen and BiPAP at night, but known not compliant with BiPAP which likely was a contributing factor to this exacerbation. Pt was at her baseline CO2 on ABG. PE was initially on the differential and in the MICU they got a d-dimer which was elevated however no additional studies were completed afterwards as apparently patient was unable to tolerate CTA and there was felt to be low likely of PE. CXR demonstrated no active infection and no leukocytosis on admission. Received lovonex 125 mg IV once in ED. On transfer to the floor, patient was restarted on home lasix dose of 80 mg PO daily, as patient with stable creatinine. repeat chest x-ray demonstrated no evidence of chf or infiltrate and mild bilateral atelectasis. Patient was continued on BiPAP at night and setting were adjusted as per respiratory therapy to optimize patient's oxygentation. Patient was continued on home COPD medications as well as standing nebulizers and PRN. On discharge patient with stable oxygen requirement and appears at baseline level of comfort . # Altered mental status: Unclear what initial presentation was in the MICU but on transfer to the floor, orientation at baseline. Initial change in mental status may be secondary to hypercarbia in the setting of BiPAP non-compliance and multiple medications including oxycodone. Oxycodone was discontinued . No white count or fever to suggest infection. Recieved small dose of narcan. Ucx negative and blood cultures no growth to date. Avoided sedating medications for pain control. . # Neck pain: Pain is chronic and likely musculoskeletal vs. DJD changes. [**Month (only) 116**] have nerve impingement in the C2 region based on her pain. Normal strenth. CT C spine done on [**10-26**] as outpatient which showed degenerative changes and limited study due to cervical positioning in lateral film. Pt cannot have MRI of her C spine due to her ICD. For pain control patient was started on round the clock tylenol as well as a lidoderm patch. Patient noted to be somewhat somnolent on standing tramadol at 50 mg PO BID, so changed patient to 25 mg PO BID PRN with goal that nursing frequently observe patient for pain. This is obviously difficult given patient is Farsi speaking. Avoid narcotics. . #CAD: h/o CABG. No chest pain or EKG changes. Patient was continued on ASA, statin, Toprol XL. . # Chronic diastolic CHF: possible that patient with CHF exacerbation as discussed above. Patient was continued on home lasix, beta-blocker, statin. Given history of CHF patient was also started on a low dose lisinopril. . # DMII, controlled. While patient was in house, held home glyburide, continued insulin sliding scale. glyburide was started again on discharge. . #HTN: BP appears well controlled continued outpatient meds, added acei . # Hypothyroidism: Continued levothyroxine, tsh was normal . # Anemia: Currently stable in 30s. Patient has previously had work-up in [**2128**] which showed normal iron, tibc, transferrin. no evidence of acute bleed. would consider outpatient follow-up as per her PCP. [**Name10 (NameIs) **] should undergo routine colonscopy screening . # Schizophrenia: Patient was continued aripiprazole, depakote, and risperdal . # Prophylaxis: sc heparin, PPI, bowel regimen . CODE: Per daughter DNR/[**Name2 (NI) 835**], but has ICD in place and on. Medications on Admission: Risperdal 2 mg daily Atorvastatin 10 mg daily Advair 2 inh [**Hospital1 **] Tiotropium daily DuoNeb nebs [**Hospital1 **] ASA 81 mg daily Digoxin 125 mcg daily Medroxyprogesterone 10 mg daily Glyburide 5 mg daily Levothyroxine 125 mcg daily Phoslo 667 mg Metoprolol SR 25 mg daily Ablify 40 mg daily Furosemide 120 mg daily recently increased from 80mg on [**12-25**] Zoloft 75 mg daily Depakote ER 500 mg daily Oxycodone 5 mg Q6H Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 13. Advair Diskus Inhalation 14. Aripiprazole 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for agitation. 17. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 18. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED): please see inpatient sliding scale. 19. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day). 20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 21. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): please apply to posterior neck region daily. 22. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). 23. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 24. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 26. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO twice a day as needed for pain: please hold for sedation. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary: dyspnea altered mental status Secondary: CAD s/p 4 vessel CABG [**2119**] CHF: with noted improvement in EF on last echo to 55% DMII HTN COPD - on home O2 3.5L, BiPAP (14/10) Discharge Condition: Patient at baseline O2 requirement. CPAP settings: Nasal CPAP w/PSV (BIPAP) Inspiratory pressure: 16 cm/h2o Expiratory pressure: 12 cm/h2o Supp O2: 15 L/min Other setting: wean Fio2 to home settings 2-3lpm. Afebrile with stable vital signs. As per patient's daughters mental status appears at baseline. Patient is able to feed herself and to use a walker for ambulation. Patient eager to leave the hospital Discharge Instructions: You were admitted to the hospital with increasing shortness of breath which was likely multifactorial and related to your obstructive sleep apnea and not taking BiPAP at home and as well your chronic lung disease. Chest x-ray demonstrated no infiltrate to suggest pneumonia. We increased your BiPAP settings while you were in the hospital to get improved oxygention which should be continued on discharge. The settings are: Nasal CPAP w/PSV (BIPAP) Inspiratory pressure: 16 cm/h2o Expiratory pressure: 12 cm/h2o Supp O2: 15 L/min Other setting: wean Fio2 to home settings 2-3lpm. Also while you were in the hospital you were started on a medication called Lisinopril which is an ACE inhibitor and is helpful in patients with heart failure and high blood pressure to prevent furthur cardiac remodeling. You should continue to take this medication on discharge. In addition, we discontinued your oxycodone as this was felt to be contributing to your sleepiness and altered mental status on presentation. We started you on standing Tylenol, and a lidocaine patch which should be standing for your chronic neck pain. You were also started on low dose tramadol which should be given as needed for pain control. Please note that pain assessment will need to be made regularly as patient is Farsi speaking, but do not want to prescribe standing as it is sedating. Additionally because of constipation we added some additional stool softeners to your regimen which may help. You should continue to take these on discharge. In looking through your medications, we have discontinued your medroxyprogresterone as there is no formal indication for this right now. You can discuss this with your primary care physician as an outpatient. You should follow up with your primary care physician [**Name Initial (PRE) 30449**]. In addition, you should be routinely evaluated by a psychiatrist to assess your optimal pharmacologic management. Followup Instructions: Routine follow-up with your primary care physician as well as your psychiatrist. Primary care can be reached at ([**Telephone/Fax (1) 6301**]. Spoke with patient's daughter about this - apparently current psychiatrist is in the process of trying to find someone who can visit the patient at home. Daughter is very active in mother's care and invested in making this happen. Completed by:[**2132-1-2**]

[ "V45.02", "428.32", "276.4", "327.23", "723.1", "518.84", "V46.2", "414.00", "295.60", "401.9", "285.9", "496", "V45.81", "362.01", "244.9", "250.50", "428.0" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

11467, 11538

4868, 6335

351, 357

11776, 12187

3565, 4845

14170, 14575

2769, 2804

9093, 11444

11559, 11755

8637, 9070

12211, 14147

2819, 3546

277, 313

385, 1944

6350, 8611

1966, 2404

2420, 2753

50,385

126,109

48509

Discharge summary

report

Admission Date: [**2126-1-1**] Discharge Date: [**2126-1-2**] Date of Birth: [**2066-12-25**] Sex: M Service: MEDICINE Allergies: Amiodarone / Rythmol / Flecainide / Lisinopril / Simvastatin / Buspirone Attending:[**First Name3 (LF) 7333**] Chief Complaint: A-fribrillation Major Surgical or Invasive Procedure: Pulmonary vein isolation Pericardiocentisis History of Present Illness: 58M with a history of HTN, HLD, and depression who was diagnosed with Atrial fibrillation approximately 6 months ago with associated DOE who was electively admitted for a Pulmonary Vein Isolation complicated by hemopericardium. Atrial fibrillation was initially managed medically however he was intolerant to amiodarone, dronaderone, propafenone, and flecainade developing visual disturbances/nausea/fatigue. On the day of admission, he underwent PVI and developed a large pericardial effusion and hypotension with SBP 80 he was transiently on phenylepherine. A pericardial drain was placed and drained frank blood. His blood pressure stabilized, pressors were weaned, and drainage from pericardial drain decreased. He was transfered to the CCU with a pericardial drain in place, a left femoral venous sheath, and off pressors. . On arrival to the CCU, his VS were T:96.8 BP 127/62 P: 89 SaO2 99% RA, Pulsus 6mmHg. EKG showed NSR at 90, with no STE or STD. He complained of mild sharp non-radiating chest pain worst at the site of the drain, made worse by inhalation. Denied SOB, presyncope. Denied fevers/ chills. . Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: - CABG: no - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: Hypertension Hyperlipidemia Atrial fibrillation Depression/anxiety S/p carpal tunnel release right side 2 years ago S/p Sinus surgery Social History: - Tobacco history: [**5-17**] daily, started smoking 3 years ago. - ETOH: [**2-14**] glasses daily of wine, - Illicit drugs: Denies Married and lives with wife on [**Hospital3 **]. He is a dentist who is retired from his own practice and currently works several days a week in a community health clinic. Family History: - No family history of cardiomyopathies or sudden cardiac death; otherwise non-contributory. - Half brother: MI in his 50s and Afib - Mother: vascular dementia - Father: [**Name (NI) **] CA Physical Exam: on Admission VS: T:96.8 BP 127/62 P: 89 SaO2 99% RA, Pulsus 6mmHg. GENERAL: Middle aged male appearing comfortable. HEENT: PERRLA, non-icteric sclera. NECK: Supple with JVP of 6cm CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: CRABL, no rales, wheezes or rhonchi. CHEST: Pericardial drain in place with minimal sanguanous drainage from the site, 100cc sanguanous fluid in the bag. ABDOMINAL: Overweight, soft nontender, non distended. BS normoactive EXTREMITIES: No c/c/e. No femoral bruits. SKIN: Left femoral sheath in place PULSES: Right: Carotid 2+ Radial 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Radial 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: On Admission [**2126-1-1**] 05:25PM BLOOD WBC-9.1 RBC-2.82* Hgb-9.8* Hct-28.0* MCV-99* MCH-34.8* MCHC-35.1* RDW-15.0 Plt Ct-216 [**2126-1-1**] 05:25PM BLOOD PT-21.9* PTT-24.3 INR(PT)-2.1* [**2126-1-1**] 05:25PM BLOOD Glucose-103* UreaN-14 Creat-1.1 Na-140 K-4.6 Cl-109* HCO3-20* AnGap-16 [**2126-1-1**] 11:41AM BLOOD freeCa-1.12 . At Discharge: [**2126-1-2**] 06:41AM BLOOD WBC-11.3* RBC-2.92* Hgb-10.1* Hct-29.3* MCV-100* MCH-34.4* MCHC-34.3 RDW-15.0 Plt Ct-217 [**2126-1-2**] 06:41AM BLOOD PT-24.8* PTT-24.8 INR(PT)-2.4* [**2126-1-2**] 06:41AM BLOOD Glucose-136* UreaN-17 Creat-1.1 Na-137 K-4.6 Cl-106 HCO3-24 AnGap-12 [**2126-1-2**] 06:41AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.1 . . - MR [**First Name (Titles) **] [**Last Name (Titles) 17367**]/FX P/P CONTRAST Study Date of [**2125-12-17**] 1. Normal size and orientation of the pulmonary veins without MR evidence of anomalous pulmonary venous return or pulmonary vein stenosis. 2. Normal left ventricular cavity size with normal regional left ventricular systolic function. The LVEF was normal at 69%. 3. Normal right ventricular cavity size and systolic function. The RVEF was normal at 62%. 4. The indexed diameters of the ascending and descending thoracic aorta were normal and mildly enlarged, respectively. The main pulmonary artery diameter index was mildly enlarged. 5. Mild atrial enlargement. . ECHO [**2126-1-1**] Digital study was continued in same Echo Pacs folder as the initial EP lab study from 1 hr earlier.. This study starts at clip [**Clip Number (Radiology) **]. PERICARDIUM: Moderate pericardial effusion. Effusion circumferential. Conclusions There is a moderate sized pericardial effusion. The effusion appears circumferential. . After repositioning of pericardial drainage catheter: no residual pericardial effusion. . ECHO [**2126-1-2**] The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: No percardial effusion. Mild concentric left ventricular hypertrophy with preserved left ventricular function. Mildly dilated right ventricle with preserved function. Borderline pulmonary hypertension. Brief Hospital Course: ASSESSMENT AND PLAN A 59 yoM with PMH Atrial fibrillation admitted for elective pulmonary vein isolation procedure complicated by hemopericardium. . # Hemopericardium: Following pulmonary vein isolation procedure, patient developed hypotension and was treated briefly with pressors. Echo revealed pericardial effusion. A pericardial drain was placed which returned which returned 700cc sanguanous drainage prior to transfer from PACU. The patient was transfered to the CCU for further monitoring. On arrival, a pulsus paradoxus was checked which was 6mmHg and patient was normotensive. He complained of pain at the site of the drain and was treated with morphine with fair control of pain. On HD2, the pericardial drain was discontinued and repeat ECHO showed no pericardial effusion. He was discharged home with a plan for outpatient follow up with Dr. [**Last Name (STitle) **] who performed the pulmonary vein isolation. He was given prescriptions for Indomethicin 25mg TID x 1 week, Omeprazole 20mg daily x 1 month. . # Atrial fibrillation: Patient was admitted for pulmonary vein isolation procedure. The procedure was complicated by hemopericardium requiring drain placement. Throughout the remainder of his hospital stay, he remained in sinus rhythm. His home dose of atenolol was decreased to 25mg Daily. . # Hypertension: Continued home dose of losartan 25mg Daily . # Hyperlipidemia: Continued Gemfibrozil 600 mg [**Hospital1 **] and Niacin 3000mg daily, patient to resume red yeast extract on discharge home. . # Chronic lower back pain. Patient reports long standing lower back pain made worse by inactivity. Continued Amitriptyline 10 mg daily . CODE: Full . COMM: Wife [**Name (NI) **] [**Telephone/Fax (1) 102106**] Medications on Admission: Losartan 25 mg daliy Atenolol 100 mg daily Aspirin 325mg daily Warfarin 7.5 mg 6 days per week, 5mg Warfarin 5 mg on Sundays Amitriptyline 10 mg daily Gemfibrozil 600 mg [**Hospital1 **] Niacin 3000mg daily Cyanocobalamin Garlic Magnesium oxide 400mg daily Multivitamin daily Omega 3 fatty acids 800 mg twice daily Red yeast rice extract 1200mg daily Discharge Medications: 1. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atenolol 25 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. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO 6X/WEEK (MO,TU,WE,TH,FR,SA). 5. warfarin 5 mg Tablet Sig: One (1) Tablet PO 1X/WEEK ([**Doctor First Name **]). 6. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. niacin 500 mg Capsule, Sustained Release Sig: Six (6) Capsule, Sustained Release PO DAILY (Daily). 9. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 30 days. Disp:*90 Capsule(s)* Refills:*0* 11. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day for 30 days. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Atrial fibrillation Pericardial effusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 18**] for pulmonary vein isolation for treatment of atrial fibrillation. After the procedure, you had accumulation of fluid in the sack around your heart. A drain was placed then pulled and the fluid did not reaccumulate. You were monitored in the hospital overnight. MEDICATION CHANGES: Continue Coumadin DECREASE Atenolol to 25mg daily from 100mg daily START Indomethacin for pain START Omeprazole for GI protection while taking indomethacin Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in two weeks on [**Location (un) **].

[ "724.2", "338.29", "423.3", "272.4", "423.0", "E879.0", "997.1", "300.4", "V58.61", "401.9", "427.31" ]

icd9cm

[ [ [] ] ]

[ "37.34", "37.0" ]

icd9pcs

[ [ [] ] ]

9010, 9016

5848, 7584

348, 393

9120, 9120

3125, 3456

9778, 9871

2224, 2418

7985, 8987

9037, 9037

7610, 7962

9271, 9577

2433, 3106

1650, 1715

3470, 5825

9597, 9755

293, 310

421, 1540

9056, 9099

9135, 9247

1746, 1882

1562, 1630

1898, 2208

74,440

167,404

4141

Discharge summary

report

Admission Date: [**2134-11-15**] Discharge Date: [**2134-11-17**] Date of Birth: [**2078-10-4**] Sex: M Service: MEDICINE Allergies: Decadron / Shellfish Derived / Coconut Flavor Attending:[**First Name3 (LF) 8388**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: [**11-15**]- EGD History of Present Illness: 56 year old male with a history of hepC cirrhosis, pancytopenia, presents w/ BRBPR this am and epistaxis. One week ago, he developed fevers, chills, myalgias and a cough. Two days ago, he developed some crampy left-sided abdominal pain. He had nausea and dry heaves, but no emeisis or constipation. His flu symptoms were improving. Yesterday, when he was going to the bathroom, he found bloody stool in the toilet. He also has had 2 episodes of nosebleeding, including this AM. He gets these episodes every few weeks. . In the ED, initial VS: 98.3 92 146/74 18 97. Rectal exam with bloody mucous, not gross. No current nose bleeding. Plt 33. He remained HD stable and was 90 137/68 prior to transfer. He got a FS of 68 got [**12-18**] amp D50. He was started on protonix plus gtt, octreatide, and ceftriaxone. He was given NAC vs. placebo per a research protocol and morphine per pan. He was seen by GI who deferred scoping until admitted to the ICU and holding on CT scan until after EGD. He did not get fluid or blood products. He had a CT scan en route. . Currently, he is confortable except for some mild abdominal pain. He denies further bleeding. . ROS: Denies headache, vision changes, rhinorrhea, congestion, sore throat, shortness of breath, chest pain, dysuria, hematuria. Past Medical History: Diabetes II - most recent A1C 6.7% [**2133-3-17**]. Hep C cirrhosis, followed by [**Doctor Last Name **] Bipolar disease Asthma Social History: Denies alcohol and tobacco use. Lives with his wife and children. He is currently unemployed. Denies IVDU. Family History: Sister with chronic pancreatitis Physical Exam: VS- T: 96.8 BP 156/89 HR 80 RR 18 SaO2 97% RA GENERAL: pleasant gentleman in NAD, conversant, comfortable. HEENT: Dry mucous membranes. Nares without visible blood or clot. Anicteric sclera. EOMI, PERRLA SKIN: No palmar erythema or spider angiomas noted. CARDIAC: RRR nl S1, S2, no murmurs appreciated LUNG: clear to auscultation bilaterally ABDOMEN: Soft, obese, minimal LUQ tenderness. Normoactive bowel sounds. No rebound or guarding. No fluid wave appreciated. EXT: WWP, no edema, 1+ DP pulses. NEURO: No asterixis noted. alert and oriented x3 Pertinent Results: repeat plt 27; HCT 30.9 Lactate:1.1; pH:7.39 [**Age over 90 **] |111 |14 -------------< 125 4.0 | 23 |0.9 Mg: 1.8 ALT: 42 AP: 59 Tbili: 1.9 AST: 57 LDH: 255 MCV 88 10.1 1.4 >-------< 29 28.8 N:63.7 L:25.4 M:8.1 E:2.1 Bas:0.5 PT: 16.5 PTT: 36.6 INR: 1.5 . STUDIES: . EGD ([**11-15**]): Scar present lower third of the esophagus at site of obliterated varices. No varices noted. Erythema, congestion, abnormal vascularity and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy. Erosions in the stomach body and antrum. Otherwise normal EGD to second part of the duodenum . CT SCAN ([**11-15**]): (prelim) cirrhosis, splenomegaly, varices. small hypodense liver lesions, too small to characterize, close f/u recommended. no evidence of diverticulitis. Called by ED with report of: swelling around [**Female First Name (un) 899**] c/w vasculitis worse than prior. . MRI Abdomen ([**10-23**]): No evidence of hepatoma. Cirrhotic liver with evidence of portal hypertension. Marked splenomegaly Brief Hospital Course: Mr. [**Known lastname 9935**] is a 56 year-old gentleman w/ HCV cirrhosis complicated by recurrent varices s/p banding and thrombocytopenia who presented with bright red blood per rectum in the setting of 2 episodes of epistaxis. Due to his history of esophageal varices, he was initially admitted to the ICU given concern for variceal bleed. 1. GI BLEED- Patient was hemodynamically stable throughout hospital course and did not require transfusion of blood products. He had upper endoscopy while in the ICU which showed no evidence of variceal bleed, but showed portal hypertensive gastropathy and erosions in the stomach body and antrum. There was no definitive source of upper GI bleeding found. Since his hematocrit was stable and there were no further episodes of bleeding, he was discharged with close GI follow-up. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 732**] from Dr.[**Name (NI) 6670**] office was notified of his admission and will set up closer follow-up and discussion on whether colonoscopy would be beneficial to identify possible lower source of GI bleed such as hemorrhoids. Of note, patient's last colonoscopy was in [**2131**] and was normal. 2. LUQ ABDOMINAL PAIN- The patient describes a vague LUQ abdominal pain similar to what he has experienced on and off in the past. Given a negative EGD, this most likely represents recurrent discomfort secondary to splenomegaly or perhaps due to vasculitis as evidenced by [**Female First Name (un) 899**] swelling on CT-he will plan to follow this up in outpatient clinic. Medications on Admission: Albuterol 90 mcg 1 neb inhaled via nebulizaiton once a day as needed for asthma Fluticasone 50 mcg [**12-18**] in each nostril twice a day as needed for allergies Fluticasone-Salmeterol 250 mcg-50 mcg/Dose 1 puff po twice daily Furosemide [Lasix] 40 mg by mouth once a day as needed for swelling Insulin Glargine 50 U twice a day am and pm Insulin Lispro [Humalog] 25 in AM, 20 at lunch, and 20 at supper Lactulose [Enulose] 30 cc by mouth daily Lisinopril 20 mg by mouth daily Lithium Carbonate 600 mg by mouth twice a day Omeprazole 20 mg by mouth twice a day (not taking) Oxycodone-Acetaminophen [Endocet] 5 mg-325 mg by mouth twice a day Quetiapine [Seroquel] 1200 mg by mouth q hs (dose confirmed) Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO once a day as needed for constipation. 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 5. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units Subcutaneous twice a day: take 50u in the morning and 50 u in the evening . 6. Humalog 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous w/ meals: take 25 units in the morning, 20 units w lunch and 20 with dinner. 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. Quetiapine 200 mg Tablet Sig: Six (6) Tablet PO HS (at bedtime). 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) spray Nasal twice a day as needed for allergy symptoms: [**12-18**] in each nostril twice a day as needed for allergies . 12. Lithium Carbonate 600 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY: GI bleed SECONDARY: HCV cirrhosis, esophageal varices Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: It was a pleasure being involved in your care, Mr. [**Known lastname 9935**]. You were admitted to the intensive care unit with bright red bloody bowel movements. Due to concern for variceal bleed, you underwent endoscopy which showed no active bleeding. You were discharged in stable condition with outpatient follow-up. Your medications have not changed. Please continue to take your current medications as indicated. Please call your physician [**Last Name (NamePattern4) **] 911 if you experience crushing chest pain, intractable nausea or vomiting, difficulty breathing, fevers/chills, large amounts of blood in your urine vomit or stool or any other concerning medical problem. Followup Instructions: ** PLEASE CALL [**First Name8 (NamePattern2) 8031**] [**Last Name (NamePattern1) **] AT DR.[**Doctor Last Name **] OFFICE [**Telephone/Fax (1) 463**] TO SCHEDULE AN EARLIER FOLLOW-UP APPOINTMENT!! 1. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10490**], [**MD Number(3) 13795**]:[**Telephone/Fax (1) 1690**] Date/Time:[**2134-12-2**] 9:00 2. GI [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2135-3-2**] 8:30 3. [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2135-3-2**] 8:30 Please make an appointment to see your primary care doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] MD at your earliest convenience for a post-hospitalization follow-up. Call [**Telephone/Fax (1) 18099**] to set up an appointment with him. Completed by:[**2134-11-18**]

[ "493.90", "571.5", "789.02", "456.1", "070.70", "537.89", "250.00", "296.80", "784.7", "578.9" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

7303, 7309

3626, 5190

317, 336

7416, 7416

2561, 3603

8271, 9137

1942, 1976

5946, 7280

7330, 7395

5216, 5923

7561, 8248

1991, 2542

269, 279

364, 1649

7430, 7537

1671, 1801

1817, 1926

70,500

149,725

39069

Discharge summary

report

Admission Date: [**2175-6-14**] Discharge Date: [**2175-6-21**] Service: MEDICINE Allergies: Erythromycin Base Attending:[**Name (NI) 9308**] Chief Complaint: SOB Major Surgical or Invasive Procedure: TEE cardioversion History of Present Illness: Mr. [**Known lastname 86608**] is a [**Age over 90 **] yoM with history of CAD, end stage CHF (LVEF 20%), atrial fibrillation, moderate atrial stenosis, CKD (baseline Cr 1.4), who developed acute shortness of breath at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] yesterday evening. He was recently admitted from [**Date range (1) 31153**]/10 for similar symptoms due to CHF exacerbation, and had an admission earlier in [**Month (only) 116**] to the [**Hospital1 882**] for similar symptoms complicated by hypotension requiring pressors. . When he developed his SOB last night, he was given a nebulizer treatment which did not help and EMS was called. The patient thinks he was in bed when it happened but is not certain; he said he had been feeling well throughout the day. O2 sat was 85% on RA per EMS, though there is no paperwork from EMS in chart. On arrival to the ED, he was found to have rales throughout with CXR showing diffuse pulm edema with small b/l effusions. He was given lasix 80 mg IV and was started on BIPAP 10/5/100% O2, which improved his O2 sats to 90's with RR in the 20's. ABG on current settings showed on the BIPAP showed 7.45/35/506. He was also started on nitro drip for HTN/CHF (not for chest pain, which patient denies). Received 325 mg ASA. Trop 0.03. In the ED prior to transfer, VS were 97.9, 1222 AFib, 107/75, RR 28, 100% O2 sat on BIPAP PS 10/5 PEEP with 100% O2. Past Medical History: 1. CARDIAC RISK FACTORS: - Dyslipidemia - History of Hypertension 2. CARDIAC HISTORY: - systolic heart failure (LVEF 20%) - Coronary artery disease - Atrial fibrillation on coumadin - moderate aortic stenosis ([**Location (un) 109**] 1.1 on echo [**2175-6-3**]) - moderate to severe mitral regurgitation (3+ on echo [**2175-6-3**]) 3. OTHER PAST MEDICAL HISTORY: - Peripheral Vascular disease - Chronic renal insufficiency (present creatinine 1.8) - H/o recent gastrointestinal bleed - Peptic ulcer disease - Benign prostatic hypertrophy - Glaucoma - Restless legs syndrome - Vitamin D deficiency - Osteoporosis - Dupuytren contracture - Cholecystectomy Social History: -Lives independently at house [**Location (un) 6409**] w/ VNA -Regular visits from only son [**Name (NI) 382**] and grandson -Widowed for past 17 years -Tobacco history: lifelong non-smoker -ETOH: No-ETOH -Illicit drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS in the ED: 97.9, 1222 AFib, 107/75, RR 28, 100% O2 sat on BIPAP PS 10/5 PEEP with 100% O2 VS on arrival to the ICU: HR 110, RR 31, 93-96% on 2L, BP 95/68, afebrile, weight GENERAL: cachectic, elderly man, comfortable in bed, conversant peaking in shorter sentences HEENT: poor dentition, conjunctiva normal/non-icteric, no LA LUNGS: labored, moderate accessory muscle use, crackles throughout in all fields including anteriorly, no wheezes CARDIO: soft irregular heart sounds, no murmurs appreciated this morning (though prior papers indicate II/VI systolic murmur RUSB) ABD: soft, NTND, no HSM apreciated EXT: [**1-7**]+ [**Location (un) **], left > right, calves not TTP, distal pulses 1+ SKIN: no rashes; sacral decub per nursing NEURO: AA, Ox3, pleasant, conversant though SOB, appropriate speech, CN II- XII grossly in tact; gait deferred Pertinent Results: Admission labs: [**2175-6-14**] 04:55AM BLOOD WBC-11.1* RBC-5.01 Hgb-14.9 Hct-46.8 MCV-93 MCH-29.7 MCHC-31.8 RDW-14.9 Plt Ct-387 [**2175-6-14**] 04:55AM BLOOD PT-26.3* PTT-28.6 INR(PT)-2.5* [**2175-6-14**] 04:55AM BLOOD Glucose-218* UreaN-28* Creat-1.8* Na-136 K-5.9* Cl-97 HCO3-21* AnGap-24* [**2175-6-14**] 01:00PM BLOOD ALT-71* AST-95* LD(LDH)-231 CK(CPK)-24* AlkPhos-111 TotBili-0.5 [**2175-6-14**] 01:00PM BLOOD Albumin-3.1* Calcium-8.1* Phos-5.1* Mg-2.0 . Discharge labs: [**2175-6-19**] 04:10AM BLOOD WBC-8.4 RBC-4.02* Hgb-11.9* Hct-37.9* MCV-94 MCH-29.7 MCHC-31.5 RDW-15.6* Plt Ct-275 [**2175-6-19**] 04:10AM BLOOD PT-34.8* PTT-33.0 INR(PT)-3.6* [**2175-6-19**] 04:10AM BLOOD Glucose-106* UreaN-25* Creat-1.3* Na-142 K-4.3 Cl-107 HCO3-27 AnGap-12 [**2175-6-19**] 04:10AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.3 . [**2175-6-16**] 5:08 pm STOOL CONSISTENCY: NOT APPLICABLE **FINAL REPORT [**2175-6-17**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2175-6-17**]): REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], R.N. ON [**2175-6-17**] AT 0530. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). A positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). . [**2175-6-16**] CXR: IMPRESSION: 1. Interval decrease, but residual mild pulmonary edema. 2. Unchanged moderate bilateral pleural effusions. 3. No evidence of pneumonia. . [**2175-6-16**] Echo: The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis (LVEF = 25%). [Intrinsic function may be more depressed given the severity of mitral regurgitation.] The left ventricular apex is heavily trabeculated, but no masses or thrombi are seen. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets and supporting structures are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial pericardial effusion. IMPRESSION: Normal left ventricular cavity size with severe global hypokinesis c/w diffuse process (multivessel CAD, toxin, metabolic, etc.). Increased PCWP. Mild aortic stenosis. Moderate mitral regurgitation. Mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2175-6-3**], the severity of mitral regurgitation and the estimated PA systolic pressure are now reduced. Right ventricular free wall motion is improved. The other findings are similar. . [**2175-6-15**] TEE: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). Right ventricular chamber size is normal. with mild global free wall hypokinesis. There are simple atheroma in the ascending aorta, aortic arch, and descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Significant aortic stenosis is present (not quantified). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets do not fully coapt. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: No left atrial/appendage thrombus seen. Moderate-severe mitral regurgitation. Aortic stenosis present (not quantified). Severely depressed left ventricular function. . [**2175-6-14**] CXR: Moderate interstitial pulmonary edema with small bilateral pleural effusions, slightly worsened since [**2175-6-3**]. . Brief Hospital Course: Mr. [**Known lastname 86608**] is a [**Age over 90 **] yoM with systolic CHF (EF 20%) and frequent admission this spring for CHF exacerbations. He is admitted with SOB thought to be from volume overload/CHF exacerbation in setting of AFib, HTN and severe AS. . #. Acute on Chronic systolic Congestive Heart Failure: Secondary to atrial fibrillation with RVR and hypertensive episode. Patient received lasix 80 mg IV x 1 in ED and was started on BIPAP in the CCU. His symptoms improved with this. He was weaned from BIPAP overnight and transitioned to nasal cannula and treated with lasix prn. He was cardioverted successfully. Post cardioversion, patient became hypoxic and developed a leukocytosis. A CXR was consistent with an aspiration event and patient was treated with levo for 5 days and flagyl (see above). An echocardiogram showed severe LV hypokinesis and mild aortic stenosis. Into his hospitalization patient went back into atrial fibrillation but his oxygenation remained stable. His carvedilol was switched to metoprolol 12.5mg tid. Low dose lisinopril was started cautiously in the setting of aortic stenosis for afterload reduction. Lasix 10mg daily started prior to discharge. If patient becomes hypertensive (SBP> 140), please place Nitroglycerin patch to prevent another CHF episode. Also need to avoid any intravenous fluid for low BP unless pt is symptomatic. His systolic blood pressures have been 80-100 here with no symptoms. . #. HYPERTENSION: Throughout admission, his blood pressure ranged in 80s-low 100s and patient tolerated this well. His carvedilol was switched to metoprolol, and an ace-inhibitor was started. Please see above for treatment plan for low and high blood pressures. . #. Atrial Fibrillation: Patient was cardioverted after confirming on TEE the absence of clot. He went back into atrial fibrillation later into his admission. He was switched to metoprolol. His INR was high and coumadin has been held for 3 days. Today INR is 2.1, would restart coumadin at 1mg every other day and check INR every other day until stable. . #. CAD: Cont home aspirin 81 mg. High dose statin was switched to Simvastatin 20 mg. . #. Aspiration pneumonia: Patient with witnessed aspiration event, had elevated WBCs and became short of breath. He was treated with levo/flagyl. . #. C DIFF: Patient has a history of c diff and completed metronidazole course [**2175-6-11**]. Stool was negative initially on this admission, but in the setting of antibiotics patient developed c diff. Flagyl will continued for 3 week taper. . #. SACRAL DECUB: Daily wound changes and standing tylenol for pain. Pt also has a healing blister on his great right toe. . # Goals of Care: pt has been followed by the palliative care team here for help with code status and to determine goals of care. Pt is mostly alert and oriented but has deferred questions about care goals to his son, [**Name (NI) **]. Pt has stated at times that he doesn't want any more pills or treatment but has not decided about returning to the hospital if his condition worsens. [**Doctor Last Name **] is understandably upset about his father's condition and has had difficulty understanding his father's complicated condition. At this time, Pt is DNR/DNI. He would benefit greatly from a palliative care team to help him and his son with goals of care and to continue teaching about his medical condition. At this time, pt needs to be fed, encouraged to increase his PO intake (albumin 2.5) and needs two people to assist to the chair. It is very difficult to obtain blood for lab tests here. If this continues, may need to discuss stopping coumadin depending on wishes of pt and son. [**Name (NI) **] (son, [**Name (NI) 382**] [**Telephone/Fax (1) 86609**]. [**Name2 (NI) 86610**]ted length of rehabilitation stay is < 30 days. Medications on Admission: Warfarin 2 mg QD Alendronate 70 mg QWeek, Wed Cholecalciferol (Vitamin D3) 1000 unit QD Calcium Carbonate 500 mg TID Aspirin 81 mg Atorvastatin 80 mg QD Omeprazole 40 mg QD Multivitamin QD Nystatin 100,000 unit/g Cream [**Hospital1 **] to groin and rectal area Furosemide 40 mg Tablet QD Amiodarone 200 mg QD Carvedilol 3.125 mg [**Hospital1 **] Completed Mmetronidazole 500 mg TID on [**6-11**] for C diff Discharge Medications: 1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day): Goal heart rate 70's, please uptitrate as tolerated . 7. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): start on [**2175-6-21**]. 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 1 weeks: Give until [**2175-6-23**], then decrease to [**Hospital1 **]. 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks: Start on [**2175-6-24**] until [**2175-6-30**], then decrease to 500 mg daily. 10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks: from [**6-30**] until [**2175-7-7**], then d/c. 11. Nitroglycerin 0.1 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours) as needed for SBP > 140: Hold for SBP < 120. 12. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 13. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO three times a day: with meals. 14. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 15. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. 16. Lisinopril 2.5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Hols SBP < 80. 17. Coumadin 1 mg Tablet Sig: One (1) Tablet PO every other day. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: Primary Diagnosis: Atrial fibrillation Acute on chronic systolic heart failure . Secondary Diagnosis: CAD Mitral regurgitaiton Aortic stenosis CKD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted with shortness of breath. We removed fluid from your lungs with a medication called lasix. We felt that your heart rhythm could also be contributing to your shortness of breath and you were electrically cardioverted. Your heart rhythm did not normalize but we are controlling your heart rate with medications. . We have made the following changes to your medications: 1. Decrease Lasix to 10 mg daily 2. Discontinue alendronate 3. change Atorvastatin to Simvastatin 20 mg daily 4. Change Carvedilol to Metoprolol 25 mg TID 5. Start Lisinopril daily 6. Continue a very slow Metronidazole taper 7. STart nitroglyceerin patch to use for hypertensive episodes 8. Start senna if needed to prevent constipation. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Dry weight is 148 pounds on [**6-20**]. Followup Instructions: Primary Care: [**Last Name (LF) **],[**First Name3 (LF) 488**] M. Phone: [**Telephone/Fax (1) 80426**] Date/Time: [**2175-7-11**] at 1:00pm at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**] [**Hospital1 **] . Cardiology: Name: [**First Name8 (NamePattern2) 2563**] [**Last Name (NamePattern1) 2564**], NP Location: [**Hospital1 **] MEDICAL ASSOC - [**Location (un) 2277**] CARDIOLOGY DEPT Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2258**] When: [**Last Name (LF) 2974**], [**6-23**] at 9:10am . Podiatry: [**First Name4 (NamePattern1) 2127**] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 86611**] Date/Time: [**2175-7-4**] at 2:00 pm. [**Location 1268**] [**Hospital1 **]. Completed by:[**2175-6-23**]

[ "008.45", "424.1", "V58.66", "285.9", "414.01", "424.0", "333.94", "707.03", "V66.7", "365.9", "403.90", "428.23", "507.0", "272.4", "600.00", "414.8", "427.31", "733.00", "585.9", "428.0", "707.22" ]

icd9cm

[ [ [] ] ]

[ "99.61", "93.90" ]

icd9pcs

[ [ [] ] ]

14063, 14185

8033, 11862

222, 242

14376, 14376

3666, 3666

15420, 16229

2668, 2783

12320, 14040

14206, 14206

11888, 12297

14511, 14868

4144, 8010

2798, 3647

1820, 2071

14897, 15397

179, 184

270, 1709

14308, 14355

3682, 4128

14225, 14287

14391, 14487

2103, 2406

1731, 1799

2422, 2652

60,204

173,317

42183+58495

Discharge summary

report+addendum

Admission Date: [**2157-10-6**] Discharge Date: [**2157-10-11**] Service: MEDICINE Allergies: Penicillin V Attending:[**First Name3 (LF) 4095**] Chief Complaint: Fever, weakness Major Surgical or Invasive Procedure: ERCP Percutaneous transhepatic cholangiogram (PTC) and placement of a 10Fr internal-external biliary drain History of Present Illness: The patient is an 89-year-old male in overall good health at baseline. He presented to [**Hospital1 **] [**Location (un) 620**] [**10-5**] c/o weakness, fatigue and feeling cold for about 2-3 days. In the [**Location (un) 620**] ED he was febrile to 101.5. . Initial lab eval was noatable for leukopenia with a white blood cell count of 1.8 and ALT, AST (1800 and 1000 respctively) out of proportion to Alk phos and bilirubin. Given the leukopenia there was concern for babesisia, lyme, and ehrlichia and he was started on doxicycline and atovaquone. . The morning after admission he developed abdominal pain and further work-up was pursued with RUQ u/s which revealed mild gallbladder thickening. CT abdomen was obtained which revealed extensive gas throughout the bile ducts, a collapsed gallbladder, and concern for abcess formation with associated septic thrombophlebitis. Blood cultures grew out gram negative bacilli. The decision was made to transfer to [**Hospital1 **] [**Location (un) 86**] for further management and given gram negative bacteremia ICU admission was preferred. Past Medical History: IBS MI depression Hypertension, Hyperlipidemia prostate cancer in remission after chemotherapy and radiation Social History: Lives at [**Location (un) **]. Very active. Does not smoke. Drinks 1 drink of wine maybe every other day. Family History: No family history of liver disease Physical Exam: Admission Exam: Vitals: T:96.8 BP:130/72 P:74 R: 18 O2:97 General: Alert, oriented, no acute distress HEENT: Sclera mildly icteric, subglossus mildly icteric as well, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Distant Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: jaundiced skin, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, palpable non-tender liver edge on inspiration only GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge Exam: AVSS Abdomen with mild ruq tenderness at site of drain. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2157-10-10**] 06:15 6.5 3.71* 11.4* 33.1* 89 30.8 34.5 14.6 176 [**2157-10-9**] 06:57 6.8 3.65* 11.7* 33.1* 90 32.0 35.3* 13.7 165 [**2157-10-8**] 04:20 8.3 3.75* 12.0* 34.4* 92 32.0 34.8 13.9 146* [**2157-10-6**] 23:39 12.8* 4.03* 12.9* 37.2* 92 32.0 34.6 14.0 152 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2157-10-10**] 06:15 111*1 16 0.8 139 3.5 107 26 10 [**2157-10-9**] 06:57 791 16 0.9 139 3.5 105 25 13 [**2157-10-8**] 04:20 [**Telephone/Fax (2) 91477**] 3.6 106 24 13 ADDED ALK ALT AST BILI @ 1229 [**2157-10-6**] 23:39 [**Telephone/Fax (2) 91478**] 4.1 103 23 14 . ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2157-10-10**] 06:15 241* 122* 158 114 0.6 [**2157-10-9**] 06:57 321* 164* 150 124 0.8 [**2157-10-8**] 04:20 498* 320* 146* 1.1 ADDED ALK ALT AST BILI @ 1229 [**2157-10-6**] 23:39 791* 605* [**Telephone/Fax (1) 91479**]* 3.3* . OTHER ENZYMES & BILIRUBINS Lipase [**2157-10-10**] 06:15 781* [**2157-10-9**] 06:57 2513* [**2157-10-6**] 23:39 1048* . CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2157-10-10**] 06:15 7.6* 2.5* 2.0 [**2157-10-9**] 06:57 8.2* 3.1 2.1 [**2157-10-8**] 04:20 8.3* 3.6 2.1 ADDED ALK ALT AST BILI @ 1229 [**2157-10-6**] 23:39 3.4* 8.2* 3.6 2.3 . CPK ISOENZYMES CK-MB cTropnT [**2157-10-6**] 23:39 4 <0.011 Studies: . CXR ([**2157-10-5**], [**Location (un) 620**]): minimal subsegmental atelectasis, otherwise unremarkable Abd U/S ([**2157-10-5**], [**Location (un) 620**]): cholelithiasis, wall thickened 4mm in depth, no pericholecystic fluid, CBD 6mm wnL. CT abdomen ([**2157-10-6**], [**Location (un) 620**], prelim report): markedly abnormal appearance to liver and biliary tree, including extensive gas throughout dilated intra- and extrahepatic biliary bile ducts, relatively collapsed gallbladder, several low-attenuation foci with reactive hyperemia most prominently in segments 3, 7, 8, relatively [**Name2 (NI) 91480**] hepatic venous radicle while intrahepatic IVC and other branches appear opacified, which demonstrates likely secondary thrombophlebitis of this branch. Findings suspicious for ascending cholangitis with early abscess formation and secondary hepatic septic thrombophlebitis. . PTBD - (prelim) mild to mod intrahepatic biliary duct dilation, CBD tight, difficult to ascertain stone, stricture . ERCP (Attempted) . Date: Friday, [**2157-10-7**] Endoscopist(s): [**Name6 (MD) **] [**Name8 (MD) 19087**], MD [**First Name (Titles) **] [**Last Name (Titles) 91481**], MD (fellow) Patient: [**Known firstname **] [**Known lastname 1557**] Ref.Phys.: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Anesthesiologists: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Assisting Nurse(s)/ Other Personnel: [**Name6 (MD) **] [**Name8 (MD) **], RN Birth Date: [**2067-12-8**] (89 years) Instrument: TJF-160VF ([**Numeric Identifier 91482**]) [**Numeric Identifier 91483**] Indications: A level 4 consult was performed 59 yr old male with fever and elevated LFT's with dilated intra & extra hepatic ducts with pneumobilia on CT Medications: Cetacaine Monitored care anesthesia 0.1 fl time 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 MAC anesthesia. The patient was placed in the prone position and an endoscope was introduced through the mouth and advanced under direct visualization until the duodenal bulb 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: Lumen: Severe stenosis was in the area of cricopharyngeus. The scope did not traverse the lesion. A forward viewing upper endoscope was used and could not traverse the area of narrowing. A pediatric upper endoscope was used and the scope traversed the area of narrowing. A Jag wire was introduced into duodenum and scope withdrawn over guidewire. Multiple attempts to pass side viewing scope over guide wire were unsuccessful. Procedure was aborted. Mucosa: Normal mucosa was noted. Stomach: Limited exam of the stomach was normal Mucosa: Normal mucosa was noted. Excavated Lesions A 1.5 cm ulcer was found in the duodenal bulb. Impression: Severe stenosis of the cricopharyngeus Normal mucosa in the stomach Normal mucosa in the esophagus Ulcer in the duodenal bulb Multiple attempts to pass ERCP scope were unsuccessful. Otherwise normal ercp to duodenal bulb Recommendations: Return to floor Start PPI [**Hospital1 **] Schedule percutaneous transhepatic biliary drainage (PTBD) Additional notes: The procedure was performed by Dr. [**Last Name (STitle) **] and the GI fellow. The patient's reconciled home medication list is appended to the hospital report FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. Specimens were taken for pathology as listed above. I supervised the acquisition and interpretation of the fluoroscopic images. The quality of the fluoroscopic images was good. Total flouro time: 0.1 minutes. Thank you Dr. [**Last Name (STitle) **] for allowing me to participate in the care of Mr. [**Known lastname 1557**]. _________________________________ _________________________________ [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD on [**2157-10-7**] 11:28:39 AM [**Name6 (MD) **] [**Name8 (MD) 91481**], MD (fellow) PROCEDURE: Percutaneous transhepatic biliary drainage. CLINICAL INDICATION: 89-year-old man with ascending cholangitis and acute pancreatitis. Unsuccessful ERCP attempt to cannulate common bile duct due to esophageal stricture. PHYSICIANS: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 4154**], the attending radiologist, performed the procedure. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45331**], fellow. Witnessed informed consent for the procedure was obtained from the patient's daughter after risks, benefits, and potential complications of the procedure had been discussed. The patient was placed on the angiographic table in supine position. The skin of the anterior and right lateral abdominal wall was prepped and draped in a sterile fashion. Timeout protocol was carried out prior to the procedure according to the [**Hospital 18**] Hospital policy. ANESTHESIA: General. Using 21-gauge Cook needle, diagonal passes through the liver were made under fluoroscopic visualization penetrating the capsule in the mid axillary line. Double needle stick technique was used with initial successful luminal opacification of the intrahepatic biliary duct. After successful ductal opacification, the second peripheral posterior segmental right hepatic lobe duct was cannulated using a second 21-gauge Cook needle. A 0.018 headliner hydrophilic guidewire was used to secure intraductal biliary ductal access. The 21-gauge Cook needle was exchanged for AccuStick system, which was advanced without resistance over a 0.018 headliner guidewire into the common bile duct. The inner sheath of the AccuStick system was then removed along with the headliner guidewire and 0.035 Bentson guidewire was advanced into the common bile duct and easily crossed across the ampulla into the duodenum. A placement of a 6 French sheath followed. A 5.0 French 40 cm long Kumpe catheter advanced through the sheath facilitated exchange of a 0.035 Bentson guidewire for a 0.035 Amplatz guidewire, which was advanced into the proximal jejunum. A 6 French sheath and Kumpe catheter were both removed and 8.0 French internal-external biliary drainage catheter was initially placed over the Amplatz guidewire. Cholangiogram through the 8 French catheter demonstrated sluggish flow across the ampulla through the catheter with stasis in the common bile duct and intrahepatic ducts. 8 French catheter was then removed over Amplatz guidewire and 10 French internal-external drainage catheter was placed. The pigtail loop was formed, and catheter was pulled into optimal position for efficient drainage. Cholangiogram through the 10 French catheter demonstrated good flow across the ampulla into the duodenum without stasis in the common bile duct. The catheter was connected to the bag for external drainage. Skin tract was anesthetized by 0.5% bupivacaine at the conclusion of the procedure to minimize tenderness in the skin tract for several hours. FINDINGS: 1. Percutaneous transhepatic cholangiogram demonstrated mild-moderate intrahepatic ductal dilatation, with a small amount of contrast passing through the ampulla. 2. As the access was difficult, a clear assessment of intraductal cholelithiasis could not be made on this study - the patient should return once once his acute course has resolved for a dedicated cholangiogram and associated intervention for any intraductal stones. 3. Successful placement of a 10Fr internal external right biliary drain. CONCLUSIONS: Successful right PTC and placement of a 10Fr internal-external biliary drain. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] DR. [**First Name8 (NamePattern2) 5650**] [**Name (STitle) **] Note Date: [**2157-10-7**] Signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2157-10-7**] at 2:21 am Affiliation: [**Hospital1 18**] Cosigned by [**Name (NI) **] [**Name8 (MD) **], MD on [**2157-10-8**] at 10:26 pm c/c: cholangitis HPI: 89[**Hospital **] transferred from [**Hospital **] [**Hospital3 628**] with concern for ascending cholangitis in association with suspected hepatic abscess formation and secondary hepatic septic thrombophlebitis on CT scan. Reportedly, presented to OSH on [**2157-10-5**] with weakness and generalized fatigue for approximately 2-3 days. On arrival, he was found to be febrile to 101.5F with leukopenia and elevated liver enzymes and bilirubin. Due to wbc of 1.8, he was started on doxycycline and atovaquone due to concern for tick-borne illness, as the patient walks everyday in park / wooded area. On HD 2, due to abdominal pain, he underwent RUQ ultrasound which demonstrated cholelithiasis and mild gallbladder thickening, although no pericholecystic fluid and non-dilated CBD. CT abdomen demonstrated pneumobilia, low-attenuation foci with reactive hyperemia in hepatic segments 3, 7, 8, and [**Month/Day/Year 91480**] hepatic venous radicle. Blood cultures (2/4 bottles) grew out gram negative bacilli, unidentified as of yet. He was initially given ceftriaxone and flagyl then switched to zosyn for suspected cholangitis. While in [**Location (un) 620**], he remained hemodynamically stable with low-grade temp and adequate urine output. He was seen by surgery (Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) and a decision was made to transfer to [**Hospital1 18**] in [**Location (un) 86**] for further evaluation and management. On arrival to [**Hospital Unit Name 153**], he was afebrile and hemodynamically stable, alert and oriented, and hungry. Denies night sweats, weight loss, headache, cough, shortness of breath, chest pain, chest pressure / palpitations, nausea / vomiting, diarrhea / constipation, abdominal pain, dysuria, or changes in bowel habits. PMH: HTN, hyperlipidemia, prostate cancer (in remission) s/p chemo/radiation, h/o acute hepatitis (received vaccination), arthritis, irritable bowel syndrome, BPH, DJD, CAD, h/o MI in [**2105**], ?esophageal narrowing PSH: s/p R inguinal hernia repair, cataract removal, cystoscopy Meds: ASA, Ca2+vitD, Fish Oil, Lipitor, Lisinopril, Ocuvite, Uroxatral, Rapiflo, Multivitamin All: PCN (rash), IV dye SocHx: lives at [**Location (un) **]. No tobacco. Drinks 1 glass wine every other day. No illicits. FamHx: no h/o liver disease Physical Exam: T 96.8 HR 74 BP 128/91 RR 16 96%RA Gen: NAD, A+Ox3 HEENT: NC/AT, non-icteric sclerae CV: RRR Pulm: clear to auscultation, bilaterally Abd: soft, NT, ND, no voluntary guarding Ext: wwp, no edema Labs: OSH ([**2157-10-5**]): wbc 1.8, hct 39.9, plt 184. N 80%, ANC 1400. na 135, k 4.3, cl 98, hco3 30, bun 17, cr 1.1 alt 1018, ast 1820, ap 218, tbili 1.75, lipase 129 ptt 25.9, inr 1.1 Blood Cx: GNR (2/4 bottles within 12h) Peripheral smear negative for malaria, babesia, anaplasma/ehrlichia Monospot negative Rapid influenza A/B negative OSH ([**2157-10-6**]): alt 993, ast 944, ap 195, tbili 3.11, dbili 2.52 [**Hospital1 18**] ([**2157-10-6**]): wbc 12.8, hct 37.2, plt 152. N 87% na 136, k 4.1, cl 103, hco3 23, bun 16, cr 1.1, glucose 83 alt 791, ast 605, ap 172, tbili 3.3 PT 14.5, PTT 39.1, INR 1.3 Trop <0.01 Imaging: CXR ([**2157-10-5**], [**Location (un) 620**]): minimal subsegmental atelectasis, otherwise unremarkable Abd U/S ([**2157-10-5**], [**Location (un) 620**]): cholelithiasis, wall thickened 4mm in depth, no pericholecystic fluid, CBD 6mm wnL. CT abdomen ([**2157-10-6**], [**Location (un) 620**], prelim report): markedly abnormal appearance to liver and biliary tree, including extensive gas throughout dilated intra- and extrahepatic biliary bile ducts, relatively collapsed gallbladder, several low-attenuation foci with reactive hyperemia most prominently in segments 3, 7, 8, relatively [**Name2 (NI) 91480**] hepatic venous radicle while intrahepatic IVC and other branches appear opacified, which demonstrates likely secondary thrombophlebitis of this branch. Findings suspicious for ascending cholangitis with early abscess formation and secondary hepatic septic thrombophlebitis. A/P: 89yoM with HTN, hyperlipidemia, and h/o prostate cancer, now transferred from [**Hospital1 **] [**Location (un) 620**] with suspected ascending cholangitis and CT findings concerning for early liver abscess formation with secondary hepatic septic thrombophlebitis. We recommend NPO/IVF, continuation of IV antibiotics, f/u blood culture results, f/u final read OSH CT, serial abdominal exams, and ERCP consult. Plan discussed with Dr [**Last Name (STitle) 26321**], chief resident, and Dr [**First Name (STitle) **], attending surgeon. Addendum by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD on [**2157-10-8**] at 10:26 pm: D/w me. I had already seen pt at [**Location (un) 620**] earlier. Agree with plan for ERCP, concern for cholangitis given imaging findings and labs, despite no abdominal tenderness on exam. Will need to hold on a/c for now given upcoming procedure. .Note Date: [**2157-10-10**] Signed by [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2157-10-10**] at 10:25 am Affiliation: [**Hospital1 18**] BEDSIDE SWALLOWING EVALUATION: HISTORY: Thank you for referring this 89 y/o male with h/o multiple medical problems including prostate cancer s/p chemo/XRT, HTN, hyperlipidemia, IBS, CAD s/p MI in [**2105**], and depression who was transferred to [**Hospital1 18**] from [**Hospital1 **] [**Location (un) 620**] with gram negative bacteremia and possible cholangitis versus peri-cholecystic abscess. Pt underwent endoscopy which revealed severe stenosis of the cricopharyngeus. Due to this finding we were consulted to evaluate oral and pharyngeal swallowing function. Pt reported that he has been aware of an esophageal narrowing for the past 3-4 years. He stated that he has "rare" episodes where taking a large pill or bite of tough meat that is not chewed thoroughly will result in "regurgitation" of material. He stated that he is currently able to tolerate all of his home medications without difficulty and he simply chews his calcium supplement rather than swallowing it whole. He also reported that he chews his solid foods well and does not have regular difficulty. He stated that he has an appointment scheduled for [**Month (only) 1096**] to discuss further treatment of his stenosis with his outpatient providers. PMH: HTN, hyperlipidemia, prostate cancer (in remission) s/p chemo/radiation, h/o acute hepatitis (received vaccination), arthritis, irritable bowel syndrome, BPH, DJD, CAD, h/o MI in [**2105**], esophageal stenosis. EVALUATION: The examination was performed while the patient was seated upright in the chair on 5 [**Hospital Ward Name 1950**]. Cognition, language, speech, voice: Pt awake, alert, oriented x3, followed all commands and answered factual questions. Expressive language was fluent, speech clear, voice WFL. Teeth: Average condition. Secretions: Normal oral secretions. ORAL MOTOR EXAM: Symmetrical facial appearance. Tongue protruded midline with adequate strength and ROM. Labial retraction, rounding and seal were WFL. Symmetrical palatal elevation noted. Gag deferred. SWALLOWING ASSESSMENT: PO trials included thin liquid (consecutive), and bites of [**Location (un) **] cracker. Oral phase was WFL without anterior spill or oral residue. Swallow initiation was timely with adequate laryngeal elevation on palpation. No coughing, throat clearing, wet vocal quality, or O2 desats noted with PO intake. Pt denied sensation of aspiration or pharyngeal residue. SUMMARY / IMPRESSION: Mr. [**Known lastname 1557**] presented with a functional swallowing mechanism without overt s/sx of aspiration. He also denied sensation of pharyngeal residue or anything stuck in his throat or chest. He does have a known narrowing at the level of the cricopharyngeus which he reports has very little impact on his day to day swallowing function aside from needing to crush his large PO medications. He is safe to continue on a PO diet of thin liquids and regular consistency solids and has a plan to f/u with his outpatient providers for management of this issue. Please re-consult if we can be of further assistance with this pt's care. This swallowing pattern correlates to a Functional Oral Intake Scale (FOIS) rating of 7. RECOMMENDATIONS: 1. PO diet: thin liquids, regular consistency solids. 2. Small pills whole with water, large pills cut or crushed. 3. [**Hospital1 **] oral care. 4. Pt has an appointment to f/u with outpatient providers for management of esophageal issues. 5. Please re-consult if we can be of further assistance with this pt's care. These recommendations were shared with the patient, nurse and medical team. ____________________________________ [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 39767**], M.S., CCC-SLP Pager #[**Numeric Identifier 39768**] Face time: 0940-0950 Total time: 40 minutes Brief Hospital Course: 89 yo M with hx of HTN, CAT, prostate ca presented to OSH with [**12-30**] weakness and fatigue, rigors and fever and found to have cholangitis. ACTIVE ISSUES: # Ascending Cholangitis/Early Liver abscess/Secondary Hepatic Septic Thrombophlebitis: Pt presented after he was found to have transaminases in the 1000s and leukopenia and was initially started on treatment for possible Babesiosis. He then developed abdominal pain and The morning after admission he developed abdominal pain; RUQ u/s which revealed mild gallbladder thickening. CT abdomen was obtained which revealed extensive gas throughout the bile ducts, a collapsed gallbladder, and concern for abcess formation with associated septic thrombophlebitis. Blood cultures grew Klebsiella sensitive to ceftriaxone. He was then transferred to the ICU at [**Hospital1 18**]. Attempted ERCP was unsuccessful due to an stenosis at the level of the cricopharnyngeus. A percutaneous billiary drain was subsequently placed and the patient was transferred to the floor on [**10-8**]. Today his diet was advanced. The ERCP team was not sure if the cricopharyngeal narrowing was due to osteophytes vs other so I ordered a barium swallow for tomorrow for further eval. Bedside swallow study is also pending. IR recommends repeat cholangiogram later this week. The drain was capped today. Hepatobiliary surgery is also following. . # Klebsiella Septicemia: +Cx at OSH source likely biliary. Repeat blood cultures with NGTD. The pt was initiated on CTX and transitioned to PO Cefpodoxime. The pt to receive a total of 2 weeks. . # Acute Pancreatitis: Elevated lipase upon admission but remained clinically asymtomatic. Pt tolerated a normal diet. . # Duodenal ulcer: An incidental duodenal ulcer seen during ERCP. H. Pylori was negative. The pt was initiated on [**Hospital1 **] PPi with plan to lower dose as an outpatient. . INACTIVE ISSUES # Esophageal narrowing: Pt asymptomatic. Bedside swallow evaluation unrevealing. The pt will f/u as an outpatient. # CAD: Hx of MI in [**2105**]'s. The pt's ASA and statin were held in setting of procedures and elevated transaminases. . # Hyperlipidemia: Statin held in setting of transaminitis, recommend outpatient follow-up. . # BPH/urinary retention: Pt is on an experimental drug Rapiflow. This was held due to unavailablity. . TRANSITIONAL ISSUES: - Patient discharged to [**Location (un) **] rehab. - Direct verbal signout was provided to the patients PCP [**Last Name (NamePattern4) **] [**2157-10-11**] via phone. - Outstanding issues include repeat cholangiogram next, titration down of the patients PPi dosing and re-initiation of aspirin and statin as outpatient. Pt was breathing comforatbly at discharge but did become slightly overloaded while inpatient, which improved with lasix 10mg IVx1. -Patient, Daughter (HCP) [**Name (NI) **] [**Name (NI) 1557**] [**Telephone/Fax (1) 91484**] -Code: Full Medications on Admission: ASA 81 Calcium Carbonate with Vitamin D Fish Oil Lipitor 20 Lisinopril 5 MVI Ocuvite Uroxatral Rapiflo Discharge Medications: 1. cefpodoxime 100 mg Tablet Sig: Four (4) Tablet PO Q12H (every 12 hours) for 8 days. 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 30 days. 3. morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Uroxatral Oral 5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) **] - [**Location (un) 620**] Discharge Diagnosis: Primary Diagnosis - Ascending Cholangitis - Acute Pancreatitis - Liver abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred to [**Hospital1 18**] in the setting of fever and abdominal pain. You were initially brought to the ICU after being diagnoses with acute cholangitis and pancreatitis. You underwent an unsuccessful ERCP due to an obstruction in your esophagus and had a drain placed. You were placed on antibiotics. . Please continue to take all of your medications. The following changes have been made: 1) Cefpodoxime 400mg twice daily for 8 days 2) Pantopazole 40mg twice daily for 1 month, please follow this up with your pcp. 3) Morphine 15mg by mouth as needed for pain Followup Instructions: Interventional Radiology will call and schedule follow-up with you as an outpatient. . Following discharge from rehab, please follow-up with your PCP. Name: [**Known lastname 10**],[**Known firstname **] Unit No: [**Numeric Identifier 14377**] Admission Date: [**2157-10-6**] Discharge Date: [**2157-10-11**] Date of Birth: [**2067-12-8**] Sex: M Service: MEDICINE Allergies: Penicillin V / cefepime / contrast dye Attending:[**First Name3 (LF) 12673**] Addendum: ACTIVE ISSUES: # Ascending Cholangitis/Early Liver abscess/Secondary Hepatic Septic Thrombophlebitis: Pt presented after he was found to have transaminases in the 1000s and leukopenia and was initially started on treatment for possible Babesiosis. He then developed abdominal pain and The morning after admission he developed abdominal pain; RUQ u/s which revealed mild gallbladder thickening. CT abdomen was obtained which revealed extensive gas throughout the bile ducts, a collapsed gallbladder, and concern for abcess formation with associated septic thrombophlebitis. Blood cultures grew Klebsiella sensitive to ceftriaxone. He was then transferred to the ICU at [**Hospital1 8**]. Attempted ERCP was unsuccessful due to an stenosis at the level of the cricopharnyngeus. A percutaneous billiary drain was subsequently placed and the patient was transferred to the floor on [**10-8**]. Today his diet was advanced. The ERCP team was not sure if the cricopharyngeal narrowing was due to osteophytes vs other so I ordered a barium swallow for tomorrow for further eval. Bedside swallow study is also pending. IR recommends repeat cholangiogram later this week. The drain was capped today. Hepatobiliary surgery is also following. . Discharge Disposition: Extended Care Facility: [**Location (un) 4641**] - [**Location (un) 407**] [**First Name11 (Name Pattern1) 1937**] [**Last Name (NamePattern4) 12674**] MD [**MD Number(2) 12675**] Completed by:[**2158-3-18**]

[ "715.90", "788.21", "576.1", "444.89", "600.01", "V10.46", "412", "038.49", "576.8", "716.90", "V87.41", "532.90", "577.0", "401.9", "530.3", "574.20", "564.1", "451.89", "478.29", "572.0", "288.50", "414.01", "790.4", "V15.3", "272.4", "449" ]

icd9cm

[ [ [] ] ]

[ "51.10", "87.51", "51.98" ]

icd9pcs

[ [ [] ] ]

27768, 28008

21430, 21576

238, 347

25220, 25220

2534, 14786

25974, 26501

1749, 1785

24497, 25001

25118, 25199

24369, 24474

25371, 25951

14801, 21407

2458, 2515

23784, 24343

182, 200

26516, 27745

375, 1473

25235, 25347

1495, 1606

1622, 1733

27,907

152,068

31444+31445

Discharge summary

report+report

Admission Date: [**2180-6-28**] Discharge Date: [**2180-9-20**] Date of Birth: [**2180-6-28**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 5656**] [**Known lastname 805**], [**First Name3 (LF) 3947**] is a 992 gram product of a 27 5/7 weeks gestation pregnancy born to a 43-year-old G 3, P 0 woman. Prenatal screens: Blood type O-, antibody positive for anti-D antibody, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group beta strep status unknown. This was an in [**Last Name (un) 5153**] fertilization pregnancy and was uncomplicated until 1 week prior to delivery when the mother experienced spontaneous rupture of membranes. She was treated with Amp and erythromycin for multiple doses prior to the pregnancy. She was also treated with betamethasone and was completed at the time of delivery. The infant was born by vaginal delivery. Apgars were 8 at 1 minute and 9 at 5 minutes. He required blow by oxygen in the delivery room. He was admitted to the neonatal intensive care unit for treatment of prematurity. Anthropometric Measurements at the time of birth: Weight 992 grams in the 25-50th percentile. Length 36.5 cm 50th percentile. Head circumference 24 cm 25th percentile. PHYSICAL EXAMINATION AT DISCHARGE: 3.145 kg. Active, alert infant on nasopharyngeal prong CPAP. Head, ears, eyes, nose and throat: Anterior fontanel open and flat. Sutures opposed. Symmetric facial features. Nasal area intact without breakdown. Palate intact. Chest: Breath sounds equal, well aerated, slightly coarse. Intercostal retractions. Cardiovascular: Grade 2-3/6 systolic murmur at the left lower sternal border. Normal S1-S2. Pulses +2. Abdomen soft, nontender, nondistended, no masses. Active bowel sounds. Cord healed. GU: Normal male. Testes descended bilaterally. Extremities: Moves all well. Normal strength and tone. Neuro: Symmetric and appropriate reflexes. HOSPITAL COURSE BY SYSTEMS: Including pertinent laboratory data. 1. Respiratory. This baby was placed on continuous positive airway pressure upon admission to the neonatal intensive care unit. He remained on nasal prong CPAP on room air for the first 4 days of life. He then transitioned to room air, but soon thereafter required nasal cannula and the re initiation of continuous positive airway pressure. He experienced nasal breakdown due to the prongs and was trialed on a cannula, but had worsening respiratory distress and was intubated for the first time on day of life #18 and placed on conventional ventilator. At that time he also had chest x-ray and trache aspirate suggestive of methicillin resistant staph aureus and Klebsiella pneumonia. He was treated with a 14 day course of antibiotics at that time and continued to have an unstable course from a respiratory standpoint, often requiring upwards of 80%-90% fraction inspired oxygen. He started a course of inhaled steroids on [**2180-8-9**], but showed no improvement and was changed to systemic steroids on [**2180-8-17**] and received an 11 day course. He was able to make small amounts of weans from the respirator, but continued to be very labile and requiring high pressures and PEEPs to maintain adequate ventilation and oxygenation. On day of life #71, he started a longer term course of prednisolone, initially 2 mg/kg once daily for 5 days, dropping to 1mg/kg daily for 5 days then 1 mg/kg every other day. He has also been treated with Lasix, Aldactone and Spironolactone diuretics. A pulmonary consult was obtained with Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**] suggesting treatment for gastric esophageal reflux and consideration of a work up for primary ciliary dyskinesia. Bronchoscopy and nasal biopsy for a planned for [**Hospital3 1810**] for [**2180-9-20**]. On [**2180-9-18**] this infant was able to be extubated from the ventilator and at the time of discharge, is on continuous positive airway pressure via prongs at 6-8 cm. Oxygen requirement is 55%-70%. His respirations are labored and he is intermittently tachypnea. His most recent blood gas on CPAP was on [**2180-9-18**] with a pH of 7.36, pCO2 62, pO2 57. As part of the evaluation for the severity of his chronic lung disease and infectious disease tendency, this infant had immunoglobulins sent which were within normal limits. He also has a surfactant protein analysis pending at the time of this dictation. HIV testing was negative. The plan is for transfer to [**Hospital3 1810**] Boson under the care of the otorhinolaryngology service for a direct bronchoscopy and nasal biopsy. 2. Cardiovascular. This baby initially had no murmur. With the onset of his severe respiratory distress he had pneumonia. An echocardiogram was obtained on [**2180-7-18**] that showed a structurally normal heart and no patent ductus arteriosus. With the persistence of his severe chronic lung disease and concerns for pulmonary hypertension, echocardiograms were reviewed on [**8-8**], [**2179**] and [**2180-9-4**]. He has no pulmonary hypertension, but on the most recent echocardiogram, supravalvular pulmonary stenosis was noted. He maintains normal heart rates and blood pressures. Baseline heart rate is 150-170 beats per minute with a recent blood pressure of 93/54 mmHg. Mean arterial pressure of 66 mmHg. 3. Fluids, electrolytes and nutrition. This infant initially received intravenous fluids via a double lumen umbilical venous catheter. Enteral feeds were started on day of life #3 and gradually advanced to full volume. His current formula is Enfamil 24 w/ [**2-20**] teaspoon BP per 60 mls. On the recommendation of the pulmonary consult and GI consult teams, he is being treated for reflux with Prilosec and Reglan. His electrolytes have been checked frequently and have remained relatively stable. They most recently were checked on [**2180-9-15**] with a sodium of 137, potassium of 5.3, chloride 100 and a total carbon dioxide of 29. Weight on the day of discharge is 3.145 kg. 4. Infectious disease. Due to the prolonged rupture of membranes at the time of delivery, the baby was evaluated for sepsis. Upon admission to the neonatal intensive care unit, complete blood count was notable for a white blood cell count of 42,300 with a normal differential. The elevated white blood cell count was felt to be due to the prolonged rupture of membranes. Blood cultures obtained prior to starting intravenous Ampicillin and Gentamicin. The blood culture was no growth. He received a total 7 day course of antibiotics. A lumbar puncture was performed and results are within normal limits. As previously noted, on day of life #18, this infant required intubation for deteriorating respiratory status and had trache aspirate showing Klebsiella and methicillin resistant staph aureus. He was treated with a 14 day course of Vancomycin, gentamicin and Ceftazidime. He also had 2 subsequent episodes of evaluation for sepsis due to clinical deterioration. Those blood cultures were no growth. Again, on [**2180-8-24**], with deterioration of his respiratory status, trache aspirate was sent and gram negative rods were once again noted in his sputum. He was treated with gent and Ceftazidime for another 10 day course. 5. Hematological. This infant is blood type O- and is direct antibody test negative. Hematocrit at birth was 53.7%. He has received 5 packed red blood cell transfusions, his most recent on [**2180-9-6**]. Most recent hematocrit at that time was 30.1%. 6. Gastrointestinal. This infant required treatment for unconjugated hyperbilirubinemia with photo therapy. Peak serum bilirubin occurred on day #3, total 8.4 mg /dL. He was treated with approximately 5 days of photo therapy with a rebound bilirubin on day #11 of 3.5 mg/dL. Repeat on [**2180-7-12**] was 1.7 mg/dL. As previously noted, this infant is being treated for gastroesophageal reflux with Prilosec and Reglan. 7. Neurological. This infant has had 2 normal head ultrasound on [**2180-7-5**] and [**2180-7-28**]. He has a normal neurological exam. He has received Ativan in the past for sedation, but was discontinued due to the onset of severe clonus. 8. Sensory. Audiology: Hearing screening has not yet been performed. Ophthalmology: This infant has had numerous screening eye exams for retinopathy of prematurity. His worst exam showed stage II zone 3, [**2-20**] clock hours. His most recent exam on [**2180-9-13**] showed regressing retinopathy of prematurity with immature vessels to zone 3 with a recommended follow up in 3 weeks. 9. Psychosocial. Both parents have been very involved and invested during their infants neonatal intensive care unit admission. The [**Hospital1 **] social worker involved with this family is [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] and she can be reached at [**Telephone/Fax (1) 57470**]. CONDITION ON DISCHARGE: Guarded. DISCHARGE DISPOSITION: Transfer to [**Hospital3 1810**] for direct bronchoscopy and nasal biopsy. PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital 1426**] Pediatrics. CARE RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. When feeding preemie Enfamil 32 calorie/oz with added benaprotein, n.p.o. for the OR with intravenous fluids of D10-W at 120 ml/kg per day. 2. Medications: Albuterol 2 puffs via MDI q.4h, prednisolone 3 mg pg every other day, Spironolactone 6 mg once day, Furosemide 6 mg pg every Monday, Wednesday and Friday, Reglan 0.5 mg q.8h, Omeprazole 3 mg q.24h, chloride supplements 3 mEq pg q.12h, potassium chloride supplements 1.8 mEq q.12h. IMMUNIZATIONS: Immunizations were given on [**2180-9-5**] and included Pediarix, hemophilus influenza B, and pneumococcal 7-valent conjugate vaccine. State newborn screens have been sent on numerous occasions with all results within normal limits. DISCHARGE DIAGNOSES: 1. Prematurity at 27 5/7 weeks gestation. 2. Transitional respiratory distress. 3. Klebsiella and methicillin resistant staph aureus pneumonia. 4. Presumed tracheitis. 5. Apnea of prematurity. 6. Anemia of prematurity. 7. Retinopathy of prematurity. 8. Supravalvular pulmonary stenosis. 9. Chronic lung disease. 10.Gastroesophageal reflux. [**First Name8 (NamePattern2) 73452**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) **] Dictated By:[**Name8 (MD) 74047**] MEDQUIST36 D: [**2180-9-20**] 02:33:28 T: [**2180-9-20**] 11:39:59 Job#: [**Job Number 74048**] Admission Date: [**2180-6-28**] Discharge Date: [**2180-10-30**] Date of Birth: [**2180-6-28**] Sex: M Service: NEONATOLOGY TRANSFER TO [**Hospital **] [**Hospital3 **] HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 5656**] [**Known lastname 805**], [**First Name3 (LF) **] is a 992 gram product of a 27-5/7 week gestation pregnancy born to a 43-year-old, gravida 3, para 0, 1 now woman. Prenatal screens are blood type 0 negative, antibody positive for anti- D antibody, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, and group B strep status unknown. This was an in [**Last Name (un) 5153**] fertilization pregnancy, and it was uncomplicated until 1 week prior to delivery when the mother experienced spontaneous rupture of membranes. She was treated with ampicillin and erythromycin for multiple doses prior to pregnancy. She was also treated with betamethasone and was completed at the time of delivery. The infant was born via vaginal delivery. Apgars were 8 at one minute and 9 at five minutes. He required blow-by oxygen in the delivery room, and he was admitted to the neonatal intensive care unit for treatment of prematurity. His anthropometric measurements at the time of birth were weight 992 grams (25th-50th percentile), length 36.5 cm (50th percentile), head circumference 24 cm (25th percentile). PHYSICAL EXAMINATION AT TRANSFER: His current weight is 4550g , his head circumference is 37 cm , and his length is 52cm . He is an active, alert infant on a ventilator. He has a 3.5 ET tube in place orally. Head, ears, eyes, nose and throat: His anterior fontanels are open and flat. Sutures are closed. He has symmetric facial features. His nasal airways are intact without breakdown. His palate is intact. Chest: Breath sounds are equal, well-aerated, slightly coarse. He has mild intercostal and subcostal retractions. Cardiovascular: He has a grade 2-3/6 systolic murmur at the left lower sternal border. He has a normal S1 and S2. Pulses are +2. His abdomen is soft, nontender, nondistended and no masses. He has active bowel sounds. His cord has healed. GU: He has normal male genitalia. His testes are descended bilaterally. Extremities: He moves all well. He has normal strength and tone. Neuro: He has symmetric and appropriate reflexes. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. RESPIRATORY: This infant was placed on continuous positive airway pressure upon admission to the neonatal intensive care unit. He remained on nasal prong CPAP on room air for the first 4 days of life. He then transitioned to room air, but soon thereafter required nasal cannula and then reinitiation of continuous positive airway pressure. He experienced nasal breakdown to the prongs and was trialed on a cannula, but had worsening respiratory distress and was intubated for the first time on day of life #18 and placed on conventional ventilator. At that time, he also had a chest x-ray and a tracheal aspirate suggestive of Methicillin resistant Staphylococcus aureus and Klebsiella pneumonia. He was treated with a 14-day course of antibiotics at that time and continued to have an unstable course from a respiratory standpoint, often requiring upwards of 80- 90% fraction inspired oxygen. He started on a course of inhaled steroids on [**2180-8-9**], but showed no improvement and was changed to systemic steroids on [**2180-8-17**] and received an 11-day course. He was able to mix small amounts of weans from the respirator but continued to be very labile and requiring high pressures and PEEPS to maintain adequate ventilation and oxygenation. On day of life #71, he started on a longer term of prednisolone, initially at 2 mg/kg once daily for 5 days. and then dropping to 1 mg/kg daily for 5 days, and then he is currently on 1 mg/kg every other day. He has also been treated with Lasix, aldactone and spironolactone diuretics. A Pulmonary consult was obtained with Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**] suggesting treatment for gastroesophageal reflux and consideration a work-up for primary ciliary dyskinesia. On [**2180-9-18**], this infant was able to be extubated from the ventilator and was placed on continuous positive airway pressure by way of prongs at 68 cm with oxygen requirement 55- 70% oxygen. On day of life 91, [**9-27**], infant transitioned off to high flow nasal cannula. On day of life 101, patient developed hypercapnia with CO2s in the 100s. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**] was consulted and infant had a trial of Diamox therapy. On day of life 5 infant reintubated due to hypercapnia. The infant remains orally intubated with current settings of 28/6, a rate of 30, pressure support of 10, with FIO2 between 26 and 30%. He has a stable CBG of 7.32, 66, 48, 36 and 4. As part of the evaluation for severity of his chronic lung disease and infectious disease tendency, this infant had immunoglobulins which were sent which were within normal limits. He also had surfactant protein analysis pending at the time of this dictation. His HIV testing was negative. The plan is to transfer this infant to [**Hospital3 18242**], [**Location (un) 86**], under the care of RL service for a direct bronchoscopy, tracheostomy, nasal biopsy and a gastrostomy tube. 1. CARDIOVASCULAR: This infant initially had no murmur. With the onset of severe respiratory distress with pneumonia, an echocardiogram was obtained on [**2180-7-18**] that showed a structurally normal heart and no patent ductus arteriosus. With the persistence of his severe chronic lung disease and concern for pulmonary hypertension, echocardiograms were reviewed on [**8-8**], [**2179**], [**2180-9-4**], and his most recent one on [**2180-9-25**]. He has had no pulmonary hypertension, but on the most recent echocardiogram he has supravalvular pulmonary stenosis. He maintains normal heart rates and blood pressure. His baseline heart rates are 120s-160 with a blood pressure of 94/48 with mean of 62. 1. FLUIDS, ELECTROLYTES AND NUTRITION: This infant initially received intravenous fluid by way of a double- lumen umbilical venous catheter. Enteral feeds were started on day of life 3 and gradually advanced to full volumes. His current formula is Enfamil 24 cal with additional Bene protein supplements. The recommendation of the Pulmonary consult. He is being treated for reflux with Prilosec and Reglan. His electrolytes have been checked frequently and have remained relatively stable. The most recent were checked on [**2180-10-26**] with sodium of 134, potassium 6.7 which was hemolyzed, his chloride was 104 and a total carbon dioxide of 22. His weight on day of transfer is . 1. INFECTIOUS DISEASE: Due to prolonged rupture of membranes at the time of delivery, the baby was evaluated for sepsis. Upon admission to the neonatal intensive care unit, complete blood count was notable for a white blood cell count of 42,300 with a normal differential. The elevated white blood cell count was felt to be due to prolonged rupture of membranes. Blood cultures obtained prior to starting intravenous ampicillin and gentamicin. The blood culture was no growth. She received a total 7 days of antibiotics. A lumbar puncture was performed and results are within normal limits. As previously noted, on day of life #18 this infant required intubation for deteriorating respiratory status and had a tracheal aspirate showing Klebsiella and Methicillin resistant Staphylococcus aureus. He was treated with a 14-day course of vancomycin, gentamicin and ceftazidime. He also had two subsequent episodes of evaluation of sepsis due to clinical deterioration. Both blood cultures were no growth, and again on [**2180-8-24**] with deterioration of his respiratory status, a trache aspirate was sent and gram-negative rods were once again noted in his sputum. He was treated with gentamicin and ceftazidime for another 10-day course. 1. HEMTOLOGICAL: This infant is blood type O negative, and his direct antibody test was negative. His hematocrit at birth was 53.7%. He has received 5 units packed red blood cell transfusion. His most recent was on [**9-6**], [**2179**]. His most recent hematocrit on [**10-11**] was 34.8%. 1. GASTROINTESTINAL: This infant required treatment for unconjugated hyperbilirubinemia with phototherapy. Peak serum bilirubin occurred on day #3 with a total of 8.4. He was treated for approximately 5 days of phototherapy with a rebound bili on day of life #11 of 3.5. Repeat on [**2180-7-12**] was 1.7 and, as previously noted, this infant is being treated for gastroesophageal reflux with Prilosec and Reglan. 1. NEUROLOGIC: This infant has had two normal head ultrasounds on [**2180-7-5**] and on [**2180-7-28**]. He has had a normal neurological exam. He has received Ativan p.r.n. for sedation. 1. SENSORY: AUDIOLOGY: Hearing screen has not yet been performed. OPHTHALMOLOGY: This infant has had numerous screening eye exams for retinopathy of prematurity. His worst exam showed stage 2 zone 3 at 3-4 clock hours, and his exam on [**2180-9-13**] showed regressing retinopathy of prematurity with immature vessels through zone 3, and then his most recent exam on [**10-4**], his eyes have matured and follow-up at age 1. 1. PSYCHOSOCIAL: Both parents had been very involved and invested during their infant's neonatal intensive care unit admission. The [**Hospital1 **] social worker involved with the family is [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **], and she can be reached at ([**Telephone/Fax (1) 74049**]. CONDITION ON TRANSFER: Guarded. DISCHARGE DISPOSITION: Transfer to [**Hospital3 1810**] for direct bronchoscopy, tracheostomy, nasal biopsy and a gastrostomy tube. PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **] [**Last Name (Titles) 1426**] Pediatrics. DISCHARGE CARE AND RECOMMENDATIONS: 1. Feedings: His current feedings are Enfamil 24 cal with added Beneprotein. 2. Current medications: Metoclopramide at 0.2 mg q.8 h (0.05 mg/kg/dose). He is also on potassium chloride supplements which is 2.5 mEq q.12 h. These are all PG meds, and that gives him 1.2 meq/kg/D. He is also on Prilosec 4 mg PG daily which is 1 mg/kg/dose. He is currently on prednisolone 4.2 mg PG every other day which is 1 mg/kg/dose. He is also on calcium chloride supplements which he gets 3.2 mEq PG q.i.d. which is 3 mEq/kg/D. He is also on furosemide 8.5 mg PG q. Monday, Wednesday and Friday which gives him 2 mg/kg/dose, and he is also on potassium phosphate which he gets 1.2 mmol PG q.12 h. which gives him 0.6 mmol/kg/D. He is also on sodium chloride supplements which he gets 2 mEq PG b.i.d. and which is 1 mEq/kg/D. He is also receiving ferrous sulfate which is 25 mg/1 mL which he gets 0.3 mL PG daily which comes out to be 2 mg/kg/dose. He is also received Combivent 2 puffs by MDI q.6 h., and he is also received lorazepam 0.4 mg PG q.[**3-26**] h. p.r.n. which comes out to be 0.1 mg/kg/dose. 3. Immunizations were given on [**2180-9-5**] which include Pediarix, Haemophilus influenza B and pneumococcal 7-[**Last Name (un) 36477**] conjugate vaccine. He also received Synagis on [**2180-10-23**]. 4. His state newborn screenings have been seen on numerous occasions and all results within normal limits. DISCHARGE DIAGNOSES: 1. Prematurity at 27-5/7 weeks' gestation. 2. Transitional respiratory distress. 3. Klebsiella and Methicillin resistant Staphylococcus aureus pneumonia. 4. Presumed tracheitis. 5. Apnea of prematurity. 6. Anemia of prematurity. 7. Retinopathy of prematurity. 8. Pulmonary stenosis. 9. Chronic lung disease. 10.Gastroesophageal reflux. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 74050**] Dictated By:[**Last Name (NamePattern1) 70824**] MEDQUIST36 D: [**2180-10-29**] 21:48:20 T: [**2180-10-30**] 13:40:33 Job#: [**Job Number 74051**]

[ "745.5", "776.6", "777.8", "530.81", "V30.00", "775.7", "769", "770.81", "770.89", "482.41", "482.0", "362.21", "765.03", "774.2", "401.9", "746.83", "464.10", "765.24", "770.7", "779.3" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "99.83", "93.90", "96.6", "03.31", "96.72", "96.04", "38.92", "99.04" ]

icd9pcs

[ [ [] ] ]

21217, 21500

23044, 23693

21526, 21610

2018, 9425

1323, 1989

21631, 23023

11334, 21193

9450, 9460

44,872

166,389

33

Discharge summary

report

Admission Date: [**2196-10-14**] Discharge Date: [**2196-10-18**] Service: MEDICINE Allergies: Hydrochlorothiazide Attending:[**First Name3 (LF) 348**] Chief Complaint: Dizzyness Major Surgical or Invasive Procedure: Hypertonic saline infusion History of Present Illness: Mr. [**Known lastname 349**] is an 89 year old man who presented with several months of dizziness, thirst, and increased urination. He was confused and found to be hyponatremic, head CT negative, CXR clear, UA negative. The patient is unable to recount a history due to word finding difficulties. He is however alert and oriented times three. When asked if there was someone to call to get more information about him, he responded that his sister would be unable to help, and he has no children as he was never married. . ED course: Vitals: T 98 80 134/90 12 100% on RA. He received IVF, 60 mEq of KCL, and was free water restricted. 1L normal saline over 3 hours. . On the floor, the patient is confused, but easily redirectable. He is aware he is in the hospital and has no current complaints. Past Medical History: -HTN -Hypercholesterolemia -Unknown facial nerve condition - ?Trigeminal neuralgia -Tinnitis, hearing loss in L ear. Social History: Originally from [**State 350**]. Owned a family business/factory. Has lived with sister for his entire life. Denies tobacco, alcohol or drug use. Family History: [**Name (NI) 351**] sister Physical Exam: On admission: Vitals: T: 98.9 BP: 162/72 P: 83 R: 21 O2: 100 % on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally no rales, wheezes or 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 Ext: Warm, well perfused, 2+ pulses, trace bilateral LE edema Neuro: AAO x3 with significant word finding difficulties, Strength 5/5 in extensors and flexors of upper and lower extremities bilaterally. Confused at times, trying to get OOB. . On discharge patient is alert and oriented to name and place, but not date. He is appropriate, does not exhibit word-finding difficulties, unable to participate in Mini Mental Status Exam due to difficulty concentrating. Pertinent Results: ON ADMISSION: [**2196-10-13**] 09:45PM BLOOD WBC-13.3* RBC-4.26* Hgb-13.1* Hct-35.4*# MCV-83# MCH-30.6 MCHC-36.9*# RDW-13.4 Plt Ct-265 [**2196-10-13**] 09:45PM BLOOD Neuts-88.8* Lymphs-7.4* Monos-3.6 Eos-0.1 Baso-0.1 [**2196-10-13**] 09:45PM BLOOD Plt Ct-265 [**2196-10-13**] 09:45PM BLOOD Glucose-132* UreaN-10 Creat-0.8 Na-114* K-3.0* Cl-78* HCO3-25 AnGap-14 [**2196-10-14**] 03:40AM BLOOD Glucose-116* UreaN-9 Creat-0.8 K-2.9* Cl-80* HCO3-24 [**2196-10-14**] 06:30AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.6 [**2196-10-14**] 08:45AM BLOOD calTIBC-302 VitB12-457 Folate-11.2 Ferritn-125 TRF-232 [**2196-10-14**] 06:30AM BLOOD Osmolal-234* ON DISCHARGE: [**2196-10-15**] 04:16AM BLOOD Neuts-88.5* Lymphs-5.7* Monos-5.6 Eos-0.2 Baso-0 [**2196-10-18**] 06:34AM BLOOD WBC-8.0 RBC-4.10* Hgb-12.4* Hct-35.6* MCV-87 MCH-30.1 MCHC-34.7 RDW-13.8 Plt Ct-261 [**2196-10-18**] 06:34AM BLOOD Plt Ct-261 [**2196-10-18**] 06:34AM BLOOD Glucose-96 UreaN-17 Creat-1.0 Na-138 K-4.1 Cl-103 HCO3-28 AnGap-11 [**2196-10-17**] 06:24AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.1 ECG Study Date of [**2196-10-13**] 10:41:12 PM Sinus rhythm. Borderline first degree A-V block. Baseline artifact. Prolonged Q-T interval. Non-specific T wave flattening in leads V4-V6. No previous tracing available for comparison. CHEST (PA & LAT) Study Date of [**2196-10-13**] 11:16 PM FINDINGS: The cardiomediastinal silhouette is normal. There is a right retrocardiac vague opacity, projecting over the posterior segment of the right lower lobe in the lateral view, concerning for developing pneumonia. The heart is mildly enlarged. There is no pleural effusion or pneumothorax. The stomach is distended with air. IMPRESSION: Findings concerning for basal pneumonia, most likely right lower lobe pneumonia. CT HEAD W/O CONTRAST Study Date of [**2196-10-14**] 1:02 AM CT HEAD W/O CONTRAST FINDINGS: Two repeat series were obtained due to patient motion. There is no evidence of infarction, hemorrhage, edema, shift of normally midline structures, or hydrocephalus. The density values of brain parenchyma are within normal limits. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Imaged paranasal sinuses and mastoid air cells are aerated. Osseous structures and extra-calvarial soft tissues are unremarkable. IMPRESSION: No acute intracranial process, including no hemorrhage, edema, or mass. Brief Hospital Course: Mr. [**Known lastname 349**] is an 89 year old man who presented with several months of dizziness, thirst, and increased urination and was found to be hyponatremic with a sodium of 114 on admission. . # Hyponatremia: The patient was treated for hyponatremia with 3% saline solution in the Medical Intensive Care Unit. Per the renal consult team recommendations, the patient was placed on free water restriction to 1L per day and 3% saline was infused at 40cc/hr via PICC, with a goal of increasing the serum sodium by [**1-13**] mEq/hour or <12 mEq/24 hrs. Over this initial 24 hours of admission the patient's serum sodium increased from 114 to 119. On day 3 of admission 3% saline solution was discontinued and the patient was transfered to the floor. The nephrology team that was consulted initially continued to follow the patient during this admission and determined that the hyponatremia was hctz-induced. The patient's serum sodium normalized with the withdrawal of hctz and an SIADH work-up was not pursued, per renal recommendations. . # Word-finding difficulty: On initial presentation the patient experienced some word-finding difficulty that resolved as his serum sodium normalized. CT of the head was negative on admission. On discharge the patient was able to converse fluently without any word-finding abnormalities. The patient will follow up with his outpatient neurologist. . # Anemia: During this hospitalization the patient's hematocrit remained stable at 35. Iron studies did not reveal iron-deficiency anemia and the patient was guaiac negative on fecal occult blood test. The patient will have outpatient follow up of his anemia. . # Home Safety: The patient met with social worker who offered additional support services which patient declined. VNA will be sent to patient's house for home safety evaluation. . # Code status: During this admission the patient stated that he wished to be full code. The patient did not identify a health care proxy. Medications on Admission: Gabapentin, HCTZ, Zolpidem, Atorvastatin Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 2. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 3. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Outpatient Lab Work Please check sodium along with chem 7 this Friday, [**10-21**]. Results to be faxed to Dr. [**Last Name (STitle) 353**],[**First Name7 (NamePattern1) 354**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]: [**Telephone/Fax (1) 355**] fax: [**Telephone/Fax (1) 356**] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Hyponatremia Discharge Condition: Good. Na 135. Discharge Instructions: You were admitted to the hospital with a dangerously low sodium level. This was because of your blood pressure medicine: hydrochlorothiazide ("HCTZ"). You should not take this medicine any more. We have started you on a pill called flomax to treat your blood pressure and to help with the urinary trouble you had in the hospital. . Please have your blood work done with sodium level this Friday. Results to be faxed to Dr. [**Last Name (STitle) **]. . If you have any more difficulty finding words, any light-headedness, dizziness, fainting, fevers, chills, or any other worrisome symptoms then please seek medical attention. Followup Instructions: Please have your sodium checked this Friday to ensure it is at a safe level. To be followed up by your PCP. [**Name10 (NameIs) 357**] fax to PCP. With Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 355**]) at 1180 Beacon. [**11-1**] at 11:30

[ "E944.3", "276.1", "780.09", "275.3", "285.9", "783.7", "599.70", "276.8", "788.29", "401.9", "272.0" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

7503, 7561

4800, 6775

238, 267

7618, 7635

2390, 2390

8312, 8564

1414, 1442

6866, 7480

7582, 7597

6801, 6843

7659, 8289

1457, 1457

3041, 4777

189, 200

295, 1094

2405, 3026

1116, 1235

1251, 1398

10,948

194,429

29958

Discharge summary

report

Admission Date: [**2157-2-15**] Discharge Date: [**2157-2-17**] Date of Birth: [**2093-8-19**] Sex: F Service: MEDICINE Allergies: Compazine / Hydromorphone Hcl / Morphine / Lisinopril / Ace Inhibitors / Trazodone / Nsaids Attending:[**First Name3 (LF) 443**] Chief Complaint: Chest Pain, Dyspnea Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: Ms. [**Known lastname 174**] is a 63 year-old female with a history of CAD s/p CABG (LIMA-LAD, SVG-Diag, SVG-RPL) and PCI with stent to LAD and LCX [**2152**], systolic CHF (EF 25-30%), s/p ICD, post-operative PEs on coumadin who had 6-8 weeks of worsening SOB with minimal exertion and associated chest discomfort, [**1-12**] pillow orthopnea, and PND. SOB was not improved with home O2. She was directly admitted to [**Hospital1 18**] yesterday for heparin bridge for known PEs prior to elective, repeat cardiac catheterization. However, on admission, she described worsened SOB this AM with acute onset of new [**5-19**] substernal chest pressure radiating to her left neck/shoulder on arrival to the floor which was different than her recent chest pain symptoms. Her pain was unresponsive to SL NTG, and her paced EKG showed ST changes concerning for acute ischemia (ST depressions in II, III, AVF and STE in AVL), so she was given aspirin, loaded with plavix, started on a nitro gtt, and transferred to the cath lab for urgent catheterization. Cardiac enzymes at that time were negative. . In the cath lab her coronaries were found to be stable. LVEDP was 43 so she was given lasix 40mg with 500 cc UOP. PA gram to look for PE was unrevealing. Pt was transfered to the CCU post-catheterization with stable vital signs. She reported improvement in her shortness of breath. She continued to complain of abdominal pain radiating to the chest, but her nitro gtt was titrated off as her pain was non-cardiac. She remained stable overnight and was called out to the floor. . On the floor, the patient continues to complain of severe abdominal pain which she describes as excruciating "torquing" left upper quadrant pain radiating from under her left rib to her chest and across her precordium. She had difficulty describing the quality, onset, and pattern of pain. However, she did report that she first experienced the pain in [**Month (only) 1096**] as a "ripping" "tearing" pain at the site of her previous hernia repair. From her outside hospital records, she had presented to Lakes [**Hospital 12018**] Hospital in the past for workup of her abdominal pain. She underwent a CT abdomen which, per records, showed a small recurrance of her ventral hernia but no incarceration or strangulation. The surgeon decided not to re-operate on the hernia. The patient reports the pain is intermittently present to fluctuating degrees of severity, but she reports she is never pain-free. Her pain is reportedly the worst it has been, and the patient repeatedly is demanding Demerol for pain, which she reports is the only medication which effectively relieves her pain. She also presented with a typed note, allegedly from the PCP, [**Name10 (NameIs) 71539**] that Demerol is the only medication she may take for pain. The PCP was called, and reported he did not write the note and that this would invalidate the patient's narcotic contract. Of note, she has had a history of narcotic abuse in the past. . She denied any prior history of stroke, TIA, bleeding at the time of surgery, myalgias, cough, hemoptysis, black stools or red stools. She denied recent fevers, chills or rigors. She denied exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: MI x 2 -CABG: s/p CABG [**12-16**] (LIMA to LAD, SVG to PLB, SVG to diag) -PERCUTANEOUS CORONARY INTERVENTIONS: [**3-15**] LAD stenting at [**Hospital3 17921**] Center hospital [**8-15**]: Cx stenting -PACING/ICD: s/p ICD 3. OTHER PAST MEDICAL HISTORY: CAD as above CABG complicated by a sternal wound infection Systolic heart failure (LVEF 25-30%) Hypertension (poorly controlled) Depression [**2153**]: Attempt at a ventral hernia repair, complicated by development of a mesh infection requiring excision Tonsillectomy Appendectomy Cholecystectomy Hysterectomy Chronic headaches History of MVA complicated by "cerebral hematoma" and coma x 5 weeks Prior colon surgery for a perforation MRSA Two prior ectopic pregnancies Hx of multiple post surgical pulmonary emboli [**6-17**], on coumadin. Social History: -Tobacco history: Quit 30 years ago; smoked 1 ppd x 15 years -ETOH: Denies -Illicit drugs: Denies Of note, patient has a recent history of narcotic abuse and manipulative drug-seeking behavior. Family History: Mother with valvular surgery; father died of PE. Reports history of heart disease on mother's side (unable to give more details). Physical Exam: VS: T= 97.3 BP= 143/86 HR= 89 RR= 24 O2 sat= 98% on 3LNC. GENERAL: 63 y/o F, uncomfortable, in NAD. Alert and oriented. HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. No pallor or cyanosis of the oral mucosa. No xanthalesma noted. NECK: Supple with no significant JVD noted. CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4 appreciated. LUNGS: Respirations were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi noted anteriorly. ABDOMEN: Obese, Soft, ND. Some tenderness in the upper abdomen, greastest on the L side. No masses or HSM noted. No rebound or guarding. BS present. EXTREMITIES: WWP. Slight pitting edema at the ankles. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas appreciated. NEURO: No gross neurologic deficits noted. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: Admission Labs [**2157-2-15**] 04:16PM BLOOD WBC-6.9 RBC-4.03* Hgb-11.9* Hct-35.6* MCV-88 MCH-29.4 MCHC-33.4 RDW-15.6* Plt Ct-263 [**2157-2-15**] 04:16PM BLOOD PT-19.3* PTT-26.2 INR(PT)-1.8* [**2157-2-15**] 04:16PM BLOOD Glucose-115* UreaN-19 Creat-1.0 Na-140 K-3.6 Cl-104 HCO3-25 AnGap-15 [**2157-2-15**] 04:16PM BLOOD Calcium-9.2 Phos-3.0# Mg-2.0 [**2157-2-15**] 06:04PM BLOOD Type-ART pO2-125* pCO2-34* pH-7.49* calTCO2-27 Base XS-3 Intubat-NOT INTUBA . Cardiac Enzymes [**2157-2-15**] 04:16PM CK(CPK)-193 CK-MB-7 cTropnT-<0.01 [**2157-2-16**] 05:27AM CK(CPK)-117 CK-MB-5 cTropnT-0.01 proBNP-3530* . . Cardiac Catheterization ([**2157-2-15**]): COMMENTS: 1. Coronary angiography in this right dominant system demonstrated three vessel CAD. The LMCA was patent with a 40% stenosis. The LAD was a small vessel with diffuse disease up to 40%. The LCx was occluded proximally. The RCA was diffusely diseased but patent with a 30% stenosis in the mid vessel. 2. Arterial conduit angiography revealed the LIMA to be small but widely patent. The SVG-Diag which also supplied OM1 was patent as was the SVG-PDA. 3. Resting hemodynamics revealed severely elevated right and left sided filling pressures with an RVEDP of 23 mmHg and an LVEDP of 43 mmHg. There was severe pulmonary arterial systolic pressure with a PASP of 67 mMHg. The cardiac index was preserved at 2.2 L/min/m2. There was moderate systemic arterial systolic hypertension with an SBP of 144 mmHg. 4. There was no pressure gradient between the left ventricle and ascending aorta on left heart pullback. 5. Left sided pulmonary angiography performed due to decreased breath sounds in the left lung fields did not demonstrate any discrete filling defects to suggest a large pulmonary embolus. . FINAL DIAGNOSIS: 1. Three vessel CAD. 2. Severe left and right ventricular diastolic dysfunction. 3. Severe pulmonary hypertension . . TTE ([**2157-2-16**]): The left atrial volume is severely increased. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 20-25%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2154-11-21**], LV diastolic dimension has increased. The other findings are similar. Cardiac dyssynchrony was not evaluated on the current study. Brief Hospital Course: 63 year-old female with PMHx of CAD s/p CABG and stents, sCHF, PE on coumadin, HTN, HL with recently worsening dyspnea, who developed intractable chest pain and underwent emergent catheterization which showed stable CAD. . # CORONARIES: The patient was admitted for chest pain and for a scheduled catheterization for further evaluation of her recent dyspnea. However, she developed intractable chest pain while on the floor and was noted to have ST depressions in II, III, aVF, with STE in I, aVL. She underwent emergent cardiac catheterization, which showed stable CAD. She was admitted to the CCU for post-catheterization monitoring. CE's were negative and she was transferred to the general cardiology floor for management of bridging to Coumadin on Heparin gtt. The patient was transitioned to Lovenox on the day of discharge, to be taken until her INR is therapeutic. INR check will be performed by [**Year (4 digits) 269**] two days following discharge and followed-up by her cardiologist. The patient was continued on her home aspirin, beta blocker, statin, and continued to have chest/abdominal pain (see below). . # PUMP: Pt with known sCHF with EF 23% in [**2153**], but with OSH TTE from [**12/2156**] which showed mild-moderate MR with improved EF 25-30% compared to prior. Cardiac catheterization showed LVEDP of 43, indicating volume overload. IV lasix was given for diuresis. The patient's sCHF may be contributing to her dyspnea, and she was discharged on her home Lasix with close f/u with her cardiologist. . # RHYTHM: V-paced rhythm. Patient was monitored on telemetry. . # Epigastric pain: Patient has a h/o of hernia repair with recurrence of small hernia without strangulation which was evaluated by her surgeon, who did not feel the need to re-operate. Patient has had a workup of her chronic abdominal pain at OSHs, including CT abdomen and renal ultrasound per PCP's office, which were unrevealing. The patient was vague and unwilling to describe or discuss her pain, and demanded IV Demerol for pain relief. Her exam revealed pain out of proportion to exam and the pt was able to eat her meals without pain. Of note, she has a history of narcotic abuse and drug-seeking behavior. She presented to the hospital with a note, allegedly from her PCP, [**Name10 (NameIs) 71539**] only Demerol 50mg IV effectively treats her pain. The PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], was contact[**Name (NI) **] and denied writing any such note. As there is no clear etiology for her pain, we conservatively managed her pain with Tylenol, Tizanadine, and Darvocet prn. . # Dyspnea: The patient has a known history of sCHF (EF 23% in [**2153**]), with elevated LVEDP on cardiac catheterization. The patient was diuresed post-cath with IV lasix in the cath lab and in the CCU. On the general cardiology floor, she subsequently was dyspneic only with agitation, she was continued on her home Lasix. Pulmonary angiogram was negative for PE. Additionally, the patient's worsening dyspnea could represent worsening underlying lung disease. She was continued on her home Flovent. . # Hypertension: Pt with a history of uncontrolled hypertension, but was adequately controlled in-house on home medications. Continued carvedilol, amlodipine, lasix per outpatient regimen. . # H/o PE on Coumadin: Pulmonary angiogram during catheterization negative for PE. Patient was bridged on Heparin pre- and post-catheterization, and transitioned to Lovenox on day of discharge. Patient was discharged on home dose of Coumadin with INR 1.7, and [**Year (4 digits) 269**] will draw INR on Saturday to determine course of Lovenox. Patient will also have f/u with PCP on [**Name9 (PRE) 766**] for another INR check. . # Depression: Patient self-discontinued buproprion and lexapro. Will need outpatient f/u. SW was consulted in-house. Prior to discharge, the patient reported she would like to re-start her Bupriprion and would be following up with her PCP the day after discharge to discuss re-initiation of the medication. She requested one 50mg dose prior to discharge from the hospital and was given a dose with instructions to follow-up with her PCP to [**Name9 (PRE) 71540**] the medication and discuss the dosing (as she was previously on a higher dose than she was willing to take). . CODE: FULL, confirmed with patient. HCP is friend [**Name (NI) **] [**Name (NI) 71541**] Medications on Admission: (per pt's home med list) - Carvedilol 6.25 mg po bid - Amlodipine 10 mg po daily - Furosemide 50 mg po bid - Zolpidem 10 mg po qhs prn insomnia - Oxycodone 15 mg po 2 per day (q3h prn pain) - Percocet 10 mg po 2 per day (q4h prn pain) * [**Name (NI) **] 325 mg po daily - Pravastatin 40 mg po qhs Potassium Chloride 20 mEq po tid (10meq po daily) - Warfarin 4 mg po qTuThSatSun, 2 mg qMWF - Flovent Diskus 100mcg inhaled [**Hospital1 **] - Senna 8.6 mg Capsule; 2 capsules po bid - Docusate Sodium 100 mg po bid (Lactulose 15ml [**Hospital1 **] prn) (Bupropion XL 50 mg po tid (pt self-discontinued several weeks ago as it made her "hyper")) (Lexapro 10mg daily) 2L Oxygen Discharge Medications: 1. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a day for 7 days: Please take until directed by your physician to stop (when INR is therapeutic). Disp:*14 syringes* Refills:*0* 2. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Furosemide 20 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). 5. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 7. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 9. Coumadin 4 mg Tablet Sig: One (1) Tablet PO qTuThSatSun. 10. Coumadin 2 mg Tablet Sig: One (1) Tablet PO qMonWedFri. 11. Flovent Diskus 100 mcg/Actuation Disk with Device Sig: One (1) Inhalation twice a day. 12. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. Outpatient Lab Work Please draw an INR on Saturday, [**2157-2-18**], and call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 59323**] at [**Telephone/Fax (1) 71542**] with the results. Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) 6930**] [**Last Name (NamePattern1) **] Nurse Assoc and Hospice Discharge Diagnosis: Chest pain, non-cardiac Chronic abdominal pain Secondary Diagnosis: Chronic Systolic Congestive Heart Failure Ischemic cardiomyopathy Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You presented to the hospital with stomach and chest pain, and underwent a cardiac catheterization which showed stable coronary artery disease which did not require any interventions. There were also no blood clots seen in your lungs. You continued to have your chronic abdominal pain during your hospital stay, but this was improved on the day of discharge. You had been worked up for this in the past, and should follow up with your primary care physician and [**Name Initial (PRE) **] surgeon regarding the pain. Please discuss all pain medications with your primary care physician. The following medication changes were made: - Lovenox was added, to be taken until your physician tells you to discontinue the medication (once your INR is therapeutic) Please discuss all of your home medications with your primary care physician, [**Name10 (NameIs) 71543**] your Buproprion (Wellbutrin). Because you have heart failure, you should weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please call your Primary Care Physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 71544**], when you are discharged to arange for an appointment on Monday [**2-21**] for a blood test to check your INR. You should also arrange for a follow-up visit at that time, to be seen by Dr. [**First Name (STitle) **] within 1-2 weeks after discharge from the hospital. Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 59323**] at [**Telephone/Fax (1) 11254**] to arrnage for a follow-up appointment within 1 week of your discharge from the hospital.

[ "428.43", "416.8", "789.07", "401.9", "272.4", "414.01", "V45.81", "786.59", "414.8", "428.0", "338.29" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.23", "88.52" ]

icd9pcs

[ [ [] ] ]

15316, 15440

8825, 13285

371, 397

15619, 15619

5918, 7672

16820, 17475

4935, 5067

14009, 15293

15461, 15509

13311, 13986

7689, 8802

15767, 16797

5082, 5899

3913, 4135

312, 333

425, 3805

15530, 15598

15634, 15743

4166, 4708

3827, 3893

4724, 4919

80,943

156,820

36604

Discharge summary

report

Admission Date: [**2169-8-25**] Discharge Date: [**2169-9-18**] Date of Birth: [**2124-10-30**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Transfer from trauma SICU for hypotension, sepsis Major Surgical or Invasive Procedure: Tracheostomy PEG placement PICC line placement History of Present Illness: 44 year old female with a history of mental retardation, deafness who was transferred from [**Hospital3 5365**] on [**2169-8-25**] for scheduled tracheostomy and PEG after a prolonged hospitalization from [**2170-7-25**] to [**2169-8-25**] complicated by multiple episodes of aspiration pneumonia and respiratory failure. She was last in her usual state of health in [**2169-7-17**]. At baseline she is high functioning and can ambulate without assistance, prepares her own meals, showers, and holds a job. She fractured her right hip in early [**Month (only) **] which requried pinning on [**2169-7-27**]. Her post operative course was complicated by aspiration pneumonia requiring intubation. She subsequently suffered a pneumothorax thought to be secondary to postitive pressure ventilation and had two chest tubes placed. She underwent IVC filter placement to allow for discontinuation of lovenox on [**2169-8-5**]. She later developed hemothorax on the same side which was felt to be related to a subclavian line which expanded after line removal. She underwent VATS with thoracoscopy and removal of blood clots on [**2169-8-22**]. She was treated with multiple rounds of antibiotics including vancomyicn and zosyn for ten days, followed by vancomycin and cefepime in early [**Month (only) 205**]. She was extubated and reintubated for aspiration events on four occassions. Tracheostomy and PEG were attempted prior to transfer but were unsuccessful secondary to the patient's small features and need for pediatric equipment. She was transferred to this hospital for further management and tracheostomy and PEG placement. Past Medical History: Mental retardation with total hearing loss Absence of nasal passages at birth, opened as a child Obsessive compulsive disorder Scoliosis Right hip fracture s/p pinning [**2169-7-27**] Aspiration pneumonia x 3 requiring intubation x 4 Tension pneumothorax with hemothorax s/p chest tube ARDS s/p IVC filter placement [**2169-8-5**] s/p right thoracoscopy, removal of pleural fluid, blood clot and partial decortication for hemothorax on [**2169-8-24**] Social History: Lives in a group home. No smoking or alcohol use. No illicit drug use. Is able to perform all activities of daily living and hold a simple job. Family History: Unknown Physical Exam: On transfer to MICU Vitals: T: 100.4 BP: 115/62 P: 147 R: 22 O2: 100% (on 50% O2) General: Alert, eyes open, deaf, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, trach in place, site intact, no erythema or pus Neck: supple, JVP elevated at ear, no LAD Lungs: Coarse breath sounds throughout with diffuse wheezing anteriorly, no rales, diffuse ronchi CV: Tachycardic, S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Hematoma on right arm. Pertinent Results: [**2169-8-25**] 09:25PM BLOOD WBC-16.3* RBC-3.61* Hgb-10.7* Hct-32.5* MCV-90 MCH-29.5 MCHC-32.8 RDW-15.9* Plt Ct-398 [**2169-8-25**] 09:25PM BLOOD Neuts-83.2* Bands-0 Lymphs-11.0* Monos-3.8 Eos-1.6 Baso-0.4 [**2169-8-25**] 09:25PM BLOOD PT-13.7* PTT-28.3 INR(PT)-1.2* [**2169-8-25**] 09:25PM BLOOD Glucose-110* UreaN-16 Creat-0.4 Na-145 K-3.3 Cl-114* HCO3-24 AnGap-10 [**2169-8-25**] 09:25PM BLOOD Calcium-7.3* Phos-2.6* Mg-1.7 . Micro from [**Hospital3 **]: Urine cultures positive for citrobacter and pseudomonas both sensitive to cefepime (per discharge summary) Staph xylous in the blood (per discharge summary) Sputum [**2169-8-21**]: [**Female First Name (un) **] albicans Urine [**2169-8-21**]: gandida glabrata . EKG: sinus tachycardia at 145, normal axis, normal intervals, no ST elevation or depression, non diagnostic q waves in I, II, avL, V4-V5, compared to prior dated [**2169-7-25**]. . Echocardiogram [**2169-8-7**]: The left ventricle is normal in size, with normal wall thickness and normal systolic function. The left atrium and right sided [**Doctor Last Name 1754**] are normal in size. The aortic valve is normal. The mitral valve is morphonologically normal, with trace MR. [**First Name (Titles) **] [**Last Name (Titles) **] valve is morphologically normal with trace TR. Estimated PA systolic pressure is 28 mmHg, assuming a righht atrial pressure of 10. There is no pericardial effusion. There is a mobile density at the base of the right atrial as seen on the apical four-chamber view. Thsi could represent the tip of a subclavian catheter. . CT Chest w/o Contrast [**2169-8-25**]: 1. Extensive bilateral interstitial and parenchymal opacities. These findings are nonspecific and should be correlated with prior imaging as well as clinical history. In the absence of other provided history, given the patient's age as well as a right- sided aortic arch, diagnostic considerations would include end stage cystic fibrosis or sarcoidosis. If immunocompromised by HIV infecton, Kaposi's sarcoma would be a diagnostic consideration. 2. Confluent areas of opacity where acute infection is not excluded. 3. Tracheobronchomalacia. 4. Loculated opacities in the pleural space, some component of which is pleural fluid and others of which are not completely characterized on this non-contrast study. 5. Right pneumothorax with right pleural tubes in place. 6. Incidental right aortic arch. . Portable CXR [**2169-8-28**]: Continued progression of diffuse infiltrative pulmonary abnormality throughout both lungs probably due to worsening edema, non-cardiogenic or less likely cardiac. Only one right pleural tube remains, there may have been an interval increase in small right pleural effusion and right apical pneumothorax since 2:04 p.m. Left subclavian line, tracheostomy tube and feeding tube are in standard placements. Some of the apparent mediastinal widening to the right of the midline at the thoracic inlet is due to a right aortic arch, some due to loculated hemothorax which has been present since [**8-26**] CT scan. . [**2169-9-15**]-IMPRESSION: Gastrostomy tube well positioned within the stomach. Significant reflux of contrast into the distal esophagus demonstrated. . [**2169-9-16**]-RUQ u/sIMPRESSION: 1. Contracted gallbladder. 2. Heterogeneous and coarsened liver echotexture without focal masses. Findings are suggestive of an underlying chronic liver disease. 3. Right pleural effusion. Brief Hospital Course: Ms. [**Known lastname **] is a 44 year old female with a history of mental retardation and deafness who was transferred from [**Hospital1 **] on [**2169-8-25**] for scheduled tracheostomy and PEG after a prolonged hospitalization from [**2170-7-25**] to [**2169-8-25**] for right hip ORIF after fall with hospital course complicated by multiple episodes of aspiration pneumonia and respiratory failure. . Septic Shock. Upon transfer to [**Hospital1 18**], Ms. [**Known lastname **] was noted to be in septic shock secondary to ventillator associated pneumonia. She was treated initially with Vnaoc/Cefepime/Cipro from [**8-28**] until [**9-6**]. Micafungin was also added due to yeast in urine. She required neosynephrine and vasopressin to support her blood pressure. She was ventillator dependent until approximately [**9-6**], when she was weaned from the vent and placed on trach collar mask. . Respiratory Failure/ARDS: Patient was transferred to [**Hospital1 18**] for trach which was placed on [**2169-8-28**]. She was initially in ARDS upon presentation, likely seconary to Pneumonia. She was treated with vanco/cefepime/cipro from [**2169-8-28**] to [**2169-9-7**] and her respiratory status improved. She was placed on trach collar mask on [**9-6**] and tolerated this well. . Hemothorax. Patient [**Month/Year (2) 18095**] a hemothorax at [**Hospital 82827**] hospital and was transferred to [**Hospital1 18**] with chest tube in place. It was removed on [**2169-8-31**]. There was no evidence of significant effusion at time of discharge from hospital. . S/p HIP fracture. Ms. [**Known lastname **] [**Last Name (Titles) 18095**] a fall at her nursing home which resulted in a right hip fracture. She underwent ORIF at Quicy on [**2169-7-26**] by Dr. [**Last Name (STitle) 82828**]. She remained non-weight bearing on her right hip during her hospital stay. . Nutrition. PEG was intended to be placed during Trach, but this was deferred secondary to enlarged liver with plans for open procedure in the future. Rather, an NGT was placed during her trach for nutrition. Due to her congenital lack of nasal pasages which were reconstructed during childhood, NGT placement was difficult even under direct visualization in the OR. Patient pulled her NGT later in her hospital course on [**9-7**] and given the difficulty in placing it, this was not replaced. She was briged with TPN for 7 days while awaiting G-tube placement. G-tube was placed on [**2169-9-13**] and she tolerated initiation of tube feeds. She did experience some abdominal pain at the PEG site the day after surgery, KUB showed evidence of ileus. However, pt had bowel sounds, tube feeds resumed, pain improved. She is not to take anything by mouth at this time due to aspiration risk. . mildly elevated LFTs-likely secondary to recent TPN. RUQ u/s-not revealing. Should have LFTs and repeat RUQ u/s in 6 week's time. . Volume status. Patient was given a significant amount of fluid in the setting of hypotension. She was getting diuresed once she was no longer pressor dependent. . Code: Full (discussed with health care proxy) . Communication: [**Name (NI) **] mother [**Name (NI) 82829**] [**Name (NI) 4553**] [**Telephone/Fax (1) 82830**] Medications on Admission: Home Medications: Clonazepam 1 mg [**Hospital1 **] Omeprazole 20 mg [**Hospital1 **] Clomipramine 200 mg QHS Simvastatin 20 mg daily Viactive 2 tabs daily Vitamin C 2 tabs daily [**Last Name (un) **] Sequels 1 tab daily . Medications on Transfer from [**First Name5 (NamePattern1) 392**] [**Last Name (NamePattern1) 19188**] 12 puffs q4H while vented Diprivan IV infusion at 23 mcg/kg/min Fenanyl 100 mcg Q1H:PRN agitation Cefepime 1 gram IV q12H Omeprazole 20 mg daily Peridex 15 mL Q8H Aqua eye drops Reglan 5 mg Q6H via G-tube Tube feeds Jevity 1.2 at 45 ml/hr Tylenol PRN Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Last Name (NamePattern1) **]: One (1) Tablet PO Q6H (every 6 hours) as needed for fever/pain. 2. Polyethylene Glycol 3350 100 % Powder [**Last Name (NamePattern1) **]: One (1) 17 g dose PO DAILY (Daily) as needed for constipation. 3. Miconazole Nitrate 2 % Powder [**Last Name (NamePattern1) **]: One (1) Appl Topical TID (3 times a day) as needed for yeast infection. 4. Clomipramine 25 mg Capsule [**Last Name (NamePattern1) **]: Eight (8) Capsule PO HS (at bedtime). 5. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (NamePattern1) **]: [**2-17**] Sprays Nasal QID (4 times a day) as needed for nasal secretions. 6. Clonazepam 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day). 7. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) tab PO BID (2 times a day). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 10. Lactulose 10 gram/15 mL Syrup [**Month/Day (2) **]: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 11. Oxycodone 5 mg/5 mL Solution [**Month/Day (2) **]: [**2-17**] 5 mg tabs PO Q4H (every 4 hours) as needed for pain. 12. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization [**Month/Day (2) **]: One (1) puff Inhalation three times a day as needed for shortness of breath or wheezing. 13. Atrovent HFA 17 mcg/Actuation Aerosol [**Month/Day (2) **]: One (1) puff Inhalation three times a day as needed for shortness of breath or wheezing. 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: Septic Shock Pneumonia ARDS Hemothorax Malnutrition . Secondary Diagnosis: Obsessive-Compulsive disorder Mental retardation Deafness Discharge Condition: Fair. In terms of her respiratory status, she has been satting well on trach collar mask for one week and tolerating tube feeds through her G-tube. Discharge Instructions: You were admitted for septic shock and ARDS due to a pneumonia. You were treated with antibiotics. You had a trach placed but you were weaned from the vent and you were tolerating trach collar mask well at the time of discharge. A PEG was placed on [**2169-9-13**] and you were started on tube feeds. . Please take your medications as prescribed. Lasix was started for diuresis and was stopped when patient's lower extremity edema resolved. Oxycodone was started for pain control at site of G-tube. . Please do not take anything by mouth. All medication and food should be through your G-tube. . Please call your physician or come to the emergency department if you have difficult breathing, lightheadedness, fevers, chills, or any other concerning symptoms. . You will need to have your LFTs and a RUQ u.s redone in 6 weeks. Followup Instructions: Please follow up with your orthopedic surgeon, Dr. [**Last Name (STitle) 82828**], [**Location (un) 82831**], [**Hospital1 392**], [**Numeric Identifier 82832**], at ([**Telephone/Fax (1) 82833**]. . Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Thoracics Surgery) who placed your trach and PEG. Phone: [**Telephone/Fax (1) 3020**]. . Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Ph. [**Telephone/Fax (1) 82834**].

[ "782.3", "300.3", "E878.3", "511.89", "V54.13", "748.1", "518.5", "995.92", "389.8", "038.9", "737.30", "785.52", "997.31", "E878.8", "263.9", "997.4", "785.0", "319", "V85.1", "998.11", "560.1", "564.09", "276.3", "789.1" ]

icd9cm

[ [ [] ] ]

[ "43.11", "31.1", "38.93", "33.21", "96.05", "99.15", "96.72", "96.07", "97.41" ]

icd9pcs

[ [ [] ] ]

12615, 12681

6902, 10145

366, 415

12877, 13027

3448, 6879

13906, 14479

2736, 2745

10771, 12592

12702, 12702

10171, 10171

13051, 13883

2760, 3429

10189, 10748

277, 328

443, 2081

12796, 12856

12721, 12775

2103, 2556

2572, 2720

71,336

134,532

883

Discharge summary

report

Admission Date: [**2122-9-3**] Discharge Date: [**2122-9-21**] Date of Birth: [**2038-11-13**] Sex: M Service: MEDICINE Allergies: Serevent Diskus / Theraflu Multi Symptom Attending:[**Doctor Last Name 1857**] Chief Complaint: Difficulty urinating, urinary retension and edema Major Surgical or Invasive Procedure: Right heart catheterization [**2122-9-14**] Peripherally inserted central catheter insertion (PICC) [**2122-9-11**] History of Present Illness: This is an 83 year-old Russian-speaking man with diastolic heart failure, CKD, DM on insulin, asthma, atrial fibrillation (on Coumadin), CAD (s/p CABG), h/o colon cancer, newly diagnosed breast cancer (s/p biopsy 2 weeks ago), presenting with abdominal distention, decreased urine output for the past two weeks with urinary retention for the past two days. His wife noticed increasing edema and abdominal girth approximately 1 month ago. He saw his outpatient cardiologist who increased his Torsemide dose from 100 to 150 mg PO daily. Approximately 2 weeks ago, his wife again noticed increasing abdominal girth and firmness as well, associated with decreasing urine output. His cardiologist again increased his Torsemide dose to 200 mg PO daily on week ago. His edema and decreased urine output continued to progress, and he began to develop scrotal edema. Two days prior to admission he was prescribed metolazone 5 mg to be taken prior to dosing Torsemide. However, he did not receive this medication. At this point he had urinary retention, and his wife brought him to the emergency department. Review of his medications from OMR revealed that he had been prescribed Tamsulosin for BPH but he was not taking this medication. In the ED, initial VS T 97.5 HR 62 BP 99/49 RR 20 SaO2 96% on RA. His creatinine was 2.6 which was an increase above his baseline of 1.5-2. A Foley was placed, >600 mL of urine was drained. A CXR showed vascular congestion and bilateral pleural effusions left>right. An EKG showed atrial fibrillation with ventricular rate of 63, RBBB, LAFB, unchanged from prior EKG. Bedside US showed bilateral pleural effusions. Abdominal U/S showed free fluid and no hydronephrosis, but scrotal fluid. He was not given diuretics initially because of his elevated creatinine. During admission to medicine service, he was given furosemide 40 mg IV with good response. However, on the following day, he failed to respond to furosedmie 40mg IV, so the dose was repeated. The following day, he also received furosedmie 40 mg IV BID. His fluid balance was even over these two days. The next day, he was given furosemide 80mg IV in the AM, 2.5 mg metolazone followed by furosemide 100mg IV in the late afternoon. In the evening, he triggered for worsening shortness of breath. He was given metolazone 5 mg with furosemide 140 mg IV around 11pm. He was also given his nebulizers and one dose of Solumedrol for possible COPD exacerbation. His O2 sats remained >95% on [**1-22**] L/min O2. His CXR at that time showed bilateral plueral effusions and vascular congestion. His net fluid balance was negative 200 cc that day. Of note he also had two episodes of hypoglycemia to 40s overnight accompanied by tachypnea and wheezing; his respiratory symptoms resolved with euglycemia. His dose of insulin had been decreased earlier that day because of decreasing PO intake. His symptoms and hypoglycemia resolved with dextrose. His insulin was further decreased to NPH 10 units QAM and 5 units QPM with sliding scale. In the morning, he again triggered for RR >30 and cardiology was consulted. Patient was transferred to cardiology service for further management. Past Medical History: CAD s/p CABG in [**2115**] (unknown anatomy) CHF (Biventricular diastolic, pulmonary HTN) Diabetes mellitus requiring insulin Chronic venous stasis dematitis left>right Diabetic ulcers on heel and foot Colon cancer(s/p Left colectomy '[**07**]) Atrial fibrillation (s/p ablation) Gout Asthma/Restrictive Lung disease CKD Stage III, baseline Cr 1.6-2.0 Social History: Patient lives with his wife at home; she is a nurse and is his primary caretaker. [**Name (NI) **] is dependent for ADLs and uses a wheelchair. Denies any history of smoking. Used to drink alcohol occasionally but now he does not. Family History: lung cancer in father (smoker) Physical Exam: General: Alert, oriented, elderly Russian speaking Caucasian man in no acute distress Vitals: T: 97.7 BP: 102/52 P: 65 R: 18 SaO2: 96% on 2 L/min NC HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP difficult to assess secondary to body habitus, no lymphadenopathy Lungs: Crackles and diminished breath sounds half way up lung fields. CV: Regular rate and rhythm, normal S1 + S2, [**1-25**] Holosystolic murmur at apex; no rubs or gallops Abdomen: Distended firm abdomen, non-tender, bowel sounds present, no rebound tenderness or guarding GU: Prominent scrotal edema, Foley in place Ext: Gross Anasarca, legs wrapped with bandages, 3 ulcers 1-2 cm in diameter. Neuro: CN II-XII intact, motor function grossly normal Pertinent Results: [**2122-9-3**] 10:57AM WBC-5.0 RBC-4.00* HGB-9.9* HCT-31.6* MCV-79* MCH-24.8* MCHC-31.4 RDW-17.2* [**2122-9-3**] 10:57AM PT-20.4* PTT-30.8 INR(PT)-1.9* [**2122-9-3**] 01:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2122-9-3**] 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2122-9-3**] 01:00PM URINE RBC-1 WBC-6* BACTERIA-FEW YEAST-NONE EPI-0 TRANS EPI-<1 [**2122-9-3**] 01:00PM URINE GRANULAR-2* HYALINE-3* [**2122-9-3**] 10:57AM GLUCOSE-94 CREAT-2.6*# SODIUM-147* POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-30 ANION GAP-16 [**2122-9-3**] 10:57AM ALBUMIN-3.7 CALCIUM-8.0* MAGNESIUM-2.3 [**2122-9-3**] 10:57AM proBNP-9471* [**2122-9-3**] 10:57AM ALT(SGPT)-48* AST(SGOT)-41* ALK PHOS-73 TOT BILI-0.4 [**2122-9-3**] 10:57AM CEA-11* CA27.29-16 ECG [**9-3**]: Artifact is present. Atrial fibrillation with a controlled ventricular response. Left axis deviation. Right bundle-branch block with left anterior fascicular block. There are small R waves in the inferior leads consistent with possible infarction. Non-specific ST-T wave changes. Compared to the previous tracing of [**2122-5-13**] there is no significant change. CXR [**9-3**]: The patient is status post median sternotomy and CABG. The heart size is moderately enlarged but appears similar compared to the prior study. There is mild-to-moderate pulmonary edema with perihilar haziness and vascular indistinctness as well as moderate-sized left and small right pleural effusions. Patchy opacities in the lung bases likely reflect compressive atelectasis. No pneumothorax is identified. There are no acute osseous abnormalities. IMPRESSION: Mild-to-moderate congestive heart failure with small right, and moderate-sized left, bilateral pleural effusions and bibasilar atelectasis. Renal Ultrasound [**9-4**]: The right kidney measured 10.5 cm. The left kidney measured 11.5 cm. Both kidneys show cortical thinning. No hydronephrosis, stones or massesis are observed. The bladder is not distended with indwelling catheter within it. IMPRESSION: Bilateral renal cortex thinning. No signs of hydronephrosis. Echocardiogram [**9-4**]: The left atrium and the right atrium are moderately dilated. The estimated right atrial pressure is at least 15 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic root is mildly dilated at the sinus level. The ascending aorta and the aortic arch are mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Severe pulmonary artery hypertension. Right ventricular cavity enlargement with free wall hypokinesis. Mild mitral regurgitation. Dilated ascending aorta. Compared with the prior study (images reviewed) of [**2121-12-12**], the findings are similar (prior study image quality was superior). These findings are suggestive of a chronic pulmonary process, e.g., PPH, chronic pulmonary embolism, COPD, OSA, etc. Chest X-ray [**9-12**]: Persistent cardiomegaly accompanied by slight improvement in degree of pulmonary edema and associated decrease in right pleural effusion, now small in size. Bibasilar opacities appear similar to the prior study as well as a moderate left pleural effusion. Right heart catheterization [**9-14**]: Hemodynamic Measurements (mmHg) Baseline Site Sys [**Last Name (un) 6043**] End Mean A Wave V Wave HR RA 11 13 14 62 RV 89 3 12 60 PCW 19 20 23 59 PA 89 19 42 60 100% O2 Site Sys [**Last Name (un) 6043**] End Mean A Wave V Wave HR PCW 22 23 28 57 PA 88 18 41 58 Nitric Oxide Site Sys [**Last Name (un) 6043**] End Mean A Wave V Wave HR PCW 21 23 26 57 PA 87 18 43 58 1. Hemodynamic catheterization revealed the presence of pulmonary arterial hypertension in the setting of moderately elevated left venticular filling pressures. Right ventricular filling pressure was mildly elevated in the setting of severe pulmonary arterial hypertension. 2. Vasodilator test wtih inhaled nitric oxide revealed no reversibility of the pulmonary hypertension. 3. Cardiac index was at the lower limit of normal. Upper extremity U/S [**9-15**]: Grayscale and Doppler son[**Name (NI) 1417**] of bilateral subclavian veins were performed; normal and symmetric flow was observed. Grayscale and Doppler son[**Name (NI) 1417**] of left internal jugular, axillary, brachial, cephalic and basilic veins were performed. There is normal compressibility, flow and augmentation. Chest, abdominal and pelvic CT [**9-17**]: CT OF THORAX: Prior median sternotomy noted. There are bilateral pleural effusions, slightly larger on the right side. There is associated collapse with volume loss involving the posterior basal segments of both the right and left lower lobes. More confluent airspace opacity is seen radiating from the hila to involve the posterior and apical segments of the right upper lobe. The right middle lobe remains well aerated. Findings are most in keeping with pulmonary edema. Ground-glass change is also seen involving the left upper lobe again in keeping with less severe pulmonary edema. Satisfactory position of the right-sided PICC line with the tip terminating in the lower SVC. Dense calcification of the left coronary artery are seen. There are multiple nonenlarged mediastinal and axillary lymph nodes. There is a 17 x 15 mm thickening in the left subareolar region likely representing the primary tumor. CT OF ABDOMEN: Note is made of a fundal gastric diverticulum (2:50). The liver is of diffuse increased attenuation with an average Hounsfield value of 100. Causes of this appearance include hemochromatosis, hemosiderosis, Wilson's disease and, most likely in this patients case, amiodarone drug therapy. No focal liver lesions are identified. The gallbladder outlines normally. The spleen is enlarged measuring 15 cm in long axis. Note is made of a 17-mm low-attenuation focus in the lower pole of spleen, which is incompletely characterized, but most likely represents a hemangioma. Both kidneys demonstrate cortical thinning; however, no focal lesions are identified. Both adrenal glands are normal in size and appearance. There are no pathologically enlarged upper abdominal. Abdominal aorta demonstrates sparse pleural calcifications, but is otherwise normal in characters and caliber CT OF PELVIS: The balloon of the Foley catheter lies within the prostatic portion of the urethra and should be repostioned. The prostate is normal in size and demonstrates coarse calcifications. Normal appearance of the common femoral artery and vein with no significant perivenous hematoma following right heart catheterization. There were no enlarged inguinal or pelvic sidewall lymph nodes. Note is made of a 21 x 18 mm low-attenuation cystic structure arising from the anterior aspect of the pancreatic body. A larger 2.8 x 3.5 cm cystic mass is seen in the pancreatic tail at the splenic hilum ( 2:56). Several other sub centimeter low attenuation foci are seen adjacent to the pancreas ( 2:56,57). Findings are in keeping with multiple pancreatic cysts or cystic neoplasms and could be further evaluated with MRCP. OSSEOUS STRUCTURES: Mild degenerative changes are seen involving the thoracolumbar spine. A 3-mm sclerotic focus in the right ilium has the appearance of a benign bone island. IMPRESSION: 1. Splenomegaly with low-attenuation lesions, incompletely characterized, but by demographics likely representing a hemangioma. 2. Malposition of the urethral catheter as described. 3. High attenuation liver parenchyma likely secondary to amiodarone therapy. 4. No evidence of a retroperitoneal hematoma. 5. Airspace opacities and pleural effussions most in keeping with pulmonary edema. 6. Cystic pancreatic lesions requiring further evaluation with MRCP. Brief Hospital Course: 83 yo M with diastolic CHF and pulmonary arterial hypertension, CKD, diabetes mellitus on insulin therapy, asthma, atrial fibrillation on Coumadin, CAD s/p CABG [**2115**], remote H/O colon cancer, new breast cancer s/p biopsy 2 weeks ago, presenting with volume overload from a combination of right sided CHF and acute on chronic kidney injury who is no longer responding to IV :asix and was transferred to [**Hospital Unit Name 196**] for aggressive diuresis. Patient was volume overloaded on admission, which was attributed to his known left and right sided diastolic CHF (with moderate RV hypokinesis). He was transferred to [**Hospital Unit Name 196**] for Lasix gtt after attempted diuresis with bolus doses of IV Lasix were unsuccessful. Repeat echo was similar to prior showing severe pulmonary arterial hypertension and resulting right sided heart failure, with EF >60%. Right heart catheterization with inhaled vasodilator testing was performed which showed elevated pulmonary pressures that were not responsive to either 100% FiO2 or inhaled nitric oxide (PA 89/19/42). Thus, it was felt he would likely not benefit from PDE inhibitor therapy. Aggressive diuresis was continued with improvement in his peripheral edema. Course was further complicated by transient bradycardia which resolved spontanously, acute on chronic renal failure and anemia. Despite response to IV diuretics, the patient's respiratory status continued to decline. CXR and CT scan of the chest demonstrated bilateral pulmonary effusions. He was started on empiric broad spectrum antibiotics with vancomycin and cefepime to complete a 7 day course. Interventional pulmonary was consulted for potential thoracentesis, however they were unable to find a pocket suitable for drainage on two occasions despite use of ultrasound guidance. The patient's O2 requirement increased to 6 L/min via shovel mask with saturations in the mid 90s. When it became clear the patient was not responding to maximal medical therapy, a conversation about goals of care was initiated with the family who ultimately decided to make him comfort measures only. Diuretics were discontinued, and the patient was given PO morphine, hyoscyamine for secretions and PRN Ativan. The plan was to transfer the patient to a hospice facility closer to his home. A few hours prior to the scheduled transfer, the patient's respirations became more labored. The patient was then noted by nursing to be unresponsive. His physician were called to bedside. After a few agonal breaths and a few faintly audible heart sounds, the patient was documented to have undetectable carotid pulses, pupils dilated to 5 mm bilateral and non-responsive to light, no apparent respirations by visualization and auscultation, no audible heart sounds, and several minutes of asystole on the bedside monitor. The patient's wife and daughter were present at his bedside. The patient was pronounced deceased at 13:13 on [**2122-9-21**]. Chief cause of death was respiratory failure secondary to congestive heart failure. Attempts to make contact with the patient's PCP were unsuccessful. Family declined autopsy. Medications on Admission: warfarin 2.5 mg daily Digoxin 62.5 mcg Toprol 25 mg daily Zolpidem 5 mg daily Fluticasone 110 mcg/actuation erythromycin ophthalmic ointment Ferrous gluconate 325 mg atorvastatin 20mg daily Humalin 30 units qPM and 10 units qPM Discharge Medications: none - patient passed away Discharge Disposition: Expired Discharge Diagnosis: Acute on chronic biventricular diastolic congestive heart failure Pulmonary arterial hypertension Atrial fibrillation Coronary artery disease with prior coronary artery bypass surgery Prior myocardial infarctions Hypertension Diabetes mellitus, poorly controlled, with hypoglycemia and Acute on chronic renal failure Bilateral pleural effusions Bifascicular heart block Edema Heel ulcers Anemia Breast cancer Prior colon cancer Gout Benign prostatic hypertrophy Urinary retention Reactive airway disease Restrictive lung disease Splenomegaly Splenic lesions on computed tomography Cystic pancreatic lesions Discharge Condition: Deceased Discharge Instructions: None - patient deceased Followup Instructions: Not applicable [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, MSC 12-339

[ "V45.81", "414.00", "585.3", "782.3", "272.0", "600.00", "493.20", "276.3", "486", "427.89", "V10.05", "287.5", "459.81", "372.30", "427.31", "403.90", "V58.61", "428.0", "V58.67", "428.23", "V49.86", "175.9", "707.14", "397.0", "041.49", "599.0", "584.9", "V66.7", "250.80", "416.8" ]

icd9cm

[ [ [] ] ]

[ "86.28", "89.64", "38.97" ]

icd9pcs

[ [ [] ] ]

17060, 17069

13594, 16731

351, 468

17719, 17729

5101, 13571

17801, 17957

4302, 4334

17009, 17037

17090, 17698

16757, 16986

17753, 17778

4349, 5082

262, 313

496, 3663

3685, 4038

4054, 4286

57,615

127,312

19057

Discharge summary

report

Admission Date: [**2158-1-21**] Discharge Date: [**2158-1-27**] Date of Birth: [**2085-11-26**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Shellfish Derived / Ciprofloxacin Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: weakness shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 72 y.o. Female w/ h.o. longstanding RA on chronic Prednisone, A. fib not anticoagulated [**2-21**] GI bld, ILD [**2-21**] ?RA, tachy-brady syndrome s/p PPM, initially seen at [**Location (un) 620**] for SOB s/p intubation for acute resp failure transferred for further respiratory management. . On review of pt's records as well as discussion with the husband it appears that Ms. [**Known lastname 52029**] initially presented to [**Location (un) 620**] on [**1-16**] with a 3 week history of progressive dyspnea. Per pt's family she had no cough, fevers, chills she had an oxygenation saturation in the low 80s which lead to her ED visit. In the [**Location (un) 620**] ED she was noted to be hypoxic saturating mid 80s on RA, she placed on 4L n.c. which resulted in an increase to mid 90s. She has a baseline home oxygen requirement of 2l. For her work up she underwent a CXr which showed a Rt [**Location (un) **] effusion, left lung was clear. Given the level of her hypoxia and history of immobilization she underwent a CTA which showed no P. Embolism but did show b/l [**Location (un) **] effusion r>>L. Rt [**Location (un) **] effusion also showed left middle and lower lobe collapse. Her initial hypoxia was thought to be [**2-21**] her b/l [**Month/Day (2) **] effusions in addition to her underlying parenchymal disease. She appeared clinically dry on admission. It appears she underwent an Echo which showed an EF of 50-55%, moderately reduced RV systolic function, moderate pul HTN, 3+ TR. On [**1-18**] it appears there was concern with her pCO2 increasing to high 60s, pt was placed on BiPAP with no change in her pCO2. She was intubated electively for possible hypercapneic failure. On review her pH at that time was 7.35-7.41, HCO3 41-43. During intubation she was noted to go into A.fib with RVR with rates in the 130s and SBP in the 80s. . With regards to her A. fib, she was noted to go into RVR requiring Amiodarone 150mg IV over 10 minutes x 2 and then a gtt with minimal improvement. Metoprolol, diltiazem were held given hypotension. Digoxin was also held given level of 2.75. After she was given her digoxin and restarted on her Dilt and Metoprolol she converted into sinus rhythm. . She was also noted to be hypotensive following intubation that was attributed to diuresis prior to intubation and anaesthesia medications. Following intubation she was given NS boluses until her BP returned to 120s. It is unclear if the increase in BP was due to rate versus prior diuresis versus ?adrenal insufficiency. Pt was given Solumedrol stress dosing in addition to the bolus. . She underwent a diagnostic thoracentesis to determine the etiology of her effusions. Effusion was exudative with cloudy, viscous material amber in colour. 4800 nucleated cells, 1% Neutrophils, 30%lymphs, 69% monos, Glc 108, TP 2.5, TGL 17, LDH 318. Culture was pending at time of transfer, gram stain showed 0-1polys but no organisms. Cytology pending, Rh factor and complement levels were unable to be added. Past Medical History: AFib-- not on Couamdin due to recent UGIB when supratherapeutic ILD [**2-21**] RA, on home O2 PRN esp at night when supine, baseline 92% on 2L Osteoporosis Vertebral compression fraxtures of T5, T7, T8, T12 in [**Month (only) 547**] [**2157**]; NS saw at time, pt declined kyphoplasty, Pacer for tachy-brady HTN Social History: Lives with husband at house; has three grown children; 20 pack year smoking hx; denied EtOH Family History: Family history is not significant for early coronary artery disease or stroke. 3 brothers with lung cancer Physical Exam: GENERAL: Elderly Caucasian Female in bed intubated HEENT: PERRL CARDIAC: S1, S2, no m/g/r, RRR LUNGS: Diminished diffusely with crackles noted ABDOMEN: No facial grimacing noted, ND, soft, +BS x 4 EXTREMITIES: Atrophy noted in lower extremities, 2+ edema noted in b/l wrists. SKIN: Ecchymoses noted over right hand, left arm. Pertinent Results: ADMISSION LABS: [**2158-1-22**] 03:54AM BLOOD WBC-9.9 RBC-3.28* Hgb-9.4* Hct-30.2* MCV-92 MCH-28.6 MCHC-31.1 RDW-15.5 Plt Ct-193 [**2158-1-22**] 03:54AM BLOOD Neuts-92.6* Lymphs-2.8* Monos-4.2 Eos-0.3 Baso-0.1 [**2158-1-22**] 03:54AM BLOOD Plt Ct-193 . [**2158-1-25**] 02:02AM BLOOD Ferritn-686* [**2158-1-24**] 04:43AM BLOOD Hapto-296* [**2158-1-27**] 03:42AM BLOOD Fibrino-206 . [**2158-1-25**] 12:50PM BLOOD ESR-5 . [**2158-1-22**] 03:54AM BLOOD Glucose-157* UreaN-31* Creat-0.2* Na-139 K-4.0 Cl-106 HCO3-27 AnGap-10 [**2158-1-22**] 03:54AM BLOOD Calcium-7.4* Phos-2.0* Mg-2.3 . [**2158-1-24**] 04:43AM BLOOD LD(LDH)-376* CK(CPK)-55 TotBili-0.6 . [**2158-1-25**] 02:02AM BLOOD Cortsol-51.1* [**2158-1-25**] 02:02AM BLOOD CRP-22.7* . [**2158-1-24**] 05:02AM BLOOD Lactate-1.4 . [**2158-1-22**] 03:54AM BLOOD Digoxin-1.5 . ABG: [**2158-1-21**] 09:23PM BLOOD Type-ART Temp-37.5 Rates-4/0 Tidal V-400 PEEP-5 FiO2-40 pO2-72* pCO2-50* pH-7.38 calTCO2-31* Base XS-2 -ASSIST/CON Intubat-INTUBATED . MYOGLOBIN, SERUM 270 H <=30 mcg/L ALDOLASE 12.7 H <=8.1 U/L [**2158-1-24**] 07:27PM BLOOD ACETYLCHOLINE RECEPTOR MODULATING ANTIBODY-PND ACETYLCHOLINE REC BINDING <0.30 <=0.30 nmol/L . MICRO: BAL neg [**Year/Month/Day **] [**Year/Month/Day **] cx neg blood and urine cx neg C. dif positive . IMAGING: CXR:These views are markedly limited secondary to difficulty in positioning patient and due to her large body habitus. The cardiac silhouette is markedly enlarged, but stable since [**Month (only) 216**] [**2157**] study. There is a tracheostomy tube whose distal tip is approximately 2 cm from the carina; however, this may be distorted due to projection. There are bilateral [**Year (4 digits) **] effusions with a left retrocardiac opacity. There is an element of [**Year (4 digits) **] overload. There are severe degenerative changes of the right glenohumeral joint. A left-sided pacemaker is identified. . TTE: The left atrium is dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2157-3-21**], the degree of mitral regurgitation has decreased. The degree of tricuspid regurgitation has increased. The other findings are similar. Brief Hospital Course: 72 y.o. Female w/ longstanding RA, tachy-brady syndrome s/p PPM, A. fib with RVR not anticoagulated [**2-21**] GI bld, s/p recent d/c for PNA initially admitted to [**Location (un) 620**] for dyspnea s/p intubation for hypercapneic resp failure w/ exudative [**Location (un) **] effusions. . ##. Hypercapneic Respiratory Failure s/p Intubation: Pt was electively intubated for concern of hypercapnea. Given pH readings were 7.39-7.41 in the setting of pCO2 of 69 suspect that pt may have chronic CO2 retention from OSA and Obesity Hypoventilation Syndrome. The presumed etiology of initial decompensation was bilateral [**Location (un) **] effusions. Pt had thoracentesis at OSH which showed exudative picture, however this was done after very aggressive diuresis. Repeat thoracentesis was done and showed transudative effusions, more consistent with clinical picture which was CHF. TTE showed LVEF>55% and stable MR. It was considered likely that forward flow was overestimated by TTE, and MR [**First Name (Titles) **] [**Last Name (Titles) 52030**] significant contirbuting to reduced forward flow. Patient was initially diuresed. Repeat imaging showed [**Last Name (Titles) **] effusions to be very mild in size, and unlikely to be causing continued inability to wean off vent. Bronch showed clear secretions, all cx data negative. . Patient was noted to be extremely weak, with strength 1/5 in extremities and very poor NIFs. In speaking with family, patient's strength had been declicing insiduously at home for 6 months. Patient had suffered compression fractures in that time. Neurology was consulted and recommended tapered steroids for possible steroid myopathy. Studies for myasthenia [**Last Name (un) 2902**] and myositis were sent. MRI could not be performed due to pacemaker, so cord compression could not be evaluated. The team and family considered further evaluation of weakness, but given poor prognosis and unlikely chance of finding a diagnosis that would be treatable, CTs and EMGs were not done. Ultimately, patient's central muscle weakness was thought to be the reason for her respiratory failure. Patient was extubated and made CMO on [**2158-1-27**]. . ##. [**Date Range 23463**] Effusions: Patient underwent U/S-guided thoracentesis. As mentioned above, transudative likely due to CHF and poor forward flow in setting of MR. [**First Name (Titles) 23463**] [**Last Name (Titles) **] gram stain, culture and cytology were negative. Glucose was not consistent with RA. She was initially treated empirically with vanco/Zosyn until all cx returned negative. . ##. Hyponatremia: Pt was noted to be hyponatremic on admission to [**Location (un) 620**] with 123, corrected with IVF. Suspected this was hypovolemic hyponatremia given correction with hydration and h.o. decreased PO intake over the past 3 weeks. . ##. A. Fib with RVR: Pt was noted to be in A. fib with RVR peri-intubation. Unclear as to whether she her nodal agents were held in the setting of hypotension versus hypotension occuring in the setting of A. fib with RVR. Pt converted to sinus spontaneously when placed on her home regimen of digoxin at OSH. She was continued on digoxin, Diltiazem and Metoprolol. On [**2158-1-24**], returned to AF with RVR, started on diltiazem gtt. As this was not effective, patient was loaded with IV amiodarone and started on drip. Rate control improved, but patient remained in AF. . #. Oliguria: Patient had decreased urine output at home for [**1-21**] weeks PTA, with 300-400cc/day. Patient continued to have poor UOP, not responsive to diuretics. Patient received conservative IVF boluses prn to maintain adequate UOP. Etiology was thought to be poor renal perfusion due to poor forward flow as above. . ##. RA: Continued pt on home regimen of plaquenil. Patient was treated with stress dose steroids given chronic prednisone use, and steroids were weaned q2 days. . ##. GERD: Continued on home regimen of Prevacid. . ##. UTI: Pt has +Urine Cx for Enterococcus at OSH, completed 10 day course of Zosyn. . ##. FEN: TF Neutropulm with a goal of 40cc/hr. Medications on Admission: Diltiazem XT 180mg [**Hospital1 **] Prednisone 7.5mg daily Hydroxychloroquine 200mg [**Hospital1 **] Tylenol 500mg TID ASA 325mg daily Atenolol 100mg [**Hospital1 **] Digoxin 125mcg daily Senna daily Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "714.0", "V58.65", "511.9", "276.2", "278.00", "515", "518.0", "518.81", "276.52", "599.0", "327.23", "530.81", "427.81", "788.5", "416.8", "V45.01", "276.3", "041.04", "278.8", "428.22", "008.45", "428.0", "276.1", "427.31", "E932.0", "397.0", "359.4" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "34.91", "33.22" ]

icd9pcs

[ [ [] ] ]

11576, 11585

7210, 11293

351, 358

11637, 11647

4325, 4325

11704, 11851

3854, 3963

11543, 11553

11606, 11616

11319, 11520

11671, 11681

3978, 4306

283, 313

386, 3392

4341, 7187

3414, 3728

3744, 3838

80,020

102,127

7949

Discharge summary

report

Admission Date: [**2132-11-17**] Discharge Date: [**2132-11-28**] Date of Birth: [**2054-6-22**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: unstable angina Major Surgical or Invasive Procedure: Coronary artery bypass grafting times three(Left internal mammary artery to left anterior descending, saphenous vein graft to right circumflex artery)[**2132-11-24**] left heart catheterization, coronary angiogram [**2132-11-21**] History of Present Illness: This 78 year old male presented with new onset of angina with minimal activity and at rest. An echocardiogram on [**11-18**] revealed hypokinesis as well as lateral anterior and inferoposterior wall hypokinesis. The EF was reduced to 30%. He also was noted to have Q wave. Catheterization revealed oteal left main, occluded LAD and a right stenosis of hemodynamic significance. He was referred for operation. Past Medical History: noninsulin dependent diabetes mellitus hyperlipidemia s/p open reduction/internal fixation of right humerus fracture s/p cholecystectomy [**2115**]. s/p Incisional hernia repair. s/p Appendectomy [**2071**]. s/p Right melanoma on right forehead removed in [**2105**], thought to be early stage. Social History: Race:caucasian Last Dental Exam:[**10-19**] Lives with: wife Contact: [**Name (NI) 28517**] Phone #([**Telephone/Fax (1) 28518**] Occupation:retired pulmonologist Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx: Other Tobacco use:cigar a couple times a year for many years ETOH: < 1 drink/week [] [**3-17**] drinks/week [x] >8 drinks/week [] Denies illicit drug use Family History: Family History:non-contributory Physical Exam: Physical Exam Pulse:81 Resp:20 O2 sat: 97%RA B/P 127/76 Height:5'[**31**]" Weight:98.1 kgs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 1+ Left:1+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit Right: - Left: - Pertinent Results: [**2132-11-26**] 04:27AM BLOOD WBC-10.1 RBC-3.06* Hgb-9.6* Hct-27.8* MCV-91 MCH-31.3 MCHC-34.4 RDW-13.0 Plt Ct-152 [**2132-11-25**] 03:09AM BLOOD WBC-8.8 RBC-3.37* Hgb-10.7* Hct-29.6* MCV-88 MCH-31.6 MCHC-36.0* RDW-13.2 Plt Ct-136* [**2132-11-28**] 08:35AM BLOOD PT-15.8* PTT-28.4 INR(PT)-1.4* [**2132-11-27**] 05:32AM BLOOD PT-14.6* INR(PT)-1.3* [**2132-11-24**] 01:12PM BLOOD PT-14.5* PTT-43.8* INR(PT)-1.2* [**2132-11-24**] 11:56AM BLOOD PT-14.5* PTT-34.1 INR(PT)-1.3* [**2132-11-28**] 08:35AM BLOOD UreaN-28* Creat-1.4* Na-135 K-4.7 Cl-97 [**2132-11-27**] 05:32AM BLOOD Glucose-130* UreaN-24* Creat-1.3* Na-137 K-4.0 Cl-99 HCO3-30 AnGap-12 [**2132-11-26**] 04:27AM BLOOD Glucose-139* UreaN-19 Creat-1.2 Na-135 K-4.3 Cl-100 HCO3-28 AnGap-11 [**2132-11-24**] Intra-op TEE Conclusions Pre-CPB: Mild spontaneous echo contrast is present in the left atrial appendage. Overall left ventricular systolic function is severely depressed (LVEF= 25 - 30 %), with mild spontaneous echo contrast in the LV. There is moderate global free wall hypokinesis. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is AV-Paced, on low dose epinephrine. Improved biventricular systolic fxn. EF now 40 - 45%. No more spontaneous contrast in LV. The apex remains akinetic and the distal walls are hypokinetic. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2132-11-24**] 15:52 Brief Hospital Course: He remained stable and pain free after admission. Preoperative workup was carried out and he went to the Operating Room on [**11-24**] where revascularization was accomplished as noted. He tolerated the procedure well and weaned from bypass on Epinephrine, Neo Synephrine and Propofol. He remained stable, weaned from pressors and the ventilator uneventfully. Of note, intra-op TEE revealed a "haze" suggestive of potential Left Atrial Appendage thrombus. The patient will be anti-coagulated for this. Beta blockade was begun and he was gently diuresed to his preoperative weight. Physical Therapy was consulted for strength and mobility. Chest tubes and pacing wires were removed uneventfully. He experienced transient diploplia and floaters postoperatively and ophthalmology and neurology consults were obtained. He will follow up as an outpatient as these were transient and likely of no consequence. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with VNA services in good condition with appropriate follow up instructions. Medications on Admission: Medications - Prescription BETAMETHASONE VALERATE - (0.1% CREAM AS DIRECTED ) - Dosage uncertain GLUCOMETER - (AS DIRECTED ) - Dosage uncertain PRECISION STRIP - (QID) - Dosage uncertain Medications - OTC ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - test one or twice a day GERIATRIC MULTIVIT W/IRON-MIN [SPECTRAVITE SENIOR] - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once daily GLUCOSAMINE-CHONDROIT-VIT C-MN [GLUCOSAMINE COMPLEX] - (OTC) - 500 mg-400 mg Capsule - 2 Capsule(s) by mouth daily LANCETS MISC. - ([**2-10**] XD) - Dosage uncertain Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 3. Outpatient Lab Work Labs: PT/INR for LAA thromus Goal 2-2.5 First draw [**2132-11-29**] Results to phone Dr. [**Last Name (STitle) 2204**] [**Telephone/Fax (1) 2205**] 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 1 weeks. Disp:*14 Tablet Extended Release(s)* Refills:*0* 7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 10. warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Dr. [**Last Name (STitle) 2204**] to manage for goal INR 2-2.5. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: unstable angina coronary artery disease prior mnyocardial infarction s/p coronary artery bypass noninsulin dependent diabetes mellitus obesity s/p open reduction/internal fixation of right humeral fracture s/p cholecystectomy s/p appendectomyh/o melano resection s/p herniorrhaphy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Leg - healing well, no erythema or drainage. Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr.[**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**2133-1-6**] 1:45 Cardiologist: Dr[**Doctor Last Name **] office will call you with an appt. Please call to schedule appointments with: Primary Care; Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 2205**]) in [**5-13**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for LAA thromus Goal 2-2.5 First draw [**2132-11-29**] Results to phone Dr. [**Last Name (STitle) 2204**] [**Telephone/Fax (1) 2205**] Completed by:[**2132-11-28**]

[ "272.4", "411.1", "V13.89", "412", "602.3", "278.00", "593.2", "414.01", "368.8", "V58.61", "250.00", "V10.82" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7576, 7634

4401, 5561

327, 560

7959, 8175

2453, 4378

9014, 9754

1749, 1768

6286, 7553

7655, 7938

5587, 6263

8199, 8991

1783, 2434

272, 289

588, 1001

1023, 1320

1336, 1718

18,819

198,091

23772

Discharge summary

report

Admission Date: [**2187-3-15**] Discharge Date: [**2187-3-30**] Date of Birth: [**2118-5-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14964**] Chief Complaint: known CAD w/worsening DOE and fatigue Major Surgical or Invasive Procedure: s/p CABG x3 [**3-23**] LIMA-LAD, SVG-OM, SVG-PDA History of Present Illness: Mr. [**Known lastname 11674**] is a 68 yo with known coronary artery disease who has been experiencing worsening dyspnea on exertion and fatigue over the last 5 months. He had a positive stress test and underwent cardiac catheterization which showed an LVEF of 65%, 90%LAD, 70%D1, 99%LCx, 100%OM3, and 100%RCA. He was transfered to [**Hospital1 18**] for surgical revascularization. Past Medical History: CAD hypercholesterolemia PVD s/p L leg burn s/p LLE thrombectomy w/patch angioplasty '[**79**] PUD Pertinent Results: [**2187-3-29**] 12:36AM BLOOD WBC-6.2 RBC-3.34* Hgb-10.0* Hct-29.8* MCV-89 MCH-30.0 MCHC-33.7 RDW-13.8 Plt Ct-243 [**2187-3-29**] 12:36AM BLOOD Plt Ct-243 [**2187-3-30**] 06:50AM BLOOD UreaN-27* Creat-1.1 K-4.2 Brief Hospital Course: Mr. [**Known lastname 11674**] was admitted to [**Hospital1 18**] [**3-15**] prior to CABG. He was started on a heparin infusion and had a carotid ultrasound which showed 70-79%[**Country **] and 60-69%[**Doctor First Name 3098**]. Due to his carotid stenosis he was evaluated by the interventional cardiology service and neurology service for potential carotid stent. He had a CTA of his head and neck which showed severe irregular stenosis with an ulcerated plaque at the origin of the [**Doctor First Name 3098**] and moderate to severe stenosis at the origin of the [**Country **] as well as narrowing of the L vertebral artery at the entrance to the intracranial space, all of which was thought to be mild disease by the neurology team. It was felt by interventional cardiology and the neurology service. that there was no indicatio to per [**Doctor Last Name **] carotid stenting prior to CABG. On [**3-23**] he was taken to the operating room with Dr. [**Last Name (STitle) 70**] for a CABGx3. He tolerated the procedure well and was transferred to the ICU in stable condition. He was weaned and extubated from mechanical ventilation on his first post op night without difficulty. He required lo dose neo synephrine for his first few postoperative days, but it was weaned to off by POD#3. He had a short episode of atrial fibrillation for which he was started on amiodarone with no further episodes. Vascular surgery was consulted on POD#$ regarding the patient's coumadin use and whether or not it was still indicated. He underwent an abdominal ultrasound which showed no evidence of AAA, and it was determined that he no longer required coumadin therapy. He was transferred to the regular floor on POD#4 and began working with physical therapy. By POD#4 he had been cleared by physical therapy and on POD#5 he had weaned off oxygen and was cleared for discharge to home. Medications on Admission: triamterene 37.5 qd lipitor 10mg qd lisinopril 10mg qd coumadin Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 3. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. 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* 7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp:*30 Tablet(s)* Refills:*0* 9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: CAD s/p CABG post operative atrial fibrillation HTN hypercholesterolemia PVD carotid artery stenosis s/p LLE thrombectomy w/patch angioplasty [**2179**] Discharge Condition: good Discharge Instructions: you may take a shower and was your incisons with mild soap and water do not swim or take a bath for 1 month do not drive for 1 month do not apply lotions, creams, ointments or powders to your incisions do not lift anything heavier than 10 pounds for 1 month Followup Instructions: follow up with Dr. [**Last Name (STitle) 30380**] in [**1-7**] weeks follow up with Dr. [**Last Name (STitle) 32255**] in [**1-7**] weeks follow up with Dr. [**Last Name (STitle) 70**] in [**5-11**] weeks Completed by:[**2187-3-30**]

[ "401.9", "V58.83", "443.9", "V12.51", "997.1", "414.01", "V15.5", "272.4", "427.31", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "36.15", "36.12", "39.61", "88.41" ]

icd9pcs

[ [ [] ] ]

4351, 4406

1201, 3094

359, 410

4603, 4609

965, 1178

4915, 5151

3208, 4328

4427, 4582

3120, 3185

4633, 4892

282, 321

438, 824

846, 946

69,676

141,707

45064

Discharge summary

report

Admission Date: [**2111-4-14**] Discharge Date: [**2111-4-26**] Date of Birth: [**2048-7-25**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest and back pain Major Surgical or Invasive Procedure: [**2111-4-14**] - Emergent repair of Type A Aortic Dissection left heart catheterization, coronary angiogram History of Present Illness: This 62 year old white male with a history of coronary artery disease went to the ED and was admitted to [**Hospital6 16464**] for chest pain. Troponins were negative and there were no EKG changes. He was then transferred for cardiac catheterization. In the lab no significant coronary disease was found, however, he was then found to have an acute type A aortic dissection. Surgical referrral was then made. Past Medical History: hypertension hypercholesterolemia depression [**Last Name (un) 309**] body disease-(followed Dr. [**Last Name (STitle) **] old brain hemorrhage on MRI, L arm tremor sleep apnea on home CPAP prostate cancer s/p radical prostatectomy s/p lumbar laminectomy x2 s/p tonsilectomy Social History: exercise -walking no tobacco social EtOH married insurance sales Family History: Noncontributory Physical Exam: Deferred Pertinent Results: [**2111-4-14**] ECHO PREBYPASS No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately/severely dilated. The descending thoracic aorta is mildly dilated. A mobile density is seen in the ascending aorta consistent with an intimal flap/aortic dissection. The flap originates just proximal to the sino-tubular junction and extends through the arch and into the descending aorta. The aortic valve leaflets (3) are mildly thickened. Severe (4+) aortic regurgitation is seen and is secondary to the disection flap prolapsing into/through the AV during diastole. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS The patient is receiving an infusion of epinephrine at 0.03 ucg/kg/min LV systolic function remains preserved in the setiing of inotropes. RV systolic function is borderline normal. The AI is now trace. The disection flap is no longer seen in the ascending aorta but remains in the arch and descending aorta. There is a tube graft visualized in the ascending aorta. The remaining study is unchanged compared to prebypass. [**2111-4-22**] 05:54AM BLOOD WBC-12.5* RBC-3.24* Hgb-9.7* Hct-30.1* MCV-93 MCH-29.9 MCHC-32.2 RDW-16.0* Plt Ct-160 [**2111-4-16**] 03:01AM BLOOD WBC-11.2* RBC-2.93* Hgb-9.1* Hct-26.5* MCV-90 MCH-31.2 MCHC-34.5 RDW-16.2* Plt Ct-114* [**2111-4-22**] 05:54AM BLOOD Glucose-131* UreaN-22* Creat-1.2 Na-143 K-2.6* Cl-102 HCO3-35* AnGap-9 [**2111-4-22**] 07:07AM BLOOD K-2.8* [**2111-4-15**] 03:59AM BLOOD Glucose-127* UreaN-18 Creat-1.2 Na-139 K-4.0 Cl-112* HCO3-22 AnGap-9 Brief Hospital Course: Following detection of the Type A dissection at cardiac catheterization he was taken for emergent repair. He was taken immediately to the Operating Room where he underwent surgical repair of his aortic dissection with resuspension of the aortic valve. Please see operative note for details. He weaned from bypass on Neo Synephrine, Epinephrine and Propofol infusions in stable condition. Postoperatively he was taken to the intensive care unit for monitoring. He awoke intact, was weaned from the ventilator and extubated. Pressors were weaned to off and he remained stable. Chest tubes were discontinued without complication. The patient was disoriented, and narcotics were minimized. His mental status improved and he became alert and oriented. He had a postoperative ileus, treated conservatively. He regained bowel sounds, had normal bowel movements and the NG tube was removed and liquidws started. His diet was gradually advanced to a regular heart healthy diet. Physical Therapy worked with him for mobility and strengthening. beta blockade was instituted and he was diuresed towards his preoperative weight. Blood pressure was controlled pharmacologically. He required reinsertion of the Foley catheter for retention and Tamsulosin was started. Foley was subsequently removed and he was able to spontaneously void. ON POD#10 His right lower extremity SVG harvest site was noted to erythematous, warma dn tender to touch. He was treated with IV Vanco and po levaquin with improvement. He was sent to rehab on POD#12 on a 7day course of oral bactrim and levaquin after being cleared by DR. [**Last Name (STitle) **]. He was referred to a rehabilitation facility for further recovery prior to return home. Medications on Admission: lisinopril, lopressor, lipitor, hydrochlorothiazide, prozac, norvasc, potassium Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for PAIN. 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever/pain. 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 10 days: while on lasix. 14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days: for right lower extremity cellulitis. 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days: until edema has resolved and at pre-op weight. 17. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: for RLE cellulitis. Discharge Disposition: Extended Care Facility: [**Hospital 745**] Health Care Center Discharge Diagnosis: Type A Aortic dissection hypertension hyperlipidemia depression prostate cancer Early [**Last Name (un) 309**] Body dementia post operative ileus saphenous vein graft cellulitis right thigh Discharge Condition: Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with Ultram prn Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with Ultram prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Surgeon Dr. [**Last Name (STitle) **] [**2111-5-20**] at 1pm ([**Telephone/Fax (1) 170**]) Please call to schedule appointments Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**] in [**2-14**] weeks ([**Telephone/Fax (1) 133**]) Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-14**] weeks ([**Telephone/Fax (1) 5768**]) Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2111-4-26**]

[ "998.59", "518.0", "682.6", "443.29", "997.4", "560.1", "403.90", "414.12", "272.0", "424.1", "997.1", "427.31", "311", "331.82", "294.10", "441.01", "E878.2", "511.9", "585.9", "V10.46", "788.20" ]

icd9cm

[ [ [] ] ]

[ "35.11", "37.22", "88.55", "39.61", "88.42", "88.53", "38.93", "38.45" ]

icd9pcs

[ [ [] ] ]

6620, 6684

3086, 4813

341, 452

6918, 7107

1351, 3063

7648, 8192

1290, 1307

4943, 6597

6705, 6897

4839, 4920

7131, 7625

1322, 1332

282, 303

480, 893

915, 1191

1207, 1274

46,467

185,232

46526

Discharge summary

report

Admission Date: [**2100-9-7**] Discharge Date: [**2100-9-17**] Date of Birth: [**2018-3-20**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Sternal cellulitis Major Surgical or Invasive Procedure: none History of Present Illness: 82 yo male s/p AVR/CABG with sternal erythema with evidence of cellulitis. Past Medical History: Sternal Cellulitis Aortic valve replacement 25-mm Biocor Epic tissue valve. Coronary artery bypass grafting x 3 (LIMA-LAD, SVG>OM, PDA) [**2100-8-6**] Insulin Dependent Diabetes Mellitus Hypertension Rheumatic Heart Disease Prostate Cancer s/p radiation therapy PSH: s/p Left total hip replacement at the [**Hospital3 **] in [**12-15**] s/p Bilateral knee replacements in [**2096**] Right shoulder surgery Prostatectomy [**2075**] Social History: Race: Caucasian Last Dental Exam: [**2-7**] mos. ago Lives with: wife Occupation: retired engineer, published his very moving book on his WWII experiences, keeps very active- builds furniture Tobacco: never ETOH: quit 3 yrs. ago Family History: non-contributory Physical Exam: VS: BP 98.4F; 128/75; 53; 18; O2 sats 100% on RA Height: 65 in.; Weight: 92.99 kgs. (205.00 lbs); BMI: 34.1 General - Alert and oriented to person, place and time; in no acute distress. HEENT - normocephalic, atraumatic, pupils equal round reactive to light, extra-ocular muscles intact, reduced visual acuity, moist mucous membranes, Neck - No lymphadenopathy, no thyroid masses, no carotid bruit. Chest - clear to auscultation bilaterally, no wheezes, rhonchi or crackles Heart - Regular rate and rhythm,distant s1 and s2 heard; Surgical scar on the chest, redness. Abd - Active bowel sounds, soft, nontender, nondistended Skin: No rash. Tatoo on both arms and chest. Extremities - No clubbing cyanosis. Neuro: non focal Pertinent Results: Micro: [**2100-9-7**] BC x 2 no growth Chest CT [**2100-9-7**]: Patient is status post CABG with intact sternotomy sutures. Unsharp edges of sternum, moderate peristernal and retrosternal mediastinal soft tissue stranding with small amount of retrosternal fluid but without features of frank abscess or mediastinitis. This could however still raise possibility of early infection and should be monitored. [**2100-9-13**] 07:10AM BLOOD WBC-5.7 RBC-3.87* Hgb-11.4* Hct-34.0* MCV-88 MCH-29.4 MCHC-33.4 RDW-14.7 Plt Ct-260 [**2100-9-13**] 07:10AM BLOOD PT-14.6* INR(PT)-1.3* [**2100-9-13**] 07:10AM BLOOD Glucose-126* UreaN-34* Creat-1.6* Na-139 K-4.7 Cl-101 HCO3-29 AnGap-14 [**2100-9-17**] 06:05AM BLOOD WBC-5.0 RBC-3.62* Hgb-10.7* Hct-31.5* MCV-87 MCH-29.6 MCHC-33.9 RDW-14.6 Plt Ct-236 [**2100-9-17**] 06:05AM BLOOD PT-14.3* INR(PT)-1.2* [**2100-9-17**] 06:05AM BLOOD Glucose-92 UreaN-26* Creat-1.4* Na-139 K-4.3 Cl-104 HCO3-26 AnGap-13 Brief Hospital Course: Mr. [**Known lastname 50500**] is an 82 year old male with a history of diabetes,on insulin, admitted to Cardiac surgery service for sternal wound cellulitis. He underwent AVR(25mm porcine)/CABGx3(LIMA-LAD, SVG->OM, PDA) on [**8-6**] with dr.[**Last Name (STitle) **]. Please refer to discharge summary [**8-14**] for further information. Overall he was doing well and making slow progress. On [**9-2**] he was seen in [**Hospital **] clinic and was found to have sternal incision with mild erythema but no obvious signs of infection. He was started empirically on Keflex at renal doses for 10 days. On [**9-7**] the patient noticed no improvement and called Dr[**Last Name (STitle) **] office. He was admitted to CT surgery service for IV antibiotics, and started on IV Vanc and oral Cipro. He was initially admitted to CVICU because he required an insulin drip for uncontrolled hyperglycemia. Mr.[**Known lastname 98814**] hyperglycemia improved and he was then transferred out to the step down unit on [**9-9**]. He has been afebrile, stable, white count has never been elevated, Blood cultures are negative but the area of redness has not improved despite antibiotics. Chest CT scan revealed small amount of retrosternal fluid and surgical changes of the sternum, without features of frank abscess or mediastinitis per Radiology. [**Last Name (un) **] was consulted for glucose control and changed his insulin regime to Lantus to [**Hospital1 **] and adjusted his humalog sliding scale. His blood sugars were very labile. Infectious disease was consulted for the cellulitis and recommended Vanco 750mg IV q12hrs and Levofloxacin 750 every 48 hrs for 4-6 weeks. Repeat Chest CT unchanged with small collection of sternal fluid. He continued to make steady progress, blood sugars well controlled, warfarin follow-up with his PCP for INR Goal of 2.0-2.5 for atrial fibrillation. He was discharged to home with [**Hospital3 **] VNA on Hospital day# 11. Follow up appointments were advised. Medications on Admission: Metoprolol Tartrate 12.5 mg PO BID Aspirin EC 81 mg PO DAILY Amiodarone 200 mg PO/NG DAILY Oxycodone-Acetaminophen [**2-7**] TAB PO Q4H:PRN pain Bisacodyl 10 mg PR DAILY:PRN constipation Psyllium 1 PKT PO TID:PRN constipation Simvastatin 10 mg PO/NG DAILY Docusate Sodium 100 mg PO BID Timolol Maleate 0.25% 1 DROP BOTH EYES [**Hospital1 **] Finasteride 5 mg PO DAILY Insulin SC (per Insulin Flowsheet) Warfarin MD to order daily dose PO DAILY Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. psyllium Packet Sig: One (1) Packet PO TID (3 times a day) as needed for constipation. Disp:*2 Packet(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 6 weeks. Disp:*21 Tablet(s)* Refills:*0* 7. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). Disp:*1 * Refills:*2* 8. insulin glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous QAM & QHS. Disp:*1 * Refills:*2* 9. Humalog insulin sliding scale 71-100 mg/dL 0 Units 0 Units 0 Units 0 Units 101-150 mg/dL 6 Units 6 Units 6 Units 0 Units 151-200 mg/dL 7 Units 7 Units 5 Units 0 Units 201-250 mg/dL 8 Units 8 Units 6 Units 1 Units 251-300 mg/dL 9 Units 9 Units 7 Units 2 Units 301-350 mg/dL 10 Units 10 Units 8 Units 3 Units 351-400 mg/dL 11 Units 11 Units 9 Units 4 Units 10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Coumadin 2 mg Tablet Sig: as directed Tablet PO once a day: based on INR goal INR 2-2.5 for afib. Disp:*30 Tablet(s)* Refills:*2* 12. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 13. vancomycin 750 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750) mg Intravenous every twelve (12) hours for 6 doses. Disp:*84 * Refills:*0* 14. Outpatient Lab Work WEEKLY Labs Creat, bun, T bili, Alt, Ast, Alk ph, CBC w/diff Vancomycin trough All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: Sternal Cellulitis Aortic valve replacement 25-mm Biocor Epic tissue valve. Coronary artery bypass grafting x 3 (LIMA-LAD, SVG>OM, PDA) [**2100-8-6**] Insulin Dependent Diabetes Mellitus Hypertension Rheumatic Heart Disease Prostate Cancer s/p radiation therapy PSH: s/p Left total hip replacement at the [**Hospital3 **] in [**12-15**] s/p Bilateral knee replacements in [**2096**] Right shoulder surgery Prostatectomy [**2075**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision: erythema full length of sternum Discharge Instructions: Shower Daily. Wash incision with mild soap and water, rinse, pat dry Monitor area of redness for changes. Please call immediately should redness increase or develops drainage Call with fevers > 101 or chills Monitor fingerstick blood sugars and cover with humalog insulin sliding scale No driving while taking narcotics No lifting more than 10 pounds for 4 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2100-10-13**] 1:30 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] Wound check on [**2100-9-23**] at 10:15am the [**Hospital Unit Name **] [**Hospital Unit Name **] cardiac surgery office [**Telephone/Fax (1) 170**] Cardiologist Dr. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2100-9-21**] 4:00 Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) 42306**] [**Telephone/Fax (1) 98813**] further Warfarin dosing Endocrinologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10088**] [**Telephone/Fax (1) 12648**] please call for appt and for blood sugar management if blood sugars <65 or >200 **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR Coumadin for atrial fibrillation Goal INR 2.0-2.5 First draw [**9-18**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [**Last Name (STitle) 42306**] Warfarin dose will fluctuate while on Antibiotics. Completed by:[**2100-9-17**]

[ "V43.65", "357.2", "682.2", "250.62", "V43.64", "V58.67", "401.9", "V45.81", "427.31", "998.59", "398.90", "V42.2", "V10.46", "E878.1", "V58.61", "250.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7641, 7702

2901, 4901

328, 335

8179, 8328

1937, 2878

8975, 10321

1160, 1178

5396, 7618

7723, 8158

4927, 5373

8352, 8952

1193, 1918

270, 290

363, 440

462, 897

913, 1144

59,999

124,025

41412

Discharge summary

report

Admission Date: [**2150-2-3**] Discharge Date: [**2150-2-11**] Date of Birth: [**2082-1-19**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 11839**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 68 YO F w likely stage 4 malignancy of uncertain primary (likely lung, likely mesothelioma) complicated by right pleural effusion s/p pleurex placement on [**1-13**] now presenting with worsening mental status over the past several days. The patient is not able to provide any history. Her daughter, who is staying with her, reports that the patient has had 2 weeks of worsening confusion now at the point that she has not eaten anything for several days. The patient's daughter has been draining her pleurex qod for ~400-500ccs with improvement in her respiratory status but, on the date of admission, the patient's VNA came to see her and drain her pleurex and found her sats to be in the 80s on her baseline 3L NC with SBP in the 80s as well so the patient was brought into the ED. . Upon arrival to the ED, her O2 sat was in the 80s ---> 90% on 6L NC and her BP was 74/50. Exam was notable for lack of interaction and decreased breath sounds throughout the right lung. Labs were notable for bandemia of 7% and leukocytosis 92k (recent baseline ~40K), creatinine 3.4 (normal baseline) and K 7.9 (repeat 8.0). CXR was c/f worsening right sided pleural effusion. She was given vanc, zosyn, Ca, insulin, glucose, albuterol neb and 1 amp of bicarb. Two 18g PIVs were placed and her pleurex was drained for 700ccs of bloody, purulent fluid. The patient's daughter was present and, despite recent discussions suggesting the patient was engaging in hospice care, felt strongly that the patient be maintained as full code. . Upon arrival to the floor, the patient cannot provide any history and only intermittently answers questions. Her daughter denies recent fevers, chills, or worsening respiratory status. She does endorse sweats. She states her mother's mental status has been progressively declining since her discharge from the hospital on [**1-22**]. Past Medical History: 1. Malignant pleural effusion 2. Diabetes 3. Hypertension 4. Hyperlipidemia 5. Ruptured cerebral aneurysm in [**2133**] causing "stroke", s/p craniotomy, s/residual deficits. Social History: Has 75 pack-year history of tobacco use; quit >1 year ago. No recent alcohol. Previously worked as a seamstress. Family History: No family history of cancers. Physical Exam: ADMISSION EXAM: Vitals: 97.4 110 88/51 22 99% on 4L General: Alert, oriented to person only, tachypneic but NAD HEENT: Sclera anicteric, MM dry Neck: supple, JVP elevated to ear Lungs: decreased BS on R lung throughout CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . DISCHARGE EXAM: Pertinent Results: ADMISSION LABS: [**2150-2-3**] 12:00PM BLOOD WBC-92.0*# RBC-2.90* Hgb-8.3* Hct-25.2* MCV-87 MCH-28.7 MCHC-32.9 RDW-15.4 Plt Ct-581* [**2150-2-3**] 12:00PM BLOOD Neuts-92* Bands-6* Lymphs-0 Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2150-2-3**] 12:00PM BLOOD Glucose-201* UreaN-82* Creat-3.4*# Na-134 K-7.9* Cl-98 HCO3-21* AnGap-23* [**2150-2-3**] 03:20PM BLOOD Calcium-9.2 Phos-5.5*# Mg-1.7 UricAcd-15.8* . MICROBIOLOGY: [**2150-2-3**] Blood Cx: NGTD [**2150-2-3**] Urine Cx: Yeast >100,000 organisms/ml [**2150-2-3**] Pleural Fluid Cx: GRAM STAIN (Final [**2150-2-4**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. FLUID CULTURE (Preliminary): STAPH AUREUS COAG +. HEAVY GROWTH. ANAEROBIC CULTURE (Preliminary): . IMAGING: [**2150-2-3**] CXR: Interval enlargement of the massive right pleural collection with scalloped margins consistent with the apparent pleural malignancy noted on recent PET-CT. The indwelling pleural drain is stable in course and position. . [**2150-2-3**] CT Head w/o con: Comparing across modalities, the study is relatively stable compared to the very recent head MRI dated [**2150-1-29**]. No acute intracranial process identified. . [**2150-2-4**] Renal U/S: No evidence of hydronephrosis in either kidney. Brief Hospital Course: 68 year old woman with malignant pleural effusion who presented with declining mental status, hypoxia, and hypotension, and was found to have hyperkalemia and [**Last Name (un) **] in the setting of worsening malignant pleural effusion and empyema. . # Malignant Pleural Effusion/Empyema: CXR demonstrated worsening right-sided effusion. Pleural fluid frankly purulent/bloody and growing gram + cocci in pairs/clusters. She was continued on vancomyin and zosyn and the pleurex catheter was drained daily. Despite this, she remained tachypneic and uncomfortable. Per oncology, she is not a candidate for treatment of her malignancy. Palliative care was consulted and the patient and her family decided to focus on comfort care. She was started on morphine with improvement in her respiratory status. . # Altered Mental Status: Likely secondary to her underlying malignancy, empyema, UTI, and pain medications. CT head unchanged from recent MRI. . # UTI: Urine culture is growing yeast. The patient's foley was changed and she was treated with a 3-day course of fluconazole. . # [**Last Name (un) **]: FENA 0.9%, suggestive of pre-renal etiology, likely from hypotension and poor renal perfusion. Creatinine improved with fluid resuscitation. Renal ultrasound was negative for hydronephrosis or obstruction. . # Hyperkalemia: Likely secondary to [**Last Name (un) **] and ongoing lisinopril use. Tumor lysis felt to be unlikely considering normal calcium and phos. Potassium normalized with kayexalate and improvement in renal function. . # DM: Metformin was held in the setting of [**Last Name (un) **] and the patient was monitored via insulin sliding scale. . # Goals of Care: Patient is DNR/DNI and is focusing on comfort care. Pt was transferred to the oncology service. Dilay drainange of teh pleural fluid was continued . Pain was treated with the fentanyl patch and oral morphine as needed with good control. During the hospital course patinet became more lethargic and pleural fluid appeared bloody.After d/w family drainage was discontinued. Patient expired on [**2150-2-11**] at 18:45 with family at bedside. Medications on Admission: 1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY 4. hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain...recently switched to fentanyl 25mcgs patch 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipatin. 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 8. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: Mental status changes Empyema Acute renal failure Hyperkalemia Urinary tract infection Diabetes mellitus Metastatic cancer of unknown primary. likely lung cancer Discharge Condition: patient expired Discharge Instructions: Pt was admitted with mental status changes, worsening of shortness and acute renal failure. She was initially admitted to the intensive care unit and diagnosed with an empyema. During the MICU stay after discussions with family goals of care were changed to comfort measures only and patient transferred to the oncology service. Patient continued on a fentanyl patch for pain and had daily drainage of pleural fluid via the pleurax cathetr. During hospital course patient became more lethargic and has become unresponsive. After discussion it was decided to discontinue drainage of the pleural fluid. On [**2150-2-11**] patinet deceased. Followup Instructions: patient expired

[ "401.9", "V66.7", "599.0", "199.1", "250.00", "511.81", "276.7", "510.9", "584.9", "272.4", "276.1", "V49.86" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7365, 7374

4480, 5291

327, 333

7580, 7598

3131, 3131

8286, 8305

2561, 2593

7325, 7342

7395, 7559

6627, 7302

7622, 8263

2608, 3094

3112, 3112

265, 289

361, 2216

3147, 3835

3934, 4457

5306, 6601

2238, 2414

2430, 2545

3865, 3901

15,209

141,701

17047

Discharge summary

report

Admission Date: [**2128-6-8**] Discharge Date: [**2128-6-15**] Date of Birth: [**2069-6-19**] Sex: F Service: [**Company 191**] ADMISSION DIAGNOSES: 1. Pneumonia and chronic obstructive pulmonary disease. 2. Hypertension. 3. Epidural abscess. 4. Paraplegia. 5. Urinary tract infection. HISTORY OF PRESENT ILLNESS: This is a 58-year-old female with a history of chronic obstructive pulmonary disease and prolonged hospitalization in [**2128-2-21**] at [**Hospital6 **] with a chronic obstructive pulmonary disease exacerbation with respiratory failure requiring intubation. She also became methicillin-resistant Staphylococcus aureus bacteremic and was treated with vancomycin for ten days, sent to rehabilitation, and then went home. She presented back to [**Hospital1 69**] in [**2128-4-22**] with increased back pain, lower extremity neuropathy bilaterally, and was diagnosed with methicillin-resistant Staphylococcus aureus bacteremia. She also had T6-T7 vertebral osteomyelitis and an epidural abscess which was initially treated with vancomycin and gentamicin for 14 days. She then underwent surgical debridement on [**2128-5-27**] and was cultured and found to be consistent with methicillin-resistant Staphylococcus aureus osteomyelitis. She remained with paraplegia postoperatively and was also diagnosed with mitral valve endocarditis, but surgery was declined for the endocarditis at that time. The patient was discharged to [**Hospital3 **] on [**2128-5-31**] for a prolonged course of intravenous vancomycin, and she remained in rehabilitation until [**6-3**] when the patient noted fevers to 101 to 102, and a cough initially periodically with yellow sputum, and noted shortness of breath at rest. She denied any chest pain or headaches. The abdomen was negative. No nausea or vomiting. Occasional diarrhea. No melena or blood with stools. She has had a Foley in place since leaving the [**Hospital1 346**] on [**5-31**]. At [**Hospital3 **], a chest x-ray with possible right lower lobe infiltrate was seen. A sputum culture was sent which was positive for hemophilus influenza per report. The patient was initially seen at [**Hospital6 1130**] Emergency Department and then transferred here to [**Hospital1 69**] after being given 2 liters of normal saline, started on a nonrebreather, and started on dopamine. She had a left subclavian peripherally inserted central catheter line placed at [**Hospital6 2121**] and received one dose of 1 g of cefepime intravenously and was started on Levophed to increase her blood pressure. She was transferred to [**Hospital1 190**]. At the [**Hospital6 1129**] Intensive Care Unit, the patient was weaned off Levophed and maintained systolic blood pressures in the 110s. A chest x-ray showed a right lower lobe infiltrate, and lower extremity examination was negative for deep venous thrombosis. A chest computed tomography was consistent with a right lower lobe consolidation. She was then transferred to [**Hospital1 188**]. Here, she was alert and oriented with the above history. She denied any shortness of breath or chest pain and felt much better. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on arrival revealed temperature was 98.6, heart rate was 103 to 108, blood pressure was 90 to 108 systolic over 39 to 70 diastolic, respiratory rate was 16, and oxygen saturation was 96% on 2.5 liters by nasal cannula. In general, she was a 50-year-old female in no acute distress. Head, eyes, ears, nose, and throat examination revealed her pupils were equal, round, and reactive to light. The oropharynx was clear. Mucous membranes were moist. Her neck examination revealed jugular venous pulsation was about 9 mm of water. A left subclavian peripherally inserted central catheter line was in place which was clean, dry, and intact. Chest examination revealed decreased breath sounds at the right border, positive egophony at the right lower lobe, and no wheezing. Cardiovascular examination revealed distant heart sounds. No murmurs. Normal first heart sounds and second heart sounds. Abdominal examination revealed positive bowel sounds. Soft and nontender, slightly obese. Extremity examination revealed no edema. The right peripherally inserted central catheter line was clean, dry, and intact. A midline scar at the upper back which was clean, dry, and intact. A positive sacral decubitus ulcer (grade 2) with surrounding erythema. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission revealed white blood cell count was 13.9, hematocrit was 26.2, and platelets were 300. Sodium was 134, potassium was 4.6, chloride was 99, bicarbonate was 33, blood urea nitrogen was 19, creatinine was 0.8, and blood glucose was 106. Prothrombin time was 13.2 and partial thromboplastin time was 38.8. ALT was 18, AST was 15, alkaline phosphatase was 103, and total bilirubin was 0.2. Albumin was 1.6. LDH was 248. Microbiology revealed sputum culture with predominant gram-negative rods with mixed gram-positive and gram-negative; and Clostridium difficile was negative. PERTINENT RADIOLOGY/IMAGING: Left subclavian line was in place. Right lower lobe infiltrate. Negative deep venous thrombosis on lower extremity examination. A chest computed tomography with bilateral pleural effusions, right lower lobe consolidation. Air bronchogram was negative for pericardial effusion, gallstones, with no thickening or fluid. Extensive destruction of vertebrae at the T6 level and a right and left paraspinal mass; right 2.6 X 9 X 7.5 and left 2.2 X 2.8 X 7. A head computed tomography was negative for any acute changes. HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to the [**Hospital1 69**] Intensive Care Unit. 1. CHRONIC OBSTRUCTIVE PULMONARY DISEASE: For her chronic obstructive pulmonary disease, she was treated with nebulizers and puffers with a goal of trying to decrease her oxygen requirement for her nosocomial pneumonia and hemophilus influenza. She was treated with levofloxacin for 14 days. 2. HYPERTENSION ISSUES: For her hypertension, she was treated with fluids after weaned off pressors. 3. EPIDURAL ABSCESS ISSUES: For her epidural abscess and recent endocarditis (which had been stable), Neurosurgery was following and agreed with the medical treatment. No surgery expected at this time or during this admission. Will continue vancomycin. 4. PARAPLEGIA ISSUES: For her paraplegia, supportive care trying to prevent decubiti ulcers. Physical Therapy was following and assisting the patient with movement in the bed. 5. IRON DEFICIENCY ANEMIA ISSUES: For iron deficiency anemia, she was receiving iron three times per day. 6. NUTRITION ISSUES: She was on a regular full diet. 7. PROPHYLAXIS ISSUES: For prophylaxis while in the hospital, she received subcutaneous heparin without any reaction. Previously had been noted to have a possible allergy which was eventually thought to be heparin-induced thrombocytopenia; however, here during this hospitalization, had maintained stable platelet counts with subcutaneous heparin. The patient has also been on beta blocker for prophylaxis during this admission trying to prevent decubiti by Physical Therapy. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. DISCHARGE STATUS: The patient was expected to be discharged to [**Hospital3 **] Center. DISCHARGE DIAGNOSES: 1. Pneumonia and hemophilus influenza. 2. Chronic obstructive pulmonary disease. 3. Epidural abscess. 4. Endocarditis. 5. Hypertension. 6. Paraplegia. 7. Iron deficiency anemia. 8. Sacral decubitus ulcer. MEDICATIONS ON DISCHARGE: (Discharge medications were as follows) 1. Psyllium one packet p.o. three times per day as needed. 2. Levofloxacin 500 mg p.o. q.24h. (continue levofloxacin until [**6-22**]). 3. Decussate sodium 100 mg p.o. twice per day. 4. Ferrous sulfate 325 mg p.o. three times per day. 5. Bisacodyl 10 mg p.o./p.r. once per day as needed. 6. Pantoprazole 40 mg p.o. once per day. 7. Acetaminophen 325 mg to 650 mg p.o. q.4-6h. as needed. 8. Oxycodone 5 mg p.o. q.4-6h. as needed. 9. Oxycodone sustained release 30 mg p.o. q.12h. 10. Gabapentin 400 mg p.o. three times per day. 11. Fluticasone propionate 110 mcg 2 puffs inhaled twice per day. 12. Albuterol ipratropium 2 puffs inhaled q.6h. 13. Ipratropium bromide nebulizer q.6h. 14. Albuterol nebulizer solution one nebulizer inhaled q.4h. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow up with her primary care physician as needed or as determined by the [**Hospital6 47933**] physician. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Name8 (MD) 264**] MEDQUIST36 D: [**2128-6-14**] 14:47 T: [**2128-6-15**] 08:55 JOB#: [**Job Number 47934**] cc:[**Hospital6 47935**]

[ "482.2", "707.0", "280.9", "421.0", "507.0", "496", "785.59", "324.1", "276.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7453, 7667

7693, 8498

8532, 8939

5710, 7277

170, 313

7292, 7432

342, 5676

24,807

163,081

9847

Discharge summary

report

Admission Date: [**2145-8-5**] Discharge Date: [**2145-8-11**] Date of Birth: [**2104-11-11**] Sex: F Service: [**Company 191**]-MEDICI HISTORY OF PRESENT ILLNESS: This is a 40 year old Caucasian female with past medical history significant for quadriplegia, chronic adrenal insufficiency, and recurrent aspiration pneumonia requiring intubation in the past several months, who now presents with a two week history of increased cough productive of green sputum and increased shortness of breath. The patient lives at [**Doctor Last Name **] [**Hospital 33095**] Rehabilitation Home and had reportedly aspirated one and one half weeks prior to admission while eating. On arrival to the [**Hospital1 69**] Emergency Department, she was noted to be hypotensive with a blood pressure of 84/70 and hypoxic with an oxygen saturation of 78%. She was immediately placed on a 100% nonrebreather and her oxygen saturation increased to 94%. The patient denied any recent fever, chills, rhinorrhea, sore throat, headaches, sinus tenderness, and recent travel. Her review of systems was essentially unremarkable. In the Emergency Department, the patient received a dose of Vancomycin, Flagyl and Levofloxacin as well as Hydrocortisone, Narcan, Florinef and two liters of normal saline. A central line was placed in her femoral vein and she was started on Dopamine given her hypotension. The patient was then transferred to the Intensive Care Unit for a brief stay until she was medically stabilized. She was then transferred to the Medicine floor on hospital day number three. PAST MEDICAL HISTORY: 1. C3-C4 spinal cord injury in [**2139**], secondary to a motor vehicle accident resulting in quadriplegia. 2. Gastroesophageal reflux disease. 3. Depression. 4. Chronic adrenal insufficiency. 5. Chronic low back pain. 6. Left heel osteomyelitis. 7. Anxiety. 8. Anemia. 9. Decubitus ulcers colonized with pseudomonas. 10. Recurrent aspiration pneumonia and a history of Methicillin resistant Staphylococcus aureus positive sputum. ALLERGIES: Penicillin and Sulfa. MEDICATIONS ON ADMISSION: 1. Baclofen 30 mg four times a day. 2. Heparin subcutaneous 5000 units twice a day. 3. Klonopin 1 mg twice a day. 4. Oxycontin 20 mg twice a day. 5. Zanaflex 4 mg three times a day. 6. Atrovent MDI two puffs q6hours. 7. Reglan 10 mg four times a day. 8. Albuterol MDI two puffs q6hours. 9. Colace 100 mg p.o. twice a day. 10. Zinc 220 twice a day. 11. Estraderm patch 0.05 mg q72hours. 12. Magnesium Citrate one bottle q.o.d. 13. Lactulose 30 cc three times a day. 14. Neurontin 900 mg three times a day. 15. Lidoderm patch on at 9:00 a.m., off at 9:00 p.m. 16. Prednisone 5 mg once daily. 17. Oxycodone 5 mg q3-4hours p.r.n. 18. Protonix 40 mg once daily. 19. Ditropan 5 mg twice a day. 20. Iron 325 mg three times a day. 21. Zoloft 50 mg once daily. 22. Multivitamin one once daily. 23. Gas-X 40 mg four times a day p.r.n. SOCIAL HISTORY: The patient lives at [**Doctor Last Name **] Farms and smokes five cigarettes a day. She denies any alcohol or intravenous drug use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: On admission, temperature is 96.9, blood pressure 106/75, pulse 74, respiratory rate 14, and saturating 96% on ten liters nonrebreather. In general, the patient was alert but noncommunicative. She was an obese middle age Caucasian female, lying in bed, in no acute distress. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. The nares patent. No sinus tenderness. The oropharynx was clear with poor dentition. Her neck was obese and no jugular venous distention could be assessed. Her lungs demonstrated coarse rhonchi bilaterally. Cardiovascular examination revealed a regular S1 and S2 with no murmurs, rubs or gallops appreciated. Her abdomen was soft and obese with normal bowel sounds and left upper and lower quadrant tenderness to palpation. There was no rebound, guarding or ascites present. Her extremities demonstrated 1+ pitting edema bilaterally. There was no clubbing, cyanosis or calf tenderness. She has a Stage IV sacral decubitus ulcer and a Stage III left upper rib decubitus ulcer, both with good granulation tissue and no pus expression. LABORATORY DATA: On admission, white blood cell count 5.9, hemoglobin 11.8, hematocrit 35.8, MCV 93, platelet count 162,000. Sodium 140, potassium 4.5, chloride 101, bicarbonate 30, blood urea nitrogen 8, creatinine 0.5, glucose 85. Arterial blood gases revealed a pH 7.32, CO2 67 and O2 68. Urinalysis was positive for pH of 8.5, moderate leukocyte esterase, negative nitrites, 100 protein, greater than 50 red blood cells, 21-50 white blood cells, and many bacteria with no epithelial cells. Chest x-ray reveals a new right lower lobe opacity consistent with a pneumonia. Urine culture from [**2145-8-5**], grew out greater than 100,000 colonies of Klebsiella pneumoniae sensitive only to Imipenem and Zosyn. Blood cultures from [**2145-8-5**], displayed one out of two bottles of gram positive cocci in pairs and clusters consistent with Staphylococcus epidermidis and sputum cultures from [**2145-8-5**], grew out 3+ oropharyngeal flora, 4+ yeast with pseudohyphae and rare gram negative rods. HOSPITAL COURSE: 1. Infectious disease - The patient was presumed to have a recurrent aspiration pneumonia and was thus started on Levofloxacin, Flagyl and Vancomycin. This coverage was later narrowed to only Flagyl and Levofloxacin and it was determined to treat the patient with a fourteen day course of each antibiotic. Given her history of chronic urinary tract infections, the patient's Foley was changed but her urinary tract infection was left untreated. Her decubitus ulcers were monitored closely and wet to dry dressings were applied on a daily basis. The patient remained afebrile with no leukocytosis throughout her hospital stay. 2. Pulmonary - Given her aspiration pneumonia, the patient was treated with appropriate antibiotics. Frequent suctioning was performed and thick yellow secretions were removed. Chest physical therapy was also performed as needed and the patient was slowly weaned off her oxygen as tolerated. She was continued on her outpatient MDIs and given nebulizers around the clock. 3. Cardiovascular - It was unclear whether the patient's hypotensive episodes were secondary to infection versus adrenal insufficiency. She was initially given aggressive normal saline hydration and started on Hydrocortisone 100 mg three times a day, Florinef 0.2 mg once daily and Dopamine. The Dopamine was discontinued on hospital day number two and the steroids were slowly tapered off and discontinued completely. She, however, continued to remain on Florinef throughout her hospital stay. 4. Hematology - Given the patient's history of anemia, she was continued on her outpatient iron supplement. Her hematocrit remained stable throughout her hospital stay and she required no transfusions. 5. Fluids, electrolytes and nutrition/gastrointestinal - The patient's electrolytes were checked on a regular basis and repleted as needed. She was placed on a regular diet as tolerated. She was continued on an aggressive bowel regimen with Dulcolax suppositories, Colace, and Lactulose. She was followed by nutrition and given vitamin supplements like zinc and Vitamin C. Given her low albumin of 2.8, she was started on Boost supplement three times a day. 6. Neuropsychiatry - The patient continued to have persistent low back pain throughout her hospital stay. Her Oxycontin was thus increased to 30 mg twice a day with Oxycodone for p.r.n. breakthrough pain. She also continued to receive her outpatient Neurontin, Klonopin, and Zanaflex. 7. Renal - Given the patient's history of urinary incontinence, a Foley was kept in place. She was continued on her outpatient dose of Ditropan. She also continued to have a persistent metabolic alkalosis most likely compensatory for her respiratory acidosis secondary to CO2 trapping in light of her substantial pneumonia. On hospital day number six, a PICC line was placed without any complications, mainly for intravenous access and future blood draws. DISCHARGE DIAGNOSES: 1. Aspiration pneumonia. 2. Quadriplegia secondary to C3-C4 spinal cord injury from a motor vehicle accident. 3. Extensive sacral decubitus ulcers. 4. Chronic back pain. 5. Hypoalbuminemia. MEDICATIONS ON DISCHARGE: 1. Albuterol nebulizers q6hours. 2. Atrovent nebulizers q6hours. 3. Zoloft 50 mg once daily. 4. Multivitamin once daily. 5. Florinef 0.2 mg once daily. 6. Dulcolax suppositories once daily. 7. Klonopin 1 mg twice a day. 8. Zanaflex 4 mg three times a day. 9. Colace 100 mg twice a day. 10. Zinc 220 mg twice a day. 11. Lactulose 30 cc three times a day. 12. Neurontin 900 mg three times a day. 13. Iron 325 mg three times a day. 14. Protonix 40 mg once daily. 15. Levaquin 500 mg once daily until [**2145-8-19**]. 16. Flagyl 500 mg three times a day until [**2145-8-19**]. 17. Ditropan 5 mg twice a day. 18. Vitamin C 500 mg twice a day. 19. Oxycontin 30 mg twice a day. 20. Ambien 5 mg q.h.s. p.r.n. 21. Oxycodone 5 to 10 mg q4-6hours p.r.n. DISCHARGE STATUS: The patient was discharged in stable condition back to [**Doctor Last Name **] Farms subacute nursing facility. She is to continue to undergo frequent suctioning, chest physical therapy and around the clock nebulizers. She is to complete a fourteen day course of both Flagyl and Levaquin p.o. Her narcotic use should be minimized, and her aggressive bowel regimen should be continued. She is to remain on aspiration precautions. Dictated By:[**Last Name (NamePattern4) 1198**] MEDQUIST36 D: [**2145-8-10**] 19:13 T: [**2145-8-10**] 19:40 JOB#: [**Job Number 33096**]

[ "790.7", "255.4", "458.9", "599.0", "276.3", "344.00", "707.0", "507.0", "280.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

3124, 3142

8263, 8459

8485, 9839

2120, 2955

5315, 8242

3165, 5298

186, 1596

1618, 2094

2972, 3107

5,242

175,154

3687

Discharge summary

report

Admission Date: [**2119-10-11**] Discharge Date: [**2119-10-31**] Date of Birth: [**2070-10-2**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 1865**] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: Right subclavian central line placement Intubation PICC placement History of Present Illness: The patient presented to OSH ED yesterday w/neck pain since the 17th. Per the OSH, she was somnolent and found to be acidotic on ABG; she was then intubated and R triple lumen femoral placed. Discussion with family per OSH records indicates that she was found down for an undetermined amount of time. CXR initially showed extensive right-sided PNA and the next day (day of transfer) was notable for left upper lobe infiltrate. Exam was notable for fresh track marks. Pt was treated with vancomycin, gatifloxicin and Unasyn per OSH ID consult. Utox + for cocaine and opiates, BZ. By report, responded to Narcan (awoke). Head CT was negative for acute intracranial abnormality. 2 sets of blood cultures were + for gram + cocci; echo (TTE) negative for vegetations and EF was 70%. * The patient was transferred to [**Hospital1 18**] per her son's request. She was on Levophed and dopamine prior to transfer, and transferred on dopamine and bicarb gtts. She received 6 liters of IVFs by report to resident over the phone. She has been ordered 1 U PRBC, but needs to come from Red Cross, so they're trying to get the blood sent directly here. Her last abg was 7.37/40/287 on AC 500, Peep 8, rr 22, FiO2 100%. She had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test but no results are available yet. Past Medical History: Hepatitis C (liver biopsy in [**2116**] as showing stage III fibrosis) Waldenstrom's macroglobulinemia/lymphoma history of IVDU depression sialolithiasis fine tremor peripheral neuropathy s/p prolonged ICU stay for heroin and benzodiazepine overdose multi-lobar pneumonia (M. cattharalis) Social History: hx for polysubstance abuse, lives with her son Family History: Noncontributory Physical Exam: PE: AF 37.2C/ 105/65// 88// 100% Vented and on dopamine Acutely-ill female, looks younger than stated age. Flushed, awake, uncomfortable in appearance. HEENT: EOMI, perrl, conjunctiva injected, tan exudate right eye, MM dry. Neck: supple, no LAD Heart: rr, no m/g/r nl s1s2 Lungs: Diffusely rhonchorous, r>l, reduced BS at left base, no rales Abd: Distended, diffusely tender, no BS audible, no organomegaly Ext: Warm, well-perfused, no lower extremity edema, track marks in left antecub, no splinter hemorrhages. 2+ DPs b/l Pertinent Results: OSH Labs: Select labs below [**10-11**]: wbc 0.9, 39%pmns, 31%Bands, 16L, 12M, 1 atyp, 1 meta [**10-10**]: wbc 2.2, 11%pmns, 62%band, 9L, 4 atyps, 2 M, 1 B, 9 metas INR 1.5 CK 2628, BUN 40, Creat 1.7, Ti .02 [**2119-10-23**] - Echo - The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. 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 regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a small (~1cm) anterior pericardial effusion but without evidence of hemodynamic compromise. [**2119-10-27**] CXR - 1. Peripheral and basilar predominant interstitial pattern affecting the right lung to a much greater degree than the left, in corresponding to more extensive areas of consolidation on earlier radiograph of [**2119-9-23**]. These findings may be due to slowly resolving pneumonia, but areas of interstitial disease from drug toxicity, previously masked by an overlying pneumonia, is within the differential diagnosis, particularly if the patient has received bleomycin therapy. Continued radiographic followup is recommended to assess for resolution. If persistent, a high-resolution CT may be considered. 2. Splenomegaly. . CXR PA/LAT [**2119-10-29**]: IMPRESSION: 1. No radiographic evidence of acute, displaced rib fracture. If symptoms are localized to a specific area, coned-down rib films with metallic marker may be helpful. 2. Interstitial lung opacities as described above. Please see recent report [**2119-10-27**] regarding differential diagnosis and recommendations. [**2119-10-11**] 11:54PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2119-10-11**] 11:54PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-TR [**2119-10-11**] 09:05PM TYPE-[**Last Name (un) **] PH-7.30* [**2119-10-11**] 09:05PM LACTATE-5.1* [**2119-10-11**] 09:05PM freeCa-0.96* [**2119-10-11**] 08:38PM GLUCOSE-220* UREA N-30* CREAT-1.1 SODIUM-137 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-21* ANION GAP-17 [**2119-10-11**] 08:38PM ALT(SGPT)-81* AST(SGOT)-196* LD(LDH)-528* CK(CPK)-[**2096**]* ALK PHOS-62 AMYLASE-22 TOT BILI-1.1 [**2119-10-11**] 08:38PM ALT(SGPT)-81* AST(SGOT)-196* LD(LDH)-528* CK(CPK)-[**2096**]* ALK PHOS-62 AMYLASE-22 TOT BILI-1.1 [**2119-10-11**] 08:38PM ALBUMIN-2.6* CALCIUM-6.6* PHOSPHATE-2.2* [**2119-10-11**] 08:38PM ALBUMIN-2.6* CALCIUM-6.6* PHOSPHATE-2.2* [**2119-10-11**] 08:38PM VANCO-13.8* [**2119-10-11**] 08:38PM WBC-5.5# RBC-4.09* HGB-11.5* HCT-34.2* MCV-84 MCH-28.2 MCHC-33.7 RDW-16.0* [**2119-10-11**] 08:38PM NEUTS-82* BANDS-14* LYMPHS-1* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2119-10-11**] 08:38PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL Brief Hospital Course: 49 year-old female with history significant for Hepatitis C, IV drug use, and Waldenstrom's macroglobulinemia now transferred from outside hospital with high grade bacteremia, septic shock, and respiratory failure. * 1) Respiratory failure: Her respiratory secondary to a right upper lobe pneumonia. On transfer, her PaO2 to FiO2 ratio was less than 200, which is consistent with ARDS. Therefore, she was switched to pressure control ventillation to keep her peak pressures less than 30. At those pressures, she was pulling tidal volumes of about 400 cc. She was intially covered with broad spectrum antibiotics vancomycin, levofloxacin, and cefepime. When her blood cultures grew out strep. pneumonia, noted from the OSH, she was switched to penicillin. She became febrile on [**10-19**] and [**10-20**] self-extubated on [**10-20**], and later had to be reintubated on [**10-21**] due to tachypnea and alkalemia. She was extubated successfully on [**10-25**] and weaned without difficulty to nasal cannula. switched to vanco on [**10-21**] for positive blood culture (GPC) on [**10-19**]. The plan is 14 days should finish on [**11-3**]. The pt remained satting well on room air until discharge. . 2) Strep Pneumo sepsis: Initially, the etiology of her gram positive cocci bacteremia was unclear. [**Name2 (NI) 227**] her history of IV drug use and her fresh track marks on exam, there was initial supicion for Endocarditis. However, at the outside hospital, she had a negative transthoracic echocardiogram for endocarditis. She had an abdominal ultrasound that was negative for ascites, therefore, SBP was unlikely the source. Once her blood cultures grew out strep. pneumonia, it seemed most likely that her pneumonia was the source of her bacteremia. On transfer, she was on dopamine through a femoral line to maintain her blood pressure. On arrival, she had a subclavian line placed. Initially, she required 3L of IV boluses to maintain her CVP above 15 (accounting for PEEP). She was continued on the dopamine and vasopressin was added. On hospital day 2, she was weaned off of the dopamine and maintained on the vasopressin; however, due to low urine output, she was switched back to the dopamine and off of the vasopressin. Her cortisol stimulation test at the outside hospital showed an appropriate response. however, when she was taken off of the stress dose steroids, she desaturated. Therefore, she was continued on the steroids. 7 days of high-dose steroids, then transitioned to prednisone. LP on [**10-19**]. The sepsis was likely from pnumococcal pneumonia. See Respitroy failure section for discussion of pneumonia treatment. The plan was to continue vanc at discharge for a 14 day course to be be completed [**2119-11-3**]. . 3) Rhabdomyolysis: She was found down by report. He CKs were elevated on initial presentation to the outside hospital, which is consistent with rhabdomyolysis. Her CK trended down with IV hydration within her first few days here. . 4) Acute renal failure: Her elevated creatinine was likely secondary to hypoperfusion in the setting of hypotension. Her creatinine improved with IV fluids. On discharge the patient's Cr was 0.5. . 5) Hepatitis C: Her interferon was held during this admission. Her liver enzymes were elevated. She had a negative abdominal ultrasound for ascites. Dr. [**Last Name (STitle) **] aware pt was admitted. Cryocrit was negative. . 6) Pancytopenia: The etiology is not clear and may be related to HCV and interferon treatment, possibly to Waldenstrom's macroglobulinemia. She was transfused when hct dropped less than than 22. . 7) Rash: groin rash c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. treated with miconazole topical . 8) s/p fall on [**10-25**] overnight. d/ced her own A-line during the fall. no head trauma. patient c/o lumbar back pain, mild headache. - oxycodone prn - fall precautions, one to one sitter . 9) EKG changes: noted [**10-23**]. cards consulted for flipped T waves in precordial leads. TTE with nothing remarkable. EKG changes reversed once extubated. . 8) FEN: She was started on tube feeds. Her electrolytes were repleted. She was given IV fluid boluses as above. transitioned to PO diet once extubated. . 9) UTI - found to have positive urinalysis on [**10-27**]. Given 3 day course of cipro. . 10. HIV test sent on [**2119-10-28**], she was informed that the test was negative. . 11) CXR - Patient with interstitial findings on CXR. Likely [**1-25**] resolving pna but could be drug toxicity. Will need follow up CXR once pna completely resolved. . 12. Prophylaxis: She was maintained on pneumoboots, heparin SC, PPI and a bowel regimen. miconazole to groin rash. fall precautions, one-to-one sitter. * Access: A right subclavian and a right A-line were place. The femoral line was removed. Right A-line d/ced and Left A-line placed on [**10-19**]. L A line d/ced by patient on [**10-25**]. R subclavian d/ced [**10-24**]. PICC placed at bedside on [**10-24**]. * Code: Full . Dispo: pt going to [**Location (un) 16662**] [**Location (un) 16663**] Medications on Admission: Meds at home: AMOXICILLIN 500MG--One tablet three times a day x 10 days EFFEXOR XR 37.5MG--3 by mouth every day FLONASE 50MCG--One spray each nostril every day GABAPENTIN 300MG--Take one tablet at bedtime IBUPROFEN 600 MG--One tablet by mouth q 6 hours as needed NAPROSYN 500MG--Take two pills by mouth every morning and one pill by mouth every evening as needed for for pain with food PEGYLATED INTERFERON --As directed by gi SEROQUEL 25MG--3 by mouth at bedtime . Meds on transfer: Tequin, Pepcid, Vancomycin, unasyn, Hydrocort, Fluorinef, MSO4 Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous Q 12H (Every 12 Hours) for 4 days. Discharge Disposition: Extended Care Facility: [**Location (un) 16662**] - [**Street Address(1) **] Discharge Diagnosis: Streptococcal pneumoniae and bacteremia Discharge Condition: Stable. Discharge Instructions: Please call your doctor or return to the ER if you experience any shortness of breath, persistent cough or fevers /chills. Followup Instructions: You have an appointment to see the nurse practitioner at Dr. [**Name (NI) 16664**] office, [**Doctor Last Name **] Brain [**2119-11-7**] 10:40am. Phone:[**Telephone/Fax (1) 250**] . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2119-12-12**] 1:0 Patient will need follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**] within 1-2 weeks.

[ "070.54", "284.8", "518.81", "599.0", "112.1", "038.2", "304.70", "481", "995.92", "273.0", "728.88", "584.5" ]

icd9cm

[ [ [] ] ]

[ "00.17", "96.6", "96.72", "38.91", "38.93", "03.31" ]

icd9pcs

[ [ [] ] ]

11984, 12063

5869, 10978

290, 358

12147, 12157

2690, 5846

12328, 12814

2111, 2128

11576, 11961

12084, 12126

11004, 11470

12181, 12305

2143, 2671

231, 252

386, 1718

1740, 2030

2046, 2095

11488, 11553

29,382

110,124

34139+57898

Discharge summary

report+addendum

Admission Date: [**2119-7-19**] Discharge Date: [**2119-8-3**] Date of Birth: [**2042-10-29**] Sex: M Service: SURGERY Allergies: Demerol / Morphine / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 473**] Chief Complaint: Pancreatic Cancer Major Surgical or Invasive Procedure: Exploratory Laparoscopy ERCP with Metal Stent EUS with Celiac Plexus Block History of Present Illness: This is a 76M s/p multiple recent admissions for pancreatitis at an OSH. Work-up at the OSH included CT demonstrating a pancreatic head mass and EUS with biopsy demonstrating pancreatic adenocarcinoma. He presented to Dr.[**Name (NI) 9886**] clinic on [**2119-6-19**] for further management. On presentation, he complained of severe epigastric pain radiating to the back, and was actively retching/vomiting. He was recently discharged [**2119-6-29**] on TPN to rehab. He is now a transfer from rehab for pre-op work-up in preparation for Whipple procedure. Review of systems: denies chest pain, denies shortness of breath, denies headaches, all other systems WNL Past Medical History: Pancreatic Cancer CAD s/p NSTEMI, s/p R circumflex stent [**12-27**], TIA, HTN, hypercholesterolemia, COPD, DM (diet controlled), hemorrhoids, recurrent UTIs, nephrolithiasis, arthritis, bladder ca s/p radical cystectomy & urostomy, s/p parastomal hernia repair, s/p L hip ORIF, s/p L CEA [**1-27**] Social History: Former truck driver. Married and divorced 3x, no children. 150+ pack-year smoking history. No EtOH. Family History: Father: cancer. Mother: cerebral hemorrhage after fall, ?stroke. 1 sister with CAD s/p triple bypass, 2 sisters s/p MI, 1 sister still living. Brother: leukemia. Physical Exam: Vitals- T 97.9, HR 87, BP 118/56, RR 18, O2sat 96% RA Gen- NAD, alert Head and neck- AT, NC, soft, supple, no masses Heart- RRR, no murmurs Lungs- CTAB, no rhonchi, no crackles Abd- RLQ ileal conduit with hernia, moderate epigastric pain, no peritoneal signs Rectal- deferred Ext- warm, well-perfused, no edema Pertinent Results: [**2119-7-19**] 05:45PM BLOOD WBC-7.4 RBC-3.24* Hgb-9.3* Hct-28.3* MCV-87# MCH-28.8 MCHC-33.0 RDW-17.0* Plt Ct-333 [**2119-7-23**] 06:30AM BLOOD WBC-11.9* RBC-3.24* Hgb-9.2* Hct-28.2* MCV-87 MCH-28.5 MCHC-32.7 RDW-18.2* Plt Ct-556* [**2119-7-24**] 03:56AM BLOOD WBC-10.8 RBC-3.50* Hgb-10.0* Hct-30.6* MCV-87 MCH-28.6 MCHC-32.7 RDW-18.3* Plt Ct-533* [**2119-7-24**] 03:56AM BLOOD Glucose-125* UreaN-25* Creat-0.8 Na-138 K-4.3 Cl-104 HCO3-26 AnGap-12 [**2119-7-21**] 05:04AM BLOOD ALT-508* AST-203* AlkPhos-980* Amylase-25 TotBili-10.7* [**2119-7-24**] 03:56AM BLOOD ALT-218* AST-42* AlkPhos-627* Amylase-25 TotBili-2.6* [**2119-7-24**] 03:56AM BLOOD Lipase-10 [**2119-7-23**] 06:30AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.1 Mg-2.0 . Radiology Report CTA PANCREAS W/ CTCP Study Date of [**2119-7-19**] 10:35 PM Preliminary Report !! PFI !! Comparison to CT [**2119-6-19**]. An Ill-defined low attenuation mass within the head of the pancreas measures 1.8 x 1.6 cm. There is new moderately severe intra and extrahepatic biliary dilatation as well as pancreatic dilatation. The pancreatic duct measures 9 mm near the level of the mass. There is peripancreatic stranding centered around the head. There is a para-aortic lymph node with a necrotic appearing center measuring 15x7mm (3b:173). New hazy soft tissue density encases the SMA as it courses near the pancreatic head (3b:164-168). The normal contour of the SMV is maintained as it courses anterior to the pancreas. New low attenuation areas including: segment VI 8 mm (3b:177), 7mm IVB (3b:175), 7 mm and 6 mm in [**Doctor First Name **] are suspicious for metastasis but are too small to definitely characterize. A ventral hernia contains a loop of small bowel and a abdominal defect in the RLQ contains a loop of colon and several loops of small bowel. There is no obstruction. . ERCP Procedures: A small sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A 6cm covered wall stent biliary stent was placed successfully (Ref: 6971 / LOT [**Numeric Identifier 78701**]). Good drainage of white bile was noted. Impression: The major papilla was buldging and distorted. Tight 3 cm malignant looking distal biliary stricture Small sphincterotomy performed. A 6 cm covered wallstent was placed successfully in bile duct. . EUS EUS findings: Celiac Plexus Neurolysis: EUS was performed using a linear echoendoscope at 7.5 Mhz frequency and Celiac Plexus Neurolysis was performed: The take-off of the celiac artery was identified. A 22 gauge needle was primed with saline and advanced adjacent to the Aorta, just superior to the celiac artery take-off. This was aspirated to assess for vascular injection. No blood was noted. Buipuvacaine 0.25% X 10 cc was injected. Dehydrated 98% alcohol X 10 cc was injected. Saline 3 cc was injected. The needle was then withdrawn. Mass: A > 1.5 cm ill-defined mass was noted in the head of the pancreas. The mass was hypoechoic and heterogenous in echotexture. The borders of the mass were irregular and poorly defined. Impression: EUS guided Celiac Plexus Neurolysis was performed. Ill-defined mass in the head of the pancreas. Brief Hospital Course: This is a 76 year old male with pancreatic cancer who was recently discharged to rehab on TPN and tolerating sips. He returned to go to the OR. A CT pancreas protocol was obtained and showed New low attenuation areas including: segment VI 8 mm (3b:177), 7mm IVB (3b:175), 7 mm and 6 mm in [**Doctor First Name **] are suspicious for metastasis but are too small to definitely characterize. On [**7-20**], he went to the OR for Exploratory Laparoscopy, aborted Whipple due to liver mets. Pain: He still complained of lots of abdominal pain. A Chronic pain consult was obtained and helped manage his medications. He then went EUS for celiac plexus block on [**2119-7-25**]. His pain was improved. Obstructive Jaundice: Due to the mass effect, his Tbili was 10. He then went for ERCP with placement of 6cm covered stent. His Tbili trended down and his jaundice improved. FEN: He continued on TPN. He was then started on a diet and his diet can be advanced as tolerated. UTI: He had a positive UA and was on Cipro/Flagyl. Oncology: He was seen by Oncology and will follow-up as outpatient. Medications on Admission: Metamucil, Senna, gabapentin 300', Plavix 75', loratadine 10', Cartia XT 180', folic acid ?, ASA 325', Tylenol, MVI, simvastatin 40', temazepam 15 qhs, Advair 500/50", Combivent"", Prilosec 20' Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO twice a day. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 9. Hydromorphone 4 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours) as needed. 10. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection four times a day. 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Discharge Disposition: Extended Care Facility: Life Care Center, [**Location (un) 2199**] Discharge Diagnosis: Pancreatic Cancer - Metastatic Acute on Chronic Pain UTI Obstructive Jaundice Discharge Condition: good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue to take a stool softener. * Continue to ambulate several times per day. * No heavy lifting (>[**10-4**] lbs) until your follow up appointment. * Continue with TPN as ordered. You may also eat and advance your diet as tolerated. Once taking in adequate POs, the TPN cn stop. sted daily. Followup Instructions: Please follow-up with Oncology Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2119-7-31**] 3:00 Completed by:[**2119-7-28**] Name: [**Known lastname 12676**],[**Known firstname 326**] F. Unit No: [**Numeric Identifier 12677**] Admission Date: [**2119-7-19**] Discharge Date: [**2119-8-3**] Date of Birth: [**2042-10-29**] Sex: M Service: SURGERY Allergies: Demerol / Morphine / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 4987**] Addendum: Mr. [**Known lastname 12679**] discharge was unfortunately delayed beyond the anticipated day of discharge due to a placement issue, and he stayed through the weekend of [**7-25**] receiving pain control. On [**7-30**] at night, he developed fever to 104F and shaking chills, with hypotension to 70/40. He was triggered, and promptly transferred to the SICU, and a sepsis work up was initiated, including a CXR, ECG, CBC, cardiac enzymes, Blood Cx. It was postulated that his indwelling PICC line may be the cause of his sepsis, so it was removed and culture tip sent. He received 1U of PRBCs in the ICU and required pressors to maintain BP. He was started on Zosyn. Over the next few days, he began to stabilize, and in a meeting with his niece [**Name (NI) **] (his medical proxy) and other family members, the decision was made to change his code status to DNR. He was seen by Palliative Care, and the ultimate decision was made with the family to change his status to CMO, and was transferred to the floor. He was discharged to Hospice Care on [**2117-8-2**] in stable condition. Major Surgical or Invasive Procedure: Exploratory Laparoscopy ERCP with Metal Stent EUS with Celiac Plexus Block Discharge Medications: 1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO twice a day. 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q2H (every 2 hours) as needed. 6. Fentanyl 50 mcg/hr Patch 72 hr Sig: Three (3) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5-1 Tablet, Rapid Dissolve PO TID (3 times a day) as needed. 8. Haloperidol Lactate 5 mg/mL Solution Sig: 1-5 mg Injection TID (3 times a day) as needed. 9. Haloperidol 1 mg Tablet Sig: 0.5-2 mg PO TID (3 times a day) as needed. 10. Hydromorphone 2 mg/mL Solution Sig: 0.5-2 mg Injection Q2H (every 2 hours) as needed for pain. Discharge Disposition: Extended Care Facility: Life Care Center, [**Location (un) 654**] Discharge Diagnosis: Pancreatic Cancer - Metastatic Acute on Chronic Pain UTI Obstructive Jaundice Pneumonia Sepsis Discharge Instructions: Continue with comfort measures. Followup Instructions: None [**Name6 (MD) 116**] [**Last Name (NamePattern4) 4988**] MD [**MD Number(1) 4989**] Completed by:[**2119-8-3**]

[ "996.62", "576.2", "038.9", "250.00", "197.7", "157.0", "414.01", "995.92", "486", "496", "576.1", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "99.15", "50.14", "45.13", "04.49", "51.87", "51.85", "38.93" ]

icd9pcs

[ [ [] ] ]

12278, 12346

5265, 6357

11265, 11342

8093, 8100

2067, 5242

12544, 12692

1555, 1720

11365, 12255

12367, 12464

6383, 6578

12488, 12521

1735, 2048

1007, 1096

261, 280

423, 988

1118, 1419

1435, 1539

25,159

188,376

1666

Discharge summary

report

Admission Date: [**2167-11-16**] Discharge Date: [**2167-11-21**] Date of Birth: [**2096-11-19**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient was a 70-year-old male with a 10 year history of external retrosternal chest discomfort that occurred periodically while exercising. The patient, however, is very active and prior to having shoulder surgery in [**5-24**] was biking up to 25 miles a day. Because of the shoulder surgery, the patient's level of physical activity has since then been diminished. The patient was scheduled for an exercise stress test on [**2167-10-16**], where he exercised for 11 minutes and achieved 84% of his predictable heart rate. The patient had some substernal chest discomfort and had electrocardiogram changes with ST segment depressions of [**12-23**].5 mm inferolaterally. Imaging revealed a mild partially reversible septal defect. The patient's ejection fraction of 67%. The patient was referred to the [**Hospital1 69**] for an outpatient cardiac catheterization. PAST MEDICAL HISTORY: 1. Hypertension. 2. Loss of hearing of left ear due to scarlet fever (hearing aid). 3. Decreased testosterone. 4. Pituitary microadenoma - 6 mm. PAST SURGICAL HISTORY: 1. On [**5-/2167**], right rotator cuff repair. 2. Mastoid surgery in the past. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Aspirin 81 mg po q day. 2. Norvasc 5 mg po q day. 3. Testosterone injections every three weeks. HOSPITAL COURSE: Patient was admitted to the [**Hospital1 188**] on [**2167-11-16**] for cardiac catheterization. He was found to have left main and multivessel disease and Cardiothoracic Surgery was consulted. Decision was made to take the patient for coronary artery bypass graft. The patient underwent bypass surgery on [**2167-11-17**] with his left internal mammary being grafted to the left anterior descending artery, and with saphenous vein graft to the PDA, the OM, and the diagonal. The patient was thereafter transferred to the SICU for continued monitoring. The patient had an uncomplicated postoperative course and was transferred to the Cardiothoracic Surgery floor on postoperative day #1. The patient's pain was well controlled. Physical therapy was initiated, and the patient was able to tolerate activity well. On postoperative day #3, the patient complained of epigastric discomfort aggravated by talking. The patient had a benign abdominal examination, and was still passing flatus, although he had not yet had a bowel movement. The pain was not anginal in type. Decision was made to order the serum amylase test to evaluate for pancreatitis. The test was negative with an amylase coming back at 40. By postoperative day #4, the patient was deemed stable for discharge to home. At the time of discharge, the patient had scratchy voice that was suspected to be caused by his intubation during surgery. The patient was instructed to contact Dr. [**Last Name (STitle) 70**] if his voice quality did not improve in the days following discharge. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Enteric coated aspirin 325 mg po q day. 2. Colace 100 mg po bid. 3. Lasix 20 mg po bid. 4. Potassium chloride 20 mEq po bid. 5. Motrin 400 mg po q6-8h prn. 6. Dilaudid 1-2 tablets po q4-6h prn (The patient did not require beta blockade because he had a resting heart rate in the 60s-70s). FOLLOWUP: The patient is to followup with Dr. [**Last Name (STitle) 70**] six weeks following discharge. The patient is asked to followup with his primary care physician [**Last Name (NamePattern4) **] [**1-26**] weeks following discharge. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 997**] MEDQUIST36 D: [**2167-11-22**] 12:29 T: [**2167-11-25**] 06:53 JOB#: [**Job Number 9629**]

[ "401.9", "424.0", "794.31", "413.9", "414.01", "V70.7" ]

icd9cm

[ [ [] ] ]

[ "39.64", "37.22", "36.13", "36.15", "89.68", "88.53", "88.56", "39.61" ]

icd9pcs

[ [ [] ] ]

3051, 3060

3083, 3906

1470, 3030

1222, 1453

158, 1031

1053, 1199

24,361

187,730

51138

Discharge summary

report

Admission Date: [**2122-5-4**] Discharge Date: [**2122-6-1**] Date of Birth: [**2066-2-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 45**] Chief Complaint: SOB, DOE, b/l LE edema Major Surgical or Invasive Procedure: Right-sided PICC placement IR guided line placement for CVVH CVVH with ultrafiltration History of Present Illness: 56 year-old female with a history of chronic systolic CHF (EF 15%), HTN, morbid obesity, and asthma who presents with increasing SOB, DOE, b/l LE edema, and weight gain. She was hospitalized from [**2122-2-4**] to [**2122-2-25**] for decompensated CHF and was diuresed aggressively (40 lbs off) with Lasix gtt and IV Diuril. She was re-admitted a few days later for abdominal pain and also found to be in acute renal failure. She was discharged on a reduced dose of torsemide and also told to stop her lisinopril, HCTZ, and spironolactone. When seen in [**Hospital 1902**] clinic at the end of [**Month (only) 958**], she appeared to still be euvolemic and arrangements were made to have her weight at home transmitted to VNA, as she did not formerly weigh herself at home. Her weight had increased by 30 lbs by the end of [**Month (only) 547**] and was told to increase her torsemide to twice a day, but her weight continued to increase to 360 lbs by [**4-30**] and she started to become more SOB and wheezy. In addition, her BP was noted to be 80/60 and her O2 sat on RA was 92%. She was reluctant to come to the hospital and so the plan was to increase torsemide to 80mg [**Hospital1 **] if her SBP was >90. However, her SOB continued to get worse and she presented to the ED. In the ED her VS were 97, 73, 102/59, 19, 100% on 4L NC (on 2L NC at home at baseline). A Foley catheter was placed. She was given 80mg Lasix IV and put out 1400cc. EKG was unchanged from prior. CXR showed mild fluid overload. Bilateral LENIs were negative for DVT. She had no chest pain and was breathing and speaking comfortably. She was admitted for decompensated CHF. Past Medical History: - NSVT & low EF; had been considered for PM/ICD due to NSVT and low EF, but not felt to be a candidate given poor compliance and other comorbidities - AVNRT: evaluated by EP in the past, pt not interested in any further intervention - COPD/Asthma (FEV1/FVC 83%) on home O2 at 2L - CHF (EF 15-20%) from non-ischemic CM (? secondary to cocaine/polysubstance use), dry weight ~300lbs - Gout - Morbid obesity - Cocaine/Heroin/ETOH abuse - Ventral hernia - OSA - h/o medication non-compliance - Hep B & C positive Social History: unemployed, lives with son and mother lives upstairs. Smokes tobacco occasionsionally. Cocaine and heroine abuse in the past but denies recent use; denies etoh. Family History: Has family hx of DM, hypertension and heart failure Physical Exam: VS - 96.8, 108/52, 73, 20, 98% 4L NC, 171.9 kg (378 lbs) Gen: alert, interactive, sleepy but arousable morbidly obese African American female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. +Exophthalmos. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple, JVP difficult to assess CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. III/VI HSM LUSB. No r/g. 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. Abd: Soft, NTND. +ventral hernia, non-tender. No HSM or tenderness. Abd aorta unable to be palpated. No abdominial bruits. Ext: [**2-17**]+ [**Location (un) **] b/l to knees. No c/c. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Labs during hospital course: [**2122-5-3**] 09:04PM BLOOD WBC-3.5* RBC-4.30 Hgb-12.1 Hct-39.6 MCV-92 MCH-28.2 MCHC-30.6* RDW-15.0 Plt Ct-218 [**2122-6-1**] 05:45AM BLOOD WBC-3.5* RBC-4.30 Hgb-12.8 Hct-38.7 MCV-90 MCH-29.8 MCHC-33.1 RDW-15.8* Plt Ct-326 [**2122-5-10**] 07:12AM BLOOD PT-15.3* PTT-33.7 INR(PT)-1.3* [**2122-5-3**] 10:15PM BLOOD Glucose-102 UreaN-47* Creat-1.7* Na-137 K-4.4 Cl-100 HCO3-28 AnGap-13 [**2122-5-9**] 05:20AM BLOOD Glucose-225* UreaN-32* Creat-1.1 Na-133 K-3.5 Cl-93* HCO3-33* AnGap-11 [**2122-5-19**] 05:58AM BLOOD Glucose-79 UreaN-48* Creat-1.8* Na-136 K-4.5 Cl-97 HCO3-30 AnGap-14 [**2122-5-20**] 05:21AM BLOOD Glucose-94 UreaN-61* Creat-2.5* Na-136 K-4.6 Cl-96 HCO3-31 AnGap-14 [**2122-5-22**] 05:56AM BLOOD Glucose-90 UreaN-76* Creat-3.0* Na-134 K-4.9 Cl-96 HCO3-28 AnGap-15 [**2122-5-27**] 03:22AM BLOOD Glucose-123* UreaN-77* Creat-2.4* Na-131* K-4.7 Cl-96 HCO3-27 AnGap-13 [**2122-5-28**] 05:31AM BLOOD Glucose-126* UreaN-95* Creat-3.5* Na-129* K-5.2* Cl-93* HCO3-25 AnGap-16 [**2122-5-28**] 03:05PM BLOOD Glucose-148* UreaN-102* Creat-3.7* Na-128* K-5.7* Cl-93* HCO3-22 AnGap-19 [**2122-5-30**] 11:41AM BLOOD Glucose-107* UreaN-107* Creat-2.4*# Na-129* K-4.5 Cl-93* HCO3-24 AnGap-17 [**2122-5-31**] 07:55AM BLOOD Glucose-102 UreaN-97* Creat-1.8* Na-133 K-4.3 Cl-98 HCO3-25 AnGap-14 [**2122-6-1**] 05:45AM BLOOD Glucose-110* UreaN-83* Creat-1.7* Na-133 K-4.6 Cl-100 HCO3-25 AnGap-13 [**2122-5-22**] 02:24PM BLOOD ALT-10 AST-19 LD(LDH)-213 AlkPhos-110 TotBili-1.1 [**2122-5-3**] 10:15PM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-3852* [**2122-5-29**] 02:02AM BLOOD proBNP-2040* [**2122-6-1**] 05:45AM BLOOD Calcium-10.2 Phos-3.7 Mg-3.1* [**2122-5-22**] 02:24PM BLOOD calTIBC-399 Hapto-103 Ferritn-64 TRF-307 [**2122-5-22**] 02:24PM BLOOD Triglyc-33 HDL-34 CHOL/HD-2.9 LDLcalc-56 [**2122-5-18**] 06:35AM BLOOD TSH-2.6 [**2122-5-22**] 02:24PM BLOOD PEP-POLYCLONAL IgG-2689* IgA-348 IgM-71 [**2122-5-23**] 02:32AM BLOOD HIV Ab-NEGATIVE [**2122-5-21**] 04:50AM BLOOD ASA-NEG Acetmnp-9.3 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2122-5-4**] 12:33PM BLOOD Type-ART Rates-/18 FiO2-97 O2 Flow-2 pO2-49* pCO2-61* pH-7.34* calTCO2-34* Base XS-4 AADO2-584 REQ O2-96 Intubat-NOT INTUBA [**2122-5-22**] 11:57PM BLOOD Type-ART pO2-113* pCO2-57* pH-7.35 calTCO2-33* Base XS-4 Imaging: BILAT LOWER EXT VEINS [**2122-5-3**] 10:34 PM IMPRESSION: Slightly limited study secondary to patient body habitus. No evidence of lower extremity DVT. CHEST (PA & LAT) [**2122-5-3**] 9:11 PM IMPRESSION: A mild congestive failure with stable marked cardiomegaly. Right Upper Ext ultrasound [**5-8**]: No DVT in the right upper extremity. CXR [**5-20**]: Marked cardiomegaly is stable. haziness of the perihilar regions is new consistent with mild interstitial pulmonary edema. Right PICC tip is in the proximal SVC. There is no pneumothorax. If any, there is a small left pleural effusion. TTE [**2122-5-21**]: The left atrium is markedly dilated. The right atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is moderate global left ventricular hypokinesis (LVEF = 30-40 %). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with severe global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is partial mitral leaflet flail (anterior leaflet). At least moderate (2+) mitral regurgitation is seen. Due to the highly eccentric (posterior) trajectory of the regurgitant flow, the severity of mitral regurgitation may be significantly underestimated (Coanda effect). The tricuspid valve leaflets are mildly thickened. At least moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2121-3-17**], partial flail anterior mitral leaflet is now present. The mitral regurgitation may be increased, and may be significantly underestimated on this study due to the Coanda effect. The left ventricular ejection fraction is increased on the current study. The pulmonary artery pressure is now markedly increased. CXR [**5-31**]: The tip of the PICC line lies in the mid to upper SVC. The heart remains markedly enlarged but failure is not currently seen. Brief Hospital Course: 56F with chronic systolic CHF (EF 15%) from non-ischemic cardiomyopathy thought to be due to cocaine abuse, HTN, and morbid obesity admitted with decompensated heart failure and acute renal failure. # Acute on chronic systolic heart failure: Patient triggered for hypotension on day of admission with SBP 80 requiring ICU stay, during which time PICC line was placed for access and pt was initiated on furosemide drip at 10mg/hr. Baseline SBP 80-100's during ICU stay for 1 day. Carvedilol was held given hypotension. Lisinopril was restarted at low dose 2.5mg po daily and was tolerating well. Pt aggressively diuresed with lasix drip, uptitrated to 12mg/hr, and spironolactone was added. Diuril 500mg IV was intermittently added for goal neg 3-4L/day. We repleted lytes aggressively, and pt was maintained on 1.5L fluid restriction as well as a low sodium diet. After diuresing 20kg on the lasix gtt, the patient's creatinine began to climb. She was switched to oral diuretics, but creatinine continued to increase, and all diuretics as well as her lisinopril were held. When creatinine continued to rise, nephrology was consulted and recommended CVVH to help with removing fluid as she was still significantly volume overloaded. She had a catheter placed by IR and was transferred to the CCU to undergo CVVH. She underwent CVVH and 30kg of fluid was removed. She went down to 273lbs (dry weight felt to be 300lbs per documentation). Her Cr however continued to rise and thus UF was discontinued and further diuresis was held. Lasix was not resumed prior to transfer back to floor. In addition, no afterload reducing agents could be given as patient's BP would not tolerate it; thus isordil and hydralazine were held. Upon return to the floor, further diuretics were held, and patient's Creatinine decreased to 1.7 on the day of discharge. At the time of discharge, she was on torsemide 40mg [**Hospital1 **] as well as carvedilol 3.125mg [**Hospital1 **]. Her lisinopril and spirinolactone were being held in the setting of relatively low blood pressures; these agents will likely need to be restarted as an outpatient. # h/o AVNRT & NSVT: Remained in NSR during admission with rare episodes of significant NSVT. Patient had been evaluated by EP for ICD/PM placement, but she was not considered a candidate for pacemaker given her comorbidities & non compliance with medications and [**Hospital1 4314**]. Her electrolytes were repleted aggressively. Although her carvedilol has been held in the setting of hypotension and acute heart failure, it was restarted during CCU course. She was placed on 3.125mg [**Hospital1 **]. She was given follow-up with EP as an outpatient in the hopes that she might be able to better comply with [**Hospital1 4314**] after her significant diuresis. # Acute renal failure: Likely hemodynamic due to poor forward flow given her depressed ejection fraction and continued diuresis. Although her creatinine initially improved with diuresis, it began to climb as discussed above. Whe renal was consulted, it was recommended that she undergo CVVH for continued volume removal. She was transferred the CCU and underwent aggressive fluid removal wtih CVVH. However her Cr continued to stay elevated. She did have a hypontensive episode into the 70s and there was concern that she may have ATN [**1-17**] hypotension; however urine sediment did not show muddy brown casts. UF was stopped and Lasix held given renal function and monitored. At the time of discharge, her Cr was 1.7 and she was restarted on torsemide 40mg [**Hospital1 **]. Her weight was 123kg (272-275lbs). She had follow-up with nephrology. # UTI: Patient was found to have a pan-sensitive E coli UTI during her hospital stay. Her Foley catheter was changed and she was started on bactrim on [**5-17**]. Because bactrim can cause the creatinine to be increased (without actually causing true renal failure), her bactrim was switched to keflex on [**5-21**]. She completed the abx course. # Asthma/COPD: Continued albuterol, atrovent, and advair. # Gout: continued home allopurinol # GERD: Patient was continued on a PPI per her home regimen, but when her creatinine worsened, the PPI was stopped. On the day of discharge, she complained of "gastritis" pain that improved with pepto bismol. She was discharged on omeprazole, sucralfate, and maalox. # Depression/anxiety: continued home regimen Celexa # Hyponatremia: Patient had hypovolemic hyponatremia in the setting of significant diuresis. Her sodium improved as her fluid shifted into the vascular space. FULL CODE # Access: Although she had a PICC during her stay, this was removed prior to discharge (especially given her h/o drug abuse). Medications on Admission: albuterol inhaler Advair 250/50 1 puff [**Hospital1 **] ASA 325mg qd carvedilol 12.5mg [**Hospital1 **] torsemide 60mg [**Hospital1 **] citalopram 30mg qhs simethicone 80mg qid prn Protonix 40mg [**Hospital1 **] allopurinol 100mg qd Zofran 4mg q8h prn Ambien 5mg qhs Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). [**Hospital1 **]:*1 Disk with Device(s)* Refills:*0* 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. [**Hospital1 **]:*20 Tablet(s)* Refills:*0* 5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. [**Hospital1 **]:*120 Tablet, Chewable(s)* Refills:*0* 6. Celexa 20 mg Tablet Sig: 1 and [**12-17**] Tablet PO at bedtime. [**Month/Day (2) **]:*45 Tablet(s)* Refills:*0* 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. [**Month/Day (2) **]:*1 inhaler* Refills:*0* 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. [**Month/Day (2) **]:*30 Tablet(s)* Refills:*0* 9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed. [**Month/Day (2) **]:*60 Tablet, Rapid Dissolve(s)* Refills:*0* 10. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Month/Day (2) **]:*60 Tablet(s)* Refills:*0* 11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). [**Month/Day (2) **]:*120 Tablet(s)* Refills:*0* 12. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day: please adjust your dose as directed by your physician. [**Name Initial (NameIs) **]:*120 Tablet(s)* Refills:*0* 13. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. [**Name Initial (NameIs) **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 14. Maalox 200-200-20 mg/5 mL Suspension Sig: Ten (10) ml PO three times a day as needed for heartburn. [**Name Initial (NameIs) **]:*500 ml* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Acute on chronic systolic heart failure Acute renal failure Non sustained ventricular tachycardia Non ischemic cardiomyopathy Gout Asthma GERD Depression/anxiety Discharge Condition: Stable, discharge weight 123kg. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Avoid food from restaurants and frozen foods. Information regarding heart failure management and low sodium diet was reviewed and discussed with you. Fluid Restriction: 1.5 liters You were admitted with congestive heart failure with fluid overload. You were aggressively diuresed with lasix and underwent CVVH to remove several kilograms of fluid. MEDICATION CHANGES: Your torsemide was decreased to 40mg twice a day Your carvedilol was decreased wot 3.125mg twice a day. Your lisinopril was stopped for the time being. It should be restarted some time in the future. We also stopped your spironolactone. We gave you prescriptions for sucralfate and maalox, which can help for your gastritis. Please take all medications as prescribed. Please call your primary doctor or come to the ED if you develop chest pain, shortness of breath or any other worrisome symptoms. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) 4883**] for [**6-16**] at 8am. His office is in the [**Hospital Ward Name 23**] Building, [**Location (un) 436**]. Call [**Telephone/Fax (1) 435**] if you need to reschedule. You also have an appointment with a new primary doctor: Monday [**6-15**] at 1:30pm with Dr. [**Last Name (STitle) **], [**Location (un) **] [**Hospital Ward Name 23**] building, North suite. Please be sure to go to this appointment as you will not be able to be followed by the [**Hospital 191**] clinic if you continue to miss [**Hospital 4314**]. [**Telephone/Fax (1) 250**]. We made an appointment for you with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**MD Number(3) 4974**]:[**Telephone/Fax (1) 3512**] Date/Time:[**2122-6-9**] 2:00 We also made an appointment for you with electrophysiology because of your history of heart arrhythmias: Dr. [**Last Name (STitle) **]. [**7-1**] at 3pm, [**Location (un) 436**] of the [**Hospital Ward Name 23**] building. Call [**Telephone/Fax (1) 62**] if you have any questions. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**] Completed by:[**2122-6-17**]

[ "465.9", "278.01", "327.23", "493.90", "305.1", "425.4", "530.81", "584.9", "428.23", "585.9", "274.9", "276.1", "V15.81" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93", "38.95" ]

icd9pcs

[ [ [] ] ]

15645, 15702

8457, 13187

333, 421

15908, 15942

3921, 3933

16962, 18203

2830, 2883

13505, 15622

15723, 15887

13213, 13482

3950, 8434

15966, 16417

2898, 3902

16437, 16939

271, 295

449, 2103

2125, 2635

2651, 2814

27,491

126,541

31535

Discharge summary

report

Admission Date: [**2111-6-17**] Discharge Date: [**2111-6-22**] Date of Birth: [**2036-8-4**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 922**] Chief Complaint: Dyspnea on exertion and fatigue Major Surgical or Invasive Procedure: [**2111-6-17**] - Aortic Valve Replacement (25mm [**Company 1543**] Mosaic Ultra Porcine Valve) History of Present Illness: 74 year old male with severe aortic stenosis. He has had a heart murmur his entire life and was diagnosed with aortic stenosis 3 years ago. Since that time, he has been followed by serial echocardiograms with his most recent showing severe aortic stenosis. A cardiac catheterization was performed which showed normal coronaries. He now presents for surgical management of his aortic stenosis. Past Medical History: Rheumatic heart disease Osteoarthritis HTN Hyperlipidemia ? Past TIA Social History: Lives with wife. [**Name (NI) **] not drank alcohol in 30 years (Prior heavy use). 5 pack/year smoking history quitting many years ago. He is an auto mechanic. Edentulous. Family History: Mother with 3 MI's and is alive at age [**Age over 90 **] Physical Exam: 52 REG 158/76 GEN: NAD SKIN: Unremarkable HEENT:PERRL, Anicteric sclera, OP benign, OS slight ptosis. healed laceration on right lip. NECK: Supple, FROM, Transmitted murm,[**Last Name (un) **] vs bruit. No JVD LUNGS: CTA HEART: RRR, IV/VI SEM ABD: Benign EXT: Warm, well perfused. NEURO: Nonfocal Pertinent Results: [**2111-6-17**] ECHO PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. 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 complex (mobile) atheroma in the descending aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. Post_Bypass: Preserved biventricular systolic function. LVEF 55%. A bioprosthesis seen in the native aortic valve site, well seated, opening and closing well and residual mean gradient of 13mm of Hg. Aortic contour is intact. [**2111-6-21**] CXR Trace residual pneumothorax, and equivocal trace residual pneumomediastinum. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2111-6-17**] for surgical management of his aortic valve stenosis. He was taken directly to the operating room where he underwent an aortic valve replacement using a 25mm [**Company 1543**] Mosaic Ultra Porcine Valve. Postoperatively he was taken to the intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Beta blockade and aspirin were resumed. Later on postoperative day one, he was transferred to the step down unit for further recovery. Mr. [**Known lastname **] was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He developed rapid atrial fibrillation which converted back to normal sinus rhythm with intravenous amiodarone. A residual pneumothorax was noted after removal of his chest tube. This improved without intervention. Mr. [**Known lastname **] continued to make steady progress and was discharged home on postoperative day five. He will follow-up with Dr. [**Last Name (STitle) 914**], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Atenolol 25mg QD Uniretic 15/12.5mg QD Gemfibrozil 600mg [**Hospital1 **] Aspirin 325mg QD Discharge Medications: 1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for constipation. Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4* 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Iron (Ferrous Sulfate) 325 (65) mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 7. Vitamin C 250 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Aortic stenosis Hypertension Anemia AF (Postoperative) ? Past TIA Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Take lasix and potassium once daily for 5 days then stop. 8) Take vitamin C and Iron for 1 month and then stop. 9) Call with any questions or concerns. Followup Instructions: [**Last Name (LF) **],[**First Name3 (LF) 177**] C. [**Telephone/Fax (1) 170**] When: Follow-up appointment should be in 1 month [**Last Name (LF) **],[**First Name3 (LF) 1955**] M. [**Telephone/Fax (1) 3183**] When: Follow-up appointment should be in 2 weeks Follow-up with Dr. [**Last Name (STitle) **] (cardiologist) in [**11-18**] weeks. ([**Telephone/Fax (1) 29561**] Please call all providers for appointments. Completed by:[**2111-6-22**]

[ "512.1", "395.0", "997.1", "715.90", "401.9", "E878.1", "272.4", "427.31" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61" ]

icd9pcs

[ [ [] ] ]

5156, 5227

2645, 3897

304, 402

5337, 5346

1513, 2622

6172, 6626

1121, 1180

4038, 5133

5248, 5316

3923, 4015

5370, 6149

1195, 1494

233, 266

430, 824

846, 916

932, 1105

26,288

198,365

54269

Discharge summary

report

Admission Date: [**2146-8-19**] Discharge Date: [**2146-8-24**] Date of Birth: [**2088-2-1**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: 58 yo male with multiple medical problems including [**Name (NI) 2320**], atrial fibrillation/atrial flutter, s/p gastric bypass who was transferred from [**Hospital6 **] for management of GI bleeding. Major Surgical or Invasive Procedure: -[**2146-8-24**] Colonoscopy -[**2146-8-24**] Endoscopy History of Present Illness: HPI: 58 yo male with multiple medical problems including [**Name (NI) 2320**], atrial fibrillation/atrial flutter, s/p gastric bypass who was transferred from [**Hospital6 **] for management of GI bleeding. Pt reports yesterday he awoke feeling "off balance" and weak. He went to [**Hospital **] hospital where he had a marroon stool and was found to have Hct of 24. He had CT abd which did not show an intra-abdominal process. He was given two units of PRBCs and transferred to [**Hospital1 18**] for further management. Pt denies any previous episodes of GI bleeding. Last [**Last Name (un) **] was [**1-12**] yrs ago and demonstrated benign polyps that were removed. . In the [**Hospital1 18**] ED initial vitals were T 98 HR 75 BP 105/75 RR 18 O2Sat 100 RA. His hct on arrival was 26, which was then post 2 units. He did have 2 more marroon stools. He received 1L NS and 1 unit PRBCs. Vitals were T96.5 HR:116 BP: 109/63 100RA on transfer to floor. Past Medical History: 1. Bariatric surgery for morbid obesity [**2139**] 2. Atrial fibrillation / atrial flutter s/p ablation [**2139**] 3. Type 2 diabetes c/b nephropathy and neuropathy 4. Chronic renal insufficiency 5. Hypertriglyceridemia 6. h/o Obstructive sleep apnea prior to gastric sx 7. Hyperoxaluria 8. ? of Non hep a, hep B hepatitis around [**2116**], also ?lft abnormalities on amiodorone in past 9. CAD: MI [**1-16**] Social History: No ETOH, tobacco or illicit drug use Family History: Mother, Father, Brother, Sister all w/ DM2. Father h/o CA Many of his family members also have problems with obesity Physical Exam: GA: AOx3, NAD HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. Extremities: wwp, no edema. DPs, PTs 2+. Skin: no lesions Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. . ECG:atrial fibrillation at 119 bpm. nl axis and intervals. NSTT changes. Pertinent Results: [**2146-8-24**] 12:50PM BLOOD Hct-27.9* [**2146-8-23**] 08:05AM BLOOD Hct-24.7* [**2146-8-21**] 07:00PM BLOOD Hct-30.9* [**2146-8-19**] 06:20PM BLOOD WBC-6.4 RBC-3.12*# Hgb-8.8*# Hct-26.1*# MCV-84 MCH-28.3 MCHC-33.9 RDW-13.8 Plt Ct-204 [**2146-8-21**] 02:54AM BLOOD PT-13.6* PTT-23.8 INR(PT)-1.2* [**2146-8-23**] 08:05AM BLOOD Glucose-77 UreaN-8 Creat-0.9 Na-138 K-4.3 Cl-106 HCO3-22 AnGap-14 [**2146-8-23**] 08:05AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.4* Brief Hospital Course: Pt was transferred from [**Hospital6 **] for management of GI bleeding. He was admitted initially to the Intensive Care Unit where he had two maroon stools and was transfused 1 unit PRBC. He had a negative NG lavage there. He was transferred to Dr[**Name (NI) **] care the following day. Aspirin, plavix and lisinopril were held. His vitals were monitored regularly and pain was well controlled. He was NPO for procedure (scope) most of his stay and was restarted on a regular diet at discharge. CV: Mr [**Known lastname 7749**] had several short episodes of atrial fibrillation on tele. He reached ventricular rates up to 120 during these runs. In sinus rhythym, his HR was 50-70 with SBP 100-110. Because of these low sinus numbers, his metoprolol was held most of the stay. Also, his aspirin and plavix were held while the source of bleeding was worked up. GI: Pt presented with maroon stools, and had two of these while in house. He took 5L of bowel prep the night before EGD/colonoscopy and showed no blood in those stools. Endoscopy on [**2146-8-24**] showed an ulcer at the anastamosis; the final report on this and the colonoscopy is pending. Medications on Admission: Trazadone 100mg qHS Bupropion SR 200mg daily Potassium citrate 10 mEq 3x/day Metformin 1000mg [**Hospital1 **] Lisinopril 5mg daily Prvastatin 20mg qHS Metoprolol 25mg [**Hospital1 **] Clopidogrel 75mg daily Vitamin D-3 [**2135**] units daily Acarbose 25mg daily ASA 81mg daily Calcium carbonate 2 tabs daily Cyanobalamin 100 mEq 3x/week Discharge Medications: 1. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day for 2 months: crush tablet. Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Misoprostol 100 mcg Tablet Sig: One (1) Tablet PO four times a day: crush tablets. Disp:*120 Tablet(s)* Refills:*2* 3. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Five (5) Tablet PO DAILY (Daily). 6. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Discharge Disposition: Home Discharge Diagnosis: 1. Melena 2. Anastamosis ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shorness fo breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, or any other symptoms which are concerning to you. Diet: Regular diet. Avoid spicy foods. Medications: Resume your home medications. You will be starting some new medications: 1. You should take a stool softener, Colace, twice daily for constipation as needed, or until you resume a normal bowel pattern. 2. You must not use aspirin or NSAIDS (non-steroidal anti-inflammatory drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and Naproxen. These agents will cause bleeding and ulcers in your digestive system. 3. You are prescribed an antacid as well to aid in healing the ulcer. Activity: No heavy lifting of items [**9-23**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Followup Instructions: - Have an endoscopy done in [**5-17**] weeks to monitor your anastamotic ulcer. - See your primary care physician [**Name Initial (PRE) 176**] 2 weeks to follow-up and assist in scheduling the endoscopy.

[ "997.4", "562.10", "412", "403.90", "250.60", "531.40", "E878.2", "414.01", "427.31", "585.9", "998.6", "250.40", "583.81", "357.2", "427.32", "455.0" ]

icd9cm

[ [ [] ] ]

[ "45.16", "45.13", "45.23" ]

icd9pcs

[ [ [] ] ]

5408, 5414

3152, 4308

515, 573

5489, 5489

2674, 3129

6678, 6885

2060, 2178

4697, 5385

5435, 5468

4334, 4674

5640, 6655

2193, 2655

274, 477

601, 1556

5504, 5616

1578, 1990

2006, 2044

27,112

164,406

33849

Discharge summary

report

Admission Date: [**2153-5-4**] Discharge Date: [**2153-5-15**] Date of Birth: [**2100-12-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1666**] Chief Complaint: L thigh pain Major Surgical or Invasive Procedure: None History of Present Illness: 52 y/o with PMH of EtOH cirrhosis and multiple back surgeries who presents with L thigh pain and swelling for two days. Patient reports that he initially injured his leg when he bumped into his metal shop table 10 days ago. He hit the outside of his leg and initially felt fine. Two days later he noticed a small bruise there and the area felt firm. 3 days ago he mowed his lawn and went about his usual activities without much difficulty. The following day he awoke and his entire thigh was bruised, swollen and very painful. The pain has made it difficult to walk. He initially presented to an OSH ([**Hospital 24356**] Hospital) where CT scan was done that did not show a fluid collection, however there was muscle edema. They were unable to measure leg pressures and due to concern for compartment syndrome he was sent to [**Hospital1 18**]. They did give his 3 gms of Unsayn for potential infection. . The patient reports that he felt some numbness on the outside of his leg during the ambulance ride but denies weakness. He has a L footdrop at baseline. He denies fever, chills, cough, CP, SOB and abdominal pain. . In ED initial vitals were T 99.7 BP 131/71 HR 100 RR 17 O2sat 99%RA. He was evaluated by ortho who reviewed OSH CT. Ortho felt that his exam was not consistent with compartment syndrome and recommended further imaging with MRI and follow CKs. Received 8mg morphine at OSH and 4mg dilaudid here. Past Medical History: --Biliary Colic/chronic pancreatitis: (per [**2153-5-3**] [**Location (un) 1475**] note) hepatitis serology negative [**11-2**], [**Doctor First Name **] 1:80, antismooth muscle negative. Saw Dr. [**Last Name (STitle) **]. CT per report two stable cysts no other lesions, but U/S ? multiple nodular densities. --EtOH cirrhosis, followed by Dr. [**Last Name (STitle) **] in Staughton -> no h/o varices, GIB, or ascites --h/o EtOH abuse : pt denies alcohol, does report drinking O'douls a non-alcoholic beer --s/p cholecystectomy --Psoriasis --chronic lower back pain/post laminectomy syndrome: MS contin 60/30/60 fair pain control. residual left foot drop. no recent falls [**First Name8 (NamePattern2) **] [**Location (un) 1475**] records. -- HTN currently off all medications --s/p multiple back surgeries following MVA in [**2123**], '[**30**], '[**45**], '[**48**], now with hardware in lower back (plates and screws) -- h/o tremor -- hands h/o dry eye since eye surgery [**2145**] Social History: Lives with his wife. On disability for back problems. 3 children from prior marriage. Prior heavy drinker, primarily wine socially. No EtOH for two years except 2 glasses of wine on his anniversary. Denies tobacco use and illicit drug use. Family History: mother had breast cancer father had prostate CA no h/o heart disease or DM Physical Exam: PE (patient post-ictal at time of exam) Vitals: T 98.9 (max 100.3), BP 158/73, 97% RA, RR20, HR 105-110 General: lying in bed, tremulous, diaphoretic HEENT: PERRL, EOMI - no nystagmus, OP with small blood, tongue with bit on left-side, MM dry, +scleral icterus, visual field full to confrontation. Neck: no LAD, supple, no JVD, no stiffness Heart: Tachy, normal s1/s2, 2/6 SEM Lungs: CTAB no wheezes, crackles, rhochi Abd: +BS, NTND, soft, firm liver edge, liver 5-6cm in midclavicular line, no ascites, mild enlargement of spleen Ext: L thigh with extensive echymosis from above knee to inguinal area, lateral thigh is firm and tender to touch, anterior and medial thigh soft. Edema on L that extends from groin to knee. Pedal pulses palpable and feet warm. Femoral pulses 2+ bilaterally. Neuro: alert and oriented to self only. CN II-XII intact, tongue slightly to right of midline, but also avoiding left side due to new laceration. Patient with increased tone in b/l lower extremity and brachial reflex 2+ brisk b/l. Sensation intact to light touch, ASTERIXIS Delt Tri [**Hospital1 **] Grip QD Ham DF PF RT: 5 5 5 5 3 4 4 5 LEFT: 5 5 5 5 5 5 5 5 Skin: nummular erythematous, scaly plaques present on both shins as well as surrounding patches of hyperpigmentation c/w psoriasis, spider angiomas. Pertinent Results: OSH [**Location (un) 24356**] [**2153-5-3**]: HCT 27.5, WBC 4 (auto diff with 71N, 17L, 10M, 1E, 0.5B), PLT 65, INR 1.6, DBili 2.9, Tbili 6.6, amylase 629, lipase 63, alkaline phosphatase 160, ast 106, alt 38, CK 277. . Na 135, K 4, cl 99, Co2 24, Bun 12, Cr 0.7, BG123. . UA Clear, Leuk small, Protein Tr, Glucose neg, Ketones 15, Bili positive, Nitrite positive. WBC 0-2, RBC 0-2, Urine Bacteria negative. . CT [**2153-5-3**]: impression: no femoral fracture or dislocation, diffuse subcutaneous edema and possible edema of the left adductors and quadriceps muscle are seen without discrete hematoma. Findings could represent diffuse left thigh cellulitis and myositis. [**2153-5-3**] 09:00PM BLOOD WBC-3.3* RBC-2.47* Hgb-9.1* Hct-25.1* MCV-102* MCH-36.8* MCHC-36.2* RDW-14.2 Plt Ct-57* [**2153-5-8**] 03:01AM BLOOD WBC-3.9*# RBC-2.36* Hgb-8.2* Hct-24.1* MCV-102* MCH-34.8* MCHC-34.0 RDW-15.8* Plt Ct-89* [**2153-5-14**] 07:00AM BLOOD WBC-6.8 RBC-3.14* Hgb-11.0* Hct-31.7* MCV-101* MCH-35.0* MCHC-34.7 RDW-15.6* Plt Ct-131* [**2153-5-3**] 09:00PM BLOOD Neuts-62.0 Lymphs-27.8 Monos-6.2 Eos-3.3 Baso-0.6 [**2153-5-10**] 04:50AM BLOOD Neuts-75.1* Lymphs-13.6* Monos-10.6 Eos-0.7 Baso-0.1 . [**2153-5-3**] 09:00PM BLOOD PT-19.0* PTT-31.1 INR(PT)-1.8* [**2153-5-7**] 03:10AM BLOOD PT-18.3* PTT-31.4 INR(PT)-1.7* [**2153-5-11**] 03:23AM BLOOD PT-18.5* PTT-33.9 INR(PT)-1.7* . [**2153-5-5**] 03:38AM BLOOD Fibrino-155 [**2153-5-10**] 05:24PM BLOOD Ret Aut-5.1* . [**2153-5-3**] 09:00PM BLOOD Glucose-102 UreaN-12 Creat-0.7 Na-137 K-3.7 Cl-104 HCO3-24 AnGap-13 [**2153-5-8**] 03:01AM BLOOD Glucose-98 UreaN-10 Creat-0.5 Na-140 K-3.8 Cl-111* HCO3-24 AnGap-9 [**2153-5-10**] 05:24PM BLOOD Glucose-105 UreaN-12 Creat-0.5 Na-138 K-3.9 Cl-108 HCO3-23 AnGap-11 [**2153-5-13**] 07:10AM BLOOD Glucose-83 UreaN-11 Creat-0.6 Na-140 K-3.5 Cl-110* HCO3-19* AnGap-15 [**2153-5-14**] 07:00AM BLOOD Glucose-75 UreaN-10 Creat-0.5 Na-140 K-3.9 Cl-110* HCO3-18* AnGap-16 [**2153-5-4**] 05:30AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.4* [**2153-5-8**] 03:01AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.7 [**2153-5-13**] 07:10AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.8 [**2153-5-14**] 07:00AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.7 . [**2153-5-3**] 09:00PM BLOOD ALT-32 AST-95* LD(LDH)-269* CK(CPK)-192* AlkPhos-126* TotBili-5.7* [**2153-5-4**] 07:43PM BLOOD ALT-29 AST-72* LD(LDH)-279* CK(CPK)-244* AlkPhos-102 Amylase-469* TotBili-5.8* [**2153-5-5**] 03:38AM BLOOD ALT-29 AST-70* AlkPhos-97 Amylase-448* TotBili-7.1* DirBili-2.4* IndBili-4.7 [**2153-5-9**] 04:15AM BLOOD ALT-22 AST-46* LD(LDH)-239 AlkPhos-108 TotBili-5.9* [**2153-5-13**] 07:10AM BLOOD ALT-28 AST-60* AlkPhos-105 TotBili-7.0* [**2153-5-4**] 07:43PM BLOOD Lipase-66* [**2153-5-5**] 03:38AM BLOOD Lipase-59 . [**2153-5-3**] 09:00PM BLOOD calTIBC-263 VitB12-1279* Folate-12.2 Ferritn-247 TRF-202 [**2153-5-5**] 03:38AM BLOOD calTIBC-248* VitB12-1211* Folate-10.9 Hapto-<20* Ferritn-238 TRF-191* . [**2153-5-4**] 09:30AM BLOOD Ammonia-48* [**2153-5-4**] 09:30AM BLOOD TSH-1.5 . [**2153-5-12**] 07:50AM BLOOD CRP-19.6* [**2153-5-12**] 07:50AM BLOOD ESR-46* . [**2153-5-3**] 09:00PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2153-5-4**] 09:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . [**2153-5-5**] 02:57PM BLOOD Type-ART Temp-37.8 PEEP-5 FiO2-100 pO2-350* pCO2-32* pH-7.48* calTCO2-25 Base XS-1 AADO2-347 REQ O2-61 -ASSIST/CON Intubat-INTUBATED [**2153-5-8**] 03:22AM BLOOD Type-ART Temp-38.0 pO2-117* pCO2-37 pH-7.45 calTCO2-27 Base XS-1 Intubat-INTUBATED [**2153-5-10**] 05:03AM BLOOD Type-ART Temp-38.3 pO2-89 pCO2-33* pH-7.51* calTCO2-27 Base XS-3 [**2153-5-11**] 03:39AM BLOOD Type-ART pO2-121* pCO2-31* pH-7.48* calTCO2-24 Base XS-1 . [**2153-5-3**] LENI LEFT LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler son[**Name (NI) 1417**] of the left common femoral, superficial femoral and popliteal veins were performed. These demonstrate normal compressibility, augmentation, color flow and waveforms. No echogenic intraluminal thrombus is identified. There is moderate edema within the regional soft tissues with no discrete fluid collection seen. IMPRESSION: 1. No evidence for lower extremity DVT. 2. Moderate nonspecific edema in the regional soft tissues. No discrete fluid collections are seen. . [**5-4**] Lspine FINDINGS: No previous images. Extensive posterior fusion is seen involving L3 through S1 with metallic screws and bony spacers. The alignment appears to be quite well maintained. Interspace narrowing is seen in several levels. . [**5-4**] CT Head CT HEAD: No evidence of hemorrhage, edema, mass, mass effect, hydrocephalus, or recent infarction is seen. Small hypodensities in the subinsular white matter is consistent with chronic ischemic changes. Prominence of the ventricles and extra-axial CSF spaces is not out of proportion for the patient's age. There is no evidence of hydrocephalus. The soft tissues, osseous structures, and orbits are unremarkable. The visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No evidence of hemorrhage. . [**5-4**] CXR Cardiac size is top normal with left ventricular configuration. The lungs are clear. There is no pneumothorax or sizeable pleural effusion. IMPRESSION: No evidence of acute cardiopulmonary abnormalities . [**5-4**] LP Cerebrospinal fluid: ATYPICAL. Atypical epithelioid cells (see note). Lymphocytes and monocytes. Note: A rare cluster of epithelioid cells is present, too few to characterize, but a reactive process is favored. . [**5-5**] Abd u/s 1. Diffusely echogenic liver, compatible with fatty infiltration. More severe forms of liver disease, including advanced hepatic fibrosis/cirrhosis cannot be excluded. 2. Portal hypertension with reversal of flow in the anterior right portal vein and a recanalized periumbilical vein with splenic varices . 6/7 L leg MRI IMPRESSION: Heterogeneous mass within the left vastus intermedius and vastus lateralis with associated extensive subcutaneous and soft tissue edema. This mass may represent a hematoma, however, an infection cannot be fully excluded. Please note that evaluation for abscess is limited as no intravenous contrast was administered. MR imaging with contrast upon resolution is recommended. . [**5-5**] EEG IMPRESSION: Likely normal portable EEG in the drowsy and sleeping states with no areas of prominent focal slowing and no clearly epileptiform features. The study was limited by lack of normal waking backgrounds. If clinically indicated, the study could be repeated for better assessment of waking background morphology. Several episodes of arm shaking were noted by the technician; review of the tracing demonstrated movement artifact. . 6/8 L leg MRI Unchanged heterogeneous mass within the left vastus intermedius and lateralis muscles which likely represents a hematoma; however, infection cannot be fully excluded as no intravenous contrast was administered. There is associated extensive soft tissue swelling and edema within the left thigh. Follow up MRI with contrast upon resolution is recommended. . [**5-7**] RUQ U/S IMPRESSION: 1. Echogenic liver suggestive of fatty infiltration. Other forms of liver disease such as cirrhosis or fibrosis cannot be excluded. 2. No evidence of portal vein thrombosis. 3. Reversed flow in the anterior branch of the right portal vein, unchanged since the prior study. 4. No evidence of ascites. . [**5-7**] Spine MRI Technically limited study due to the presence of extensive lower lumbar metallic hardware. No definite signs for the presence of discitis, osteomyelitis, or an epidural abscess. Other findings as noted above. . [**5-9**] 2D Echo The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No endocarditis, abscess or signficant valvular regurgitation seen. Normal global and regional biventricular systolic function. No diastolic dysfunction or pulmonary hypertension. . [**5-10**] CXR FINDINGS: A bedside frontal chest radiograph is compared to [**5-9**], [**2152**]. The patient has been extubated. The lungs are clear aside from mild bibasilar atelectasis. Cardiomegaly with a left ventricular configuration and tortuous aorta are stable. The pulmonary vasculature is normal. IMPRESSION: No acute cardiopulmonary process. . [**5-11**] CTU IMPRESSION: 1. No evidence of renal stones or renal masses to suggest malignancy. There are multiple renal hypodensities which are too small to characterize. 2. There is recanalization of the paraumbilical vein as well as splenomegaly suggestive of chronic liver disease. 3. 3mm lung nodule. If the patient is at high risk for lung cancer, follow- up in 1 year to assess stability is recommended. cancer. . Brief Hospital Course: 52 y/o M with h/o EtOH cirrhosis who presents with L thigh pain and swelling following trauma. Transferred from OSH with concern for compartment syndrome. Shortly after arrival to [**Hospital1 **], pt had tonic-clonic seizure, likely [**12-30**] alcohol withdrawal, and was transferred to the MICU. He was managed in the ICU until HD#8, when he was called out to the floor. Please see below for clinical course by problem. . *) L thigh hematoma: Degree of swelling and bruising seems out of proportion to trauma, however has coagulopathy from liver disease predisposing him to bleeding. Was sent from OSH given concern for compartment syndrome but thigh soft, distal pulses intact, CK 192. LENI negative for DVT. Ortho was consulted and did not believe the presentation was suggestive of compartment syndrome. He had left leg MRI that did revealed a likely hematoma. His pain was controlled with IV morphine. On HD#11, pt was seen by PT, who recommended inpatient rehabilitation with physical therapy. . *) Seizure: Likely tonic-clonic based on observation. Unclear etiology, but likely [**12-30**] alcohol withdrawal as does have a prior history of seizure in setting of alcohol and narcotic withdrawal. Pt has no abnormal findings on head CT, no known thyroid disease, normal Na and normal renal function. No apparent syncope or cardiac arrhythmias, or severe hypoglycemia. EEG was without epiletpiform features and LP was unremarkable. Pt was seen by neurology. He was placed on a CIWA scale. He had no further seizures throughout the hospitalization. . *) Fever: Pt had persistent fevers throughout admission. Originally attributed to hematoma, but fever persisted despite reduction in size of hematoma. MRI of the leg showed no abscess. MRI of the spine also showed no abscess. Cultures were unrevealing. TTE unremarkable. CXR w/o PNA. Was empirically given vanco and zosyn, but both abx were discontinued as there was no clear source of infection. ID was consulted and recommended repeating imaging studies for further evaluation of questionable abscess, but pt was not febrile over last 3 days of hospitalization. . *) Anemia: Unknown baseline. Concern for hemolysis with dropping HCT vs continued bleeding into left leg. Likely component of chronic disease with marrow suppression from liver disease and EtOH. MCV elevated. [**Month (only) 116**] also have some hyperslenism given all cell lines down. Hct was stable and slowly increasing throughout hospitalization. . *) Respiratory difficulty: Pt was intubated for MRI and upon extubation, exhibited tachycardia, tachypnea, and agitation. He was reintubated and extubated successfully on HD#8. He was maintained on O2NC and successfully weaned by HD#10. . *) Swallowing dysfunction: Pt had speech/swallow eval after extubation and found to have coughing/concern for aspiration. Pt was made NPO and NGT placed for tubefeeds (pt desired). Unfortunately, pt d/c'd NGT. Diet advanced on HD#9, but RN with concern for coughing during meal. Repeat speech/swallow eval suggested pt could advance to soft solids/nectar liquids with observation at all meals, which he tolerated well. . *) Confusion: Pt frequently not oriented to place or time, perseverating on issues. Felt to be secondary to hepatic encephalopathy, as workup for sources of infection or organic neurologic issues unrevealing. On day of discharge, mental status seemed much improved, with pt engaging easily in conversation. . *) Cirrhosis: Secondary to chronic EtOH, followed by Dr. [**Last Name (STitle) **] in Staughton. Coagulopathic with INR 1.8 so decreased synthetic function, elevated bilirubin, AST, ALT all c/w mod-severe liver cirrhosis. Also thrombocytopenic, no baseline available. Coags, platelets overall stable/improved throughout hospitalization. Pt to continue outpatient follow up with hepatologist. . *) Chronic back pain: Pt on morphine SR at home. Unable to receive home dose secondary to frequent sedation. Pain control with PO morphine prn. . *) Psoriasis: Pt given sarna lotion for symptomatic relief. . Pt was discharged to rehab on HD#11 for further PT/OT. Medications on Admission: MEDS (confirmed with PCP and patient): Morphine SR 60mg qAM and qPM Morphine SR 30mg in afternoon Viagra prn Discharge Medications: 1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: -L thigh hematoma -Alcohol withdrawal -Persistent fevers of unknown origin -Benign hypertension Secondary: -Chronic back pain Discharge Condition: Stable for transfer to rehab Discharge Instructions: You were admitted after sustaining an injury to your left leg, with concern for continued bleeding and infection. You were transferred to the ICU after having a seizure, which was likely secondary to alcohol withdrawal. Because you have had a recent seizure, BY LAW [**Street Address(1) 15947**] FOR 6 MONTHS (until [**2153-11-6**]). . While in the ICU, you had continued fevers, which raised concern for an infection. The infectious workup was overall negative. You had multiple imaging studies which did not reveal extension of the hematoma or an abscess. . While in the ICU, you were intubated for an MRI and had difficulty with breathing upon extubation, which eventually resolved. . You also had difficulty eating, which was likely from sedation and deconditioning. You should continue to eat soft solids and thick liquids until further cleared by speech and swallow. . Your blood pressures were elevated while in the hospital. You should follow up with your PCP for further evaluation and possible treatment of hypertension. Followup Instructions: You should follow up with your primary care physician and your hepatologist upon discharge from rehab. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]

[ "924.00", "724.5", "338.29", "780.39", "780.6", "V16.3", "572.2", "572.3", "E917.3", "696.1", "571.2", "V45.4", "V16.42", "401.9", "291.81", "786.06", "284.1" ]

icd9cm

[ [ [] ] ]

[ "99.07", "99.05", "96.04", "99.04", "38.91", "96.6", "96.71", "03.31" ]

icd9pcs

[ [ [] ] ]

18743, 18815

13917, 18021

327, 334

18994, 19025

4508, 9060

20104, 20339

3062, 3138

18180, 18720

18836, 18973

18047, 18157

19049, 20081

3153, 4489

275, 289

362, 1781

9069, 13894

1803, 2789

2805, 3046

78,342

179,212

40702

Discharge summary

report

Admission Date: [**2199-10-17**] Discharge Date: [**2199-10-31**] Date of Birth: [**2149-3-13**] Sex: M Service: SURGERY Allergies: Bactrim Attending:[**First Name3 (LF) 668**] Chief Complaint: liver/kidney transplantation Major Surgical or Invasive Procedure: [**2199-10-17**]: Exploratory laparotomy, orthotopic liver transplant, renal transplant. [**2199-10-18**]: Exploratory laparotomy, removal of intra-abdominal packing, liver biopsy, and hepaticojejunostomy. History of Present Illness: 50M with ESLD due to hepatitis C cirrhosis and ESRD thought to be multifactorial from HTN, DM and hepatorenal syndrome, recently started on dialysis, presents today for liver-kidney transplantation. His ELSD has been characterized by ascites (requiring multiple taps), encephalopathy (treated with lactulose/rifaximin) and grade 1 varices (no history of GI bleed). He was recently admitted from [**Date range (1) 30596**] for these issues; he was tapped twice, treated with lactulose for asterixis, and started on dialysis for worsening renal failure. He was tapped again yesterday at [**State 792**]Hospital. He feels well today. No complaints. Denies recent fever, chill, nausea or vomiting or pain anywhere. Past Medical History: PMH: hepatitis C ([**2184**]) c/b cirrhosis, salmonella gastroenteritis with acute renal failure, chronic kidney disease with renal stones s/p lithotripsy ([**2192**]), DM (dx [**2188**], off medications, diet-controlled), HTN ([**2196**], well-controlled, off medications), ITP s/p splenectomy ([**2173**]), asthma PSH: splenectomy [**2173**], lithotripsy [**2192**] Social History: SH: Lives with fiancee, has two children. Prior heroin user, sober for two years, on methadone program. Family History: FH: His family history is significant for an aunt and uncle with diabetes. Physical Exam: Discharge Physical VS: T 98.4 P 95 BP 137/96 RR 18 O2sat 99RA NAD, AAOx3 no murmurs ctab abd soft, apropriately tender over incision, incision closed with staples c/d/i, minimal surrounding ecchymosis, no discharge from incisions. two JP sites closed with nylon suture. no LE edema Pertinent Results: [**2199-10-20**] LIVER U/S: 1. No evidence of biliary dilation. Patent hepatic vasculature. 2. Stable appearance of a postoperative right perihepatic fluid collection adjacent to the right hepatic dome. A left subhepatic collection is newly apparent, though this may be secondary to differences in imaging technique, and is likely post-operative in nature. 3. Moderate left pleural effusion. 4. Diffusely increased echogenicity of the liver most compatible with fatty infiltration, with focal areas of sparing, concerning for a substantial parenchymal abnormality. 5. Geographic and nodular hypoechoic areas in the liver, which may be associated with focal fatty sparing. A 6 mm lesion in the right lobe is not specific; follow-up ultrasound surveillance or consideration of MR evaluation is recommended if clinically indicated. PATH: Pt's liver: Liver, native hepatectomy (A-M): Established cirrhosis, confirmed by trichrome stain. Moderate septal and mild periseptal and lobular mononuclear inflammation (Grade 2 inflammation), consistent with chronic viral hepatitis C. Several microscopic foci of small cell dysplasia; reticulin stain evaluated. Gallbladder with chronic cholecystitis and cholelithiasis. Negative vascular and biliary margin. Iron stain shows mild iron deposition in hepatocytes. [**10-18**]/:11 Donor Liver, allograft, needle core biopsy: 1. Moderate mixed macro- and microvesicular steatosis and focally prominent neutrophils. 2. Mild portal mononuclear inflammation, non-specific. 3. No necrosis or features of acute cellular rejection are seen. 4. Trichrome and iron stains will be reported in an addendum. LABS: [**2199-10-30**] 05:18AM BLOOD WBC-18.4* RBC-3.90* Hgb-12.3* Hct-37.3* MCV-96 MCH-31.6 MCHC-33.0 RDW-15.7* Plt Ct-173 [**2199-10-23**] 02:13AM BLOOD PT-14.3* PTT-21.4* INR(PT)-1.2* [**2199-10-30**] 05:18AM BLOOD Plt Ct-173 [**2199-10-31**] 05:20AM BLOOD Glucose-125* UreaN-33* Creat-1.2 Na-135 K-4.1 Cl-102 HCO3-24 AnGap-13 [**2199-10-31**] 05:20AM BLOOD ALT-18 AST-16 AlkPhos-141* TotBili-1.4 [**2199-10-31**] 05:20AM BLOOD Albumin-2.8* Calcium-7.6* Phos-2.3* Mg-1.4* Brief Hospital Course: Pt was admitted to hospital for combined liver/kidney transplant. Pt was brought to OR, after informed consent was obtained, including explaining to the patient the risks associated with the donor liver including steatosis and increased risk of delayed graft function and failure. Intraop significant hemorrhage with no surgical bleeding but a massive amount of just diffuse ooze was encountered. Activated factor VII was given and shortly after the patient began making clot and drying up. It was not thought to be safe to close primarily packed the right upper quadrant and the iliac fossa with sponges and placed a temporary abdominal closure with anticipation of returning the patient to the operating room in 24 hours for washout and definitive closure. Introp received 16 of packed cells, 6 of CRYO, 15 of FFP, 5 of platelets and 1 dose of factor VII. See operative dictation for full details. Transferred to SICU intubated. Overnight, continued transfusions to goal hct >30, plt >100, INR <1.5, receiving 7 units pRBCs, 3 plts. Morning POD#1 returned to OR for Exploratory laparotomy, removal of intra-abdominal packing, liver biopsy, and hepaticojejunostomy. See operative dictation for full details. Transferred back to SICU intubated. [**2199-10-18**] U/S showed all vessels are patent. Over next two days hct remained stable ~30 with 4 units pRBCs, 3 units plts. No other transfusions during hospital course. Extubated on [**2199-10-19**]. Following day had increasing oxygen requirement secondary to pulm edema as mobilized fluid. Was diuresed in SICU and transferred to floor on [**2199-10-23**]. Course on floor was uneventful, except for pain control. Methadone and dilaudid doses were adjusted apropriately. Was ultimately continued on home methadone dose 35 mg, and pain well controlled with intermittent dilaudid po 5 mg q6 prn. Lateral JP d/c'ed [**10-25**], medial removed [**10-30**]. No evidence ascites leak through JP sites or incision. Immunosuppression was administered and titrated per pathway. Ppx was given per pathway. Pt tolerated regular diet, pain controlled with oral pain medications, voiding without difficulty, and ambulating. PT felt safe for pt to be d/c'ed home. On day of discharge pt and staff felt it safe for pt to be discharged home with VNA. Medications on Admission: nephrocaps 1', clotrimazole 10 troche''''', lasix 80'', lactulose 30''', propanolol 20'', rifaximin 550'', renleva 800''', spironolactone 50', venlafaxine 37.5', MVI,methadone 35'(methadone clinic, Codac in RI [**Telephone/Fax (1) 89015**], fax [**Telephone/Fax (1) 89016**]) Discharge Medications: 1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): follow taper schedule. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. methadone 5 mg Tablet Sig: Seven (7) Tablet PO DAILY (Daily): For Pain . Disp:*49 Tablet(s)* Refills:*0* 7. venlafaxine 37.5 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 8. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 10. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous once a day: AM. Disp:*1 bottle* Refills:*2* 11. Humalog 100 unit/mL Solution Sig: follow sliding scale units Subcutaneous four times a day: see printed scale. 12. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day. 13. Kayexalate Powder Sig: Four (4) tsp PO prn: 4 tsp Powder(s) by mouth once a day as needed for for high potassium level Transplant . 14. pentamidine 300 mg Recon Soln Sig: One (1) inh Inhalation once a month: last dose [**2199-10-24**]. 15. One Touch UltraSoft Lancets Misc Sig: One (1) Miscellaneous four times a day. Disp:*1 box* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of Greater [**Location (un) 511**] Discharge Diagnosis: Hep C Cirrhosis/ESRD now s/p combined liver/kidney transplant DM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: VNA of Greater [**Location (un) 511**] [**State 792**]Hospital for labs every Monday and Thursday Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fevers, chills, nausea, vomiting, diarrhea, constipation, increased redness, drainage or bleeding from the incision, increased abdominal pain, yellowing of the skin or eyes, inability to tolerate food, fluids or medications. No heavy lifting You may shower, no tub baths or swimming Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-11-7**] 2:20 [**2199-11-14**] at 9:00 Dr. [**Last Name (STitle) 9835**] at [**Hospital **] Clinic [**Telephone/Fax (1) 2384**], [**Last Name (un) 3911**], [**Location (un) 551**] [**2199-11-14**] at 10:00, [**Last Name (un) **] Nurse educator [**Telephone/Fax (1) 2384**] at [**Last Name (un) 3911**], [**Location (un) 551**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-11-14**] 2:40 Completed by:[**2199-11-1**]

[ "572.4", "571.5", "300.4", "286.9", "338.28", "V13.01", "493.90", "285.1", "309.81", "V14.1", "V45.11", "572.3", "250.40", "997.49", "518.4", "789.59", "456.1", "V45.79", "998.11", "403.91", "574.10", "V18.0", "305.1", "304.01", "585.6", "272.0", "583.81", "568.0", "070.54", "572.8", "456.8" ]

icd9cm

[ [ [] ] ]

[ "54.59", "54.12", "00.93", "51.36", "38.93", "51.79", "51.37", "54.62", "55.69", "97.85", "50.59", "50.12" ]

icd9pcs

[ [ [] ] ]

8439, 8508

4324, 6617

298, 507

8617, 8617

2179, 4301

9243, 9890

1785, 1862

6945, 8416

8529, 8596

6643, 6922

8768, 9220

1877, 2160

229, 260

535, 1253

8632, 8744

1275, 1646

1662, 1769

20,128

172,793

17927

Discharge summary

report

Admission Date: [**2172-4-30**] Discharge Date: [**2172-5-7**] Date of Birth: [**2144-11-3**] Sex: M Service: ADMISSION DIAGNOSIS: ETOH intoxication/withdrawal. HISTORY OF PRESENT ILLNESS: The patient is a 27-year-old admitted with a history of bipolar disorder on Seroquel and Lamictal who presented to an outside hospital on [**4-29**] with ETOH intoxication and multiple superficial injuries. The patient said he broke up with his girlfriend on [**4-29**] and went on a drinking binge. Later that day, the patient was out driving while intoxicated, and trying to shovel snow, when he had multiple falls which were witnessed by a neighbor. EMS was called. The patient was treated at an outside hospital with Haldol 5 mg, ativan 2 mg, Benadryl 50 mg IV, cogentin 1 mg IV, Reglan 10, Anzemet 12.5 mg, thiamine banana bag, tetanus shot, IV fluid. While at outside hospital, the patient spiked a temperature to 101.3. There was concern for neuromalignant syndrome versus serotonin syndrome. The patient was also found to have rhabdo. The patient was transferred to [**Hospital1 18**] for further evaluation. In the Emergency Room here, the patient was given ativan 4 mg IV x 2, Tylenol 1 gm, dantrolene 200 mg po, D5 [**2-13**] with bicarb. The patient denies getting into altercation. The patient is currently without complaints. Denies any ingestion other than alcohol. A Foley was placed. Of note, the patient is a body builder. He uses ephedra and Ripfuel. The patient was admitted to the MICU for ETOH withdrawal, CIWA-A scale and monitoring. In the MICU, it was felt that the patient's continued agitation and symptoms were consistent with ETOH withdrawal requiring benzodiazepines. After being given 750 mg of benzodiazepine, the patient still continued to be agitated, tachycardic and hypertensive. Toxicology was consulted. Given the lack of control of withdrawal, the patient was electively intubated in unit, and the patient started on a propofol drip on [**5-1**], and extubated on the same day. Panculture was performed and a chest x-ray showed possible aspiration pneumonia. The patient was initiated on antibiotics including Keflex and clinda. In MICU, a head CT was also performed which showed a possible right basal ganglion density thought possibly to be a CVA. Therefore, a follow-up MRI had to be performed which was negative. In his hospital stay in the MICU, the patient was reevaluated by toxicology. It was then felt that his symptoms might be consistent more with benzodiazepine withdrawal versus ETOH withdrawal. Therefore, his benzos were held. The patient's mental status gradually cleared, and he was transferred to the medicine floor on [**4-30**]. PAST MEDICAL HISTORY: Bipolar. MEDS: 1) Seroquel 600 qd, 2) Lamictal 100 [**Hospital1 **]. ALLERGIES: Ampicillin. SOCIAL HISTORY: The patient is a body builder. He uses ephedra. ETOH - 4-5 beers qd. No drugs. No history of IV drugs. No history of seizure. No history of DTs. LABS ON ARRIVAL/DATA FROM OUTSIDE HOSPITAL: Sodium 140, K 4.2, chloride 94, bicarb 27, BUN 16, creatinine 1.9, glucose 133, calcium 9.3, T-bili 0.3, albumin 4.7, alk phos 100, total protein 8.2, ALT 40. Serum ETOH at outside hospital was 352 on [**4-29**]. Amylase 180, AST 72, ALT 40, lipase 27, white blood cell count 15.9, hematocrit 42.9, platelets 432, N 93, L3, M3, E1. UA - trace ketones, trace blood, trace protein, RBC 0-2, WBC 0-5, a few epis/bacteria. Urine negative for amphetamines, cocaine, opiates, benzos, cannabinoid, PCP. [**Name10 (NameIs) **] for TCA. A right ankle x-ray was negative. C-spine was negative. Head CT was negative. Chest x-ray was negative. CK was 2248, MB 14.2, and troponin 0.03. At 5:00 am on [**4-30**], labs notable for hematocrit of 30.9, CK 3258, amylase 220, AST 93. HOSPITAL COURSE - 1) MENTAL STATUS: The patient's presentation mental status was felt to be consistent with ETOH intoxication, then benzodiazepine overdose/withdrawal. The patient's mental status cleared with cessation of all benzos. The patient will be discharged on his Seroquel dose and prn 1 mg po bid of Haldol. The patient was followed by psychiatry and toxicology in-house. The patient will be discharged to rehabilitation center for management of intoxication. 2) ID: Patient with a history of fever. A chest x-ray notable for possible aspiration pneumonia. Subsequent blood cultures were negative. The patient's antibiotics were discontinued. The patient was afebrile 48 hours prior to discharge. No evidence of acute infection. 3) ORTHO: Patient with a history of trauma to right ankle. X-ray films were negative for fracture. Patient was seen by PT, evaluated in-house, and provided with crutches. 4) ANEMIA: The patient had a history of anemia. Iron work-up was negative. The patient also had guaiac positive stools. The patient should be evaluated with a colonoscopy as an outpatient. 5) RHABDO: Patient with a history of rhabdomyolysis. The patient showed no evidence of kidney dysfunction. The patient's CK levels declined while in-house. The patient was well-hydrated. 6) GI: Patient with slightly elevated LFTs. ALT on [**5-6**] was 96, AST 96, alk phos 150, T-bili 0.4. LFTs were likely due to ETOH. However, hepatitis panel was obtained to evaluate, and this should be followed up as an outpatient. RECOMMENDATIONS: 1) The patient discharged to rehabilitation center for management of drug use. 2) The patient should be followed by psychiatry to evaluate. Of note, the patient was evaluated here by psychiatry and there was a question as to the basis for his bipolar disorder. There was recommendation for the patient not to continue to use his ephedra. 3) The patient should be followed as an outpatient for his guaiac positive stools with a colonoscopy. DISCHARGE MEDICATIONS: .................... PRN x 3 days. CONDITION: Fair. DISCHARGE DIAGNOSES: 1) Benzodiazepine overdose with benzodiazepine withdrawal. 2) Alcohol intoxication with alcohol withdrawal. 3) Rhabdomyolysis. 4) Bipolar. DR.[**First Name (STitle) 2515**],[**First Name3 (LF) **] 12-927 Dictated By:[**Last Name (NamePattern1) 201**] MEDQUIST36 D: [**2172-5-7**] 11:28 T: [**2172-5-7**] 10:30 JOB#: [**Job Number 49651**]

[ "969.4", "292.0", "303.91", "E980.9", "728.89", "291.0", "792.1", "980.0", "296.89" ]

icd9cm

[ [ [] ] ]

[ "94.68", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

5949, 6320

5872, 5927

152, 183

212, 2726

3874, 5848

2749, 2846

2863, 3858

26,130

143,303

29675

Discharge summary

report

Admission Date: [**2138-12-9**] Discharge Date: [**2138-12-29**] Date of Birth: [**2077-1-16**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: Chronic Pancreatitis Pleural effusion Major Surgical or Invasive Procedure: Flexible Bronchoscopy VAT with Pleural Drainage Decortication Distal Pancreatectomy with Splenectomy Puestow Procedure Drainage of Retroperitoneal/Abdominal Abscess History of Present Illness: This is a 61 year old male with chronic pancreatitis [**1-2**] etoh abuse who presented to [**Hospital1 1562**] w/ abdominal pain. Pt. found to have pancreatic pseudocyst w/ pleural effusion. He had a thoracentesis w/ 800 cc fluid removed(Amylase 1722, LD 2229, Glu 1, Protein 5.2). He also had a splenic hematoma per CT read at [**Hospital1 1562**]. He was transferred to [**Hospital1 18**] and on arrival to the floor he was found to be tachycardic, tachpneic and O2 sat in the 80s. He was then transferred to TSICU [**12-9**]. Past Medical History: Chronic Pancreatitis, DM, HTN, Anemia, COPD?, ETOH abuse, Smoker PSH:Appy, Tonsillectomy, Adenoidectomy Social History: smoker/ etoh abuse Physical Exam: PE: 99.1, 123, 126/76, 18, 89% 4L Gen: A+O x 3, ill appearing Lungs: coarse rales bilat., dyspneic CV: tachy, reg rhythm Abd: tender on palpation to epigaastrc and LUQ, slightly distended, no masses. Ext: +2 pulses bilat., warm Pertinent Results: [**2138-12-25**] 09:19AM BLOOD Hct-23.4* [**2138-12-25**] 04:20AM BLOOD WBC-22.6* RBC-2.40* Hgb-7.3* Hct-21.6* MCV-90 MCH-30.6 MCHC-34.1 RDW-15.1 Plt Ct-1272* [**2138-12-25**] 04:20AM BLOOD Glucose-199* UreaN-13 Creat-0.5 Na-129* K-4.6 Cl-95* HCO3-29 AnGap-10 [**2138-12-16**] 05:15AM BLOOD ALT-78* AST-50* AlkPhos-93 Amylase-18 TotBili-0.2 [**2138-12-16**] 05:45PM BLOOD Lipase-23 [**2138-12-25**] 04:20AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.9 [**2138-12-23**] 08:45AM BLOOD calTIBC-215* TRF-165* . CT CHEST W/O CONTRAST [**2138-12-11**] 11:39 AM IMPRESSION: 1. Large multiloculated left pleural effusion, likely exudate, infected until proved otherwise, may be related to large, subcapsular splenic fluid collection and, ultimately, to chronic, calcific pancreatitis. 2. Severe relaxation atelectasis and cental adenopathy, due to left pleural abnormality. . CTA ABD W&W/O C & RECONS [**2138-12-15**] 9:37 AM IMPRESSION: 1. Small area of contrast extravasation into the left anterior pleural cavity which most likely is related to recent surgery. 2. Small hematoma above the spleen. 3. Subcapsular fluid collection which may represent old subcapsular hematoma or pseudocyst. 4. Thrombosed distal SMV and splenic veins, multiple mesenteric collaterals are present which reconstitute the portal vein. 5. Moderate right pleural effusion. 6. Ascites. . CHEST (PA & LAT) [**2138-12-22**] 10:54 AM IMPRESSION: Slight decrease in pleural effusions. . CT ABD W&W/O C [**2138-12-23**] 10:58 PM [**Hospital 93**] MEDICAL CONDITION: 61 year old man with chronic pancreatitis c/b leaking pseudocyst. s/p distal pancreatectomy, splenectomy REASON FOR THIS EXAMINATION: evaluate abdomen post-op for residual fluid collections IMPRESSION: 1. Status post splenectomy and distal pancreatectomy, prominent tissue stranding in left upper quadrant, but no focal fluid collections or abscesses. 2. Persistent small amount of contrast within the left anterior pleural space, likely related to recent surgery. 3. Left chest tube and two intra-abdominal drains as positioned above. 4. Small amount of ascites, in keeping with recent surgery. 5. Trace left and small right pleural effusions unchanged since [**2137-12-15**]. 6. The previously noted thrombosis of the distal SMV is not clearly visualized on today's study, possibly related to the phase of contrast injection. The portal vein remains patent. The imaged portion of the splenic vein is also patent. . SPECIMEN SUBMITTED: SPLEEN AND DISTAL PANCREAS Procedure date Tissue received Report Date Diagnosed by [**2138-12-16**] [**2138-12-17**] [**2138-12-22**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 1431**]/nbh Previous biopsies: [**Numeric Identifier 71101**] LT. PLEURAL TISSUE (1). DIAGNOSIS: a. Marked fibrosis and atrophy of pancreas consistent with chronic pancreatitis. b. Splenomegaly (spleen=320 grams): No evidence of malignancy. c. Accessory spleen, No evidence of malignancy. Clinical: Chronic pancreatitis. . [**2138-12-25**] 9:55 pm STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT [**2138-12-26**]** FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. . [**2138-12-28**] 6:40 am STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT [**2138-12-29**]** CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2138-12-29**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Brief Hospital Course: He was admitted to [**2138-12-9**] and transferred to the TSICU [**12-9**] for some respiratory distress. He had O2 sats in the low 80%. He responded well to a nonrebreather face mask. He was transfered back to the floor on [**12-11**]. Thoracics: On [**2138-12-12**], he went for a Left VATS with decortication. He had drained 1500cc of serous fluid. [**2138-12-12**] Pleural fluid cx - pansensitive Klebsiella. Post-operatively he did well from the VATS. He was followed by Thoracics for care of the CT.He had serial CXR to evaluate his effusion and the CT were sequentially removed. Apical anterior d/c'd [**12-18**], apical posterior d/c'd [**12-19**], basilar d/c'd [**12-24**]. . Pain: He had a PCA for pai control after the VATS. He was using it appropriately and had good control. After his abdominal procedure: 1. Distal pancreatectomy with splenectomy. 2.. Peustow procedure. 3. Drainage of retroperitoneal/intra-abdominal abscess. 4. Feeding jejunostomy tube placement, he had an epidural [**12-17**] Pt comfortable on APS 10 solution. No change. [**12-18**] Pt comfortable on APS 10 soln at 6 cc/hr. No change. Plan for removal tomorrow. [**12-19**] comfortable. [**12-20**] ng tube still in place. on APS 10. will likely take out epidural [**12-21**] [**12-21**] epidural out. He was then switched to PO Percocet and had good pain control. Pancreatits: He went to the OR on [**2138-12-17**] for the above mentioned procedure. He was placed on a modified "Whipple" pathway. He was NPO, with a NGT. The NGT was removed on POD 3. His JP x 2 in the LLQ were tested and the amylase was low and the drains were removed. Pneumococcal, HiB Vaccines were given for the splenectomy. . Abd: His abdominal incision was noted to be red. He was started on Kefzol. On POD 8, the incision was opened slightly due to a seroma. This was packed with gauze and will require [**Hospital1 **] dressing change. His CT sites and JP sites were C,D,I and will just require monitoring. . EtOH withdrawl: Upon admission, while in the ICU, he was placed on a CIWA scale and required Ativan. . Anemia: We continued to watch his HCT for post-op blood loss. His HCT hovered in the mid 20's. On POD 13/9, he received 2 units of PRBC when his HCT dipped to 21.6. He was assymptomatic during this time. A post-transfusion HCT was 30 . Post-op lower extremity edema: He received Lasix 10mg IV BID for LE edema and responded well. . Post-op hyponatremia: His sodium was 130 post-op. We limited all free water intake and continued to monitor for any signs of hyponatremia. He will follow-up with his PCP for repeat electrolyte monitoring. . Hyperglycemia: [**Last Name (un) **] was consulted for hyperglycemia. While on TPN he was receiving insulin in the TPN bag. TPN was stopped on POD [**6-2**]. [**Last Name (un) **] continued to evaluate and increase his NPH at HS while on tube feedings. His tube feedings were stopped on [**12-26**] in hopes that his blood sugars would then be in better control. The sugars continued to be elevated in the 300'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] continued to evaluate and adjust his insulin. His sugars were better controlled at time of discharge and he will need continued monitoring at home and with his PCP. . FEN: He was NPO and TPN was started on [**12-11**] (HD 3). He was started on TF on POD 2 and these were slowly increased. He was then started on sips and advanced over the few days and was tolerating a regular diet. TF at 100/hr were cycled at night. He was able to tolerate a regular diet at time of discharge and tube feedings were discontinued. His nutrition labs indicated that he was still malnourished. His Albumin was 2.5. . PT: PT was consulted and worked with him. He was cleared to go home. . C. Diff: He reported + loose stool on [**12-24**] and [**12-25**]. A C.diff was tested and was positive. He was started on Flagyl. He will need to be tested for C.diff by his PCP to rule out C.diff. He will finish a 10 day course of Flagyl. . ID: He was started on Meropenem for the Klebsiella in the pleural fluid. This was changed to Levofloxacin on [**2138-12-19**] and he will complete a 14 day course. He was also started on Kefzol for wound erythema and infection and completed a 10 day course. Medications on Admission: Metformin 1000", Glipizide 10.5', Actos 45' Discharge Medications: 1. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:*30 Patch 24HR(s)* Refills:*2* 2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Insulin Glargine 100 unit/mL Solution Sig: Twenty Six (26) Units Subcutaneous HS. Disp:*qs * Refills:*2* 8. Humalog 100 unit/mL Solution Sig: Sliding Scale Subcutaneous four times a day: See Sliding Scale. Disp:*qs * Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Chronic Pancreatitis Splenic Hematoma Retroperitoneal Abscess Left Pleural Effusion Post-op Hyperglycemia Wound Infection C. Diff Discharge Condition: Good Discharge Instructions: * Increasing pain * Fever (>101.5 F) * Persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain . Please resume all of your regular medications and take any new meds as ordered. . Continue to ambulate several times per day. . All Alcohol must be avoided. . You may shower and wash with soap and water. Keep incisions clean and dry. Change gauze dressing daily. . Followup Instructions: Please follow-up with your PCP regarding your low sodium. Have your electrolytes checked by your PCP next week. Please follow-up with Dr. [**Last Name (STitle) 468**] in [**1-3**] weeks. Call ([**Telephone/Fax (1) 27730**] to schedule an appointment. Please follow-up with Dr. [**Last Name (STitle) **] in [**1-3**] weeks. Call ([**Telephone/Fax (1) 4044**] to schedule an appointment. Completed by:[**2138-12-29**]

[ "865.00", "511.9", "276.1", "263.9", "510.0", "E928.9", "998.59", "577.1", "567.22", "008.45", "567.38", "250.00", "518.82" ]

icd9cm

[ [ [] ] ]

[ "99.15", "34.51", "41.5", "33.23", "54.0", "34.04", "96.6", "46.39", "34.21", "52.59" ]

icd9pcs

[ [ [] ] ]

10341, 10392

4979, 9245

353, 520

10566, 10573

1508, 2998

11027, 11445

9339, 10318

3035, 3140

10413, 10545

9271, 9316

10597, 11004

1259, 1489

275, 315

3169, 4956

548, 1079

1101, 1208

1224, 1244

31,717

195,093

8036

Discharge summary

report

Admission Date: [**2145-9-10**] Discharge Date: [**2145-9-12**] Date of Birth: [**2094-10-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5510**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: None History of Present Illness: 52 yo female with IDDDM c/b neuropathy and gastropathy, ESRD on HD, and HTN who was just discharged from [**Hospital1 18**] today at 3pm and returned at 9pm with hematemesis and HTN. Pt reports she had HD today and then was discharged home. She felt unwell when she got home and reports some vomiting of blood; small quantities. She reports that her BP was "high" as well, but not sure if the numher. She also says her sugar was i the 400s for which she took 10U insulin and it came down to the 200s. She reports +N/V, + hematemesis, no adominal pain/diarrhea or BRBPR. She also denies any headache, visual changes, numbness/weakness or tingling. She reports being compliant with her medications and had taken her BP meds after dialysis yesterday, however "can't remember if took Lantus prior to coming to ED) . Of note, pt was admitted to the MICU [**9-3**] and discharged [**9-4**] for hyperglycemia and was briefly placed on insulin gtt and [**Last Name (un) **] was consulted at the time; her insulin regimen was adjusted. She was subsequently readmitted [**9-5**] with coffee ground emesis, HTN and hyperglycemia. She received IV labetolol in the ED which dropped her SBPs from 200s to 90s and subsequently developed drowsyness, decreased responsiveness, and aphasia. She was seen by neurology who felt that her sxs were to global hypoperfusion in the setting of low BP, and she improved with normalization of her BP. GI saw the patient and she underwent an EGD which demonstrated gastritis. She was placedo Protonix 40mg daily and discharged home [**9-9**]. Her HTN was tx with her regular home medications w/o adjustment. . Pt initially presented to [**Hospital6 28728**] center with SBP 220 and coughing "brownish material" and was then transferred here for ongoing care given recent admission. At [**Location (un) 1121**], Hct 42.6, WBC 8 (82N, 9.8L), INR 0.9, Cr 5.3, Potassium 3.2. She was given IV lopressor (2.5mg IV x3). . On arrival to [**Hospital1 18**] ED, T 98.5, BP 180/70, HR 93, RR 16 100%RA. She had a glucose of 248 and was given 10U insulin. She was given 2.5mg IV Lorpessor and placed on nitro gtt. She also received zofran and ativan for nausea. . Currently pt reports feeling ongoing mild nausea, no recent vomiting. Deneis CP, SOB or palpitations. Denies abdominal discomfort, diarrhea/constipation or BPRBRP. All other ROS negative. Past Medical History: 1. Poorly controlled DM type 1, diagnosed in [**2117**]. Followed at the [**Last Name (un) **] (Dr. [**Last Name (STitle) 14116**]. Last HbA1c 9.8 in [**2-16**] at [**Last Name (un) **]. AV fistula on [**2145-1-20**], currently seeing Dr.[**Doctor Last Name 4849**] for evaluation of kidney transplant 2. Severe gastroparesis 3. Diabetic neuropathy, with Charcot joints 4. Chronic renal insufficiency baseline Cr ~4 .Started dialysis in [**2-16**] 5. Hypertension 6. Non-healing left foot ulcer with several foot surgeries 7. Hx. of MRSA 8. h/o UGIB 9. peripheral neuropathy 10. Diabetic retinopathy s/p laser surgery (blind right eye) Social History: Lives with her husband and two sons, remote smoking history and occasional ETOH. Currently unemployed. Family History: NC Physical Exam: Vitals: T= 98.3 BP 140/60 HR 76 95%RA RR 16 GENERAL: well appearing female in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. NGT in place Neck: Supple, JVD flat CARDIAC: Regular rhythm, normal rate. 2/6 SEM at RUSB. LUNGS: CTAB, no wheezing ABDOMEN: Soft, NT, ND. +NS EXTREMITIES: No LE edema/clubbing or cyanosis, 2+DP/PT pulses LUE: Fistula in place; no bruit SKIN: No rashes/lesions, ecchymoses. NEURO: A&O x3, CN 2-12 grossly intact Pertinent Results: [**2145-9-9**] 05:45AM PLT COUNT-317 [**2145-9-9**] 05:45AM NEUTS-55.2 LYMPHS-33.9 MONOS-5.2 EOS-4.7* BASOS-0.9 [**2145-9-9**] 05:45AM WBC-7.5 RBC-4.09* HGB-12.7 HCT-39.0 MCV-95 MCH-31.1 MCHC-32.6 RDW-14.6 [**2145-9-9**] 05:45AM CALCIUM-9.2 PHOSPHATE-7.1* MAGNESIUM-2.2 [**2145-9-9**] 05:45AM GLUCOSE-47* UREA N-35* CREAT-7.1* SODIUM-141 POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-30 ANION GAP-14 [**2145-9-10**] 02:35AM GLUCOSE-248* SODIUM-140 POTASSIUM-5.0 CHLORIDE-99 TOTAL CO2-20* ANION GAP-26* [**2145-9-10**] 03:55AM PLT SMR-NORMAL PLT COUNT-295 [**2145-9-10**] 03:55AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2145-9-10**] 03:55AM NEUTS-89.4* BANDS-0 LYMPHS-7.4* MONOS-2.7 EOS-0.1 BASOS-0.3 [**2145-9-10**] 03:55AM WBC-9.3 RBC-4.05* HGB-13.0 HCT-38.8 MCV-96 MCH-32.1* MCHC-33.5 RDW-14.5 [**2145-9-10**] 05:59AM CALCIUM-8.6 PHOSPHATE-5.0*# MAGNESIUM-2.0 [**2145-9-10**] 05:59AM GLUCOSE-181* UREA N-22* CREAT-5.2*# [**2145-9-10**] 06:11AM LACTATE-1.9 [**2145-9-10**] 06:11AM COMMENTS-GREEN TOP [**2145-9-10**] 09:58AM OSMOLAL-314* [**2145-9-10**] 09:58AM GLUCOSE-222* UREA N-23* CREAT-5.7* SODIUM-143 POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-28 ANION GAP-14 [**2145-9-10**] 11:44AM URINE MUCOUS-RARE [**2145-9-10**] 11:44AM URINE HYALINE-1* [**2145-9-10**] 11:44AM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-5 [**2145-9-10**] 11:44AM URINE BLOOD-NEG NITRITE-NEG PROTEIN->600 GLUCOSE-1000 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2145-9-10**] 11:44AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2145-9-10**] 11:44AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2145-9-10**] 11:44AM URINE OSMOLAL-352 [**2145-9-10**] 11:44AM URINE HOURS-RANDOM UREA N-114 CREAT-40 SODIUM-93 [**2145-9-10**] 06:10PM GLUCOSE-272* UREA N-25* CREAT-6.1* SODIUM-135 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-22 ANION GAP-17 Brief Hospital Course: 50 y.o. female with PMH significant for IDDM c/b ESRD on HD and gastroparesis who presented to the ED with hematemesis and found to have SBP 200s. The following issues were investigated during this hospitalization: . #GI Bleed: Repeat EGD was deferred as it had been done just days before and only showed gastritis without varices. Consideration was given to bleeding from gastritis vs. [**Doctor First Name 329**]-[**Doctor Last Name **] tear from retching. Patient remained hemodynamically stable, not requiring a transfusion and maintaining a stable Hct. PPI [**Hospital1 **] was continued. . #Hyperglycemia/Diabetes: Pt initially presented with a blood sugar in the 200s with an anion gap. Of note, she had not taken her Lantus prior to arrival to the ED and reportedly has a history of non-compliance. This was corrected with insulin and IVF. . #Labile blood pressure: Pt with markedly elevated BP on presentation to ED requiring nitro gtt. Of note, patient had a recent episode of mental status change when her BP dropped to SBP of 90 after receiving Labetalol IV for hypertension. She has since been taking Fludricortisone PRN for orthostasis. Labile BP has been attributed to autonomic dysfunction in the setting of poorly-controlled DM. BP was moderately well-controlled during the remaineder of this hospitalization with a goal SBP of 150-170s. . #Rash: Patient was noted to have a rash on discharge that resembled shingles. It was not painful, though it was pruritic and was unilateral on the left side of her mid-back, extending forward onto the chest wall. Per the patient, it had been present for over a week and thus Acyclovir was felt to not be likely to be beneficial. Patient has no known [**Hospital1 28729**] besides relative [**Name (NI) 28729**] with DM. She was discharged with instructions to employ supportive care for her rash while it lasted. Her PCP was notified of this development for follow-up. . #ESRD: Patient was followed by renal and last HD was performed on [**9-9**]. She was discharged on a Tu/Th/Sat schedule with her next session being Tuesday, [**9-14**]. . #Gastroparesis: Patient was maintained on outpatient Metaclopramide. . #Hyperlipidemia: Patient was maintained on outpatient Pravachol. Medications on Admission: Amitriptyline 25 mg qhs Amlodipine 5 mg daily Toprol XL 25 mg daily ASA 81 mg daily Pravastatin 40 mg daily Metoclopramide 5 mg qidachs Lantus 30 U qhs Humalog Zantac 150 mg [**Hospital1 **] Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. 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* 3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Insulin Continue your previous insulin regimen Discharge Disposition: Home Discharge Diagnosis: Gastritis Discharge Condition: Hemodynamically Stable. Discharge Instructions: You were seen and evaluated for concern of bleeding from your digestive tract. However, your blood counts and blood pressure have remained stable and since you had a recent upper endoscopy that did not show any evidence of bleeding, you were simply monitored. You are now being discharged home. . Take all of your medications as directed. . Keep all of your follow-up appointments. . Call your doctor or go to the ER for any of the following: vomiting up blood or coffee grounds, blood in your bowel movements or dark black bowel movements, lightheadedness, palpitations, shortness of breath, chest pain, fevers/chills or any other concerning symptoms. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2145-9-17**] 9:50 . Provider: [**Name10 (NameIs) **] INTAKE,EIGHT [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2145-9-22**] 8:30 . Provider: [**Name10 (NameIs) **] PROCEDURES FELLOW Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2145-9-22**] 9:30

[ "V58.67", "V15.81", "094.0", "V62.0", "581.81", "357.2", "458.0", "782.1", "713.5", "403.91", "272.4", "585.6", "250.63", "250.53", "250.43", "535.51", "362.01", "250.13", "536.3" ]

icd9cm

[ [ [] ] ]

[ "39.95", "99.17" ]

icd9pcs

[ [ [] ] ]

9259, 9265

6053, 8291

328, 335

9319, 9345

4056, 6030

10046, 10429

3526, 3530

8533, 9236

9286, 9298

8317, 8510

9369, 10023

3545, 4037

277, 290

363, 2727

2749, 3389

3405, 3510